A mathematical model for designing networks of C-Reactive Protein point of care testing.

One approach to improving antibiotic stewardship in primary care may be to support all General Practitioners (GPs) to have access to point of care C-Reactive Protein tests to guide their prescribing decisions in patients presenting with symptoms of lower respiratory tract infection. However, to date there has been no work to understand how clinical commissioning groups might approach the practicalities of system-wide implementation. We aimed to develop an accessible service delivery modelling tool that, based on open data, could generate a layout of the geographical distribution of point of care facilities that minimised the cost and travel distance for patients across a given region. We considered different implementation models where point of care tests were placed at either GP surgeries, pharmacies or both. We analysed the trade-offs between cost and travel found by running the model under different configurations and analysing the model results in four regions of England (two urban, two rural). Our model suggests that even under assumptions of short travel distances for patients (e.g. under 500m), it is possible to achieve a meaningful reduction in the number of necessary point of care testing facilities to serve a region by referring some patients to be tested at nearby GP surgeries or pharmacies. In our test cases pharmacy-led implementation models resulted in some patients having to travel long distances to obtain a test, beyond the desired travel limits. These results indicate that an efficient implementation strategy for point of care tests over a geographic region, potentially building on primary care networks, might lead to significant cost reduction in equipment and associated personnel training, maintenance and quality control costs; as well as achieving fair access to testing facilities.

Prediction Equations Underestimate Resting Energy Expenditure in Patients With End-Stage Cystic Fibrosis.

BACKGROUND: Resting energy expenditure (REE) is increased in patients with cystic fibrosis (CF) with end-stage lung disease due to chronic inflammation and pulmonary infections. After lung transplantation (LTx), energy expenditure is expected to be lower because inflammation will decrease. We assessed the agreement between measured and predicted REE in pre-LTx CF and post-LTx patients with CF and differences in REE in pre-LTx CF and post-LTx patients with CF in a cross-sectional study. METHODS: Included were 12 pre-LTx patients with CF (9 women; median age 31.6 years; interquartile range [IQR], 23.3-40.0) and 12 patients with CF within 2 years after LTx (6 women; median age 33.5 years; IQR, 22.3-40.3). REE was measured in a fasted state using indirect calorimetry. Values were compared with predicted REE calculated by formulas of Harris-Benedict (1919 and 1984), Schofield, and the World Health Organization (1985). A calculated REE between 90% and 110% of REE measured was considered adequate. RESULTS: Prediction equations underestimate REE in at least 75% of pre-LTx and 33% of post-LTx patients with CF. Mean (SD) REE measured by indirect calorimetry was 1735 (251) kcal pre-LTx and 1650 (235) kcal post-LTx ( P = .40). REE expressed per kilogram of fat-free mass (FFM) was 40.5 kcal/kg in pre-LTx patients with CF, which was higher than the 34.3 kcal/kg in post-LTx patients with CF ( P = .01). CONCLUSIONS: Prediction equations underestimate REE in patients with end-stage CF. REE per kg of FFM is lower post-LTx than pre-LTx in patients with CF. Measurement of REE is recommended for patients with CF, especially pre-LTx, to optimize energy requirements for improving nutrition status.

The Vitamin D Assessment (ViDA) Study: design of a randomized controlled trial of vitamin D supplementation for the prevention of cardiovascular disease, acute respiratory infection, falls and non-vertebral fractures.

Observational studies have shown that low vitamin D status is associated with an increased risk of cardiovascular disease, acute respiratory infection, falls and non-vertebral fractures. We recruited 5110 Auckland adults, aged 50-84 years, into a randomized, double-blind, placebo-controlled trial to test whether vitamin D supplementation protects against these four major outcomes. The intervention is a monthly cholecalciferol dose of 100,000IU (2.5mg) for an estimated median 3.3 years (range 2.5-4.2) during 2011-2015. Participants were recruited primarily from family practices, plus community groups with a high proportion of Maori, Pacific, or South Asian individuals. The baseline evaluation included medical history, lifestyle, physical measurements (e.g. blood pressure, arterial waveform, lung function, muscle function), and a blood sample (stored at -80°C for later testing). Capsules are being mailed to home addresses with a questionnaire to collect data on non-hospitalized outcomes and to monitor adherence and potential adverse effects. Other data sources include New Zealand Ministry of Health data on mortality, hospitalization, cancer registrations and dispensed pharmaceuticals. A random sample of 438 participants returned for annual collection of blood samples to monitor adherence and safety (hypercalcemia), including repeat physical measurements at 12 months follow-up. The trial will allow testing of a priori hypotheses on several other endpoints including: weight, blood pressure, arterial waveform parameters, heart rate variability, lung function, muscle strength, gait and balance, mood, psoriasis, bone density, and chronic pain.

