Towards a patient-centred approach in therapeutic patient education. A qualitative study exploring health care professionals' practices and related representations.

OBJECTIVES: This study aimed to explore the practice-representation links among Health Care Professionals (HCP)s practising Therapeutic Patient Education (TPE). Understanding these links might actually help to address the challenges of TPE implementation, particularly the patient-centred dimension. METHODS: A qualitative study using individual interviews was conducted with HCPs practising in French-speaking Belgium or in France. Data analysis was carried out in two steps: to draw up a typology of educational practices (including variations) and, in line with the Social Representation Theory, to identify possible related social representations. RESULTS: The typology, based on HCP-Patient power distribution, was built from 26 interviews. Four types and nine subtypes were identified. Besides the power distribution, practice (sub)types were also specific regarding communication modes, consideration for patients' representations, motivational approach, personalization, complexity of methods and learning contents, and practice reflexivity. Practices were seldom constant. Three variations were highlighted: within a subtype, between different subtypes, and between education and technical care. Both practice subtypes and variations were related to specific decisive representations. DISCUSSION: Representations related to practices and those related to practices variations offer new perspectives for TPE implementation. There is no panacea for achieving more patient-centred approaches; tailored strategies based on practice subtypes are needed.

General Practitioners and Community Pharmacists' Collaboration in Primary Care: Small Steps for a Major Change.

BACKGROUND: Healthcare authorities worldwide search for ways to develop integrated care and interprofessional collaboration. In Belgium, Medical-Pharmaceutical Concertation (MPC) was introduced as a format to promote constructive dialogues between GPs and community pharmacists (CPs) with a focus on pharmacotherapy. OBJECTIVE: To evaluate the implementation of MPC from the perspective of healthcare authorities and GPs/CPs. METHODS: Mixed-methods approach, including semi-structured interviews with stakeholders and service users, observations of MPC meetings and surveys in GPs/CPs. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed inductively. RESULTS: The implementation of MPC took a slow start. Parties involved had divergent views on the goals of the MPC: stakeholders focused on measurable results, while service users aimed on improving interprofessional communication. Additionally, service users felt that the lack of local structures hindered consensus building and implementation of agreements in daily practice. Support from professional associations was considered indispensable for the implementation of MPC. In order to organize this efficiently, the establishment of an independent institution, coordinating the MPC initiative, was highly recommended. CONCLUSION: The study confirms that a thorough context assessment prior to implementation of a complex project is needed and that a step-wise approach should be respected to achieve effective interprofessional relationships.

Process evaluation of a complex intervention to optimize quality of prescribing in nursing homes (COME-ON study).

BACKGROUND: The COME-ON study was a cluster-controlled trial of a complex intervention that consisted of a blended training program, local interdisciplinary meetings, and interdisciplinary case conferences in Belgian nursing homes. The intervention was associated with significant improvements in the appropriateness of prescribing. The aims of this study were to describe the implementation of the intervention and to explore the experiences of participants, for the purpose of identifying factors associated with implementation and perceived impact and to draw lessons for future implementation. METHODS: We performed a mixed-method process evaluation. Questionnaires and reports were used to collect quantitative data on implementation and experiences from the 24 NHs and participating healthcare professionals (coordinating physicians, general practitioners, pharmacists, and nurses) in the intervention group. Multidisciplinary focus groups focusing on factors associated with implementation and perceived impact were conducted in 11 NHs. RESULTS: Overall, the rate of implementation and the satisfaction of participants were good, despite some variability between NHs and HCPs. Although perceived impact on nursing home residents varied, most participants perceived a positive impact for themselves. Factors associated with implementation and perceived impact were identified at different levels: intervention, healthcare professionals, organization, and external context. The interdisciplinary and face-to-face approaches were recognized as key elements for the success of the intervention, despite organizational constraints. The attitude of general practitioners was identified both as a barrier to and a facilitator for implementation and its success. The professional role and competency of the pharmacist influenced perceived impact. The pre-existing relationships between HCPs and the presence of a leader facilitated implementation and perceived impact. Remuneration was deemed necessary for the study and for future implementation. CONCLUSIONS: Overall, the intervention, and more specifically its interdisciplinary aspect, was well implemented and appreciated by HCPs. This probably contributed to the positive effect on the appropriateness of prescribing. Future implementation must take into account the various factors found to affect implementation and perceived impact, in order to maximize effect and sustainability. Trial registration Current Controlled Trials ISRCTN66138978; registered 18 November 2015, retrospectively registered, https://www.isrctn.com/ISRCTN66138978.

