Asthma-specific health-related quality of life of people in Great Britain: A national survey.

BACKGROUND: Although the ultimate goal of asthma treatment is to improve asthma-specific Health-Related Quality-Of-Life (HRQOL), in the UK population this is insufficiently studied. National asthma-specific HRQOL data is needed to inform strategies to address this condition. AIMS AND OBJECTIVES: To benchmark asthma-specific HRQOL in a national survey of adults with asthma, and explore differences in this measure within subsections of the population. METHODS: We analysed answers to the Marks Asthma Quality-of-Life Questionnaire (AQLQ-M) from a representative sample of 658 adults with asthma. Respondents answered asthma-specific questions to assess control, previous hospital admissions, asthma attacks and an indicator of severity. Higher scores indicate poorer HRQOL (maximum = 60). The highest quintile formed a subgroup 'Poor HRQOL'. Data were weighted to correct for any biases caused by differential non-response. Chi-square analyses were used to determine differences between good and poor quality of life and regression analyses performed to determine what factors are associated with poor HRQOL. RESULTS: The response rate was 49%. AQLQ-M median (IQR) scores were 5 (2-13) for the total sample (poor HRQOL = 21, good HRQOL = 3). Significant differences between good and poor HRQOL were observed in smoking status, SES, employment status and co-morbidities, but no differences were found between age groups. Those with poorly controlled asthma were significantly more likely to have poor HRQOL, ≥1 breathing related hospital admission or ≥1 asthma attack. CONCLUSIONS: This article provides benchmarking data on asthma-specific HRQOL. Improved strategies are needed to target interventions towards people experiencing poor HRQOL.

Development of depressive symptoms post hip fracture is associated with altered immunosuppressive phenotype in regulatory T and B lymphocytes.

Hip fracture is a common physical trauma in older adults that is also associated with a high incidence of new onset depression. The immune system declines with age and is also compromised by physical and psychological stress. This study examined whether hip fracture and depressive symptoms had additive effects upon the aged immune system that might contribute to poor health outcomes after hip fracture. We assessed the frequency of regulatory T cells, Tregs (CD4(+) CD25(+) Foxp3(+)) and IL10 production by CD4 T cells, and the frequency and IL10 production by regulatory B cells, Bregs (CD19(+) CD24(hi) CD38(hi)) in 101 hip fracture patients (81 female) 6 weeks after injury and 43 healthy age-matched controls (28 female). 38 hip fracture patients (37%) developed depressive symptoms. Hip fracture did not have an effect on circulating Tregs frequency but a significant reduction in the frequency of Bregs was observed in patients who developed depression compared with non-depressed patients (p = 0.001) or healthy controls (p < 0.001). Bregs also showed a significant decline in IL10 production in depressed hip fracture patients compared with controls (p = 0.04) and non-depressed patients (p = 0.01). In contrast, there was an increase in IL10 production by CD4 T cells in hip fracture patients with new onset depression compared to hip fracture patients without depression (p = .04) and healthy controls (p = .02). We conclude that the reduced immunity associated with new onset depression post hip fracture could include a contribution by heightened Tregs function.

Patient-reported side effects, concerns and adherence to corticosteroid treatment for asthma, and comparison with physician estimates of side-effect prevalence: a UK-wide, cross-sectional study.

