Moderate-to-severe asthma in individuals of European ancestry: a genome-wide association study

BACKGROUND

Few genetic studies that focus on moderate-to-severe asthma exist. We aimed to identity novel genetic variants associated with moderate-to-severe asthma, see whether previously identified genetic variants for all types of asthma contribute to moderate-to-severe asthma, and provide novel mechanistic insights using expression analyses in patients with asthma.

METHODS

In this genome-wide association study, we used a two-stage case-control design. In stage 1, we genotyped patient-level data from two UK cohorts (the Genetics of Asthma Severity and Phenotypes [GASP] initiative and the Unbiased BIOmarkers in PREDiction of respiratory disease outcomes [U-BIOPRED] project) and used data from the UK Biobank to collect patient-level genomic data for cases and controls of European ancestry in a 1:5 ratio. Cases were defined as having moderate-to-severe asthma if they were taking appropriate medication or had been diagnosed by a doctor. Controls were defined as not having asthma, rhinitis, eczema, allergy, emphysema, or chronic bronchitis as diagnosed by a doctor. For stage 2, an independent cohort of cases and controls (1:5) was selected from the UK Biobank only, with no overlap with stage 1 samples. In stage 1 we undertook a genome-wide association study of moderate-to-severe asthma, and in stage 2 we followed up independent variants that reached the significance threshold of p less than 1 × 10^-6 in stage 1. We set genome-wide significance at p less than 5 × 10^-8. For novel signals, we investigated their effect on all types of asthma (mild, moderate, and severe). For all signals meeting genome-wide significance, we investigated their effect on gene expression in patients with asthma and controls.

FINDINGS

We included 5135 cases and 25 675 controls for stage 1, and 5414 cases and 21 471 controls for stage 2. We identified 24 genome-wide significant signals of association with moderate-to-severe asthma, including several signals in innate or adaptive immune-response genes. Three novel signals were identified: rs10905284 in GATA3 (coded allele A, odds ratio [OR] 0·90, 95% CI 0·88-0·93; p=1·76 × 10^-10), rs11603634 in the MUC5AC region (coded allele G, OR 1·09, 1·06-1·12; p=2·32 × 10^-8), and rs560026225 near KIAA1109 (coded allele GATT, OR 1·12, 1·08-1·16; p=3·06 × 10^-9). The MUC5AC signal was not associated with asthma when analyses included mild asthma. The rs11603634 G allele was associated with increased expression of MUC5AC mRNA in bronchial epithelial brush samples via proxy SNP rs11602802; (p=2·50 × 10^-5) and MUC5AC mRNA was increased in bronchial epithelial samples from patients with severe asthma (in two independent analyses, p=0·039 and p=0·022).

INTERPRETATION

We found substantial shared genetic architecture between mild and moderate-to-severe asthma. We also report for the first time genetic variants associated with the risk of developing moderate-to-severe asthma that regulate mucin production. Finally, we identify candidate causal genes in these loci and provide increased insight into this difficult to treat population.

FUNDING

Asthma UK, AirPROM, U-BIOPRED, UK Medical Research Council, and Rosetrees Trust.

Real-world outcomes of unrestricted direct-acting antiviral treatment for hepatitis C in Australia: The South Australian statewide experience

In March 2016, the Australian government offered unrestricted access to direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) to the entire population. This included prescription by any medical practitioner in consultation with specialists until sufficient experience was attained. We sought to determine the outcomes and experience over the first twelve months for the entire state of South Australia. We performed a prospective, observational study following outcomes of all treatments associated with the state's four main tertiary centres. A total of 1909 subjects initiating DAA therapy were included, representing an estimated 90% of all treatments in the state. Overall, SVR12 was 80.4% in all subjects intended for treatment and 95.7% in those completing treatment and follow-up. 14.2% were lost to follow-up (LTFU) and did not complete SVR12 testing. LTFU was independently associated with community treatment via remote consultation (OR 1.50, 95% CI 1.04-2.18, P = .03), prison-based treatment (OR 2.02, 95% CI 1.08-3.79, P = .03) and younger age (OR 0.98, 95% CI 0.97-0.99, P = .05). Of the 1534 subjects completing treatment and follow-up, decreased likelihood of SVR12 was associated with genotype 2 (OR 0.23, 95% CI 0.07-0.74, P = .01) and genotype 3 (OR 0.23, 95% CI 0.12-0.43, P ≤ .01). A significant decrease in treatment initiation was observed over the twelve-month period in conjunction with a shift from hospital to community-based treatment. Our findings support the high responses observed in clinical trials; however, a significant gap exists in SVR12 in our real-world cohort due to LTFU. A declining treatment initiation rate and shift to community-based treatment highlight the need to explore additional strategies to identify, treat and follow-up remaining patients in order to achieve elimination targets.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Ethical issues surrounding the transplantation of organs from animals into humans

