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Purpose Law enforcement officers (LEOs) suffer from premature mortality, intentional and unintentional injury, suicide and are at an increased risk for several non-communicable disease outcomes including cardiovascular disease and several cancers, compared to those employed in other occupations. Repeated exposure to stressful and traumatic stimuli is a possible mechanism driving these adverse health outcomes among LEOs. To better identify the sources of these health problems, the purpose of this paper is to determine the feasibility of conducting a cohort study using physiological measures of stress (e.g. heart rate) with LEOs; perceptions of the FitBit device, including LEO buy-in and attitudes associated with the protocol. Design/methodology/approach Data were collected from ten recent graduates of the Dallas Police Training Academy. Findings Results suggest that officer buy-in and protocol compliance was high. Officers were eager to participate in this study, and completion of weekly surveys was 100 percent. Minute-level missing data from wearable devices was relatively low (25 percent), and 90 percent of participants wore the FitBit devices on more than 90 percent of study days. Originality/value Results from this study suggest that wearable physiological devices can be effectively used in law enforcement populations to measure stress.

Background The unpredictable, and sometimes dangerous, nature of the occupation exposes officers to both acute and chronic stress over law enforcement officers’ (LEO) tenure. The purpose of this study is two-fold: 1) Describe multi-level characteristics that define high-stress calls for service for LEO; and 2) Characterize factors that impact cumulative stress over the course of a LEO’s shift. Methods Qualitative data were collected from 28 LEOs at three law enforcement agencies in the Dallas-Fort Worth areas from April 2019 to February 2020. Focus group data were iteratively coded by four coders using inductive and deductive thematic identification. Results Five multi-level factors influenced officer stress: 1) officer characteristics (e.g. military experience; gender); 2) civilian behavior (e.g. resistance, displaying a weapon); 3) supervisor factors (micromanagement); 4) environmental factors (e.g. time of year); and, 5) situational factors (e.g. audience present; complexity of calls). Four themes that characterized cumulative stress: 1) cyclical risk; 2) accelerators; 3) decelerators; and 4) experience of an adverse event. Conclusions LEOs become susceptible to adverse events (e.g. injury, excessive use of force) after repeated exposure to high-stress calls for service. Ongoing exposures to stress continue to occur throughout the shift. Our long-term goal is to interrupt this repetitive, cumulative process by restricting the number of consecutive high-risk, high-intensity calls an officer is permitted to respond to.

Introduction A high prevalence of OSA has been observed in asthma populations, with detrimental impact on clinical outcomes. Aim To determine if CPAP treatment of co-existing OSA improves asthma-related symptoms and quality of life. Methods Literature review of EMBASE and MEDLINE databases prior to July 2017. Study populations included asthmatics with co-existing OSA treated with CPAP, and ≥1 asthma-related clinical outcome measure. Results 12 studies; 8 prospective quasi-experimental and 4 observational. Mean CPAP duration; 19.5 (2–100) weeks. Meta-analysis demonstrated significant improvement in mean Asthma Quality of Life Questionnaire scores (AQLQ and mini-AQLQ); 0.59 (95%CI; 0.25, 0.92), p = 0.0006. No significant improvement was demonstrated in forced expiratory volume in 1 s (FEV1)% predicted; 0.32 (95%CI; −2.84, 3.47), p = 0.84. Asthma Control Test/Asthma Control Questionnaire improved in 2 studies, with no improvement in 1 study. 4 studies demonstrated improvement in asthma daytime/night-time symptoms, and 3 studies showed improved asthma severity. Conclusion Asthmatics with co-existing OSA can experience improved quality of life with CPAP treatment. This effect appears more pronounced in severe OSA or poorly controlled asthma.

Bronchial asthma and obstructive sleep apnoea (OSA) are common respiratory disorders that can co-exist. The strength of this association, and also the impact of OSA on asthma-related clinical outcomes remain unclear.Literature review was performed in EMBASE and MEDLINE databases. Studies up to and including 2016 were selected.Studies were included if they contained; 1) a population with asthma AND 2) a prevalence of OSA reported using either polysomnography or validated questionnaires such as the Sleep Apnoea Scale of the Sleep Disorders Questionnaire (SA-SDQ), STOP BANG or the Berlin questionnaire.Nineteen studies were identified. Thirteen questionnaire-based studies met the inclusion/exclusion criteria and twelve of these demonstrated a prevalence of OSA in asthma of 8-52.6%, with one study showing no association between the two conditions. Six studies using polysomnography demonstrated a high prevalence of 19.2-60%; which was higher at 50-95% in severe asthma. Two polysomnography and four questionnaire studies found worse asthma-related clinical outcomes with co-existing OSA. One polysomnography and two questionnaire studies showed no difference.This systematic review suggests that there is a high prevalence of OSA in asthma, particularly within severe asthma populations and that co-diagnosis of OSA in asthma patients is associated with worse clinical outcomes. However this outcome was not uniform and the number of studies using polysomnography to confirm OSA was small. This weakens the conclusions that can be drawn and prompts the need for adequately powered and well-designed studies to confirm or refute these findings.

