A Mathematical Modeling Approach to the Cort-Fitness Hypothesis

The Cort-Fitness Hypothesis has generated much interest from investigators integrating field endocrinology with evolutionary biology, ecology, and conservation. The hypothesis was developed to test the assumption that if glucocorticoid levels increase with environmental challenges and fitness decreases with environmental challenges, then there should be a negative relationship between baseline glucocorticoid levels and fitness. Indeed, studies across diverse taxa have found that the relationship between baseline glucocorticoid levels and fitness are not consistent: some studies show a positive relationship, others negative, and some show no correlation. Hence, a deeper understanding of the mechanisms underlying the relationship between baseline glucocorticoid levels, environmental challenges, and fitness is needed. We propose a mathematical model representing the links between baseline glucocorticoid levels, environmental challenges, and fitness. Our model describes how variation in the predictability and intensity of environmental challenges, reproductive strategies, and fitness metrics can all contribute to the variability observed in empirical tests of the Cort-Fitness Hypothesis. We provide qualitative results showing that much of the inconsistency in previous studies can be explained and we discuss how the model can be used to inform future Cort-Fitness studies.

Understanding stakeholder important outcomes and perceptions of equity, acceptability and feasibility of a care model for haemophilia management in the US: a qualitative study

INTRODUCTION

Care for persons with haemophilia (PWH) is most commonly delivered through the integrated care model used by Hemophilia Treatment Centers (HTCs). Although this model is widely accepted as the gold standard for the management of haemophilia; there is little evidence comparing different care models.

AIM

We performed a qualitative study to gain insight into issues related to outcomes, acceptability, equity and feasibility of different care models operating in the US.

METHODS

We used a qualitative descriptive approach with semi-structured interviews. Purposive sampling was used to recruit individuals with experience providing or receiving care for haemophilia in the US through either an integrated care centre, a specialty pharmacy or homecare company, or by a specialist in a non-specialized centre. Persons with haemophilia, parents of PWH aged ≤18, healthcare providers, insurance company representatives and policy developers were invited to participate.

RESULTS AND CONCLUSIONS

Twenty-nine interviews were conducted with participants representing 18 US states. Participants in the study sample had experience receiving or providing care predominantly within an HTC setting. Integrated care at HTCs was highly acceptable to participants, who appreciated the value of specialized, expert care in a multidisciplinary team setting. Equity and feasibility issues were primarily related to health insurance and funding limitations. Additional research is required to document the impact of care on health and psychosocial outcomes and identify effective ways to facilitate equitable access to haemophilia treatment and care.

Qualitative effects of omalizumab on concomitant IgE-mediated disease in a severe asthmatic population: a real life observational study

INTRODUCTION

Omalizumab is a recombinant humanized monoclonal antibody (anti-IgE) licensed for use in GINA 5 asthma or for chronic idiopathic urticaria. Many patients with asthma have concomitant allergic diseases such as dermatitis and sinusitis. IgE is also implicated in allergic-bronchopulmonary disease (ABPA). In addition, extreme sensitivity to allergen can prevent the initiation of allergen immunotherapy.

AIM

The aim of this study was to assess the efficacy of omalizumab on symptoms of concomitant non asthmatic IgE-mediated allergic disease in a population of severe GINA 5 in a real life observational setting.

DESIGN

This study is a retrospective, observational study assessing patients reported allergic, non-asthmatic symptom response to omalizumab treatment.

METHODS

Fifty-six severe asthmatics treated with omalizumab were studied. Thirty-seven patients had concomitant rhino-sinusitis, 13 had dermatitis and 4 ABPA. Subjects were asked to grade the improvement in their symptom scores on an analogue scale from 0 (no response) to 10 (excellent response).

RESULTS

Mean improvement from baseline was 5 and 1.8 in patients with allergic rhino-sinusitis and dermatitis, respectively. Mean improvement from baseline in respiratory symptoms in patients with ABPA was 4.0.

CONCLUSIONS

The results from our study suggest that omalizumab may have a role in allergic disease outside of its current license.

