Understanding the potential role of mobile phone-based monitoring on asthma self-management: qualitative study

BACKGROUND

National and international healthcare policy increasingly seeks technological solutions to the challenge of providing care for people with long-term conditions. Novel technologies, however, have the potential to change the dynamics of disease monitoring and self-management. We aimed to explore the opinions and concerns of people with asthma and primary care clinicians on the potential role of mobile phone monitoring technology (transmitting symptoms and peak flows, with immediate feedback of control and reminder of appropriate actions) in supporting asthma self-management.

METHODS

This qualitative study recruited 48 participants (34 adults and teenagers with asthma, 14 asthma nurses and doctors) from primary care in Lothian (Central Scotland) and Kent (South East England). Thirty-nine participated in six focus groups, which included a demonstration of the technology; nine gave in-depth interviews before and after a 4-week trial of the technology.

RESULTS

Participants considered that mobile phone-based monitoring systems can facilitate guided self-management although, paradoxically, may engender dependence on professional/technological support. In the early phases, as patients are learning to accept, understand and control their asthma, this support was seen as providing much-needed confidence. During the maintenance phase, when self-management predominates, patient and professionals were concerned that increased dependence may be unhelpful, although they appreciated that maintaining an on-going record could facilitate consultations.

CONCLUSION

Mobile phone-based monitoring systems have the potential to support guided self-management by aiding transition from clinician-supported early phases to effective self-management during the maintenance phase. Continuing development, adoption and formal evaluation of these systems should take account of the insights provided by our data.

The national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis

OBJECTIVES

This study summarises the results of a National Audit of sino-nasal surgery carried out in England and Wales. It describes patient and operative characteristics as well as patient outcomes up to 36 months after surgery.

DESIGN

Prospective cohort study.

SETTING

NHS hospitals in England and Wales.

PARTICIPANTS

Consecutive patients undergoing surgery for nasal polyposis and/or chronic rhinosinusitis.

MAIN OUTCOME MEASURE

The total score derived from a 22-item version of the Sino-Nasal Outcome Test (SNOT-22). Lower scores represent better health-related quality of life.

RESULTS

A total of 3128 consecutive patients at 87 NHS hospitals were enrolled. There is a large improvement in SNOT-22 scores from the pre-operative period (mean = 42.0) to 3 months after surgery (mean = 25.5). The scores for patients undergoing nasal polypectomy improved from 41.0 before surgery to 23.1 at 3 months after surgery, while the scores for patients undergoing surgery for chronic rhinosinusitis alone improved from 44.2 to 31.2. The SNOT-22 scores reported at 12 and 36 months after surgery were similar to those reported at 3 months. Excessive bleeding occurred in 5% of patients during the operation and in 1% of patients after the operation. Intra-orbital complications were reported in 0.2%. Of those patients undergoing primary surgery for bilateral grade I or II polyposis, 18% had not received a pre-operative course of steroid treatment. At the 36-month follow-up, 11.4% of patients had undergone revision surgery.

CONCLUSIONS

The audit confirms that sino-nasal surgery is generally safe and effective. There is some evidence that patient selection for surgery could be improved.

Searching for HLA-DRB1*1206 in volunteer marrow donors in four US population groups

The frequencies of DRB1*12 alleles were determined in four US population groups by DNA sequencing. Only DRB1*120101 (or DRB1*1206 or *1210) and DRB1*120201 alleles were identified, the latter primarily in the Asian American population. Additional testing of a subset of samples to detect the presence of DRB1*1206 found all of the alleles to be DRB1*120101 (or DRB1*1210). Retesting of six samples previously typed as DRB1*1206 found only DRB1*120101 (or DRB1*1210).

Variation in day-case nasal surgery - why cannot we improve our day-case rates?

OBJECTIVES

The NHS plan states that 75% of all elective operations should be performed as day-cases. We set out to evaluate day surgery rates in sinonasal surgery and to identify factors limiting current practice.

