Chronic Obstructive Pulmonary Disease (COPD) management in the community: how could primary care team contribute?

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a progressive lung disease commonly encountered in primary care. This study aimed to audit COPD care at primary care clinics of Hong Kong and to work out improvement strategies. METHOD: All COPD patients aged 40 or above who had been followed up at 13 public primary care clinics of Kowloon Central Cluster (KCC) under the Hospital Authority of Hong Kong (HAHK) were included in this clinic audit. Evidence-based audit criteria and performance standards were established after thorough literature review. Phase 1 was from 1st April 2016 to 31st March 2017, with deficiencies of care identified. It was followed by a one-year implementation phase through which a series of improvement strategies were executed. Outcome of the enhancement was reviewed during Phase 2 from 1st April 2018 to 31st March 2019. Chi-square test and student's t test were used to detect statistically significant changes between Phase 1 and Phase 2. RESULTS: A total of 2358 COPD cases were identified in Phase 1 where 658 of them were smokers. Of those smokers, 332 (50.5%) had been referred to Smoking Counselling and Cessation Service (SCCS) and 289 (43.9%) actually attended it. 991 cases (42%) received Seasonal Influenza Vaccine (SIV) and 938 cases (39.8%) received Pneumococcal Vaccine (PCV). 698 patients (29.6%) had spirometry done before and 423 patients (17.9%) had been admitted to hospital due to acute exacerbation of COPD (AECOPD). With the concerted effort taken during the implementation phase, Phase 2 data showed significant improvement in nearly all criteria. There was a marked increase in the SIV and PCV uptake rate, spirometry performance rate and most importantly, a significant reduction in AECOPD rate leading to hospital admission (13.5%, P = 0.000043). However, the referral rate and attendance rate of SCCS among smokers remained stagnant (P > 0.05). CONCLUSION: Via a systematic team approach, COPD care at primary care clinics of KCC under HAHK had been significantly improved for most of the audit criteria, which in turn reduced the burden of the healthcare system.

Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial.

BACKGROUND: There is a lack of evidence on the effectiveness of postnatal depression (PND) screening programmes in reducing morbidity. The aim of this study was to evaluate the effectiveness of a PND screening programme using Edinburgh Postnatal Depression Scale (EPDS) in improving maternal mental health. METHODS: The randomized controlled trial design was used. Participants were 462 Chinese mothers with 2-month-old babies visiting Maternal and Child Health Centres in Hong Kong. Participants in the intervention group were screened for PND using the EPDS, whereas those in the control group were screened by clinical assessment. In both groups, participants identified with PND were offered follow-up management according to protocol. RESULTS: Participants in the intervention group had better maternal mental health outcome as assessed by EPDS at 6 months (risk ratio: 0.59; 95% confidence interval: 0.39-0.89). The number needed to screen was 25. CONCLUSIONS: A PND screening programme comprising the use of EPDS as the screening tool and the provision of follow-up care had resulted in an improvement in maternal mental health at 6 months.

Cefepime versus vancomycin plus netilmicin therapy for continuous ambulatory peritoneal dialysis-associated peritonitis.

Cefepime is a cephalosporin with a broad spectrum of activity against most gram-positive and gram-negative pathogens. In this study, we attempted to compare the safety and efficacy of cefepime monotherapy against the potentially more toxic combination of vancomycin and netilmicin in the treatment of continuous ambulatory peritoneal dialysis (CAPD)-associated bacterial peritonitis. Eighty-one consecutive CAPD patients who presented with peritonitis from January 1, 1998, to June 30, 2000, were recruited for study. Patients were randomized to be administered either intraperitoneal (IP) cefepime, 1 g once daily (group A), or intravenous vancomycin and netilmicin at conventional doses (group B) for 10 days. Bacterial growth was obtained in 52 episodes (66%), and pathogens identified included gram-positive organisms (30 episodes; 38%), gram-negative organisms (14 episodes; 18%), mixed organisms (2 episodes; 2.5%), and fungus (6 episodes; 8%). Eight patients were excluded after randomization for various reasons (6 patients, fungal peritonitis; 2 patients, wrong diagnoses). Because of the relatively low peritonitis rate after the use of a disconnect system, the sample size of this study was relatively small, giving a power of 0.45. There were no significant differences in primary response rates and cure rates (no relapse >28 days after completion of antibiotic therapy) between both groups of patients (group A versus group B, 82% [32 of 39 patients] versus 85% [29 of 34 patients] and 72% [28 of 39 patients] versus 76% [26 of 34 patients], respectively; P = not significant). No significant side effect was encountered in either group. Total peritonitis-related hospitalizations were 84 patient-days (1, 7, 8, 11, 20, and 37 patient-days) and 115 patient-days (3, 6, 9, 14, 21, 21, and 41 patient-days), whereas total costs per patient cure were estimated to be US $1,039 and US $1,371 in groups A and B, respectively. We conclude that once-daily 1-g IP cefepime monotherapy is a simple, safe, and cost-effective alternative to vancomycin and netilmicin therapy in the treatment of CAPD-associated bacterial peritonitis.