Links Between Perceptions and Practices in Patient Education: A Systematic Review.

Background. Two decades after "patient education" was defined by the World Health Organization, its integration in health care practices remains a challenge. Perceptions might shed light on these implementation difficulties. This systematic review aims to investigate links between perceptions and patient education practices among health care professionals, paying particular attention to the quality of practices in order to highlight any associated perception. Method. PubMed, PsycINFO, and Scopus were searched using the following search terms: "perceptions," "patient education," "health care professionals," and "professional practices." PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used. Results. Twenty studies were included. Overall findings supported the existence of links between some perceptions and practices. Links were either correlational or "causal" (generally in a single direction: perceptions affecting practices). Four types of perceptions (perceptions of the task including patient education, perceptions about the patient, perceptions of oneself as a health care professional, and perceptions of the context) were identified as being linked with educational practices. Links can although be mediated by other factors. Results concerning links should, however, be considered with caution as practices were mostly assessed by prevalence measurements, were self-reported and concerned exclusively individual education. When analyzing the quality of practices, the two retained studies highlighted their changing nature and the central role of perceptions with respect to the individual patient. Conclusions. This literature review led us to specify the quality criteria for further research: covering the entire spectrum of patient education, operationalizing variables, exploring specific practices, measuring the quality of practices, developing designs that facilitate causation findings, and considering a bidirectional perspective.

Storage mite concentrations are underestimated compared to house dust mite concentrations.

Dwellings are increasingly well insulated to save energy and this leads to higher humidity and temperature, which improves conditions for mites. Dermatophagoides antigens are the main allergens involved and tested in atopic asthma. We developed three new species-specific quantitative PCR (qPCR) methods for house dust mites (Dermatophagoides pteronyssinus and D. farinae) and storages mites (Acarus siro, Glycyphagus domesticus, Lepidoglyphus destructor). We sampled dust with electrostatic dust collectors, in the bedrooms, under beds and in the kitchens of patients with allergies (n = 24) and healthy controls (n = 18). Mite quantification was carried out with the three new qPCRs and the qPCR previously described for the Dermatophagoides genus. The qPCRs were highly specific and efficient for house dust mite species and the storage mites. Storage mite concentrations were higher than house dust mite concentrations and were higher in dwellings of patients with allergies. Consequently, allergists should test more often patients against the storage mite antigens by prick tests or IgE serology. Dampness is a major factor in storage mite development and the presence of effective mechanical ventilation can reduce storage mite concentrations four-fold. In addition, to limit exposure to dust mites, treatments should be used throughout dwellings and not only in patients' bedrooms.

Fungal contamination of wind instruments: Immunological and clinical consequences for musicians.

INTRODUCTION: Playing a wind instrument is an increasingly reported cause of hypersensitivity pneumonitis. However, current knowledge about contamination of wind instruments by fungi and specific fungal sensitization is scarce. Therefore, we aimed: (i) to assess the current prevalence and type of fungal contamination of wind instruments, (ii) to identify potential risk factors associated with instrument contamination, and (iii) to evaluate the prevalence of sensitization to these fungi among musicians. MATERIAL AND METHODS: Musicians from music schools in eastern France and who played a wind instrument were prospectively recruited (NCT01487850). The mouthpiece and the reed of their instrument were sampled to quantify the magnitude and type of fungi. Each subject had a physical examination, a mycological analysis of saliva and a blood sample in search of serum precipitins against the most frequent fungi isolated from instruments. The results were compared with those of 40 healthy non-exposed controls. RESULTS: Forty musicians playing a wind instrument (bassoon, clarinet, oboe, saxophone) were included. (i) 95% of wind instruments were colonized by fungi, mainly with Phoma spp., Penicillium spp. and Rhodotorula mucilaginosa; (ii) absence of systematic drying of the instrument was a main contributing factor; (iii) serum precipitins were significantly more present in the musicians' sera than in control sera and were consistent with the fungi present in their instrument. CONCLUSION: This study reveals a constant and specific fungal contamination among wind reed instruments with a significant sensitization among musicians, pleading in favour of regular instrument cleaning. Physicians should be aware of this possible source of antigenic exposure.

