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Background: Microaspiration is often considered a potential cause of cough. The aim of this study was to investigate the relationship between microaspiration, the degree and type of gastroesophageal reflux, and the frequency of coughing in patients with chronic cough.Methods: One hundred patients with chronic cough (mean [± SD] age, 55.8 years [± 11.0 years]; 65 women) and 32 healthy volunteers (median age, 43.5 years [interquartile range (IQR), 30-50.8 years]; 16 women) were recruited. Patients with chronic cough performed 24-h objective cough frequency with simultaneous esophageal impedance/pH monitoring and measurement of pepsin concentrations in sputum and BAL. Twelve healthy volunteers underwent bronchoscopy/BAL, and 20 underwent impedance/pH monitoring.Results: Patients with chronic cough had significantly more reflux episodes than healthy volunteers (median, 63.5 reflux episodes [IQR, 52.5-80.0] vs 59.0 [IQR, 41.8-66.0]; P = .03), although the absolute difference was small, and there was no difference in numbers of events extending into the proximal esophagus (median, 17.2% [IQR, 8.0%-26.0%] vs 20.3% [IQR, 5.1%-32.1%]; P = .36). BAL pepsin levels were also similar in chronic cough to control subjects (median, 18.2 ng/mL [range, 0-56.4 ng/mL] vs 9.25 ng/mL [range, 0-46.9 ng/mL]; P = .27). Sputum but not BAL pepsin weakly correlated with the number of proximally occurring reflux events (r = 0.33, P = .045) but was inversely related to cough frequency (r = −0.52, P = .04). Sputum pepsin was, therefore, best predicted by combining the opposing influences of cough and proximal reflux (r = 0.50, P = .004).Conclusions: Proximal gastroesophageal reflux and microaspiration into the airways have limited roles in provoking chronic cough. Indeed, coughing appears to be protective, reducing pepsin concentration in the larger airways of patients with chronic cough. [ABSTRACT FROM AUTHOR]

Sentinel Lymph Node Biopsy has become the standard surgical procedure for the sampling of axillary lymph nodes in breast cancer. Intra-operative node assessment of these nodes would allow definitive axillary surgery to take place immediately with associated benefits for patient management. Our experimental study aims to demonstrate that a Raman spectroscopy probe system could overcome many of the disadvantages of current intra-operative methods. 59 axillary lymph nodes, 43 negative and 16 positive from 58 patients undergoing breast surgery at our district general hospital were mapped using Raman micro-spectroscopy. These maps were then used to model the effect of using a Raman spectroscopic probe by selecting 5 and 10 probe points across the mapped images and evaluating the impact on disease detection. Results demonstrated sensitivities of up to 81% and specificities of up to 97% when differentiating between positive and negative lymph nodes, dependent on the number of probe points included. The results would have concurred with histopathology assessment in 89% and 91% of cases in the 5 and 10 point models respectively. Using Raman spectroscopy in this way could allow lymph node assessment within a time-frame suitable for intra-operative use. [ABSTRACT FROM AUTHOR]

Background Prosthesis-patient mismatch (PPM) is characterised by the effects of inadequate prosthesis size relative to body surface area (BSA). It is uncertain whether PPM after mitral valve replacement impacts upon clinical outcome. This was examined in an Australian population. Methods From 2001 to 2009, 1006 mechanical and bioprosthetic mitral valves were implanted across 10 institutions. Effective orifice areas (EOA) were obtained from a literature review of in vivo echocardiographic data. Absent, moderate and severe PPM was defined as an indexed EOA (EOA/BSA) of >1.20cm(2)/m(2), >0.90 to <=1.20cm(2)/m(2) and <=0.9cm(2)/m(2), respectively. Early outcomes and 7-year survival were compared between these three groups. Results PPM was absent in 34%, moderate in 53% and severe in 13% of patients. Patients with PPM were more likely to be male (42% vs 52% vs 62%, p<0.0001) and obese (14% vs 20% vs 56%, p<0.0001). Postoperatively there was similar 30-day mortality (5% vs 5% vs 6%, p=0.83) and early any mortality/morbidity (24% vs 27% vs 29%, p=0.40). Seven-year survival was similar between groups (72±4.1% vs 76±3.2% vs 69±10.3%, p=0.76). PPM did not predict adverse events after logistic and Cox regressions with and without propensity score adjustment. Subgroup analyses of those with isolated mitral valve surgery, patients with preoperative congestive heart failure and non-obese patients failed to show an association between PPM and mid-term mortality. Conclusions Overall, PPM was not associated with poorer early outcomes or mid-term survival. Oversizing valves may be technically hazardous and do not yield superior outcomes. Easier implantation by appropriate sizing appears justified. [ABSTRACT FROM AUTHOR]