Background Bronchial airway inflammation is the hallmark of asthma, which may be driven by an imbalance between oxidative stress and antioxidant defenses. Antioxidants deficiency may play a role, but this has remained unconfirmed. Objective To evaluate the oxidative stress burden and antioxidants defenses in patients with increasing asthma severity. Methods This prospective case-control study compared fractional exhaled nitric oxide (FeNO), exhaled breath condensate nitrite/nitrate (EBC-NOx), spirometry, and serum vitamins and trace elements among patients with and without asthma. Results Sixty participants were recruited (30 with severe asthma number; 23 women [76.7%]; mean age, 41.4 years; mean forced expiratory volume in 1 second [FEV 1 ], 2.2 L [72.2% predicted]; mean inhaled corticosteroid dosage, 2,540 μg/d; 18/30 [60%] receiving maintenance oral corticosteroids; 15 with mild asthma; all corticosteroids naive; 9 women [60%]; mean age, 34.6 years; mean FEV 1 , 3.48 L [100.5% predicted]; 15 healthy controls; 12 women [80%]; mean age, 37.6 years; and mean FEV 1 , 3.53 L [111.7% predicted]). The mean FeNO levels increased significantly with increasing asthma severity ( P = .01), but the EBC-NOx levels did not change significantly ( P = .90). Paradoxically, vitamin A and vitamin E increased with increased disease severity, with vitamin E levels increasing significantly ( P = .07 and P P = .37), zinc ( P = .97), or selenium ( P = .90). Conclusion FeNO but not EBC-NOx is increased significantly with asthma severity with no evidence of vitamins or trace elements deficiency in severe asthma. Impaired oxidative stress defenses in severe asthma may be driven by factors other than vitamins or trace elements deficiency.

Introduction MND is a terminal, neurodegenerative condition resulting in muscle weakness leading to chronic hypercapnic respiratory failure (CHRF). NIV is an evidence-based therapy for treating both the symptoms and physiology of CHRF. NICE recommend a trial of NIV in patients who present with clinical signs of CHRF including dyspnoea, orthopnoea, FVC Methodology All MND patients referred during a 2-year period were included. Physiological measurements including FVC, SNIP and pCO2 taken during the assessment for NIV were collected from the departments ventilation database. NIV compliance (>4 hrs per night >5 nights per week) was obtained from a remote monitoring platform (ResMed AirView). Patients were sub-grouped into reason for NIV trial; physiological impairment (Phys) and physiological impairment plus symptoms (Comb). Between group comparisons were made using pC02, FVC, SNIP, 30 and 90-day compliance. Results Patient demographics are shown in Table 1. In total 30 patients with MND were referred. A total of 21(70%) patients were initiated on NIV due to a combination of physiological impairment plus symptoms. No between group differences were observed for FVC, SNIP and pC02 (p=0.135, p=0.822, p=0.526, respectively). There was no difference in time from diagnosis to NIV trial (p=0.082) or time from NIV initiation to follow up (p=4.83). Both 30 and 90-day compliance were similar between groups (p=0.376, p=0.073, respectively). MND phenotypes (bulbar; limb) had similar 30-day compliance (p=0.961). Discussion Our data provides evidence to suggest commencement of NIV at the earliest opportunity may increase the likelihood of effective symptom control and survival advantage regardless of initial patient presentation. Even in the absence of significant symptoms patients with both types of clinical features present with similar baseline physiology and achieve comparable therapy compliance. In addition, patients with bulbar impairment are as compliant as those without.

