Better Respiratory Education and Treatment Help Empower (BREATHE) study: Methodology and baseline characteristics of a randomized controlled trial testing a transitional care program to improve patient-centered care delivery among chronic obstructive pulmonary disease patients.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of hospitalizations. Interventional studies focusing on the hospital-to-home transition for COPD patients are few. In the BREATHE (Better Respiratory Education and Treatment Help Empower) study, we developed and tested a patient and family-centered transitional care program that helps prepare hospitalized COPD patients and their family caregivers to manage COPD at home. METHODS: In the study's initial phase, we co-developed the BREATHE transitional care program with COPD patients, family-caregivers, and stakeholders. The program offers tailored services to address individual patients' needs and priorities at the hospital and for 3months post discharge. We tested the program in a single-blinded RCT with 240 COPD patients who were randomized to receive the program or 'usual care'. Program participants were offered the opportunity to invite a family caregiver, if available, to enroll with them into the study. The primary outcomes were the combined number of COPD-related hospitalizations and Emergency Department (ED) visits per participant at 6months post discharge, and the change in health-related quality of life over the 6months study period. Other measures include 'all cause' hospitalizations and ED visits; patient activation; self-efficacy; and, self-care behaviors. DISCUSSION: Unlike 1month transitional care programs that focus on patients' post-acute care needs, the BREATHE program helps hospitalized COPD patients manage the post discharge period as well as prepare them for long term self-management of COPD. If proven effective, this program may offer a timely solution for hospitals in their attempts to reduce COPD rehospitalizations.

Stillbirth: Genome-wide copy number variation profiling in archived placental umbilical cord samples with pathologic and clinical correlation.

INTRODUCTION: Stillbirth remains a devastating health issue with 26,000 stillbirths occurring annually in the United States. Formalin-fixed, paraffin-embedded (FFPE) umbilical cord samples are available for many stillbirths. Our aim was to validate the use of these samples in identifying genetic variations in stillbirth through microarray analysis. METHODS: This is a retrospective case-control study from a single institution of stillbirths ≥ 23 weeks gestational age and control liveborn infants. Fetal genomic DNA was extracted from FFPE umbilical cord samples of stillborn and control placentas, and genotyping was performed using the Illumina HumanOmniExpresss-12v1 Beadchip. Array results were verified with qPCR. RESULTS: 31 case-specific CNVs (17 deletions and 14 amplifications) with an average size of 294 kb for amplifications and 74 kb for deletions were identified among 94 FFPE samples (86 cases; 8 controls). In total 38 (44%) of the stillbirth samples had a CNV detected. Validation of a subset of microarray findings with qPCR confirmed deletions on 1p (2 cases), 11q (4 cases) and amplifications on 18 (1 case). Placental underperfusion changes were seen in stillborns with deletions on 1p, a region containing complement regulatory genes which have been shown to play a role in preeclampsia. DISCUSSION: This study validated the use of archived FFPE umbilical cord samples for genome-wide copy number profiling in stillbirths, and demonstrates specific CNV deletions and amplifications. Microarray analysis in an expanded cohort of stillbirth FFPE samples has the potential to identify biomarkers involved in stillbirth pathogenesis.

Inhaler competence in asthma: common errors, barriers to use and recommended solutions.

Whilst the inhaled route is the first line administration method in the management of asthma, it is well documented that patients can have problems adopting the correct inhaler technique and thus receiving adequate medication. This applies equally to metered dose inhalers and dry powder inhalers and leads to poor disease control and increased healthcare costs. Reviews have highlighted these problems and the recent European Consensus Statement developed a call to action to seek solutions. This review takes forward the challenge of inhaler competence by highlighting the issues and suggesting potential solutions to these problems. The opportunity for technological innovation and educational interventions to reduce errors is highlighted, as well as the specific challenges faced by children. This review is intended as a policy document, as most issues faced by patients have not changed for half a century, and this situation should not be allowed to continue any longer. Future direction with respect to research, policy needs and practice, together with education requirements in inhaler technique are described.

Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma.