CONTEXT: Yoga is increasing in popularity, with an estimated 15 million practitioners in the United States, yet there is a dearth of empirical data addressing the holistic benefits of yoga. OBJECTIVE: To compare the physical and mental benefits of an exercise-based yoga practice to that of a more comprehensive yoga practice (one with an ethical/spiritual component). DESIGN: Students with mild to moderate depression, anxiety, or stress and who agreed to participate were assigned to one of three groups: integrated yoga, yoga as exercise, control. PARTICIPANTS: A total of 81 undergraduate students 18 years and older at a university in the southeastern United States participated in the study. MAIN OUTCOME MEASURES: Depression, anxiety, stress, hope, and salivary cortisol. RESULTS: Over time, participants in both the integrated and exercise yoga groups experienced decreased depression and stress, an increased sense of hopefulness, and increased flexibility compared to the control group. However, only the integrated yoga group experienced decreased anxiety-related symptoms and decreased salivary cortisol from the beginning to the end of the study. CONCLUSIONS: Yoga, practiced in a more integrated form, ie, with an ethical and spiritual component, may provide additional benefits over yoga practiced as an exercise regimen. [ABSTRACT FROM AUTHOR]

Background: The treatment of patients with advanced or recurrent endometrial cancer remains problematic, because chemotherapy and hormonal therapy have yielded low response rates and limited progression-free survival. Because the combination of gemcitabine and cisplatin demonstrated synergism in preclinical studies, the authors attempted to determine the efficacy and toxicity of this combination in women with advanced or recurrent endometrial cancer.Methods: A prospective, single-institution, phase 2 study was performed in women with histologically documented International Federation of Gynecology and Obstetrics (FIGO) stage III or IV or recurrent endometrioid endometrial carcinoma. Gemcitabine at a dose of 1000 mg/m2 and cisplatin at a dose of 35 mg/m2 were administered intravenously on Days 1 and 8 of each 21-day cycle; because of myelosuppression, the protocol was revised to gemcitabine at a dose of 900 mg/m2 and cisplatin at a dose of 30 mg/m2. Patients were treated until disease progression, unacceptable toxicity, or complete response.Results: A total of 21 patients were enrolled and received a median of 5 courses of therapy (range, 1-9 courses). The median age at the time of study enrollment was 62 years (range, 41-75 years). Of 20 evaluable patients, 2 (10%) had a confirmed complete response, 8 (40%) had a partial response, 6 (30%) had stable disease, and 4 (20%) developed progressive disease. The median progression-free survival was 7.5 months (range, 2.3-33.6 months), and the median overall survival was 18.2 months (range, 2.5-49.4 months). The development of toxicity mandated dose reductions in 16 of 20 patients (80%). Eighteen patients experienced grade 3 or 4 toxic effects (graded according to the Common Terminology Criteria for Adverse Events [version 3.0]).Conclusions: The objective response rate of 50% noted with gemcitabine and cisplatin combination chemotherapy merits the further development of this regimen in women with advanced or recurrent endometrial cancer. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether HLA-B27 misfolding and the unfolded protein response (UPR) result in cytokine dysregulation and whether this is associated with Th1 and/or Th17 activation in HLA-B27/human beta(2)-microglobulin (Hubeta(2)m)-transgenic rats, an animal model of spondylarthritis. METHODS: Cytokine expression in lipopolysaccharide (LPS)-stimulated macrophages was analyzed in the presence and absence of a UPR induced by chemical agents or by HLA-B27 up-regulation. Cytokine expression in colon tissue and in cells purified from the lamina propria was determined by real-time reverse transcription-polymerase chain reaction analysis, and differences in Th1 and Th17 CD4+ T cell populations were quantified after intracellular cytokine staining. RESULTS: Interleukin-23 (IL-23) was found to be synergistically up-regulated by LPS in macrophages undergoing a UPR induced by pharmacologic agents or by HLA-B27 misfolding. IL-23 was also increased in the colon tissue from B27/Hubeta(2)m-transgenic rats concurrently with the development of intestinal inflammation, and IL-17, a downstream target of IL-23, exhibited robust up-regulation in a similar temporal pattern. IL-23 and IL-17 transcripts were localized to CD11+ antigen-presenting cells and CD4+ T cells, respectively, from the colonic lamina propria. Colitis was associated with a 6-fold expansion of CD4+ IL-17-expressing T cells. CONCLUSION: The IL-23/IL-17 axis is strongly activated in the colon of B27/Hubeta(2)m-transgenic rats with spondylarthritis-like disease. HLA-B27 misfolding and UPR activation in macrophages can result in enhanced induction of the pro-Th17 cytokine IL-23. These results suggest a possible link between HLA-B27 misfolding and immune dysregulation in this animal model, with implications for human disease. