RESUMEN
PURPOSE: The National Lung Screening Trial (NLST) has renewed interest in low-dose computed tomography (LDCT) screening for lung cancer. Smokers may be less receptive toward LDCT screening, however, compared with never smokers. The views of patients with COPD, a particularly high-risk group, toward LDCT screening for lung cancer are currently unknown. We therefore evaluated attitudes of patients with COPD toward LDCT screening for lung cancer. METHODS: Interviews with Irish patients with COPD who satisfied NLST eligibility criteria were conducted in clinical settings using a questionnaire based on that of a comparable study of U.S. current/former smokers of unspecified disease status. RESULTS: A total of 142 subjects had a mean age of 65.09 ± 6.07 years (46.4 % were male, mean pack years 54.5 ± 33.3, mean FEV1 59.16 ± 23 %); 97.8 % had an identifiable usual source of healthcare. Compared with data from a U.S. cohort of current/former smokers, a higher proportion of Irish COPD smokers: believed that they were at risk for lung cancer (63.6 vs. 15.7 %); believed that early detection improved chances of survival (90 vs. 51.2 ); were willing to consider LDCT screening (97.9 vs. 78.6 %); were willing to pay for a LDCT scan (68.6 vs. 36.2 %); and were willing to accept treatment recommendations arising (95.7 vs. 56.2 %; p < 0.0001 for all comparisons). CONCLUSIONS: Urban Irish smokers with COPD who would be eligible for LDCT screening are almost universally in favor of being screened and treated for screening-detected lung cancers. This readily accessible high-risk population should be actively targeted in future screening programs.
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Actitud Frente a la Salud , Detección Precoz del Cáncer/psicología , Neoplasias Pulmonares/diagnóstico , Aceptación de la Atención de Salud , Enfermedad Pulmonar Obstructiva Crónica/psicología , Tomografía Computarizada por Rayos X , Población Urbana , Anciano , Femenino , Humanos , Irlanda , Masculino , Persona de Mediana Edad , Dosis de Radiación , FumarRESUMEN
The glutathione S-transferase (GST) enzymes catalyse the conjugation of xenobiotics to glutathione. Based on reports that inherited copy number variations (CNVs) modulate some GST gene expression levels, and that the small airway epithelium (SAE) and alveolar macrophages (AMs) are involved early in the pathogenesis of smoking-induced lung disease, we asked: do germline CNVs modulate GST expression levels in SAE and AMs? Microarrays were used to survey GST gene expression and determine CNVs genotypes in SAE and AMs obtained by bronchoscopy from current smokers and nonsmokers. 26% of subjects were null for both GSTM1 alleles, with reduced GSTM1 mRNA levels seen in both SAE and AMs. 30% of subjects had homozygous deletions of GSTT1, with reduced mRNA levels in both tissues. Interestingly, GSTT2B exhibited homozygous deletion in the blood of 27% of subjects and was not expressed in SAE in the remainder of subjects, but was expressed in AMs of heterozygotes and wild-type subjects, proportionate to genotype. These data show a germline CNV-mediated linear relationship of genotype with expression level, suggesting minimal compensation of gene expression levels in heterozygotes, consistent with GST polymorphisms playing a role in the risk of smoking-associated, xenobiotic-induced lung disease.
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Dosificación de Gen , Regulación de la Expresión Génica , Glutatión Transferasa/genética , Pulmón/metabolismo , Adulto , Alelos , Femenino , Perfilación de la Expresión Génica , Genotipo , Homocigoto , Humanos , Masculino , Persona de Mediana Edad , Análisis de Secuencia por Matrices de Oligonucleótidos , Polimorfismo GenéticoRESUMEN
BACKGROUND: Digital health technology (DHT) promises to support patients and healthcare professionals (HCPs) to optimize the management of chronic obstructive pulmonary disease (COPD). However, there is a lack of evidence demonstrating the effectiveness of DHT for the management of COPD. One reason for this is the lack of user-involvement in the development of DHT interventions in COPD meaning their needs and preferences are rarely accounted for in the design phase. Although HCP adoption issues have been identified in relation to DHT, little is known about the challenges perceived by HCPs providing care to COPD patients. Therefore, this study aims to qualitatively explore the barriers and facilitators HCPs perceive for the use of DHT in the management of COPD. METHODS: Participants (n = 32) were recruited using snowball sampling from two university hospitals and several general practitioner clinics. A semi-structured interview was conducted with each participant. NVivo 12 software was used to complete thematic analysis on the data. RESULTS: Themes identified include: data quality; evidence-based care; resource constraints; and digital literacy presented as barriers; and facilitators include the following themes: digital health training and education; improving HCP digital literacy; and Personalized prescribing. Patient-centered approaches, such as pulmonary rehabilitation and shared decision-making were suggested as implementation strategies to ease the adoption of digital health for the management of COPD. CONCLUSION: These findings contribute new insights about the needs and preferences of HCPs working in COPD regarding DHT. The findings can be used to help mitigate user-experience issues by informing the design of person-centered implementation and adoption strategies for future digital health interventions in COPD.