STUDY DESIGN AND SETTING

Prospective multicentre cohort study.

PARTICIPANTS

3128 patients undergoing sinonasal surgery during 2000 and 2001.

OUTCOME MEASURES

Same day discharge, complication and readmission rates.

RESULTS

There is potential selection bias due to the non-random selection of NHS Trusts and patients in this study. However, as results are similar to Hospital Episode Statistics data such bias is probably small. Only 15.5% of all procedures are performed as day surgery. We are achieving day-case rates of 18, 20 and 6% for nasal polypectomy, intranasal antrostomy and extensive FESS respectively, compared with recently published targets of 90%, 80% and 50%. Factors significantly associated with overnight admission were use of packs, extensive surgery, excess post-operative bleeding and high ASA grade. There was considerable unexplained variation in day-case rates and the use of packs between different surgeons. A third of consultants pack all patients post-operatively. More than 51% of consultants admit all patients, while 5% discharge all patients on the day of surgery. There were no excess adverse events or readmissions amongst the day surgery patients. However, only 17% of in-patients would have liked to be discharged on the day of surgery. Both patient and surgeon must overcome resistance to day case surgery before targets can be reached.

CONCLUSIONS

Strategies for improving day-case rates in sinonasal surgery. All ASA grade 1 and 2 patients could be considered for day-case surgery, but particularly those with less extensive disease on radiography, and those planned to undergo less extensive procedures. Excess peri-operative bleeding was reported in 6% of patients. There must therefore be provision for overnight admission if required. Greater utilisation of day-case units, selective use of packs, and earlier removal may increase the proportion of patients managed as day-cases. There remains considerable variation in practice at both consultant and trust levels. Units should continue to audit their own figures and compare them against national rates in order to reduce nationwide variation in practice.

15-year follow-up results of the hydroxyapatite ceramic-coated femoral stem

PURPOSE

To evaluate the clinical and radiological outcomes following implantation of the Furlong hydroxyapatite ceramic-coated femoral stem in total hip arthroplasty.

METHODS

A longitudinal cohort of 116 consecutive patients (134 hips) was followed up prospectively. The follow-up period was at least 13 years (range, 13- 15 years). Clinical and radiological assessments were made using the Merle d'Aubigne and Postel score and Engh score for fixation and stability, respectively. Osteointegration was assessed radiographically by examining the bone implant interface using the method described by Gruen.

RESULTS

22 patients died during the study period and 6 were lost to follow-up. The respective mean Merle d'Aubigne and Postel scores for pain, range of movement, and ability to walk were 2.2, 2.8, and 2.4 preoperatively and 5.8, 4.8, and 5.4 postoperatively. Engh described satisfactory bony ongrowth as 10 points or more; the mean Engh score for fixation and stability was 24.7 (fixation=10, stability=14.7). One femoral stem was revised for a periprosthetic fracture caused by a fall, but none was revised for loosening. This gave a 99% survival at 13 years (95% confidence interval 94-100).

CONCLUSION

The long-term results of this hydroxyapatite ceramic-coated femoral prosthesis are very satisfactory.

Hospital volume of throughput and periprocedural and medium-term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17,417 procedures undertaken in Scotland, 1997-2003

OBJECTIVE

To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix.

DESIGN

Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period.

METHODS

All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models.

RESULTS

Of the 17,417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events.

CONCLUSION

Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery.