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to evaluate the impact of increasing the magnesium (Mg(2+)) supplementation in the pre- and posthydration of patients receiving cisplatin plus radiation (CisXRT) to prevent chemotherapy-induced hypomagnesemia (CIH) events.Materials and Methods: The study was conducted on newly diagnosed cervical cancer patients receiving CisXRT. The first prospective intervention to prevent CIH was to increase the pre- and posthydration Mg(2+) from 1 to 2 g. After completion of the first intervention, the analysis demonstrated the persistent occurrence of CIH on cycle 3, and later, a second intervention was implemented to increase Mg(2+) to 3 g in the pre- and posthydration. Patients that failed to complete at least five cycles or received cisplatin in combination with another chemotherapy regimen were excluded from the study. Baseline group included 70 patients that had received CisXRT prior to any changes in magnesium supplementation.Results: There were 62.8% (44/70) and 32.6% (22/70) of patients with episodes of CIH in the baseline and first intervention groups, respectively (P = 0.007). In the second intervention group, a 49.6% decrease in the total number of episodes compared to control group was observed. Patients in the second intervention group showed a 100% improvement incidence of persistent CIH over the two other cohorts (P = 0.001).Conclusions: The increase of Mg(2+) to 2 g for the initial two cycles and then to 3 g with the third cycle of CisXRT therapy prevented episodes of CIH and decreased associated treatment delays. [ABSTRACT FROM AUTHOR]

Tumour necrosis factor (TNF)-alpha inhibitors are widely used agents in the treatment of a variety of inflammatory and granulomatous diseases. It has long been appreciated that these agents confer an increased risk of tuberculosis; however, more recently it has been recognized that patients being treated with TNFalpha inhibitors are also at significant risk for infection with the endemic fungi, in particular Histoplasma capsulatum, and when infected, to develop severe disseminated infection. Patients often present in an atypical manner and the symptoms of the fungal infection can be mistaken for those of the underlying disease. Thus, delay in diagnosis and treatment is common, and mortality has been high. In an attempt to increase awareness of this problem, the US FDA issued a 'black box' warning for clinicians in September 2008 to alert providers of the risks of endemic fungal infections in patients treated with TNFalpha inhibitors. The management of patients who develop endemic fungal infection while receiving TNFalpha inhibitor therapy should include discontinuation of the TNFalpha inhibitor and early use of antifungal agents including polyenes and/or azoles according to the Infectious Diseases Society of America guidelines for treatment of these infections in immunocompromised hosts. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The principal objective of this study was to characterize how nurses and pharmacists at a poison control center (PCC) determine the likelihood of caller adherence to a health care facility referral. METHODS: A focus group was conducted with 6 nurses and 4 pharmacists from a regional PCC. Content analysis was used to determine themes within the discussion. All participants were certified as specialists in poison information (SPIs). RESULTS: Four themes were identified: (1) SPIs' generation of informal 'likelihood-of-adherence' assessments as to whether a caller will follow the recommendation to go to a health care facility, (2) SPI communication strategies used to promote adherence, (3) behavior of SPIs during periods of high call volume, and (4) communication training for PCC staff members. DISCUSSION: This pilot study provides insights in SPIs' current assessment and communication, particularly those related to promoting caller adherence to recommendations. [ABSTRACT FROM AUTHOR]

