Optimizing nonpharmacological management following an acute exacerbation of chronic obstructive pulmonary disease.

Samantha L Harrison,1 Roger Goldstein,1 Laura Desveaux,1 Verity Tulloch,1 Dina Brooks2 1Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, ON, Canada; 2Department of Medicine Physical Therapy, University of Toronto, Toronto, ON, Canada Abstract: Though the guidelines for the optimal management of chronic obstructive pulmonary disease (COPD) following an acute exacerbation (AE) are well established, issues associated with poor adherence to nonpharmacological interventions such as self-management advice and pulmonary rehabilitation will impact on hospital readmission rates and health care costs. Systems developed for clinically stable patients with COPD may not be sufficient for those who are post-exacerbation. A redesign of the manner in which such interventions are delivered to patients following an AECOPD is necessary. Addressing two or more components of the chronic care model is effective in reducing health care utilization in patients with COPD, with self-management support contributing a key role. By refining self-management support to incorporate the identification and treatment of psychological symptoms and by providing health care professionals adequate time and training to deliver respiratory-specific advice and self-management strategies, adherence to nonpharmacological therapies following an AE may be enhanced. Furthermore, following up patients in their own homes allows for the tailoring of advice and for the delivery of consistent health care messages which may enable knowledge to be retained. By refining the delivery of nonpharmacological therapies following an AECOPD according to components of the chronic care model, adherence may be improved, resulting in better disease management and possibly reducing health care utilization.Keywords: acute exacerbation, chronic obstructive pulmonary disease, pulmonary rehabilitation, self-management, physical activity, oxygen, adherence, chronic care mode

Effects of exercise training on cognition in chronic obstructive pulmonary disease:A systematic review

Background As exercise may mitigate cognitive decline in individuals with chronic obstructive pulmonary disease (COPD), its effect has been evaluated in a number of clinical trials. The objective of the present systematic review was to describe the impact of exercise training on cognition in COPD. Methods Electronic searches of four databases were performed from inception until March 24, 2015 and last updated 23rd October 2017. Included studies reported on at least one cognitive outcome before and after a formal exercise-training program in individuals with COPD. Two reviewers independently rated study quality using the Downs and Black checklist. The protocol was registered on PROSPERO (CRD42015017884). Results Seven articles, representing six exercise interventions in 293 individuals with COPD (55% males, mean age 67 ± 2 year) were included. Although each study documented a significant pre-post training improvement in at least one cognitive domain, the heterogeneity in study design, exercise intervention and cognitive outcome measures among studies precluded a meta-analysis. The only randomized controlled trial available reported an improvement on a letter verbal fluency task in the exercise group only. Conclusions Exercise training may positively impact cognition in COPD patients, but current evidence is limited by the heterogeneity of study design, exercise intervention and cognitive outcome measures. Future studies should emphasize comprehensive reporting of intervention parameters, including program length, type(s) of exercise, and duration of individual sessions, in order to facilitate applied insights to inform replication and/or program development

Distributive Laws for Monotone Specifications

Turi and Plotkin introduced an elegant approach to structural operational semantics based on universal coalgebra, parametric in the type of syntax and the type of behaviour. Their framework includes abstract GSOS, a categorical generalisation of the classical GSOS rule format, as well as its categorical dual, coGSOS. Both formats are well behaved, in the sense that each specification has a unique model on which behavioural equivalence is a congruence. Unfortunately, the combination of the two formats does not feature these desirable properties. We show that monotone specifications - that disallow negative premises - do induce a canonical distributive law of a monad over a comonad, and therefore a unique, compositional interpretation.Comment: In Proceedings EXPRESS/SOS 2017, arXiv:1709.0004

Correction: Type III Effector Activation via Nucleotide Binding, Phosphorylation, and Host Target Interaction