Usefulness of à la carte antigens for bird fancier's lung serodiagnosis: total dropping extract and/or dropping's microflora antigens.

Bird fancier's lung (BFL) is a pulmonary disease caused by inhalation of avian proteins. The involvement of the microorganisms of droppings has been assumed in the past and this idea still persists today. Our study aimed to compare by immunoprecipitation assay the detection of antibodies against both droppings and microorganisms in the sera of patients (n=15) and asymptomatic exposed controls (n=18). We found that 14/15 BFL patients had negative serological results for isolated microorganisms of the droppings, only one positive against Enterobacter sakasakii. Serological arguments were in accordance with diagnosis in 87 % of cases by testing à la carte antigens from each bird dropping versus 20 % using the standard antigenic panel. Otherwise, the microorganisms antigens issued from dropping flora were negative in 93 % of cases. Consequently, it's preferable to use the total extract from the patient's bird droppings to establish the serodiagnosis of the disease.

An immunoproteomic approach revealed antigenic proteins enhancing serodiagnosis performance of bird fancier's lung.

BACKGROUND: Bird fancier's lung (BFL) caused by repeated inhalation of avian proteins is the most common form of hypersensitivity pneumonitis. However, the exact identification of proteins involved is unknown, and serological test use for diagnosis need to be standardized. The objectives of this study were (i) to identify antigenic proteins from pigeon droppings (ii) to provide information about their location in avian matrices and (iii) to produce them in recombinant proteins to evaluate their diagnostic performances. METHOD: Antigenic proteins of pigeon dropping extracts were investigated using 2-dimensional immunoblotting with sera from patients with BFL, asymptomatic exposed controls and healthy volunteers. We investigated the origin of these antigenic proteins by analyzing droppings, blooms and sera using a shotgun proteomic analysis. BFL-associated proteins were produced as recombinant antigens in E. coli and were assessed in ELISA with sera from patients (n=25) and subject exposed controls (n=30). These diagnostic performances were compared with those obtained by precipitin techniques (agar gel double diffusion, immunoelectrophoresis). RESULTS: We identified 14 antigenic proteins mainly located in droppings and blooms. These proteins were involved in either the digestive or immune systems of pigeons. Using the recombinant BFL-associated proteins: Immunoglobulin lambda-like polypeptide-1 (IGLL1: sensitivity: 76%; specificity: 100%; AUC: 0.93) and Proproteinase E (ProE: sensitivity: 84%; specificity: 80%; AUC: 0.85), the ELISA test showed better performance than precipitin assays with pigeon dropping extracts (sensitivity: 60%; specificity: 93.3%; AUC: 0.76). CONCLUSION: IGLL1 and ProE were identified as the biomarkers of the disease. The use of these highly standardized antigens discriminates BFL cases from exposed subjects in serological assays. The results of this study offer new possibilities for the serological diagnosis of the disease. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: Identifier NCT03056404.

Assessment of pets (cats and dogs) in homes using electrostatic dust collectors and QPCR: new tools to evaluate exposure and risk of allergies.

Contradictory results are found in the literature concerning fungi, bacteria, and pet exposure and the risk of developing asthma. All these allergens have been thoroughly studied separately in cohort studies, and a variety of sampling and analytical methods are used. It is already possible to characterize fungi, mites, and bacteria by QPCR. The aim of our study is to evaluate QPCR systems to quantify the presence of cats and dogs in homes. Twenty-four houses were sampled with an Electrostatic Dust Collector which was analyzed by QPCR. Questionnaires on the presence of pets in homes were completed. The results from QPCR were correlated for real presence of cats and dogs, and highlighted indirect exposure. This study provides a useful screening tool that will be used in future large cohort studies, such as the ELFE cohort study.

Identification of Antigenic Proteins from Lichtheimia corymbifera for Farmer's Lung Disease Diagnosis.