BACKGROUND: Non-adherence to corticosteroid treatment has been shown to reduce treatment efficacy, thus compromising asthma control. AIMS: To examine the experiences of treatment side effects, treatment concerns and adherence to inhaled (ICS) and oral corticosteroids (OCS) among people with asthma and to identify the degree of concordance between clinician estimates of side effects and the prevalence reported by patients. METHODS: Asthma UK members were sent validated questionnaires assessing treatment concerns, experiences of side effects and adherence. Questionnaires measuring clinicians' estimates of the prevalence of corticosteroid side effects were completed online. RESULTS: Completed questionnaires were returned by 1,524 people taking ICS, 233 taking OCS and 244 clinicians (67% of clinicians were primary care nurses). Among people with asthma, 64% of those taking ICS and 88% of those taking OCS reported ⩾ 1 side effect. People reporting high adherence to ICS (t = -3.09, P<0.005) and those reporting low adherence to OCS (t = 1.86, P < 0.05; one-tailed test) reported more side effects. There was a disparity between clinicians' estimates of the frequency of side effects and the frequency reported by people with asthma: e.g., although 46% of people taking ICS reported sore throat, clinicians estimated that this figure would be 10%. Patients who reported side effects had stronger concerns about both ICS (r = 0.46, P < 0.0001) and OCS (r = 0.50, P < 0.0001). Concerns about corticosteroids were associated with low adherence to ICS (t = 6.90, P < 0.0001) and OCS (t = 1.71; P < 0.05; one-tailed test). CONCLUSIONS: An unexpectedly large proportion of people with asthma experienced side effects and had strong concerns about their treatment, which compromised adherence. These findings have implications for the design of interventions to optimise asthma control through improved adherence.

NK cell immunesenescence is increased by psychological but not physical stress in older adults associated with raised cortisol and reduced perforin expression.

NK cell cytotoxicity (NKCC) reduces with age and this has been associated previously with increased mortality. The immune response is also modulated by stress, and here, we assessed the effect of the physical stress of hip fracture and the psychological stress of depression on NKCC in an aged immune system. NKCC was assessed in 101 hip fracture patients (81 female) 6 weeks and 6 months after injury and in 50 healthy age-matched controls (28 female). Thirty-eight patients were depressed at 6 weeks post-injury, and NKCC was reduced in patients who developed depression compared with non-depressed hip fracture patients (p = 0.004) or controls (p < 0.02). NKCC remained lower in the depressed patients compared to those without depression 6 months post-fracture (p = 0.017). We found reduced expression of perforin in NK cells of depressed hip fracture patients compared with controls at 6 weeks (p = 0.001) post-fracture. Serum cortisol levels were also elevated in patients with depression compared to non-depressed patients at 6 weeks (p = 0.01) and 6 months (p = 0.05). NK cells treated with dexamethasone showed a concentration-dependent reduction in NKCC and perforin expression. We propose that depression is the major factor affecting NK cell immunity after hip fracture.

Depressive symptoms in hip fracture patients are associated with reduced monocyte superoxide production.

Ageing is accompanied by reduced functioning of the immune system, termed immunesenescence which is associated with increased risk of infection and mortality. However the immune system does not operate in isolation and can be modified by many environmental factors, including stress. In this study we determined whether physical stress (hip fracture) and psychological distress (depressive symptoms) had additive effects upon the aged immune system, specifically on monocyte numbers and function. We assessed immune function in 101 hip fracture patients (81 female) 6weeks and 6months after injury and 43 healthy age matched controls (28 females). Thirty-eight of the hip fracture group were found to be depressed at the 6week sampling. No differences in peripheral monocyte count, distribution of monocyte subsets or TNFα secretion were observed between hip fracture patients and healthy controls. However we observed significantly reduced superoxide production in response to Escherichia coli in the monocytes of hip fracture patients who developed depressive symptoms compared with non-depressed hip fracture patients (p=0.002) or healthy controls (p=0.008) 6weeks after the fracture which remained decreased 6months following injury. In previous studies we have shown an effect of depression on neutrophil superoxide generation in hip fracture patients, suggesting a particular susceptibility of this aspect of immune cell function to psychological stress.

Depressive symptoms post hip fracture in older adults are associated with phenotypic and functional alterations in T cells.

