Risk factors for requiring intravenous antibiotic therapy in hospital and 30-day readmission for exacerbations of bronchiectasis.

BACKGROUND: The safety and efficacy of domiciliary intravenous (IV) antibiotic therapy compared to inpatient hospital treatment for exacerbations of bronchiectasis has been established. Factors that determine the setting for IV antibiotic therapy need to be characterized further. AIM: We aimed to identify factors at presentation that were associated with the requirement for IV antibiotic therapy delivered in hospital and 30-day readmission. DESIGN: Retrospective cohort study of all IV antibiotic courses administered to patients with bronchiectasis by a specialist respiratory unit over a 2-year period. METHODS: We assessed demographic data, treatment outcomes, morbidity, mortality, and 30-day readmission rates. Multiple linear regression analysis was performed to identify factors associated with inpatient IV antibiotics and 30-day readmission. RESULTS: One hundred six patients received 243 courses of IV antibiotic therapy in 2 years. Sixty-six cases (27.2%) were managed in hospital, 28 cases (11.5%) required initial admission prior to early supported discharge to complete IV antibiotics at home and 149 cases (61.3%) received domiciliary IV antibiotics. Bronchiectasis Severity Index (P < 0.0001) and emergency presentation with an exacerbation (P < 0.0001) were independent factors associated with the requirement for inpatient IV antibiotic therapy. There were no differences between mortality (P = 0.06) and morbidity (P = 0.1) between groups. Thirty-day readmission following early supported discharge was higher compared to inpatient or domiciliary therapy (P=0.0004). CONCLUSION: A higher Bronchiectasis Severity Index and emergency presentation with an exacerbation are independently associated with the need for IV antibiotics delivered in hospital. We could not identify any factors that predicted 30-day readmission in a multi-variable model.

Crystal structure of 4-(2-bromo-prop-ion-yl)-3-phenyl-sydnone.

Sydnones are a class of mesoionic compounds containing a five-membered heterocyclic ring. In general, sydnone com-pounds are synthesized with an aromatic substutuent at the N(3) position. This feature, adds to the stability of the heterocyclic ring. In the title compound {systematic name: 4-(2-bromo-propano-yl)-3-phenyl-1,2,3λ(5)-oxa-diazol-3-ylium-5-olate}, C11H9BrN2O3, the aromatic substitutent is an unsubstituted phenyl ring. The sydnone ring is almost planar, with a maximum deviation from the mean plane of 0.023 (1) Å, but is not coplanar with the phenyl ring, having a dihedral angle of 40.93 (8)°. The carbonyl side chain is twisted relative to the syndone ring by 15.8 (2)°. The mol-ecules are packed in the unit cell as pairs related by an inversion center at (1, 0, 1/2). The pairs inter-act via π-stacking, with the distance separating the centroids being 3.824 (1) Å. The Br atom has two contacts, one to an N atom in a neighboring asymmetric unit with a distance of 3.346 (2) Š(the sum of the van der Waals radii is 3.40 Å) and a second to an H atom with a distance of 3.03 Å. The contact with the H atom is perpendicular (C-Br⋯H = 98.60°) to the C-Br bond, and that to the N atom is linear [C-Br⋯N = 169.10 (5)°] to the C-Br bond. The O atom of the sydnone ring is involved in two hydrogen bonds, one intra-molecular with a donor-acceptor distance of 3.1486 (19) Šand a second that is inter-molecular, with a phenyl H atom as the donor and has a donor-acceptor distance of 3.346 (2) Å.

Bosutinib plus capecitabine for selected advanced solid tumours: results of a phase 1 dose-escalation study.

