Evaluation of a paper and electronic pictorial COPD action plan

Personalised written action plans are increasingly regarded as an important component of chronic obstructive pulmonary disease (COPD) self-management support and yet they may not be understood by those with limited literacy skills. This study was designed to produce a comprehensible pictorial COPD action plan for use by patients and health care professionals. With advice from a group of doctors and nurses a 'standard' written COPD action plan was translated by a medical artist into a series of pictorial images. These were assessed using the techniques of guessability and translucency in 21 adults attending a COPD clinic in a London hospital. Guessability and translucency scores show that pictograms were reasonably well understood, with only 3 pictograms showing low score in both guessability and translucency questionnaires. These included images depicting increased sputum production, swollen ankles, and use of extra doses of reliever medication. However, after brief spoken reinforcement about self-management, most patients could use the pictorial plan to suggest appropriate self-management behaviour such as when to access medical care. We have developed a pictorial COPD action plan. Pictorial methods represent an effective method of reinforcing the spoken word for all ranges of literacy.

Are evaluated respiratory service developments implemented into clinical practice?

INTRODUCTION

Evaluation of the way in which respiratory care is delivered is increasingly recognised to be an important area for research. When service developments are reported, it is not always clear whether they are subsequently implemented within the reporting institution, and if not why not.

METHODS

3281 abstracts from three specialist journals and one general journal were reviewed, and 36 reported evaluated service developments identified. The authors of each of these were approached to determine whether the reported service developments were in use in their institution.

RESULTS

30 of the 36 authors responded (83%). 10 reports were of sharing care with nurses and five with other health professionals, and the remainder involved new technologies, education, patient information or guideline implementation. 15/30 had implemented the reported development into practice, 11 of which were implemented immediately. Delays were due to staffing, funding and organisational issues. 10/15 studies were not put into practice, the main reason being that the key person had left. Four respondents embarked upon further study to confirm their preliminary published findings.

CONCLUSIONS

Reports of apparently positive service developments are only implemented in approximately one-half of institutions reporting the development. In a third of cases, non-implementation reflects the original authors believing that further study is necessary to confirm effectiveness.

Recent developments in radionuclide neutron source emission rate measurements at the National Physical Laboratory

This paper outlines the key features of the new manganese bath facility of the National Physical Laboratory and describes the measurements performed to characterise and validate the facility. Other developments have focused on the use of MCNP to calculate the fraction of neutrons captured by nuclei other than manganese and the fraction escaping from the bath. This has highlighted the large difference in the oxygen(n,alpha) capture fraction when different cross-section evaluations are applied. This can change the value obtained for the neutron emission rate of a source by up to 0.8%.

A nurse led intermediate care package in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVES

To determine the effects of a nurse led intermediate care programme in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

DESIGN

Randomised controlled trial.

SETTING

Community and hospital care in west London.

PARTICIPANTS

122 patients with COPD.

INTERVENTION

A care package incorporating initial pulmonary rehabilitation and self-management education, provision of a written, personalised COPD action plan, monthly telephone calls and 3 monthly home visits by a specialist nurse for a period of 2 years.

MAIN OUTCOME MEASURE

Hospital readmission rate.

SECONDARY OUTCOMES

Unscheduled primary care consultations and quality of life.

RESULTS

There were no differences in hospital admission rates or in exacerbation rates between the two groups. Self-management of exacerbations was significantly different and the intervention group were more likely to be treated with oral steroids alone or oral steroids and antibiotics, and the initiators of treatment for exacerbations were statistically more likely to be the patients themselves. 12 patients in the control group died during the 2 year period, eight as a result of COPD, compared with six patients in the intervention group, of whom one died from COPD. This is a significant difference. When the numbers were adjusted to reflect the numbers still alive at 2 years, in the intervention group patients reported a total of 171 unscheduled contacts with their general practitioner (GP) and in the control group, 280 contacts. The number needed to treat was 0.558--ie, for every one COPD patient receiving the intervention and self-management advice, there were 1.79 fewer unscheduled contacts with the GP.