Invasive fungal infections (IFIs) cause significant morbidity, mortality, and increased cost of care in patients with hematological malignancies, prolonged (i.e. < 7-10 days) treatment induced neutropenia, and other disease states causing underlying immunosuppression. One strategy often used to combat the development of invasive infections is the use of antifungal agents as prophylaxis in at risk patients. Posaconazole is an oral triazole with a useful spectrum of activity against many fungal pathogens of concern in patients at risk for the development of IFIs. Posaconazole is only available in oral formulation and therapeutic drug monitoring may provide value due to variable absorption and serum concentrations. Clinical efficacy and pharmacoeconomic data have demonstrated the utility of posaconazole in the treatment of oropharyngeal candidiasis and for prophylaxis in patients at risk for development of IFIs. Several organizations or expert groups involved in developing guidelines for the management of IFIs recommend posaconazole anti-fungal prophylaxis in patients with AML or MDS and chemotherapy induced neutropenia or significant GVHD. In addition, nonrandomized studies (largely of salvage therapy) and case series suggest that posaconazole may be effective as treatment for invasive aspergillosis, zygomycosis, and coccidiomycosis. Further, small case series or individual case reports suggest activity against other less commonly encountered filamentous fungi and Histoplasma. [ABSTRACT FROM AUTHOR]

The perceived warmth and competence of men and women who varied in number of hours worked and childcare responsibilities were assessed using either subjective trait ratings or objective behavioral frequency estimates. Trait ratings were determined by number of hours worked, and not target gender. Estimates of behavioral frequency indicated that women and men were viewed as equally likely to engage in work related competence behaviors, but that women were expected to perform more warmth related behaviors, and their childcare responsibilities remained more constant regardless of hours worked. Thus although trait perceptions are driven by individuating information regarding time distribution to work and home, gender affects judgments of who performs childcare related tasks such that women continue to be viewed as more likely to deal with these. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether macrophages, a type of cell implicated in the pathogenesis of ankylosing spondylitis (AS), exhibit a characteristic gene expression pattern. METHODS: Macrophages were derived from the peripheral blood of 8 AS patients (median disease duration 13 years [range <1-43 years]) and 9 healthy control subjects over 7 days with the use of granulocyte-macrophage colony-stimulating factor. Cells were stimulated for 24 hours with interferon-gamma (IFNgamma; 100 units/ml), were left untreated for 24 hours, or were treated for 3 hours with lipopolysaccharide (LPS; 10 ng/ml). RNA was isolated and examined by microarray and real-time quantitative reverse transcription-polymerase chain reaction analysis. RESULTS: Microarray analysis revealed 198 probe sets detecting the differential expression of 141 unique genes in untreated macrophages from AS patients compared with healthy controls. Clustering and principal components analysis clearly distinguished AS patients and controls. Of the differentially expressed genes, 78 (55%) were IFN-regulated, and their relative expression indicated a 'reverse' IFN signature in AS patient macrophages, where IFNgamma-up-regulated genes were underexpressed and down-regulated genes were overexpressed. Treatment of macrophages with exogenous IFNgamma normalized the expression of these genes between patients and controls. In addition, the messenger RNA encoded by the IFNgamma gene was approximately 2-fold lower in AS patient macrophages at baseline (P = 0.004) and was poorly responsive to LPS (P = 0.018), as compared with healthy controls. CONCLUSIONS: Our findings reveal consistent differences in gene expression in macrophages from AS patients, with evidence of a striking 'reverse' IFN signature. Together with poor expression and responsiveness of the IFNgamma gene, these results suggest that there may be a relative defect in IFNgamma gene regulation, with autocrine consequences and implications for disease pathogenesis. [ABSTRACT FROM AUTHOR]

