Feasibility of a respiratory nurse specialist-led sleep disorder service in a district general hospital.

Aim The burden of referrals to investigate sleep disorders has escalated considerably. In order to address this, the feasibility of a nurse-led sleep disorder clinic was investigated. Methods Sleep referrals were stratified on the basis of information contained within the primary care referral, and appropriate home-based sleep studies arranged if obstructive sleep apnoea was considered the most likely working diagnosis. Selected patients were started on continuous positive airway pressure treatment if deemed appropriate. Education was almost exclusively provided by specialist nursing staff or by means of validated information by the British Lung Foundation. Results Eighty patients were included in the respiratory nurse-led sleep service. Feedback from the patient questionnaire was positive and 59 patients were managed without requirement to attend consultant-led outpatient services. Non-sleep breathing disorders as the reason for daytime somnolence, and patients requiring referral to tertiary services, were identified. Conclusion Developing a respiratory nurse-led sleep service is adequate to identify non-sleep breathing disorders, is fit for purpose, functions broadly in accordance with American Sleep Society guidelines, and is well received by patients.

Community dynamics and the lower airway microbiota in stable chronic obstructive pulmonary disease, smokers and healthy non-smokers.

RATIONALE: The role bacteria play in the progression of COPD has increasingly been highlighted in recent years. However, the microbial community complexity in the lower airways of patients with COPD is poorly characterised. OBJECTIVES: To compare the lower airway microbiota in patients with COPD, smokers and non-smokers. METHODS: Bronchial wash samples from adults with COPD (n=18), smokers with no airways disease (n=8) and healthy individuals (n=11) were analysed by extended-culture and culture-independent Illumina MiSeq sequencing. We determined aerobic and anaerobic microbiota load and evaluated differences in bacteria associated with the three cohorts. Culture-independent analysis was used to determine differences in microbiota between comparison groups including taxonomic richness, diversity, relative abundance, 'core' microbiota and co-occurrence. MEASUREMENT AND MAIN RESULTS: Extended-culture showed no difference in total load of aerobic and anaerobic bacteria between the three cohorts. Culture-independent analysis revealed that the prevalence of members of Pseudomonas spp. was greater in the lower airways of patients with COPD; however, the majority of the sequence reads for this taxa were attributed to three patients. Furthermore, members of Bacteroidetes, such as Prevotella spp., were observed to be greater in the 'healthy' comparison groups. Community diversity (α and ß) was significantly less in COPD compared with healthy groups. Co-occurrence of bacterial taxa and the observation of a putative 'core' community within the lower airways were also observed. CONCLUSIONS: Microbial community composition in the lower airways of patients with COPD is significantly different to that found in smokers and non-smokers, indicating that a component of the disease is associated with changes in microbiological status.

Does deficiency of von Willebrand factor protect against cardiovascular disease? Analysis of a national discharge register.

INTRODUCTION: von Willebrand factor (VWF) plays a critical role in platelet adhesion and aggregation after vascular injury and at sites of high shear rate. Elevated VWF levels are associated with an increased risk of ischemic cardiovascular events; however, it is unclear whether VWF deficiency is protective against atherosclerosis. We aimed to compare the prevalence of cardiovascular disease (CVD) among patients with and without von Willebrand disease (VWD). METHODS: A cross-sectional analysis was performed on discharge data for adults from the Nationwide Inpatient Sample (NIS) between the years 2009 and 2011. CVD was defined as ischemic heart disease, myocardial infarction, ischemic cerebrovascular disease, or peripheral vascular disease. For prevalence calculations and statistical analyses, we used discharge-level weights provided by the NIS to reflect national estimates. CVD was compared across groups by use of the Rao-Scott chi-square test. Multivariable logistic regression was used to estimate the likelihood of CVD in VWD patients after adjustment for age, gender, and CVD-related risk factors. RESULTS: The prevalence of CVD in VWD patients was less than the prevalence of CVD in non-VWD patients (15.0% versus 26.0%). VWD was associated with a decreased likelihood of CVD after adjustment for age, gender, and CVD-related risk factors (odds ratio 0.85; 95% confidence interval 0.79-0.92). DISCUSSION: These findings indicate that the risk of CVD is decreased among VWD patients, and that VWF deficiency may be protective against CVD.

Domiciliary non-invasive ventilation in the elderly. Effective, tolerated and justified.

