Accuracy of diagnostic registers and management of chronic obstructive pulmonary disease: the Devon primary care audit

Background

Guidelines on COPD diagnosis and management encourage primary care physicians to detect the disease at an early stage and to treat patients according to their condition and needs. Problems in guideline implementation include difficulties in diagnosis, using spirometry and the disputed role of reversibility testing. These lead to inaccurate diagnostic registers and inadequacy of administered treatments. This study represents an audit of COPD diagnosis and management in primary care practices in Devon.

Methods

Six hundred and thirty two patients on COPD registers in primary care practices were seen by a visiting Respiratory Specialist Nurse. Diagnoses were made according to the NICE guidelines. Reversibility testing was carried out either routinely or based on clinical indication in two sub-samples. Dyspnoea was assessed. Data were entered into a novel IT-based software which computed guideline-based treatment recommendations. Current and recommended treatments were compared.

Results

Five hundred and eighty patients had spirometry. Diagnoses of COPD were confirmed in 422 patients (73%). Thirty nine patients were identified as asthma only, 94 had normal spirometry, 23 were restrictive and 2 had a cardiac disorder. Reversibility testing changed diagnosis of 11% of patients with airflow obstruction, and severity grading in 18%. Three quarters of patients with COPD had been offered practical help with smoking cessation. Short and long-acting anticholinergics and long acting beta-2 agonists had been under-prescribed; in 15–18% of patients they were indicated but not received. Inhaled steroids had been over-prescribed (recommended in 17%; taken by 60%), whereas only 4% of patients with a chronic productive cough were receiving mucolytics. Pulmonary rehabilitation was not available in some areas and was under-used in other areas.

Conclusion

Diagnostic registers of COPD in primary care contain mistakes leading to inaccurate prevalence estimates and inappropriate treatment decisions. Use of pre-bronchodilator readings for diagnosis overestimates the prevalence and severity in a significant minority, thus post bronchodilator readings should be used. Management of stable COPD does often not correspond to guidelines. The IT system used in this study has the potential to improve diagnosis and management of COPD in primary care.     

Phylogenetic studies of the genus <Emphasis Type="Italic">Cebus</Emphasis>(Cebidae-Primates) using chromosome painting and G-banding

Background  

Chromosomal painting, using whole chromosome probes from humans and Saguinus oedipus, was used to establish karyotypic divergence among species of the genus Cebus, including C. olivaceus, C. albifrons, C. apella robustus and C. apella paraguayanus. Cytogenetic studies suggested that the species of this genus have conservative karyotypes, with diploid numbers ranging from 2n = 52 to 2n = 54.     

Delayed blockade of the kinin B1 receptor reduces renal inflammation and fibrosis in obstructive nephropathy

Renal fibrosis is the common histological feature of advanced glomerular and tubulointerstitial disease leading to end-stage renal disease (ESRD). However, specific antifibrotic therapies to slow down the evolution to ESRD are still absent. Because persistent inflammation is a key event in the development of fibrosis, we hypothesized that the proinflammatory kinin B1 receptor (B1R) could be such a new target. Here we show that, in the unilateral ureteral obstruction model of renal fibrosis, the B1R is overexpressed and that delayed treatment with an orally active nonpeptide B1R antagonist blocks macrophage infiltration, leading to a reversal of the level of renal fibrosis. In vivo bone marrow transplantation studies as well as in vitro studies on renal cells show that part of this antifibrotic mechanism of B1R blockade involves a direct effect on resident renal cells by inhibiting chemokine CCL2 and CCL7 expression. These findings suggest that blocking the B1R is a promising antifibrotic therapy.     

A flexible bioreactor system for constructing in vitro tissue and organ models

To develop in vitro models of cells, tissues and organs we have designed and realized a series of cell culture chambers. Each chamber is purpose designed to simulate a particular feature of the in vivo environment. The bioreactor system is user friendly, and the chambers are easy to produce, sterilize and assemble. In addition they can be connected together to simulate inter-organ or tissue cross-talk. Here we discuss the design philosophy of the bioreactor system and then describe its construction. Preliminary results of validation tests obtained with hepatocytes and endothelial cells are also reported. The results show that endothelial cells are extremely sensitive to small levels of shear stress and that the presence of heterotypic signals from endothelial cells enhances the endogenous metabolic function of hepatocytes.     

Characterization of cytochrome c folding intermediates induced by sucrose and phosphate

Spectroscopic and calorimetric investigations of the folding of denatured cytochrome c in the presence of phosphate ion and sugar were carried out to understand subtle differences in the nature of induced conformation and folding energy landscape. Altered conformations of cyt c induced by sucrose and phosphate, with same absorbance wavelength maxima, exhibit lack of tertiary interactions in segment 70-85 and similar α-helical content. However, compactness, the exposure of the heme to solvent and the secondary structure content in the two conformations are different. Although downhill folding was observed for both conformations, extent of cooperativity is higher in case of phosphate-induced conformation.     

Population Distribution of the Sagittal Abdominal Diameter (SAD) from a Representative Sample of US Adults: Comparison of SAD,Waist Circumference and Body Mass Index for Identifying Dysglycemia

Background

The sagittal abdominal diameter (SAD) measured in supine position is an alternative adiposity indicator that estimates the quantity of dysfunctional adipose tissue in the visceral depot. However, supine SAD’s distribution and its association with health risk at the population level are unknown. Here we describe standardized measurements of SAD, provide the first, national estimates of the SAD distribution among US adults, and test associations of SAD and other adiposity indicators with prevalent dysglycemia.