The Efficacy of Bronchial Thermoplasty for Severe Persistent Asthma: The First National Experience

There is an unmet need for new therapies in severe persistent asthma. Bronchial thermoplasty is a bronchoscopic procedure which employs radiofrequency energy to reduce airway smooth muscle and has been demonstrated to improve symptomatic control in severe persistent asthma in other populations. Seven patients have completed bronchial thermoplasty at a tertiary referral centre in Ireland. Asthma Control Test scores and data on hospitalisations, exacerbations, maintenance corticosteroid requirements, rescue bronchodilator use and peak expiratory flow rate (PEFR) were compared one year before and one year post treatment. Significant improvements were demonstrated in mean Asthma Control Test scores, from 8.9 to 14.7 (p = 0.036). Trends towards improvement were seen in mean hospitalisations (respective values for total in 12 month period 5.0, 0.9; p = 0.059) and PEFR (181.4 l/min, 280 l/min respectively; p = 0.059). These data support the use of bronchial thermoplasty in severe persistent asthma in the Irish population.

Palliative Subcutaneous Terbutaline Infusion in Severe Asthma

Continuous subcutaneous infusion of terbutaline (CSIT) has been shown to improve asthma control. As an adjunct to standard asthma pharmacotherapy, 3-12mg/day of CSIT can stabilise asthmatic symptoms, reduce hospitalisations and reduce corticosteroid need1,2. Asthmatics who demonstrate a wide diurnal variability in their peak-flows (>40%), termed brittle asthmatics tend to benefit the most from this therapy3. CSIT can have adverse effects and should only be used in specialist respiratory centres.

The Value of the Combined Assessment of COPD in Accurate Characterization of Stable COPD

There is evidence showing a tendency to upgrade COPD severity previously staged with spirometric-based GOLD (GOLD 1234) when using the new GOLD combined disease assessment (GOLD ABCD). The aim of our study was to compare the GOLD 1234 classification in a population of stable COPD patients with the GOLD ABCD classification to determine whether stable COPD was upgraded when using this new classification. After an observational study of a stable COPD cohort (n = 112), 61 patients (54.5%) had an increase in their COPD severity when moving from the old GOLD 1234 classification to the current GOLD ABCD assessment (p < 0.01). 42 patients (37.5%) had no change in severity of COPD. 9 patients COPD were assessed to be better on using GOLD ABCD. This study highlights previously missed high-risk patients when reviewing stable COPD. Continued incorporation of GOLD ABCD will translate into better evidence-based management.

Safety of Grass Pollen Sublingual Immunotherapy for Allergic Rhinitis in Concomitant Asthma

Seasonal allergic rhinitis (AR) occurs predominantly as a result of grass pollen allergy. Grass pollen sublingual immunotherapy (SLIT) has been proven effective in treating AR1. SLIT is currently licensed for use in AR with concomitant stable mild asthma. There is evidence that SLIT improves asthma control when primarily used to treat AR2. The aim was to assess the safety of SLIT in patients with severe seasonal allergic rhinitis who have co-existing stable mild asthma. The secondary aim was to determine whether asthma control improved post SLIT. There was no deterioration in asthma control after 6-36 months of SLIT. 27/30 (90%) patients' asthma control remained stable or indeed improved (p < 0.021). Of this 15 (50%) patients' asthma improved. There was no statistically significant change in their asthma pharmacotherapy after SLIT (p = 0.059). In conclusion, grass pollen SLIT is safe and can potentially treat dual allergic rhinitis- mild asthmatic patients.

The Efficacy of COPD Outreach in Reducing Length of Stay and Improving Quality of Life

COPD exacerbations results in prolonged hospitalisation, re-admissions, reduces health-related quality of life (HRQoL) and increases mortality. The study aimed to assess the efficacy of a COPD Outreach service in reducing average length of stay (ALOS), reducing readmissions within 90 days of admission, improving HRQoL and reducing mortality among COPD patients with acute exacerbations (AECOPD). AECOPD data for a 2 year period commencing September 2011 was analysed. The COPD Assessment test (CAT) quantified HRQoL at enrolment and 6 weeks post Outreach. COPD Outreach had an ALOS of 2.47 days compared to ALOS 8.59 days and 8.5 days for all AECOPD before and during an operational COPD Outreach. Re-admission rates among patients enrolled in COPD Outreach were 36.3%. CAT improved from mean 19.3 to 13.5. Mortality was 4.9% among Outreach patients and 2.5% for overall AECOPD in 2012-2013. COPD Outreach reduced ALOS and improved HRQoL for selected patients with AECOPD. It did not reduce re-admissions or mortality.

