Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

Secondhand smoke exposure in school children in Malta assessed through urinary biomarkers

School children may be exposed to secondhand smoke (SHS) either at home, in transit or in social gatherings permitting smoking in their presence. Questionnaires about SHS often underestimate prevalence and extent of exposure. A more accurate tool is the use of biomarkers such as cotinine (COT) and trans-3'-hydrocycotinine (3HC) as biomarkers of SHS exposure, alongside 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a reduction product in the body of the tobacco-specific nitrosamine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), both potent carcinogens. We measured urinary COT, 3HC and total NNAL using sensitive and specific high-performance LC-MS/MS methods. The limit of quantification (LOQ) for each assay were 0.05 ng/mL, 0.1 ng/mL and 0.25 pg/mL respectively. The aim of this study was to evaluate the exposure to SHS of school children (9-11 years), from five public schools in the island of Malta, from questionnaire information about smoking at home and verify it by urinary biomarker data of COT, 3HC and NNAL. These biomarkers were measurable in 99.4%, 95.4% and 98.3% of the participating children respectively. From the children reporting smoking at home, 11% had a history of asthma and had COT, 3HC and NNAL geometric mean concentrations double compared to the non-asthmatic group. In has been confirmed that non-smokers exposed to SHS and THS have a higher NNAL/COT ratio than the group identified as smokers according to specific and defined COT threshold levels (despite the fact that a priori, the entire study group was composed of non-smokers). The implication of high measured levels of urinary NNAL in children should be of concern given its potency. A main effects multifactor ANOVA model was developed and the children's house and school locations and the smoking frequency were statistically significant to predict the levels of the three metabolites. For 3HC only, the status of the employment of the mother was also an important predictor.

Differentiation of COVID-19 signs and symptoms from allergic rhinitis and common cold: An ARIA-EAACI-GA2 LEN consensus

Background

Although there are many asymptomatic patients, one of the problems of COVID‐19 is early recognition of the disease. COVID‐19 symptoms are polymorphic and may include upper respiratory symptoms. However, COVID‐19 symptoms may be mistaken with the common cold or allergic rhinitis. An ARIA‐EAACI study group attempted to differentiate upper respiratory symptoms between the three diseases.

Methods

A modified Delphi process was used. The ARIA members who were seeing COVID‐19 patients were asked to fill in a questionnaire on the upper airway symptoms of COVID‐19, common cold and allergic rhinitis.

Results

Among the 192 ARIA members who were invited to respond to the questionnaire, 89 responded and 87 questionnaires were analysed. The consensus was then reported. A two‐way ANOVA revealed significant differences in the symptom intensity between the three diseases (p < .001).

Conclusions

This modified Delphi approach enabled the differentiation of upper respiratory symptoms between COVID‐19, the common cold and allergic rhinitis. An electronic algorithm will be devised using the questionnaire.

The Impact of COVID-19 on Hospitalised COPD Exacerbations in Malta

METHOD

Data was collected retrospectively from electronic hospital records during the periods 1st March until 10th May in 2019 and 2020.

RESULTS

There was a marked decrease in AECOPD admissions in 2020, with a 54.2% drop in admissions (n = 119 in 2020 vs. n = 259 in 2019). There was no significant difference in patient demographics or medical comorbidities. In 2020, there was a significantly lower number of patients with AECOPD who received nebulised medications during admission (60.4% in 2020 vs. 84.9% in 2019; p ≤ 0.001). There were also significantly lower numbers of AECOPD patients admitted in 2020 who received controlled oxygen via venturi masks (69.0% in 2020 vs. 84.5% in 2019; p = 0.006). There was a significant increase in inpatient mortality in 2020 (19.3% [n = 23] and 8.4% [n = 22] for 2020 and 2019, respectively, p = 0.003). Year was found to be the best predictor of mortality outcome (p = 0.001). The lack of use of SABA pre-admission treatment (p = 0.002), active malignancy (p = 0.003), and increased length of hospital stay (p = 0.046) were also found to be predictors of mortality for AECOPD patients; however, these parameters were unchanged between 2019 and 2020 and therefore could not account for the increase in mortality.

