Asthma control with extrafine-particle hydrofluoroalkane-beclometasone vs. large-particle chlorofluorocarbon-beclometasone: a real-world observational study

BACKGROUND

The extrafine-particle formulation of hydrofluoroalkane-beclometasone (EF HFA-BDP; Qvar®) demonstrates improved total and small airway deposition compared with large-particle chlorofluorocarbon (CFC)-BDP. In some short-term studies, EF HFA-BDP provides greater effects on lung function than CFC-BDP, and hence is recommended to be prescribed at a lower dose, but whether there are differences in asthma outcomes during long-term treatment is unknown.

OBJECTIVE

To compare the effectiveness of EF HFA-BDP vs. CFC-BDP over 1 year.

METHODS

This retrospective matched cohort study examined outcomes in a large primary care database for patients aged 5-60 years with asthma receiving their first inhaled corticosteroid (ICS) prescription (initiation population) or first ICS dose increase (step-up population) by a pressurized metered-dose inhaler (pMDI) as EF HFA-BDP or CFC-BDP. Patients were matched on baseline demographic and asthma severity measures in EF HFA-BDP:CFC-BDP ratios of 1:3 and 1:2 for initiation and step-up populations, respectively. Step-up patients were matched also on ICS dose during a baseline year. Co-primary endpoints were asthma control (composite measure comprising no recorded hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory infection) and exacerbation rate during the outcome year.

RESULTS

For the initiation population (EF HFA-BDP n=2882; CFC-BDP n=8646), adjusted odds of achieving asthma control with EF HFA-BDP vs. CFC-BDP was 1.15 (95% CI 1.02-1.28). For the step-up population (n=258 and 516), adjusted odds of asthma control with EF HFA-BDP was 1.72 (95% CI 1.14-2.56). EF HFA-BDP was prescribed at a median dose half that of CFC-BDP.

CONCLUSION AND CLINICAL RELEVANCE

During 1 year after initiating or stepping up ICS therapy by pMDI, patients who received EF HFA-BDP were more likely to achieve asthma control than those receiving CFC-BDP. These findings suggest that ICS formulation, particle size, and deposition characteristics play important roles in real-life effectiveness of asthma therapy. This study shows that an EF-particle formulation of beclometasone can be used at half the dose of the large-particle formulation with at least as good clinical outcomes.

Adhesive bowel obstruction? Not always

A 58-year-old man presented acutely with features of post-surgical adhesive small bowel obstruction. Following an unsuccessful trial of conservative management, computed tomography (CT) of the abdomen was performed. This revealed a mass in the ileocaecal region, for which he underwent a subsequent right hemicolectomy. Histology revealed diffuse B-cell Non-Hodgkin's lymphoma of the terminal ileum. Confounding obstructive lesion of the intestine in patients with a history of previous laparotomy is extremely uncommon. Early high resolution imaging may predict diagnosis and consolidate clinical management plans.

Development of the Fibromyalgia Burden Assessment: measuring the multifaceted burden of fibromyalgia

OBJECTIVES

To develop a questionnaire assessing the burden of fibromyalgia's impacts on patients' lives.

METHODS

A literature review was conducted to identify impacts of fibromyalgia and their consequences on patients' lives. Exploratory interviews were performed with 15 fibromyalgia patients in France, Germany and Spain. Using patients' wording, items were generated simultaneously in French, German, Spanish, and UK English. Relevance and comprehension of the resulting questionnaire versions were tested with 21 additional fibromyalgia patients; questionnaires were revised accordingly.

RESULTS

Three domains, Burden associated with the impacts of fibromyalgia, Symptoms and Influencing factors, were identified from the literature review. Following patient interviews, the burden domain was further divided based on the nature of the impact: Pain, Physical impact (including tiredness, sleep problems and other symptoms), Activities of Daily Living impact (including autonomy and coping), Social and Family Life impact, Work, Studies and Personal Finances impact, Psychological impact (including cognitive impact), and Relationship to Medicine and Disease. The resulting test versions of the questionnaire contained 79 items. Comprehension tests identified problematic items and cultural differences and suggested deletions or rewording. After revision and linguistic harmonization, the pilot version of the questionnaire contained 62 items divided into 7 sections, and was named Fibromyalgia Burden Assessment (FMBA©).

CONCLUSIONS

The FMBA is a self-reported questionnaire allowing the assessment and a better understanding of the impacts of fibromyalgia and the burden associated with these on patients' daily lives. It is available in UK English, French, German and Spanish. Its scoring and validation remain to be undertaken.