CONCLUSIONS

An intermediate care package incorporating pulmonary rehabilitation, self-management education and the receipt of a written COPD action plan, together with regular nurse contact, is associated with a reduced need for unscheduled primary care consultations and a reduction in deaths due to COPD but did not affect the hospital readmission rate.

Characterization and utilization of a Bonner sphere set based on gold activation foils

Bonner sphere (BS) sets which use activation foils as the central thermal neutron sensor have advantages over active BS systems in certain environments, for example, pulsed fields, or fields with high photon components. In such environments, they may be the only type of neutron spectrometer which can be used. This paper describes work, using both measurements and calculations, to validate the response functions for a BS set based on gold activation foils. As an illustration of the use of such a system, a measurement is described of the contaminant neutron spectrum in the treatment room of a 21 MV hospital linear accelerator providing photon beams for radiotherapy.

Investigation of combined unfolding of neutron spectra using the UMG unfolding codes

An investigation of the simultaneous unfolding of data from neutron spectrometers using the UMG codes MAXED and GRAVEL has been performed. This approach involves combining the data from the spectrometers before unfolding, thereby performing a single combined unfolding of all the data to yield a final combined spectrum. The study used measured data from three proton recoil counters and also Bonner sphere and proton recoil counter responses calculated from their response functions. In each case, the spectrum derived from combined unfolding is compared with either the spectrum obtained from merging the independently unfolded spectra or the spectrum used to calculate the responses. The advantages and disadvantages of this technique are discussed.

The content of 250Cf and 248Cm in 252Cf neutron sources and the effect on the neutron emission rate

One of the most common radionuclide neutron sources used for the calibration of detectors is (252)Cf. However, these sources also contain (250)Cf, which is present in the material from which the sources are made, and (248)Cm, which is formed as the daughter of (252)Cf via alpha-decay. Both decay by spontaneous fission with longer half-lives than (252)Cf. Consequently, as the source becomes older, the emission rate does not follow the decay curve of (252)Cf. Fits have been made to emission rate measurements of (252)Cf sources at NPL spanning over 30 y to deduce their (250)Cf and (248)Cm content. The emission rate of a source can be significantly underestimated if the presence of (250)Cf and (248)Cm is not taken into account, and this has been investigated for a typical (252)Cf source. The importance of this problem to other calibration laboratories and users of (252)Cf sources is emphasised.

How is difficult asthma managed?

Most patients with asthma can be easily treated. Some have difficult asthma; in some because the diagnosis is erroneous, in others because of comorbidity or noncompliance. A European Respiratory Society Task Force has called for an integrated approach for these patients, and positive results have been reported using protocols. In the UK, there is no overall understanding of the size of this problem, or how these patients are managed. A postal survey of 683 consultant members of the British Thoracic Society designed to elicit respondents' views on how they would manage four clinical scenarios was conducted. There was a 50.4% response rate. Few reported a uniform approach to the investigation of such patients. The availability of allied healthcare professionals was variable. The 21 consultant respiratory physicans, reporting a special interest in difficult asthma, were significantly more likely to objectively assess compliance, perform skin-prick tests and to utilise a liaison psychiatrist than those without an expressed special interest in asthma. Many reported difficulty in accessing psychologists, liaison psychiatrists and social workers. Approaches to the diagnosis and management of "vocal cord dysfunction" were variable. The results of this postal survey of specialist thoracic physicians in the UK suggest that a protocol for difficult asthma is not in widespread use and that access to necessary allied healthcare professionals is not uniform. Pulmonologists with a declared special interest in difficult asthma may have configured their services and approaches more in line with that proposed by the European Respiratory Society Task Force.