BACKGROUND: Asthma guidelines advise addressing adherence at every visit, but no simple tools exist to assist clinicians in identifying key adherence-related beliefs or behaviours for individual patients. AIMS: To identify potentially modifiable beliefs and behaviours that predict electronically recorded adherence with controller therapy. METHODS: Patients aged ≥ 14 years with doctor-diagnosed asthma who were prescribed inhaled corticosteroid/long-acting ß(2)-agonist (ICS/LABA) completed questionnaires on medication beliefs/behaviours, side-effects, Morisky adherence behaviour score and Asthma Control Test (ACT), and recorded spirometry. Adherence with ICS/LABA was measured electronically over 8 weeks. Predictors of adherence were identified by univariate and multivariate analyses. RESULTS: 99/100 patients completed the study (57 female; forced expiratory volume in 1 s mean ± standard deviation 83 ± 23% predicted; ACT 19.9 ± 3.8). Mean electronically recorded adherence (n= 85) was 75% ± 25, and mean self-reported adherence was 85% ± 26%. Factor analysis of questionnaire items significantly associated with poor adherence identified seven themes: perceived necessity, safety concerns, acceptance of asthma chronicity/medication effectiveness, advice from friends/family, motivation/routine, ease of use and satisfaction with asthma management. Morisky score was moderately associated with actual adherence (r=-0.45, P < 0.0001). In regression analysis, 10 items independently predicted adherence (adjusted R(2) = 0.67; P < 0.001). Opinions of friends/family about the patient's medication use were strongly associated with poor adherence. Global concerns about ICS/LABA therapy were more predictive of poor adherence than were specific side-effects; the one-third of patients who reported experiencing side-effects from their steroid inhaler had lower adherence than others (mean 62% vs 81%; P= 0.015). CONCLUSIONS: This study identified several specific beliefs and behaviours which clinicians could use for initiating patient-centred conversations about medication adherence in asthma.

Cancer diagnostic assessment programs: standards for the organization of care in Ontario.

BACKGROUND: Improving access to better, more efficient, and rapid cancer diagnosis is a necessary component of a high-quality cancer system. How diagnostic services ought to be organized, structured, and evaluated is less understood and studied. Our objective was to address this gap. METHODS: As a quality initiative of Cancer Care Ontario's Program in Evidence-Based Care, the Diagnostic Assessment Standards Panel, with representation from clinical oncology experts, institutional and clinical administrative leaders, health service researchers, and methodologists, conducted a systematic review and a targeted environmental scan of the unpublished literature. Standards were developed based on expert consensus opinion informed by the identified evidence. Through external review, clinicians and administrators across Ontario were given the opportunity to provide feedback. RESULTS: The body of evidence consists of thirty-five published studies and fifteen unpublished guidance documents. The evidence and consensus opinion consistently favoured an organized, centralized system with multidisciplinary team membership as the optimal approach for the delivery of diagnostic cancer assessment services. Independent external stakeholders agreed (with higher mean values, maximum 5, indicating stronger agreement) that DAP standards are needed (mean: 4.6), that standards should be formally approved (mean: 4.3), and importantly, that standards reflect an effective approach that will lead to quality improvements in the cancer system (mean: 4.5) and in patient care (mean: 4.3). INTERPRETATION: Based on the best available evidence, standards for the organization of DAPS are offered. There is clear need to integrate formal and comprehensive evaluation strategies with the implementation of the standards to advance this field.

15-year follow-up results of the hydroxyapatite ceramic-coated femoral stem.

PURPOSE: To evaluate the clinical and radiological outcomes following implantation of the Furlong hydroxyapatite ceramic-coated femoral stem in total hip arthroplasty. METHODS: A longitudinal cohort of 116 consecutive patients (134 hips) was followed up prospectively. The follow-up period was at least 13 years (range, 13- 15 years). Clinical and radiological assessments were made using the Merle d'Aubigne and Postel score and Engh score for fixation and stability, respectively. Osteointegration was assessed radiographically by examining the bone implant interface using the method described by Gruen. RESULTS: 22 patients died during the study period and 6 were lost to follow-up. The respective mean Merle d'Aubigne and Postel scores for pain, range of movement, and ability to walk were 2.2, 2.8, and 2.4 preoperatively and 5.8, 4.8, and 5.4 postoperatively. Engh described satisfactory bony ongrowth as 10 points or more; the mean Engh score for fixation and stability was 24.7 (fixation=10, stability=14.7). One femoral stem was revised for a periprosthetic fracture caused by a fall, but none was revised for loosening. This gave a 99% survival at 13 years (95% confidence interval 94-100). CONCLUSION: The long-term results of this hydroxyapatite ceramic-coated femoral prosthesis are very satisfactory.