Rationale: A focus on distinctive collections of symptoms may be more informative of the probability of respiratory disease than individual and possibly transient phenotypes. However, such collections or components of overall symptomatology need to be valid, and their relationship established with the known risk factors and physiologic measures.Objectives: To analyze detailed parentally reported respiratory symptoms by principal components analysis and derive symptom components; to examine the relationship of such components with measures of lung physiology and atopy.Methods: An unselected, population-based birth cohort (n = 946).Measurements and Main Results: Interviewer-administered questionnaires, lung function (specific airway resistance [sRaw]), airway reactivity (dry air challenge), and atopic status were obtained at ages 3 and 5 years; principal components analysis and multivariate analysis of variance were used to analyze the data. The four-component solution (wheeze, cough, colds, chronic symptoms) explained 53.2% of the variance in symptoms at age 3, and the five-component solution (wheeze, wheeze with irritants, wheeze with allergens, cough, chest congestion) explained 49.8% of variance at age 5. The multivariate analysis revealed novel relationships between symptoms, risk factors for asthma, and measures of lung function. At age 3, sRaw and the interaction between maternal asthma and child's atopy were not only related to wheeze but also independently to the cough component. At age 5, overall wheeze and allergic wheeze were related to lung function and airway reactivity; child's atopy was only related to symptoms when considered as a continuous trait.Conclusions: Our analysis supports the need to move beyond the presence or absence of individual symptoms. Syndromes of coexisting symptoms more likely reflect underlying pathophysiologic processes. [ABSTRACT FROM AUTHOR]

Online courses are an integral part of nursing education programs. The responsibility for developing and teaching asynchronous online courses can be challenging, especially for neophyte educators. Two experienced educators discuss strategies for developing and enhancing selected aspects of asynchronous online courses. Practical, evidence-based aspects of designing, conducting, and evaluating vieb-based courses are presented. Examples from courses using WebCT are shown. [ABSTRACT FROM AUTHOR]

There has been little research into the impact of Juvenile Huntington's Disease (JHD) on the family, and the issues facing this group are poorly understood. The study reported here is part of larger project that aimed to address this. Ten semi-structured interviews with the main carer were carried out, and were analysed using Interpretative Phenomenological Analysis (IPA). This article reports three themes arising from the study relating to the psychosocial impact of JHD on the family: (1) dealing with something so different; (2) lack of understanding (3) isolation. This information is useful in developing appropriate services for families affected by JHD, as well as being of relevance to other childhood conditions. Copyright © 2008 SAGE Publications [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study to examine adjustment and its relationship with stoma acceptance and social interaction, and the link between stoma care selfefficacy and adjustment in the presence of acceptance and social interactions. Background. There have been significant advances in stoma appliances and an increase in nurses specialising in stoma care. Despite this, a large proportion of patients continue to experience adjustment problems, which suggests that improvements in the management of the stoma are by themselves not enough to enhance psychosocial functioning. Illness acceptance and interpersonal relationships are widely reported as correlates of adjustment to chronic illness, but these have not been specifically examined in patients with a colostomy. Evidence of their association could offer stoma therapists alternative ways of aiding adjustment. Method. Between 2000 and 2002, 51 patients with colostomies provided demographic and clinical data and completed validated questionnaires to measure acceptance of the stoma, relationship with others and stoma care self-efficacy 6 months after surgery. Findings. Multiple regression analysis showed that stoma care self-efficacy, stoma acceptance, interpersonal relationship and location of the stoma were strongly associated with adjustment. The model explained 77% of the variance. Stoma-care self-efficacy accounted for 57.5%, the psychosocial variables 13% and location of the stoma 4.6%. The addition of gender, which was not statistically significant (P > 0.05), explained a further 1.9% of the variance. Conclusion. Addressing psychosocial concerns should become part of the care routinely given to stoma patients. We recommend more emphasis on dispelling negative thoughts and encouraging social interactions. [ABSTRACT FROM AUTHOR]

Concern about excessive alcohol consumption among young men demands an understanding of why some young men drink excessively while others do not. The aim of this study was to identify how young men's patterns of alcohol consumption are related to their beliefs about masculinity, and the importance of drinking to their masculine identities. Thirty-one individual interviews and five group discussions were conducted with an ethnically- and socioeconomically-diverse sample of men aged 18-21 living in London, England. Analysis revealed a variety of associations between masculinity and alcohol consumption. Some men believed that alcohol consumption is a marker of masculinity and behaved accordingly. Other men emphasised the importance of other behaviours to masculine identity. There was also evidence that men traded drinking competence with competence in other behavioural domains. The links between masculinity and health-related social behaviours such as drinking are not simple. Implications for health education and health promotion are discussed. [ABSTRACT FROM AUTHOR]