Cross-transmission of nosocomial pathogens in an adult intensive care unit: incidence and risk factors

The incidence and determinants of cross-transmission in an adult intensive care unit (ICU) were examined under normal conditions. Four hundred and thirty patients were followed for 3947 patient-days. Cross-transmitted pathogens were identified by genetic typing. A cross-transmission episode was defined as when two or more patients had indistinguishable isolates and had been treated in the ICU during intervals up to seven days apart. The direction of cross-transmission was confirmed if the incriminated pathogen was isolated from the donor before admission of the recipient; otherwise, both patients could potentially be a donor or a recipient. These patients were excluded from the risk factor analysis. Recipients of pathogens were compared with those who were not involved in cross-transmission. Out of 22 056 examined specimens, 275 isolates were typed and 40 episodes of cross-transmission were detected. The overall incidence of cross-transmission was 10.7 [95% confidence intervals (CI) 7.6-14.5] per 1000 patient-days. In multivariate analysis, those who were nursed in an understaffed environment [odds ratio (OR) = 3.3, 95% CI 1.4-7.8], had a nasogastric tube (OR = 2.9, 95% CI 1.1-7.8) and were ventilated (OR = 2.5, 95% CI 1.1-6.0) for all of their stay, compared with none or part of their stay, showed an increase in the risk of cross-transmission. Repeated bronchoscopy (OR = 5.1, 95% CI 1.04-25) compared with no bronchoscopy and immunosuppresion (OR = 3.9, 95% CI 1.2-12.5) also increased the risk. This study showed that cross-transmission of nosocomial pathogens in the ICU is associated with understaffing, immunosuppression and factors that result in multiple staff/patient contacts, thus emphasizing the importance of hand hygiene.

Co-localization of cortactin and phosphotyrosine identifies active invadopodia in human breast cancer cells

Invadopodia are filopodia-like projections possessing protease activity that participate in tumor cell invasion. We demonstrate that co-localization of cortactin and phosphotyrosine identifies a subset of cortactin puncta termed "invadopodial complexes" that we find to be closely associated with the plasma membrane at active sites of focal degradation of the extracellular matrix in MDA-MB-231 breast cancer cells. Manipulation of c-Src activity in cells by transfection with kinase activated c-Src(527) or kinase inactive c-Src(295) results in a dramatic increase or decrease, respectively, in the number of these structures associated with changes in the number of sites of active matrix degradation. Overexpression of kinase-inactive c-Src(295) does not prevent localization of cortactin at the membrane; however, co-localized phosphotyrosine staining is decreased. Thus, elevated phosphotyrosine at invadopodial complexes is specifically associated with the proteolytic activity of invadopodia. Further, invadopodial complexes are spatially, morphologically and compositionally distinct from focal adhesions as determined by localization of focal adhesion kinase (FAK), which is not present in invadopodial complexes. Expression of kinase-inactive c-Src(295) blocks invadopodia activity, but does not block filopodia formation. Thus, invadopodia, but not filopodia, are highly correlated with matrix invasion, and sites of invadopodial activity can be identified by the formation of invadopodial complexes.

Paroxetine Is an Effective Treatment for Hot Flashes: Results From a Prospective Randomized Clinical Trial

Purpose

In an open-label trial we have previously demonstrated that paroxetine reduces hot flashes. We initiated a stratified, randomized, double-blind, cross-over, placebo-controlled trial to investigate the efficacy of paroxetine 10 mg and 20 mg compared to placebo in reducing hot flash frequency and composite score. A secondary objective was to evaluate quality of life (QOL) parameters.

Patients and Methods

Women who suffered at least two hot flashes a day for 1 month or longer were eligible. Women were randomly assigned to 4 weeks of paroxetine 10 mg or 20 mg followed by placebo for 4 weeks, or placebo for 4 weeks followed by paroxetine 10 mg or 20 mg for 4 weeks. Participants completed baseline daily hot flash diaries for one week prior to the start of the study and throughout the study, and QOL questionnaires at baseline, week 5 and week 9.

Results

279 women were screened, and 151 were randomly assigned. Paroxetine 10 mg reduced hot flash frequency and composite score by 40.6% and 45.6%, respectively, compared to 13.7% and 13.7% for placebo (P = .0006 and P = .0008, respectively). Paroxetine 20 mg reduced hot flash frequency and composite score by 51.7% and 56.1%, respectively, compared with 26.6% and 28.8% for placebo (P = .002 and P = .004, respectively). Efficacy was similar between the two doses, but women were less likely to discontinue low-dose paroxetine. Paroxetine 10 mg was associated with a significant improvement in sleep compared with placebo (P = .01).

