Designing and implementing a COPD discharge care bundle

National surveys have revealed significant differences in patient outcomes following admission to hospital with acute exacerbation of COPD which are likely to be due to variations in care. We developed a care bundle, comprising a short list of evidence-based practices to be implemented prior to discharge for all patients admitted with this condition, based on a review of national guidelines and other relevant literature, expert opinion and patient consultation. Implementation was then piloted using action research methodologies with patient input. Actively involving staff was vital to ensure that the changes introduced were understood and the process followed. Implementation of a care bundle has the potential to produce a dramatic improvement in compliance with optimum health care practice

Management of Fracture Risk in Patients with Chronic Obstructive Pulmonary Disease (COPD): Building a UK Consensus Through Healthcare Professional and Patient Engagement

Introduction: Osteoporosis and bone fractures are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to morbidity and mortality. Current national guidance on COPD management recommends addressing bone health in patients, however, does not detail how. This consensus outlines key elements of a structured approach to managing bone health and fracture risk in patients with COPD.Methods: A systematic approach incorporating multifaceted methodologies included detailed patient and healthcare professional (HCP) surveys followed by a roundtable meeting to reach a consensus on what a pathway would look like.Results: The surveys revealed that fracture risk was not always assessed despite being recognised as an important aspect of COPD management by HCPs. The majority of the patients also stated they would be receptive to discussing treatment options if found to be at risk of osteoporotic fractures. Limited time and resource allocation were identified as barriers to addressing bone health during consultations. The consensus from the roundtable meeting was that a proactive systematic approach to assessing bone health should be adopted. This should involve using fracture risk assessment tools to identify individuals at risk, investigating secondary causes of osteoporosis if a diagnosis is made and reinforcing non-pharmacological and preventative measures such as smoking cessation, keeping active and pharmacological management of osteoporosis and medicines management of corticosteroid use. Practically, prioritising patients with important additional risk factors, such as previous fragility fractures, older age and long-term oral corticosteroid use for an assessment, was felt required.Conclusion: There is a need for integrating fracture risk assessment into the COPD pathway. Developing a systematic and holistic approach to addressing bone health is key to achieving this. In tandem, opportunities to disseminate the information and educational resources are also required

Mechanosensing is critical for axon growth in the developing brain.

During nervous system development, neurons extend axons along well-defined pathways. The current understanding of axon pathfinding is based mainly on chemical signaling. However, growing neurons interact not only chemically but also mechanically with their environment. Here we identify mechanical signals as important regulators of axon pathfinding. In vitro, substrate stiffness determined growth patterns of Xenopus retinal ganglion cell axons. In vivo atomic force microscopy revealed a noticeable pattern of stiffness gradients in the embryonic brain. Retinal ganglion cell axons grew toward softer tissue, which was reproduced in vitro in the absence of chemical gradients. To test the importance of mechanical signals for axon growth in vivo, we altered brain stiffness, blocked mechanotransduction pharmacologically and knocked down the mechanosensitive ion channel piezo1. All treatments resulted in aberrant axonal growth and pathfinding errors, suggesting that local tissue stiffness, read out by mechanosensitive ion channels, is critically involved in instructing neuronal growth in vivo.This work was supported by the German National Academic Foundation (scholarship to D.E.K.), Wellcome Trust and Cambridge Trusts (scholarships to A.J.T.), Winston Churchill Foundation of the United States (scholarship to S.K.F.), Herchel Smith Foundation (Research Studentship to S.K.F.), CNPq 307333/2013-2 (L.d.F.C.), NAP-PRP-USP and FAPESP 11/50761-2 (L.d.F.C.), UK EPSRC BT grant (J.G.), Wellcome Trust WT085314 and the European Research Council 322817 grants (C.E.H.); an Alexander von Humboldt Foundation Feodor Lynen Fellowship (K.F.), UK BBSRC grant BB/M021394/1 (K.F.), the Human Frontier Science Program Young Investigator Grant RGY0074/2013 (K.F.), the UK Medical Research Council Career Development Award G1100312/1 (K.F.) and the Eunice Kennedy Shriver National Institute Of Child Health & Human Development of the National Institutes of Health under Award Number R21HD080585 (K.F.).This is the author accepted manuscript. The final version is available from Nature Publishing Group via https://doi.org/10.1038/nn.439