CONCLUSIONS

There was a decrease in the number of admissions with AECOPD in 2020 during the COVID-19 pandemic, when compared to 2019. The year 2020 proved to be a significant predictor for inpatient mortality, with a significant increase in mortality in 2020. The decrease in nebuliser and controlled oxygen treatment noted in the study period did not prove to be a significant predictor of mortality when corrected for other variables. Therefore, the difference in mortality cannot be explained with certainty in this retrospective cohort study.

Pleural Fluid Has Pro-Growth Biological Properties Which Enable Cancer Cell Proliferation

Objectives

Patients with malignant pleural mesothelioma (MPM) or pleural metastases often present with malignant pleural effusion (MPE). This study aimed to analyze the effect of pleural fluid on cancer cells.

Materials and Methods

Established patient-derived cancer cell cultures derived from MPE (MPM, breast carcinoma, lung adenocarcinoma) were seeded in 100% pleural fluid (exudate MPM MPE, transudate MPE, non-MPE transudate fluid) and proliferation was monitored. In addition, the establishment of new MPM cell cultures, derived from MPE specimens, was attempted by seeding the cells in 100% MPE fluid.

Results

All established cancer cell cultures proliferated with similar growth rates in the different types of pleural fluid. Primary MPM cell culture success was similar with MPE fluid as with full culture medium.

Conclusions

Pleural fluid alone is adequate for cancer cell proliferation in vitro, regardless of the source of pleural fluid. These results support the hypothesis that pleural fluid has important pro-growth biological properties, but the mechanisms for this effect are unclear and likely not malignant effusion specific.

Rituximab therapy in a patient with steroid-refractory bird fancier's lung

A 62-year-old woman presented with a 3-month history of shortness of breath on exertion and dry cough. On examination, she was noted to have fine end-inspiratory crepitations over the upper zone of the lungs. Pulmonary function tests (PFTs) showed a restrictive defect. Initial chest radiography revealed diffuse reticular interstitial shadowing while high-resolution CT scan of the thorax showed fibrotic changes. Avian precipitins were also highly positive for pigeons, parrots and budgerigars. Taking into account these results, the patient was diagnosed with hypersensitivity pneumonitis. Antigen avoidance, oral glucocorticoids and azathioprine achieved an initial improvement in PFTs and symptoms; however, the patient still deteriorated, requiring long-term oxygen therapy. While working the patient up for lung transplantation, rituximab was given to good effect (acting as a bridging therapy) as it achieved symptomatic relief and stabilisation of her PFTs.

Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

Pulmonary rehabilitation for chronic obstructive pulmonary disease: effects of a high versus low intensity programme

Background/Aims

Pulmonary rehabilitation is known to facilitate improvements in chronic obstructive pulmonary disease symptoms, exercise tolerance and quality of life. Despite this, there is no consensus on the ideal programme intensity. This article aims to explore and compare the benefits of a high intensity and low intensity pulmonary rehabilitation programme.

Methods

A total of 30 patients with a diagnosis of chronic obstructive pulmonary disease were randomly and blindly allocated to either a high intensity or low intensity 12-week pulmonary rehabilitation programme.

Results

Significant improvements in functional and health-related quality of life measures were obtained in both groups. Most of the significant changes for the high intensity group were achieved by week 8. The low intensity group required a further 4 weeks of rehabilitation in order to reach a significant difference.

Conclusions

Results show that both low and high intensity pulmonary rehabilitation programmes were beneficial. However, the high intensity programme was more efficient in achieving these improvements than the low intensity group.

Comparison of aeroallergen sensitisation patterns in the United States and Europe

The global prevalence of allergic diseases have increased considerably and are a major socio-economic burden. Asthma is a complex disease and understanding asthma phenotypes and endotypes could eventually lead to individualised management, and offer better symptom control and quality of life. In this review, we first summarise the pathogenesis of atopic asthma and delve into the assessment of sensitisation to aeroallergens through skin prick testing and serological testing with total and specific immunoglobulin E testing. We will then analyse the distribution of aeroallergen sensitisation patterns in the United States and Europe and its effect on the population. This review gives a comprehensive overview on atopy and it compares the prevalence and effect of atopy within various regions of both continents using data from large multicentre studies. We will conclude this review by discussing the efficacy of add-on treatments in the most prevalent severe asthma phenotypes and endotypes.