Treatment decision-making among Canadian youth with severe haemophilia: a qualitative approach

The first generation of young men using primary prophylaxis is coming of age. Important questions regarding the management of severe haemophilia with prophylaxis persist: Can prophylaxis be stopped? At what age? To what effect? Can the regimen be individualized? The reasons why some individuals discontinue or poorly comply with prophylaxis are not well understood. These issues have been explored using predominantly quantitative research approaches, yielding little insight into treatment decision-making from the perspectives of persons with haemophilia (PWH). Positioning the PWH as a source of expertise about their condition and its management, we undertook a qualitative study: (i) to explore and understand the lived experience of young men with severe haemophilia A or B and (ii) to identify the factors and inter-relationships between factors that affect young men's treatment decision-making. This manuscript reports primarily on the second objective. A modified Straussian, grounded theory methodology was used for data collection (interviews) and preliminary analysis. The study sample, youth aged 15-29, with severe haemophilia A or B, was chosen selectively and recruited through three Canadian Haemophilia Treatment Centres. We found treatment decision-making to be multi-factorial and used the Framework method to analyze the inter-relationships between factors. A typology of four distinct approaches to treatment was identified: lifestyle routine prophylaxis, situational prophylaxis, strict routine prophylaxis and no prophylaxis. Standardized treatment definitions (i.e.: 'primary' and 'secondary', 'prophylaxis') do not adequately describe the ways participants treat. Naming the variation of approaches documented in this study can improve PWH/provider communication, treatment planning and education.

Pulmonary Langerhans cell histiocytosis

We report the case of a 57 year old man who presented with increased shortness of breath together with increased pulmonary nodules in his upper lobes over a two year period. His strong smoking history and pattern of distribution makes Langerhans cell Histiocytosis a likely diagnosis that was confirmed on biopsy.

Sleep apnoea and its relationship with cardiovascular, pulmonary, metabolic and other morbidities

Sleep apnoea (OSAS) is a multisystem disorder. There is a high prevalence of cardiovascular and metabolic morbidities in patients investigated for sleep apnoea. We aim to evaluate any association between cardiovascular, metabolic and pulmonary co morbidities in patients investigated for OSAS and whether clinical findings based on Epworth sleep score (ESS) and snoring helps in diagnosing sleep apnoea. 258 consecutive patients who were electively admitted for sleep assessment in Peamount Hospital, Dublin from Sept 2009 to Aug 2011 were retrospectively reviewed. 139/258 were diagnosed as OSAS. Cardiovascular, metabolic and pulmonary co morbidities were 46.12%, 37.2% and 29% respectively. There is no correlation found between ESS, Snoring with Apnoea Hypopnoea Index in OSAS group. Screening for OSAS should be considered in patients with certain cardiovascular and metabolic disorders. PSG is so far considered the gold standard investigation to diagnose OSAS and better clinical evaluating tools need to be formulated.

A study into efficacy of omalizumab therapy in patients with severe persistent allergic asthma at a tertiary referral centre for asthma in Ireland

BACKGROUND

Asthma is a chronic airway disease characterized by airway inflammation, bronchial hyperresponsiveness and airflow obstruction. Patients with persistent symptoms despite maximum standard treatment as per Global Initiative of Asthma guidelines are considered to have severe persistent asthma. Omalizumab is a recombinant humanized monoclonal antibody licenced for use as an add-on therapy in these patients.

AIM

To assess the clinical benefit amongst responders to omalizumab therapy at a tertiary referral centre.

METHODS

This was a retrospective audit assessing the effect of omalizumab therapy on asthma control, frequency of exacerbation and hospitalization rates over 6 months before and after therapy.

RESULTS

The study included 30 responders (14 females). There was a reduction in exacerbation and hospitalization rates following initiation of omalizumab, 73 and 91%, respectively (P-value < 0.0001). The number of exacerbations decreased from 3.48 ± 2.20 to 0.93 ± 0.83 and the mean number of admissions decreased from 1.07 ± 1.1 to 0.1 ± 0.40 over the study duration (P < 0.001). There was 73% reduction in the weekly need for rescue salbutamol therapy with mean of 30.33 ± 6.49 puffs to 8.23 ± 1.51 puffs after omalizumab therapy (P < 0.0001). Seventy-nine per cent of patients were able to reduce their maintenance oral corticosteroid therapy.

