Feasibility and impact of a computer-guided consultation on guideline-based management of COPD in general practice.

Prim Care Respir J. 2012 Dec;21(4):425-30

Authors: Angus RM, Thompson EB, Davies L, Trusdale A, Hodgson C, McKnight E, Davies A, Pearson MG

Abstract
BACKGROUND: Applying guidelines is a universal challenge that is often not met. Intelligent software systems that facilitate real-time management during a clinical interaction may offer a solution.
AIMS: To determine if the use of a computer-guided consultation that facilitates the National Institute for Health and Clinical Excellencebased chronic obstructive pulmonary disease (COPD) guidance and prompts clinical decision-making is feasible in primary care and to assess its impact on diagnosis and management in reviews of COPD patients.
METHODS: Practice nurses, one-third of whom had no specific respiratory training, undertook a computer-guided review in the usual consulting room setting using a laptop computer with the screen visible to them and to the patient. A total of 293 patients (mean (SD) age 69.7 (10.1) years, 163 (55.6%) male) with a diagnosis of COPD were randomly selected from GP databases in 16 practices and assessed.
RESULTS: Of 236 patients who had spirometry, 45 (19%) did not have airflow obstruction and the guided clinical history changed the primary diagnosis from COPD in a further 24 patients. In the 191 patients with confirmed COPD, the consultations prompted management changes including 169 recommendations for altered prescribing of inhalers (addition or discontinuation, inhaler dose or device). In addition, 47% of the 55 current smokers were referred for smoking cessation support, 12 (6%) for oxygen assessment, and 47 (24%) for pulmonary rehabilitation.
CONCLUSIONS: Computer-guided consultations are practicable in general practice. Primary care COPD databases were confirmed to contain a significant proportion of incorrectly assigned patients. They resulted in interventions and the rationalisation of prescribing in line with recommendations. Only in 22 (12%) of those fully assessed was no management change suggested. The introduction of a computer-guided consultation offers the prospect of comprehensive guideline quality management.

PMID: 23131871 [PubMed - in process]

Guideline for office spirometry in adults, 2012.

S Afr Med J. 2013 Jan;103(1):52-62

Authors: Koegelenberg CF, Swart F, Irusen EM

Abstract
Background. Office spirometry remains an integral part of a comprehensive respiratory evaluation and is used to categorise the nature, severity and progression of respiratory diseases and to measure response to treatment. These updated guidelines are aimed at improving the quality, standardisation and usefulness of office spirometry in South Africa. Recommendations. All equipment should have proof of validation regarding resolution and the system's linearity (consistency). Moreover, equipment must be calibrated daily and quality controlled. It is also important to have standard operating procedures in place, including the documentation of ambient conditions and infection control measures. Adequate spirometry relies on a competent operator, accurate equipment, standardised operating procedures, quality control and patient co-operation. The indication for spirometry in a particular patient should be unambiguous and should be documented. Subjects should be appropriately prepared for testing, and patient details must be documented. Forced vital capacity (FVC) manoeuvres (either closed or open circuit) must be performed strictly according to guidelines, and strict quality assurance methods should be in place, including acceptability criteria (for any given effort) and repeatability (between efforts). Testing should continue until at least 3 acceptable curves are produced (with 2 fulfilling repeatability criteria). Other indices are derived from these efforts. Conclusion. Test results must be categorised and graded according to current guidelines, taking into account the indication for the test and the appropriateness of reference values.

PMID: 23237126 [PubMed - in process]

Prognostic role of clusterin in resected adenocarcinomas of the lung.

Lung Cancer. 2012 Dec 28;

Authors: Panico F, Casali C, Rossi G, Rizzi F, Morandi U, Bettuzzi S, Davalli P, Corbetta L, Storelli ES, Corti A, Fabbri LM, Astancolle S, Luppi F

Abstract
RATIONALE: Clusterin expression may change in various human malignancies, including lung cancer. Patients with resectable non-small cell lung cancer (NSCLC), including adenocarcinoma, have a poor prognosis, with a relapse rate of 30-50% within 5 years. Nuclear factor kB (Nf-kB) is an intracellular protein involved in the initiation and progression of several human cancers, including the lung. OBJECTIVES: We investigate the role of clusterin and Nf-kB expression in predicting the prognosis of patients with early-stage surgically resected adenocarcinoma of the lung. FINDINGS: The level of clusterin gradually decreased from well-differentiated to poorly differentiated adenocarcinomas. Clusterin expression was significantly higher in patients with low-grade adenocarcinoma, in early-stage disease and in women. Clusterin expression was inversely related to relapse and survival in both univariate and multivariate analyses. Finally, we observed an inverse correlation between Nf-kB and clusterin. CONCLUSIONS: Clusterin expression represents an independent prognostic factor in surgically resected lung adenocarcinoma and was proven to be a useful biomarker for fewer relapses and longer survival in patients in the early stage of disease. The inverse correlation between Nf-kB and clusterin expression confirm the previously reported role of clusterin as potent down regulator of Nf-kB.

PMID: 23276503 [PubMed - as supplied by publisher]

Is the H4 receptor a new drug target for allergies and asthma? 

Front Biosci (Elite Ed). 2013;E5:178-187

Authors: Salcedo C, Pontes C, Merlos M

Abstract
Histamine H4 receptor (H4R) has become a promising target for immuno-inflammatory diseases, such as allergic rhinitis, asthma or dermal allergies. Its distribution pattern in immune cells and the preclinical data obtained from different biological systems using diverse histamine H4 modulators (1) suggest a key role of H4R in immunity and in inflammatory cell trafficking. Recent results with UR-63325, the first H4R antagonist from which clinical data has been reported (2), confirm the feasibility of complete H4R blocking in humans without limiting safety concerns. Also, H4R blockade results in clear pharmacodynamic effects in relevant human cells, e.g. eosinophils. It is believed that allergic rhinitis and asthma are manifestations of one unique syndrome in two parts of the respiratory tract. Dermal allergies are also recognized as related manifestations in a different location. The coexistence of allergic-related diseases in the same patients could permit a single treatment approach e.g.. the systemic use of H4R antagonists. Further clinical studies are needed to establish the role of H4R antagonists in the treatment of allergic diseases.

PMID: 23276980 [PubMed - as supplied by publisher]