Conclusion

Paroxetine is an effective treatment for hot flashes in women with or without a prior breast cancer.

Differential alteration of stem and other cell populations in ducts and lobules of TGFα and c-Myc transgenic mouse mammary epithelium

Genes associated with proliferation are active in stem and progenitor cells, and their over-expression can promote cancer. Two such genes, c-Myc and TGFalpha, promote morphologically dissimilar mammary tumors in transgenic mice. We investigated whether their over-expression affects population size and cell cycle activity in stem and other cell populations in non-neoplastic mammary epithelia. Results indicated that both cell population and cell cycle regulation are cell type- and microenvironment-specific. To create a tool for identifying and categorizing the five cellular phenotypes by light microscopy, we adapted previously established ultrastructural criteria. Using nulliparous MMTV-c-myc or MT-tgfalpha mice, we determined and compared the relative sizes the putative stem, progenitor and differentiated cell populations. PCNA staining was used to compare the portion of each cell population in the cell cycle. Cell population sizes were analyzed relative to: (1) their location in ducts versus lobules (microenvironment), (2) genotype, and (3) cell type. Population sizes differed significantly by genotype, depending on microenvironment (p=0.0008), by genotype, depending on cell type (p<0.0001), and by microenvironment, depending on cell type (p=0.03). The number of cycling cells was also affected by all three factors, confirming that the interplay of cell type, gene expression and three-dimensional organization are very important in tissue morphogenesis and function. We describe a structure in mammary epithelium consistent with that of a stem cell niche, and show that it is altered in MMTV-c-myc and likely altered in MT TGFalpha transgenic epithelia.

A multicenter randomized clinical trial evaluating interleukin-2 activated hematopoietic stem cell transplantation and post-transplant IL-2 for high risk breast cancer patients

PURPOSE

This Phase III randomized multicenter trial compared progression-free (PFS) and overall survival (OS) for autologous peripheral blood stem cell (aPBSC) transplantation with or without immunotherapy in high-risk breast cancer patients.

METHODS

Eligible patients had American Joint Committee on Cancer (AJCC) 5th Edition Stage II/IIIA with > or = 4 axillary nodes, Stage IIIB, or chemotherapy-sensitive or stable Stage IV disease. Following treatment with cyclophosphamide, thiotepa and carboplatin (STAMP V), patients were randomized to aPBSC transplant with or without immunotherapy. Patients on immunotherapy received cells that were incubated in interleukin-2 (IL-2) for 24 h followed by parenteral IL-2 for 5 days then 2 days of rest for 4 weeks.

RESULTS

Fifty-nine patients were treated (35 Stage II/IIIA; 13 Stage IIIB; 11 Stage IV), 30 patients were randomized to immunotherapy and 29 patients to no immunotherapy. Neutrophils engrafted a median of 10 days post-transplant in both groups. The median times to platelet engraftment were 9 and 10 days after transplant in the no-immunotherapy and immunotherapy groups, respectively (p = 0.03). There was no statistical evidence (p = 0.61) of a difference in progression-free and surviving (PFS) at 3 years for patients receiving immunotherapy (53%) compared with no immunotherapy (48%). There was some evidence of superiority in overall survival (OS) at 3 years for patients receiving immunotherapy (83%) compared with no immunotherapy (69%), but the difference between survival curves was not statistically significant (p = 0.08). Also, there was some evidence that patients developing acute graft versus host disease (aGVHD) had superior PFS (p = 0.02) but not OS (p = 0.19) than patients not developing aGVHD. Toxicities were transient and similar between groups, with no treatment-related deaths.

