Patient and provider perspectives on home telecare: Preliminary results from a randomized controlled trial

A randomized controlled trial of home telecare for the management of acute exacerbations of chronic obstructive pulmonary disease has been undertaken in the north-west of England. A videophone was used that communicates via the ordinary telephone network. The intervention period for each participant was two weeks. Participants in the telecare arm of the trial were asked to complete logbooks to record their experiences of each telecare encounter. A simple, self-completed, 10–item questionnaire was used that consisted of a Likert scale, ranging from 1 (totally disagree) to 5 (totally agree). Fourteen nurses completed 150 logbooks and 22 patients completed 145 logbooks. These results demonstrate significant differences in perception between patients and their health-care providers with regard to telecare encounters across all the domains addressed. Participating patients consistently demonstrated more positive views of the telecare encounters than their health-care providers.

Human sleep and adrenal individual reactions to exercise

Six fit men, aged 20, participated in the 16 day experiment. After a 5 day control period, the subjects marched on 6 consecutive days (from 09:00 h to 17:00 h) for 34 km/day at a speed of 6 km/h, with a backpack adjusted to complete a 35% of individual VO2 max energy expenditure. Control conditions were resumed for a 5 day recovery period. Sleep records were taken every night from 22:00 h to 06:00 h. Urinary 17-hydroxycorticosteroids (17-OHCS) were analysed from a 09:00 h to 17:00 h sample and from overnight urines. Two groups of subjects were defined by their responses to exercise. Four subjects exhibited an increase in stage 3 during the last third of the exercise nights (mean: 163.8 +/- 7.3% of control values) without any change in their adrenal response. Two subjects had no change or a slight decrease in stage 3 but showed increased 09:00--17:00 h 17-OHCS urine excretion (mean: 147 +/- 13% of control values). Sleep latencies were decreased in both groups. However, the 2 subjects of the second group exhibited increased restlessness as measured by the levels of wakefulness, stage 1 and EMG activity. In all subjects, paradoxical sleep was not altered, along with an unchanged all-night excretion of 17-OHCS. It is suggested that differences in adrenal responses to exercise may be responsible for differences in sleep quality. This could explain the discrepancies encountered in the literature about sleep variations after physical exercise.

Assessing the burden of respiratory disease in the UK

This review explores the health and social burden of some of the main respiratory diseases (asthma, chronic obstructive pulmonary disease, cryptogenic fibrosing alveolitis, cystic fibrosis, lung cancer, mesothelioma, obstructive sleep apnoea and tuberculosis) in order to increase awareness of these diseases and highlight areas where improvements in care are required. The overall impact of respiratory diseases in the U.K. in terms of prevalence, mortality, morbidity and economic costs, with particular reference to secondary care has been considered and comparisons made with the rest of Europe where data are available. Respiratory diseases are responsible for a significant proportion of serious morbidity and premature death among the population of the U.K. and they will continue to present a growing challenge; special support is needed to tackle this burden.

Recruitment difficulties in a home telecare trial

We analysed the difficulties encountered in recruiting predominantly older patients, suffering from an acute exacerbation of a chronic illness, to a randomized controlled trial of home telecare. Of 653 patients approached for study participation, after full assessment, 80% (519) met the trial eligibility criteria. Of these, 104 (20%) consented to study participation and 415 (80%) refused. A logistic regression model was constructed to examine independent effects of patient factors on probability of trial participation. Only two independent variables were associated with decreased likelihood of consent: increasing age (1 year older: odds ratio [OR] = 0.96); and being on inhaled steroid medication (OR = 0.60). The most common reason for refusal to participate, accounting for almost one-third of respondents, was a stated preference for a face-to-face nurse visiting service rather than a telecare service. Perhaps home telecare services should continue to be targeted at the more stable chronically ill population and not at those suffering from acute illness.

Short-acting beta 2-agonist and oral corticosteroid use in asthma patients prescribed either concurrent beclomethasone and long-acting beta 2-agonist or salmeterol/fluticasone propionate combination

Prescriptions for short-acting beta(2)-agonists (SABAs) and oral corticosteroids recorded in a primary care database were used as markers of asthma control. Drug use in the 6 months before and after step-up in treatment from inhaled corticosteroids [ICs; total daily dosage of < or =1000 microg beclomethasone dipropionate (BDP) or equivalent] to either salmeterol/fluticasone propionate combination (SFC) or concurrent BDP and long-acting beta(2)-agonists (LABAs) given in separate inhalers was compared. After step-up, the calculated median number of doses of SABAs prescribed fell by 100 in the SFC group (n = 211) but was unchanged with BDP + LABA (n = 377, p < 0.0001), and fewer patients in the SFC group were prescribed oral corticosteroids (13.7 vs. 20.7%, p = 0.036). Other measures of SABA use after step-up indicated lower use in the SFC group. In clinical practice, adding LABA to IC therapy by using a combination inhaler produces significantly better asthma control than administering the drugs in separate inhalers.