In this paper, the authors provide an analysis of the ethical issues surrounding the transplantation of organs from animals into humans. The main objections to xenotransplantation relate to safety concerns for the recipient; public health concerns about new viruses spreading from animals to humans; the possibility of animals developing human features; concerns about human dignity; and the fact that animals must be sacrificed so humans can benefit from their organs. Despite these objections, the urgency of the organ shortage situation is such that xenotransplantation may be justified, if further advances make it a realistic possibility.

Efficacy and safety results of patients with HCV genotype 2 or 3 infection treated with ombitasvir/paritaprevir/ritonavir and sofosbuvir with or without ribavirin (QUARTZ II-III)

The efficacy and safety of an investigational combination of ombitasvir/paritaprevir/ritonavir (OBV/PTV/r) plus sofosbuvir (SOF) ± ribavirin (RBV) in patients with HCV genotype 2 or 3 infection with or without cirrhosis was evaluated. Patients with HCV genotype 3 infection without cirrhosis were randomized to receive OBV/PTV/r + SOF ± RBV for 12 weeks; OBV/PTV/r + SOF + RBV was administered to genotype 3-infected patients with cirrhosis for 12 weeks and to genotype 2-infected patients without cirrhosis for either 6 or 8 weeks. Efficacy was assessed by sustained virologic response [HCV RNA <25 IU/mL] 12 weeks post-treatment (SVR12). Safety was assessed in all treated patients. In patients with genotype 3 infection with or without cirrhosis treated with 12 weeks of OBV/PTV/r + SOF ± RBV, the overall SVR12 rate was 98% (50/51), with no virologic failures. Patients with genotype 2 infection treated with OBV/PTV/r + SOF + RBV had SVR12 rates of 90% (9/10) and 44% (4/9) following 8- and 6-week treatment durations, respectively; failure to achieve SVR12 for these patients was due to relapse without baseline or treatment-emergent resistance-associated substitutions. Thus, the investigational combination of OBV/PTV/r with SOF ± RBV was well tolerated and achieved high SVR rates with no virologic failures in patients with genotype 3 infection. Combining direct-acting antivirals with complementary mechanisms of action and different viral targets may be an effective treatment strategy that may allow for shorter durations of therapy.

Expression of polycomb protein BMI-1 maintains the plasticity of basal bronchial epithelial cells

The airway epithelium is altered in respiratory disease and is thought to contribute to disease etiology. A caveat to disease research is that the technique of isolation of bronchial epithelial cells from patients is invasive and cells have a limited lifespan. The aim of this study was to extensively characterize the plasticity of primary human bronchial epithelial cells that have been engineered to delay cell senescence including the ability of these cells to differentiate. Cells were engineered to express BMI‐1 or hTERT using viral vector systems. Cells were characterized at passage (p) early (p5), mid (p10), and late (p15) stage for: BMI‐1, p16, and CK14 protein expression, viability and the ability to differentiate at air–liquid interface (ALI), using a range of techniques including immunohistochemistry (IHC), immunofluorescence (IF), transepithelial electrical resistance (TEER), scanning electron microscopy (SEM), MUC5AC and beta tubulin (BTUB) staining. BMI‐1‐expressing cells maintained elevated levels of the BMI‐1 protein and the epithelial marker CK14 and showed a suppression of p16. BMI‐1‐expressing cells had a viability advantage, differentiated at ALI, and had a normal karyotype. In contrast, hTERT‐expressing cells had a reduced viability, showed limited differentiation, and had an abnormal karyotype. We therefore provide extensive characterization of the plasticity of BMI‐1 expressing cells in the context of the ALI model. These cells retain properties of wild‐type cells and may be useful to characterize respiratory disease mechanisms in vitro over sustained periods.