CONCLUSION

Overall, responders to omalizumab therapy are less likely to experience an asthma exacerbation and hospitalization. They were also more likely to reduce maintenance corticosteroid therapy and the need for rescue reliever therapy. These data suggest that omalizumab has proven effective in improving health outcomes for a cohort of carefully selected patients with severe allergic asthma in Ireland.

The thickness of the falling film of liquid around a Taylor bubble

We present the results of laboratory experiments that quantify the physical controls on the thickness of the falling film of liquid around a Taylor bubble, when liquid–gas interfacial tension can be neglected. We find that the dimensionless film thickness λ ′ (the ratio of the film thickness to the pipe radius) is a function only of the dimensionless parameter , where ρ is the liquid density, g the gravitational acceleration, D the pipe diameter and μ the dynamic viscosity of the liquid. For , the dimensionless film thickness is independent of N f with value λ ′≈0.33; in the interval , λ ′ decreases with increasing N f ; for film thickness is, again, independent of N f with value λ ′≈0.08. We synthesize existing models for films falling down a plane surface and around a Taylor bubble, and develop a theoretical model for film thickness that encompasses the viscous, inertial and turbulent regimes. Based on our data, we also propose a single empirical correlation for λ ′( N f ), which is valid in the range 10 −1 < N f <10 5 . Finally, we consider the thickness of the falling film when interfacial tension cannot be neglected, and find that film thickness decreases as interfacial tension becomes more important.

Therapy with omalizumab for patients with severe allergic asthma improves asthma control and reduces overall healthcare costs

BACKGROUND

Patients with asthma who have persistent symptoms despite treatment with inhaled steroids and long-acting beta agonists are considered to have severe asthma. Omalizumab is a monoclonal antibody directed against IgE, which is used as an add-on treatment for patients who have severe persistent allergic asthma.

AIMS

The aim of this study was to assess the clinical benefit and healthcare utilisation of patients who responded to omalizumab therapy and to establish an overall cost implication.

METHODS

This was an observational retrospective cohort study designed to investigate the effect of omalizumab on exacerbations of asthma before and after 6 months of treatment in Irish patients.

RESULTS

Centres who had treated patients with severe allergic asthma for the 6 months prior and post omalizumab treatment were audited with a standardised assessment tool. Sixty-three (32 male) patients were studied. In the 6 months prior to omalizumab 41 of 63 (66%) had been hospitalised, and this fell to 15 of 63 (24%), p < 0.0001 in the 6 months after treatment was started. Hospital admissions reduced from 2.4 ± 0.41 to 0.8 ± 0.37 and the mean number of bed days occupied was reduced from 16.6 ± 2.94 to 5.3 ± 2.57 days, p < 0.001. The number of oral corticosteroid doses used fell from 3.1 ± 0.27 to 1.2 ± 0.17, p < 0.001. The overall cost saving per omalizumab responder patients for 6 months was <euro>834.

CONCLUSIONS

Six months therapy with omalizumab reduced the number of bed days, the number of hospitalisations and the use of oral corticosteroids compared to the 6 months prior to commencement. Despite the cost of the additional therapy there were overall savings in health costs.

An unusual cause of spontaneous pneumothorax: the Mounier-Kuhn syndrome

We present the case of a 54-year old woman referred to our service with an unusual presentation of an under-diagnosed condition. A life-long non-smoker, she was referred to respiratory services by our emergency department with a left sided pneumothorax, progressive dyspnoea on exertion, and recurrent chest infections. Subsequent investigation yielded findings consistent with Mounier-Kuhn syndrome (Tracheobronchomegaly), a condition characterised by marked dilatation of the proximal airways, recurrent chest infection, and consequent emphysema and bronchiectasis. Although rarely diagnosed, some degree of Mounier-Kuhn syndrome may occur in up to 1 in 500 adults.

Exercise induced fatigue: unfit or unwell?

This case report outlines the diagnoses of a rare myophosphorylase deficiency (McArdle Syndrome) in a unique way. A set of characteristic values from a Cardiopulmonary Exercise Test (CPET) combined with a typical patient history pointed to a failure of the glycolytic pathway in the skeletal muscle. McArdle Syndrome was confirmed with a skeletal muscle biopsy. There is no evidence of such a diagnostic method in the literature.