New genotypes and factors associated with Cryptosporidium detection in mussels (Mytilus spp.) along the California coast

A 3 year study was conducted to evaluate mussels as bioindicators of faecal contamination in coastal ecosystems of California. Haemolymph samples from 4680 mussels (Mytilus spp.) were tested for Cryptosporidium genotypes using PCR amplification and DNA sequence analysis. Our hypotheses were that mussels collected from sites near livestock runoff or human sewage outflow would be more likely to contain the faecal pathogen Cryptosporidium than mussels collected distant to these sites, and that the prevalence would be greatest during the wet season when runoff into the nearshore marine environment was highest. To test these hypotheses, 156 batches of sentinel mussels were collected quarterly at nearshore marine sites considered at higher risk for exposure to livestock runoff, higher risk for exposure to human sewage, or lower risk for exposure to both faecal sources. Cryptosporidium genotypes detected in Haemolymph samples from individual mussels included Cryptosporidium parvum, Cryptosporidium felis, Cryptosporidium andersoni, and two novel Cryptosporidium spp. Factors significantly associated with detection of Cryptosporidium spp. in mussel batches were exposure to freshwater outflow and mussel collection within a week following a precipitation event. Detection of Cryptosporidium spp. was not associated with higher or lower risk status for exposure to livestock faeces or human sewage sources. This study showed that mussels can be used to monitor water quality in California and suggests that humans and animals ingesting faecal-contaminated water and shellfish may be exposed to both host-specific and anthropozoonotic Cryptosporidium genotypes of public health significance.

Survivin expression in in situ and invasive breast cancer relates to COX-2 expression and DCIS recurrence

In lung cancer cyclooxygenase-2 (COX-2) expression has been reported to stabilise survivin, an inhibitor of apoptosis (IAP) which prevents cell death by blocking activated caspases. COX-2 expression limits the ubiquitination of survivin, protecting it from degradation. To determine if COX-2 expression in breast cancer showed an association with survivin expression, we assessed the levels of each protein in ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC); relating expression patterns to recurrence of DCIS after surgery. Patterns of COX-2 and survivin expression were determined by intensity-graded immunohistochemistry of the primary tumours. Patients with DCIS (n=161) which had either recurred (n=47) or shown no evidence of recurrence (n=114) 5 years following primary surgery were studied. These were compared to 58 cases of IBC. Survivin was expressed in the cytoplasm of 59% of DCIS and 17% of IBC. High levels of both cytoplasmic survivin and COX-2 expression significantly correlated to DCIS recurrence. COX-2 expression was present in 72% of DCIS, and levels of expression positively correlated with cytoplasmic survivin expression in DCIS and invasive disease. The majority of DCIS that recurred expressed both proteins (69%) vs 39% nonrecurrent. Recurrence was not seen in DCIS lacking both proteins at 5 years (P=0.001). Expression of the IAP survivin is increased in DCIS and correlates closely with COX-2 expression. Increased expression of IAP, (leading to reduced apoptosis) may explain the effect of COX-2 in increasing recurrence of DCIS after surgical treatment.

Operational Performance of Waste-to-Energy Plants

The recovery of heat from the mass incineration of solid waste can make a useful contribution to the nation's energy needs. Whilst we have been slow to exploit fully this resource in Great Britain, there are some notable plants both here and abroad which have demonstrated commercial success over a number of years. When operated with engineering judgement they are reliable and dispose of waste economically in urban areas.

Anti-reflux surgery for the neonatal intensive care-dependent infant

AIM

The benefit of anti-reflux surgery for gastro-oesophageal reflux (GOR) in early infancy is uncertain. The aim of this study was to assess the value of Nissen fundoplication in a group of infants with severe GOR.

METHODS

10 infants underwent Nissen fundoplication for gastro-oesophageal reflux following a failure of medical management. All had suffered life-threatening respiratory episodes as a consequence of gastro-oesophageal reflux, and were neonatal intensive care-dependent. Median (range) birth weight was 1.26 kg (0.48-3.8 kg), gestation 30 weeks (25-38 weeks); at surgery, weight was 3.25 kg (2.5-6.1 kg) at a corrected age of 11.5 weeks (term-22) weeks. For each infant, the success of enteral feeding and the level of support required pre- and post-operatively was compared, and where appropriate, the facilitation of palliative feeding was assessed. Median follow-up was 14 (3-36) months.

RESULTS

No infant suffered intra-operative morbidity or mortality. One infant died within 1 month of surgery from a collapse unrelated to surgery. Eight of nine surviving infants were discharged from intensive care following extubation and the establishment of enteral feeding. One patient died of severe bronchopulmonary dysplasia 3 months post-surgery. One infant developed a gastrostomy site infection, and two required gastrostomy tube replacement within 6 months of surgery. All were thriving at follow-up. Two infants with a congenital myopathy died as a result of their muscle disease at 9 and 11 months post-operatively.

CONCLUSIONS

Nissen fundoplication is a feasible, effective and safe operation in severe gastro-oesophageal reflux unresponsive to medical treatment in term and pre-term infants. It has an additional important role in facilitating safe palliative enteral feeding in infants with a diagnosis incompatible with survival into adulthood.