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Manejo de la Enfermedad , Personal de Salud , Enfermedad Pulmonar Obstructiva Crónica/terapia , Telemedicina/métodos , Actitud del Personal de Salud , Humanos , Entrevistas como Asunto , Investigación Cualitativa , Telemedicina/normasRESUMEN
It can be challenging to teach and assess medical students successfully in the setting of a hospital ward using real patients. We describe a novel method of providing weekly formative clinical assessment and teaching to final year students on an acute medical ward: The Team Objective Structured Bedside Assessment (TOSBA). The TOSBA involves three groups of five students rotating through three ward-based stations (each station consists of an inpatient and facilitator). Each group spends 25 minutes at a bedside station where the facilitator asks consecutive students to perform one of five clinical tasks. Every student receives a standardised grade and is provided with educational feedback at each of the three stations. We report our 15-month experience using the TOSBA format to assess and teach a large number of medical students on a weekly basis. We discuss the advantages and potential drawbacks of our approach.
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Educación de Pregrado en Medicina , Evaluación Educacional/métodos , Hospitales de Enseñanza , Pacientes , Enseñanza , Evaluación Educacional/normas , Estudios de Factibilidad , Retroalimentación Psicológica , Humanos , Encuestas y Cuestionarios , Enseñanza/normasRESUMEN
Animals will continue to encounter increasingly warm environments, including more frequent and intense heat waves. Yet the physiological consequences of heat waves remain equivocal, potentially because of variation in adaptive plasticity (reversible acclimation) and/or aspects of experimental design. Thus, we measured a suite of physiological variables in the corn snake (Pantherophis guttatus) after exposure to field-parameterized, fluctuating temperature regimes (moderate temperature and heat wave treatments) to address two hypotheses: (1) a heat wave causes physiological stress, and (2) thermal performance of immune function exhibits adaptive plasticity in response to a heat wave. We found little support for our first hypothesis because a simulated heat wave had a negative effect on body mass, but it also reduced oxidative damage and did not affect peak performance of three immune metrics. Likewise, we found only partial support for our second hypothesis. After exposure to a simulated heat wave, P. guttatus exhibited greater performance breadth and reduced temperature specialization (the standardized difference between peak performance and performance breadth) for only one of three immune metrics and did so in a sex-dependent manner. Further, a simulated heat wave did not elicit greater performance of any immune metric at higher temperatures. Yet a heat wave likely reduced innate immune function in P. guttatus because each metric of innate immune performance in this species (as in most vertebrates) was lower at elevated temperatures. Together with previous research, our study indicates that a heat wave may have complex, modest, and even positive physiological effects in some taxa.
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Calor/efectos adversos , Estrés Oxidativo/fisiología , Serpientes/fisiología , Animales , Femenino , Inmunidad Innata/fisiología , Masculino , Serpientes/sangre , Serpientes/inmunologíaRESUMEN
The legal/ethical status of Do Not Attempt Resuscitation (DNAR) orders in Ireland has not been clarified, nor have national policies been formulated. We questioned 298 consultant physicians in the Republic of Ireland about DNAR orders. 173 replies were received (58%). 85 expressed unsatisfactory understanding of issues relating to Irish DNAR orders (49%). 116 physicians felt that alert patients preferred not to discuss their own resuscitation (67%). 55 physicians felt that if a competent adult patient is the subject of a DNAR order without the patient's knowledge, the reasons for this decision are "almost never" documented in the patient's medical record (32%). 75 consultants "almost never" had advance discussion of resuscitation preferences with the patient (43%). 47 physicians had experienced advance directives for Irish patients (27%). 102 physicians felt that both they and the patient's next of kin had joint responsibility for deciding resuscitation status for an incapacitated patient with no advance directive (59%). 37 respondents described a formal resuscitation policy in their place of work (21%). We feel that physicians require greater national guidance regarding DNAR order-making, and we advocate more widespread use of resuscitation policies.