Results of a hydroxyapatite-coated (Furlong) total hip replacement: a 13- to 15-year follow-up.

We describe the survival of 134 consecutive JRI Furlong hydroxyapatite-coated uncemented total hip replacements. The mean follow-up was for 14.2 years (13 to 15). Patients were assessed clinically, using the Merle d'Aubigné and Postel score. Radiographs were evaluated using Gruen zones for the stem and DeLee and Charnley zones for the cup. Signs of subsidence, radiolucent lines, endosteal bone formation (spot welds) and pedestal formation were used to assess fixation and stability of the stem according to Engh's criteria. Cup angle, migration and radiolucency were used to assess loosening of the cup. The criteria for failure were revision, or impending revision because of pain or loosening. Survival analysis was performed using a life table and the Kaplan-Meier curve. The mean total Merle d'Aubigné and Postel score was 7.4 pre-operatively and 15.9 at follow-up. During the study period 22 patients died and six were lost to follow-up. None of the cups was revised. One stem was revised for a periprosthetic fracture following a fall but none was revised for loosening, giving a 99% survival at 13 years. Our findings suggest that the long-term results of these hydroxyapatite-coated prostheses are more than satisfactory.

Inflammation and changes in cytokine levels in neurological feline infectious peritonitis.

Feline infectious peritonitis (FIP) is a progressive, fatal, predominantly Arthus-type immune-mediated disease that is triggered when cats are infected with a mutant enteric coronavirus. The disease presents variably with multiple organ failure, seizures, generalized effusion, or shock. Neurological FIP is clinically and pathologically more homogeneous than systemic 'wet' or 'dry' FIP; thus, comparison of cytokine profiles from cats with neurological FIP, wet FIP, and non-FIP neurological disease may provide insight into some baseline characteristics relating to the immunopathogenesis of neurological FIP. This study characterizes inflammation and changes in cytokines in the brain tissue of FIP-affected cats. Cellular infiltrates in cats with FIP included lymphocytes, plasma cells, neutrophils, macrophages, and eosinophils. IL-1 beta, IL-6, IL-12, IL-18, TNF-alpha, macrophage inhibitory protein (MIP)-1 alpha, and RANTES showed no upregulation in the brains of control cats, moderate upregulation in neurological FIP cats, and very high upregulation in generalized FIP cats. Transcription of IFN-gamma appeared upregulated in cats with systemic FIP and slightly downregulated in neurological FIP. In most cytokines tested, variance was extremely high in generalized FIP and much less in neurological FIP. Principal components analysis was performed in order to find the least number of 'components' that would summarize the cytokine profiles in cats with neurological FIP. A large component of the variance (91.7%) was accounted for by levels of IL-6, MIP-1 alpha, and RANTES. These findings provide new insight into the immunopathogenesis of FIP and suggest targets for immune therapy of this disease.

Replacement of antipsychotic and antiepileptic medication by L-alpha-methyldopa in a woman with velocardiofacial syndrome.

We report the case of a 23-year-old woman with velocardiofacial syndrome (VCFS) and a history of psychosis and seizures. She had been treated with conventional antipsychotic and antiepileptic drugs for 10 and 3 years, respectively. However, she continued to experience occasional hallucinations and paroxysmal jerking of the extremities. L-alpha-methyldopa 500 mg b.i.d. (later reduced to 250 mg t.i.d.) was added to her regimen. Hallucinations and seizures stopped shortly. Over the course of approximately 1 year, the previous medications were discontinued without recurrence of psychotic and epileptic symptoms. Eventually, improved mental functions and behaviour enabled her transition from living in a licensed residential facility to sharing a private residence with a partner. VCFS is associated with haploinsufficiency of catecholamine-methyltransferase, leading to excessive extraneuronal catecholamine concentrations. Alpha-Methyldopa inhibits catecholamine neurotransmission in a variety of ways. It is possible that the drug compensated for genetically disturbed catecholamine transmission thus achieving beneficial effects in this case.