Introduction Acute non-invasive ventilation (aNIV) is a well evidenced treatment for acute hypercapnic respiratory failure (AHRF) in COPD and other conditions including obesity hypoventilation syndrome, restrictive chest wall conditions and neuromuscular diseases. Within our service we recognised similar challenges and outcomes highlighted by NCEPOD’s ‘Inspiring Change’ document. In response to this and utilising BTS Quality Standards, we undertook a quality improvement project (QIP), introducing a multidisciplinary aNIV team including the skills of Clinical Scientists, Physiologists, Physiotherapists and Nurses. We present results from our first dataset. Methods This is a retrospective study of patients who commenced aNIV according to local policy at a large university teaching hospital over a 6-month period. Outcome variables were based on BTS Quality Standards and reviewed using NCEPOD audit toolkit. In addition, physiology data, inpatient mortality, 30-day mortality and readmission rates were recorded. Results Our patient cohort (47) was predominantly COPD patients (79%) with a mean pH of 7.25 (NCEPOD cohort; COPD 69%, pH 7.25). Mean referral to mask time was 22 minutes, with 80% seen and treated by aNIV team within 1 hour (30% prior to aNIV team). In total 30% of patients had a pre-NIV pH Discussion Our data shows that an aNIV MDT utilising NCEPOD toolkit is able to deliver BTS quality standards to a large percentage of patients and contribute towards a reduction in inpatient mortality. A well-defined aNIV pathway, dedicated on-call rota, specific proforma and robust staff competency framework contribute towards achieving these outcomes. Future research is required in order to fully understand the mechanisms by which further improvements in patient outcomes can be achieved.

Introduction: MND is a neurodegenerative condition that can present with either limb or bulbar muscle weakness and may lead to chronic hypercapnic respiratory failure. NIV provides ventilatory support for symptomatic type II respiratory failure. However, it has been reported that bulbar patients are less likely to tolerate NIV (Gruis, 2005). Methodology: We reviewed all MND patients commenced on NIV over a 2 year period and divided them into bulbar and limb onset phenotypes. Patient demographics and NIV settings were collected from the departments NIV database. NIV survival and therapy compliance were compared between groups. Results: The use of NIV therapy adhered to NICE guidance in all patients. No difference could be identified in time from diagnosis to starting NIV (211 vs 402 days, respectively; p=0.077). or in NIV survival time (p=0.877). Compliance at 30 and 90 days between bulbar and limb onset patients was comparable (p= 0.755; p= 0.747, respectively.) and there was no difference between pre NIV SNIP (26 vs 44; p=0.112), pre NIV pC02 (6.02 vs 6.29; p=0.662) or pre FVC% (72 vs 57; p=0.209). There was no difference between bulbar and limb MND in initiation IPAP and EPAP (13 vs 15; p=0.86; 5 vs 5; p=0.142, respectively). Discussion: Our data suggest that bulbar patients may be successfully initiated onto NIV and remain as compliant as limb patients at both 30 and 90 days. There was no demonstrable NIV survival advantage between groups. Bulbar patients may experience dyspnoeic symptoms sooner than limb MND patients due to preserved mobility and are more likely to commence NIV earlier. A trial of NIV in MND bulbar patients is advised.

BackgroundPrevious officer-involved shooting (OIS) research has focused primarily on antecedents to fatal shootings, with few studies investigating injury more broadly. Our study examined the factors associated with fatal or non-fatal injury to both civilians and officers during OIS incidents, to better understand how harm might be reduced in the most extreme law enforcement scenarios.MethodsData included 281 officers involved in 177 unique shooting incidents recorded by Dallas Police Department between 2005 and 2015. Bivariate logistic regression and multivariable generalised estimation equation analyses were used to investigate incident characteristics associated with fatal or non-fatal injury to civilians and officers.ResultsCivilian injury occurred in 61% and officer injury in 14% of unique OIS incidents. In adjusted models, multiple shooting officers increased the odds of injury to both civilians (adjusted OR (AOR): 3.22, 95% CI 1.39 to 7.50) and officers (AOR 4.73, 95% CI 1.64 to 13.65). Odds of civilian injury were also significantly higher during the daytime and among non-Hispanic white compared with non-Hispanic black and Hispanic/Latina/o civilians, although a majority of OIS incidents (79%) involved non-Hispanic black or Hispanic/Latino/a civilians. Odds of officer injury were significantly higher for detectives compared with patrol (AOR=9.32, 95% CI 1.85 to 47.03) and during off-duty versus on-duty shootings (AOR=5.23, 95% CI 1.37 to 19.99).ConclusionsBoth civilians and officers are at risk for injury during OIS incidents, though to different degrees and with unique risk factors. Additional research is needed to understand whether these results are replicated elsewhere and to further understand the mechanisms of injury.