Localization of type 1 diabetes susceptibility to the MHC class I genes HLA-B and HLA-A

The major histocompatibility complex (MHC) on chromosome 6 is associated with susceptibility to more common diseases than any other region of the human genome, including almost all disorders classified as autoimmune. In type 1 diabetes the major genetic susceptibility determinants have been mapped to the MHC class II genes HLA-DQB1 and HLA-DRB1 (refs 1-3), but these genes cannot completely explain the association between type 1 diabetes and the MHC region. Owing to the region's extreme gene density, the multiplicity of disease-associated alleles, strong associations between alleles, limited genotyping capability, and inadequate statistical approaches and sample sizes, which, and how many, loci within the MHC determine susceptibility remains unclear. Here, in several large type 1 diabetes data sets, we analyse a combined total of 1,729 polymorphisms, and apply statistical methods - recursive partitioning and regression - to pinpoint disease susceptibility to the MHC class I genes HLA-B and HLA-A (risk ratios >1.5; Pcombined = 2.01 × 10-19 and 2.35 × 10-13, respectively) in addition to the established associations of the MHC class II genes. Other loci with smaller and/or rarer effects might also be involved, but to find these, future searches must take into account both the HLA class II and class I genes and use even larger samples. Taken together with previous studies, we conclude that MHC-class-I-mediated events, principally involving HLA-B*39, contribute to the aetiology of type 1 diabetes. ©2007 Nature Publishing Group

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

A global experiment on motivating social distancing during the COVID-19 pandemic

Finding communication strategies that effectively motivate social distancing continues to be a global public health priority during the COVID-19 pandemic. This cross-country, preregistered experiment (n = 25,718 from 89 countries) tested hypotheses concerning generalizable positive and negative outcomes of social distancing messages that promoted personal agency and reflective choices (i.e., an autonomy-supportive message) or were restrictive and shaming (i.e., a controlling message) compared with no message at all. Results partially supported experimental hypotheses in that the controlling message increased controlled motivation (a poorly internalized form of motivation relying on shame, guilt, and fear of social consequences) relative to no message. On the other hand, the autonomy-supportive message lowered feelings of defiance compared with the controlling message, but the controlling message did not differ from receiving no message at all. Unexpectedly, messages did not influence autonomous motivation (a highly internalized form of motivation relying on one’s core values) or behavioral intentions. Results supported hypothesized associations between people’s existing autonomous and controlled motivations and self-reported behavioral intentions to engage in social distancing. Controlled motivation was associated with more defiance and less long-term behavioral intention to engage in social distancing, whereas autonomous motivation was associated with less defiance and more short- and long-term intentions to social distance. Overall, this work highlights the potential harm of using shaming and pressuring language in public health communication, with implications for the current and future global health challenges