The Pseudomonas syringae type III effector protein avirulence protein B (AvrB) is delivered into plant cells, where it targets the Arabidopsis RIN4 protein (resistance to Pseudomonas maculicula protein 1 [RPM1]–interacting protein). RIN4 is a regulator of basal host defense responses. Targeting of RIN4 by AvrB is recognized by the host RPM1 nucleotide-binding leucine-rich repeat disease resistance protein, leading to accelerated defense responses, cessation of pathogen growth, and hypersensitive host cell death at the infection site. We determined the structure of AvrB complexed with an AvrB-binding fragment of RIN4 at 2.3 Å resolution. We also determined the structure of AvrB in complex with adenosine diphosphate bound in a binding pocket adjacent to the RIN4 binding domain. AvrB residues important for RIN4 interaction are required for full RPM1 activation. AvrB residues that contact adenosine diphosphate are also required for initiation of RPM1 function. Nucleotide-binding residues of AvrB are also required for its phosphorylation by an unknown Arabidopsis protein(s). We conclude that AvrB is activated inside the host cell by nucleotide binding and subsequent phosphorylation and, independently, interacts with RIN4. Our data suggest that activated AvrB, bound to RIN4, is indirectly recognized by RPM1 to initiate plant immune system function

Implementing a Virtual Emergency Department: Qualitative Study Using the Normalization Process Theory

BACKGROUND: COVID-19 necessitated the rapid implementation and uptake of virtual health care; however, virtual care's potential role remains unclear in the urgent care setting. In December 2020, the first virtual emergency department (ED) in the Greater Toronto Area was piloted at Sunnybrook Health Sciences Centre by connecting patients to emergency physicians through an online portal. OBJECTIVE: This study aims to understand whether and how ED physicians were able to integrate a virtual ED alongside in-person operations. METHODS: We conducted semistructured interviews with ED physicians guided by the Normalization Process Theory (NPT). The NPT provides a framework to understand how individuals and teams navigate the process of embedding new models of care as part of normal practice. All physicians who had worked within the virtual ED model were invited to participate. Data were analyzed using a combination of inductive and deductive techniques informed by the NPT. RESULTS: A total of 14 physicians were interviewed. Participant experiences were categorized into 1 of 2 groups: 1 group moved to normalize the virtual ED in practice, while the other described barriers to routine adoption. These groups differed in their perception of the patient benefits as well as the perceived role in the virtual ED. The group that normalized the virtual ED model saw value for patients (coherence) and was motivated by patient satisfaction witnessed (reflexive monitoring) at the end of the virtual appointment. By contrast, the other group did not find virtual ED work reflective of the perceived role of urgent care (cognitive participation) and felt their skills as ED physicians were underutilized. The limited ability to examine patients and a sense that patient issues were not fully resolved at the end of the virtual appointment caused frustration among the second group. CONCLUSIONS: As further digital integration within the health care system occurs, it will be essential to support the evolution of staff skill sets to ensure physicians are satisfied with the care they are providing to their patients, while also ensuring the technology and process are efficient

Type III Effector Activation via Nucleotide Binding, Phosphorylation, and Host Target Interaction

The Pseudomonas syringae type III effector protein avirulence protein B (AvrB) is delivered into plant cells, where it targets the Arabidopsis RIN4 protein (resistance to Pseudomonas maculicula protein 1 [RPM1]–interacting protein). RIN4 is a regulator of basal host defense responses. Targeting of RIN4 by AvrB is recognized by the host RPM1 nucleotide-binding leucine-rich repeat disease resistance protein, leading to accelerated defense responses, cessation of pathogen growth, and hypersensitive host cell death at the infection site. We determined the structure of AvrB complexed with an AvrB-binding fragment of RIN4 at 2.3 Å resolution. We also determined the structure of AvrB in complex with adenosine diphosphate bound in a binding pocket adjacent to the RIN4 binding domain. AvrB residues important for RIN4 interaction are required for full RPM1 activation. AvrB residues that contact adenosine diphosphate are also required for initiation of RPM1 function. Nucleotide-binding residues of AvrB are also required for its phosphorylation by an unknown Arabidopsis protein(s). We conclude that AvrB is activated inside the host cell by nucleotide binding and subsequent phosphorylation and, independently, interacts with RIN4. Our data suggest that activated AvrB, bound to RIN4, is indirectly recognized by RPM1 to initiate plant immune system function