The addition of TASERs as a less lethal use-of-force option for police officers has facilitated much discussion in recent scholarship. Many police agencies have responded with force policy changes specific to appropriate applications for these weapons. While the goal of these changes is often to minimize concern about injury to citizens, debate rests on whether injury rates for officers are influenced by such transitions in policy. The present study used officer injury panel data from the City of Dallas (Texas) Human Resources Department to assess the impact of a 2005 modification to the Dallas Police Department’s TASER policy. The goal of the study was to assess change in the rate of officer injury after the implementation of a more restrictive policy. We observed a modest increase in the monthly rate of police officer injuries following the policy restricting use. These results were found net of other effects, with some noteworthy between-patrol-division variation. Implications for TASER use policy and future research are discussed within.

A primary responsibility of organizational leaders in large metropolitan areas is to find the right balance between becoming more efficient while remaining highly effective, and these aspects of municipal governance are no less true in the City of Dallas, Texas. Among responsibility for law enforcement, an important job component of its police officers is to arrest and transport prisoners to jail. However, book-in procedures are unnecessarily time consuming due in part to the medical screening process. To examine this process, data were collected over a 90-day period from the Dallas County (Texas) jail. Findings from the current study indicate that adjustments to prisoner transfer times and changes to the staffing of medical personnel could significantly reduce jail wait times for officers. The current study utilizes organizational process theory and general systems theory to explain various relationships found within the Dallas County jail’s medical evaluation system. Finally, several policy recommendations are suggested.

Introduction A high prevalence of OSA has been observed in asthma populations, with detrimental impact on clinical outcomes. Aim To determine the impact of CPAP treatment on asthma-related clinical outcomes in co-existing OSA. Methods Literature review of EMBASE and MEDLINE databases prior to July 2017. Study populations of asthmatics and co-existing OSA treated with CPAP, with ≥1 asthma-related clinical outcome measure were included. Results 12 studies; 8 prospective quasi-experimental and 4 observational. Mean CPAP duration; 19.5 (2–100) weeks. Meta-analysis demonstrated significant improvement in mean Asthma Quality of Life Questionnaire scores (AQLQ and mini-AQLQ); 0.59 (95%CI; 0.25, 0.92), p=0.0006. No significant improvement was demonstrated in mean forced expiratory volume in one second (FEV1)%predicted; 0.32 (95%CI; −2.84, 3.47), p=0.84. Asthma Control Test/Asthma Control Questionnaire improved in 2 studies, with no improvement in 1 study. 4 studies demonstrated improvement in asthma daytime/night-time symptoms, and 3 studies showed improved asthma severity. There is mixed evidence for improvement in bronchial airway responsiveness. Single studies demonstrated improved peak expiratory flow rates, arterial oxygenation/carbon dioxide levels, fractional exhaled nitric oxide and annual decline in FEV1. Conclusion Preliminary data suggests CPAP has a positive impact on quality of life in asthmatics with co-existing OSA. Further investigation with randomised controlled trials is needed.

Introduction National cancer audit data consistently report variation in care and outcomes which is not entirely explained by case mix. The organisation and delivery of healthcare services has been hypothesised to be a contributing factor. We collate the evidence on the impact of service delivery on patient outcomes and apply our findings to lung cancer pathways. Methods A narrative synthesis was conducted of eligible studies using standard review methodology. (PROSPERO: CRD42017074510). Included studies investigated a component of service delivery and related this to patient outcomes. After identification of themes, each theme was searched with the term ‘Lung cancer’. Risk of bias was assessed appropriately. Results Fifteen studies, of which 9 were Cochrane reviews, were included. The following themes were identified: staff workload, specialist care, coordination of care, use of technology, home care and clinical pathways. Six out of 11 studies found an association between hospital resources and organisation of care on survival. All six advocated greater provision of specialist staff/units. Evidence in the lung cancer literature demonstrating a link with survival is limited. A stronger association is found between improved active treatment rates and increased access to specialist care achieved through the formation of specialist centres. Conclusion Review of the medical literature highlight key organisational themes that impact patient outcomes. Applying these themes to lung cancer pathways reveals the change in health service design most likely to improve patient outcomes is the delivery of adequate specialist staff with dedicated time to provide care in specialist centres or with a hub and spoke model.

PurposeThe purpose of this paper is to examine a police promotional process, in order to determine factors important for a sergeant to be promoted to lieutenant. To do this, written scores, assessment scores, and other demographic variables are used, thus providing a unique look into what it truly takes to promote to an important managerial rank in this large Texas metropolitan police department (LTMPD).Design/methodology/approachThis is an exploratory study utilizing data collected from departmental databases. The original data set was accessed through public information laws, and compiled by the lead author, a 21‐year police veteran and participant in this promotional process.FindingsSignificant findings were both expected and unexpected. Of no surprise were the findings that an officer's written score and assessment score significantly affected the likelihood of promotion. Unexpected were past behavior patterns, age, and number of times tested significantly affected both assessment center performance score and promotion.Originality/valueThis paper examines the promotional process within an LTMPD. It illustrates how promotions are made in a department that relies heavily on assessment center outcomes to decide who is promoted. Up to now, police promotional processes have received little attention. This current research is an exploratory analysis which seeks to fill the gap by examining the process by which police lieutenants are chosen.

