Modern innovative solutions to improve outcomes in severe asthma : Protocol for a mixed methods observational comparison of clinical outcomes in mission versus current care delivery

Background: Asthma that is poorly controlled and undertreated can progress to more severe disease that is associated with high levels of unscheduled care that requires high-cost therapy, leading to a significant health economic burden. The identification and appropriate referral to a specialist asthma service is also often delayed by several months or years because of poor recognition and understanding of symptom severity. Current severe asthma services may take several months to provide a comprehensive multidisciplinary assessment, often necessitating multiple hospital visits and costing up to £5000 per patient. Objective: This study aims to evaluate whether a new service model could identify poorly controlled and potentially severe asthma much earlier in the patient pathway, and then compare clinical outcomes between this new care model with standard care. Methods: Modern Innovative Solutions to Improve Outcomes in (MISSION) Severe Asthma is a novel service model developed by asthma specialists from Portsmouth and Southampton severe asthma services. MISSION Severe Asthma identified patients with poorly controlled disease from general practice databases who had not been under secondary outpatient care in the last 12 months or who were not known to secondary care. In 1- or 2-stop assessments, a thorough review of diagnosis, disease phenotype, and control is undertaken, and clinical outcomes collected at baseline. Results: A variety of clinical outcomes will be collected to assess the service model. The results will be reported in February 2020. Conclusions: This protocol outlines a mixed methods study to assess the impact on disease control, unscheduled health care usage, and quality of life in patients seen in the MISSION clinic compared with a closely matched cohort who declined to attend

How do people with asthma use Internet sites containing patient experiences?

Objective: To understand how people engage with websites containing patient authored accounts of health and illness. To examine how people with asthma navigate their way through this information and make use of the patient experiences they find. Methods: Twenty-nine patients with diagnoses ranging from mild to severe asthma were shown a range of websites, some containing patient experiences, and selected two sites to explore further. They discussed their choices in a series of focus groups and interviews. Results: Participants were influenced initially by the design quality of the sites and were subsequently drawn to websites containing patient experiences but only when contributions were from similar people offering ‘relevant stories’. The experiences reminded participants of the serious nature of the disease, provided new insights into the condition and an opportunity to reflect upon the role of the disease in their lives. Conclusion: For people with asthma websites containing other patients’ personal experiences can serve as a useful information resource, refresh their knowledge and ensure their health behaviours are appropriate and up-to-date. Practice Implications: Health professionals should consider referring asthma patients to appropriate websites whilst being aware that online experiences are most engaging when they resonate with the participants own situation

Synthesis and Characterisation of a New Anion Exchangeable Layered Hydroxyiodide

Lu4O(OH)9I·3H2O is a new member of the anion exchangeable lanthanide hydroxyanion family of materials which has been synthesised hydrothermally. Its structure comprises positively charged [Lu4O(OH)9(H2O)3]+ layers with exchangeable charge balancing iodide anions located in the interlayer gallery. It has been found to undergo facile anion exchange reactions with dicarboxylate anions such as succinate and terephthalate at room temperature but reacts less readily with disulfonate anions such as 1,5- and 2,6-naphthalenedisulfonate under the same conditions. At reaction temperatures above 200 °C the cationic inorganic framework Lu3O(OH)6I·2H2O forms instead of the layered phase

The Epstein-Barr Virus G-Protein-Coupled Receptor Contributes to Immune Evasion by Targeting MHC Class I Molecules for Degradation

Epstein-Barr virus (EBV) is a human herpesvirus that persists as a largely subclinical infection in the vast majority of adults worldwide. Recent evidence indicates that an important component of the persistence strategy involves active interference with the MHC class I antigen processing pathway during the lytic replication cycle. We have now identified a novel role for the lytic cycle gene, BILF1, which encodes a glycoprotein with the properties of a constitutive signaling G-protein-coupled receptor (GPCR). BILF1 reduced the levels of MHC class I at the cell surface and inhibited CD8+ T cell recognition of endogenous target antigens. The underlying mechanism involves physical association of BILF1 with MHC class I molecules, an increased turnover from the cell surface, and enhanced degradation via lysosomal proteases. The BILF1 protein of the closely related CeHV15 c1-herpesvirus of the Rhesus Old World primate (80% amino acid sequence identity) downregulated surface MHC class I similarly to EBV BILF1. Amongst the human herpesviruses, the GPCR encoded by the ORF74 of the KSHV c2-herpesvirus is most closely related to EBV BILF1 (15% amino acid sequence identity) but did not affect levels of surface MHC class I. An engineered mutant of BILF1 that was unable to activate G protein signaling pathways retained the ability to downregulate MHC class I, indicating that the immune-modulating and GPCR-signaling properties are two distinct functions of BILF1. These findings extend our understanding of the normal biology of an important human pathogen. The discovery of a third EBV lytic cycle gene that cooperates to interfere with MHC class I antigen processing underscores the importance of the need for EBV to be able to evade CD8+ T cell responses during the lytic replication cycle, at a time when such a large number of potential viral targets are expressed