BACKGROUND: This phase 1 study evaluated the maximum tolerated dose (MTD), safety, and efficacy of bosutinib (competitive Src/Abl tyrosine kinase inhibitor) plus capecitabine. METHODS: Patients with locally advanced/metastatic breast, pancreatic, or colorectal cancers; cholangiocarcinoma; or glioblastoma received bosutinib plus capecitabine at eight of nine possible dose combinations using an 'up-down' design to determine the toxicity contour of the combination. RESULTS: Among 32 enrolled patients, none of the 9 patients receiving MTD (bosutinib 300 mg once daily plus capecitabine 1000 mg m(-2) twice daily) experienced dose-limiting toxicities (DLTs). Overall, 2 out of 31 (6%) evaluable patients experienced DLTs (grade 3 neurologic pain (n=1); grade 3 pruritus/rash and increased alanine aminotransferase (n=1)). Most common treatment-related adverse events (AEs) were diarrhoea, nausea, vomiting, palmar-plantar erythrodysesthesia (PPE), fatigue; most frequent grade 3/4 AEs: PPE, fatigue, and increased alanine/aspartate aminotransferase. Although diarrhoea was common, 91% of affected patients experienced maximum grade 1/2 events that resolved. Best overall confirmed partial response or stable disease >24 weeks (all tumour types) was observed in 6 and 13% of patients. CONCLUSIONS: In this population of patients with advanced solid tumours, bosutinib plus capecitabine demonstrated a safety profile similar to that previously reported for bosutinib or capecitabine monotherapy; limited efficacy was observed.

Prospective evaluation of unmet needs of rural and aboriginal cancer survivors in Northern British Columbia.

BACKGROUND: The unmet needs of cancer survivors in rural, remote, and aboriginal communities are largely unexplored. We explored potential differences between rural survivors (rss) in 4 general population (gp) and 4 First Nations (fn) communities. METHODS: We approached 4 gp and 4 fn rs communities to participate in a mixed-methods project. Participants completed the Hospital Anxiety and Depression Scale (hads) and the Survivor Unmet Needs Survey (suns) and provided demographic information. Each question on the suns can be scored from 0 to 4, with 0 representing "no unmet need" and 4 representing "very high unmet need." A directed approach to content analysis of focus group and interview data was used to triangulate the hads and suns results. RESULTS: We prospectively accrued 23 fn rss and 56 gp rss for this study. More fn rss had borderline or abnormal anxiety (5% vs. 21%, p = 0.02). Compared with gp rss, fn rss had higher unmet needs scores in all categories: Information (2.29 vs. 0.8, p < 0.001), Work and Financial (1.66 vs. 0.5, p < 0.001), Access and Continuity of Health Care (1.83 vs. 0.44, p < 0.001), Coping and Sharing (2.22 vs. 0.62, p < 0.001), and Emotional (2.12 vs. 0.63, p < 0.001). The qualitative findings provided examples and insight into the unmet needs experienced by rss. CONCLUSIONS: First Nations rss had significantly higher anxiety and unmet needs compared with their gp rs counterparts. In addition, different qualitative themes were identified in the groups. Our findings support the development of tailored approaches to survivorship for these populations.

Eight-weekly intravenous antibiotics is beneficial in severe bronchiectasis.

AIM: The aim of our study was to assess the impact of 8-weekly intravenous (IV) antibiotics on exacerbation frequency and health-related quality of life in bronchiectasis. METHODS: Patients were recruited prospectively from June 2008 to December 2010. Patients with recurrent exacerbations (five or more exacerbations per year) and subjectively reporting ill health between antibiotic courses were recruited. Eight-weekly IV antibiotics (for 14 days) were initiated. Patients were followed up for 1 year. Main outcome was reduction in exacerbation frequency and improvement in health-related quality of life (HRQoL) at 1 year after starting intravenous antibiotic therapy. Other outcomes recorded were forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC), incremental shuttle walk test (ISWT), 24-h sputum volume, sputum microbiology, body mass index (BMI), markers of inflammation--white cell count (WCC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). RESULTS: In total, 19 patients were recruited. Mean age was 64.1 years and 52.6% were female. With 8-weekly antibiotics, there was a significant reduction in the number of exacerbations [mean (SE): 9.3 (0.5) in the year before vs. 8.0 (0.4) in the year after; P = 0.02]. In 63.2%, Leicester Cough Questionnaire (LCQ) improved by ≥1.3 U (P = 0.006)] and in 42.1% St. George's Respiratory Questionnaire (SGRQ) improved by ≥4 U (P = 0.03). Exercise capacity increased by 58.7 m (P = 0.004). There was no improvement in the other end points. CONCLUSION: Treatment with 8-weekly intravenous antibiotics in severe bronchiectasis reduced exacerbation frequency and improved exercise tolerance and health-related quality of life.

