Integrated multidisciplinary community service for chronic obstructive pulmonary disease reduces hospitalisations.

BACKGROUND: Hospitalisations for chronic obstructive pulmonary disease (COPD) exacerbation affect patient outcomes and healthcare costs. The long-term impact of an integrated COPD disease-management approach on hospitalisation remains controversial. AIM: The aim of this study was to evaluate whether a multidisciplinary community service reduces respiratory hospitalisations for COPD patients. METHODS: A total of 346 patients was followed for a mean duration of 27.3 months. The number of admissions, total bed days for respiratory (COPD exacerbation or pneumonia) or general medical causes and length of stay (LOS) per respiratory admission was compared before and after referral with the service. A secondary multivariate analysis examined which clinical parameters best predict benefit from such service. RESULTS: The total respiratory admission and hospital bed days after referral were reduced by 31% (288 vs 417, P < 0.001) and 40.4% (1637 vs 2746, P < 0.0001) respectively, compared with the equivalent duration prior. The average LOS for each respiratory admission was also significantly reduced after referral (6.61 vs 5.70, P = 0.02). Overall, 55% patients experienced a reduction in admission frequency and hospital days. The impact on admission frequency and hospital days was the greatest in those with an at least moderate disease (GOLD ≥2, odds ratio (OR): 3.2, 95% confidence interval (CI): 1.2, 8.9; P = 0.019) and those who completed pulmonary rehabilitation (PR) (OR: 1.7, 95% CI: 1.1, 2.8; P = 0.04). In contrast, general medical admissions increased, one-third attributable to a cardiovascular cause both before and after referral. CONCLUSIONS: The implementation of COPD multidisciplinary community service was associated with reduced respiratory hospitalisations in the long term. Patients with moderate or severe disease and who are able to complete PR are much more likely to benefit.

Superantigen enhanced protection against a weak tumor-specific melanoma antigen: implications for prophylactic vaccination against cancer.

B16F10 melanoma is a tumor derived from C57BL/6 mice that has been found to be poorly immunogenic and highly aggressive. Here we have shown that vaccination of mice with irradiated B16F10 cells followed by treatment with a combination of staphylococcal enterotoxins A and B (SEA/SEB) leads to significant and specific protection against subsequent challenge with viable B16F10 cells (at least 25-fold greater than a lethal dose). Also, 75% of mice surviving over 150 days remained tumor-free after rechallenge with viable B16F10 cells, evidence of the development of strong immunologic memory. Additional studies showed increases in CD4(+) and CD8(+) T-cell populations, cytotoxic T-lymphocyte activity and interferon-gamma production, all of which may contribute to enhanced survival. Furthermore, failure to produce protection in either CD4(-/-) or CD8(-/-) T-cell knockout mice is evidence that CD4(+) and CD8(+) T cells play an essential role in induction of immunity. These results show that superantigen administration subsequent to vaccination with inactivated tumor cells results in protective antitumor immunity. Thus, prophylactic vaccination against cancer is a feasible method for arming the immune system prior to the incidence of cancer.

Hypertension awareness, detection and treatment in a university community: results of a worksite screening.

This study aimed to assess knowledge levels, explore the extent of undiagnosed hypertension, record previous screening activity and monitor the outcomes of previous hypertension treatment. To this end, information was collected from volunteer members of a university community, by means of a self-report questionnaire, about their personal characteristics, knowledge and experience of hypertension and stroke, and previous blood pressure measurements. In addition, their current blood pressure was recorded. A total of 653 staff and students completed the questionnaire and had their blood pressure measured. Analysis revealed that 82% were normotensive (diastolic blood pressure <90 mmHg). Hypertension was significantly associated with age, self-reported excess weight P<0.001) and marginally with self-reported non-healthy eating (P=0.06). Of the volunteers, 57% could not provide an accurate definition of a stroke. Knowledge levels were significantly and positively related to experience of stroke, healthy eating, not smoking and a recent blood pressure check. Of the respondents, 30% stated that they had not had their blood pressure measured in the previous two years. 51% of known hypertensives were not controlled. 68% of volunteers with diastolic blood pressure >89 mmHg were previously unaware of a potential hypertension problem. Hypertension rates amongst the university volunteers are higher than those recently recorded from a population sample. Scope exists for increasing knowledge and awareness, and for raising both screening rates and treatment outcomes. Improvements in these areas are required if current public health targets for heart disease and stroke are to be achieved. Worksite screening programmes can contribute to this endeavour.

