Multiple atopy phenotypes and their associations with asthma: similar findings from two birth cohorts

BACKGROUND

Although atopic sensitization is one of the strongest risk factors for asthma, its relationship with asthma is poorly understood. We hypothesize that 'atopy' encompasses multiple sub-phenotypes that relate to asthma in different ways.

METHODS

In two population-based birth cohorts (Manchester and Isle of Wight - IoW), we used a machine learning approach to independently cluster children into different classes of atopic sensitization in an unsupervised manner, based on skin prick and sIgE tests taken throughout childhood and adolescence. We examined the qualitative cluster properties and their relationship to asthma and lung function.

RESULTS

A five-class solution best described the data in both cohorts, with striking similarity between the classes across the two populations. Compared with nonsensitized class, children in the class with sensitivity to a wide variety of allergens (~1/3 of children atopic by conventional definition) were much more likely to have asthma (aOR [95% CI0; 20.1 [10.9-40.2] in Manchester and 11.9 [7.3-19.4] in IoW). The relationship between asthma and conventional atopy was much weaker (5.5 [3.4-8.8] in Manchester and 5.8 [4.1-8.3] in IoW). In both cohorts, children in this class had significantly poorer lung function (FEV1 /FVC lower by 4.4% in Manchester and 2.6% in IoW; P < 0.001), most reactive airways, highest eNO and most hospital admissions for asthma (P < 0.001).

CONCLUSIONS

By adopting a machine learning approach to longitudinal data on allergic sensitization from two independent unselected birth cohorts, we identified latent classes with strikingly similar patterns of atopic response and association with clinical outcomes, suggesting the existence of multiple atopy phenotypes.

Towards 'sepsis with optimal treatment': evaluating the sepsis care pathway in acute medicine and identifying scope for systems improvement

Sepsis commonly presents to the acute medicine unit (AMU). Timely recognition and treatment can reduce the significant associated mortality, but United Kingdom AMUs and emergency departments are often inadequately equipped to manage sepsis with early-goal directed therapy. We conducted an observational study of 50 consecutive patients admitted with severe sepsis. Demographic, physiological and microbiological data, and information about the provision and timing of care were collected in real time. Treatment fell below "surviving sepsis" targets with only 28% of patients receiving sufficient fluid, and 64% receiving antibiotics within 3 hours, associated with delays in seeing physicians; however despite this mortality was lower than the nationally quoted average (14% at 90 days).

Platelet size and adenine nucleotides in patients undergoing bone marrow ablation: a useful model for studying platelet ageing

Peripheral blood platelets were examined in 7 patients who underwent bone marrow ablation with high dose chemotherapy and total body irradiation prior to bone marrow transplantation (BMT). Platelets were studied for 9 days, by which time the platelet counts had fallen to levels at which platelet transfusion support was necessary. Values for (111)Indium autologous mean platelet lifespan were similar to those reported in thrombocytopenic patients by other authors. During the period of study, there was no significant change in mean platelet volume or platelet nucleotides. The results indicate that in man, platelet size and platelet nucleotides are not affected when platelets age in the peripheral circulation.

Genome-wide association study to identify genetic determinants of severe asthma

BACKGROUND

The genetic basis for developing asthma has been extensively studied. However, association studies to date have mostly focused on mild to moderate disease and genetic risk factors for severe asthma remain unclear.

OBJECTIVE

To identify common genetic variants affecting susceptibility to severe asthma.

METHODS

A genome-wide association study was undertaken in 933 European ancestry individuals with severe asthma based on Global Initiative for Asthma (GINA) criteria 3 or above and 3346 clean controls. After standard quality control measures, the association of 480 889 genotyped single nucleotide polymorphisms (SNPs) was tested. To improve the resolution of the association signals identified, non-genotyped SNPs were imputed in these regions using a dense reference panel of SNP genotypes from the 1000 Genomes Project. Then replication of SNPs of interest was undertaken in a further 231 cases and 1345 controls and a meta-analysis was performed to combine the results across studies.

RESULTS

An association was confirmed in subjects with severe asthma of loci previously identified for association with mild to moderate asthma. The strongest evidence was seen for the ORMDL3/GSDMB locus on chromosome 17q12-21 (rs4794820, p=1.03×10((-8)) following meta-analysis) meeting genome-wide significance. Strong evidence was also found for the IL1RL1/IL18R1 locus on 2q12 (rs9807989, p=5.59×10((-8)) following meta-analysis) just below this threshold. No novel loci for susceptibility to severe asthma met strict criteria for genome-wide significance.