Assessment of oxidative stress biomarkers in exhaled breath condensate and blood of Thoroughbred foals.

This study reports preliminary data on systemic and local biomarkers of oxidative stress (OS) in Thoroughbred foals. Blood and exhaled breath condensate (EBC) were sampled from 13 foals on two farms. Values of reactive oxygen metabolites (d-ROMs), biological antioxidant potential (BAP), antioxidant barrier (OXY-ads), thiol antioxidant barrier (SHp) and advanced oxidation protein products (AOPPs) were determined in blood, while EBC samples were assayed for hydrogen peroxide (H(2)O(2)) levels. Systemic and local OS biomarkers did not differ between farms and gender. Increased oxidative stress index (OSI) values in a foal recovering from pneumonia and elevated H(2)O(2) in EBC coupled with low SHp and elevated AOPPs in the blood of a foal with overt upper respiratory tract disease suggested that the OS markers measured in this study may relate to the respiratory health status of foals.

Effects of exposure to calves persistently infected with bovine viral diarrhea virus type 1b and Mannheimia haemolytica challenge on animal performance, nitrogen balance, and visceral organ mass in beef steers.

Bovine viral diarrhea viruses (BVDV) have been isolated alone or in combination with other viral and bacterial pathogens in animals diagnosed with bovine respiratory disease (BRD), a disease causing major economic loss to the feedlot industry. The objective of this experiment was to determine the effects of Mannheimia haemolytica challenge after short-term exposure (72 h) to bovine viral diarrhea virus type 1b (BVDV1b) persistently infected (PI) calves on performance, N balance, and organ mass in finishing cattle. Treatments (6 steers/treatment; initial BW = 314 +/- 31 kg) were 1) steers not exposed to steers PI with BVDV nor challenged with M. haemolytica (control; CON); 2) steers exposed to 2 steers PI with BVDV1b (BVD) for 72 h; 3) steers intratracheally challenged with M. haemolytica (MH); or 4) steers exposed to 2 steers PI with BVDV1b for 72 h and challenged with M. haemolytica (BVD+MH). There were 12 h between exposure to PI steers and challenge with M. haemolytica. Steers were housed in metabolism stanchions during the first 5 d after the M. haemolytica challenge and on d 7 to 11, 28 to 32, and for 5 d before slaughter (average 119 d on feed) to determine N balance and were weighed every 28 d. At slaughter, carcass and organ mass data were collected. Data were analyzed as a randomized complete block design with a 2 x 2 factorial arrangement of treatments, and steer was used as the experimental unit. From d -3 (beginning of PI steer exposure) to 4, steers challenged with M. haemolytica had less (P = 0.04) ADG than steers not challenged with M. haemolytica. In addition, steers exposed to steers PI with BVDV tended (P = 0.09) to have less ADG and G:F across the entire finishing period than steers not exposed to BVDV. Before slaughter, retained N expressed as grams per day (P = 0.03) and as a percentage of N intake (P = 0.04) was less in BVD steers compared with steers not exposed to BVDV. There were no effects (P > 0.10) of BVDV exposure or M. haemolytica challenge on empty BW (EBW) or carcass characteristics. Expressed as a percentage of EBW, HCW was less (P = 0.02) and total offal weight was greater (P = 0.02) for steers challenged with M. haemolytica compared with steers not challenged. Results are in agreement with those reported in larger scale finishing studies and suggest that acute exposure to BRD-related pathogens can have long-term effects on animal performance.