Down-regulation of neu/HER-2 by interferon-gamma in prostate cancer cells.

Interferons (IFNs) are known to possess potent antitumor properties. Previous studies have indicated that IFNs are capable of modulating the expression of various tumor suppressor genes and oncogenes. In this study, we looked at the effect of IFN-gamma on the neu/HER-2 proto-oncogene in the DU145, LNCaP, and PC-3 prostate cancer cell lines. IFN-gamma inhibited cell proliferation in both DU145 and PC-3 cells in a dose-dependent manner, whereas no inhibition of proliferation was seen in LNCaP cells. Correspondingly, IFN-gamma treatment of DU145 and PC-3 cells resulted in an increased production of the cyclin-dependent kinase inhibitor p21(WAF1), whereas no increase in p21(WAF1) was seen in LNCaP cells. In addition, IFN-gamma induced phosphorylation of signal transducer and activator of transcription (STAT) 1 in DU145 and PC-3 cells, but not in LNCaP cells. Consistent with these findings, we found that IFN-gamma treatment of DU145 and PC-3 cells caused a reduction in neu/HER-2 expression, with no change seen in the LNCaP cell line. Transfection and overexpression of the transcriptional coactivator p300 in PC-3 cells suppressed the reduction in neu/HER-2 expression after IFN-gamma treatment, suggesting a role for p300 in neu/HER-2 expression. The antiproliferative activity and p21(WAF1) production of these cells after IFN-gamma treatment were found to be reduced as well. We propose that the down-regulation of neu/HER-2 by IFN-gamma occurs via the interaction of phosphorylated STAT1 with p300 because IFN-gamma activities requiring phosphorylated STAT1 are reduced in cells overexpressing p300. These findings suggest that neu/HER-2 may play a role in the growth of some prostate cancers and that IFN-gamma may suppress such cancers by down-regulation of neu/HER-2.

Respiratory bronchiolitis associated interstitial lung disease (RB-ILD) presenting with haemoptysis.

Respiratory bronchiolitis associated interstitial lung disease is an uncommon condition in current or ex-smokers. The presentation is non-specific, but haemoptysis is uncommonly reported in this condition. We report the case of a 25-year-old woman who presented with significant haemoptysis, dyspnoea, reduced transfer factor and normal clinical examination. In addition, a Medline literature search was performed to review the clinical features and prognosis of this disease. Other causes of haemoptysis were excluded with extensive investigation. The diagnosis was made on thoracoscopic lung biopsy. The patient had significant postoperative complications of prolonged air leak and hydropneumothorax requiring further surgery and prolonged hospital stay. Advice regarding smoking cessation was given. Her pulmonary physiology remains abnormal on follow up but symptoms have improved. Respiratory bronchiolitis-ILD may present with normal examination and radiology. Haemoptysis in this case may have been associated with the underlying disease but could have been incidental. Diagnosis, in general, requires lung biopsy. As in this patient, lung function does not appear to improve significantly on follow up.

Diaphragm inhibition with positive pressure ventilation: quantification of mechanical effects.