CONCLUSIONS

The largest genome-wide association study of severe asthma to date was carried out and strong evidence found for the association of two previously identified asthma susceptibility loci in patients with severe disease. A number of novel regions with suggestive evidence were also identified warranting further study.

Chronic plantar ulcer secondary to congenital indifference to pain

Congenital indifference to pain (CIP) is a rare condition characterised by painless injuries beginning in early life, with normal sensory exam findings. Young people with inexplicable, painless chronic wounds may present to the plastic surgeon for surgical management. Given the young age of onset and high likelihood of postoperative failure, alternative options for closure of non-healing wounds should be considered. We present the case of a 17-year-old boy with congenital indifference to pain and successful management of his longstanding plantar ulcer.

The role of inhalant allergens in allergic airways disease

Immunoglobulin (Ig) E-mediated sensitization to domestic inhalant allergens (eg, dust mite, cockroach, cat, and dog) is the most important risk factor for asthma. The severity of asthma increases among atopic patients exposed to high levels of sensitizing allergen. In addition, synergism between high allergen exposure and respiratory virus infection increases the risk of asthma exacerbation. However, opinions on the role of allergen avoidance in the management of asthma are diverse, partly because most currently used allergen avoidance measures are usually tested in highly artificial experimental conditions, often with no assessment of their effect on personal inhaled allergen exposure or their clinical effectiveness. While there is little evidence for the clinical benefits of single avoidance measures (eg, bedding encasings, vacuum cleaners, and air filters), multifaceted intervention in carefully selected patients may be of benefit. Until conclusive evidence is available, a pragmatic approach in clinical practice should involve the following: (a) interventions tailored to the patient's sensitization and allergen exposure (if exposure cannot be estimated, specific IgE antibody level or the results of skin testing can be used as a marker); (b) a multifaceted allergen avoidance regime, based on removal of the accumulating allergen; (c) initiation of the intervention as early as possible. Currently, no evidence-based advice on the use of allergen avoidance for prevention of allergic disease can be given; however, it is increasingly clear that no single strategy will be applicable to all children, only to those with specific genetic susceptibility.

Dual Use of Biotechnology

This article addresses issues that are central to the dual use of biotechnology, such as the public perception of risk and the need for physical containment to prevent the release of potentially dangerous microorganisms. It also examines the public and media perception of the scientists who handle and manipulate these pathogens and discusses the controls that are currently in place to ensure that scientists engaged in defense-related dual-use medical research act in a transparent and ethical manner. Finally, the article discusses what can be done by scientists to allay the fears of their fellow citizens.

P3-14-28: ANZ 0502 NeoGem: A Phase II Trial Evaluating the Efficacy and Safety of Epirubicin and Cyclophosphamide Followed by Docetaxel with Gemcitabine (+ Trastuzumab If HER2 Positive) as Neoadjuvant Chemotherapy for Women with Large Operable or Locally Advanced Breast Carcinoma

Background

Neoadjuvant chemotherapy may provide an early indication of treatment effect and pathologic complete response (pCR) rate is a surrogate measure of disease-free and overall survival. Anthracyclines remain an important component of chemotherapy regimens for breast cancer (BC), adding a taxane conveys additional survival benefit. Gemcitabine (G) has established safety and efficacy in metastatic breast cancer (MBC) and combining G with docetaxel (D) shows preclinical synergy but not overlapping toxicities. In MBC, efficacy of trastuzumab (T) combined with single agent taxanes and G has been demonstrated for tumours that over-express human epidermal growth factor receptor 2 (HER2+). NeoGem aimed to evaluate the efficacy and safety of neoadjuvant epirubicin (E) and cyclophosphamide (C), followed by D and G +/− T (depending on HER2 status) in women with large operable or locally advanced BC.