Spontaneous pneumothorax management

Guidelines for the management of spontaneous pneumothorax were published by the British Thoracic Society (BTS) in 2003. The aim of our study was to assess compliance with the BTS guidelines. A retrospective review was performed on all spontaneous pneumothoraces admitted to our hospital between June 2006 and December 2007. There were 29 pneumothoraces during the study period, 20 of which were primary spontaneous pneumothoraces (PSPs). All 15 (100%) large PSPs had an intercostal drain (ICD) inserted with a mean calibre of 20Fr, however only 1 of the 15 (6.7%) had a prior attempt at aspiration. High flow oxygen was used in 3/20 (15%) PSPs and 1/9 (11%) secondary spontaneous pneumothoraces (SSPs). 5/6 (83%) of large SSPs had ICDs placed with a mean calibre of 23.3Fr. Compliance with BTS guidelines was suboptimal. In particular, simple aspiration was underutilised with an over-reliance on unnecessary tube thoracostomy. Moreover, the calibre of intercostal drains used was in excess of BTS recommendations. This study highlights the need to formally adopt BTS guidelines, thereby establishing a more standardised practice which should improve management of spontaneous pneumothoraces.

Endoscopic ultrasound with fine needle aspiration and biopsy in lung cancer and isolated mediastinal lymphadenopathy

Endoscopic ultrasound with fine-needle aspiration and biopsy (EUS-FNAB) is well established in diagnosing and staging lung cancer in patients with mediastinal adenopathy. EUS-FNAB is highly sensitive, less invasive and has lower complication rates when compared to surgical staging of mediastinal nodes. In this study we describe our experience of EUS-FNAB in lung cancer and other causes of mediastinal lymphadenopathy. EUS-FNAB was performed for assessment of PET positive mediastinal lymph nodes between January 2007 and March 2009 in AMNCH. The endpoints of our study were sensitivity and specificity of EUS-FNAB, morbidity and length of hospital stay. Thirty four patients underwent EUS-FNAB during the study period for both diagnosis and staging. Thirty patients had positive lymph node invasion and 4 had no evidence of malignant invasion. In these 4 patients negative cytology was confirmed on mediastinoscopy giving EUS-FNAB a sensitivity and specificity of 100%. EUS-FNAB upstaged the disease in 12 patients. EUS-FNAB is a reliable tool for mediastinal staging in lung cancer, significantly reducing the need for surgical staging procedures in patients with suspected mediastinal involvement.

Compliance in the measurement of CURB-65 in patients with community acquired pneumonia and potential implications for early discharge

The CURB-65 community-acquired pneumonia (CAP) severity score is a convenient 5-variable disease-specific tool validated to predict mortality and the decision to admit. This prospective study seeks to determine (a) the accuracy CAP diagnosis; (b) the degree to which the CURB-65 score was being documented; and (c) the degree to which CURB-65 was being utilised as an admission and early discharge tool in the A&E Department in the evaluation of patients presenting with CAP. Of 45 patients referred with an admitting diagnosis of CAP, 28 were subsequently found to satisfy the criteria of CAP, an over diagnosis of 38%. Documentation of CURB-65 was 7%; recording of core variables was 81% i.e. 4 out of 5 variables and confusion was the variable least likely to be documented. On re-scoring, 50% of patients had a score of 0 or 1 and a further 28% had a score of 2. We conclude that CAP is significantly overdiagnosed; that the CURB-65 severity score is not being utilised and that between 50 and 78% of patients with CAP may be admitted unnecessarily. This study raises important issues in the current management of CAP in the Irish Healthcare system.

