Non-cystic fibrosis bronchiectasis

Bronchiectasis is a chronic debilitating condition with considerable phenotypic diversity. A vicious cycle of infection and inflammation exists in damaged airways with patients suffering from persistent cough, purulent sputum production, recurrent chest infections and general malaise. The associated burden of disease in terms of increased morbidity, reduced quality of life and the socioeconomic cost of long-term management is significant. Further research is essential to improve our understanding of the development and progression of this disease. This article reviews what is currently known about bronchiectasis, its pathophysiology, aetiology and management strategies.

Identifying individual psychosocial and adherence support needs in patients with psoriasis: a multinational two-stage qualitative and quantitative study

BACKGROUND

Psoriasis has a serious impact on patients' lives. However, adherence to medications is often poor, potentially compounding the burden of disease. Identifying patients who need support with psychosocial problems, or issues with adherence, can be complex.

OBJECTIVES

We aimed to develop statements that could assist the consultation process, identifying the relative importance of factors related to effective management of psoriasis for patients.

METHODS

A two-stage study design was used to comprehensively identify, and assess validity of, statements describing psoriasis impact and management issues. Both components were conducted in Canada, France, Germany, Italy, Spain, the United Kingdom and the United States. Findings from patient observation and interviews were analysed for pattern strength, and were then used to inform the development of statements that were quantitatively assessed using a survey. The association of drivers towards agreement with 'my psoriasis dictates how I lead my life' was assessed using anova.

RESULTS

Fifty-six patients participated in the qualitative component, and 1,884 patients using prescription medications completed the survey. Two thematic categories were identified; disappointment with treatments, and confusion regarding psoriasis associated with a lack of direction. When assessed quantitatively, key statements associated with a strong burden of psoriasis on patients' lives were related to isolation, social stigma, visible symptoms, impact on activities and feelings of hopelessness. A mixture of patient-, doctor- and treatment-related factors were among the most common reasons for non-adherence.

CONCLUSION

Questioning using the statements most associated with psychosocial impact and non-adherence could help identify patients with additional support needs, and assist in overcoming adherence issues.

TNFα from classically activated macrophages accentuates epithelial to mesenchymal transition in obliterative bronchiolitis

Bronchiolitis obliterans syndrome is characterized by fibrotic obliteration of small airways which severely impairs graft function and survival after lung transplantation. Bronchial epithelial cells from the transplanted lung can undergo epithelial to mesenchymal transition and this can be accentuated by activated macrophages. Macrophages demonstrate significant plasticity and change phenotype in response to their microenvironment. In this study we aimed to identify secretory products from macrophages that might be therapeutic targets for limiting the inflammatory accentuation of epithelial to mesenchymal transition in bronchiolitis obliterans syndrome. TNFα, IL-1β and IL-8 are elevated in bronchoalveolar lavage from lung transplant patients prior to diagnosis of bronchiolitis obliterans syndrome. Classically activated macrophages secrete more TNFα and IL-1β than alternatively activated macrophages and dramatically accentuate TGF-β1-driven epithelial to mesenchymal transition in bronchial epithelial cells isolated from lung transplant patients. Blocking TNFα, but not IL-1β, inhibits the accentuation of epithelial to mesenchymal transition. In a pilot unblinded therapeutic intervention in five patients with progressive bronchiolitis obliterans syndrome, anti-TNFα treatment improved forced expiratory volume in 1 second and 6-min walk distances in four patients. Our data identify TNFα as a potential new therapeutic target in bronchiolitis obliterans syndrome deserving of a randomized placebo controlled clinical trial.

Testing a peer support intervention for people with type 2 diabetes: a pilot for a randomised controlled trial

BACKGROUND

People with Type 2 diabetes face various psycho-social, self-management and clinical care issues and evidence is mixed whether support from others with diabetes, 'peer support', can help. We now describe a 2 month pilot study of different peer support interventions.

METHODS

The intervention was informed by formative evaluation using semi-structured interviews with health professionals, community support groups and observation of diabetes education and support groups. Invitations to participate were mailed from 4 general practices and included a survey of barriers to care. Participants were randomized by practice to receive individual, group, combined (both individual and group) or no peer support. Evaluation included ethnographic observation, semi-structured interviews and questionnaires at baseline and post-intervention.