BACKGROUND: The limited research on police sexual misconduct (PSM), a common form of police misconduct, suggests that no evidence-based strategies for prevention are available for use by police departments. To identify new avenues for prevention, we critically evaluated 'front-end' police recruiting, screening, hiring and training procedures. METHODS: Internal Affairs records were linked with administrative reports and police academy graduation data for officers accused of sexual assault or misconduct between 1994 and 2014. Logistic and proportional hazards regression methods were used to identify predictors of discharge for sustained allegations of PSM and time to discharge, respectively. RESULTS: Officer's graduating class size was positively associated with odds of discharge for PSM. For every one-officer increase in class size, the rate of discharge for PSM increased by 9% [hazard ratio (HR) = 1.09, P 35 graduates), discharge rates were at least four times greater than smaller classes (HR = 4.43, P CONCLUSIONS: Large class sizes and more annual graduates increase rates of PSM. Officer recruitment strategies or training quality may be compromised during periods of intensive hiring. Trainee to instructor ratios or maximum class sizes may be instituted by academies to ensure that all police trainees receive the required supervision, one-on-one training, feedback and attention necessary to maximize public safety. Language: en

Drug arrests have increased steadily for going on 30 years, yet drug use has fluctuated wildly during the same period. Some have argued (and found) that state forfeiture laws may explain variation in drug arrests. Using data from 572 law enforcement agencies, we sought to replicate such findings and test their robustness by invoking a variety of forfeiture measures. Our findings indicate that drug asset forfeiture laws (and even past forfeiture activities) have no discernible effect on drug arrest rates.

Introduction: The factors predicting the likelihood of failure of NIV, ie requirement of intubation or death, have been well documented with low pH shown to be the most important factor. Factors affecting the duration of NIV required in those patients who receive ward based treatment without the need for intubation have not been established. This study aimed to identify factors which influence the duration of NIV treatment required in acute hypercapnic respiratory failure. Method: A retrospective analysis of 123 consecutive episodes of acute hypercapnic respiratory failure requiring NIV between June 2013 and June 2014 was carried out. Correlation between duration of NIV treatment and a number of variables, namely admission creatinine, pH, worst CO 2 , presence and severity of chronic kidney disease and presence of acute kidney injury was assessed by correlation analysis by simple linear regression. Results: There was a statistically significant regression coefficient between worst observed CO 2 level and the duration of NIV (p 0.019). The plotted linear relationship showed an increase in duration of NIV treatment of 14.35 hours for every 1kPa increase in CO 2 above 6. The admission creatinine and severity of chronic kidney disease did not significantly alter the duration of NIV required. The presence of acute kidney injury was also not significant. The pH value did not significantly affect the duration of NIV treatment. Conclusion: This study shows that the level of CO2 influences the duration of NIV required, in that for every 1kPa rise in CO2, the duration of NIV treatment rises by 14.35 hours. The other studied variables do not correlate with treatment duration.

Introduction: Cardio pulmonary exercise testing (CPET) is widely used in pre-operative (general anaesthesia) risk stratification. More recently, the utility of CPET has become better defined in the evaluation of unexplained dyspnoea. We evaluated the use of CPET in Respiratory Medicine within an English acute hospital trust in the second year after establishing the service. Methods: The reason for CPET referrals from Respiratory Medicine between July 2013 and November 2014 was retrospectively analysed by searching patient's notes. For those referred for unexplained dyspnoea, the outcome of the test (diagnosis) was recorded. Results: The total number of CPET referrals received was 377. 40 (11%) of these were from respiratory medicine. Of these, 26 (65%) were using CPET to evaluate unexplained dyspnoea and 20% for dyspnoea on exertion. 22 of the unexplained dyspnoea referrals were followed up in clinic and 68% utilised the CPET report to aid diagnosis. [Table 1][1] lists the diagnoses. View this table: Table 1. Post CPET diagnosis Conclusion: CPET is a comprehensive assessment tool for the non invasive investigation of patients with unexplained dyspnoea, which offers clinically useful information regarding diagnosis and management. Promoting awareness, understanding and timely utilisation of CPET amongst UK respiratory communities could improve diagnostic pathways and reduce the cost of unnecessary investigations. [1]: #T1