To quantify any mechanical inhibitory effect of nasal intermittent positive pressure ventilation (IPPV) on inspiratory activity of the diaphragm we ventilated five conscious relaxed subjects on two occasions at respiratory rates similar to quiet breathing (QB) and at three levels of applied pressure (Pappl)--6, 9 and 12 cmH2O, each during hypocapnia (P(CO2) allowed to decrease) and eucapnia (CO2 added to inspired gas). Diaphragm activity was assessed from transdiaphragmatic pressure (esophageal and gastric balloons) and diaphragm EMG (surface electrodes) both integrated with time (integral(Pdi x dt) and integral(EMGdi x dt), respectively). Neural inspiratory time (Tin) was measured as onset to peak of the integral(EMGdi x dt) signal. Relative to QB, integral(Pdi x dt) was 50-69% less during eucapnic IPPV 6-12 cmH2O (P < 0.005) and 67-85% less during hypocapnic IPPV (P < 0.005). Tin decreased (P < 0.05) with IPPV and, on ceasing IPPV, there was apnoea (prolonged expiratory time) on 23 of 27 occasions; these changes were independent of P(CO2). Integral(EMGdi x dt) decreased (P < 0.05) at Pappl 12 cmH2O during eucapnia and at all Pappl during hypocapnia. The repeatability of integral(EMGdi x dt) was substantially less than integral(Pdi x dt) (F = 42, P << 0.01). We conclude that, during non-invasive IPPV in awake healthy subjects mechanical factors are of major importance in inhibiting inspiratory activity of the diaphragm.

Cooperative signaling by tumor necrosis factor receptors CD120a (p55) and CD120b (p75) in the expression of nitric oxide and inducible nitric oxide synthase by mouse macrophages.

Tumor necrosis factor-alpha (TNFalpha) is recognized by the cell-surface receptors CD120a (p55) and CD120b (p75). In the present study, we have investigated the role of these receptors in the expression of NO2-, a stable metabolite of nitric oxide, and inducible nitric oxide synthase (iNOS) by mouse macrophages. Specific antibody-mediated aggregation of CD120a (p55) induced NO2- accumulation in culture supernatants and iNOS mRNA expression in macrophage lysates, whereas cross-linking of CD120b (p75) had a minimal effect. In contrast, simultaneous cross-linking of both receptors led to a marked augmentation in NO2- and iNOS mRNA expression. Antibody-mediated blockade of CD120a (p55) completely inhibited NO2- expression in response to TNFalpha, whereas blockade of CD120b (p75) reduced NO2- accumulation by approximately 50%. Specific ligation of CD120a (p55) with either (i) human TNFalpha or (ii) by incubation with mouse TNFalpha following pretreatment of macrophages with blocking concentrations of anti-CD120b (p75) antibody resulted in a similar reduction in NO2- production in response to TNFalpha. Quantification of iNOS mRNA, protein, and NO2- expression during independent and co-ligation of CD120a (p55) and CD120b (p75) indicated that iNOS mRNA and protein expression was transient in nature when CD120a (p55) was cross-linked alone but was prolonged when both receptors were simultaneously cross-linked. In addition, cross-linking both receptors also led to a potentiation of NO2- accumulation in culture supernatants that was more pronounced at later time points. These findings suggest that while cross-linking of CD120a (p55) is necessary and sufficient for iNOS mRNA and NO2- expression, CD120b (p75) participates by (i) increasing the sensitivity of the cells to TNFalpha, probably by "passing" ligand to CD120a (p55), and (ii) initiating a signaling event that results in a more sustained induction of iNOS mRNA and protein and thereby augments the production of nitric oxide.

Ultrastructural analyses of the attachment (bonding) zone between bone and implanted biomaterials.

This report presents transmission electron and high voltage transmission electron microscopic observations of bone and associated remodeling tissues directly interfacing with endosteal dental implants. Undecalcified interfacial tissues were serially sectioned from mandibular samples encasing 60 implants placed into 30 dogs. Two-dimensional ultrastructural analyses and three-dimensional stereology showed that osteogenesis adjacent to dental implants is a dynamic interaction of osseous cells and a collagenous fiber matrix. This study showed that the interfacial bone consists of a mineralized collagen fiber matrix associated with an inorganic (hydroxylapatite) matrix. This study suggested that an unmineralized collagen fiber matrix initially is laid down directly at the implant surface, and that this matrix then is mineralized. Osteoblasts interacted with this matrix, eventually becoming encased within developing lacunae during the remodeling process. This process formed the cellular (osteocyte) aspects of the developed bone. Osteocyte processes extended through canaliculi directly to the implant surface. Apparently, these processes also were entrapped within canaliculi during the mineralization events. At times, these processes paralleled the implant surface. The bone-implant interfacial zone was primarily fibrillar (both mineralized and unmineralized) in morphology, with an electron-dense, ruthenium positive deposition. This electron-dense material was approximately 20 to 50 nanometers in thickness, and only this thin layer separated the remodeled mineralized bone from the implant.