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Directivas Anticipadas/ética , Actitud del Personal de Salud , Órdenes de Resucitación/ética , Directivas Anticipadas/legislación & jurisprudencia , Comprensión , Recolección de Datos , Gobierno Federal , Humanos , Irlanda , Política Organizacional , Satisfacción del Paciente , Rol del Médico , Médicos de Familia , Órdenes de Resucitación/legislación & jurisprudencia , Encuestas y CuestionariosRESUMEN
INTRODUCTION: Long-term daily azithromycin therapy reduces the frequency of exacerbations in chronic obstructive pulmonary disease (COPD) in a randomized controlled clinical trial setting. Concerns exist regarding arrhythmic and auditory toxicities from chronic use in the real-world setting. We hypothesized that risk factors for adverse drug reactions to azithromycin would be more frequent than previously reported, that certain specific subgroups would have different frequencies of these risk factors and that the whispered voice test would be a useful test with which to test for hearing deficits. METHODS: Following ethical approval, 47 consecutive hospital-based patients with a mean age 69 years ± 8.2, and with physician-diagnosed COPD (mean FEV1 45.1 ± 18 % predicted), were screened for subjective hearing impairment (screening questions and whispered voice test) and by electrocardiogram for prolonged QTc. Other potential risk factors and contraindications to long-term daily azithromycin were sought. RESULTS: In total, 38 patients (80.9 %) had at least one risk factor or contraindication to azithromycin treatment. 19 patients (40.4 % of total) had subjective hearing impairment. 17 (36.1 %) had prolonged QTc intervals. 4 patients (8.51 %) had contraindicating co-morbidities. Those on long-term oxygen therapy were significantly more likely to have at least one risk factors or contraindications to azithromycin (p = 0.0025). CONCLUSION: In a COPD population who would otherwise potentially be candidates for long-term daily azithromycin therapy, over 80 % had risk factors for complications from long-term daily azithromycin. Preventative treatment with long-term daily azithromycin may be appropriate for fewer COPD patients than previously thought, especially in those on long-term oxygen therapy.
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Antibacterianos , Azitromicina , Trastornos de la Audición/inducido químicamente , Oxígeno/uso terapéutico , Enfermedad Pulmonar Obstructiva Crónica/terapia , Anciano , Antibacterianos/uso terapéutico , Contraindicaciones , Femenino , Insuficiencia Cardíaca/complicaciones , Humanos , Síndrome de QT Prolongado/complicaciones , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
Inhaled nitric oxide (NO) is effective as a selective pulmonary vasodilator, but its effects on uninjured lungs subjected to normoxia and hypoxia have not been fully studied. The authors sought the response of pulmonary vascular resistance (PVR) to inhaled NO in piglet lungs devoid of ischemic injury in a model of reversible pulmonary hypertension. If the changes were dose-responsive, the authors asked whether the PVR changes were related to normoxia or hypoxia, and hypothesized that the change would be more pronounced for hypoxia than normoxia. In situ isolated piglet lungs were prepared by occlusive tracheostomy and ligation of the ductus arteriosus and aorta. Cannulae positioned in the left atrium and pulmonary artery were connected to a standard extracorporeal membrane oxygenation (ECMO) circuit, and flow was increased to approximate cardiac output. After stabilization, piglets (aged 5 to 14 days, weighing 3.2 to 6.4 kg) were divided into two groups of four each: normoxic (FIO2 0.30, normal PVR) and hypoxic (FIO2 0.07, increased PVR). NO was administered at 10 to 80 parts per million (ppm) in increments of 10 ppm, for 5 minutes at each concentration, with a return to baseline before each new dose. Flow, pulmonary arterial (PA) and left atrial (LA) pressures were continuously monitored, from which PVR was calculated (PVR = [PPA - PLA]/flow) and expressed as log delta PVR. Data were analyzed statistically by repeated measures of analysis of variance, comparing log delta PVR to baseline at each dose of NO, and comparing log delta PVR for normoxic and hypoxic lungs at each dose of NO.(ABSTRACT TRUNCATED AT 250 WORDS)
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Hipertensión Pulmonar/tratamiento farmacológico , Hipoxia/fisiopatología , Pulmón/fisiopatología , Óxido Nítrico/farmacología , Animales , Animales Recién Nacidos , Relación Dosis-Respuesta a Droga , Oxigenación por Membrana Extracorpórea , Porcinos , Resistencia Vascular/efectos de los fármacosRESUMEN
BACKGROUND: Quinolones have traditionally had limited application in the area of community-acquired respiratory tract infections due to poor cover against Streptococcus pneumoniae. This trend is changing with the broader spectrum of newer fluoroquinolones. A rare serious side effect of fluoroquinolones is tendinopathy. AIMS: This study describes two cases of levofloxacin-associated tendinopathy in patients with severe chronic obstructive pulmonary disease (COPD) and the implications and mechanisms involved are discussed. CONCLUSIONS: The finding of two cases of levofloxacin-induced tendinopathy in our patients suggests that the problem may be more frequent than previously considered. Patients with COPD treated with fluoroquinolones may have other risk factors for tendinopathy such as advanced age, corticosteroid use and renal impairment and merit vigilance for signs of tendonitis.