Methods and Findings

In the 2011–2012 National Health and Nutrition Examination Survey, supine SAD was measured (“abdominal height”) between arms of a sliding-beam caliper at the level of the iliac crests. From 4817 non-pregnant adults (age ≥20; response rate 88%) we used sample weights to estimate SAD’s population distribution by sex and age groups. SAD’s population mean was 22.5 cm [95% confidence interval 22.2–22.8]; median was 21.9 cm [21.6–22.4]. The mean and median values of SAD were greater for men than women. For the subpopulation without diagnosed diabetes, we compared the abilities of SAD, waist circumference (WC), and body mass index (BMI, kg/m²) to identify prevalent dysglycemia (HbA1c ≥5.7%). For age-adjusted, logistic-regression models in which sex-specific quartiles of SAD were considered simultaneously with quartiles of either WC or BMI, only SAD quartiles 3 (p<0.05 vs quartile 1) and 4 (p<0.001 vs quartile 1) remained associated with increased dysglycemia. Based on continuous adiposity indicators, analyses of the area under the receiver operating characteristic curve (AUC) indicated that the dysglycemia model fit for SAD (age-adjusted) was 0.734 for men (greater than the AUC for WC, p<0.001) and 0.764 for women (greater than the AUC for WC or BMI, p<0.001).

Conclusions

Measured inexpensively by bedside caliper, SAD was associated with dysglycemia independently of WC or BMI. Standardized SAD measurements may enhance assessment of dysfunctional adiposity.     

Aberrant,ectopic expression of VEGF and VEGF receptors 1 and 2 in malignant colonic epithelial cells. Implications for these cells growth via an autocrine mechanism

Vascular endothelial growth factor A (referred to as VEGF) is implicated in colon cancer growth. Currently, the main accepted mechanism by which VEGF promotes colon cancer growth is via the stimulation of angiogenesis, which was originally postulated by late Judah Folkman. However, the cellular source of VEGF in colon cancer tissue; and, the expression of VEGF and its receptors VEGF-R1 and VEGF-R2 in colon cancer cells are not fully known and are subjects of controversy.     

Modular bioreactor for primary human hepatocyte culture: medium flow stimulates expression and activity of detoxification genes

Down-regulation of detoxification genes, notably cytochrome P450 (CYPs), in primary hepatocyte cultures is a long-standing and major concern. We evaluated the influence of medium flow in this model. Hepatocytes isolated from 12 different liver donors were cultured either in a multichamber modular bioreactor (MCmB, flow rate 250-500 μL/min) or under standard/static conditions, and the expression of 32 genes, enzyme activities and biological parameters were measured 7-21 days later. mRNA expression of genes involved in xenobiotic/drug metabolism and transport, including CYP1A1, 1A2, 2B6, 2C9, 3A4 (and activities for some of them), UDP-glucuronosyltransferase (UGT) 1A1, UGT2B4, UGT2B7, glutathione S-transferase (GSTα), and multidrug resistance protein 1 (MDR1) and MRP2, were specifically up-regulated by medium flow as compared with static controls in all cultures tested. In 2-week-old cultures, expression of detoxification genes reached levels close to or higher than those measured in freshly isolated hepatocytes. In contrast, CYP2D6 and most of other tested genes were not affected by medium flow. We conclude that medium flow specifically interferes with, and up-regulates, the activity of xenosensors and/or the expression of detoxification genes in primary human hepatocytes. Down-regulation of detoxification genes in conventional (static) cultures is therefore partly a consequence of the absence of medium circulation.     

Trends from 2002 to 2010 in Daily Breakfast Consumption and its Socio-Demographic Correlates in Adolescents across 31 Countries Participating in the HBSC Study

Breakfast is often considered the most important meal of the day and children and adolescents can benefit from breakfast consumption in several ways. The purpose of the present study was to describe trends in daily breakfast consumption (DBC) among adolescents across 31 countries participating in the HBSC survey between 2002 to 2010 and to identify socio-demographic (gender, family affluence and family structure) correlates of DBC. Cross-sectional surveys including nationally representative samples of 11–15 year olds (n = 455,391). Multilevel logistic regression analyses modeled DBC over time after adjusting for family affluence, family structure and year of survey. In all countries, children in two-parent families were more likely to report DBC compared to single parent families. In most countries (n = 19), DBC was associated with family affluence. Six countries showed an increase in DBC (Canada, Netherland, Macedonia, Scotland, Wales, England) from 2002. A significant decrease in DBC from 2002 was found in 11 countries (Belgium Fr, France, Germany, Croatia, Spain, Poland, Russian Federation, Ukraine, Latvia, Lithuania and Norway), while in 5 countries (Portugal, Denmark, Finland, Ireland, Sweden) no significant changes were seen. Frequency of DBC among adolescents in European countries and North America showed a more uniform pattern in 2010 as compared to patterns in 2002. DBC increased significantly in only six out of 19 countries from 2002 to 2010. There is need for continued education and campaigns to motivate adolescents to consume DBC. Comparing patterns across HBSC countries can make an important contribution to understanding regional /global trends and to monitoring strategies and development of health promotion programs.