BACKGROUND: Ageing is accompanied by reduced immunity, termed immunesenescence. The immune system does not act in isolation and is sensitive to both psychological and physical stress. Hip fracture is a common physical stressor in older adults with a high incidence of new onset depression, which relates to poorer prognosis. We therefore set out to examine the possible synergistic effects of physical stress (hip fracture) and psychological stress (depressive symptoms) on the aged immune system. RESULTS: T cell phenotype and function was assessed in 101 hip fracture patients (81 female) 6 weeks after hip fracture and 43 healthy age-matched controls (26 female). 38 fracture patients had depressive symptoms at 6 weeks. T cell frequency (p = .01) and numbers (p = .003) were both lower in depressed hip fracture patients compared to healthy controls. The frequency of senescent CD28(-ve) (p = .001), CD57(+ve) (p = .001), KLRG1(+ve) (p = .03) CD8 T cells, as well as senescent CD28(-ve) CD4(+ve) (p = .01) and CD57(+ve) CD4(+ve) (p = .003) T cells were higher in depressed hip fracture patients compared with healthy controls and the frequency of CD28(-ve) CD8 T cells was also higher when compared to patients with hip fracture alone (p = .01). Additionally, activated CD69(+ve) (p = .005) and HLADR(+ve) (p < .001) CD8 T cells, were also higher in depressed hip fracture patients compared to healthy controls. On examining cytokine production by activated T cells, a significant increase in TNFα (p = .03) and IL6 (p = .04) production was observed in CD4 T cells from hip fracture patients with depressive symptoms compared to healthy controls. CONCLUSIONS: As none of the patients in the study had a prior history of depression, our data suggest that the development of depressive symptoms in hip fracture patients is associated with altered T cell phenotype and increased pro-inflammatory function which is not seen in patients who do not develop depression after hip fracture. Treating depressive symptoms promptly in hip fracture patients may therefore improve immunity and outcomes in these patients.

Depressive symptoms are associated with reduced neutrophil function in hip fracture patients.

Hip fracture is a common trauma in older adults with a high incidence of depression, which relates to poorer prognosis including increased risk of infection. Ageing is accompanied by reduced immunity, termed immunesenescence, resulting in increased susceptibility to infection. We examined whether physical trauma (hip fracture) and psychological distress (depressive symptoms) had additive effects upon the aged immune system that might contribute to poor outcomes after injury. Neutrophil function was assessed in 101 hip fracture patients (81 female) 6 weeks and 6 months after injury and 43 healthy age-matched controls (28 female). Thirty eight fracture patients had depressive symptoms at 6 weeks. No difference in neutrophil phagocytosis of Escherichia coli was observed between controls and hip fracture patients, but superoxide production was significantly reduced in hip fracture patients with depressive symptoms compared with patients without symptoms (p=.001) or controls (p=.004) at 6 weeks. Superoxide production improved 6 months following fracture to the level seen in controls. We detected elevated serum cortisol, reduced dehydroepiandrosterone sulphate (DHEAS) and an increased cortisol:DHEAS ratio in fracture patients with depressive symptoms compared with patients without depressive symptoms or controls at 6 weeks and 6 months after injury. Serum IL6, TNFα and IL10 were higher among patients with depressive symptoms at 6 weeks. The cortisol:DHEAS ratio and IL6 levels related to depressive symptom scores but not to neutrophil function. In conclusion, depressive symptoms related to poorer neutrophil function after hip fracture, but this was not driven by changes in stress hormone or cytokine levels.

Depression following hip fracture is associated with increased physical frailty in older adults: the role of the cortisol: dehydroepiandrosterone sulphate ratio.

BACKGROUND: Hip fracture in older adults is associated with depression and frailty. This study examined the synergistic effects of depression and hip fracture on physical frailty, and the mediating role of the cortisol:dehydroepiandrosterone sulphate (DHEAS) ratio. METHODS: This was an observational longitudinal study of patients with a hip fracture carried out in a hospital setting and with follow up in the community. Participants were 101 patients aged 60+ years (81 female) with a fractured neck of femur. Measurements of the ability to carry out activities of daily living (ADL), cognitive function, physical frailty and assays for serum cortisol and DHEAS were performed six weeks and six months post-hip fracture. Depressed and non-depressed groups were compared by ANOVA at each time point. RESULTS: Hip fracture patients who developed depression by week six (n = 38) had significantly poorer scores on ADL and walking indices of frailty at both week six and month six, and poorer balance at week six. The association with slower walking speed was mediated by a higher cortisol:DHEAS ratio in the depressed group. CONCLUSION: Depression following hip fracture is associated with greater physical frailty and poorer long term recovery post-injury. Our data indicate that the underlying mechanisms may include an increased cortisol:DHEAS ratio and suggest that correcting this ratio for example with DHEA supplementation could benefit this patient population.