Self-reported satisfaction of patients receiving omalizumab for severe allergic asthma in Malta

Treatment satisfaction is of utmost importance for ensuring adherence. Omalizumab is administered long-term if effective and well-tolerated in a hospital setting. The aim was to evaluate treatment satisfaction with omalizumab in Malta and to identify factors that may influence patients' satisfaction. A questionnaire was distributed to all asthmatic adult patients receiving omalizumab for at least one year. The questionnaire included demographic data, dosing regimen, asthma control test and the 14-item English version of the Treatment Satisfaction Questionnaire for Medication (TSQM) Version 1.4. The TSQM 1.4 domain scores range from 0 to 100. Higher scores represent higher satisfaction. Our cohort included 33 patients (52% males), mean age 53.7 ± 11 years, mean baseline IgE level 510.6IU/ml, mean duration of treatment 3.8 ± 1.98 years and mean number of injections per month 4.6 ± 2.6. Median TSQM scores were as follows: graded effectiveness 78%, graded side effects 100%, graded convenience 74.2% and overall satisfaction 76%. Regression analysis showed that convenience score, effectiveness score and ACT score were significantly associated with global satisfaction. Global satisfaction scored high among the Maltese cohort of patients despite the inconvenience and side effects associated with receiving omalizumab. This is an add-on beneficial effect to the efficacy and effectiveness already been achieved with this medication.

Pulmonary Rehabilitation in patients with Interstitial Lung Disease: The effects of a 12-week programme

BACKGROUND

The inclusion of Pulmonary Rehabilitation as part of the management of Interstitial Lung Disease, although being highly recommended in most recent guidelines, still has limited studies exploring the outcomes from such an intervention. The present study aims to contribute to the available literature by investigating the effects of a high intensity, 12 week PR programme on functional and quality of life measures in patients with a diagnosis of Interstitial Lung Disease.

METHOD

ology: This paper reports outcomes of an observational, prospective, quasi experimental type of study. A total of 120 participants were recruited: 60 patients formed part of the active group, and another 60 patients were enrolled in an inactive group. Each participant was classified according to the modified Medical Research Council dyspnoea scale and placed in one of 5 categories (0-4) according to self-perceived breathlessness during daily activities. The following outcomes were measured: Lung function tests including plethysmography and diffusion capacity of carbon monoxide (D_LCO), functional tests (6-min walking distance test, Dyspnoea Borg Scale) and health status measures (St George's Respiratory Questionnaire and Hospital Anxiety and Depression Score).

RESULTS

A 12-week PR programme for patients with Interstitial Lung Disease, led to significant improvements in the active group of patients in the 6 min walking distance test, the modified Borg Scale, mMRC scores and in the health status measures. Lung function measures did not show any significant improvement following this intervention.

CONCLUSION

This 12week Pulmonary Rehabilitation programme resulted in improvements in functional aspects for patients with Interstitial Lung Disease. Further studies are recommended as Pulmonary Rehabilitation for Interstitial Lung Disease may have an impact at both an individual level and at global organisational/financial levels.

Food consumption and the risk of childhood allergy

Background

The prevalence of allergic conditions is increasing in most countries. One possible explanation may be childhood nutrition.

Objective

The aim of the study was to investigate the relationship between consumption of pre-specified types of food in school-aged children and presence of respiratory and allergic symptoms.

Methods

A total of 191 students aged 9-11 years were recruited from 5 schools to geographically cover all of Malta. Data was collected between October 2011 and February 2012. This was part of a bigger study which included clinical and environmental tests besides standardized health questionnaires. For the purposes of this part of the study only the health questionnaires were used. These standardized health questionnaires based on the International Study of Asthma and Allergies in Childhood (ISAAC) were used to identify the presence of respiratory and allergic symptoms and to identify the types of foods and the frequency of consumption of various types of foods.

Results

We found that milk, meat, butter, olive oil, and yoghurt consumption had a negative association with allergic symptoms in children, whilst fish consumption had a detrimental effect. These relationships remained significant after correction for paternal level of education.

Conclusion

The study highlights the fact that nutrition in early childhood may have a significant effect on the risk of allergic conditions. Our results, taken together with data in the literature, suggest that different types of fish might have had different effects. This is probably related to their different fatty acid constitution thus warranting further studies.

