Impact of clinical pathway on clinical outcomes in the management of COPD exacerbation

ABSTRACT: BACKGROUND: Exacerbations, a leading cause of hospitalization in patients with chronic obstructive pulmonary disease (COPD), affect the quality of life and prognosis. Treatment recommendations as provided in the evidence-based guidelines are not consistently followed, partly due to absence of simplified task-oriented approach to care. In this study, we describe the development and implementation of a clinical pathway (CP) and evaluate its effectiveness in the management of COPD exacerbation. METHODS: We developed a CP and evaluated its effectiveness in a non-randomized prospective study with historical controls on patients admitted for exacerbation of COPD to UniversitiKebangsaan Malaysia Medical Centre (UKMMC). Consecutive patients who were admitted between June 2009 and December 2010 were prospectively recruited into the CP group. Non-CP historical controls were obtained from case records of patients admitted between January 2008 and January 2009. Clinical outcomes were evaluated by comparing the length of stay (LOS), complication rates, readmissions, and mortality rates. RESULTS: Ninety-five patients were recruited in the CP group and 98 patients were included in the non-CP historical group. Both groups were comparable with no significant differences in age, sex and severity of COPD (p = 0.641). For clinical outcome measures, patients in the CP group had shorter length of stay than the non-CP group (median (IQR): 5 (4-7) days versus 7 (7-9) days, p < 0.001) and 24.1% less complications (14.7% versus 38.8%, p < 0.001). We did not find any significant differences in readmission and mortality rates. CONCLUSION: The implementation of CP -reduced the length of stay and complication rates of patients hospitalized for acute exacerbation of COPD.     

An efficient sample size adaptation strategy with adjustment of randomization ratio

In clinical trials, sample size reestimation is a useful strategy for mitigating the risk of uncertainty in design assumptions and ensuring sufficient power for the final analysis. In particular, sample size reestimation based on unblinded interim effect size can often lead to sample size increase, and statistical adjustment is usually needed for the final analysis to ensure that type I error rate is appropriately controlled. In current literature, sample size reestimation and corresponding type I error control are discussed in the context of maintaining the original randomization ratio across treatment groups, which we refer to as “proportional increase.” In practice, not all studies are designed based on an optimal randomization ratio due to practical reasons. In such cases, when sample size is to be increased, it is more efficient to allocate the additional subjects such that the randomization ratio is brought closer to an optimal ratio. In this research, we propose an adaptive randomization ratio change when sample size increase is warranted. We refer to this strategy as “nonproportional increase,” as the number of subjects increased in each treatment group is no longer proportional to the original randomization ratio. The proposed method boosts power not only through the increase of the sample size, but also via efficient allocation of the additional subjects. The control of type I error rate is shown analytically. Simulations are performed to illustrate the theoretical results.     

Elevation of gene expression for salmon gonadotropin‐releasing hormone in discrete brain loci of prespawning chum salmon during upstream migration

Our previous studies suggested that salmon gonadotropin‐releasing hormone (sGnRH) neurons regulate both final maturation and migratory behavior in homing salmonids. Activation of sGnRH neurons can occur during upstream migration. We therefore examined expression of genes encoding the precursors of sGnRH, sGnRH‐I, and sGnRH‐II, in discrete forebrain loci of prespawning chum salmon, Oncorhynchus keta. Fish were captured from 1997 through 1999 along their homing pathway: coastal areas, a midway of the river, 4 km downstream of the natal hatchery, and the hatchery. Amounts of sGnRH mRNAs in fresh frozen sections including the olfactory bulb (OB), terminal nerve (TN), ventral telencephalon (VT), nucleus preopticus parvocellularis anterioris (PPa), and nucleus preopticus magnocellularis (PM) were determined by quantitative real‐time polymerase chain reactions. The amounts of sGnRH‐II mRNA were higher than those of sGnRH‐I mRNA, while they showed similar changes during upstream migration. In the OB and TN, the amounts of sGnRH mRNAs elevated from the coast to the natal hatchery. In the VT and PPa, they elevated along with the progress of final maturation. Such elevation was also observed in the rostroventral, middle, and dorsocaudal parts of the PM. The amounts of gonadotropin IIβ and somatolactin mRNAs in the pituitary also increased consistently with the elevation of gene expression for sGnRH. These results, in combination with lines of previous evidence, indicate that sGnRH neurons are activated in almost all the forebrain loci during the last phases of spawning migration, resulting in coordination of final gonadal maturation and migratory behavior to the spawning ground. © 2005 Wiley Periodicals, Inc. J Neurobiol, 2005     

Adipose-derived stem cells extract has a proliferative effect on myogenic progenitors

Finding an effective method to regenerate muscle is a growing issue in the orthopedic field. Platelet-rich plasma (PRP) has recently been considered for therapeutic use due to its capacity to induce proliferation of myogenic progenitor cells (MPCs). Adipose-derived stem cells (ASCs) and its extract are regarded as a promising treatment for various disorders within the orthopedic field but their therapeutic relevance in the muscle regeneration is poorly investigated. In this study, rabbit MPCs were cultured from the supraspinatus of rabbit and characterized by myogenic markers. To investigate the paracrine effect of ASCs on MPCs, coculture experiments were performed. In order to see the anabolic effect of ASC-extracts (ASC-ex) in MPCs, cell proliferation assays were performed and compared with the PRP-added condition. Coculture experiment showed ASCs had an anabolic paracrine effect on proliferation of MPCs. PRP had a positive effect on proliferation of MPCs when compared to the control (100?±?7.4% vs 195.2?±?19.2%, p?p?p?p?相似文献   