An age-related numerical and functional deficit in CD19(+) CD24(hi) CD38(hi) B cells is associated with an increase in systemic autoimmunity.

Autoimmunity increases with aging indicative of reduced immune tolerance, but the mechanisms involved are poorly defined. In recent years, subsets of B cells with immunoregulatory properties have been identified in murine models of autoimmune disorders, and these cells downregulate immune responses via secretion of IL10. In humans, immature transitional B cells with a CD19(+) CD24(hi) CD38(hi) phenotype have been reported to regulate immune responses via IL10 production. We found the frequency and numbers of CD19(+) CD24(hi) CD38(hi) cells were reduced in the PBMC pool with age. IL10 expression and secretion following activation via either CD40, or Toll-like receptors was also impaired in CD19(+) CD24(hi) CD38(hi) B cells from healthy older donors. When investigating the mechanisms involved, we found that CD19(+) CD24(hi) CD38(hi) B-cell function was compromised by age-related effects on both T cells and B cells: specifically, CD40 ligand expression was lower in CD4 T cells from older donors following CD3 stimulation, and signalling through CD40 was impaired in CD19(+) CD24(hi) CD38(hi) B cells from elders as evidenced by reduced phosphorylation (Y705) and activation of STAT3. However, there was no age-associated change in expression of costimulatory molecules CD80 and CD86 on CD19(+) CD24(hi) CD38(hi) cells, suggesting IL10-dependent immune suppression is impaired, but contact-dependent suppressive capacity is intact with age. Finally, we found a negative correlation between CD19(+) CD24(hi) CD38(hi) B-cell IL10 production and autoantibody (Rheumatoid factor) levels in older adults. We therefore propose that an age-related decline in CD19(+) CD24(hi) CD38(hi) B cell number and function may contribute towards the increased autoimmunity and reduced immune tolerance seen with aging.

Correlation between perceived asthma control and thoraco-abdominal asynchrony in primary care patients diagnosed with asthma.

OBJECTIVE: Thoraco-abdominal asynchrony (TAA), the discordant movement of the abdomen and thorax, may impact upon health-related variables. Here, we investigated the extent to which TAA is associated with health-related variables, particularly perceived asthma control and quality of life. METHODS: Ambulatory respiratory data from 43 patients diagnosed with asthma and 43 healthy age and sex-matched controls were recorded over 4 hours. Phase relation (Ph Rel Total), the percentage of time that the effects of rib cage (RC) and diaphragmatic movement result in opposite effects on intra-thoracic volume, quantified TAA. Subjects completed the Mini Asthma Quality of Life Questionnaire (AQLQ), Asthma Control Questionnaire (ACQ), Nijmegen questionnaire (NQ), Hospital Anxiety and Depression Scale (HADS), Spielberger State-Trait Anxiety Inventory (STAI), and General Health Perception (GHP) subscale of the short form 36 questionnaire'. Capnography profiling, breath-hold time (BHT), and standard spirometry were performed. RESULTS: The time in asynchrony was significantly greater in the asthma than in the healthy control group (Ph Rel Total = 14% (interquartile range (IQR) 8.5-20.7%) versus 10.4% (IQR 7.1-14.5%), p = .012). In patients with asthma, Ph Rel Total was weakly associated with poorer ACQ scores (r = 0.33, p = .03), and in the healthy control group with GHP (r = 0.319, p = .037). Post-hoc exploratory analysis revealed a moderate relationship in the female asthma subgroup between Ph Rel Total and AQLQ (r = -0.56, p = .003). CONCLUSIONS: TAA may be associated with decreased perceived asthma control. In healthy individuals, asynchrony may be associated with low perception of general health. Further studies are required to investigate if the reduction of TAA improves these health-related variables.

