Allergic Rhinitis and its Impact on Asthma (ARIA): achievements in 10 years and future needs

Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

Association between hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes

AIMS

This retrospective observational study examined the association between International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-coded outpatient hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes.

METHODS

Data were derived from healthcare claims for individuals with employer-sponsored Medicare supplemental insurance. The study period consisted of two consecutive 1-year periods; the baseline period (1 April 2008 to 31 March 2009) and the evaluation period (1 April 2009 to 31 March 2010). Patients selected for study were at least 65 years of age with evidence of type 2 diabetes during the baseline period, as identified using a Healthcare Effectiveness Data and Information Set algorithm or by at least two prescription claims for oral antidiabetic drugs. The baseline period was used to collect information on the patients' demographics and clinical characteristics. The evaluation period was used to identify the presence of hypoglycaemic events and fall-related fractures. Logistic regression was employed to examine the association between hypoglycaemic events and fall-related fractures occurring during the evaluation period, adjusting for patients' demographics and clinical characteristics.

RESULTS

Of 361 210 included patients, 16 936 had hypoglycaemic events during the evaluation period. Patients with hypoglycaemic events had 70% higher regression-adjusted odds (hypoglycaemic events odds ratio = 1.70; 95% confidence interval = 1.58-1.83) of fall-related fractures than patients without hypoglycaemic events. Multiple sensitivity analyses also yielded results suggesting increased odds of fall-related fractures in patients with hypoglycaemic events.

CONCLUSIONS

ICD-9-CM-coded outpatient hypoglycaemic events were independently associated with an increased risk of fall-related fractures. Further studies of the relationship between hypoglycaemia and the risk of fall-related fractures are warranted.

Renal kallikrein excretion and epigenetics in human acute kidney injury: expression, mechanisms and consequences

Background

Renal kallikrein (KLK1) synthesis and urinary excretion are reportedly diminished during AKI (acute kidney injury) in animal models, and provision of kallikrein abrogates renal injury in this setting, but data in human AKI is limited. Therefore we first examined KLK1 renal excretion in human AKI, and then probed potential endocrine and epigenetic mechanisms for its alterations.

Methods

KLK1 enzymatic activity excretion was evaluated in urine from patients with established or incipient AKI, versus healthy/non-hospital as well as ICU controls. Endocrine control of KLK1 excretion was then probed by catecholamine and aldosterone measurements in established AKI versus healthy controls. To examine epigenetic control of KLK1 synthesis, we tested blood and urine DNA for changes in promoter CpG methylation of the KLK1 gene, as well as LINE-1 elements, by bisulfite sequencing.

Results

Patients with early/incipient AKI displayed a modest reduction of KLK1 excretion, but unexpectedly, established AKI displayed substantially elevated urine KLK1 excretion, ~11-fold higher than healthy controls, and ~3-fold greater than ICU controls. We then probed potential mechanisms of the change. Established AKI patients had lower SBP, higher heart rate, and higher epinephrine excretion than healthy controls, though aldosterone excretion was not different. Promoter KLK1 CpG methylation was higher in blood than urine DNA, while KLK1 methylation in blood DNA was significantly higher in established AKI than healthy controls, though KLK1 methylation in urine tended to be higher in AKI, directionally consistent with earlier/incipient but not later/established changes in KLK1 excretion in AKI. On multivariate ANOVA, AKI displayed coordinate changes in KLK1 excretion and promoter methylation, though directionally opposite to expectation. Control (LINE-1 repetitive element) methylation in blood and urine DNA was similar between AKI and controls.

Conclusions

Unexpectedly, increased KLK1 excretion in AKI patients was found; this increase is likely to be due in part to increments in adrenergic tone during BP depression. Epigenetic changes at KLK1 may also play a role in early changes of KLK1 expression and thus AKI susceptibility or recovery.

Development and implementation of guidelines in allergic rhinitis – an ARIA-GA2LEN paper

The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients’ values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.

