Responsiveness to oral prednisolone in severe asthma is related to the degree of eosinophilic airway inflammation

BACKGROUND

Patients with severe asthma appear relatively corticosteroid resistant. Corticosteroid responsiveness is closely related to the degree of eosinophilic airway inflammation. The extent to which eosinophilic airway inflammation in severe asthma responds to treatment with systemic corticosteroids is not clear.

OBJECTIVE

To relate the physiological and inflammatory response to systemic corticosteroids in asthma to disease severity and the baseline extent of eosinophilic inflammation.

METHODS

Patients with mild/moderate and severe asthma were investigated before and after 2 weeks of oral prednisolone (Clintrials.gov NCT00331058 and NCT00327197). We pooled the results from two studies with common protocols. The US study contained two independent centres and the UK one independent centre. The effect of oral corticosteroids on FEV₁ , Pc20, airway inflammation and serum cytokines was investigated. Baseline measurements were compared with healthy subjects.

RESULTS

Thirty-two mild/moderate asthmatics, 50 severe asthmatics and 35 healthy subjects took part. At baseline, both groups of asthmatics had a lower FEV₁ and Pc20 and increased eosinophilic inflammation compared to healthy subjects. The severe group had a lower FEV₁ and more eosinophilic inflammation compared to mild/moderate asthmatics. Oral prednisolone caused a similar degree of suppression of eosinophilic inflammation in all compartments in both groups of asthmatics. There were small improvements in FEV₁ and Pc20 for both mild/ moderate and severe asthmatics with a correlation between the baseline eosinophilic inflammation and the change in FEV₁ . There was a ~50% reduction in the serum concentration of CXCL10 (IP-10), CCL22 (MDC), CCL17 (TARC), CCL-2 (MCP-1) and CCL-13 (MCP-4) in both asthma groups after oral corticosteroids.

CONCLUSIONS AND CLINICAL RELEVANCE

Disease severity does not influence the response to systemic corticosteroids. The study does not therefore support the concept that severe asthma is associated with corticosteroid resistance. Only baseline eosinophilic inflammation was associated with the physiological response to corticosteroids, confirming the importance of measuring eosinophilic inflammation to guide corticosteroid use.

Probiotics Reduce the Prevalence of Oral Candida in the Elderly—a Randomized Controlled Trial

Overgrowth of oral yeast is a common problem among the elderly. Probiotic bacteria are known to inhibit the growth of pathogenic microbes. We tested the hypothesis that cheese containing probiotic bacteria can reduce the prevalence of oral Candida. During this 16-week, randomized, double-blind, placebo-controlled study, 276 elderly people consumed daily 50 g of either probiotic (n = 136) or control cheese (n = 140). The primary outcome measure was the prevalence of a high salivary yeast count (≥ 104 cfu/mL) analyzed by the Dentocult® method. The prevalence decreased in the probiotic group from 30% to 21% (32% reduction), and increased in the control group from 28% to 34%. Probiotic intervention reduced the risk of high yeast counts by 75% (OR = 0.25, 95%CI 0.10–0.65, p = 0.004), and the risk of hyposalivation by 56% (OR = 0.44, 95%CI 0.19–1.01, p = 0.05). Thus, probiotic bacteria can be effective in controlling oral Candida and hyposalivation in the elderly.

The relationship between biomarkers of fungal allergy and lung damage in asthma

BACKGROUND

Immunological biomarkers are the key to the diagnosis of allergic bronchopulmonary aspergillosis (ABPA) and fungal sensitisation, but how these relate to clinically relevant outcomes is unclear.

OBJECTIVES

To assess how fungal immunological biomarkers are related to fixed airflow obstruction and radiological abnormalities in moderate to severe asthma.

METHODS

Cross-sectional study of 431 asthmatics. Inflammatory biomarkers, lung function and an IgE fungal panel to colonising filamentous fungi, yeasts and fungal aeroallergens were measured. CT scans were scored for the presence of radiological abnormalities. Factor analysis informed the variables used in a k-means cluster analysis. Fixed airflow obstruction and radiological abnormalities were then mapped to these immunological variables in the cluster analysis.

RESULTS

329 (76.3%) subjects were sensitised to ≥ 1 fungi. Sensitisation to Aspergillus fumigatus and/or Penicillium chrysogenum was associated with a lower post-bronchodilator FEV₁ compared with those not sensitised to fungi ((73.0 (95% CI 70.2-76) vs. 82.8 (95% CI 78.5-87.2)% predicted, P < 0.001), independent of atopic status (P = 0.005)), and an increased frequency of bronchiectasis (54.5%, P < 0.001), tree-in-bud (18.7%, P < 0.001) and collapse/consolidation (37.5%, P = 0.002). Cluster analysis identified three clusters: (i) hypereosinophilic (n = 71, 16.5%), (ii) high immunological biomarker load and high frequency of radiological abnormalities (n = 34, 7.9%) and (iii) low levels of fungal immunological biomarkers (n = 326, 75.6%).