311 RISK ASSESSMENT OF α-LACTALBUMIN TRANSGENIC PIGS

Assessment of the general risk posed by transgenic animals is important to their future contributions to society. Identification of potentially harmful properties of transgenic livestock is the initial step in a risk assessment. Direct and indirect impacts of potential harmful properties of transgenic livestock need to be evaluated at 3 levels: (1) characterization of how the transgene, the transgene product, and the transgenic livestock behave in their immediate environment; that is, in their barn or pen; (2) determination of possible impacts of large-scale release of transgenic livestock; that is, if they were to be integrated into the larger population of food animal livestock; and (3) determination of the more complex environmental and safety consequences of their release into the livestock population. We previously developed and characterized transgenic swine containing a mammary-specific transgene (bovine α-lactalbumin, bALAC) that results in increased milk production in sows (Bleck et al. 1998). We are currently determining whether bALAC is expressed in tissues of transgenic (T) swine other than the lactating mammary gland, and whether the transgene (DNA; Tg) crosses into non-transgenic control (C) swine under various physiological and physical conditions. The specific aims addressed in the present study were to determine (1) whether the Tg can be transferred directly from T animals to C animals by physical association or contact, and (2) whether the Tg can be transferred directly from an adult T animal to an adult C animal via mating. The T animals utilized in these studies were in generation 10 at least and have stable incorporation of the Tg. Comparable age- and weight-matched animals, T and C, were housed together allowing for general contact that is normal within swine production, for 180, 220, or 250 days after weaning. Due to the nature of swine behavior, these animals may ingest saliva, regurgitated food, and stool and urinary products as well as other bodily fluids and cells during normal housing and establishment of dominance hierarchy. In a second study, vaginal, cervical, uterine, oviductal, and ovarian tissues were collected from C females on 2 or 7 days after mating to T males. The presence of Tg in tissues from all C animals was tested via PCR. We have analyzed for the presence of the Tg in various tissues, including mammary gland, salivary gland, skin (sebaceous gland), muscle, lung, liver, kidney, brain, ovary, oviduct, uterus, cervix, vagina, and intestine. Preliminary results indicate no presence of the Tg in tissues of C animals (n = 20) after cohabitation for 180, 220, or 250 days (n = 201 samples analyzed) or at 2 (n = 3) or 7 (n = 5) days post-mating (n = 38 and 59 samples analyzed, respectively). This work provides a critical first step toward providing rigorous scientific data for risk assessment of transgenic livestock. The USDA BRAG Program, Project No. 2005–03799, supported this work.

Embryonic disc development and subsequent viability of cattle embryos following culture in two media under two oxygen concentrations

Bovine embryos were produced in vitro using a 2 x 2 design of modified medium (KSOM or SOF) and oxygen concentration (5% or 20%). Day 7 blastocysts were transferred in bulk (n = 11, on average) to recipient heifers and recovered non-surgically at Day 14. In two replications of a Latin square, eight heifers received embryos from each combination of factors. Recovered embryos were evaluated for trophoblast length and width, as well as the presence and diameter of an embryonic disc (ED). An ED was detected in a higher percentage of embryos that had been cultured in KSOM than SOF (72% v. 46%, respectively; P < 0.05). The aim of a second series of experiments was to associate Day 14 morphology with subsequent developmental capacity. In vitro-produced blastocysts were transferred (n = 17-20) on Day 7 to each of eight heifers and recovered at Day 14. Thirty-eight blastocysts were retransferred to heifers following morphological evaluation. Embryos in which an ED with no signs of degeneration had been detected maintained more pregnancies than other embryos in which an ED had either shown signs of degeneration or had not been detected (5/8 v. 2/30, respectively; P < 0.01). Further investigation into ED integrity at the elongating stage may contribute to our understanding of pregnancy establishment and maintenance.

The role of endobronchial electrocautery in the management of malignant airway obstruction

Bronchoscopy has evolved well beyond a simple look-see examination, with new interventional techniques becoming more commonly employed. So-called interventional bronchoscopy implies the use of bronchoscopy as a therapeutic, in addition to diagnostic, tool. We present 2 cases to illustrate the utility of one such interventional technique, tumour ablation by endobronchial electrocautery and snaring, in the management of airway obstruction by tumour. This procedure, performed via a flexible bronchoscope under local anaesthesia can spare patients time-consuming, expensive treatments with their attendant morbidity, and in some cases can be life-saving. There is minimal morbidity associated with this technique. It is anticipated that interventional bronchoscopy will continue to revolutionise management of such conditions in the future, and become a necessary facility in all pulmonary medicine units.

Evaluation of the efficacy of nebulised lignocaine as adjunctive local anaesthesia for fibreoptic bronchoscopy: a randomised, placebo-controlled study

Optimisation of topical anaesthesia for flexible fibreoptic bronchoscopy (FOB) is becoming increasingly important as a wider range of more complex, and thereby more prolonged, interventional endoscopic procedures are becoming available. Lignocaine is the most commonly used topical anaesthetic agent for bronchoscopy, but there is variability in current practice as to its optimum mode of administration. In this prospective, randomised, placebo-controlled, blinded study, we examine whether there was enhanced effectiveness of additional nebulised lignocaine as compared to our current regime utilising two visual analogue scales as markers of efficacy. Treatment groups were matched in terms of age (p = 0.39), gender, concomitant sedation (p = 0.51 midazolam; p = 0.12 fentanyl) and dose of background administered lignocaine (290 mg). We found no significant additional differences between any of the treatment groups in terms of general ease of procedure (p = 0.09) or in cough severity (p = 0.12). We conclude that this study does not support the hypothesis that additional nebulised lignocaine confers any additional benefit to the ease of procedure or cough severity in patients undergoing fibreoptic bronchoscopy. We suggest that preparation regimes for bronchoscopic examinations need optimization.