Modelling of neutron survey instrument performance and experimental validation of those calculated response data

Three moderator-type neutron survey instruments have been modelled for energy and angle dependence of the response, in greater detail than before. These response data have been verified by comparison with published experimental measurements and measurements made specifically for this project. Influences on the instrument response have also been investigated. These have included its mode-of-use and perturbations caused by variations in the instrument manufacture. The implications of these new response data have been assessed by an extensive programme of folding the responses with workplace energy distributions.

Characterisation of the IRSN CANEL/T400 facility producing realistic neutron fields for calibration and test purposes

The new CANEL/T400 facility has been set-up at the Institute for Radiological Protection and Nuclear Safety (IRSN) to produce a realistic neutron field. The accurate characterisation of this neutron field is mandatory since this facility will be used as a reference neutron source. For this reason an international measuring campaign, involving four laboratories with extensive expertise in neutron metrology and spectrometry, was organised through a concerted EUROMET project. Measurements were performed with Bonner sphere (BS) systems to determine the energy distribution of the emitted neutrons over the whole energy range (from thermal energy up to a few MeV). Additional measurements were performed with proton recoil detectors to provide detailed information in the energy region above 90 keV. The results obtained by the four laboratories are in agreement with each other and are compared with a calculation performed with the MCNP4C Monte-Carlo code. As a conclusion of this exercise, a reliable characterisation of the CANEL/T400 neutron field is obtained.

Angle dependence of response characteristics of neutron survey instruments

Neutron area survey instruments are designed to have an approximately isotropic response. In practice, the response cannot be perfectly isotropic for instruments that do not have spherical symmetry, and for all instruments it is modified by the inclusion of batteries, electronics, handles, etc. This affects the ability of the survey instrument to measure accurately an isotropic dose equivalent quantity. Measurements of the angle dependence of response for four of the most commonly used designs of survey instrument (Harwell 0949, Mark 7 NRM, NM2 and Studsvik 2202D) have been performed in a low-scatter room using radionuclide and monoenergetic neutron sources. The Monte Carlo code MCNP has been used to model the responses and to investigate their sensitivity to the polyethylene density, counting gas pressure and other manufacturing tolerances. Preliminary modelling results are presented here.

Practical implications of neutron survey instrument performance

Improvements have been made to the Monte Carlo modelling used to calculate the response of the neutron survey instruments most commonly used in the UK, for neutron energies up to 20 MeV. The improved modelling of the devices includes the electronics and battery pack, allowing better calculations of both the energy and angle dependence of response. These data are used to calculate the response of the instruments in rotationally and fully isotropic, as well as unidirectional fields. Experimental measurements with radionuclide sources and monoenergetic neutron fields have been, and continue to be made, to test the calculated response characteristics. The enhancements to the calculations have involved simulation of the sensitivity of the response to variations in instrument manufacture, and will include the influence of the user and floor during measurements. The practical implications of the energy and angle dependence of response, variations in manufacture, and the influence of the user are assessed by folding the response characteristics with workplace energy and direction distributions.

Airway epithelial inflammatory responses and clinical parameters in COPD

This study examined inflammatory responses from primary cultured human bronchial epithelial cells in chronic obstructive pulmonary disease (COPD) and the clinical factors modulating them. Epithelial cells from bronchoscopic biopsies from 14 patients with COPD ((mean +/- SD) age 74.6 +/- 5.7 yrs, forced expiratory volume in one second (FEV1) 1.21 +/- 0.36 L, FEV1 %, predicted 51.1 +/- 15.8%, 51.5 +/- 24.0 pack-yrs of smoking, inhaled steroid dosage 1237.5 +/- 671.0 microg x day(-1), Medical Research Council (MRC) dyspnoea score 3.18 +/- 1.33) and eight current/exsmokers with normal pulmonary function (age 60.4 +/- 13.5 yrs, FEV1 2.66 +/- 1.27 L, FEV1 % pred 89.6 +/- 17.7%, 49 +/- 44 pack-yrs of smoking, MRC dyspnoea score 1 +/- 0) were grown in primary culture and exposed to 50 ng x mL(-1) tumour necrosis factor-alpha. Stimulated COPD cells produced significantly more interleukin (IL)-6 at 24 and 48 h, and IL-8 at 6 and 24 h than unstimulated COPD cells. This response was not seen in cells from current/exsmokers. IL-6 and IL-8 production was lower in COPD patients taking inhaled steroids. Following an inflammatory stimulus, bronchial epithelial cells in chronic obstructive pulmonary disease show a significant cytokine response not seen in smokers with normal pulmonary function and this may be modified by inhaled steroid therapy.