AIM: To determine if the long terms effects of non-invasive home mechanical ventilation (NIHMV) in the elderly are as beneficial as in younger subjects for a dedicated non-invasive ventilation unit in a tertiary referral hospital within the UK. PATIENTS AND METHODS: The study population included 256 patients who were successfully established on NIHMV between May 2009 and August 2013. Patients were divided into three groups according to age: group 1 (n=103) ≥75; group 2 (n=81) 65 -74; and group 3 (n=72) < 65 years of age. Initial assessments, both prior to starting NIHMV and at 12 month follow up were determined which included establishing the primary cause of respiratory insufficiency, measurement of arterial blood gas parameters, spirometry, overnight oximetry, and sniff nasal inspiratory pressure (SNIP) in those patients with neuromuscular disease. The number of hospital admissions in the year prior to starting NIHMV, and in the subsequent year, along with the number of days spent as an inpatient were ascertained as a measure of burden to local health care resources. Compliance with NIV at follow up, facilitated by recorded data within the ventilator software, was established along with an assessment of any reported side effects. RESULTS: Group 3 had the most profound abnormalities in lung function and blood gas parameters at initial assessment with a trend towards a higher number of acute admissions. In absolute terms, there was a greater decline in the number of admissions for subjects in group 2 after being established on NIHMV. Although more subjects in group 3 had chest wall deformities, COPD or bronchiectasis, this group had the lowest number of subjects with neuromuscular disease. Improvements in gas exchange were most pronounced for group 3 subjects despite no significant differences in the selected ventilator settings across the 3 groups. For neuromuscular patients, when measured, SNIP pressures were lowest in group 3. CONCLUSION: NIHMV was effective and tolerated for all three age groups. There was an improvement in measured patient centred endpoints across all three age groups, all of whom benefited equally.

Comparison of listing strategies for allosensitized heart transplant candidates requiring transplant at high urgency: a decision model analysis.

Allosensitized children who require a negative prospective crossmatch have a high risk of death awaiting heart transplantation. Accepting the first suitable organ offer, regardless of the possibility of a positive crossmatch, would improve waitlist outcomes but it is unclear whether it would result in improved survival at all times after listing, including posttransplant. We created a Markov decision model to compare survival after listing with a requirement for a negative prospective donor cell crossmatch (WAIT) versus acceptance of the first suitable offer (TAKE). Model parameters were derived from registry data on status 1A (highest urgency) pediatric heart transplant listings. We assumed no possibility of a positive crossmatch in the WAIT strategy and a base-case probability of a positive crossmatch in the TAKE strategy of 47%, as estimated from cohort data. Under base-case assumptions, TAKE showed an incremental survival benefit of 1.4 years over WAIT. In multiple sensitivity analyses, including variation of the probability of a positive crossmatch from 10% to 100%, TAKE was consistently favored. While model input data were less well suited to comparing survival when awaiting transplantation across a negative virtual crossmatch, our analysis suggests that taking the first suitable organ offer under these circumstances is also favored.

Hypothyroid-associated sensorineuronal deafness.

A case of panhypopituitarism with hypothyroid-induced deafness in a man improving with hormone replacement is reported. A review of the medical literature reveals conflicting evidence regarding the underlying mechanism and prognosis of the defect in this context, but the association with hypothyroidism is more than spurious. Sensorineuronal hearing loss was initially evident, resolving both subjectively and on formal audiological evaluation after administering thyroxine. Central pathology affecting the eighth cranial nerve, as opposed to a conductive or mixed component is the likely culprit.

Clinical phenotype of cystic fibrosis patients with the G551D mutation.

BACKGROUND: Data on whether the phenotype of cystic fibrosis (CF) patients with compound heterozygocity for G551D (Gly551Asp) differs from patients with F508del (Phe508del) homozygous mutations is divergent. AIM: We hypothesized that CF patients with the G551D mutation would have less severe disease than F508del homozygotes. DESIGN: We compared the clinical phenotype of adult patients with a G551D mutation with adult patients homozygous for F508del and those with the missense mutation R117H (Arg117His). Compound heterozygotes for the G551D and R117H were analysed separately. METHODS: Data were collected for 101 adult CF patients. Group 1-4 represents in order F508del homozygote patients (n = 61), those with the G551D mutation and a more severe mutation (n = 13), those with R117H mutation and a more severe mutation (n = 23) and also those compound for both the R117H and G551D mutations (n = 4). RESULTS: Our findings have shown that adult patients with the G551D mutation and a second severe mutation have a milder clinical phenotype than F508del homozygous adult patients. Higher FEV(1) and body mass index and less impaired glucose tolerance was demonstrated in the patients with G551D and R117H compared to F508del homozygotes. There was a reduced yearly rate of decline of FEV(1) (P < 0.05), infection with Pseudomonas aeruginosa along with reduced burden of care. Compound heterozygosity for G551D and R117H mutations was associated with normal spirometry, body mass index, no chronic infection and no symptoms. CONCLUSION: Mutations on different chromosomes are not independent of each other for the overall impact on the amount of functional CFTR. This study suggests that patients with the G551D mutation and a second severe mutation have a milder clinical phenotype than F508del homozygous patients, but the phenotype is not as mild as patients with the R117H mutation.