Safe Opioid Prescripting: A SMART on FHIR Approach to Clinical Decision Support

Prescription opioid pain medication overuse, misuse and abuse has been a significant contributing factor in the opioid epidemic. The rising death rates from opioid overdose has caused healthcare practitioners and researchers to work on optimizing pain therapy and limiting the prescriptions for pain medications. The state of New York has implemented a prescription drug monitoring program(PDMP), amended public health law to limit the prescription of opioids for acute pain and utilized the resources of the state and county health departments to help in curbing this epidemic. The recent publication of guidelines for prescription opioids from CDC [2] and ASIPP (American Society of Interventional pain practitioners) [4] have independently reviewed literature and found good evidence of limiting opioid prescription for acute and chronic non cancer pain.MethodClinical Decision Support Systems (CDSS) have been developed over the last decade to help in the work flow of healthcare providers since advanced technology is increasing the complexity of electronic health records systems. There are several systematics reviews on the effectivity and utility of CDSSs. The common consensus seems to be that commercially and locally developed CDSS are effective in improving patient measures while actual workload improvement and efficient cost cutting measure are not significantly improved by CDSS. Patient provider involvement in developing CDSS is a determinant of its success and utilization rates. In this light, a plug and play form of CDSS which is independent of the vendors of Electronic Health Records and can be implemented from an external platform through secure channels would be more effective.The Health Level Seven’s (HL7) open licensed interoperability standard called Fast Health Interoperability Resources (FHIR) has a platform, Substitutable Medical Applications and Reusable Technologies (SMART) for CDSS app development by a third party. (Mandl and Kohane) [13] We adopted these open source standard to develop an app for proper implementation of the recently published guidelines for management of pain with opioid pain medications.The goal for this CDSS tool would be to achieve proper monitoring of prescription drugs, patients’ medication list and potential interactive medications, surveillance for abuse/ misuse, patient involvement in alternative therapy, reporting problems and obtaining adequate pain control

Safe Opioid Prescripting: A SMART on FHIR Approach to Clinical Decision Support

Prescription opioid pain medication overuse, misuse and abuse has been a significant contributing factor in the opioid epidemic. The rising death rates from opioid overdose has caused healthcare practitioners and researchers to work on optimizing pain therapy and limiting the prescriptions for pain medications. The state of New York has implemented a prescription drug monitoring program(PDMP), amended public health law to limit the prescription of opioids for acute pain and utilized the resources of the state and county health departments to help in curbing this epidemic. The recent publication of guidelines for prescription opioids from CDC [2] and ASIPP (American Society of Interventional pain practitioners) [4] have independently reviewed literature and found good evidence of limiting opioid prescription for acute and chronic non cancer pain.MethodClinical Decision Support Systems (CDSS) have been developed over the last decade to help in the work flow of healthcare providers since advanced technology is increasing the complexity of electronic health records systems. There are several systematics reviews on the effectivity and utility of CDSSs. The common consensus seems to be that commercially and locally developed CDSS are effective in improving patient measures while actual workload improvement and efficient cost cutting measure are not significantly improved by CDSS. Patient provider involvement in developing CDSS is a determinant of its success and utilization rates. In this light, a plug and play form of CDSS which is independent of the vendors of Electronic Health Records and can be implemented from an external platform through secure channels would be more effective.The Health Level Seven’s (HL7) open licensed interoperability standard called Fast Health Interoperability Resources (FHIR) has a platform, Substitutable Medical Applications and Reusable Technologies (SMART) for CDSS app development by a third party. (Mandl and Kohane) [13] We adopted these open source standard to develop an app for proper implementation of the recently published guidelines for management of pain with opioid pain medications.The goal for this CDSS tool would be to achieve proper monitoring of prescription drugs, patients’ medication list and potential interactive medications, surveillance for abuse/ misuse, patient involvement in alternative therapy, reporting problems and obtaining adequate pain control

Technology and its role in respiratory care

Introduction: Telemonitoring, telemedicine, clinical and medical informatics or telecare, are terms used to describe the use of technology along with local clinical protocols to monitor remotely a patient's medical condition in their own home. In respiratory medicine, where large numbers of people have long term conditions such as asthma and chronic obstructive pulmonary disease (COPD), the role of such monitoring technology in the management of patients is of great interest. Aim: This review seeks to explore what evidence exists to support the deployment of technology to improve the care of people with respiratory conditions. Method: Narrative review . Result: A wide variety of technologies have been involved in asthma and COPD care, from management systems to self monitoring devices. Many studies report that staff and patients 'liked' the technology. The service, care and financial benefits to both patients and the health care system were less obvious. Many studies suffered from poor methodology and lacked clear endpoints. Conclusion: There is an enormous potential for telemonitoring to assist in the provision of better care for those with long term lung diseases. However, evidence of benefit is unclear and there remains a need for robust studies and answers to clear research questions for specific patient populations before such technologies can be recommended for widespread implementation