Methods: Eligible patients (pts), ≥18 years, had unilateral, operable (at presentation) T2 (≥3cm), T3-4, N0-1, M0 primary BC, no prior chemotherapy or hormonal therapy and ECOG status 0–2. All pts received E (90mg/m2 i.v.) in combination with C (600mg/m2 i.v.) on day 1 q 21 for 4 cycles followed by D (75mg/m2 i.v.) on day 1 in combination with G (1000mg/m2 i.v.) on days 1 and 8 q 21 for 4 cycles. HER2+ pts received T (4mg/kg loading then 2mg/kg i.v.) concurrent with DG on days 1, 8 and 15 q 21 for 4 cycles. HER2+ pts received post-surgical T (6mg/kg) 3 weekly, for a total of one year of T therapy. Using a Simon's 2 stage trial design, the decision to proceed to stage 2 followed interim analysis of stage 1. Primary endpoint, pCR, was defined as no histologic evidence of invasive cancer in the breast. Secondary endpoint, pCRax, was defined as no histologic evidence of invasive cancer in the breast and axilla. EC followed by DG/DGT was expected to achieve a pCR rate of 35% in HER2 negative (HER2−) pts and 40% in HER2+, with the lowest limit of therapeutic efficacy being a pCR rate of 22% (HER2−) and 24% (HER2+). Hence 84 HER2− and 63 HER2+ pts were needed to detect significant differences in pCR rates (power 80%, 95% level of significance).

Results: Over 32 months 81 pts (63 HER2− and 18 HER2+) were enrolled, 78 (96% [61 HER2− and 17 HER2+]) proceeded to surgery. Of 78 pts, 21 (27%) achieved pCR and 19 (24%) achieved pCRax. Of the 61 HER2− pts, 12 (20% [95% CI: 12%-31%]) achieved pCR compared with 9 (53% [95%CI: 31%-74%]) of 17 HER2+ pts. Planned chemotherapy was completed by 67 pts (83%), 9 pts (11%) discontinued due to adverse events. Thirteen pts (16%) required DG dose reductions compared with 7 (8%) pts during EC; 57 (70%) pts had ≥ grade 3 neutropenia.

Conclusion: Efficacy in the HER2− cohort did not reach predetermined levels of significance (interim analysis); HER2+ recruitment proved too slow to continue. High haematological toxicity during DG, particularly neutropenia required use of supportive therapy (GCSF). Despite relatively small patient numbers, 53% pCR in the HER2+ cohort warrants further investigation.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-14-28.

Door locking and exit security measures on acute psychiatric admission wards

Locking the exit doors of psychiatric wards is believed to reduce the risk of patients absconding. The aims of the study were to investigate both the prevalence of door locking and other exit security measures on UK admission wards, as well as whether door locking appears to be effective in keeping inpatients in. A cross-sectional survey on 136 acute psychiatric wards in the UK was conducted, in which a range of data on patients, staff, and conflict and containment events, including door locking and absconding, were collected from shift to shift during a period of 6 months. About one-third of the participating wards (30%) operated with their ward exit door permanently locked, whereas another third (34%) never locked the ward door. Univariate analyses suggested little association between exit security measures and absconding. A more robust multilevel statistical analysis, however, did indicate a reduction of about 30% of absconding rates when the ward door was locked the entire shift. Although locking the ward door does seem to reduce absconding to a certain extent, it far from completely prevents it. As it may be unrealistic to strive for a 100% absconding-proof ward, alternative measures for door locking to prevent absconding are discussed.

Modelling air pollution for epidemiologic research--part II: predicting temporal variation through land use regression

Over recent years land use regression (LUR) has become a frequently used method in air pollution exposure studies, as it can model intra-urban variation in pollutant concentrations at a fine spatial scale. However, very few studies have used the LUR methodology to also model the temporal variation in air pollution exposure. The aim of this study is to estimate annual mean NO(2) and PM(10) concentrations from 1996 to 2008 for Greater Manchester using land use regression models. The results from these models will be used in the Manchester Asthma and Allergy Study (MAAS) birth cohort to determine health effects of air pollution exposure. The Greater Manchester LUR model for 2005 was recalibrated using interpolated and adjusted NO(2) and PM(10) concentrations as dependent variables for 1996-2008. In addition, temporally resolved variables were available for traffic intensity and PM(10) emissions. To validate the resulting LUR models, they were applied to the locations of automatic monitoring stations and the estimated concentrations were compared against measured concentrations. The 2005 LUR models were successfully recalibrated, providing individual models for each year from 1996 to 2008. When applied to the monitoring stations the mean prediction error (MPE) for NO(2) concentrations for all stations and years was -0.8μg/m³ and the root mean squared error (RMSE) was 6.7μg/m³. For PM(10) concentrations the MPE was 0.8μg/m³ and the RMSE was 3.4μg/m³. These results indicate that it is possible to model temporal variation in air pollution through LUR with relatively small prediction errors. It is likely that most previous LUR studies did not include temporal variation, because they were based on short term monitoring campaigns and did not have historic pollution data. The advantage of this study is that it uses data from an air dispersion model, which provided concentrations for 2005 and 2010, and therefore allowed extrapolation over a longer time period.