Hypokalaemic paralysis precipitated by distal renal tubular acidosis secondary to Sjögren's syndrome.

A 43-year-old woman presented with a sudden onset of hypokalaemic paralysis requiring intubation and ventilatory support. Subsequent biochemical and clinical assessments established a diagnosis of distal renal tubular acidosis (RTA) in association with underlying Sjögren's syndrome as the aetiology of her profound hypokalaemia. Distal RTA is rare, but Sjögren's syndrome is one of the more common causes in adults and should be considered in the differential diagnosis of patients who present with hypokalaemic muscular paralysis.

Functional limitations of school-aged children seen in primary care.

OBJECTIVE: The purpose of the present study was to assess the prevalence of functional limitations in children seen in a large paediatric practice network and to identify sociodemographic, family and psychosocial factors related to functional limitations. STUDY DESIGN: Cross-sectional analysis. POPULATION: Children were recruited from two large, practice-based primary care research networks during their paediatric office visits. For the present study, participants included 14 630 school-aged children (ages 6-15 years) and their caregivers. OUTCOMES MEASURED: Parents completed written questionnaires including the Pediatric Symptom Checklist, the Family Apgar and the Functional Limitations Index. RESULTS: Findings indicated that 15% of children surveyed had some limitation in their daily functioning. More children had schoolwork and physical function limitations than limitations in personal and self-care. Logistic regression equations predicted functional limitations and health status in children from a model of sociodemographic factors, psychosocial symptoms and family functioning. CONCLUSIONS: A low but significant number of school-age children seen in the primary care setting experience functional limitations. Children with any psychosocial symptoms were at increased risk for functional limitations, indicating the critical need to screen for functional impairment in children with suspected behavioural or emotional problems. A screening tool of functional limitations may be useful for assessing the presence or absence of such limitations in children's daily function and warrants further investigation.

Treatment services for children with ADHD: a national perspective.

OBJECTIVE: To summarize knowledge on treatment services for children and adolescents with attention-deficit hyperactivity disorder (ADHD), trends in services from 1989 to 1996, types of services provided, service mix, and barriers to care. METHOD: A review of the literature and analyses from 2 national surveys of physician practices are presented. RESULTS: Major shifts have occurred in stimulant prescriptions since 1989, with prescriptions now comprising three fourths of all visits to physicians by children with ADHD. Between 1989 and 1996, related services, such as health counseling, for children with ADHD increased 10-fold, and diagnostic services increased 3-fold. Provision of psychotherapy, however, decreased from 40% of pediatric visits to only 25% in the same time frame. Follow-up care also decreased from more than 90% of visits to only 75%. Family practitioners were more likely than either pediatricians or psychiatrists to prescribe stimulants and less likely to use diagnostic services, provide mental health counseling, or recommend follow-up care. About 50% of children with identified ADHD seen in real-world practice settings receive care that corresponds to guidelines of the American Academy of Child and Adolescent Psychiatry. Physicians reported significant barriers to service provision for these children, including lack of pediatric specialists, insurance obstacles, and lengthy waiting lists. CONCLUSIONS: The trends in treatment services and physician variations in service delivery point to major gaps between the research base and clinical practice. Clinical variations may reflect training differences, unevenness in the availability of specialists and location of services, and changes in health care incentives.

Prospective study of displaced children's symptoms in wartime Bosnia.

BACKGROUND: This study examines the psychological symptoms of Bosnian children exposed to war and trauma, and detects changes in these symptoms over time. METHOD: A total of 147 displaced children residing in refugee centers in Bosnia completed self-report assessments of anxiety, depressive, and posttraumatic stress symptoms at two time points. RESULTS: Symptoms of posttraumatic stress, anxiety, and depression showed a greater decrease in boys relative to girls over time. CONCLUSION: Gender may be an important factor in the natural course of trauma-related symptoms among war traumatized children. Further research is needed to better understand the psychological effects of war trauma on children, and the natural course of posttraumatic symptoms, so as to improve interventions targeted to this vulnerable population.