New National Standards for Child Protection in Sport require state-funded sport organizations in England to record and monitor allegations of abuse, yet very few sport organizations have robust case-recording and management systems in place. Those that do have found the task of collecting and managing data very challenging. The management and research functions of data systems for abuse allegations are explored with reference to sample data from a study of extant referrals to the Football Association. A preliminary template for the analysis was generated using variables from previous inductive studies. Data for an initial set of 50 variables were extracted from 132 case files and entered into the database. The resultant descriptive data were subjected to visual inspection against a set of concerns from the literature about, for example, false allegations, perpetrator roles and location of abuse. Fears of false allegations of abuse against coaches and other authority figures were shown to be unfounded. However, the case-recording system utilized yielded very few usable data, underlining the need for a functional recording system based on a more tightly specified data-recording method. Keywords: Soccer Language: en

As I drove back the heavens opened wide to reveal a chorus and trumpets making Handel-like noises (de Bruyne, N.A. ‘My Life’, Midsummer Books, 1996). These were Norman de Bruyne's feelings when he returned from the de Havilland works in Hatfield, on 9th April 1936, with a cheque for £1000 and a consultancy to research into reinforced phenolformaldehyde resins for use in propeller manufacture. This decision by de Havilland turned out to be one of considerable importance as it led directly to the acceptance and use of structural adhesive bonding in many, if not all, aircraft from the mid-1940s to the present day.

Background Sharing of data about variation and the associated phenotypes is a critical need, yet variant information can be arbitrarily complex, making a single standard vocabulary elusive and re-formatting difficult. Complex standards have proven too time-consuming to implement. Results The GEN2PHEN project addressed these difficulties by developing a comprehensive data model for capturing biomedical observations, Observ-OM, and building the VarioML format around it. VarioML pairs a simplified open specification for describing variants, with a toolkit for adapting the specification into one's own research workflow. Straightforward variant data can be captured, federated, and exchanged with no overhead; more complex data can be described, without loss of compatibility. The open specification enables push-button submission to gene variant databases (LSDBs) e.g., the Leiden Open Variation Database, using the Cafe Variome data publishing service, while VarioML bidirectionally transforms data between XML and web-application code formats, opening up new possibilities for open source web applications building on shared data. A Java implementation toolkit makes VarioML easily integrated into biomedical applications. VarioML is designed primarily for LSDB data submission and transfer scenarios, but can also be used as a standard variation data format for JSON and XML document databases and user interface components. Conclusions VarioML is a set of tools and practices improving the availability, quality, and comprehensibility of human variation information. It enables researchers, diagnostic laboratories, and clinics to share that information with ease, clarity, and without ambiguity.

Background A number of antioxidant defences counteract potentially damaging oxidising species within the respiratory tract. Many enzymes, such as the superoxide dismutases and glutathione peroxidases, require essential elements to maintain function. Vitamins A, C and E also have antioxidant properties. It has been suggested that asthmatic patients are deficient in antioxidants. This study assessed levels of serum antioxidants, markers of airways inflammation and resultant oxidative stress burden with increasing severity of asthma. Method This is a case control study comparing patients with severe asthma (BTS steps 4/5) to mild corticosteroids-naive asthmatics and normal healthy controls. Participants were assessed in terms of asthma diagnosis, severity, exhaled breath condensate (EBC) nitrite, fractional exhaled nitric oxide (feNO), spirometry, and serum copper, zinc, selenium, vitamin A and vitamin E measurements. Analyses were conducted using Kruskal-Wallis, one way analysis of variance. Results The severe asthma group was comprised of 30 patients (23 females, mean age 41.4 years [range 19 to 56], mean FEV1 2.2 litres [% predicted 72.2%], mean FEV1/FVC ratio 72.7%, mean daily inhaled corticosteroid equivalent to 2,390 µg BDP, with 17/30 [57%] on maintenance oral corticosteroids). Fifteen mild and corticosteroid naive patients were recruited (9 females, mean age 34.6 years [range 19–57], mean FEV1 3.48l [% predicted 100.5%], FEV1/FVC ratio 82.2%). All 15 were treated with salbutamol only. The control group was comprised of 15 patients (12 females, mean age 37.6 years [range 25–52], mean FEV1 3.53 [%predicted 111.7%], and FEV1/FVC ratio 81.9%). FeNO increased significantly with increasing severity (p = 0.001), but EBC nitrite did not (p = 0.9). Vitamin A and E levels increased significantly with increased disease severity (p = 0.04 and 0.0008 respectively). There was no significant difference between groups with copper (p = 0.98), zinc (p = 0.8) or selenium (p = 0.9). Conclusion We observed no evidence of deficiency in the serum minerals or vitamins in the severe asthmatics with increased FeNO but not EBC nitrite. We conclude that impaired oxidative stress defences in severe asthma may be driven by factors other than vitamin or mineral deficiency.