Determinação do prazo de validade do medicamento carbocisteína xarope através do método de Arrhenius / Determination of carbocysteine syrup shelf life by Arrhenius method

A carbocisteína é um agente mucolítico utilizado como adjuvante no tratamento de infecções do trato respiratório. A qualidade, segurança e eficácia do medicamento durante o seu prazo de validade são responsabilidades da indústria farmacêutica. A validade pode ser determinada através de estudos de estabilidade acelerados, nos quais fatores extrínsecos provocam a degradação do produto. De acordo com Arrhenius, existe uma relação entre temperatura e cinética química. Desta forma, amostras do produto foram expostas a condições drásticas: 40, 50, 60 e 70 ºC. O método de doseamento do xarope de carbocisteína foi validado podendo ser aplicado nas avaliações de rotina do controle de qualidade e no estudo de estabilidade deste produto. O prazo de validade proposto para o xarope de carbocisteína, calculado através da equação de Arrhenius, para a temperatura de 25 ºC foi de 240,9 dias. No entanto, foi observada diferença entre o prazo proposto e a validade usualmente praticada para este produto. Este estudo, ainda, demonstrou a presença de picos endógenos, que precisam ser melhor estudados a fim de se confirmar a presença de produtos de degradação.

Carbocysteine is a mucolytic agent in adjunctive therapy of respiratory tract infections. The pharmaceutical industry is responsible for quality, safety and efficiency of the product during its shelf life. Shelf life can be determinated through an accelerated stability study where the degradation of the drug is managed with the extrinsic factors. According to Arrhenius, there is a relationship between temperature and chemical kinetic, so, the samples were exposed to drastic conditions at 40, 50, 60 and 70 ºC. The syrup assay method has been validated and it may be applied to analysis of carbocysteine syrup in routine quality control and stability studies. Through Arrhenius equation the proposed shelf life of carbocysteine syrup was 240.9 days when the dosage form is stored in appropriated conditions, 25 ºC. However difference was found between the proposed shelf life and the usual shelf life of this drug. In addition, this study has showed the presence of endogenous peaks that must be better evaluated to confirm or not the presence of degradation products.

Feasibility of assessment of regulatory lipids in breath condensate as potential presymptomatic harbingers of pulmonary pathobiology.

Regulatory lipids from the airway surface readily form aerosols that can be recovered non-invasively by cooling expired breath to form breath condensate (BC). Regulatory lipids have been detected previously utilizing enzyme-linked-immunosorbent serologic assay (ELISA). Here we test the feasibility of assessment of regulatory lipids in BC by mass spectrometry so presently unknown lipid regulatory components can be detected without addition of specific antibodies as in the ELISA procedure. Baseline regulatory lipids were detected in >pg/mL BC in control animals or human lung tissue culture cells. In nearly every case animals exposed to toxins or infectious bacteria showed increases in the BC regulatory components. Lipids were recovered from BC by solid phase extraction. Phosphatidylcholine (PC) based lipids were detected as the progenitor (parent) ions of isomers that fragmented in producing product positive ions at m/z 184 (of phosphocholine) in tandem MS using capillary HPLC and electrospray ionization. BC eicosanoids such as prostaglandins, thromboxane, and isoprostanes require capillary gas chromatography for separation and detection that necessitates methoximation, pentafluorobenzyl (PFB) ester formation, and trimethyl silylation of hydroxyls prior to gas chromatography/ion trap tandem mass spectrometry of negative ions after chemical ionization (NICI). Tetradeuterated internal standards were utilized for quantitation with the GC/NICI/MS. Changes in concentrations of lipids and eicosanoids were observed in piglets, and rats exposed to aerosolized 100 mug/kg lipopolysaccharide (LPS), or 50 mug/kg and 150 mug/kg aerosolized Staphylococcal enterotoxin B (SEB) in BC as well as in human THP-1 cell culture cell supernatants and bronchoalveolar lavage (BAL) samples in rats. Responses of the molecular species of phosphatidylcholines (PCs), platelet activating factors (PAFs) and specific eicosanoids correlated to the toxin and bacterial infections suggesting that patterns of differential responses could be detected with further experimentation. Initial targets included prostaglandins (PGE(2), PGF(2alpha)), thromboxane (TXB2), and prostacyclin (as 6-Keto PGF(1alpha)) that show differential responses to inflammation, the leukotriene (LTB4) and PGD2 for allergic responses, isoprostanes (8-iso-PGF(2alpha)) for free radical oxidative stress responses, and HETEs for differential lipoxygenase activities. PAFs and lysoPAFs have been shown to increase with inflammation and in the feasibility experiments reported here. Preliminary studies show pulmonary responses of piglets to intrathecal exposure of toxicants (LPS and SEB) or infections with Actinobacillus pleuropneumoniae induce increased levels of lipids and two eicosanoids with the suggestion that differential patterns might be detected with expanded testing. Preliminary experience indicates numerous other eicosanoids were available for assay in BC. This suggests an important potential application of BC to observe a wide array of factors to establish comprehensive profiles for physiological and pathophysiological states. Ultimately this technique could be used as a non-invasive possibly presymptomatic assessment of pulmonary pathobiology.