Translational framework for implementation evaluation and research: Protocol for a qualitative systematic review of studies informed by Normalization Process Theory (NPT)

Background: Normalization Process Theory (NPT) identifies mechanisms that have been demonstrated to play an important role in implementation processes. It is now widely used to inform feasibility, process evaluation, and implementation studies in healthcare and other areas of work. This qualitative synthesis of NPT studies aims to better understand how NPT explains observed and reported implementation processes, and to explore the ways in which its constructs explain the implementability, enacting and sustainment of complex healthcare interventions. Methods: We will systematically search Scopus, PubMed and Web of Science databases and use the Google Scholar search engine for citations of key papers in which NPT was developed.  This will identify English language peer-reviewed articles in scientific journals reporting (a) primary qualitative or mixed methods studies; or, (b) qualitative or mixed methods evidence syntheses in which NPT was the primary analytic framework. Studies may be conducted in any healthcare setting, published between June 2006 and 31 December 2021. We will perform a qualitative synthesis of included studies using two parallel methods: (i) directed content analysis based on an already developed coding manual; and (ii) unsupervised textual analysis using Leximancer® topic modelling software. Other: We will disseminate results of the review using peer reviewed publications, conference and seminar presentations, and social media (Facebook and Twitter) channels. The primary source of funding is the National Institute for Health Research ARC North Thames. No human subjects or personal data are involved and no ethical issues are anticipated

Translational framework for implementation evaluation and research: Protocol for a qualitative systematic review of studies informed by Normalization Process Theory (NPT) [version 1; peer review: 2 approved]

Background: Normalization Process Theory (NPT) identifies mechanisms that have been demonstrated to play an important role in implementation processes. It is now widely used to inform feasibility, process evaluation, and implementation studies in healthcare and other areas of work. This qualitative synthesis of NPT studies aims to better understand how NPT explains observed and reported implementation processes, and to explore the ways in which its constructs explain the implementability, enacting and sustainment of complex healthcare interventions. Methods: We will systematically search Scopus, PubMed and Web of Science databases and use the Google Scholar search engine for citations of key papers in which NPT was developed.  This will identify English language peer-reviewed articles in scientific journals reporting (a) primary qualitative or mixed methods studies; or, (b) qualitative or mixed methods evidence syntheses in which NPT was the primary analytic framework. Studies may be conducted in any healthcare setting, published between June 2006 and 31 December 2021. We will perform a qualitative synthesis of included studies using two parallel methods: (i) directed content analysis based on an already developed coding manual; and (ii) unsupervised textual analysis using Leximancer® topic modelling software. Other: We will disseminate results of the review using peer reviewed publications, conference and seminar presentations, and social media (Facebook and Twitter) channels. The primary source of funding is the National Institute for Health Research ARC North Thames. No human subjects or personal data are involved and no ethical issues are anticipated

Community-based Physical Activity Following Rehabilitation in Chronic Disease

The overlap in physical impairments and rehabilitative management for heart failure (HF), chronic obstructive pulmonary disease (COPD), stroke, and diabetes supports the potential for an integrated symptom-directed approach to long-term management and physical activity promotion. The main objective of this thesis was to align the evidence across conditions to allow for comparison of PA levels following rehabilitation and to evaluate whether individuals with HF, COPD, stroke, and diabetes experience similar barriers to PA following discharge from rehabilitation. The first study in this thesis showed that physical activity levels for diabetic adults with a transtibial amputation remain stable following discharge from prosthetic rehabilitation, but fall well below recommended guidelines of 150 minutes/week for adults with diabetes. In the second study, we found similarly low levels of physical activity following rehabilitation for individuals with HF and COPD. In this study, participants also expressed the need for minimally supervised community-based programs tailored to functional ability to support adherence to exercise and prescribed activity following rehabilitation. The third study identified similar perceptions across chronic conditions with respect to barriers to and facilitators of physical activity in the community. However significant differences were found between healthcare professionals and older adults with chronic disease with the respect to their perception of barriers. The findings from the three studies included in this thesis support the need for exercise maintenance programs following rehabilitation and the potential for an integrated approach to management.Ph.D