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Antiinfecciosos/efectos adversos , Levofloxacino , Ofloxacino/efectos adversos , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Tendinopatía/inducido químicamente , Tendón Calcáneo , Anciano , Humanos , Masculino , Persona de Mediana Edad , Streptococcus pneumoniae/efectos de los fármacosRESUMEN
BACKGROUND: Hydatid disease is rare in Ireland and its incidence and prevalence are unknown. Most cases are diagnosed by a combination of clinical findings, morphological features on imaging and by serological testing. AIMS: We describe an Irish case of pulmonary hydatid disease detected at bronchoscopy by bronchoalveolar lavage, and discuss the diagnosis and treatment of the disorder. CONCLUSION: The diagnosis of this rare disease requires a high index of suspicion. Treatment is primarily surgical, with a role for antihelminthic agents.
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Equinococosis Pulmonar/diagnóstico , Adulto , Lavado Broncoalveolar , Broncoscopía , Terapia Combinada , Diagnóstico Diferencial , Equinococosis Pulmonar/terapia , Femenino , Humanos , IrlandaRESUMEN
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a major cause of hospital admissions. Because of the consequent morbidity, mortality and burden on hospital resources, COPD management guidelines have been formulated. We reviewed 62 consecutive patients with AECOPD admitted from September 1st to December 18th 2000 in St. Vincents University Hospital, Ireland, including 3 months follow-up data, to evaluate the quality of care and in particular to assess the care of such patients by respiratory and non-respiratory physicians. There was a frequent failure to objectively confirm the diagnosis of COPD by spirometry (completed in 39 of the 51 patients who, at admission, had been previously labelled with COPD (76%), and in 53 out of 62 patients (85%) at the end of the study period), or to estimate severity by quantifying the FEV1 as a percentage of the normal predicted range (estimated in only 21 of the 39 patients who had spirometry previously performed (53%)). Those patients managed with input from respiratory physicians were more likely to have their diagnosis of COPD confirmed with spirometry (p < 0.05). They were also more likely to have out-patient follow-up arranged at discharge (p < 0.05). There was a trend towards the more frequent prescribing of oxygen to hypoxic patients in "respiratory" than in "non-respiratory" managed cases (p = 0.182) and a shorter hospital stay (0.1 < p < 0.5). 4 out of 11 severely hypoxaemic patients at admission (PO2 < 7.3kPa) were not screened at discharge for possible long term oxygen therapy (36%). 20 patients received combination antibiotic therapy with no infiltrate on CXR (32%). Pulmonary rehabilitation was offered to 12 patients (19%). 5 out of 18 current smokers had documented smoking cessation advice (28%) and none received smoking cessation pharmacotherapy. Finally we noted that the Hospital In-Patient Enquiry (HIPE) data and casualty department admission books were frequently misleading or medical records unlocatable (in 30 out of 92 cases (33%)). We conclude that the management of AECOPD at St. Vincent's University Hospital is frequently suboptimal, and may be managed better with respiratory physician involvement. In particular, there could be more frequent spirometric confirmation of the diagnosis of COPD, better screening for long term oxygen therapy and more conservative use of antibiotics. Audit is complicated by difficulty accessing relevant data.