Adherence to asthma therapy in the preschool child.

Preschool children's adherence to asthma therapy is often sub-optimal and can result in decreased quality of life for children and parents, as well as an increased risk for dangerous asthma exacerbations. Asthma management for the preschool child presents some unique challenges to adherence to therapy, including the child's limited ability to communicate, multiple caregivers responsible for medications, and parental concerns about medications. Parent beliefs, characteristics of the regimen, and family functioning have been associated with adherence levels. Understanding and improving adherence to asthma therapy for the preschool child will necessarily require addressing these age-specific concerns.

An unusual case of a postoperative bone cyst.

We describe an unusual case of a postoperative bone cyst resulting from a retained fragment of surgical glove. We highlight some of the problems associated with gloves and suggest ways of safeguarding against similar complications.

Clinical, microscopic, and molecular aspects of canine leproid granuloma in the United States.

Leproid granulomas from seven dogs in the United States were evaluated. Gross characteristics included nodular and ulcerated dermal and subcutaneous lesions primarily on the caudal aspects of the pinnae and to a lesser extent on the muzzle, face, and forelimbs. In all except one dog, there was complete regression of the lesions within 6 months, either with no therapy or after surgical resection. Cytology or histopathology revealed pyogranulomatous inflammation with few to many acid-fast mycobacterial bacilli within macrophages. The organisms could not be cultivated in vitro. DNA sequencing of part of the 16S ribosomal RNA gene region revealed 99-100% homology among fragments from five of these dogs and fragments from dogs in the south Pacific. This syndrome occurs in dogs in North America and the prognosis is excellent, in contrast to the prognosis for rapid-growing or tuberculous mycobacteriosis.

Heterotopic ossification after uncemented hydroxyapatite-coated primary total hip arthroplasty.

A total of 134 patients who had a cementless hydroxyapatite-coated total hip arthroplasty (THA) and had no recognized risk factors for heterotopic ossification (HO) were reviewed retrospectively. The average follow-up period was 83 months. Pharmacologic or radiotherapeutic prophylaxis against HO was not used. HO was seen in 90 (67.2%) of the 134 patients reviewed. HO was rated as Brooker class I in 68 (50.7%) patients, class II in 17 (12.7%) patients, class III in 3 (2.2%) patients, and class IV in 2 (1.5%) patients. The average Merle d' Aubigne score in patients with mild forms of HO (Brooker classes I and II) was 16 compared with 13.2 in patients with severe HO (Brooker classes III and IV). A statistically significant negative correlation was found between the presence of HO and the postoperative hip score. Based on our study findings and on a comparison with data in the literature, hydroxyapatite-coated cementless THA alone does not seem to increase the likelihood of HO over other types of THA. The presence of a hydroxyapatite coating does not result in more class III or IV HO, which are the only classes of HO with real clinical significance. Fear of HO should not be a factor in the choice of fixation for THA.

Children with asthma and nebulizer use: parental asthma self-care practices and beliefs.

We examined demographic characteristics, patterns of medication use, asthma morbidity, and asthma self-management practices and beliefs among inner-city children currently using a nebulizer. We also describe the relationship between asthma self-management practices and beliefs and anti-inflammatory (AI) therapy. We observed a high rate of morbidity, including frequent emergency room visits, hospitalizations, symptom days and nights, and school absences in this group of school-aged children with asthma. More than three-quarters (81%) reported asthma symptoms consistent with mild persistent or greater severity of asthma, and therefore these subjects should be taking AI medications. Another 16% (36 of 231) of these children reported symptoms consistent with mild intermittent asthma. Only 1 out of 7 children in this study reported taking AI medications. We found that parents of children taking daily AI medications were more likely to agree with the belief that children should use asthma medications daily even when the child is not reporting any symptoms.

Reasons for pediatrician nonadherence to asthma guidelines.