The standardized and mini versions of the PAQLQ are valid, reliable, and responsive measurement tools.

OBJECTIVE: The Paediatric Asthma Quality of Life Questionnaire (PAQLQ) is a validated tool developed to assess the impact of symptoms on quality of life. Here we assess the validity, reliability and responsiveness of two new simpler versions of this questionnaire: the Standardised PAQLQ and the MiniPAQLQ. STUDY DESIGN AND SETTING: Participants included 42 children with asthma, who completed the PAQLQ, PAQLQ(S), MiniPAQLQ, Asthma Control Questionnaire, and Health Utilities Index at baseline, one, five and nine weeks. Concordance between questionnaires was examined using intraclass correlation coefficients (ICC), bias by paired Student's t-tests and closeness of association by Pearson correlation coefficients. RESULTS: Correlation coefficients for each of the corresponding domains of the PAQLQ with the PAQLQ(S) were strong (r>0.97), and moderate to strong (r=0.50-0.94) with the MiniPAQLQ. Reliability was strong for both the PAQLQ(S) (ICC>0.89) and MiniPAQLQ (ICC>0.91). The responsiveness index values for the PAQLQ(S) (0.96) and the MiniPAQLQ (1.05) were both higher than that of the original PAQLQ (0.90). Cross sectional and longitudinal correlation coefficients were similar for all three instruments. CONCLUSION: The PAQLQ(S) and the MiniPAQLQ are valid, reliable and responsive to change. They can be used with confidence for long-term monitoring in clinical trials.

COPD uncovered: an international survey on the impact of chronic obstructive pulmonary disease [COPD] on a working age population.

BACKGROUND: Approximately 210 million people are estimated to have chronic obstructive pulmonary disease [COPD] worldwide. The burden of disease is known to be high, though less is known about those of a younger age. The aim of this study was to investigate the wider personal, economic and societal burden of COPD on a cross country working-age cohort. METHODS: A cross-country [Brazil, China, Germany, Turkey, US, UK] cross-sectional survey methodology was utilised to answer the research questions. 2426 participants aged 45-67 recruited via a number of recruitment methods specific to each country completed the full survey. Inclusion criteria were a recalled physician diagnosis of COPD, a smoking history of > 10 pack years and the use of COPD medications in the previous 3 months prior to questioning. The survey included items from the validated Work Productivity and Activity Impairment [WPAI] scale and the EuroQoL 5 Dimension [EQ-5D] scale. Disease severity was measured using the 5-point MRC [Medical Research Council] dyspnoea scale as a surrogate measure. RESULTS: 64% had either moderate [n = 1012] or severe [n = 521] COPD, although this varied by country. 75% of the cohort reported at least one comorbid condition. Quality of life declined with severity of illness [mild, mean EQ-5D score = 0.84; moderate 0.58; severe 0.41]. The annual cost of healthcare utilisation [excluding treatment costs and diagnostic tests] per individual was estimated to be $2,364 [£1,500]. For those remaining in active employment [n: 677]: lost time from work cost the individual an average of $880 [£556] per annum and lifetime losses of $7,365 [£4,661] amounting to $596,000 [£377,000] for the cohort. 447 [~40%] of the working population had retired prematurely because of COPD incurring individual estimated lifetime income losses of $316,000 [£200,000] or a combined total of $141 m [£89.6 m]. As the mean age of retirees was 58.3 and average time since retirement was 4 years, this suggests the average age of retirement is around 54. This would mean a high societal and economic impact in all study countries, particularly where typical state retirement ages are higher, for example in Brazil, Germany and the UK [65] and the US [65,66,67], compared to Turkey [58 for women, 60 for men] and China [60]. CONCLUSIONS: Although generalisation across a broader COPD population is limited due to the varied participant recruitment methods, these data nevertheless suggest that COPD has significant personal, economic and societal burden on working age people. Further efforts to improve COPD diagnosis and management are required.

The influence of selenium-enriched milk proteins and selenium yeast on plasma selenium levels and rectal selenoprotein gene expression in human subjects.