Patient race and ethnicity in primary care management of child behavior problems: a report from PROS and ASPN. Pediatric Research in Office Settings. Ambulatory Sentinel Practice Network.

BACKGROUND: Minority persons have less access to many specialty treatments and services, possibly because of clinician biases. It is not clear whether any such biases exist in primary care settings, especially for children with psychosocial problems. OBJECTIVES: The objective was to compare primary care recognition and treatment of pediatric psychosocial problems among African American, Hispanic American and European American patients. DESIGN: A survey was made of parents and respective clinicians in primary care offices in two large practice-based research networks (PROS and ASPN) from 44 states, Canada, and Puerto Rico. Mixed regression analyses were employed to control for patient, clinician, and practice effects. SUBJECTS: The subjects were 14,910 children aged 4 to 15 years seen consecutively for non-emergent care by 286 primary care clinicians in office-based practice. MEASURES: Measures were parents' report for sociodemographics and behavioral symptoms using the Pediatric Symptom Checklist, and clinicians' report of psychosocial problems, type, management, and severity. RESULTS: Of the sample, 8.0% were African American youth, 9.5% were Hispanic American youth, and 82.5% were European American youth. After controlling for other factors, race and ethnicity were not associated with any differences in psychotropic drug prescribing, counseling, referral, or recognition of psychosocial problems. Clinicians reported spending slightly more time with minority patients. CONCLUSION: Race and ethnic status were not related to receipt of mental health services for children in primary care offices, suggesting that clinician biases may not be the primary cause of the racial differences in services noted earlier research. Improving services for minority youth may require increasing access to office-based primary care.

Somatization in pediatric primary care: association with psychopathology, functional impairment, and use of services.

OBJECTIVE: To determine whether classification as pediatric "somatizers" identifies a group of children and adolescents at high risk for psychopathology, functional impairment, and frequent use of health services in a large, multisite study of pediatric primary care. METHOD: Parental reports of frequent aches and pains and visits to the doctor for medically unexplained symptoms in children aged 4 to 15 years were used to construct a classification of somatization in pediatric primary care. Affected and unaffected children and adolescents were compared on measures of demographics, family functioning, psychopathology, functional status, and service use. RESULTS: Classification as a somatizer was more common in adolescents, females, minority subjects, urban practices, nonintact families, and families with lower levels of parental education and was associated with heightened risk of clinician- and parent-identified psychopathology, family dysfunction, poor school performance and attendance, perceived health impairment, and more frequent use of health and mental health services. CONCLUSIONS: Children classified as pediatric somatizers are at heightened risk for psychiatric disorder, family dysfunction, functional impairment, and frequent use of health services. Additional research is warranted, and clinicians should recognize the need for careful assessment and potential behavioral health referral in this population.

Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study.

BACKGROUND: Routine use of a brief psychosocial screening instrument has been proposed as a means of improving recognition, management, and referral of children's psychosocial morbidity in primary care. OBJECTIVE: To assess the feasibility of routine psychosocial screening using the Pediatric Symptom Checklist (PSC) in pediatrics by using a brief version of the checklist in a large sample representative of the full range of pediatric practice settings in the United States and Canada. We evaluated large-scale screening and the performance of the PSC in detecting psychosocial problems by (1) determining whether the prevalence of psychosocial dysfunction identified by the PSC was consistent with findings in previous, smaller samples; (2) assessing whether the prevalence of positive PSC screening scores varied by population subgroups; and (3) determining whether the PSC was completed by a significant proportion of parents from all subgroups and settings. PATIENTS AND METHODS: Twenty-one thousand sixty-five children between the ages of 4 and 15 years were seen in 2 large primary care networks: the Ambulatory Sentinel Practice Network and the Pediatric Research in Office Settings network, involving 395 pediatric and family practice clinicians in 44 states, Puerto Rico, and 4 Canadian provinces. Parents were asked to complete a brief questionnaire that included demographic information, history of mental health services, the 35-item PSC, and the number of pediatric visits within the past 6 months. RESULTS: The overall prevalence rates of psychosocial dysfunction as measured by the PSC in school-aged and preschool-aged pediatric outpatients (13% and 10%, respectively) were nearly identical to the rates that had been reported in several smaller samples (12%-14% among school-aged children and 7%-14% among preschoolers). Consistent with previous findings, children from low-income families were twice as likely to be scored as dysfunctional on the PSC than were children from higher-income families. Similarly, children from single-parent as opposed to those from 2-parent families and children with a past history of mental health services showed an elevated risk of psychosocial impairment. The current study was the first to demonstrate a 50% increase in risk of impairment for male children. The overall rate of completed forms was 97%, well within an acceptable range, and at least 94% of the parents in each sociodemographic subgroup completed the PSC form. CONCLUSIONS: Use of the PSC offers an approach to the recognition of psychosocial dysfunction that is sufficiently consistent across groups and locales to become part of comprehensive pediatric care in virtually all outpatient settings. In addition to its clinical utility, the consistency and widespread acceptability of the PSC make it well suited for the next generation of pediatric mental health services research, which can address whether earlier recognition of and intervention for psychosocial problems in pediatrics will lead to cost-effective outcomes.