Challenges and Opportunities in the Hydrologic Sciences

This is the Table of Contents and Introduction of a Report published as Hornberger, G. M., E. Bernhardt, W. E. Dietrich, D. Entekhabi, G. E. Fogg, E. Foufoula-Georgiou, W. J. Gutowski, W. B. Lyons, K. W. Potter, S. W. Tyler, H. J. Vaux, C. J. Vorosmarty, C. Welty, C. A. Woodhouse, C. Zheng, Challenges and Opportunities in the Hydrologic Sciences. 2012: Water Science and Technology Board, Division on Earth and Life Studies, National Academy of Sciences, Washington, DC. 173 pp. Posted with permission.</p

Family values : popular British cinema and the family, 1940-1949

Belonging to the field of British cinema history, this revisionist thesis examines the portrayal of the family in feature film, 1940-1949. Using a sample of popular films as extended case studies, the method of analysis is qualitative, identifying recurring narrative themes and patterns across a range of film genres. It investigates what familial forms were depicted in popular British feature films; how family representations operated within (patriotic) film narratives; whether the family was presented as an ideal; whether contradictions existed in the representation of the family; and to what extent film portrayals of the family articulated or related to wider public concerns about the family in general, and about the role of the mother in particular. In addition, this thesis also scrutinises how the idea of the family was an important construct for rendering non-familial structures comprehensible according to commonly held cultural understandings.;Overall, it arrives at four main findings: that popular British cinema, 1940-1949, was characterised by diversity; families in some shape or form were a pervasive element of British cinema during the 1940s; familial representations were characterised by a multi-dimensional morality; and that women (especially in their roles as mothers and wives) were frequently figured as a 'problem' or 'threat' to the family and family life, fathers were presented as less central to family life, and children were usually portrayed as innocents

Cognitive impairment is independently associated with mortality, extended hospital stays and early readmission of older people with emergency hospital admissions: a retrospective cohort study

Background: older adults admitted to hospital are often cognitively impaired. It is not clear whether the presence of cognitive impairment conveys an additional risk for poor hospital outcomes in this patient population.Objectives: to determine whether cognitive impairment in hospitalised older adults is independently associated with poor outcomes.Design: retrospective cohort study using electronic, routinely collected data from linked clinical and administrative databases.Setting: large, acute district general hospital in England.Participants: 21,399 incident emergency admissions of people aged ≥75, screened for cognitive impairment, categorised to 3 groups: (i) cognitive impairment with a diagnosis of dementia, (ii) cognitive impairment with no dementia diagnosis, (iii) no cognitive impairment.Methods: multivariable logistic regression and Fine and Gray competing risks survival models were employed to explore associations between cognitive impairment and mortality (in-hospital alone, and in-hospital plus up to 30 days after discharge), time to hospital discharge, and hospital readmission within 30 days of discharge. Covariates included age, severity of illness, main diagnosis, comorbidities and nutritional risk.Results: twenty-seven percent of patients had cognitive impairment; of these, 61.5% had a diagnosis of dementia and 38.5% did not. Patients with cognitive impairment and no diagnosis of dementia were most likely to die in hospital or be readmitted, they also had the longest hospital stays. Cognitive impairment was independently associated with mortality in hospital (Odds Ratio 1.34 [1.17–1.55] with dementia; Odds Ratio 1.78 [1.52–2.07] without), mortality in hospital or within 30 days of discharge (Odds Ratio 1.66 [1.48–1.86]; Odds Ratio 1.67 [1.46–1.90]); readmission (Odds Ratio 1.21 [1.04–1.40]; Odds Ratio 1.47 [1.25–1.73]), and increased time until discharge (sub-hazard ratio 0.80 [0.76–0.83]; sub-hazard ratio 0.66 [0.63–0.69]).Conclusions: cognitive impairment is associated with an increased risk of adverse outcomes in hospitalised older people with an unscheduled admission, by increasing hospital mortality, extending hospital stays and increasing frequency of readmissions. Future research should focus on understanding the mechanisms contributing to poorer outcomes in this population

The association between ward staffing levels, mortality and hospital readmission in older hospitalised adults, according to presence of cognitive impairment: a retrospective cohort study

Background: lower nurse staffing levels are associated with increased hospital mortality. Older patients with cognitive impairments have higher mortality rates than similar patients without cognitive impairments and may be additionally vulnerable to low staffing.Objectives: to explore associations between registered nurse (RN) and nursing assistant (NA) staffing levels, mortality and readmission in older patients admitted to general medical/surgical wards.Research Design: retrospective cohort.Participants: all unscheduled admissions to an English hospital of people aged ≥75 with cognitive screening over 14 months. Measures: the exposure was defined as deviation in staffing hours from the ward daily mean, averaged across the patient stay. Outcomes were mortality in hospital/ within 30 days of discharge and 30-day re-admission. Analyses were stratified by cognitive impairment.Results: 12,544 admissions were included. Patients with cognitive impairment (33.2%) were exposed to similar levels of staffing as those without. An additional 0.5 RN hours per day was associated with 10% reduction in the odds of death overall (Odds Ratio 0.90 [95% CI 0.84-0.97]): 15% in patients with cognitive impairment (OR 0.85 [0.74-0.98]) and 7% in patients without (OR 0.93 [0.85-1.02]). An additional 0.5 NA hours per day was associated with a 15% increase in mortality in patients with no impairment. Readmissions decreased by 6% for an additional 0.5 RN hours in patients with cognitive impairment. Conclusions: although exposure to low staffing was similar, the impact on mortality and readmission for patients with cognitive impairment was greater. Increased mortality with higher NA staffing in patients without cognitive impairment needs exploration. <br/