Certain forms of dietary Se may have advantages for improving human Se status and regulating the risk for disease, such as cancers, including colorectal cancer (CRC). The present study compared the effects of a Se-enriched milk protein (dairy-Se) with a Se-rich yeast (yeast-Se) on plasma Se levels and rectal selenoprotein gene expression since we reasoned that if these genes were not regulated, there was little potential for regulating the risk for CRC in this organ. A total of twenty-three healthy volunteers with plasma Se in the lower half of the population range were supplemented with dairy-Se (150 µg/d) or yeast-Se (150 µg/d) for 6 weeks, followed by 6 weeks of washout period. Blood was sampled every 2 weeks, and rectal biopsies were obtained before and after Se supplementation and after the washout period. Plasma Se levels and glutathione peroxidase (GPx) activity, and rectal mRNA of selenoprotein P (SeP), cytosolic GPx-1 (GPx-1), gastrointestinal GPx-2 (GPx-2) and thioredoxin reductase-1 (TrxR-1) were measured. Plasma Se levels increased rapidly in both Se groups (P < 0·001); plasma GPx activity was not significantly changed. Rectal SeP mRNA increased at 6 weeks compared with baseline in both Se groups (P < 0·05); only dairy-Se resulted in a sustained elevation of SeP after the washout period (P < 0·05). Rectal GPx-1 and GPx-2 mRNA were higher with dairy-Se (P < 0·05) than with yeast-Se at 6 weeks. In conclusion, three rectal selenoprotein mRNA were differentially regulated by dairy-Se and yeast-Se. Changes in rectal selenoproteins are not predicted by changes in plasma Se; dairy-Se effectively regulates the expression of several rectal selenoproteins of relevance to the risk for CRC.

What provokes experienced COPD clinical practitioners in the UK to initiate or change medication? A consensus study.

BACKGROUND: In the absence of clarity in national guidelines, this study aimed to reach a consensus among experts in chronic obstructive pulmonary disease (COPD) regarding when medication should be initiated or changed in patients demonstrating a gradual decline. METHODS: An electronic three-stage Delphi exercise was undertaken with 37 leading UK experts in COPD. The panel submitted criteria which they scored in subsequent rounds. Consensus was defined as ≥ 80% of the panel scoring an item as important. RESULTS: Consensus was reached on seven criteria: decreased exercise tolerance (97%); increased breathlessness at rest or on exertion (97%); quality of life impairment (91%); low or reduced oxygen saturations based on pulse oximetry readings (86%); ability to perform activities of daily living independently (85%); increase in sputum (80%); and increase in wheeze (80%). CONCLUSIONS: These criteria could be used to guide clinical practice. Empirical research is now required to test their reliability and validity.

Shared decision making or paternalism in nursing consultations? A qualitative study of primary care asthma nurses' views on sharing decisions with patients regarding inhaler device selection.

BACKGROUND: Although patients with asthma would like more involvement in the decision-making process, and UK government policy concerning chronic conditions supports shared decision making, it is not widely used in practice. OBJECTIVE: To investigate how nurses approach decision making in relation to inhaler choice and long-term inhaler use within a routine asthma consultation and to better understand the barriers and facilitators to shared decision making in practice. SETTING AND PARTICIPANTS: Semi-structured interviews were conducted with post-registration, qualified nurses who routinely undertook asthma consultations and were registered on a respiratory course. Interviews were recorded, transcribed and analysed using the Framework approach. RESULTS: Twenty participants were interviewed. Despite holding positive views about shared decision making, limited shared decision making was reported. Opportunities for patients to share decisions were only offered in relation to inhaler device, which were based on the nurse's pre-selected recommendations. Giving patients this 'choice' was seen as key to improving adherence. DISCUSSION: There is a discrepancy between nurses' understanding of shared decision making and the depictions of shared decision making presented in the academic literature and NHS policy. In this study, shared decision making was used as a tool to support the nurses' agenda, rather than as a natural expression of equality between the nurse and patient. CONCLUSION: There is a misalignment between the goals of practice nurses and the rhetoric regarding patient empowerment. Shared decision making may therefore only be embraced if it improves patient outcomes. This study indicates attitudinal shifts and improvements in knowledge of 'shared decision-making' are needed if policy dictates are to be realised.