CONCLUSIONS AND CLINICAL RELEVANCE

IgE sensitisation to thermotolerant filamentous fungi, in particular A. fumigatus but not total IgE, is associated with fixed airflow obstruction and a number of radiological abnormalities in moderate to severe asthma. All patients with IgE sensitisation to A. fumigatus are at risk of lung damage irrespective of whether they meet the criteria for ABPA.

Reflection and celebration — Neal (1960-1987): narrative of a young man with profound and multiple disabilities

Achieving quality of life for people with profound learning disabilities and multiple impairments is often judged, by some, to be incompatible with the nature of the impairments with which the individual, their family and society must cope. However, those making such difficult judgments may often do so from their own able-bodied, unimpaired perspective, a perspective that may result in disabling consequences. This paper demonstrates how, by use of reflective practice, a group of nurses and carers learnt, from a young man with quite profound learning disabilities and multiple impairments, how to assist him, direct and control significant aspects of his own life. Above all, however, this paper is a celebration of his short but rich life.

Twelve-month outcomes following surgical repair of the Achilles tendon

INTRODUCTION

Incidence of Achilles tendon rupture (ATR) has increased over recent years, and debate regarding optimal management has been widely documented. Most papers have focused on surgical success, complications and short term region-specific outcomes. Inconsistent use of standardised outcome measures following surgical ATR repair has made it difficult to evaluate the impact of ATR on a patient's health status post-surgery, and to compare this to other injury types. This study aimed to report the frequency of surgical repairs of the Achilles tendon over a five-year period within an orthopaedic trauma registry, and to investigate return to work (RTW) status, health status and functional outcomes at 12 months post-surgical repair of the Achilles tendon.

METHODS

Two hundred and four adults registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who underwent surgical repair of the Achilles tendon between July 2009 and June 2014 were included in this prospective cohort study. The Extended Glasgow Outcome Scale (GOS-E), 3-level European Quality of Life 5 Dimension measure (EQ-5D-3L), and RTW status 12 months following surgical ATR repair were collected through structured telephone interviews conducted by trained interviewers.

RESULTS

At 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work. 42% of patients reported a full recovery on the GOS-E scale. The prevalence of problems on the EQ-5D-3L at 12 months was 0.5% for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain. 16% of patients reported problems with more than one domain. The number of surgical repairs of the Achilles tendon within the VOTOR registry decreased by 68% over the five-year study period.

CONCLUSIONS

Overall, patients recover well following surgical repair of the Achilles tendon. However, in this study, deficits in function persisted for over half of patients at 12 months post-injury. The decreased incidence of surgical Achilles tendon repair may reflect a change in practice at VOTOR hospitals whereby surgery may be becoming less favoured for initial ATR management.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Day surgery for achalasia cardia: Time for consensus?

INTRODUCTION

Laparoscopic Heller's myotomy (LHM) is the most effective therapy for achalasia of the oesophagus. Most case series of LHM report a length of hospital stay (LOS) >1 day. We present 14 years of experience of LHM to examine the safety and feasibility of LHM as a day case procedure.

METHODS

We retrospectively examined patients undergoing elective LHM for achalasia at our institution between 2000 and 2014. Demographics, episode statistics, prior investigations and interventions were collated. Outcomes, including LOS, complications and re-interventions, were compared for the periods before and after a consensus decision at our institution in 2008 to perform LHM as a day case procedure.

RESULTS

Sixty patients with a mean age of 41 ± 13 years were included, of whom 58% were male. The median LOS for all patients was 1 day (interquartile range [IQR] 0-2.25). Overall, LHM was performed as a day case in 27 (45%) cases, at 2/26 (7.7%) in the first period versus 25/34 (73.5%) in the second (p<0.01). There were no significant differences in age, gender or previous interventions between day surgery and non-day surgery groups. One patient required subsequent unplanned surgery, while six (10%) needed endoscopic treatment of recurrent symptoms within 12 months.

CONCLUSIONS

LHM can be performed safely as a day case procedure. Complication rates are low, with only a small proportion of patients requiring endoscopic treatment for symptom recurrence within 1 year.