Resting energy expenditure in young patients with cystic fibrosis receiving antibiotic therapy for acute respiratory exacerbations.

BACKGROUND: patients with cystic fibrosis commonly have severe malnutrition and growth retardation. Among possible causes of these manifestations are low caloric intake, loss of nutrients and increased resting energy expenditure. This study was designed to assess the influence of antibiotic therapy for infectious exacerbations on resting energy expenditure in young patients with cystic fibrosis. METHODS: We studied 17 patients with cystic fibrosis (mean age, 13.6 years). All were hospitalized to receive intravenous antibiotic therapy (mean duration, 2 weeks) for acute respiratory exacerbations. At the beginning of therapy and after it ended, all patients underwent blood chemical tests, anthropometrical measures, determination of body composition by bioelectrical impedance, spirometry, and indirect calorimetry. RESULTS: Antibiotic therapy led to a significant improvement in biochemical, spirometric variables and in estimated calorimetry measurements expressed in relation to fat-free mass. These findings suggest that infective exacerbations are among the causes of increased resting energy expenditure in young patients with cystic fibrosis. CONCLUSIONS: Indirect calorimetry may prove useful in the diagnosis of infective exacerbations and in monitoring the effect of antibiotic therapy in patients with cystic fibrosis.

A risk-benefit assessment of levofloxacin in respiratory, skin and skin structure, and urinary tract infections.

As a class, the quinolone antibacterials can no longer be assumed to be both effective and relatively free of significant adverse effects. Recent safety issues with newer generation fluoroquinolones, and concerns regarding drug-use associated bacterial resistance have made all drugs in this class subject to intense scrutiny and further study. Levofloxacin is a second generation fluoroquinolone with a post marketing history of well tolerated and successful use in a variety of clinical situations. Quinolones as a class cause a variety of adverse effects, including phototoxicity, seizures and other CNS disturbances, tendonitis and arthropathies, gastrointestinal effects, nephrotoxicity, prolonged QTc interval and torsade de pointes, hypo- or hyperglycaemia, and hypersensitivity reactions. Levofloxacin has been involved in only a few case reports of adverse events, which include QTc prolongation, seizures, glucose disturbances, and tendonitis. Levofloxacin has been shown to be effective at dosages of 250mg to 500mg once-daily in clinical trials in the management of acute maxillary sinusitis, acute bacterial exacerbations of chronic bronchitis, community-acquired pneumonia, skin and skin structure infections, and urinary tract infections. There are data suggesting that levofloxacin may promote fluoroquinolone resistance among the Streptococcus pneumoniae, and that clinical failures may result from this therapy. Other data suggest that fluoroquinolones with lower potency against Pseudomonas aeruginosa than ciprofloxacin, such as levofloxacin, may drive class-wide resistance to this pathogen. Levofloxacin is an effective drug in many clinical situations, but its cost is significantly higher than amoxicillin, erythromycin, or first and second generation cefalosporins. Because of the propensity to select for fluoroquinolone resistance in the pneumococcus and potentially other pathogens, levofloxacin should be an alternative agent rather than a drug-of-choice in routine community-acquired respiratory tract, urinary tract, and skin or skin structure infections. In areas with increasing pneumococcal beta-lactam resistance, levofloxacin may be a reasonable empiric therapy in community-acquired respiratory tract infections. Similarly, in patients with risk factors for infectious complications or poor outcome, levofloxacin may be an excellent empiric choice in severe community-acquired respiratory tract infections, urinary tract infections, complicated skin or skin structure infections, and nosocomial respiratory and urinary tract infections. Better clinical data are needed to identify the true place in therapy of the newer fluoroquinolones in common community-acquired and nosocomial infections. Until then, these agents, including levofloxacin, might best be reserved for complicated infections, infection recurrence, and infections caused by beta-lactam or macrolide-resistant pathogens.