BACKGROUND: The 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines include recommendations on how to improve the quality of care for asthma. OBJECTIVE: To identify barriers to physician adherence to the NHLBI guidelines. DESIGN: Cross-sectional survey. PARTICIPANTS: A national random sample of 829 primary care pediatricians. MAIN OUTCOME MEASURES: Self-reported adherence to 4 components of the NHLBI guidelines (steroid prescription, instructing peak flow meter use, screening and counseling patients with asthma for smoking, and screening and counseling parents for smoking). We also collected information on physician demographics, practice characteristics, and possible barriers to adherence. We defined adherence as following a guideline component more than 90% of the time. RESULTS: The response rate was 55% (456/829). Most of the responding pediatricians were aware of the guidelines (88%) and reported having access to a copy of the guidelines (81%). Self-reported rates of adherence were between 39% and 53% for the guideline components. After controlling for demographics and other barriers, we found that nonadherence was associated with specific barriers for each guideline component: for corticosteroid prescription, lack of agreement (odds ratio [OR], 6.8; 95% confidence interval [CI], 3.2-14.4); for peak flow meter use, lack of self-efficacy (OR, 3.4; 95% CI, 1.9-6.1) and lack of outcome expectancy (OR, 4.7; 95% CI, 2.5-8.9); and for screening and counseling of patients and parents for smoking, lack of self-efficacy (OR, 3.8; 95% CI, 1.7-6.2 and OR, 2.8; 95% CI, 1.3-5.9, respectively). CONCLUSIONS: Although pediatricians in this sample were aware of the NHLBI guidelines, a variety of barriers precluded their successful use. To improve NHLBI guideline adherence, tailored interventions that address the barriers characteristic of a given guideline component need to be implemented.

Cockroach allergen abatement with extermination and sodium hypochlorite cleaning in inner-city homes.

BACKGROUND: Although the importance of cockroach allergen in chronic asthma has now been well defined, little progress has been made in the control of cockroach allergen in infested homes. OBJECTIVE: The objective of this study was to examine the ability of a combination of professional pest extermination and household cleaning using a solution of sodium hypochlorite to reduce cockroach infestation and allergen levels in cockroach infested homes. METHODS: Seventeen cockroach-infested homes were studied with three homes serving as controls. In the intervention homes, a professional exterminator applied 0.05% abamectin twice at 2-week intervals at study entry and a professional cleaner cleaned the homes before and after the extermination. All washable surfaces were cleaned throughout the study with a solution of 0.5% hypochlorite. Monthly home visits were conducted to inspect the home, interview the homeowner, place passive cockroach traps, and to collect settled dust samples from the kitchen, bedroom, and TV/living room. RESULTS: The number of cockroaches in the passive traps decreased rapidly after the initial intervention in most homes. Median Blatella germanica allergen 1 levels in the settled dust samples fell by 91% in the kitchen, 78% in the bedroom, and 77% in the living room over the course of the study in the intervention homes but gradually rose in the control homes. The overall reductions were very similar to those seen in a previous study with a similar protocol except for the use of the sodium hypochlorite. CONCLUSIONS: Successful extermination is possible in most inner-city homes and cockroach allergen levels can be reduced by 80% to 90%. However, 0.5% sodium hypochlorite did not seem to improve allergen reduction, and in many homes, allergen levels remained above the proposed threshold of 8 U/g of dust throughout the study.

Rural school nurses' asthma education needs.

School nurses play an important role in identifying children with asthma and providing care during school hours. Educational programs designed to improve nurses' asthma knowledge and practices have concentrated on urban settings. The purpose of this investigation was to determine asthma-related practices and educational needs of rural school nurses. A survey about asthma was mailed to school nurses in all counties of the state of Maryland and in Washington, D.C. Responses were compared between rural Maryland counties and counties from the remainder of Maryland and Washington, D.C. The survey addressed attitudes and beliefs, function and roles, medication administration, and educational needs about asthma. We found that rural nurses used peak flow meters less often to assess and monitor asthma, requested fewer referrals for asthma, had fewer interactions with health room assistants, and had reduced access to asthma educational resources. Also, they provided less asthma education in the schools than other school nurses. These results suggest a need for comprehensive asthma educational programs in rural areas that are based on national guidelines, and that address the unique needs of rural school nurses. These programs should also emphasize the need for open communication between rural school nurses, health room assistants, primary care providers, and parents/caregivers.