Interstitial lung disease in recent onset rheumatoid arthritis.

Interstitial lung disease (ILD) is associated with rheumatoid arthritis (RA); however, the prevalence and natural history are undefined. Our aim was to determine the prevalence of ILD associated with RA using a number of sensitive techniques in patients with joint disease of less than 2-yr duration. Patients who met ARA criteria for RA were recruited from community-based and hospital rheumatologists and assessed using the following measures: clinical, lung physiology, radiology (chest X-ray, high resolution CT [HRCT]), bronchoalveolar lavage (BAL) and 99mTc-DTPA nuclear scan. Thirty-six patients (25 female and 11 male) of joint disease duration of (mean +/- SD) 13.2 +/- 8.6 mo were studied. Abnormalities consistent with ILD were found in one or more investigations in 21 of 36 (58%), which were in lung physiology in 22%, CXR in 6%, HRCT in 33%, BAL in 52%, and 99mTc-DTPA nuclear scan in 15%. Based on the results, they were categorized as having clinically significant ILD (Group 1), abnormalities compatible with ILD, but no clinically significant ILD (Group 2) and no abnormalities compatible with ILD (Group 3). Five of 36 (14%) were in Group 1, 16 of 36 (44%) in Group 2, and 15 of 36 (42%) in Group 3. The only risk factor for the presence of abnormalities compatible with ILD was male gender (p < 0.04, Student's t test). In conclusion, changes consistent with ILD in early RA are frequent. The significance of these changes is being determined in a longitudinal study.

Composite morphology of the bone and associated support-tissue interfaces to osseointegrated dental implants: TEM and HVEM analyses.

Correlated transmission electron and high-voltage electron microscopic analyses examined the undecalcified bone and associated support tissues of 60 endosseous titanium blade and titanium and ceramic root-form implants in dogs. The implants supported fixed partial dentures for up to 2 years. Data obtained from this investigation suggest that a range of tissues, both mineralized and unmineralized, support osseointegrated dental implants. This study examined the tissues apposing not just isolated aspects of the implant surface, but the entire length of the implant, and found that mineralized and unmineralized tissues existed concurrently. Much of the implant surface was apposed by mandibular bone, and both root-form and blade implants osseointegrated. The densely mineralized collagen fibril matrix was often separated from the implant by only a 20-nm to 50-nm electron-dense, ruthenium-positive deposit. High-voltage electron microscope stereology demonstrated that cellular processes extended directly to the implant from underlying osteocytes. In the same implants, areas containing an unmineralized collagen matrix interposed between the bone and implant surface were observed. In this region osteoblasts interacted with this matrix, and Howship's lacunae, containing vascular elements and osteoclasts, were also observed. The remodeling activities appear to be a homeostasis of catabolic activity (osteoclasts) and metabolic activity (osteoblasts). The apex of the implant was often apposed by a fibrofatty stroma. The support tissue response appears to be the result of the interrelations of osteoblasts, osteocytes, and osteoclasts in association with vascular elements. Therefore, the support tissue response to osseointegrated implants is a dynamic activity that involves the healthy interaction of these cells and tissues along the entire length of the implant.

Cryptogenic fibrosing alveolitis: have we made any progress?