A pilot study of pulmonary rehabilitation and chest physiotherapy versus chest physiotherapy alone in bronchiectasis.

AIM: The aim of our study was to assess the efficacy of pulmonary rehabilitation in addition to regular chest physiotherapy in non cystic fibrosis bronchiectasis. METHODS: Thirty patients with clinically significant bronchiectasis and limited exercise tolerance were randomized into either the control group receiving chest physiotherapy (8 weeks) or into the intervention group, receiving pulmonary rehabilitation in addition to chest physiotherapy (8 weeks). Both groups were encouraged to maintain their exercise program and or chest physiotherapy, following completion of the study. RESULTS: End of training (8 weeks) No improvement in control group. In the intervention group, incremental shuttle walk test (ISWT) improved by 56.7 m (p = 0.03), endurance walk test (EWT) by 193.3 m (p = 0.01), Leicester Cough Questionnaire (LCQ) improved by 2.6 units (p < 0.001) and St. George's Respiratory Questionnaire (SGRQ) by 8 units (p < 0.001). At 20 weeks (12 weeks post end of training) No improvement in control group. In the intervention group, ISWT improved by 80 m (p = 0.04) and EWT by 247.5 m (p = 0.003). LCQ improved by 4.4 units (p < 0.001) and SGRQ by 4 units (p < 0.001). CONCLUSION: Pulmonary rehabilitation in addition to regular chest physiotherapy, improves exercise tolerance and health related quality of life in non cystic fibrosis bronchiectasis and the benefit was sustained at 12 weeks post end of pulmonary rehabilitation. Clinical trials regn no. NCT00868075.

Use of specialist knowledge and experience to manage patients with mixed aetiology leg ulcers.

OBJECTIVE: To discuss the role of the clinical nurse specialist in managing patients with ulceration caused by mixed venous arterial disease. METHOD: A small scale retrospective audit study of eight mixed aetiology patients drawn from the caseload of leg ulcer patients within a specialist leg ulcer service in Ayrshire, Scotland was conducted by two specialist nurses with over 8 years' experience in specialist leg ulcer management. Patients were individually assessed using Doppler ultrasound and a rigorous set of validated risk factor criteria. Where Doppler ultrasound was considered to be unreliable, due to an inability to detect sounds, or where further diagnostic information was required in order to safely plan care, arterial duplex scanning was carried out by the cardiac department at Ayr Hospital. All patients were treated with a cohesive inelastic compression bandage system and closely observed by the specialist nurse. RESULTS: All eight patients with mixed aetiology leg ulcers were reported to experience complete ulcer healing within 6-30 weeks after first application of the inelastic bandage system. The regimen was well tolerated by all patients and no adverse events were recorded. CONCLUSION: With accurate assessment and treatment by a specialist team, patients with mixed venous arterial disease were safely and successfully managed where they may have remained unhealed. DECLARATION OF INTEREST: This was an independent retrospective audit study conducted by two clinical nurse specialists, with educational support by Activa Healthcare to assist in bringing it to print.

Phase II study of single-agent bosutinib, a Src/Abl tyrosine kinase inhibitor, in patients with locally advanced or metastatic breast cancer pretreated with chemotherapy.

BACKGROUND: This phase II study evaluated single-agent bosutinib in pretreated patients with locally advanced or metastatic breast cancer. PATIENTS AND METHODS: Patients received oral bosutinib 400 mg/day. The primary end point was the progression-free survival (PFS) rate at 16 weeks. Secondary end points included objective response rate, clinical benefit rate, 2-year overall survival rate, safety, and changes in levels of bone resorption/formation biomarkers. RESULTS: Seventy-three patients were enrolled and treated. Median time from diagnosis of metastatic disease to initiation of bosutinib treatment was 24.5 months. For the intent-to-treat population, the PFS rate at 16 weeks was 39.6%. Unexpectedly, all responding patients (n = 4) were hormone receptor positive. The clinical benefit rate was 27.4%. The 2-year overall survival rate was 26.4%. The main toxic effects were diarrhea (66%), nausea (55%), and vomiting (47%). Grade 3-4 laboratory aminotransferase elevations occurred in 14 (19%) patients. Myelosuppression was minimal. No consistent changes in the levels of bone resorption/formation biomarkers were seen. CONCLUSIONS: Bosutinib showed promising efficacy in prolonging time to progression in chemotherapy-pretreated patients with locally advanced or metastatic breast cancer. Bosutinib was generally well tolerated, with a safety profile different from that of the Src/Abl tyrosine kinase inhibitor dasatinib in a similar patient population.