The challenge of teaching undergraduates evidence-based veterinary medicine

The Royal College of Veterinary Surgeons now lists 'How to evaluate evidence' as a day one competence for newly qualified vets. In this article, representatives from each of the veterinary schools in the UK discuss how the challenge of delivering and assessing the concepts of evidence-based veterinary medicine in a crowded undergraduate curriculum can be met.

A Transcriptome-driven Analysis of Epithelial Brushings and Bronchial Biopsies to Define Asthma Phenotypes in U-BIOPRED

RATIONALE

Asthma is a heterogeneous disease driven by diverse immunologic and inflammatory mechanisms.

OBJECTIVES

Using transcriptomic profiling of airway tissues, we sought to define the molecular phenotypes of severe asthma.

METHODS

The transcriptome derived from bronchial biopsies and epithelial brushings of 107 subjects with moderate to severe asthma were annotated by gene set variation analysis using 42 gene signatures relevant to asthma, inflammation, and immune function. Topological data analysis of clinical and histologic data was performed to derive clusters, and the nearest shrunken centroid algorithm was used for signature refinement.

MEASUREMENTS AND MAIN RESULTS

Nine gene set variation analysis signatures expressed in bronchial biopsies and airway epithelial brushings distinguished two distinct asthma subtypes associated with high expression of T-helper cell type 2 cytokines and lack of corticosteroid response (group 1 and group 3). Group 1 had the highest submucosal eosinophils, as well as high fractional exhaled nitric oxide levels, exacerbation rates, and oral corticosteroid use, whereas group 3 patients showed the highest levels of sputum eosinophils and had a high body mass index. In contrast, group 2 and group 4 patients had an 86% and 64% probability, respectively, of having noneosinophilic inflammation. Using machine learning tools, we describe an inference scheme using the currently available inflammatory biomarkers sputum eosinophilia and fractional exhaled nitric oxide levels, along with oral corticosteroid use, that could predict the subtypes of gene expression within bronchial biopsies and epithelial cells with good sensitivity and specificity.

CONCLUSIONS

This analysis demonstrates the usefulness of a transcriptomics-driven approach to phenotyping that segments patients who may benefit the most from specific agents that target T-helper cell type 2-mediated inflammation and/or corticosteroid insensitivity.

Predicting hospital stay, mortality and readmission in people admitted for hypoglycaemia: prognostic models derivation and validation

AIMS/HYPOTHESIS

Hospital admissions for hypoglycaemia represent a significant burden on individuals with diabetes and have a substantial economic impact on healthcare systems. To date, no prognostic models have been developed to predict outcomes following admission for hypoglycaemia. We aimed to develop and validate prediction models to estimate risk of inpatient death, 24 h discharge and one month readmission in people admitted to hospital for hypoglycaemia.

METHODS

We used the Hospital Episode Statistics database, which includes data on all hospital admission to National Health Service hospital trusts in England, to extract admissions for hypoglycaemia between 2010 and 2014. We developed, internally and temporally validated, and compared two prognostic risk models for each outcome. The first model included age, sex, ethnicity, region, social deprivation and Charlson score ('base' model). In the second model, we added to the 'base' model the 20 most common medical conditions and applied a stepwise backward selection of variables ('disease' model). We used C-index and calibration plots to assess model performance and developed a calculator to estimate probabilities of outcomes according to individual characteristics.

RESULTS

In derivation samples, 296 out of 11,136 admissions resulted in inpatient death, 1789/33,825 in one month readmission and 8396/33,803 in 24 h discharge. Corresponding values for validation samples were: 296/10,976, 1207/22,112 and 5363/22,107. The two models had similar discrimination. In derivation samples, C-indices for the base and disease models, respectively, were: 0.77 (95% CI 0.75, 0.80) and 0.78 (0.75, 0.80) for death, 0.57 (0.56, 0.59) and 0.57 (0.56, 0.58) for one month readmission, and 0.68 (0.67, 0.69) and 0.69 (0.68, 0.69) for 24 h discharge. Corresponding values in validation samples were: 0.74 (0.71, 0.76) and 0.74 (0.72, 0.77), 0.55 (0.54, 0.57) and 0.55 (0.53, 0.56), and 0.66 (0.65, 0.67) and 0.67 (0.66, 0.68). In both derivation and validation samples, calibration plots showed good agreement for the three outcomes. We developed a calculator of probabilities for inpatient death and 24 h discharge given the low performance of one month readmission models.