Structure of a eukaryotic cytoplasmic pre‐40S ribosomal subunit

Final maturation of eukaryotic ribosomes occurs in the cytoplasm and requires the sequential removal of associated assembly factors and processing of the immature 20S pre‐RNA. Using cryo‐electron microscopy (cryo‐EM), we have determined the structure of a yeast cytoplasmic pre‐40S particle in complex with Enp1, Ltv1, Rio2, Tsr1, and Pno1 assembly factors poised to initiate final maturation. The structure reveals that the pre‐rRNA adopts a highly distorted conformation of its 3′ major and 3′ minor domains stabilized by the binding of the assembly factors. This observation is consistent with a mechanism that involves concerted release of the assembly factors orchestrated by the folding of the rRNA in the head of the pre‐40S subunit during the final stages of maturation. Our results provide a structural framework for the coordination of the final maturation events that drive a pre‐40S particle toward the mature form capable of engaging in translation.     

Phospholipid transfer function of PTPIP51 at mitochondria‐associated ER membranes

In eukaryotic cells, mitochondria are closely tethered to the endoplasmic reticulum (ER) at sites called mitochondria‐associated ER membranes (MAMs). Ca²⁺ ion and phospholipid transfer occurs at MAMs to support diverse cellular functions. Unlike those in yeast, the protein complexes involved in phospholipid transfer at MAMs in humans have not been identified. Here, we determine the crystal structure of the tetratricopeptide repeat domain of PTPIP51 (PTPIP51_TPR), a mitochondrial protein that interacts with the ER‐anchored VAPB protein at MAMs. The structure of PTPIP51_TPR shows an archetypal TPR fold, and an electron density map corresponding to an unidentified lipid‐like molecule probably derived from the protein expression host is found in the structure. We reveal functions of PTPIP51 in phospholipid binding/transfer, particularly of phosphatidic acid, in vitro. Depletion of PTPIP51 in cells reduces the mitochondrial cardiolipin level. Additionally, we confirm that the PTPIP51–VAPB interaction is mediated by the FFAT‐like motif of PTPIP51 and the MSP domain of VAPB. Our findings suggest that PTPIP51 is a phospholipid transfer protein with a MAM‐tethering function.     

MicroRNA-192 regulates hypertrophic scar fibrosis by targeting SIP1

Hypertrophic scar (HS) is a fibro-proliferative disorder which is characterized by excessive deposition of collagen and accumulative activity of myofibroblasts. Increasing evidences have demonstrated miRNAs play a pivotal role in the pathogenesis of HS. MiR-192 is closely associated with renal fibrosis, but its effect on HS formation and skin fibrosis remains unknown. In the study, we presented that miR-192 was up-regulated in HS and HS derived fibroblasts (HSFs) compared to normal skin (NS) and NS derived fibroblasts (NSFs), accompanied by the reduction of smad interacting protein 1 (SIP1) expression and the increase of Col1, Col3 and α-SMA levels. Furthermore, we confirmed SIP1 was a direct target of miR-192 by using luciferase reporter assays. Meanwhile, the overexpression of miR-192 increased the levels of Col1, Col3 and α-SMA. The synthesis of collagen and more positive α-SMA staining were also observed in bleomycin-induced dermal fibrosis model of BALB/c mice treated with subcutaneous miR-192 mimics injection, whereas the inhibition of miR-192 decreased the expression of Col1, Col3 and α-SMA. Moreover, SIP1 siRNA could enhance the levels of Col1, Col3 and α-SMA, showing that the effect of knockdown SIP1 was similar to miR-192 mimics, and the phenomenon manifested miR-192 regulated HS fibrosis by targeting SIP1. Together, our results indicated that miR-192 was a critical factor of HS formation and facilitated skin fibrosis by targeting directly SIP1.     

Antisense inhibition of a spermidine synthase gene highlights the role of polyamines for stress alleviation in pear shoots subjected to salinity and cadmium

Three transgenic European pear (Pyrus communis L.) lines with reduced spermidine synthase (SPDS) expression and spermidine (Spd) titers were developed using a construct containing an apple SPDS gene (MdSPDS1) in antisense orientation. After exposure to either salt or cadmium stress, growth inhibition was more severe in the antisense lines than in the wild-type (WT). The antioxidant system, as shown by glutathione (GSH) content, activity of glutathione reductase (GR) and superoxide dismutase (SOD), and proline accumulation, was not effectively induced under stress in the antisense lines as compared with the WT. The reduction in antioxidant system function in the antisense lines was accompanied by a greater accumulation of malondialdehyde (MDA), an indicator of lipid peroxidation. Growth inhibition, Spd level, and parameters indicative of the antioxidant system were significantly ameliorated by exogenous Spd application. Under either salt or cadmium stress, GSH content, GR and SOD activity, and proline accumulation were positively correlated with Spd, putrescine (Put), and total polyamine titers. Conversely, MDA level showed a significantly negative correlation with these polyamines under both stress conditions. Thus, the responses to stress treatments were first identified in the SPDS antisense European pears, and the results provide further evidence for the important role of polyamines in both salt and cadmium stress tolerance, in which the polyamines act, at least in part, by influencing the antioxidant system.