Sputum colour: a useful clinical tool in non-cystic fibrosis bronchiectasis.

This study explored the utility of sputum colour in clinically stable patients with bronchiectasis. Interpretation of sputum colour between the doctor and the patient was reliable (intraclass correlation coefficient 0.83 (95% confidence interval 0.76-0.89). Sputum colour predicted bacterial colonisation (5% in mucoid sputum; 43.5% in mucopurulent sputum; 86.4% in purulent sputum; p<0.0001). On multivariate logistic regression analysis, independent factors associated with purulent sputum were bacterial colonisation, varicose or cystic bronchiectasis, forced expiratory volume in 1 s <80% predicted and diagnosis of bronchiectasis aged <45 yrs.

Validation of the Leicester Cough Questionnaire in non-cystic fibrosis bronchiectasis.

Health-related quality of life is a potentially important marker for evaluating existing and new therapies in bronchiectasis. The Leicester Cough Questionnaire (LCQ) is a symptom specific questionnaire designed to assess the impact of cough severity, a major symptom of bronchiectasis. This study aimed to validate the LCQ in bronchiectasis. The validity, responsiveness and reliability of the LCQ were assessed as follows: ability to discriminate severe and mild disease; change in score following antibiotic treatment for exacerbations; repeatability over a 6-month period in stable disease; and comparison with the St George's Respiratory Questionnaire (SGRQ). In total, 120 patients (51 with severe disease, 29 with moderate disease and 40 with mild disease) completed the LCQ and SGRQ. The area under the receiver-operator curve was good for both severe and mild disease (0.84 and 0.80 respectively, p<0.0001). Following 2 weeks' antibiotic treatment, the median LCQ score (interquartile range) improved from 11.3 (9.3-13.7) to 17.8 (15-18.8) (p<0.0001). The LCQ score was repeatable over 6 months in stable disease (intraclass correlation coefficient of 0.96 (95%CI 0.93-0.97), p<0.0001). Correlation between the LCQ and SGRQ scores was -0.7 in both stable disease and exacerbations (p<0.0001). The LCQ can discriminate disease severity, is responsive to change and is reliable for use in non-cystic fibrosis bronchiectasis.

Assessing response to treatment of exacerbations of bronchiectasis in adults.

The present study aimed to assess the effect of intravenous antibiotic therapy on clinical and laboratory end-points in exacerbations of noncystic fibrosis bronchiectasis and to determine whether the outcomes were influenced by the pathogenic organism isolated. A prospective cohort study was conducted from November 2006 to March 2008 of exacerbations requiring intravenous antibiotics. End-points included 24-h sputum volume, forced expiratory volume in one second (FEV(1)), forced vital capacity (FVC), incremental shuttle walk test, qualitative sputum microbiology, white cell count, erythrocyte sedimentation rate, C-reactive protein (CRP) and St George's Respiratory Questionnaire (SGRQ). Exacerbations due to Pseudomonas aeruginosa were compared with exacerbations due to other potential pathogenic organisms. In total, 32 exacerbations were studied. Following 14 days of intravenous antibiotics, all outcomes significantly improved independent of a pathogenic organism, except FEV(1) and FVC. The most responsive markers were: 24-h sputum volume (reduced in all patients and 80% had >/=50% reduction); sputum bacterial clearance (78.1%); CRP (>/=75% reduction in 62.5%) and SGRQ (>/=4 unit improvement in 89.7%). CRP, 24-h sputum volume and SGRQ improved independent of microbial clearance. In the current study, 24-h sputum volume, microbial clearance, C-reactive protein and St George's Respiratory Questionnaire were the most useful parameters to assess response to treatment of exacerbations of bronchiectasis. Outcomes were similar independent of the pathogenic organism with the exception of forced expiratory volume in one second and forced vital capacity.