The interstitial lung diseases (ILD) are a heterogeneous group of disorders the most common of which is cryptogenic fibrosing alveolitis (CFA). This article has summarized recent work in particular on the diagnosis, pathogenesis and treatment of CFA, by reviewing published data accessed through Medline searching. Recent reports suggest a higher prevalence of CFA than previously documented (13.2-20.2/100,000 population) and a rising mortality rate. The prognosis is universally poor with 50% of patients dying within 5 years. Although approximately 30% of patients may live for long periods (> 10 years), morbidity is significant and quality of life in the long-term survivors is poor. Diagnosis is traditionally based on an open lung biopsy, however, more recently the high resolution computer tomography (HRCT) is often used; however, its use without a tissue diagnosis remains controversial. In conclusion, we know substantially more about the pathogenesis of the disease and from this work have a number of possibilities for new therapeutic strategies that will hopefully reach the bedside in the near future. Additionally we have some new non-invasive tests that offer hope for stratifying patients but require further evaluation. For assessing both therapy and investigations we will need substantial groups of patients in multicentre studies to provide sufficient power to allow a conclusion to be reached. To ensure any further progress we must collaborate and enter our patients into such trials.

A comparative investigation in dogs: 2-year morphometric results of the dental implant--bone interface.

One hundred twenty titanium and ceramic root-form and titanium blade implants were placed into 30 dog mandibles. Twenty-four implants in six control dogs (in situ for 5 months) did not receive prostheses. Ninety-six implants in 24 dogs supported prostheses for 6, 12, 18, or 24 months. Computerized morphometry data presented the percent of the implant surface apposed directly by bone. A three-way factorial analysis of variance was used to assess significance. Individual implant means ranged from 0% (mobile implant) to 71% bone adaptation. From these data, two-stage titanium root-form implants were shown to be apposed by more bone than the other five systems, and overall, titanium implant systems were apposed by more bone than ceramic systems. Between 41% and 50% of the surface of integrated ceramic implants were apposed by bone, whereas between 50% and 65% of the surfaces of titanium implants were apposed by bone. Also, two-stage surgery for blade implants appears important for implant success. Furthermore, the use of Nomarski differential illumination appears to be useful for examining the quality of interfacial bone to correlate with the amount of bone quantified by morphometric protocols.

Divergence in macrophage insulin-like growth factor-I (IGF-I) synthesis induced by TNF-alpha and prostaglandin E2.

Increased synthesis of insulin-like growth factor I (IGF-I), a fibroblast growth factor, is induced in murine macrophages by TNF-alpha. TNF-alpha also induces macrophages to express cytocidal activity, but only during costimulation with IFNs. Since prostaglandin E2 (PGE2) is known to inhibit macrophage cytocidal activity, its possible reciprocal enhancement of IGF-I synthesis was examined. PGE2 or dibutyryl cyclic AMP (dbcAMP) stimulated the synthesis of IGF-I similarly to TNF-alpha in magnitude and time course. TNF-alpha did not increase IGF-I synthesis by first inducing PGE2 synthesis, because indomethacin was unable to block the effect of TNF-alpha. PGE2 did not stimulate IGF-I synthesis by first inducing TNF-alpha production, because 1) anti-TNF-alpha Ab did not block PGE2-induced IGF-I synthesis, and 2) PGE2 down-regulated TNF-alpha mRNA levels and did not affect levels of the cytokine in supernatants. Moreover, the difference in the induction of IGF-I was observed at the level of signal transduction, in that PGE2 and dbcAMP increased cAMP-dependent protein kinase (PKA) activity, whereas TNF-alpha stimulated the mitogen-activated protein (MAP) kinase pathway. Divergence between the two pathways was also noted in the regulation of IGF-I at the mRNA level, and an additive effect on IGF-I synthesis was observed when cells were incubated with the combination of TNF-alpha plus PGE2 or dbcAMP. Collectively, these data suggest that TNF-alpha and PGE2 stimulate IGF-I synthesis in macrophages by two separate pathways, and that PGE2 acts as a positive stimulus for IGF-I synthesis through a cyclic AMP/PKA pathway.

Histologic observations of bone remodeling adjacent to endosteal dental implants.