CONCLUSIONS/INTERPRETATION

This simple and pragmatic tool to predict in-hospital death and 24 h discharge has the potential to reduce mortality and improve discharge in people admitted for hypoglycaemia.

Combined Analysis of Neutrino and Antineutrino Oscillations at T2K

T2K reports its first results in the search for CP violation in neutrino oscillations using appearance and disappearance channels for neutrino- and antineutrino-mode beams. The data include all runs from January 2010 to May 2016 and comprise 7.482×10^{20} protons on target in neutrino mode, which yielded in the far detector 32 e-like and 135  μ-like events, and 7.471×10^{20} protons on target in antineutrino mode, which yielded 4 e-like and 66  μ-like events. Reactor measurements of sin^{2}2θ_{13} have been used as an additional constraint. The one-dimensional confidence interval at 90% for the phase δ_{CP} spans the range (-3.13, -0.39) for normal mass ordering. The CP conservation hypothesis (δ_{CP}=0, π) is excluded at 90% C.L.

See I told you I was taking it! - Attitudes of adolescents with asthma towards a device monitoring their inhaler use: Implications for future design

Adherence to treatment in asthma is often poor, particularly in adolescents and children where the condition is most prevalent. Electronic monitoring devices have shown potential for improving inhaler use, yet little research has considered the attitudes of patients towards these devices. We gave seven adolescents with asthma an electronic monitoring device to use for one month and collected their views on important issues including monitoring and data sharing. Our results showed that participants felt positively about using the data to demonstrate responsibility for their condition to both their parents and medical professionals, but expressed concern for the attention the device's appearance could draw to them and their asthma. This paper considers the positive and negative perceptions of this novel device and provides new insight into the attitudes of adolescents towards inhaler monitoring, as well as future directions for design and development of monitoring devices for asthma and other chronic medical conditions.

What are the pros and cons of electronically monitoring inhaler use in asthma? A multistakeholder perspective

Introduction

Electronic monitoring devices (EMDs) are the optimal method for collecting objective data on inhaler use in asthma. Recent research has investigated the attitudes of patients with asthma towards these devices. However, no research to date has formally considered the opinions of stakeholders and decision-makers in asthma care. These individuals have important clinical requirements that need to be taken into account if EMDs are to be successfully provisioned, making collecting their opinions on the key barriers facing these devices a valuable process.

Methods

Three rounds of surveys in a Delphi format were used to assess the most important pros and cons of EMDs for asthma care in a sample of 31 stakeholders which included healthcare professionals and members of clinical commissioning groups.

Results

The respondents identified 29 pros and 32 cons. Pros that were rated as most important included new visual evidence to aid clinical discussions with a patient and an increase in patient involvement and motivation. The cons that were rated as most important included a need for more clinical evidence of the effectiveness of EMDs, as well as better clarity over who has responsibilities in managing, interpreting and discussing data with a patient.

Conclusions

The research provides a guide for EMD developers by highlighting where these devices may provide the most benefit as well as prioritising the key issues that need addressing if they are to be used effectively in everyday asthma care.

Measurement of Coherent π^{+} Production in Low Energy Neutrino-Carbon Scattering

We report the first measurement of the flux-averaged cross section for charged current coherent π^{+} production on carbon for neutrino energies less than 1.5 GeV, and with a restriction on the final state phase space volume in the T2K near detector, ND280. Comparisons are made with predictions from the Rein-Sehgal coherent production model and the model by Alvarez-Ruso et al., the latter representing the first implementation of an instance of the new class of microscopic coherent models in a neutrino interaction Monte Carlo event generator. We observe a clear event excess above background, disagreeing with the null results reported by K2K and SciBooNE in a similar neutrino energy region. The measured flux-averaged cross sections are below those predicted by both the Rein-Sehgal and Alvarez-Ruso et al.

Nine-year results of whole femoral head allograft with articular cartilage for acetabular impaction grafting in revision hip replacement