The Physician Belief Scale and psychosocial problems in children: a report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network.

Clinicians' management of children with psychosocial problems may vary with their attitudes and beliefs. However, we lack sound instruments to assess these factors. This study examined the psychometric properties of the Physician Belief Scale (PBS). A modified version of the PBS was sent to clinicians who participated in two primary care research networks. Using factor analysis, we reduced the PBS to 14 items and 2 subscales. Cronbach's alpha values were high. Female clinicians, those using DSM-IV, and those having completed training earlier rated themselves as more psychosocially oriented. Identification and treatment of psychosocial problems were significantly related to scores on the Belief and Feeling subscale. The PBS provided only a modest amount of information regarding primary care practices. It is not clear if these limitations are attributable to the instrument or the many other barriers to effective psychosocial care.

Whole-body hyperhydration in endurance-trained males determined using radionuclide dilution.

Despite evidence of hypervolemia following endurance training, there is little information regarding corresponding extravascular fluid volumes. Quantification of such volumes relies upon radionuclide dilution methods, previously hampered by the loss of plasma albumin. It was our purpose to measure human body-fluid distribution in eight endurance-trained males, using a simultaneous radionuclide dilution technique, incorporating radioiodinated serum fibronogen (RISF). Fluid distribution was measured on three occasions, using 2 microCi of RISF, 8 microCi of 51 Cr-labeled erythrocytes, and 20 microCi of Na82Br and 450 microCi of 3H2O; to measure PV, erythrocyte (RCV), extracellular (ECFV), and total-body water (TBW) volumes, respectively. Respective volume means, standard deviations, and coefficients of variation were: 46.6 (+/- 4.9; 8.44%), 33.3 (+/- 2.9; 3.89%), 258.1 (+/- 12.1; 4.93%), and 654.2 (+/- 13.4; 3.24%) ml.kg-1. The incorporation of RISF provided a reliable modification to previous methods, and revealed a body-fluid expansion in endurance-trained males. It was concluded that such subjects were hyperhydrated, possessing proportionately expanded fluid volumes throughout both intravascular and extravascular spaces. This was attributed to training history and accompanying reductions in adiposity.

A solution-phase strategy for the synthesis of chemical libraries containing small organic molecules: a universal and dipeptide mimetic template.

A general approach to the solution phase, parallel synthesis of chemical libraries, which allows the preparation of multi-milligram quantities of each individual member, is exemplified with both a universal and dipeptide mimetic template. In each step of the sequence, the reactants, unreacted starting material, reagents and their byproducts are removed by simple liquid/ liquid or liquid/solid extractions providing the desired intermediates and final compounds in high purities (> or = 90-100%) independent of the reaction yields and without deliberate reaction optimization.

Pulse oximetry. Implications for practice.

Pulse oximetry is used routinely in neonatal care to monitor oxygen in compromised neonates. A discussion of oximetry for monitoring unstable neonates is presented. Topics covered include physiologic principles of oxygen transport, technical aspects of the oximeter (accuracy, reliability, advantages, and limitations), acceptable limits of arterial oxygen saturation, implications for nursing practice, and use of the device in selected clinical conditions.

Peers as key contributors to the socialization of newcomers.

How can clinical laboratory managers retain employees as the shortage of medical technologists grows? They can help to ensure that new employees become satisfied and productive by using peers as agents for socialization. According to results from both oral interviews and written questionnaires, peers bring newcomers "on board" by providing key information. Responses of 83 organizational newcomers indicate that peers have four qualities: accessibility; empathy; organizational experience; technological proficiency; that equip them to contribute significantly to the socialization of newcomers. Also, joining a newcomer with a peer helps the newcomer to acquire essential, work-related information.