Efficacy and tolerability of formoterol in elderly patients with reversible obstructive airways disease

This study has compared the efficacy and tolerability of formoterol (FORADIL) dry powder and salbutamol in elderly patients with reversible obstructive airways disease (ROAD). A total of 262 elderly outpatients with clinically stable ROAD participated in a multicentre, double-blind, parallel study. Patients were randomized in equal numbers to receive formoterol 12 micrograms b.i.d. formoterol 24 micrograms b.i.d. or salbutamol 400 micrograms q.i.d. for a 3 month period. All study drugs were inhaled through an Aeroliser device. Daily morning and evening peak expiratory flow (PEF) values, symptom scores and additional bronchodilator use were recorded by the patients throughout the study. Clinic assessment which included spirometry and PEF measurements was made at 4, 8 and 12 weeks. Morning and evening PEF values were significantly higher with both doses of formoterol compared with salbutamol. This difference was statistically significant both for the overall study period and during the week preceding each of the clinic visits (4, 8 and 12 weeks). There was no significant difference for the two doses of formoterol with respect to PEF values. The FEV1 and FVC values between the three treatment groups were similar. The daily use of rescue medication was significantly lower for the formoterol 24 micrograms group compared with the salbutamol group. The percentage of patients rating the therapeutic effect as 'very good' was significantly higher for formoterol: 41% on 12 micrograms; 34% on 24 micrograms; 19% on salbutamol. All treatments were well tolerated. This study demonstrates that formoterol 12 micrograms and 24 micrograms b.i.d. by dry powder inhalation are equally effective and are both significantly superior to salbutamol 400 micrograms q.i.d. in the treatment of ROAD in the elderly.

A randomized controlled trial of home telecare

We have established a randomized controlled trial of home telecare. The intervention aims to address a growing problem in the National Health Service (NHS), that is, high admission rates of patients with exacerbations of chronic obstructive pulmonary disease (COPD). Equipment procurement for the trial has been difficult, as no single supplier was able to meet the project s full requirements. The fact that the service is provided by existing clinical NHS staff has advantages when considering the generalizability of the results within the NHS. However, there are also disadvantages, since existing staff have little research experience. Considerable time has been required to help staff familiarize themselves with the equipment and become comfortable with its use. This has posed a barrier to the implementation of the service.

The effect of alpha and gamma interferon on cell growth and histocompatibility antigen expression by human renal carcinoma cells in vitro

Tumour cells were separated from 19 renal carcinomas and cultured in vitro. The effect of interferon (IFN) alpha and gamma on cell proliferation was measured and compared to the effect of IFN on the expression of class I and class II major histocompatibility complex (MHC) antigens. When tested within the first 14 days of culture, IFN-alpha inhibited protein synthesis in 12 of 15 and IFN-gamma in four of nine tumours. Reduction in cell counts was in parallel. In six tumours the culture period was extended and in all six the effect of IFN-alpha was lost. Exposure to IFN-alpha induced or enhanced class I antigen expression in eight of 19 tumours and class II expression in two of 19. The analogous figures for IFN-gamma were five and three tumours. In four of five cases where a comparison could be made there was a correlation between the effects of IFN-alpha on cell proliferation and class I antigen expression. The efficacy of IFN in the treatment of renal carcinomas may thus, in part, result from inhibition of cell proliferation and enhancement of antigen expression.

Expression of major histocompatibility complex (MHC) antigens and their loss on culture in renal carcinoma

Biopsies from the tumour and the adjacent normal kidney were obtained from 15 patients with renal cell carcinoma (RCC). The proximal convoluted tubules from which the tumour arose expressed major histocompatibility complex (MHC) class I antigen (Ag) in 3 cases and class II in none. By contrast, the carcinoma cells expressed class I Ag in 14 cases and class II Ag in 5 cases. Cells from each carcinoma were established in culture. As the culture period increased, cells from six of eight RCC showed diminished expression of class I Ag and five of six reduced expression of class II Ag. This is similar to the relative loss of class I Ag in synchronous metastases from RCC.

Effects of ischaemic heart disease, Crohn's disease and antimicrobial therapy on the pharmacokinetics of sulphinpyrazone

The renewed interest in sulphinpyrazone in recent years has arisen from its potential to inhibit platelet aggregation. In vivo much of the activity is probably due to the thioether or sulphide metabolite which has a greater potency and a longer half-life than the parent compound. The sulphide metabolite is formed exclusively by the gut microflora in man. The pharmacokinetics of sulphinpyrazone (200 mg orally) have been studied, with particular attention to the formation of the sulphide metabolite, in groups of patients who might be expected to show abnormal formation of this active metabolite due to altered delivery of the drug to the lower gut or altered gut flora. Five patients studied 1 month after a myocardial infarction did not differ markedly from young, normal volunteers with respect to either sulphinpyrazone or its metabolite. Crohn's disease in the quiescent phase did not significantly alter the pharmacokinetics or metabolism of the drug, but 1 patient who had undergone a hemicolectomy formed negligible concentrations of the active metabolite. Antimicrobial therapy produced highly variable results with almost complete suppression of sulphide formation in some subjects but no apparent effect in others.