INTRODUCTION Acetabular impaction bone grafting with a cemented polyethylene socket aims to reconstitute the bone stock in hip revision. This is an effective but resource intensive and time consuming technique. Usually, the articular cartilage is removed from the femoral head allograft. Our objective was to assess the late results of using the whole femoral head, retaining the cartilage. METHODS Forty-two acetabular revisions using impacted morselised bone graft (retaining the articular cartilage) and a cemented socket were studied retrospectively. The mean follow-up duration was 9.3 years (range: 6-13 years). Clinical and radiological assessment was made using the Oxford hip score, the classification of Hodgkinson et al (1988) for socket loosening and the classification of Gie et al (1993) for evaluation of allograft incorporation. RESULTS Twenty-seven sockets (75.0%) were radiologically stable, six (16.7%) were radiologically loose and three (8.3%) had migrated. Thirty cases (83.3%) showed good trabecular remodelling and six (16.74%) showed trabecular incorporation without remodelling. Six patients were lost to follow-up. Kaplan-Meier analysis calculated a survival rate of 94.5% at a mean of 9.3 years (95% confidence interval: 8.1-10.4 years) for all reasons of failure, with two re-revisions. CONCLUSIONS The nine-year results of the aforementioned technique are comparable with other major studies. Particularly when the supply of allograft and operative time are limited, retaining the articular cartilage of the femoral head is a safe and successful alternative.

Severe asthma exists despite suppressed tissue inflammation: findings of the U-BIOPRED study

The U-BIOPRED study is a multicentre European study aimed at a better understanding of severe asthma. It included three steroid-treated adult asthma groups (severe nonsmokers (SAn group), severe current/ex-smokers (SAs/ex group) and those with mild-moderate disease (MMA group)) and healthy controls (HC group). The aim of this cross-sectional, bronchoscopy substudy was to compare bronchial immunopathology between these groups.In 158 participants, bronchial biopsies and bronchial epithelial brushings were collected for immunopathologic and transcriptomic analysis. Immunohistochemical analysis of glycol methacrylate resin-embedded biopsies showed there were more mast cells in submucosa of the HC group (33.6 mm^-2) compared with both severe asthma groups (SAn: 17.4 mm^-2, p<0.001; SAs/ex: 22.2 mm^-2, p=0.01) and with the MMA group (21.2 mm^-2, p=0.01). The number of CD4⁺ lymphocytes was decreased in the SAs/ex group (4.7 mm^-2) compared with the SAn (11.6 mm^-2, p=0.002), MMA (10.1 mm^-2, p=0.008) and HC (10.6 mm^-2, p<0.001) groups. No other differences were observed.Affymetrix microarray analysis identified seven probe sets in the bronchial brushing samples that had a positive relationship with submucosal eosinophils. These mapped to COX-2 (cyclo-oxygenase-2), ADAM-7 (disintegrin and metalloproteinase domain-containing protein 7), SLCO1A2 (solute carrier organic anion transporter family member 1A2), TMEFF2 (transmembrane protein with epidermal growth factor like and two follistatin like domains 2) and TRPM-1 (transient receptor potential cation channel subfamily M member 1); the remaining two are unnamed.We conclude that in nonsmoking and smoking patients on currently recommended therapy, severe asthma exists despite suppressed tissue inflammation within the proximal airway wall.

The differential effects of azithromycin on the airway epithelium in vitro and in vivo

Macrolides including azithromycin (AZM) can improve clinical symptoms in asthma regardless of infection status. The mechanisms underlying these beneficial effects are yet to be elucidated. The aim of this study was to determine the effect of AZM on the airway epithelial barrier both in an in vitro model and in patients with asthma. Primary human bronchial epithelial cells (HBEC) were grown at air liquid interface (ALI) and challenged using lipopolysaccharides from Pseudomonas aeruginosa. AZM was added at various stages and barrier integrity assessed using transepithelial electrical resistance (TEER) and permeability to FITC‐dextran. MMP‐9 levels were measured using ELISA. AZM enhanced barrier integrity (TEER/FITC‐dextran), increased thickness, suppressed mucin production, and MMP‐9 release during the formation of a normal epithelial barrier in vitro. MMP‐9 levels inversely correlated with TEER. AZM also enhanced maintenance of the barrier and facilitated repair post‐LPS challenge. To provide translation of our findings, 10 patients with moderate‐severe asthma were recruited and received 250 mg AZM o.d for 6 weeks. Bronchial biopsies taken pre‐ and post‐AZM treatment did not show evidence of increased epithelial barrier thickness or decreased mucin production. Similarly, bronchial wash samples did not show reduced MMP‐9 levels. Overall, our data show that AZM can significantly improve the development of a normal bronchial epithelial barrier in vitro, mimicking reepithelization postinjury. AZM also suppressed MMP‐9 release which correlated with barrier integrity, suggesting a putative mechanism. However, these effects were not observed in biopsy samples from asthma patients treated with AZM, possibly due to small sample size.