To examine bone morphology associated with endosteal dental implants at various time intervals, we inserted 20 one-stage and 20 two-stage titanium blade implants and 20 one-stage and 20 two-stage titanium root-form implants into 30 dog mandibles. Sixteen implants in 6 control (c) dogs (in situ five months) did not receive bridgework. Sixty-four implants in 24 dogs supported bridges for six, 12, 18, or 24 months. The entire area of the mandible containing the implants was examined by routine light and Nomarski differential interference microscopy (NM) for bone morphology (including osteon orientation) at the implant surface and at regions away from the implant. Control root-form implants were apposed by woven bone, with homogenous compact bone in the cortical plate distant to the implant. After 6 mo of load, immature bone was predominant apposing the implant, but initial osteonal maturation was apparent. NM clearly demonstrated the interstitial and concentric lamellae of the bone. Surprisingly, compact bone formed internal to the cortical plate, an area where trabecular bone is expected. At later periods of load, more mature osteons were seen apposing the implants; however remodeling events were still apparent. These remodeling events extend further away from the implant than was expected if the events resulted only from surgical repair. Also, when the implant inclined so that half was totally in the cortical plate and half in the marrow (in trabecular patterns), osteonal bone appeared to remodel in both areas. Control blade implants and blades loaded for six months were apposed by immature osteons when the implant was placed into the cortical plate. A trabecular meshwork was inferior to the osteonal bone. At 12 mo of load, the bone internal to the cortical plate appeared similar to the lamina dura supporting teeth; however, no PDL existed; the lamina-dura-like pattern directly apposed the implant. Even after 24 mo of load, extensive bone remodeling was apparent adjacent to the implant, markedly different from the bone making up the existing cortical plate. From these data, remodeling activities to blade implants may involve the development of a lamina-dura-like bone morphology after longer periods of load. Osteonal bone was apparent, but only at regions where the implant was inserted into the cortical plate. Further, bone remodeling was apparent even after long periods of load.

Transmission electron and high-voltage electron microscopy of osteocyte cellular processes extending to the dental implant surface.

Examination of the morphology of osteocytes within the bone supporting endosteal dental implants was performed using conventional transmission and high-voltage transmission electron microscopy (HVEM). The in vivo dog model used 72 implants inserted into the premolar region of 18 experimental animals. Forty-eight implants in 12 dogs were used as anterior abutments for fixed bridges for periods up to 12 months. The mineralized matrix of the supporting bone was either directly apposed to the implant surface or was separated from the implant by a narrow region of unmineralized matrix. Osteocytes were routinely observed to be closely associated with the bone-implant interface, as well as at a distance from the implant. Osteocytes were found to extend cellular processes directly to the implant surface through canaliculi. The osteocyte processes contained microfilaments. The three-dimensional capabilities of HVEM elucidated the nature of these cell processes at the point of exit from the osteocyte, as the processes extended through the mineralized matrix, and as the processes terminated at the implant interface. This report suggests that avenues of communication may exist between the implant and the osseous cells, providing intriguing hypotheses regarding biomechanical forces and osteogenesis at the implant interface. Furthermore, an electron-dense deposit was observed upon the inner confines of the canalicular wall, upon the outer aspects of the osteocyte lacuna, and upon the outer aspect of the bone interfacing the implant.

Osteoblast activity at the dental implant-bone interface: transmission electron microscopic and high voltage electron microscopic observations.

The purpose of this report is to present transmission electron microscopic and high voltage transmission electron microscopic (HVEM) observations of a longitudinal investigation examining the activities of osteoblasts and associated tissues apposing titanium and alumina oxide ceramic endosteal dental implants. The HVEM permitted 3-dimensional stereologic observations. All observations were obtained from undecalcified interfacial tissues from this in vivo experimental dog model using commercially available implants placed into the mandible. Two similar implants were placed in both sides of the mandible, with implants in 12 of the 18 dogs supporting fixed bridges for either 6 or 12 months. From the study, we observed that a mineralized matrix exists in direct apposition to the implant. Since bone does not interface the entire length of the implant, other interfacial zones were found to exist which consisted of unmineralized tissues. In such zones, we observed that osteoblasts were routinely found directly at the implant interface to the mandibular bone. These interfacial tissues included unmineralized collagen fibers, proteinaceous material, a finely fibrillar matrix, and the osteoblasts. This study has reinforced the concept that the oral tissue-dental implant interface is a dynamic zone consisting of remodeling activities of the osseous cells and extracellular matrices.