The use of recombinant antigens has been shown to improve both the sensitivity and the standardization of the serological diagnosis of Farmer's lung disease (FLD). The aim of this study was to complete the panel of recombinant antigens available for FLD serodiagnosis with antigens of Lichtheimia corymbifera, known to be involved in FLD. L. corymbifera proteins were thus separated by 2D electrophoresis and subjected to western blotting with sera from 7 patients with FLD and 9 healthy exposed controls (HEC). FLD-associated immunoreactive proteins were identified by mass spectrometry based on a protein database specifically created for this study and subsequently produced as recombinant antigens. The ability of recombinant antigens to discriminate patients with FLD from controls was assessed by ELISA performed with sera from FLD patients (n = 41) and controls (n = 43) recruited from five university hospital pneumology departments of France and Switzerland. Forty-one FLD-associated immunoreactive proteins from L. corymbifera were identified. Six of them were produced as recombinant antigens. With a sensitivity and specificity of 81.4 and 77.3% respectively, dihydrolipoyl dehydrogenase was the most effective antigen for discriminating FLD patients from HEC. ELISA performed with the putative proteasome subunit alpha type as an antigen was especially specific (88.6%) and could thus be used for FLD confirmation. The production of recombinant antigens from L. corymbifera represents an additional step towards the development of a standardized ELISA kit for FLD diagnosis.

New Commercially Available IgG Kits and Time-Resolved Fluorometric IgE Assay for Diagnosis of Allergic Bronchopulmonary Aspergillosis in Patients with Cystic Fibrosis.

Allergic bronchopulmonary aspergillosis (ABPA) is difficult to diagnose; diagnosis relies on clinical, radiological, pathological, and serological criteria. Our aim was to assess the performance of two new commercially available kits and a new in-house assay: an Aspergillus fumigatus enzyme-linked immunosorbent assay (ELISA) IgG kit (Bordier Affinity Products), an Aspergillus Western blotting IgG kit (LDBio Diagnostics), and a new in-house time-resolved fluorometric IgE assay (dissociation-enhanced lanthanide fluorescent immunoassay, or DELFIA) using recombinant proteins from an Aspergillus sp. recently developed by our laboratory for ABPA diagnosis in a retrospective study that included 26 cystic fibrosis patients. Aspergillus fumigatus-specific IgG levels measured by a commercial ELISA kit were in accordance with the level of precipitins currently used in our lab. The ELISA kit could accelerate and help standardize ABPA diagnosis. Aspergillus fumigatus-specific IgE levels measured by ImmunoCAP (Phadia) with A. fumigatus M3 antigen and by DELFIA with a purified protein extract of A. fumigatus were significantly correlated (P < 10(-6)). The results with recombinant antigens glucose-6-phosphate isomerase and mannitol-1-phosphate dehydrogenase were encouraging but must be confirmed with sera from more patients. The DELFIA is an effective tool that can detect specific IgE against more fungal allergens than can be detected with other commercially available tests.

Western blotting as a tool for the serodiagnosis of farmer's lung disease: validation with Lichtheimia corymbifera protein extracts.

Electrosyneresis and double diffusion are immunoprecipitation techniques commonly used in the serological diagnosis of Farmer's lung disease (FLD). These techniques are reliable but lack standardization. The aim of this study was to evaluate Western blotting for the serodiagnosis of FLD. We carried out Western blotting with an antigenic extract of Lichtheimia corymbifera, an important aetiological agent of the disease. The membranes were probed with sera from 21 patients with FLD and 21 healthy exposed controls to examine the IgG antibody responses against purified somatic antigens. Given the low prevalence of the disease, 21 patients could be considered as a relevant series. Four bands were significantly more frequently represented in membranes probed with FLD sera (bands at 27.7, 40.5, 44.0 and 50.5 kDa) than those probed with control sera. We assessed the diagnostic value of different criteria alone or in combination. The diagnostic accuracy of the test was highest with the inclusion of at least two of the following criteria: at least five bands on the strip and the presence of one band at 40.5 or 44.0 kDa. Sensitivity, specificity and positive and negative predictive values were all 81%, and the odds ratio was 18.06. Inclusion of bands of high intensity diminished rather than improved the diagnostic value of the test. We concluded that Western blotting is a valuable technique for the serodiagnosis of FLD. The industrial production of ready-to-use membranes would enable the routine use of this technique in laboratories, and provide reliable and standardized diagnostic results within a few hours.