This paper presents an in-depth, idiographic study illustrating how chronic benign low back pain may have a serious debilitating impact on the sufferer's sense of self. Semi-structured interviews were conducted with six patients and the resultant transcripts subjected to interpretative phenomenological analysis. The analysis points to the powerful ways in which chronic pain has negative impact on patients' self and identity. This impact is made worse in the public arena. Some of the participants describe how the ensuing derogatory self image also seems to lead to their directing negative affect towards other people. The results section gives a detailed account of these processes at work. The results are then considered in relation to relevant constructs in the extant literature, including work on illness and identity, shame and acceptance. [ABSTRACT FROM AUTHOR]

Rationale: Human lung transplantation is a therapeutic option for selected patients with advanced cardiopulmonary disease, but long-term survival is limited by chronic rejection. Persistent acute rejection and gastric aspiration have been implicated as risk factors but there is little or no evidence to date that they are associated.Objectives: We have tested the hypothesis that pepsin, a marker of gastric aspiration, is present in lung transplant recipients, and that high levels are associated with biopsy-diagnosed acute rejection and/or bronchiolitis obliterans syndrome.Methods: Levels of bronchoalveolar lavage (BAL) pepsin were measured by ELISA in 36 lung transplant recipients, 4 normal volunteers, and 17 subjects with unexplained chronic cough.Measurements and Main Results: Our primary finding was that, compared with control subjects, BAL pepsin levels were elevated in stable lung transplant recipients, subjects with acute rejection, and subjects with bronchiolitis obliterans syndrome. Our secondary finding was that the highest levels were found in recipients with acute vascular rejection grade > or = A2 (median, 11.2; range, 5.4 - 51.7 ng/ml; normal median, 1.1; range, 0-2.3 ng/ml; p = 0.004).Conclusions: We have shown that elevated levels of pepsin, a biomarker of gastric aspiration, are consistently identified in the BAL of lung allografts. The highest levels were seen in patients with > or = grade A2 acute rejection. This provides further evidence supporting the possible role of aspiration in the development of overall allograft injury. [ABSTRACT FROM AUTHOR]

There has been little research into the psychosocial impact of Juvenile Huntington's Disease on the child and family. This study investigates the social and health care needs of those affected by Juvenile Huntington's Disease. Ten semi-structured interviews with carers were analysed using the qualitative methodology interpretative phenomenological analysis. This article reports three themes on the social support that families received. The first theme describes how parents perceived the support that they received from family and friends. The second and third themes describe how parents perceived helpful and unhelpful experiences of professional support. This corresponds to the view that social support is a 'double-edged sword', which can both ameliorate the effects of, and be a source of, stress. This information should be useful to those supporting the family of a child with a chronic or terminal illness. [ABSTRACT FROM AUTHOR]

ABSTRACT: Penetrating neck injuries are uncommon in children, and when they do occur, they can be a challenge to manage. Injuries can be cardiovascular, aerodigestive, and neurovascular. In the past, injuries were explored surgically to evaluate the extent of the injury; studies are now showing that observation and less invasive studies have a positive outcome for the patient. Immediate surgical intervention remains mandatory for the clinically unstable patient, whereas stable patients have studies done that pertain to their signs and symptoms, thus having a conservative nonoperative approach to care. [ABSTRACT FROM AUTHOR]

The study of young men's health-related behaviour offers an opportunity to examine the links between masculine identity and social behaviour. This article presents a case study of a 19-year-old man living in London, who describes himself as different to his peers on several important dimensions, including his engagement in health-related behaviours. The case study demonstrates the importance of health-related social behaviours such as drinking, drug use, physical activity, sport and sexual behaviour in the construction of a masculine identity. This case study also reveals that the way in which men position themselves in relation to different discourses of masculinity can have important implications not only for their masculine identities, but also for their health-related behaviour. [ABSTRACT FROM AUTHOR]