Clinical efficacy and antimicrobial pharmacodynamics.

Changes in the susceptibility of bacterial pathogens and the availability of new antimicrobial drugs mean that physicians need to understand the underlying pharmacodynamics of each antimicrobial therapy. Antimicrobial pharmacodynamics determine clinical efficacy and should therefore be carefully considered when selecting appropriate antibiotic agents in the therapeutic setting.

Avaliaçäo comparativa da eficácia e tolerabilidade do nimesulide, diclofenaco e dipirona sódica aplicados aos processos inflamatórios do trato respiratório superior em populaçäo pediátrica / Comparative assessment on the efficacy and tolerability of nimesulide, diclofenac potassium and dipyrone applyed to inflammatory processes of the superior respiratory tract in the pediatric population

Em um estudo randomizado, comparativo e prospectivo se analizou a eficácia e a tolerabilidade de dois antiinflamatórios (nimesulide e diclofenaco potássico) e uma droga analgésica/antitérmica (dipirona) diante de processos inflamatórios do trato respiratório superior (faringites e/ou amigdalites) em uma populaçäo pediátrica. Os sinais e sintomas próprios a essas patologias foram analisados e a febre monitorizada durante um período de 24 horas. Observou-se uma melhora significativa e homogênea dos sinais e sintomas em todos os grupos de tratamento. A febre apresentou queda pronunciada após a administraçäo de nimesulide e diclofenaco e também após a administraçäo da dipirona, sendo que ocorreu uma reversäo do efeito da dipirona após algumas horas. Dois pacientes apresentaram efeitos adversos que, no caso do diclofenaco devido a intensidade, forçaram a retirada do medicamento. Os dados obtidos ressaltam a eficácia antipirética do nimesulide tal qual a da dipirona com as vantagens em tolerabilidade que näo säo encontradas com o uso de diclofenaco potássico. Assim concluímos que o nimesulide, além de uma poderosa açäo antitérmica, apresenta vantagens no combate ao processo inflamatório, principalmente com relaçäo a sua segurança.

Tumour necrosis factor-alpha, resting energy expenditure and cachexia in cystic fibrosis.

1. We investigated the relationship between circulating tumour necrosis factor-alpha concentrations, resting energy expenditure, cachexia and altered intermediary metabolism in patients with cystic fibrosis and chronic pulmonary infection. 2. Twenty adult patients with cystic fibrosis and chronic bronchial sepsis covering a spectrum of severity of lung disease (forced expiratory volume in 1 s 30-100% of predicted) were compared with 10 age matched, healthy, non-cystic fibrosis subjects. 3. Circulating tumour necrosis factor-alpha, C-reactive protein and neutrophil elastase-alpha 1-antiproteinase complex concentrations were determined simultaneously with glycerol, non-esterified fatty acids, catecholamines, anthropometric indices and resting energy expenditure (ventilated hood method). 4. Weight, body mass index and arm muscle mass were reduced in patients with cystic fibrosis compared with healthy control subjects (P < 0.01), whereas mean resting energy expenditure was increased [121 versus 101% predicted, mean difference 19.2% (95% confidence interval 11.0-27.4%), P < 0.001]. Circulating concentrations of glycerol (P < 0.01), non-esterified fatty acids (P < 0.01), adrenaline (P < 0.05), tumour necrosis factor-alpha, C-reactive protein and neutrophil elastase-alpha 1-antiproteinase complex (P < 0.01) were increased in patients compared with control subjects [tumour necrosis factor-alpha 96.9 versus 24.7 pg/ml, mean difference 72.2 pg/ml [95% confidence interval 27.7-116.7 pg/ml), P < 0.001]. Resting energy expenditure was significantly related to tumour necrosis factor-alpha levels and forced expiratory volume in 1 s. 5. In patients with cystic fibrosis and chronic pulmonary sepsis changes in resting energy expenditure, body composition and intermediary metabolism are consistent with the systemic effects of the host inflammatory response, which may be responsible for cachexia in adult patients. In particular these changes are consistent with the action of tumour necrosis factor-alpha, which was detected in the circulation during a period of apparent clinical stability.