[Erythema induratum Bazin. "Tuberculid" or tuberculosis?]. / Erythema induratum Bazin: "Tuberkulid" oder Tuberkulose?

A 66-year-old woman presented with erythematous nodules on both legs and told of a history of lymph node tuberculosis that had been treated with surgery and tuberculostatic therapy years before. A biopsy taken from a nodule showed nodular vasculitis. PCR for Mycobacterium tuberculosis-specific DNA on the paraffin-embedded tissue was positive. Based on the experience with our patient, positive PCR results for Mycobacterium tuberculosis-specific DNA in lesions of nodular vasculitis are discussed critically. The historical background of "tuberculids", such as erythema induratum Bazin, is elucidated.

The organization of genes tightly linked to the Ha locus in Aegilops tauschii, the D-genome donor to wheat.

The grain hardness locus, Ha, is located at the distal end of the short arm of chromosome 5D in wheat. Three polypeptides, puroindoline-a, puroindoline-b, and grain softness protein (GSP-1), have been identified as components of friabilin, a biochemical marker for grain softness, and the genes for these polypeptides are known to be tightly linked to the Ha locus. However, this region of the chromosome 5D has not been well characterized and the physical distance between the markers is not known. Separate lambda clones containing the puroindoline-a gene and the puroindoline-b gene have been isolated from an Aegilops tauschii (the donor of the D genome to wheat) genomic lambda library and investigated. Considerable variation appears to exist in the organization of the region upstream of the gene for puroindoline-b among species closely related to wheat. Using in situ hybridization the genes for puroindoline-a, -b, and GSP-1 were demonstrated to be physically located at the tip of the short arm of chromosome 5 of A. tauschii. Four overlapping clones were isolated from a large-insert BAC library constructed from A. tauschii and of these one contained genes for all of puroindoline-a, puroindoline-b, and GSP-1. The gene for puroindoline-a is located between the other two genes at a distance no greater than approximately 30 kb from either gene. The BAC clone containing all three known genes was used to screen a cDNA library constructed from hexaploid wheat and cDNAs that could encode novel polypeptides were isolated.

Early expression of grain hardness in the developing wheat endosperm.

Seeds from near-isogenic hard and soft wheat lines were harvested at regular intervals from 5 days post-anthesis to maturity and examined for hardness using the single kernel characterisation system (SKCS). SKCS analysis revealed that hard and soft lines could be distinguished from 15 days post-anthesis (dpa). This trend continued until maturity where the difference between the hard and soft lines was most marked. SKCS could not be applied to the small 5- and 10-dpa wheat kernels. Fresh developing endosperm material was examined using light microscopy and no visible differences between the cultivars were detected. When air-dried material was examined using scanning electron microscopy (SEM) differences between soft and hard lines were visible from as early as 5 dpa. Accumulation of puroindoline a and puroindoline b was investigated in developing seeds using both Western blotting and ELISA. Low levels of puroindoline a could be detected in the soft cultivar from 10 dpa, reaching a maximum at 32 dpa. In the hard cultivar, puroindoline a levels were negligible throughout grain development. Puroindoline b accumulates in both the soft and hard cultivars from 15 dpa, but overall contents were higher in the soft cultivar. These findings indicate that endosperm hardness is expressed very early in developing grain when few starch granules and storage proteins were deposited in the endosperm cells. Further, the near-isogenic soft and hard Heron lines could be differentiated by SEM at a stage in development when the accumulation of puroindolines could not be detected by the methods used in this study.

Quinone methide phosphodiester alkylations under aqueous conditions.