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Pautas de la Práctica en Medicina , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Irlanda , Masculino , Auditoría Médica , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Pneumococcal disease, especially in its invasive form, is a significant cause of morbidity and mortality worldwide. However, with the advent of vaccination, invasive disease is potentially avoidable. This study aimed to assess the documentation of pneumococcal vaccination status in elderly patients by healthcare professionals in a busy teaching hospital environment. METHODS: One hundred and fifty-seven open (active) medical records of inpatients and outpatients aged over 65 years were reviewed, to examine for evidence of documentation of pneumococcal vaccination status. RESULTS: From the medical records, 338 patient encounters were studied. Overall, there was a mean of 2.4±1.2 indications for pneumococcal vaccination, with more indications in medical than in surgical patients (P=0.04). The rate of recording in respiratory outpatient clinics was 71.4% in comparison to 0% in other medical and surgical outpatient clinics. Overall the documentation rate was 2.1%. CONCLUSIONS: Only respiratory physicians had demonstrable evidence of actively asking about pneumococcal vaccination on a regular basis. There is considerable need for increased awareness among healthcare professionals and improvement in methods of recording vaccination status.
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Pacientes Internos/estadística & datos numéricos , Pacientes Ambulatorios/estadística & datos numéricos , Infecciones Neumocócicas/prevención & control , Vacunas Neumococicas/administración & dosificación , Vacunación/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Documentación , Femenino , Hospitales de Enseñanza , Humanos , Masculino , Registros MédicosRESUMEN
PURPOSE: The Global Paediatric Surgery Network (GPSN) website was launched in May 2010, with the following goals: to serve as a clearing house for pediatric surgery volunteer work performed worldwide, to provide online resources for surgeons working in areas of limited medical resources, and to provide practical and educational information for surgeons who wish to volunteer. The purpose of this study was to assess use of the website over the first year since its launch (May 6, 2010-May 5, 2011). METHODS: The GPSN website was examined for number of pages, number of listings in Past Work, Present Work, and Help Needed categories, as well as number of volunteers available. The online tool Google Analytics was used to assess parameters that measure use of the website, such as number of visits, number of page views, number of visitors, time on the website, and geographic origin of visitors. RESULTS: The GPSN website consists of 30 pages. There are 9 listings in Past Work, 23 listings in Present Work, and 13 listings in Help Needed categories. 118 people have registered as willing to volunteer, and 96 have indicated that they are able to work in times of a natural disaster. There were 8437 visits to the website, with 28 916 page views by 5170 visitors from 145 countries, with an average number of page views of 3.43 and an average time on the website of 4:05 min. The most visited pages were the homepage, the meetings page, and the pediatric surgery organizations page. 4 websites of pediatric surgery organizations have links to the GPSN website. CONCLUSIONS: Based on early website use, we conclude that there is an interest in the GPSN. We speculate that participation in the GPSN will continue to grow, but that there is a continued need to promote the website in the global pediatric surgery community.
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Internet/estadística & datos numéricos , Sistemas en Línea/estadística & datos numéricos , Pediatría/estadística & datos numéricos , Humanos , Especialidades Quirúrgicas , VoluntariosRESUMEN
Despite advances in infant transport and intensive care, congenital diaphragmatic hernia (CDH) still poses a serious threat to life during the neonatal period. Only with the introduction of extracorporeal membrane oxygenation (ECMO) has mortality declined significantly. Understanding the pathophysiology of CDH and its devastating effect on the lungs' bronchial and vascular development assists the clinician in rational management during the perioperative period. Successful treatment demands prompt diagnosis, informed preoperative assessment and preparation, carefully timed surgical repair, and aggressive postoperative intensive care with a thorough understanding of the role of ECMO. Improvements in ventilatory support and pharmacologic management of pulmonary hypertension have allowed surgeons to delay repair until circulatory hemodynamics, electrolytes, and oxygenation can be optimized, even resorting to preoperative ECMO in selected cases if needed. Patients with severe bilateral pulmonary hypoplasia pose serious dilemmas in terms of selection for ECMO, as well as for surgical repair. Long-term follow-up of patients after CDH repair reveals persistent hypoperfusion of the involved lung but no debilitating pulmonary disease. Future therapies may include early fetal intervention or lung transplantation, although these areas remain controversial and experimental, and clinical experience is limited.