Introduction and objectives Optimal utilisation of critical care resources requires timely discharge of patients from critical care to appropriate wards. This represents a challenging and high risk transition. Local audits revealed that a few multimorbid patients with difficult respiratory weans accounted for 30% of critical care bed days. A weekly ventilation multidisciplinary team (VMDT) meeting combining respiratory and critical care expertise was established at a 692-bed hospital to improve management and resource use for this patient group. The effect was compared to a 2 nd hospital within the same trust without VMDT. Method A retrospective comparison of 6 month periods before (period 1: 1/10/07–31/3/08) and after (period 2: 1/10/12–31/3/13) introducing VMDT was carried out using data collected for Intensive Care National Audit and Research Centre. The same data was collected for a sister hospital, belonging to the same trust, without VMDT. The numbers of discharges to a respiratory ward with non- invasive ventilation (NIV) facilities were compared with Chi-Square test. The numbers of level 1 critical care bed days were compared with T test. Results In period 1, hospital 1 discharged 458 patients from critical care and hospital 2 discharged 456. In period 2 these figures were 494 (p = 0.30) and 495 (p = 0.84) respectively. There was no change to background parameters. The number of discharges to respiratory ward with NIV facilities increased significantly in hospital 1 (36 to 65, p = 0,011) after VMDT. Whilst the number of patients discharged to respiratory ward increased in hospital 2 this was not significant (9 to 19, p = 0.13). The number of level 1 bed days fell significantly (208 to 18, p Conclusion Introduction of VMDT increased the proportion of respiratory patients discharged to a respiratory ward from critical care and reduced level one bed days in hospital 1 by expediting the discharge of complex respiratory wean patients thereby increasing patient flow and liberating critical care resources. The same reduction was not observed in the hospital 2 suggesting this effect was not due to trust wide changes in critical care practice.

Introduction and objectives Factors predicting the likelihood of failure of NIV, i.e. requirement of intubation or death, have been well documented with low pH shown to be the most important factor. Factors affecting the duration of NIV required in those patients who receive ward base treatment without the need for intubation have not been established. This study aimed to identify factors which influence the duration of NIV required in acute hypercapnic respiratory failure. Methods A retrospective analysis of 123 consecutive episodes of acute hypercapnic respiratory failure requiring NIV between June 2013 and June 2014 was carried out. Correlation between duration of NIV treatment and a number of variables, namely admission creatinine, pH, worst arterial carbon dioxide level (CO 2 ) and presence and severity of chronic kidney disease (CKD) was assessed by simple linear regression. Results There was a statistically significant regression coefficient between worst observed CO 2 and the duration of NIV (fitted equation: NIV Duration = 4.281 + 14.357 × Worst CO 2 , p = 0.019). The plotted linear relationship showed an increase in duration of NIV treatment of 14.35 h for every 1 kPa increase in CO 2 above 6 kPa. The admission creatinine and severity of CKD did not significantly alter the duration of NIV required. The presence of acute kidney injury was also not significant. The pH value did not significantly alter the duration of NIV treatment. Conclusion This survey shows that the level of CO 2 influences the duration of acute NIV required, in that for every 1 kPa rise in CO 2 , the duration of acute NIV treatment rises by 14.35 h. The other studied variables do not correlate with treatment duration.

Introduction and objectives The benefits of continuous positive airways pressure in the treatment of obstructive sleep apnoea syndrome have been well established. Despite this, CPAP adherence remains a significant issue resulting in many patients not receiving adequate treatment. A number of variables have been suggested as contributing to non-concordance, however study results have been inconsistent. Studies assessing long term concordance, suggest severity of OSAS and sleepiness to be good predictors of this. This scientific survey looked at the influence of co-morbidity and the severity of OSAS as represented by apnoea hypopnoea index (AHI) at diagnosis on the usage and concordance with CPAP. Methods Data from 230 patients completing annual follow up after initiation of CPAP by 31 st December 2014 was collected retrospectively. The presence and severity of co-morbidity was assessed by the Adult Co-morbidity Evaluation- 27 (ACE-27) score. CPAP usage per day was averaged over the preceding year. The association between usage and initial AHI (data available for 207 patients) was analysed by linear regression. The association between usage and ACE-27 score was analysed by ANOVA. Results The regression coefficient for initial AHI against CPAP usage shows a statistically significant effect ([p = 0.00126] fitted equation: concordance = 4.161 + 0.024 × AHI). There was no significant difference in CPAP usage between different ACE-27 groups. Further analysis of individual co-morbidities revealed significance in four categories; cardiac arrhythmia (p = 0.031), coronary artery disease (p = 0.006), congestive heart failure (p = 0.045) and malignancy (p = 0.001). Conclusion AHI at diagnosis remains a strong determinant of CPAP concordance at 1 year. Severity of co-morbidity cannot be conclusively demonstrated to influence usage however further studies into overall and specific co-morbidities are warranted.