200 TRANSPLANTATION AND IN VIVO DIFFERENTIATION OF ADIPOSE-DERIVED STEM CELLS IN SWINE

A primary concern in stem cell biology is that observations made in vitro may be an artifact of the in vitro culture environment. In vitro derived stem cells can be implanted into the environment from which they are derived so that their response to physiological conditions may be observed. Several important cellular characteristics need to be examined following the cell's reintroduction to the in vivo environment, including the potential for differentiation, proliferative ability, and life span. Studying implanted stem cells will assist in determining the potential for stem cell use in clinical therapies and provide further understanding of the role adult stem cells have in the adult body. Currently, the scientific literature is lacking a detailed description of the cellular response of adipose-derived stem cells (ADSCs) reintroduced to their exact tissue of origin. Thus, the aim of this study was to evaluate porcine ADSC growth in vivo and to analyze cell differentiation in vivo following injection of undifferentiated ADSCs into subcutaneous fat. Subcutaneous adipose tissue was isolated from the back fat of male pigs (11 months of age) and digested with 0.075% collagenase at 37�C for 90 min. The digested tissue was centrifuged at 200g for 10 min to obtain a cell pellet. The pellet was re-suspended with DMEM and the ADSCs were plated onto 75 cm2 flasks (5000-10 000 cells per cm2) and cultured in DMEM supplemented with 10% fetal bovine serum (FBS) and 1% gentamicin. Passage 3 ADSCs were labeled with fluorescent dye (PKH26; Sigma, St. Louis, MO, USA) and sorted by flow cytometry. After sorting, positive cells were washed and re-suspended in culture medium. For transplantation, 100 �L of cell suspension in DMEM containing one of four cell concentrations (0 (control); 30 000; 300 000; and 900 000 cells) were placed in a 1-mL syringe and injected into the subcutaneous back fat of recipient pigs (n = 2). Each pig had previously been tattooed with 12 13 � 13 squares to mark injection sites. The treatments were replicated three times within each animal. Two and three weeks after transplantation, animals were euthanized, the back fat containing the transplantation site was harvested, and the cells were disaggregated as described above. The buoyant adipocytes and pelleted ADSCs cells were then analyzed by flow cytometry. The results indicated that there were dose- and time-dependent increases in labeled ADSCs and labeled adipocytes in the fat samples with increasing cell number (from 0 to 300 000 cells). There was, however, a decrease in labeled ADSCs at the 900 000-cell dose, which is likely due to excess cells being transplanted or an immune reaction. Both of these aspects are currently being evaluated. In conclusion, undifferentiated ADSCs from swine can be isolated from and returned to the subcutaneous adipose layer and differentiate into mature adipocytes. This work was supported by the Council for Food and Agricultural Research (C-FAR) Sentinel Program, University of Illinois.

Role for macrophage migration inhibitory factor in asthma

Macrophage migration inhibitory factor (MIF) is an immunologic regulator that is expressed in inflammatory and autoimmune disorders. We investigated MIF's role in asthma using genetic approaches in a mouse model and in a cohort of asthma patients. Mice genetically deficient in MIF that were primed and aerosol-challenged with ovalbumin showed less pulmonary inflammation and lower airway hyperresponsiveness than genetically matched, wild-type controls. MIF deficiency also resulted in lower titers of specific IgE, IgG(1), and IgG(2a), and decreased pulmonary, T(H)2 cytokine levels. IL-5 concentrations were lower and corresponded to decreased eosinophil numbers in bronchoalveolar lavage fluid. T cell studies also showed a lower level of antigen-specific responses in MIF-KO versus wild-type mice. In an analysis of 151 white patients with mild, moderate, or severe asthma (Global Initiative for Asthma criteria), a significant association was found between mild asthma and the low-expression, 5-CATT MIF allele. Pharmacologic inhibition of MIF may be beneficial and could be guided by the MIF genotype of affected individuals.