CONCLUSIONS

This phase III study of high-risk breast cancer patients randomized to immunotherapy or no immunotherapy demonstrated that a well-tolerated immunotherapy regimen added to aPBSC transplant did not improve PFS, but there was some improvement in OS, but not by an amount that was statistically significant (p = 0.08).

Results of a hydroxyapatite-coated (Furlong) total hip replacement

We describe the survival of 134 consecutive JRI Furlong hydroxyapatite-coated uncemented total hip replacements. The mean follow-up was for 14.2 years (13 to 15).

Patients were assessed clinically, using the Merle d’Aubigné and Postel score. Radiographs were evaluated using Gruen zones for the stem and DeLee and Charnley zones for the cup. Signs of subsidence, radiolucent lines, endosteal bone formation (spot welds) and pedestal formation were used to assess fixation and stability of the stem according to Engh’s criteria. Cup angle, migration and radiolucency were used to assess loosening of the cup. The criteria for failure were revision, or impending revision because of pain or loosening. Survival analysis was performed using a life table and the Kaplan-Meier curve.

The mean total Merle d’Aubigné and Postel score was 7.4 pre-operatively and 15.9 at follow-up. During the study period 22 patients died and six were lost to follow-up. None of the cups was revised. One stem was revised for a periprosthetic fracture following a fall but none was revised for loosening, giving a 99% survival at 13 years. Our findings suggest that the long-term results of these hydroxyapatite-coated prostheses are more than satisfactory.

Use of computer-aided detection (CAD) tools in screening mammography: a multidisciplinary investigation

We summarise a set of analyses and studies conducted to assess the effects of the use of a computer-aided detection (CAD) tool in breast screening. We have used an interdisciplinary approach that combines: (a) statistical analyses inspired by reliability modelling in engineering; (b) experimental studies of decisions of mammography experts using the tool, interpreted in the light of human factors psychology; and (c) ethnographic observations of the use of the tool both in trial conditions and in everyday screening practice. Our investigations have shown patterns of human behaviour and effects of computer-based advice that would not have been revealed by a standard clinical trial approach. For example, we found that the negligible measured effect of CAD could be explained by a range of effects on experts' decisions, beneficial in some cases and detrimental in others. There is some evidence of the latter effects being due to the experts using the computer tool differently from the intentions of the developers. We integrate insights from the different pieces of evidence and highlight their implications for the design, evaluation and deployment of this sort of computer tool.

Phase I study of sequential vaccinations with fowlpox-CEA(6D)-TRICOM alone and sequentially with vaccinia-CEA(6D)-TRICOM, with and without granulocyte-macrophage colony-stimulating factor, in patients with carcinoembryonic antigen-expressing carcinomas

PURPOSE

Our previous clinical experience with vaccinia and replication-defective avipox recombinant carcinoembryonic antigen (CEA) vaccines has demonstrated safety and clinical activity with a correlation between CEA-specific immune response and survival. Preclinical evidence demonstrated that the addition of the transgenes for three T-cell costimulatory molecules (B7-1, ICAM-1, LFA-3, designated TRICOM) results in a significant improvement in antigen-specific T-cell responses and antitumor activity. We describe here the first trial in humans of the CEA-TRICOM vaccines (also including an enhancer agonist epitope within the CEA gene).

PATIENTS AND METHODS

Fifty-eight patients with advanced CEA-expressing cancers were accrued to eight cohorts that involved vaccinations with the following: replication-defective fowlpox recombinant (rF)-CEA(6D)-TRICOM; primary vaccination with recombinant vaccinia (rV)-CEA(6D)-TRICOM plus rF-CEA(6D)-TRICOM booster vaccinations; and rV-CEA(6D)-TRICOM and then rF-CEA(6D)-TRICOM, plus granulocyte-macrophage colony-stimulating factor (GM-CSF) with vaccines, or with divided doses of vaccine with GM-CSF. Vaccines were administered every 28 days for six doses and then once every 3 months. Reverting to treatments every 28 days was allowed if patients progressed on the 3-month schedule.