Instrumentation and Measurement Strategy for the NOAA SENEX Aircraft Campaign as Part of the Southeast Atmosphere Study 2013

Natural emissions of ozone-and-aerosol-precursor gases such as isoprene and monoterpenes are high in the southeast of the US. In addition, anthropogenic emissions are significant in the Southeast US and summertime photochemistry is rapid. The NOAA-led SENEX (Southeast Nexus) aircraft campaign was one of the major components of the Southeast Atmosphere Study (SAS) and was focused on studying the interactions between biogenic and anthropogenic emissions to form secondary pollutants. During SENEX, the NOAA WP-3D aircraft conducted 20 research flights between 27 May and 10 July 2013 based out of Smyrna, TN. Here we describe the experimental approach, the science goals and early results of the NOAA SENEX campaign. The aircraft, its capabilities and standard measurements are described. The instrument payload is summarized including detection limits, accuracy, precision and time resolutions for all gas-and-aerosol phase instruments. The inter-comparisons of compounds measured with multiple instruments on the NOAA WP-3D are presented and were all within the stated uncertainties, except two of the three NO₂ measurements. The SENEX flights included day- and nighttime flights in the Southeast as well as flights over areas with intense shale gas extraction (Marcellus, Fayetteville and Haynesville shale). We present one example flight on 16 June 2013, which was a daytime flight over the Atlanta region, where several crosswind transects of plumes from the city and nearby point sources, such as power plants, paper mills and landfills, were flown. The area around Atlanta has large biogenic isoprene emissions, which provided an excellent case for studying the interactions between biogenic and anthropogenic emissions. In this example flight, chemistry in and outside the Atlanta plumes was observed for several hours after emission. The analysis of this flight showcases the strategies implemented to answer some of the main SENEX science questions.

Instrumentation and Measurement Strategy for the NOAA SENEX Aircraft Campaign as Part of the Southeast Atmosphere Study 2013

Natural emissions of ozone-and-aerosol-precursor gases such as isoprene and monoterpenes are high in the southeast of the US. In addition, anthropogenic emissions are significant in the Southeast US and summertime photochemistry is rapid. The NOAA-led SENEX (Southeast Nexus) aircraft campaign was one of the major components of the Southeast Atmosphere Study (SAS) and was focused on studying the interactions between biogenic and anthropogenic emissions to form secondary pollutants. During SENEX, the NOAA WP-3D aircraft conducted 20 research flights between 27 May and 10 July 2013 based out of Smyrna, TN. Here we describe the experimental approach, the science goals and early results of the NOAA SENEX campaign. The aircraft, its capabilities and standard measurements are described. The instrument payload is summarized including detection limits, accuracy, precision and time resolutions for all gas-and-aerosol phase instruments. The inter-comparisons of compounds measured with multiple instruments on the NOAA WP-3D are presented and were all within the stated uncertainties, except two of the three NO₂ measurements. The SENEX flights included day- and nighttime flights in the Southeast as well as flights over areas with intense shale gas extraction (Marcellus, Fayetteville and Haynesville shale). We present one example flight on 16 June 2013, which was a daytime flight over the Atlanta region, where several crosswind transects of plumes from the city and nearby point sources, such as power plants, paper mills and landfills, were flown. The area around Atlanta has large biogenic isoprene emissions, which provided an excellent case for studying the interactions between biogenic and anthropogenic emissions. In this example flight, chemistry in and outside the Atlanta plumes was observed for several hours after emission. The analysis of this flight showcases the strategies implemented to answer some of the main SENEX science questions.

Ross procedure is a safe treatment option for aortic valve endocarditis: Long-term follow-up of 42 patients

BACKGROUND

Aortic root replacement with a pulmonary autograft (Ross procedure) can be performed as a treatment of aortic valve endocarditis, avoiding prosthetic valve implantation in septic context. We sought to assess long-term outcomes of the Ross procedure in this indication.

METHODS

From April 1992 to March 2009, the intervention was performed in 42 patients (mean age 34 ± 8 years) suffering from an active or ancient aortic valve endocarditis. 36% of the patients had extensive perivalvular involvement, and surgery was urgent in 18 patients (43%). We performed a prospective clinical and echocardiographic follow-up of this population.

RESULTS

Median follow-up was 10 years (4-21 years). Overall survival at 10 and 15 years was respectively 87 ± 5% and 81 ± 8%. Perioperative mortality was 4.7% (2 patients) and no late cardiac death was reported. Eight patients (19%) underwent repeat surgery for autograft and/or homograft dysfunction at a median time of 8.4 years (3 months-18 years). Rate of recurrent endocarditis was low (7%-3 patients), including 1 in a context of persistent intravenous drug abuse. Clinical follow-up showed good functional status for all patients with NYHA ≤ II, and less than 25% of patients requiring cardiovascular medication. Late echocardiographic follow-up demonstrated well-functioning autograft and homograft, with only one severe aortic regurgitation, and one significant increase in pulmonary mean gradient.

CONCLUSION

The Ross procedure in aortic valve endocarditis is an interesting alternative to prosthetic valvular replacement in a selected population, with a high rate of survival free from any cardiovascular event or medication requirement.