Intermittent enteral nutrition--a comparative study examining the effect on gastric pH and microbial colonization rates

In a prospective randomized study we aimed to examine the effect on gastric pH and microbial colonization of enteral nutrition (EN) delivered both by intermittent and continual infusion. Forty-three mechanically ventilated patients were randomized to receive EN by one of three methods, intermittent or continual gastric or continual jejunal. We sampled gastric aspirate for pH and culture in all patients at 0600 hours and pH in gastric intermittent feeders at 2200 hours daily. Patients were studied for 12 days or until extubated. Data was obtained on 41 patients, of whom 73% had a diagnosis of trauma. Median APACHE II score was 17 and ventilation time 11 days. Twelve patients received gastric continuous, 15 gastric intermittent and 14 jejunal nutrition. No significant difference was observed between the three groups with regard to median 0600 pH (P = 0.16). This was lowest in the jejunal group (3.2) followed by the gastric intermittent group (4.0) and then gastric continuous group (5.0). With overnight cessation of EN in the gastric intermittent group, the median pH fell from 5.2 at 2200 to 4.0 at 0600 (P = 0.01) with no effect on gastric colonization. The probability of gastric colonization over time however was significantly lower in the jejunal group compared with the two gastric groups (Log rank test, P = 0.02). These results demonstrate that in a patient population consisting predominantly of trauma, overnight cessation of EN made no overall difference to 0600 gastric pH or colonization rates. The preservation of pH and lowered colonization in those given jejunal feeding may have implications in the pathogenesis of ventilator-associated infection and may warrant further study using larger patient numbers.

Assessing the burden of respiratory disease in the UK

This review explores the health and social burden of some of the main respiratory diseases (asthma, chronic obstructive pulmonary disease, cryptogenic fibrosing alveolitis, cystic fibrosis, lung cancer, mesothelioma, obstructive sleep apnoea and tuberculosis) in order to increase awareness of these diseases and highlight areas where improvements in care are required. The overall impact of respiratory diseases in the U.K. in terms of prevalence, mortality, morbidity and economic costs, with particular reference to secondary care has been considered and comparisons made with the rest of Europe where data are available. Respiratory diseases are responsible for a significant proportion of serious morbidity and premature death among the population of the U.K. and they will continue to present a growing challenge; special support is needed to tackle this burden.

Effects of fluticasone propionate on inflammatory cells in COPD: an ultrastructural examination of endobronchial biopsy tissue

BACKGROUND

Inhaled corticosteroids (ICS) markedly reduce bronchial mucosal inflammation in asthma but whether they have an anti-inflammatory effect in airway tissue in chronic obstructive pulmonary disease (COPD) is unknown.

METHODS

A study of endobronchial biopsy samples was conducted as part of a double blind, placebo controlled, randomised trial of parallel design. Patients had mild to moderately severe COPD (FEV(1) 25-80% of predicted) and were given 3 months treatment with ICS, fluticasone propionate (FP; 500 micro g twice daily, n=14) or placebo (n=10). Biopsy tissue taken at baseline and after treatment was examined by transmission electron microscopy to count the numbers of all ultrastructurally distinct inflammatory cells.

RESULTS

Compared with their baseline values, FP resulted in a significant decrease (on average 65%) in the numbers of mucosal mast cells (median 7.8 (range 1-33) v 2.8 (1-14), p<0.05). The reductive effect of FP held true when the post-treatment values of the placebo and FP groups were compared: 8.8 (1-24) v 2.8 (1-14) (p<0.05). Unexpectedly, there were significantly more neutrophils in the FP than in the placebo group: 4.0 (0-23) v 1.7 (0-8), respectively (p<0.05). There were no alterations to other cell types including mononuclear cells. Symptoms markedly improved in the patients treated with FP for 3 months.

CONCLUSION

Fluticasone propionate given for 3 months to patients with COPD has selective effects on the inflammatory cells in the bronchial mucosa: the reduction in mast cell numbers may account for the improvement in symptoms over this time.

A review and assessment of tributyltin contamination in the North Sea, based on surveys of butyltin tissue burdens and imposex/intersex in four species of neogastropods

It is evident from measures of butyltin tissue burdens and imposex or intersex in neogastropods that tributyltin (TBT) contamination of coastal waters and open parts of the North Sea is now low. It has been declining for at least the past decade. This is probably due to two measures. First, regulations prohibiting the use of TBT-based paints on small boats and fish farms have reduced inputs of TBT from these sources so that they are now negligible (except possibly where the regulations are flaunted). Second, there is evidence from sites, where commercial vessels are the sole source of TBT, that the adoption of TBT SPC paints has been effective in reducing environmental levels of these contaminants. However, poor dockyard practices, allowing TBT-contaminated wastes, including paint flakes, to accumulate in sediments have left a legacy of hot-spots of contamination in some ports. The impact is localised so that TBT contamination is low in coastal areas immediately adjacent to ports.