A new synthesis of chlorins.

A new synthesis of chlorins has been developed, based upon the acid-catalyzed condensation of dialdehydes AB with dipyrromethanes CD.

New syntheses of the C,D-ring pyrromethenones of phytochrome and phycocyanin.

Pyrromethenone 7, the C,D-ring segment of phytochrome (Pr, 4), has been prepared in an efficient fashion employing three new strategies. Each of these has potential advantages for the synthesis of labeled material. Our first approach is related to the Gossauer synthesis, with the difference that strong alkali is avoided in the condensation of the C- and D-ring components 8 and 17. The key silyloxypyrrole 17 was readily prepared on multigram scales beginning with inexpensive butyrolactone (10). A second synthesis began with 2-acetylbutyrolactone (41). The key steps involved conversion of 41 to the Z-enoltriflate 42, followed by Pd(0)-catalyzed coupling with trimethylsilylacetylene, p-chlorophenylselenide ring opening, and finally, amidation to afford the ring-D synthon 45 having the proper geometry and oxidation state for conversion to 7. Sonogashira coupling of 45 with the iodopyrrole 22, followed by oxidative elimination, and F(-)-induced 5-exo-dig cyclization of the resultant pyrroloalkyne 47, then completed the synthesis. In similar fashion, we have also prepared pyrromethenone 6, the C,D-ring segment of phycocyanin (2).

New strategies for the synthesis of biologically important tetrapyrroles. The "B,C + D + A" approach to linear tetrapyrroles.

Linear tetrapyrroles related to phytochrome (1) were prepared in enantiospecific fashion by a new strategy beginning with ring-B,C synthons of type 19 (bis-iododipyrrins). Rings A and D were elaborated by Pd(0)-mediated coupling of 19a with the appropriate alkyne acid or amide derivatives 9 and 20, followed by intramolecular cyclization (method C: BC + D + A --> ABCD).

Polyanionic hydrogel as a gastric retentive system.

Gastric emptying of a polyanionic hydrogel, polycarbophil (PC), from the canine stomach was studied using a duodenal cannulation technique. The basis of the study is to employ a certain quantity of swelling hydrogel that, by virtue of its swollen size and viscosity, converts a fasted stomach to a fed state and resists discharge from the stomach for an extended period of time. Different amounts of PC, in 200 ml water plus buffering agents, were administered orally to fasted canines. The gastric emptying lag time was found to increase with the viscosity of the administered dose. Addition of a base, sodium bicarbonate, to PC increased gastric retention via an increase in its apparent viscosity. The polymer mass is retained in the canine stomach until a sufficient quantity of stomach acid secretion reduces the viscosity of the viscous mass, through protonation of polycarbophil, and, at that point, discharge of the hydrogel will commence. Thus, gastric retention of PC hydrogel in the canine stomach can be prolonged by increasing the apparent viscosity of the hydrogel administered.

Binding of acrylic polymers to mucin/epithelial surfaces: structure-property relationships.

Bioadhesion, and more specifically mucoadhesion, is becoming an important strategy for drug delivery. As a result, it is important to understand the various mechanisms that govern attachment of polymeric substances to the glycoproteins on epithelial surfaces, along with the associated structure-activity relationships of the polymer. This article reviews fundamentals of mucoadhesion, with special emphasis on structural features of the polymer as they contribute to the process of mucoadhesion. There are four possible general interactions between mucoadhesive polymers and glycoproteins: (1) covalent attachment; (2) electrostatic interaction, which requires matching of charge groups between the polymer and mucus; (3) hydrogen bonding; and (4) hydrophobic interactions. Aside from covalent attachment, which is not presently a prominent mechanism for mucoadhesion, the remaining mechanisms require maximum contact between the polymer and mucin for optimum adhesion. With polyelectrolyte polymers, the charged groups are important in controlling the degree of hydration of both the polymer and the mucous network. The expanded nature of the swollen polymer and mucus enhances the interdiffusion process and permits both a mechanical entanglement and an increase in surface contact for hydrogen bonding and/or electrostatic interaction between the polymer and the mucous network. A number of techniques are available to study mucoadhesion. Some of these are better suited to study the kinetics of the mucoadhesion process whereas others are more useful for equilibrium studies. To date, the major deficiency in basic studies of mucoadhesion is the lack of suitable information on the organization and physicochemical properties of the mucin layer.