Immunoreactive proteins of Saccharopolyspora rectivirgula for farmer's lung serodiagnosis.

PURPOSE: Saccharopolyspora rectivirgula is the principal cause of farmer's lung disease (FLD). Serodiagnosis is based on immunoprecipitation techniques or enzyme immunoassays with homemade crude antigens and is not standardized. We aimed to produce specific recombinant antigens for the development of a standardized ELISA. EXPERIMENTAL DESIGN: We recruited 41 patients and 43 healthy exposed controls from five university hospital pneumology departments in France and Switzerland. S. rectivirgula proteins were extracted, separated by 2D electrophoresis, and subjected to Western blotting, with sera from FLD patients or controls. FLD-specific proteins were identified by MS and were produced as recombinant antigens. The diagnostic performance of ELISA tests using the recombinant antigens was assessed with all the sera from FLD patients and controls. RESULTS: We identified 25 FLD-specific proteins, some of which play important roles in transport, nutrition, or virulence. We produced 17 of these proteins as recombinant antigens and assessed their suitability for inclusion in the ELISA test. A combination of three of these proteins (SR1FA, SR17, and SR22) proved remarkably effective at discriminating between patients and controls, with a sensitivity of 83% and a specificity of 77%. CONCLUSIONS AND CLINICAL RELEVANCE: The recombinant antigens produced in this study constitute a major step toward the improvement of diagnostic performance and the standardization of FLD serodiagnosis.

Immunoproteomics for serological diagnosis of hypersensitivity pneumonitis caused by environmental microorganisms.

Diagnosis of immunoallergenic pathologies due to microorganisms such as hypersensitivity pneumonitis includes detection of circulating specific antibodies. Detection of precipitins has classically been performed using immunoprecipitation techniques with crude antigenic extracts from microorganisms implicated as etiologic agents. However, these techniques lack standardization because of the different composition of fungal antigenic extracts from one batch to another. Therefore, there is high interest in developing standardized serological diagnostic methods using recombinant antigens. Immunoproteomics have proved to be useful for identifying the immunogenic proteins in several microorganisms linked to hypersensitivity pneumonitis. With this approach, the causative microorganisms are first isolated from the environment of patients. Then the proteins are separated by two-dimensional electrophoresis and revealed by Western blotting with sera of different patients suffering from the disease compared to sera of asymptomatic exposed controls. Immunoreactive proteins are identified by mass spectrometry. Identified immunoreactive proteins found to be specific markers for the disease could be subsequently produced as recombinant antigens using various expression systems to develop ELISA tests. Using recombinant antigens, standardized ELISA techniques can be developed, with sensitivity and specificity reaching 80% and 90%, respectively, and more if using a combination of several antigens. Immunoproteomics can be applied to any environmental microorganisms, with the aim of proposing panels of recombinant antigens able to improve the sensitivity and standardization of serologic diagnosis of hypersensitivity pneumonitis, but also other mold-induced allergic diseases such as allergic broncho pulmonary aspergillosis or asthma.

Immunogenic proteins specific to different bird species in bird fancier's lung.

Bird fancier's lung (BFL) is a disease produced by exposure to avian proteins present in droppings, blooms, and serum of a variety of birds. Although serological test results are currently used to confirm clinical diagnosis of the disease, bird species specificity is poorly understood. This study aimed to contribute to a better understanding of the specificity of immunogenic proteins revealed from the droppings of three bird species. Sera from four patients with BFL and two controls without exposure were analyzed by Western blotting with antigens from droppings of two pigeon and budgerigar strains and two hen species. When the antigens from the droppings of the three bird species were compared, the profile of immunogenic proteins was different and there were similarities between strains of the same species. Only one 68-kD protein was common to pigeon and budgerigar droppings, while proteins of 200, 175, 140, 100, and 35 kD were detected as specific in one bird species. These results provide insight to further characterize these proteins, and to design new serological tests specific to different bird species. These tests may help to refine strategies of antigenic exclusion and also to allow a patient compensation in case of BFL of occupational origin.

qPCR standard operating procedure for measuring microorganisms in dust from dwellings in large cohort studies.