RESULTS

In this phase I study, no significant toxicity was observed. Twenty-three patients (40%) had stable disease for at least 4 months, with 14 of these patients having prolonged stable disease (> 6 months). Eleven patients had decreasing or stable serum CEA, and one patient had a pathologic complete response. Enhanced CEA-specific T-cell responses were observed in the majority of patients tested.

CONCLUSION

We demonstrated that the CEA-TRICOM vaccines are safe and can generate significant CEA-specific immune responses, and they seem to have clinical benefit in some patients with advanced cancer.

Improvements in carotid endarterectomy in Scotland: results of a national prospective survey

BACKGROUND AND AIMS

The effectiveness of carotid endarterectomy (CEA) depends upon selection of patients with a high absolute risk of stroke, avoidance of delays from intial presentation to surgery and provsion of surgery with a low perioperative risk of stroke. We evaluated these aspects of practice in Scottish hospitals and, by encouraging adherence to national (SIGN) guidelines, attempted to improve the effectiveness of CEA.

METHODS

Prospective independent survey of patient selection, pre-operative delays and surgical performance for all CEAs performed in Scottish National Health Service hospitals over two 13 month periods from September 1997 and February 1999 respectively.

RESULTS

Thirteen hospitals performed 485 CEAs in the first period and 392 in the second, equating to an overall annual rate of 79 per million population. During both periods at least 95% of patients reported symptoms of carotid terittory ischaemia, but the proportion with stenoses greater than >70% rose from 89% to 97% (p<0.0001). The delays between referral, surgical consultation and subsequent surgery fell significantly but remained unacceptably long. The proportion seen by the surgeon within two weeks of referral rose from 36% to 43% (p=0.05) and the proportion operated on within one month thereafter rose from 35% to 49% (p<.0001). The perioperative combined major stroke and death rate was 3% in both periods.

CONCLUSION

We demonstrated significant changes in practice, in line with national guidelines, which would be expected to improve the effectiveness of our national programme of CEA. There is further scope for improving performance, particularly in relation to pre-operative delays.

Community-acquired Legionnaires' disease in Nottingham--too many cases?

The aim of this study was to compare the incidence of community-acquired Legionnaires' Disease in Nottingham with England and Wales and to explore reasons for any difference observed. Based on data from the National Surveillance Scheme for Legionnaires' Disease (1980-1999), the rate of infection in England and Wales was 1.3 per million/year compared with 6.6 per million/ year in Nottingham. Domestic water samples were obtained from 41 (95%) of 43 Nottingham cases between 1997 and 2000. In 16 (39%) cases, Legionella sp. were cultured in significant quantities. Proximity to a cooling tower was examined using a 1:4 case-controlled analysis. No significant difference in the mean distance between place of residence to the nearest cooling tower was noted (cases 2.7 km vs. controls 2.3 km; P = 0.5). These data suggest that Nottingham does have a higher rate of legionella infection compared to national figures and that home water systems are a source.

Simultaneous Suppression of Epidermal Growth Factor Receptor and c-erbB-2 Reverses Aneuploidy and Malignant Phenotype of a Human Ovarian Carcinoma Cell Line

Coexpression of epidermal growth factor receptor (EGFR) and c-erbB-2 in 47-68% of ovarian cancer cells indicate their strong association with tumor formation. We examined the effects of simultaneous antisense- or immunosuppression of EGFR and c-erbB-2 expression on the invasive phenotype, aneuploidy, and genotype of cultured human ovarian carcinoma cells (NIH:OVCAR-8). We report here that suppression of both EGFR and c-erbB-2 results in regression of aneuploidy and genomic imbalances in NIH:OVCAR-8 cells, restores a more normal phenotype, and results in a more normal gene expression profile. Combined with cytogenetic analysis, our data demonstrate that the regression of aneuploidy is due to the selective apoptosis of double antisense transfected cells with highly abnormal karyotype.