RESULTS

Of 1,101 invited, 15% expressed an interest in participating in the pilot. Sufficient numbers volunteered to become peer supporters, although 50% of these (8/16) withdrew. Those in the pilot were similar to other patients, but were less likely to feel they knew enough about diabetes (60.8% vs 44.6% p = 0.035) and less likely to be happy with the diabetes education/care to date (75.4% vs 55.4% p = 0.013). Key issues identified were the need to recruit peer supporters directly rather than through clinicians, to address participant diabetes educational needs early and the potential for group sessions to have lower participation rates than 1:1 sessions.

CONCLUSIONS

Recruitment to a full trial of peer support within the existing study design is feasible with some amendments. Attendance emerged as a key issue needing close monitoring and additional intervention during the trial.

Towards 'sepsis with optimal treatment': evaluating the sepsis care pathway in acute medicine and identifying scope for systems improvement

Sepsis commonly presents to the acute medicine unit (AMU). Timely recognition and treatment can reduce the significant associated mortality, but United Kingdom AMUs and emergency departments are often inadequately equipped to manage sepsis with early-goal directed therapy. We conducted an observational study of 50 consecutive patients admitted with severe sepsis. Demographic, physiological and microbiological data, and information about the provision and timing of care were collected in real time. Treatment fell below "surviving sepsis" targets with only 28% of patients receiving sufficient fluid, and 64% receiving antibiotics within 3 hours, associated with delays in seeing physicians; however despite this mortality was lower than the nationally quoted average (14% at 90 days).

MYBL2 haploinsufficiency increases susceptibility to age-related haematopoietic neoplasia

The haematopoietic system is prone to age-related disorders ranging from deficits in functional blood cells to the development of neoplastic states. Such neoplasms often involve recurrent cytogenetic abnormalities, among which a deletion in the long arm of chromosome 20 (del20q) is common in myeloid malignancies. The del20q minimum deleted region contains nine genes, including MYBL2, which encodes a key protein involved in the maintenance of genome integrity. Here, we show that mice expressing half the normal levels of Mybl2 (Mybl2^+/Δ) develop a variety of myeloid disorders upon ageing. These include myeloproliferative neoplasms, myelodysplasia (MDS) and myeloid leukaemia, mirroring the human conditions associated with del20q. Moreover, analysis of gene expression profiles from patients with MDS demonstrated reduced levels of MYBL2, regardless of del20q status and demonstrated a strong correlation between low levels of MYBL2 RNA and reduced expression of a subset of genes related to DNA replication and checkpoint control pathways. Paralleling the human data, we found that these pathways are also disturbed in our Mybl2^+/Δ mice. This novel mouse model, therefore, represents a valuable tool for studying the initiation and progression of haematological malignancies during ageing, and may provide a platform for preclinical testing of therapeutic approaches.

Factors associated with a difficult induction of general anaesthesia

BACKGROUND

Many children experiencing a procedure under general anaesthetic (GA), including those having surgery for cochlear implantation, display behaviours indicative of distress during induction of anaesthesia. It would be useful to ascertain which factors in the pre-operative period are related to the presence of distress at induction in order to target appropriate psychological preparation.

METHODS

The families of 84 children aged 4-7 years undergoing a procedure under GA (including insertion of a cochlear implant) completed three questionnaires assessing temperament, behavioural difficulties, and pre-operative worries. Demographic variables were also recorded. The outcome measure was the amount of behavioural distress at induction.

RESULTS

Statistically significant relationships with the outcome measure of distress at induction were obtained for three factors; an emotional or sociable temperament, and the number of previous procedures. Further, children receiving inhalation inductions displayed greater distress than those receiving intravenous inductions.

CONCLUSION

Undergoing cochlear implantation under GA is a major life event for many recipients. Psychologically preparing children for this has been found to be efficacious, but is not currently available to all children. It is suggested that preparation can be targeted at children, as identified in this study, who have elevated emotionality or sociability scores or who have previous experience of procedures under general anaesthesia. This is of particular current relevance as children are increasingly likely to require re-implantation as they grow older and as unilaterally implanted children are now being offered a sequential bilateral implant, both necessitating further surgery.