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An overview from the past and an outlook for the future of fundamentallaser-plasma interactions research enabled by emerging laser systems.

David Gillespie,1,2 Nick Francis,3 Haroon Ahmed,4 Kerenza Hood,2 Carl Llor,5 Patrick White,6 Emma Thomas-Jones,2 Helen Stanton,2 Bernadette Sewell,7 Rhiannon Phillips,8 Gurudutt Naik,4 Hasse Melbye,9 Rachel Lowe,2 Nigel Kirby,2 Ann Cochrane,10 Janine Bates,2 Mohammed Fasihul Alam,11 Christopher Butler1 1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UK; 2Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, Wales, UK; 3Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK; 4Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, UK; 5University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain; 6School of Population Health and Environmental Sciences, Kings College London, London, England, UK; 7Swansea Centre for Health Economics, Swansea University, Swansea, Wales, UK; 8Cardiff School of Sport & Health Science, Cardiff Metropolitan University, Cardiff, Wales, UK; 9General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway; 10York Trials Unit, Department of Health Sciences, University of York, York, England, UK; 11Department of Public Health, College of Health Sciences, QU-Health, Qatar University, Doha, QatarCorrespondence: David Gillespie, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, England, OX2 6GG, UK, Email david.gillespie@phc.ox.ac.ukBackground: It has been demonstrated that antibiotic prescribing for Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD) can be safely reduced in primary care when general practitioners have access to C-reactive protein (CRP) rapid testing.Aim: To investigate the factors associated with post-consultation COPD health status in patients presenting with AECOPD in this setting.Design and Setting: A cohort study of patients enrolled in a randomised controlled trial. Patients aged 40+ years with a clinical diagnosis of COPD who presented in primary care across England and Wales with an AECOPD were included.Methods: Participants were contacted for follow-up at one- and two-weeks by phone and attended the practice four weeks after the index consultation. The outcome of interest was the Clinical COPD Questionnaire (CCQ) score. Multivariable multilevel linear regression models fitted to examine the factors associated with COPD health status in the four-weeks following consultation for an AECOPD.Results: A total of 649 patients were included, with 1947 CCQ total scores analysed. Post-consultation CCQ total scores were significantly higher (worse) in participants with diabetes (adjusted mean difference [AMD]=0.26; 95% confidence interval (CI) 0.08– 0.45), obese patients compared to those with normal body mass index (AMD = 0.25, 95% CI 0.07– 0.43), and those who were prescribed oral antibiotics in the prior 12 months (AMD = 0.26; 95% CI 0.11– 0.41), but only the two latter associations remained after adjusting for other sociodemographic variables.Conclusion: COPD health status was worse in the four weeks following primary care consultation for AECOPD in patients with obesity and those prescribed oral antibiotics in the preceding year.Keywords: chronic obstructive, health status, Primary Health Care, pulmonary disease, symptom exacerbation

Nick A Francis,1 David Gillespie,2 Mandy Wootton,3 Patrick White,4 Janine Bates,2 Jennifer Richards,3 Hasse Melbye,5 Kerenza Hood,2 Christopher C Butler6 1Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK; 2Centre for Trials Research, Cardiff University, Cardiff, Wales, UK; 3Specialist Antimicrobial Chemotherapy Unit, Microbiology Cardiff, Public Health Wales, Cardiff, Wales, UK; 4School of Population Health and Environmental Sciences, King’s College London, London, England, UK; 5Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway; 6Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UKCorrespondence: Nick A FrancisPrimary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UKEmail nick.francis@soton.ac.ukIntroduction: Identifying predictors of bacterial and viral pathogens in sputum from patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) may help direct management.Methods: We used data from a trial evaluating a C-reactive protein (CRP) point of care guided approach to managing COPD exacerbations in primary care. We used regression analyses to identify baseline clinical features, including CRP value in those randomized to testing, associated with bacterial, viral or mixed infections, defined by the presence of bacterial and viral pathogens in sputum, detected by culture or polymerase chain reaction (PCR), respectively.Results: Of 386 participants with baseline sputum samples, 79 (20.5%), 123 (31.9%), and 91 (23.6%) had bacterial, viral/atypical, and mixed bacterial/viral/atypical pathogens identified, respectively. Increasing sputum purulence assessed by color chart was associated with increased odds of finding bacterial and mixed (bacterial and viral/atypical) pathogens in sputum (area under the ROC curve (AUROC) for bacterial pathogens =0.739 (95% CI: 0.670, 0.808)). Elevated CRP was associated with increased odds of finding bacterial pathogens and mixed pathogens but did not significantly increase the AUROC for predicting bacterial pathogens over sputum color alone (AUROC for combination of sputum color and CRP = 0.776 (95% CI: 0.708, 0.843), p for comparison of models = 0.053). We found no association between the presence of sputum pathogens and other clinical or demographic features.Conclusion: Sputum purulence was the best predictor of sputum bacterial pathogens and mixed bacterial viral/atypical pathogens in patients with COPD exacerbations in our study. Elevated CRP was associated with bacterial pathogens but did not add to the predictive value of sputum purulence.Keywords: COPD, exacerbation, infection, bacteria, sputum, primary care

Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the "the relationship between" competent individuals and competent teams. Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members' perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team's collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams' delivery of care for the complex, chronically ill.