Evaluating Quality and Adequacy of Gastrointestinal Samples Collected using Reusable or Disposable Forceps

Background

Sample quality of gastrointestinal endoscopic biopsies is of paramount importance for accurate histological diagnosis. Many veterinary practices use reusable forceps as a result of perceived decreased cost. With reusable forceps, it remains unknown whether sample quality declines with repeated use and becomes inferior to single‐use forceps and is therefore more or less cost effective than single‐use forceps.

Hypothesis/Objectives

The study hypothesis was that reusable forceps sample quality would deteriorate after repeated use as compared to single‐use forceps.

Animals

Sixty‐five dogs undergoing gastrointestinal endoscopy for diagnostic investigations at the Hospital for Small Animals, Edinburgh University.

Method

A prospective, pathologist‐blinded study comparing single‐use and reusable alligator standard cup biopsy forceps (Olympus 2.0 mm 1550 mm) with 5 randomized reusable forceps. Sample quality (stomach, duodenum, ileum, and colon) was assessed by a single pathologist using the WSAVA guidelines.

Results

There was no difference in the adequacy, depth, villi number, or crush artifact in the 4 intestinal areas between forceps type with at least 10, and up to 15, repeated uses of the reusable forceps.

Conclusions and clinical importance

This study demonstrates that reusable cup biopsy forceps provide equivalent biopsy quality after repeated uses to single‐use forceps and are cost effective at 10‐case use.

NightShift simulation to train newly qualified doctors in non-technical skills: a feasibility study

There is growing evidence of greater rates of morbidity and mortality in hospitals during out-of-hours shifts, which appears to be exacerbated during the period in which newly qualified doctors commence work. In order to combat this issue, an online simulation of a night shift was developed and trialled in order to improve the non-technical skills of newly qualified doctors and, ultimately, improve clinical outcomes. A randomised feasibility trial of the electronic training simulation was performed with medical students (n=30) at the end of their training and in the initial weeks of working at a large teaching hospital. The study showed that participants in the intervention group completed their non-urgent tasks more rapidly than the control group: mean (SD) time to complete a non-urgent task of 85.1 (50.1) versus 157.6 (90.4) minutes, p=0.027. This difference persisted using linear regression analysis, which was undertaken using rota and task volume as independent cofactors (p=0.028). This study shows the potential for simulation technologies to improve non-technical skills.

Measurement of Muon Antineutrino Oscillations with an Accelerator-Produced Off-Axis Beam

T2K reports its first measurements of the parameters governing the disappearance of ν[over ¯]_{μ} in an off-axis beam due to flavor change induced by neutrino oscillations. The quasimonochromatic ν[over ¯]_{μ} beam, produced with a peak energy of 0.6 GeV at J-PARC, is observed at the far detector Super-Kamiokande, 295 km away, where the ν[over ¯]_{μ} survival probability is expected to be minimal. Using a data set corresponding to 4.01×10^{20} protons on target, 34 fully contained μ-like events were observed. The best-fit oscillation parameters are sin^{2}(θ[over ¯]_{23})=0.45 and |Δm[over ¯]_{32}^{2}|=2.51×10^{-3}  eV^{2} with 68% confidence intervals of 0.38-0.64 and 2.26-2.80×10^{-3}  eV^{2}, respectively. These results are in agreement with existing antineutrino parameter measurements and also with the ν_{μ} disappearance parameters measured by T2K.

Effect of smoking status on the efficacy of the SMART regimen in high risk asthma

BACKGROUND AND OBJECTIVE

The optimal management of people with asthma with a significant smoking history is uncertain. The aim of this study was to determine whether the efficacy/safety profile of single combination inhaled corticosteroid (ICS)/long acting beta-agonist (LABA) inhaler maintenance and reliever therapy is influenced by smoking status.

METHODS

We undertook secondary analyses from an open-label 24-week randomized study of 303 high risk adult asthma patients randomized to budesonide/formoterol 200/6-µg-metred dose inhaler for maintenance (two actuations twice daily) and either budesonide/formoterol 200/6-µg-metred dose inhaler one actuation ('single ICS/LABA maintenance and reliever therapy (SMART)' regimen) or salbutamol 100 µg 1-2 actuations for symptom relief ('Standard' regimen). Smoking status was classified in to three groups, as 'current', 'ex' or 'never', and a smoking/treatment interaction term tested for each outcome variable. The primary outcome variable was number of participants with at least one severe exacerbation.