Changes in alkaline phosphatase isoenzyme activity in tissues and plasma of Atlantic salmon (Salmo salar) before and during smoltification and gonadal maturation

Changes in tissue and plasma isoenzymes of alkaline phosphatase (ALP) were qualitatively and quantitatively determined for male and female Atlantic salmon parr, silvery parr, smolt, immature grilse, prespawning grilse and postspawning grilse using cellulose acetate electrophoresis, densitometry and spectrophotometry. Tissue ALP isoenzymes were isolated from intestine, kidney, bone, liver, and gonad and compared to plasma isoenzymes. Parr plasma displayed three isoenzymes from bone and liver (slow and fast). During smoltification, ALP activity increased in tissue extracts from liver, gonad, and kidney of males and females. Total plasma ALP activity also increased and was due to slow and fast liver isoenzymes. During ovarian development, total ALP plasma activity increased in females and was due mostly to liver isoenzymes and an incompletely identified isoenzyme or isoenzyme mixture (band 2). However, in males total ALP plasma activity did not increase during maturation and no band 2 was evident. In male and female maturing adult grilse, bone ALP activity declined and the isoenzyme band evident in parr plasma could not be detected. ALP activity declined in the plasma of postspawning males and females. In females this was due partly to the total clearance of band 2 from the plasma, together with lowered levels of liver isoenzymes. Treatment of postspawned grilse in February and March with triiodothyronine and thyroxine elevated plasma thyroid hormone levels and increased plasma ALP levels. In conclusion, plasma ALP isoenzyme activities change with physiological state, and knowledge of the conditions governing these changes is important when using these enzymes as a diagnostic tool.

Expression of glutathione-s-transferase isotypes in relation to Doxorubicin sensitivity and prognosis in patients with renal-carcinoma

Specimens were obtained from the tumour and adjacent normal kidney in 29 patients with renal carcinoma. Expression of the alpha, pi and mu isoforms of gluthatione-S-transferase (GST) was estimated in formalin fixed paraffin embedded sections of the normal and neoplastic kidney following exposure to the appropriate polyclonal antibodies. binding of which was recognised by the indirect peroxidase technique. Expression of alpha, pi and mu GST in each tumour specimen was compared with the in vitro sensitivity of tumour cells to doxorubicin determined by drug inhibition of [Se-75] selenomethionine uptake by the appropriate tumour cells in culture. Expression of pi GST was associated with tumour cell resistance to doxorubicin. The level of alpha, pi and mu GST was not related to patient survival.

Tractional force generation by porcine Müller cells: stimulation by growth factors in human vitreous

PURPOSE

To examine the levels of Müller cell contraction-stimulating activity in human vitreous, correlate these levels with clinical presentation, and identify, the causative growth factors.

METHODS

Human vitreous was collected from patients undergoing pars plana vitrectomy (n = 84). Müller cells were isolated from porcine retina and maintained in tissue culture. Tractional forces generated by cells incubated on three-dimensional collagen gels were measured as changes in gel thickness. Contraction-stimulating activity in vitreous (VA) was calculated from the close-response profiles of gel contraction to vitreous protein. The contributions of individual growth factors to vitreous activity (n = 10) were assessed by inhibition with specific neutralizing antibodies.

RESULTS

The mean VA of patients with retinal detachment (3.65) and proliferative vitreoretinopathy stages A, B, and C (2.06) were elevated above that of patients without retinal pathology (vitreous activity = 0.23) or retinal defects alone (0.57). Mean activities in patients with epimacular proliferation (1.22) and vitreous hemorrhage (1.40) were also significantly elevated. The percentage of this activity attributable to insulin-like growth factor 1 (IGF-1) varied from 9.2% to 84.5% with a mean of 61.3%. Similarly, the percent contribution of platelet-derived growth factor (PDGF) ranged from 6.8% to 49.0% with a mean of 26.5%.

CONCLUSIONS

The vitreous of patients with retinal detachment, proliferative retinal disease, and vitreous hemorrhage contain varying amounts of growth factors that stimulate tractional force generation by Müller cells. The majority of the activity can be attributed to IGF-1 and a smaller proportion to PDGF.

P-glycoprotein expression, tumor differentiation, chemosensitivity of tumor-cells in-vitro and clinical outcome in patients with renal-cell carcinoma

There was no association between expression of P-170 glycoprotein on cells derived from 14 renal carcinomas and the in vitro sensitivity of the cells to doxorubicin or its potentiation by verapamil. Furthermore expression of P-170 on the cells of individual tumours was unrelated to nuclear differentiation or patient prognosis. These observations may in part resolve the dilemma posed by the reported association in some tumour types between expression of P-170 and the metastatic phenotype together with the previously observed relation in renal carcinoma between P-170 expression, good tumour differentiation and therefore a favourable prognosis.