This chapter falls, quite logically, into four distinct sections. The first deals with wooden aircraft from the first heavier-than-air machines through to the mid-1940s. Here animal-based adhesives were a natural choice for bonding wood; furniture makers had been using them for centuries. This section ends with the success story of the de Havilland Mosquito; a wooden airplane held together with a urea-formaldehyde (U/F) glue — one of the first truly synthetic adhesives. The second section traces the use of structural adhesives, first, in all-metal aircraft and then in aeroplanes having complex structures manufactured from both metal and composite components; indicating why the industry persevered with adhesive bonding when, perhaps, mechanical joining appeared to be more logical. The third section devotes itself to an in-depth examination of the structural bonded joint: the substrates, primers and the structural adhesives themselves. In this last area, a full appraisal is made of a typical range of commercially available structural adhesives. This examines their role in the bonded structure, the formats in which they are supplied, the basic chemistries employed with their relative cure cycles and generic formulations. This is augmented with key properties of selected adhesives from this range and a typical qualification package generated for one adhesive to meet typical aerospace specifications. The section concludes with brief outlines as to how the adhesives are made, how they are applied to the substrates to be bonded and the methods by which they can be cured. The fourth and final section is, in essence, a series of case studies showing how various sections of the industry use structural adhesives in modern aircrafts. This deals with each of the relevant adhesive chemistries in turn and covers both military and commercial engines and aeroplanes, helicopters, bonded components within the airframe, satellites and missiles.

Considering the importance of the ox warbles as pests of cattle, it is odd that so little is known by entomologists regarding their distribution and relative abundance. It is well known that H. lineata is widely distributed in this country, but the fact that there are areas where this species is almost or entirely absent has not been recognized.

Identification of sequence variants robustly associated with predisposition to diabetic kidney disease (DKD) has the potential to provide insights into the pathophysiological mechanisms responsible. We conducted a genome-wide association study (GWAS) of DKD in type 2 diabetes (T2D) using eight complementary dichotomous and quantitative DKD phenotypes: the principal dichotomous analysis involved 5,717 T2D subjects, 3,345 with DKD. Promising association signals were evaluated in up to 26,827 subjects with T2D (12,710 with DKD). A combined T1D+T2D GWAS was performed using complementary data available for subjects with T1D, which, with replication samples, involved up to 40,340 subjects with diabetes (18,582 with DKD). Analysis of specific DKD phenotypes identified a novel signal near GABRR1 (rs9942471, P = 4.5 × 10-8) associated with microalbuminuria in European T2D case subjects. However, no replication of this signal was observed in Asian subjects with T2D or in the equivalent T1D analysis. There was only limited support, in this substantially enlarged analysis, for association at previously reported DKD signals, except for those at UMOD and PRKAG2, both associated with estimated glomerular filtration rate. We conclude that, despite challenges in addressing phenotypic heterogeneity, access to increased sample sizes will continue to provide more robust inference regarding risk variant discovery for DKD. ASTAR (Agency for Sci., Tech. and Research, S’pore) NMRC (Natl Medical Research Council, S’pore)

The American Mosquito Control Association has come forth with another important aid to medical men, engineers and public health workers in general. This AMCA Bulletin No. 2 and its companion Bulletin No. 1, The Use of Aircraft in the Control of Mosquitoes, will help all those engaged in public health work to answer many perplexing problems connected with the selection and use of equipment and insecticides. These contributions are not limited in usefulness to mosquito control but are applicable to many other problems in the field of public health. The discussion of the characteristics and principles of dispersion of insecticides and the classification of sprays and dusts by particle size clears up many of the misconceptions, and should tend to check the present loose usages of terms. Equipment of various types for dispersing insecticides, including hand atomizers and dusters, blower equipment, aerosol devices and hydraulic pumps are described and illustrated.