Degradation of Kraft Indulin Lignin by Streptomyces viridosporus and Streptomyces badius

Crawford and collaborators have studied extensively the solubilization of lignocellulose by two Streptomyces species, S. badius and S. viridosporus. Using a condensed industrial lignin essentially devoid of carbohydrates, Indulin AT, as the sole source of carbon, similar results were obtained: (i) the growths of the bacteria were optimum at pH 7.5 to 8.5; (ii) yeast extract was a better source of nitrogen than NH(4)Cl; (iii) the products of the depolymerization of Indulin were soluble, acid-precipitable polymers. When d-glucose was added as a secondary carbon source, it was used preferentially and the production of acid-precipitable polymers began only after the complete depletion of the sugar. On the assumption that the degradation of Indulin was catalyzed by enzymes, proteins found in the culture media and soluble and insoluble intracellular proteins were incubated with Indulin at pH 7.0 at 37 degrees C. Proteins in all fractions from S. badius had ligninolytic activities which, with the exception of those in the intracellular soluble fraction, were increased in the presence of H(2)O(2). In S. viridosporus, both extra- and intracellular soluble activities were found which were not increased by H(2)O(2). The extracellular activity of S. viridosporus was not affected by heat, resisted partially an exposure to pH 1.0, and was completely destroyed by proteolysis.

DUPLICATE: Digital instrumentation and management of dead time: First results on a NaI well-type detector setup

The Publisher regrets that this article is an accidental duplication of an article that has already been published, doi:10.1016/j.apradiso.2010.01.040. The duplicate article has therefore been withdrawn.

Analysis of glycaemic control and weight change in patients initiated with human or analog insulin in an US ambulatory care setting

BACKGROUND

Insulin is a mainstay in the treatment of type 1 diabetes and is a recommended option in patients with type 2 diabetes who fail to maintain glycaemic control on other non-insulin therapies. The purpose of this study was to describe patient characteristics and evaluate changes in glycaemic control and weight in patients treated with insulin in an ambulatory care setting.

METHODS

Patients with diabetes were identified from the General Electric electronic medical record (EMR) database (1 September 2004 to 30 April 2008). Patients were > or =18 years, insulin naive, newly treated with monoinsulin therapy (index date). Baseline characteristics were identified overall and stratified by insulin type (basal, mixed, and rapid). Basal insulins were described by human versus analog and for insulin detemir and insulin glargine. Change in haemoglobin A1C (HbA1C) and weight from baseline (45 days pre- to 15 days postindex date) to 6 months (+/-90 days) were compared. Regression analyses were used to evaluate HbA1C outcomes across insulins and for the likelihood of gaining 0.9 kg (2 lbs) for detemir versus glargine controlling for baseline characteristics.

RESULTS

A total of 12 136 patients were included. A majority were initiated on a basal insulin (64.7%) followed by mixed (20.8%) and rapid (14.4%). Basal users had significantly higher mean body weight and lower mean baseline HbA1C than mixed users (p < 0.001 for all), and were significantly older, had higher baseline HbA1C and higher baseline body mass index (BMI) than rapid insulin users (p < 0.001 for all). Glargine patients had a significantly higher mean baseline HbA1C (p = 0.003) than detemir patients. The adjusted reduction in HbA1C was greater for rapid insulin than for mixed or basal insulin (p < or = 0.05). The adjusted differences in HbA1C between basal human and basal analog insulins and between detemir and glargine were not statistically significant (p > 0.05). Patients using detemir were 30% less likely to gain 0.9 kg or more than glargine users (p < 0.05).

CONCLUSIONS

HbA1C outcomes in the ambulatory care setting were generally not different between insulin classes. The likelihood of weight gain was less with insulin detemir than with insulin glargine. Thus, real-world weight outcomes for basal analog insulin may differ by specific product.

Renal replacement therapy for acute renal failure

Renal replacement therapy became a common clinical tool to treat patients with severe acute kidney injury (AKI) since the 1960s. During this time dialytic options have expanded considerably; biocompatible membranes, bicarbonate dialysate and dialysis machines with volumetric ultrafiltration control have improved the treatment for acute kidney injury. Along with advances in methods of intermittent hemodialysis, continuous renal replacement therapies have gained widespread acceptance in the treatment of dialysis-requiring AKI. However, many of the fundamental aspects of the renal replacement treatment such as indication, timing of dialytic intervention, and choice of dialysis modality are still controversial and may influence AKI patient's outcomes. This review outlines current concepts in the use of dialysis techniques for AKI and suggests an approach for selecting the optimal method of renal replacement therapy.