The aim of the present study was to assess performance, feasibility and relevance of a Standard Operational Procedure (SOP) for large-scale use in the microbial analysis of children's indoor environments. We analyzed dust settled on Electrostatic Dust Fall Collectors (EDCs) by using qPCR which targeted 6 molds, 3 bacteria and 1 mite, chosen for their involvement in allergic or inflammatory processes. Six types of commercialized electrostatic wipes were tested for their releasing capacity of fungal DNA from fungal spores captured by the wipes. Specificity, repeatability and detection limits of the qPCR procedure were tested using calibrated microbial suspensions. The feasibility and relevance of this sampling and analysis method were assessed in a 75-home pilot study. Our result showed that one specific make of wipe was more effective than the others in releasing fungal DNA. qPCR procedure showed good repeatability. The quantification limit was about 5 fg DNA/µL for all species except Penicillium chrysogenum (0.5 fg DNA/µL) and Dermatophagoïdes pteronyssinus (10 fg DNA/µL). No cross-reactivity was observed. DNA concentrations in the 53/75 homes participating in the pilot study were between 0 and 24 625, 0 and 69 738 equivalent cells per cm(2) for the fungi and bacteria, and between 0 and 1 equivalent mites per cm(2) for D. pteronyssinus. Using the SOP described, we were able to classify the 53 dwellings from the least to the most contaminated according to the quantity of DNA measured for each species. Our SOP measured fungi, bacteria and mites using a cost-efficient, discreet and well-accepted sampling method with just one qPCR tool. The whole procedure can be used for microbial analysis in large cohort studies such as the ELFE study ("Etude Longitudinale Française depuis l'Enfance") and could help improve our understanding of the interactions between the environment, allergic diseases and child development.

Validation of an automated blood culture system for sterility testing of cell therapy products.

BACKGROUND AIMS: Automated blood culture systems are widely used for the detection of microorganisms in cell therapy products. However, they are not validated by the manufacturers for this purpose. The aim of this study was to assess the ability of the Bactec system (Becton-Dickinson, Le Pont-De-Claix, France) to detect the microorganisms that could contaminate cell therapy products. METHODS: Three types of vials and conditions were tested: Plus Aerobic/F and Anaerobic/F media incubated at 35°C and Mycosis IC/F medium incubated at 30°C. All vials were incubated 10 days. We tested 18 microorganisms, including slow growers and some with fastidious nutritional requirements (10 bacteria, four yeasts, four filamentous fungi), each with four inocula (10-10(4) colony-forming units) performed in quintuplicate. RESULTS: The combination of Plus Aerobic/F and Plus Anaerobic/F vials detected all the tested pathogenic bacteria, all the tested Gram-positive skin commensal or environmental bacteria, all the tested yeasts, and three of four tested filamentous fungi. The addition of the Mycosis IC/F vial extended the range of detected microorganisms to one fungal environmental contaminant. Two bacterial environmental contaminants were not detected by our method. Low inocula of the skin contaminant Propionibacterium acnes were detected only after 7 days of incubation. CONCLUSIONS: These data suggest that (i) the prolongation of the incubation time of Plus Aerobic/F and Plus Anaerobic/F vials from 7 to 10 days and (ii) the use of Mycosis IC/F medium make minor contributions in the sterility testing of cell therapy products. We have validated the Bactec method using aerobic and anaerobic vials incubated 7 days at 35°C.

External validation of recombinant antigens for serodiagnosis of machine operator's lung.

BACKGROUND: Machine operator's lung (MOL) is a hypersensitivity pneumonitis the diagnosis of which is difficult. Our laboratory previously developed an ELISA test using recombinant antigens from Mycobacterium immunogenum isolated in French plant. The objective was to validate the previous ELISA results with ten new suspected cases from Germany. METHODS: Two serological analyses were performed: ELISA with the six recombinant antigens, and electrosyneresis with crude antigens of M. immunogenum and three other main species isolated from contaminated metalworking fluids. RESULTS: The two recombinant antigens acyl-CoA dehydrogenase and dihydrolipoyl dehydrogenase, combined together, and electrosyneresis are useful in making the diagnosis regardless of the clinical and radiological data. Finally 9 out of the 10 suspected cases were declared as MOL. CONCLUSIONS: Despite the geographical distance, the crude and recombinant antigens produced to investigate the clustered French cases also proved to be useful in diagnosing the suspected cases in Germany.