Human lymphocyte apoptosis after exposure to influenza A virus

Infection of humans with influenza A virus (IAV) results in a severe transient leukopenia. The goal of these studies was to analyze possible mechanisms behind this IAV-induced leukopenia with emphasis on the potential induction of apoptosis of lymphocytes by the virus. Analysis of lymphocyte subpopulations after exposure to IAV showed that a portion of CD3(+), CD4(+), CD8(+), and CD19(+) lymphocytes became apoptotic (terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling positive). The percentage of cells that are infected was shown to be less than the percentage of apoptotic cells, suggesting that direct effects of cell infection by the virus cannot account fully for the high level of cell death. Removal of monocytes-macrophages after IAV exposure reduced the percent of lymphocytes that were apoptotic. Treatment of virus-exposed cultures with anti-tumor necrosis factor alpha did not reduce the percentage of lymphocytes that were apoptotic. In virus-exposed cultures treated with anti-FasL antibody, recombinant soluble human Fas, Ac-DEVD-CHO (caspase-3 inhibitor), or Z-VAD-FMK (general caspase inhibitor), apoptosis and production of the active form of caspase-3 was reduced. The apoptotic cells were Fas-high-density cells while the nonapoptotic cells expressed a low density of Fas. The present studies showed that Fas-FasL signaling plays a major role in the induction of apoptosis in lymphocytes after exposure to IAV. Since the host response to influenza virus commonly results in recovery from the infection, with residual disease uncommon, lymphocyte apoptosis likely represents a part of an overall beneficial immune response but could be a possible mechanism of disease pathogenesis.

Detection of rare mutant alleles by restriction endonuclease-mediated selective-PCR: assay design and optimization

BACKGROUND

Restriction endonuclease-mediated selective (REMS)-PCR, allows detection of point mutations, deletions, and insertions. Reactions require concurrent activity of a restriction endonuclease (RE) and a DNA polymerase, both of which must be sufficiently thermostable to retain activity during thermocycling. The inclusion of the RE in REMS-PCR inhibits amplification of sequences containing the RE recognition site, thus producing selective amplification of sequences that lack the RE site.

METHODS

Assays were used that allowed the selection of conditions that produce concurrent RE/DNA polymerase activity. The RE thermostability assay involved thermocycling a RE under various conditions and assessing residual cleavage activity at various time points. Conditions found to preserve RE activity during thermocyling were then tested for their compatibility with DNA polymerase-mediated PCR.

RESULTS

A range of conditions that preserve activity of the RE BstNI over 30 cycles of PCR was identified. A subset of these conditions was subsequently found to mediate specific amplification using Taq DNA polymerase. These conditions were used to develop a REMS-PCR protocol for the detection of mutations at codon 12 of the K-ras gene. This protocol allowed the detection of 1 mutant allele in a background of 1000 wild-type alleles. The presence of primer sets for RE and PCR control amplicons provided unambiguous assessment of mutant status.

CONCLUSION

Implementation of the assays described may facilitate development of REMS-PCR assays targeted to other loci associated with disease.

Supportive management in bacterial meningitis

The central nervous system and systemic complications of bacterial meningitis cause significant morbidity and mortality. This article offers insight into the clinical features, pathogenesis, and management of these complications. In many instances, the improved outcome of intervention is based on clinical suspicion and early recognition. The management of complications is evolving and is presently based mainly on supportive care.