A detailed analysis of the alkylation of phosphodiesters with a p-quinone methide under aqueous conditions has been accomplished. The relative rates of phosphodiester alkylation and hydrolysis have been examined by (1)H NMR analysis of the reaction of 2,6-dimethyl-p-quinone methide in a buffered diethyl phosphate/acetonitrile solution (1:9 v/v, pH 4.0). The rate of hydrolysis of the quinone methide was confirmed by UV analysis in 28.5% solutions of aqueous inorganic phosphate in acetonitrile at pH 4.0 and 7.0. Similarly, the rate of phosphodiester alkylations by the quinone methide was also confirmed by UV analysis in 28.5% solutions of aqueous dibenzyl, dibutyl, or diethyl phosphate in acetonitrile at pH 4.0 and 7.0. These kinetic studies further establish that the phosphodiester alkylation reactions are acid-catalyzed, second-order processes. The rate constant for phosphodiester alkylation was found to range from approximately 370-3700 times the rate constant of quinone methide hydrolysis with diethyl and dibenzyl phosphate, respectively (pH 4.0, 28.5% aqueous acetonitrile).

Control of reaction chemoselectivity with a circular DNA template in the ligation of short oligodeoxyribonucleotides.

A study has been conducted to examine the chemoselective control attained in the ligation of short oligodeoxyribonucleotides (ODNs) directed by association on a circular DNA template through triplex formation relative to the same ligation on a single-strand DNA template through duplex formation. The highly efficient, chemospecific ligation achieved under a variety of conditions on the circular DNA template presumably arises from the higher substrate-template association resulting in improved transition state accessibility and protection of the ODNs from side reactions.

Trapping phosphodiester-quinone methide adducts through in situ lactonization.

The goal of in situ modification of DNA via phosphodiester alkylation has led to our design of quinone methide derivatives capable of alkylating dialkyl phosphates. A series of catechol derivatives were investigated to trap the phosphodiester-quinone methide alkylation adduct through in situ lactonization. The catechol derivatives were uniquely capable of characterizable p-quinone methide formation for mechanistic clarity. These investigations revealed that with a highly reactive lactonization group (phenyl ester), lactonization competed with quinone methide formation. Lactone-forming groups of lower reactivity (methyl ester, n-propyl ester, and dimethyl amide) allowed quinone methide formation followed by phosphodiester alkylation; however, they were ineffective at in situ lactonization to drain the phosphodiester alkylation equilibrium to the desired phosphotriester product. The derivatives tethered with lactone-forming functionality of intermediate reactivity (chloro-, trichloro-, and trifluoroethyl esters), allowed quinone methide formation, phosphodiester alkylation, and in situ lactonization to efficiently afford the trapped phosphotriester adduct.

Caspase-3-like activity is necessary but not sufficient for daunorubicin-induced apoptosis in Jurkat human lymphoblastic leukemia cells.

In the present study we have shown that the cancer therapeutic drug, daunorubicin, induces apoptosis in the human lymphoblastic leukemia cell line Jurkat E6.1. This effect was both dose-and time-dependent with nuclear fragmentation detectable by 8 h. Caspases have been implicated in pro-apoptotic events. By utilizing synthetic fluorochrome-linked substrates of the caspases, we observed that a caspase-3-like enzyme had dramatically increased activity (3340 130% with respect to basal levels) in response to daunorubicin treatment. Furthermore, by using an inhibitor to caspase-3, Ac-DEVD-CHO, we have shown that activation of a caspase-3-like enzyme appears to be necessary for nuclear fragmentation and apoptotic body formation, but is not required for chromatin condensation. In contrast, a general caspase inhibitor, Z-VAD-fmk, inhibited all apoptotic parameters measured. Ceramide has been implicated in daunorubicin-induced apoptosis in human myeloid leukemia cells. However, in Jurkat cells, caspase activation does not appear to be a consequence of ceramide generation since, although ceramide levels were elevated through the action of ceramide synthase in response to daunorubicin treatment, this occurred with slower kinetics than either nuclear fragmentation or caspase activation. In contrast, caspase inhibitors abrogated ceramide elevation induced by DNR treatment, suggesting that ceramide synthase may be a downstream target for caspase action. Therefore, daunorubicin-induced apoptosis does not appear to be mediated by ceramide in the lymphoblastic leukemia cell line, Jurkat E6.1. Instead, caspase 3 activity appears to be necessary, but not sufficient for this process.