The implementation of a nurse-provided, ward-based bilevel non-invasive ventilation service

Bilevel non-invasive ventilation (NIV) is now standard of care for patients with acute hypercapnic respiratory failure (AHRF), and has an increasing role to play in patients with stable chronic hypercapnic respiratory failure (CHRF). The institution of an NIV service in a hospital setting requires major infrastructural and multidisciplinary input to be effective. This paper describes our experiences in setting up a 24-hour, nurse-provided, ward-based NIV service in a new acute teaching hospital in Dublin over a 39-month period. In addition, we provide audit data on 78 patients with AHRF treated with NIV by this service over this time period. The majority of patients (65) had their respiratory acidosis corrected and were discharged home; 11 patients failed NIV and were intubated and mechanically ventilated in the ITU; 13 patients died, 8 from respiratory causes and 5 from non-respiratory causes, indicating the critical nature of this condition.

COPD: illness severity, resource utilisation and cost

COPD is a major source mortality and morbidity International evidence suggests the associated financial burden substantial. This research was undertaken to capture the costs associated with COPD in an Irish secondary care setting. 150 COPD patients attending a respiratory clinic were interviewed. Data on healthcare utilisation were collected. Prescription data and clinical severity data were collected from patient notes. The average direct cost of COPD was estimated at 4,730 euros. Secondary care costs accounted for 44% of total costs. Lost productivity averaged 668 euros. The main direct cost driver was in-patient admissions. A positive relationship was found between average direct costs and both clinical and symptom severity. The costs of COPD increased with increasing illness severity driven mainly by secondary care in-patient costs. If illness progression can be slowed and symptom severity can be reduced it may be possible to achieve significant reductions in expenditure and free resources within the healthcare system.

Auditing a new lung cancer service

The Adelaide and Meath Hospital (AMNCH) is a new hospital, with the respiratory service established in 1999. We report on our experience with lung cancer in this short time. We conducted a retrospective chart audit, identifying patients from the Oncology Nurse patient list, of lung cancer cases diagnosed in 2001-2002. In 2001, 47 cases were diagnosed, with 71 cases diagnosed in 2002. Time to tissue diagnosis was 14.8, 2-46 (mean, range, one subject skewing the data) days. Diagnosis by tissue type was as follows: non-small cell carcinoma (NSCLC) n=92 (77.9%), small cell lung carcinoma (SCLC) n=17 (14.4%), mesothelioma n=2 (17%), carcinoid n=1 (0.8%) and no tissue diagnosis n=6 (5.1%). Staging of NSCLC: stage 1a n=3 (3.2%), stage 1b n=6 (6.5%), stage 2a n=5 (5.4%), stage 2b n=2 (2.2%), stage 3a n=10 (10.9%), stage 3b n=22 (23.9%) and stage 4 n=44 (47.8%). Staging of SCLC: limited stage n=5 (29.4%), extensive stage n=12 (70.6%). Positive emission tomography (PET) was employed in the staging of 22 patients. In these patients PET up-staged the disease in 8 patients, and management was unchanged in 8 patients. We conclude that 1. the relatively new respiratory service in AMNCH is handling increasing numbers of lung cancer cases, 2. cases are diagnosed within an acceptable time-frame, 3. rate of tissue diagnosis is comparable to national figures, 4. most patients present with advanced disease and 5. PET is a useful imaging modality for detection of cancer spread in selected patients.

Corticosteroid-insensitive asthma: molecular mechanisms

Corticosteroids are the most potent anti-inflammatory agents used to treat chronic inflammatory diseases such as bronchial asthma. However, there are a small number (<5%) of asthmatic patients who do not respond well, or at all, to corticosteroid therapy - the corticosteroid-resistant and corticosteroid-dependent patients. Although this phenomenon is relatively uncommon, it poses a difficult therapeutic problem because few alternative therapies are available and these patients account for >50% of the health care costs of asthma. If the mechanisms for corticosteroid insensitivity are understood they may, in turn, provide insight into the key mechanism of corticosteroid action and allow a rational way to treat these individuals whose disease tends to be severe. Corticosteroid insensitivity is not limited to asthma and is a feature of other inflammatory diseases, such as rheumatoid arthritis and inflammatory bowel disease. Thus, elucidation of the cause for the relative lack of corticosteroid response in this subgroup of asthmatic individuals may have important implications for other diseases.