RESULTS

There were 59 current, 97 ex and 147 never smokers included in the analyses. The smoking status/treatment interaction term was not statistically significant for any of the outcome measures. With adjustment for smoking status, the number of participants with severe exacerbations was lower with the SMART regimen (OR 0.45, 95% CI: 0.26-0.77, P = 0.004; P value for interaction between smoking status and treatment 0.29).

CONCLUSION

We conclude that the favourable safety/efficacy profile of the SMART regimen applies to patients with high risk asthma, irrespective of smoking status.

The Effects of Azithromycin in Treatment-Resistant Cough: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Chronic cough is a common clinical problem worldwide. Although many patients have underlying precipitating conditions such as asthma, gastroesophageal reflux, or rhinitis, many remain symptomatic despite treating these conditions. New approaches are needed for the treatment of this group of patients.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial to determine whether 250 g of azithromycin three times a week for 8 weeks would affect the Leicester Cough Questionnaire (LCQ) score in 44 patients with treatment-resistant cough. Cough severity on a visual analog scale and bronchial exhaled nitric oxide were measured as secondary outcomes.

RESULTS

There was a clinically important improvement in LCQ score with azithromycin (mean change, 2.4; 95% CI, 0.5 to 4.2) but not placebo (mean change, 0.7; 95% CI, -0.6 to 1.9), but the between-group difference was not statistically significant (P = .12). There were no significant between-group differences for any of the secondary outcome measures. Looking at subgroups of responders, there was a large and significant improvement in LCQ score in patients with chronic cough and a concurrent diagnosis of asthma who were treated with azithromycin (mean, 6.19; 95% CI, 4.06 to 8.32).

CONCLUSIONS

Treatment with low-dose azithromycin for 8 weeks did not significantly improve LCQ score compared with placebo. The use of macrolides for treatment-resistant cough cannot be recommended from this study, but they may have a place in the treatment of chronic cough associated with asthma; this is worthy of further investigation.

TRIAL REGISTRY

WHO International Clinical Trials Registry; No.: ISRCTN75749391. URL: http://apps.who.int.

The burden of severe asthma in childhood and adolescence: results from the paediatric U-BIOPRED cohorts

U-BIOPRED aims to characterise paediatric and adult severe asthma using conventional and innovative systems biology approaches. A total of 99 school-age children with severe asthma and 81 preschoolers with severe wheeze were compared with 49 school-age children with mild/moderate asthma and 53 preschoolers with mild/moderate wheeze in a cross-sectional study. Despite high-dose treatment, the severe cohorts had more severe exacerbations compared with the mild/moderate ones (annual medians: school-aged 3.0 versus 1.1, preschool 3.9 versus 1.8; p<0.001). Exhaled tobacco exposure was common in the severe wheeze cohort. Almost all participants in each cohort were atopic and had a normal body mass index. Asthma-related quality of life, as assessed by the Paediatric Asthma Quality of Life Questionnaire (PAQLQ) and the Paediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), was worse in the severe cohorts (mean±se school-age PAQLQ: 4.77±0.15 versus 5.80±0.19; preschool PACQLQ: 4.27±0.18 versus 6.04±0.18; both p≤0.001); however, mild/moderate cohorts also had significant morbidity. Impaired quality of life was associated with poor control and airway obstruction. Otherwise, the severe and mild/moderate cohorts were clinically very similar. Children with severe preschool wheeze or severe asthma are usually atopic and have impaired quality of life that is associated with poor control and airflow limitation: a very different phenotype from adult severe asthma. In-depth phenotyping of these children, integrating clinical data with high-dimensional biomarkers, may help to improve and tailor their clinical management.

Republished: Respiratory microbiota: addressing clinical questions, informing clinical practice

Over the last decade, technological advances have revolutionised efforts to understand the role played by microbes in airways disease. With the application of ever more sophisticated techniques, the literature has become increasingly inaccessible to the non-specialist reader, potentially hampering the translation of these gains into improvements in patient care. In this article, we set out the key principles underpinning microbiota research in respiratory contexts and provide practical guidance on how best such studies can be designed, executed and interpreted. We examine how an understanding of the respiratory microbiota both challenges fundamental assumptions and provides novel clinical insights into lung disease, and we set out a number of important targets for ongoing research.