A Nod factor-binding lectin is a member of a distinct class of apyrases that may be unique to the legumes

Recent studies from our laboratory have found that a root lectin from the legume Dolichos hifloris is present on the root surface, binds rhizobial Nod factor and has apyrase activity. To assess the broader significance of this lectin/nucleotide phosphohydrolase (Db-LNP), we have cloned a second related cDNA (Db-apyrase-2) from D. hiflorus, as well as related cDNAs from the legumes Lotus japonicus and Medicago sativa, and from Arabidopsis thaliana, a non-legume. The deduced amino acid sequences of these apyrases were aligned with one another and with the sequences of other apyrases from plants, animals, yeast and protozoa. Phylogenetic analysis shows that Db-LNP has closely related orthologs only in other legumes, while Db-apyrase-2 is more closely related to apyrase sequences from non-leguminous plants. We also show that the orthologs of Db-LNP from M. sativa and Pisum sativum have carbohydrate binding activity. The results suggest that legume LNPs may represent a special class of apyrases that arose by gene duplication and subsequent specialization.

A nod factor binding lectin with apyrase activity from legume roots

A lectin isolated from the roots of the legume, Dolichos biflorus, binds to Nod factors produced by rhizobial strains that nodulate this plant and has a deduced amino acid sequence with no significant homology to any lectin reported to date. This lectin also is an enzyme that catalyzes the hydrolysis of phosphoanhydride bonds of nucleoside di- and triphosphates; the enzyme activity is increased in the presence of carbohydrate ligands. This lectin-nucleotide phosphohydrolase (LNP) has a substrate specificity characteristic of the apyrase category of phosphohydrolases, and its sequence contains four motifs characteristic of this category of enzymes. LNP is present on the surface of the root hairs, and treatment of roots with antiserum to LNP inhibits their ability to undergo root hair deformation and to form nodules on exposure to rhizobia. These properties suggest that this protein may play a role in the rhizobium-legume symbiosis and/or in a related carbohydrate recognition event endogenous to the plant.

QacR is a repressor protein that regulates expression of the Staphylococcus aureus multidrug efflux pump QacA

The Staphylococcus aureus QacA protein is a multidrug transporter that confers resistance to a broad range of antimicrobial agents via proton motive force-dependent efflux of the compounds. Primer extension analysis was performed to map the transcription start points of the qacA and divergently transcribed qacR mRNAs. Each gene utilized a single promoter element, the locations of which were confirmed by site-directed mutagenesis. Fusions of the qacA and qacR promoters to a chloramphenicol acetyl transferase reporter gene were used to demonstrate that QacR is a trans-acting repressor of qacA transcription that does not autoregulate its own expression. An inverted repeat overlapping the qacA transcription start site was shown to be the operator sequence for control of qacA gene expression. Removal of one half of the operator prevented QacR-mediated repression of the qacA promoter. Purified QacR protein bound specifically to this operator sequence in DNase I-footprinting experiments. Importantly, addition of diverse QacA substrates was shown to induce qacA expression in vivo, as well as inhibit binding of QacR to operator DNA in vitro, by using gel-mobility shift assays. QacR therefore appears to interact directly with structurally dissimilar inducing compounds that are substrates of the QacA multidrug efflux pump.

Genetic evaluation of suspected cases of transient HIV-1 infection of infants

Detection of human immunodeficiency virus-type 1 (HIV-1) on only one or a few occasions in infants born to infected mothers has been interpreted to indicate that infection may be transient rather than persistent. Forty-two cases of suspected transient HIV-1 viremia among 1562 perinatally exposed seroreverting infants and one mother were reanalyzed. HIV-1 env sequences were not found in specimens from 20; in specimens from 6, somatic genetic analysis revealed that specimens were mistakenly attributed to an infant; and in specimens from 17, phylogenetic analysis failed to demonstrate the expected linkage between the infant's and the mother's virus. These findings argue that transient HIV-1 infection, if it exists, will only rarely be satisfactorily documented.