Locked doors: a survey of patients, staff and visitors

ACCESSIBLE SUMMARY

• Locking of psychiatric wards doors is more frequent, but the impact is unknown. • Staff patients and visitors returned a questionnaire about the issue. • Patients did not like the door being locked as much as staff, and being on a locked ward was associated with greater rejection of the practice. • Staff working on locked wards were more positive about it than those who did not.

ABSTRACT

Locking the door of adult acute psychiatric wards has become increasingly common in the UK. There has been little investigation of its efficacy or acceptability in comparison to other containment methods. We surveyed the beliefs and attitudes of patients, staff and visitors to the practice of door locking in acute psychiatry. Wards that previously participated in a previous study were contacted and sent a questionnaire. A total of 1227 responses were obtained, with the highest number coming from staff, and the smallest from visitors. Analysis identified five factors (adverse effects, staff benefits, patient safety benefits, patient comforts and cold milieu). Patients were more negative about door locking than the staff, and more likely to express such negative judgments if they were residing in a locked ward. For staff, being on a locked ward was associated with more positive judgments about the practice. There were significant age, gender and ethnicity effects for staff only. Each group saw the issue of locked doors from their own perspective. Patients registered more anger, irritation and depression as a consequence of locked doors than staff or visitors thought they experienced. These differences were accentuated by the actual experience of the ward being locked.

Modelling air pollution for epidemiologic research--Part I: A novel approach combining land use regression and air dispersion

A common limitation of epidemiological studies on health effects of air pollution is the quality of exposure data available for study participants. Exposure data derived from urban monitoring networks is usually not adequately representative of the spatial variation of pollutants, while personal monitoring campaigns are often not feasible, due to time and cost restrictions. Therefore, many studies now rely on empirical modelling techniques, such as land use regression (LUR), to estimate pollution exposure. However, LUR still requires a quantity of specifically measured data to develop a model, which is usually derived from a dedicated monitoring campaign. A dedicated air dispersion modelling exercise is also possible but is similarly resource and data intensive. This study adopted a novel approach to LUR, which utilised existing data from an air dispersion model rather than monitored data. There are several advantages to such an approach such as a larger number of sites to develop the LUR model compared to monitored data. Furthermore, through this approach the LUR model can be adapted to predict temporal variation as well as spatial variation. The aim of this study was to develop two LUR models for an epidemiologic study based in Greater Manchester by using modelled NO(2) and PM(10) concentrations as dependent variables, and traffic intensity, emissions, land use and physical geography as potential predictor variables. The LUR models were validated through a set aside "validation" dataset and data from monitoring stations. The final models for PM(10) and NO(2) comprised nine and eight predictor variables respectively and had determination coefficients (R²) of 0.71 (PM(10): Adj. R²=0.70, F=54.89, p<0.001, NO(2): Adj. R²=0.70, F=62.04, p<0.001). Validation of the models using the validation data and measured data showed that the R² decreases compared to the final models, except for NO(2) validation in the measured data (validation data: PM(10): R²=0.33, NO(2): R²=0.62; measured data: PM(10): R²=0.56, NO(2): R²=0.86). The validation further showed low mean prediction errors and root mean squared errors for both models.

Household characteristics and allergen and endotoxin levels in Aleppo, Syrian Arab Republic

Few data are available from Eastern Mediterranean countries about levels of domestic allergens and endotoxins. Dust samples were collected from mattresses and floors of 457 homes in the Syrian city of Aleppo and analysed for antigens and endotoxins. The most important predictors for detectable levels of house-dust mite allergen Der p 1 were Arabic-style houses (OR 3.21) and newer houses (OR 1.56). In homes without cats, rubber mattresses were associated with detectable cat allergen Fel d 1 in mattress dust (OR 1.6). Cockroach allergen Bla g 2 was significantly more likely to be detected in houses over 20 years old than newer houses. Endotoxin levels were significantly higher in wool/cotton mattresses and older houses.