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

<p>Abstract</p> <p>Background</p> <p>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.</p> <p>Methods</p> <p>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.</p> <p>Results</p> <p>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.</p> <p>Conclusion</p> <p>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.</p

Comparison of asthma treatment given in addition to inhaled corticosteroids on airway inflammation and responsiveness.

There is increasing evidence that the assessment of eosinophilic airway inflammation using induced sputum and measurement of airway hyperresponsiveness provides additional, clinically important information concerning asthma control. The aim of this study was to directly compare the effects of different treatments on these markers in patients with asthma and persistent symptoms, despite the use of low-dose inhaled corticosteroids. A double-blind four-way crossover study was performed, which compared a 1-month treatment with budesonide 400 mug b.i.d., additional formoterol, additional montelukast and placebo in 49 patients with uncontrolled asthma despite budesonide 100 mug b.i.d., with each treatment separated by a 4-week washout period. The change in sputum eosinophil count with formoterol (2.4 to 3.8% change, 0.6-fold reduction, 95% confidence interval (CI) 0.5-0.9) differed significantly from placebo (2.8 to 2.5% change, 1.1-fold reduction, 95% CI 0.7-1.6) and high-dose budesonide (2.7 to 1.6% change, 1.6-fold reduction, 95% CI 1.2-2.2). The effects of montelukast did not differ from placebo. The changes in methacholine airway responsiveness were small and did not differ between treatments. High-dose budesonide had the broadest range of beneficial effects on other outcomes, including symptom scores, morning peak expiratory flow and forced expiratory volume in one second. In conclusion, treatment given in addition to low-dose inhaled corticosteroids results in modest benefits. Formoterol and high-dose budesonide have contrasting effects on eosinophilic airway inflammation

Sähköpostiviestinnän pelikirja

Tämän opinnäytetyön tavoitteena oli laatia selkeä ja käytännönläheinen sähköpostiviestinnän ohje, joka keskittyy viestinnän sisältöön ja vuorovaikutukseen viestinnän onnistumisessa. Tarkoituksena oli tutustua sähköpostiviestinnän merkitykseen tämän päivän yhteisöviestinnässä ja luoda sen pohjalta yleispätevä sähköpostiviestinnän ohje, joka olisi helppo ottaa käyttöön missä tahansa yrityksessä. Työ toteutettiin toiminnallisena opinnäytetyönä, joka käsitti teoreettisen viitekehyksen ja toiminnallisen osan. Viitekehys koostui yhteisöviestintään ja sähköpostiviestintään liittyvästä teoriasta. Teoriaosuudessa tuotiin esille yhteisöviestinnän nykytila ja sen erilaisia kanavia sekä sähköpostiviestinnän merkitys yhteisöviestinnässä. Teoriaosuudessa käsiteltiin myös tarkemmin sähköpostiviestintää ja siihen liittyviä haasteita ja kehittämistä sekä sen vaikutusta yrityksen maineeseen. Toiminnallinen osuus muodostui sähköpostiviestinnän ohjeesta, jonka tarkoituksena oli yhdenmukaistaa yrityksen sähköpostiviestintää ja kehittää henkilöstön viestinnällistä osaamista. Ohjeen sisällöksi valikoitui sähköpostin merkitys ja käyttö yrityksessä, viestien sisältö ja kirjoittaminen sekä viestinnän kehittäminen. Johtopäätöksissä todettiin, että sähköpostilla on edelleen tärkeä rooli ja merkitys tämän päivän yhteisöviestinnässä. Johdonmukaisella viestinnällä edistetään työssä onnistumista ja työhyvinvointia. Viestinnällisen osaamisen ja viestintäkulttuurin kehittämisellä tehostetaan työntekoa ja edistetään myönteisen yrityskuvan rakentumista.The aim of this study was to establish a clear and easy-to-use instruction manual for email communication with a focus on the content of email communication and interaction. The aim was to explore the significance of email communication in today's corporate communication and create a general email communication manual based on it. The aim was to create the instruction manual so that it would be easy to deploy in any company. This is a functional thesis, which consists of a theoretical framework and a practical part. The framework consists of corporate communication and email related theory. The theory section highlights the current state of corporate communications and its variety of channels as well as the importance of email communication. The theoretical part also discusses, in more detail, email communications and its challenges and development as well as its impact on the company’s reputation. The practical part consists of creating an email communication manual with the purpose to harmonize the company's communication and to develop the communicative skills of the staff. The purpose and use of email, its content and writing as well as improvement of communication was chosen as the content of the manual. It was concluded that email still has an important role and is significant in today’s corporate communication. Consistent communication promotes satisfaction and success at work. Moreover, the development of communication skills and culture promotes more efficient work and further the creation of a positive corporate image

Environment Changes Genetic Effects on Respiratory Conditions and Allergic Phenotypes

© 2017 The Author(s). The prevalence of asthma and allergic diseases is disproportionately distributed among different populations, with an increasing trend observed in Western countries. Here we investigated how the environment affected genotype-phenotype association in a genetically homogeneous, but geographically separated population. We evaluated 18 single nucleotide polymorphisms (SNPs) corresponding to 8 genes (ADAM33, ALOX5, LT-a, LTC4S, NOS1, ORMDL3, TBXA2R and TNF-a), the lung function and five respiratory/allergic conditions (ever asthma, bronchitis, rhinitis, dermatitis and atopy) in two populations of Inuit residing either in the westernized environment of Denmark or in the rural area of Greenland. Our results showed that lung function was associated with genetic variants in ORMDL3, with polymorphisms having a significant interaction with place of residence. LT-a SNP rs909253 and rs1041981 were significantly associated with bronchitis risk. LT-a SNP rs2844484 was related to dermatitis susceptibility and was significantly influenced by the place of residence. The observed gene-phenotype relationships were exclusively present in one population and absent in the other population. We conclude that the genotype-phenotype associations relating to bronchitis and allergy susceptibility are dependent on the environment and that environmental factors/lifestyles modify genetic predisposition and change the genetic effects on diseases

Missing Concepts in Natural Selection Theory Reconstructions

The concept of fitness has generated a lot of discussion in philosophy of biology. There is, however, relative agreement about the need to distinguish at least two uses of the term: ecological fitness on the one hand, and population genetics fitness on the other. The goal of this paper is to give an explication of the concept of ecological fitness by providing a reconstruction of the theory of natural selection in which this concept was framed, that is, based on the way the theory was put to use in Darwin’s main texts. I will contend that this reconstruction enables us to account for the current use of the theory of natural selection. The framework presupposed in the analysis will be that of metatheoretical structuralism. This framework will provide both a better understanding of the nature of ecological fitness and a more complete reconstruction of the theory. In particular, it will provide what I think is a better way of understanding how the concept of fitness is applied through heterogeneous cases. One of the major advantages of my way of thinking about natural selection theory is that it would not have the peculiar metatheoretical status that it has in other available views. I will argue that in order to achieve these goals it is necessary to make several concepts explicit, concepts that are frequently omitted in usual reconstructions.Fil: Ginnobili, Santiago. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad de Buenos Aires; Argentina. Universidad Nacional de Quilmes. Centro de Estudios e Investigación. Instituto de Estudios Sobre la Ciencia y Tecnología; Argentin