Assessment of psychosocial problems in primary care COPD patients.

The emphasis placed on assessing psychosocial needs in nurse-led practice based consultations for chronic obstructive pulmonary disease (COPD) has not been reported. We investigated the frequency with which nurses performed a range of tasks, and explored if the types of tasks performed were related to levels of training or the setting of clinical consultations. Participants were lead COPD nurses based at 500 randomly selected UK general practices. Respondents completed a questionnaire between February and June 2006. The frequency with which key task were performed - never, sometimes, often or always - was recorded. Follow-up consultations were conducted by 349 of the 368 nurses who responded (74% response rate). Of these, 51% (95% confidence interval (CI):45-56%) reported often or always assessing psychosocial needs, in comparison to 98% (97-99%) who reported often or always checking inhaler technique and 86% (82-89%) who often or always recorded spirometry values. Frequent assessment of psychosocial needs was associated with postregistration COPD education and consultations taking place in designated respiratory clinics. Nurses focus on objective tasks, possibly to the detriment of assessing psychosocial needs. To raise the profile of these aspects of care: updates of the COPD section of the GMS contract should encompass the assessment of patient's psychosocial status and potential impact of this on quality of life; and appropriate education should be provided.

National survey on the roles and training of primary care respiratory nurses in the UK in 2006: are we making progress?

OBJECTIVES: To describe nurse-led UK general practice asthma and chronic obstructive pulmonary disease (COPD) care, and the training undertaken to support it. METHODS: Questionnaires were sent to 500 randomly-selected UK asthma and COPD practice nurses. RESULTS: 382 nurses (76%) completed the practice characteristics section, 389 (78%) described their asthma roles and training, and 368 (74%) described their COPD roles and training. 96 practices (25%; 95%CI 21-29%) ran designated asthma clinics, 87 (23%; 95%CI 19- 27%) ran designated COPD clinics, and 170 (45%; 95%CI 40-49%) did not run designated respiratory clinics. Of the 255 nurses with an advanced asthma role, 51 (20%; 95%CI 15-25%) did not have accredited asthma training. Of the 215 nurses with an advanced COPD role, 111 (52%; 95%CI 45-58%) did not have accredited COPD training. CONCLUSION: Patients are increasingly being seen outside of designated asthma or COPD clinics, often by nurses with an advanced role. It is important that nurses have the training to fulfil this role.

Poorer self assessed health in a prospective study of men with screen detected abdominal aortic aneurysm: a predictor or a consequence of screening outcome?

STUDY OBJECTIVES: To assess the extent to which poorer self assessed health in men in whom an abdominal aortic aneurysm (AAA) is detected at screening is a consequence or a predictor of screening outcome. DESIGN: Prospective study. SETTING: Community based screening. PARTICIPANTS: 23 654 men who attended for AAA screening as part of the UK multicentre aneurysm screening study completed a measure of self assessed health before screening. A total of 1156 had an aneurysm detected. A sub-sample of screened men (571 with an aneurysm and 609 with a normal aorta) also completed the measure of self assessed health six weeks after screening. MAIN RESULTS: Men in whom an aneurysm was detected at screening perceived their health to be poorer before screening than those with a normal aorta. Adjusting for risk factors for AAA made no difference to this RESULT: self assessed health remained a strong predictor of having an aneurysm (odds ratio 1.7 comparing the extreme quartiles of self assessed health, 95% confidence intervals: 1.4 to 2.0). Men with an aneurysm also perceived their health to be poorer after screening had detected their aneurysms, but only to an extent in line with their pre-screening perceptions. CONCLUSIONS: Self assessed health seems to predict having an aortic aneurysm, independently of known risk factors. This emphasises the importance of assessing baseline perceptions of health to prevent erroneously inferring that poorer self assessed health in those who screen positive is a consequence as compared with a predictor of screening outcome.