Validation study of a new technique for absolute activity measurement with 4pi solid angle metallic magnetic calorimeters

In this paper we present a prototype of a new class of detectors, metallic magnetic calorimeters operating at cryogenic temperatures, which we are developing for absolute activity measurement of low-energy-emitting radionuclides. We explain the detection principle and give a detailed description of the realisation of the prototype, containing an (55)Fe source inside the detector absorber. The analysis of first data taken with this detector is presented and the result of activity measurement compared with liquid scintillation counting. Some ways for reducing the uncertainty that can be achieved with this new technique are proposed.

Acid-base disturbances in the intensive care unit: current issues and the use of continuous renal replacement therapy as a customized treatment tool

Continuous renal replacement therapies (CRRT) are often used to manage complex acid-base problems in critically ill patients. These techniques allow a constant manipulation of the plasma composition. Several technical factors from CRRT influence the acid-base status; namely, the effluent rate, the operational characteristics of the technique, the content of the solutions and the metabolic rate of the buffer. This article reviews the common acid base disorders occurring in the intensive care unit, using both the anion gap and the strong ion gap approaches, and describes the influence of CRRT on acid-base physiology. The use of CRRT as a customized therapy for acid-base disorders is discussed, allowing an integration of both physiological and technical concepts.

Standardization of 67Ga using a 4π(LS)β–γ anti-coincidence system

(67)Ga is an interesting radionuclide as it is widely used in nuclear medicine. The meta-stable level related to the 93.3keV gamma-transition represents the main difficulty when using the coincidence method to standardize this radionuclide. The 4pi(LS)beta-gamma anti-coincidence system implemented at LNHB is based on the use of electronic modules specifically designed for radioactivity metrology. On the contrary to classical coincidence systems, activity measurements of (67)Ga are carried out as for prompt beta-gamma emitters; indeed, when using a live-timed anti-coincidence system with extendable dead times, the problem due to the excess of counting generated by the meta-stable level is avoided. Considering that the standardization of (67)Ga does not depend on the decay scheme parameters (except for the half-life), the measurement of the gamma-emission intensities has been performed. The standardization of this radionuclide was also a good opportunity for a new participation of our laboratory in the SIR of (67)Ga (International Reference System); the result obtained with the 4pi(LS)beta-gamma anti-coincidence system is compared with those submitted by other National Metrology Institutes (NMIs). The non-extendable dead times used in most of the participations could be one of the causes responsible for the abnormal dispersion of the results. The optimization of the standard solution of (67)Ga for the radioactive source preparation is also discussed.

High-energy resolution alpha spectrometry using cryogenic detectors

Applications such as environment monitoring implying alpha emitters activity measurement associated with isotope identification, require high-energy resolution detectors. Conventional silicon detectors are inexpensive therefore widely used, although intrinsically limited in energy resolution. Thermal detection principle of cryogenic detectors introduces a breakthrough in alpha particle measurement. For the first time, spectra with 5.5 keV FWHM energy resolution have been obtained for several external alpha emitting sources using a copper-germanium bolometer specially developed for alpha spectrometry.

Pharmacologic and anti-IgE treatment of allergic rhinitis ARIA update (in collaboration with GA2LEN)

The pharmacologic treatment of allergic rhinitis proposed by ARIA is an evidence-based and step-wise approach based on the classification of the symptoms. The ARIA workshop, held in December 1999, published a report in 2001 and new information has subsequently been published. The initial ARIA document lacked some important information on several issues. This document updates the ARIA sections on the pharmacologic and anti-IgE treatments of allergic rhinitis. Literature published between January 2000 and December 2004 has been included. Only a few studies assessing nasal and non-nasal symptoms are presented as these will be discussed in a separate document.