Unusual case of primary pulmonary Hodgkin's lymphoma presenting with a continuous murmur

Systemic to pulmonary fistulas are an unusual entity, even more so in association with Hodgkin's lymphoma. We herein report a case of a 33-year-old woman that presented with an incidental lung lesion on a chest radiograph with an associated high-frequency continuous murmur over the lesion. The diagnosis of primary pulmonary Hodgkin's lymphoma, nodular sclerosis type, was obtained by a CT transthoracic biopsy. We achieved an excellent response after polychemotherapy with near-complete disappearance of the mass and a residual faint systolic murmur over the lesion.

Relationship between domestic smoking and metals and rare earth elements concentration in indoor PM2.5

Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM_2.5 and heavy metals, 73 children were investigated by parental questionnaire and skin prick tests. The houses of residence of 41 "cases" and 32 "controls" (children with and without respiratory symptoms, respectively) were evaluated by 48-h PM_2.5 indoor/outdoor monitoring. PM_2.5 mass concentration was determined by gravimetry; the extracted and mineralized fractions of elements (As, Cd, Ce, La, Mn, Pb, Sb, Sr, Tl) were evaluated by ICP-MS. PM_2.5 and Ce, La, Cd, and Tl indoor concentrations were higher in smoker dwellings. When corrected for confounding factors, PM_2.5, Ce, La, Cd, and Tl were associated with more likely presence of respiratory symptoms in adolescents. We found that: i) indoor smoking is associated with increased levels of PM_2.5, Ce, La, Cd, and Tl and ii) the latter with increased presence of respiratory symptoms in children.

Eosinophilic gastrointestinal disorder: is it what it seems to be?

Background

Eosinophilic gastroenteropathy is an uncommon condition whose causes can be numerous and non-specific. The aim of the study was to characterize the presence of gastrointestinal disorders in the adult Maltese population and assess the degree of association with atopic diseases.

Methods

Adult patients with gastrointestinal eosinophilia in the gastrointestinal tract on histology were identified and their clinical case notes were reviewed. Patients were interviewed and asked questions regarding asthma, allergic rhinitis, and eczema.

Results

Sixty-six patients (39 female) were recruited. The most common clinical symptoms were diarrhea (42.4%) and abdominal pain (33.3%). The sites involved were stomach (10.6%), colon (56.1%), small bowel (10.6%), small bowel and colon (18.2%), esophagus (1.5%), and esophagus and colon (1.5%). Forty percent had persistent lower gastrointestinal symptoms and a repeat ileocolonoscopy was performed within 12 months. These patients were diagnosed with ulcerative colitis (n=10; 47.6%), Crohn's disease (n=6; 28.6%), indeterminate colitis (n=1; 4.8%) or microscopic colitis (n=4; 19%). Allergic rhinitis was present in 39.4% of the study group, eczema in 26.1%, and asthma in 19.7%. These findings were compared with local data for atopic conditions and the study group was found to have a significantly higher prevalence of allergic rhinitis (P=0.002), but not of asthma (P=0.62) or eczema (P=0.19).

Conclusions

A high proportion of patients with eosinophilic gastrointestinal infiltration were subsequently diagnosed with inflammatory bowel disease. Patients persistently symptomatic or who do not respond to treatment should be reassessed to exclude inflammatory bowel disease, given its high prevalence in this group of patients.

Caseous mitral annular calcification mimicking a lung tumor on chest X-ray

Mitral annular calcification (MAC) is a common condition of the mitral valve apparatus. A case involving caseous calcification, a rare variant of MAC is presented. This variant which has a benign course can present as an intracardiac mass and needs to be differentiated from more sinister causes of calcified cardiac masses such as tumor, abscess, and infective vegetation. Often, this requires multimodality imaging with echocardiography, computed tomography, and magnetic resonance imaging. Features of caseous calcification of the mitral valve on these imaging modalities are reviewed as the associations and clinical features.

Sensitization to dust mite defines different phenotypes of asthma: A multicenter study

BACKGROUND

Indoor allergens are risk factors for asthma: Thus, the characterization of indoor air quality is important for studying environment-health relationships in children. In particular, Dermatophagoides pteronyssinus is the dominant allergen for asthma. We cross-sectionally investigated the relationships among respiratory symptoms and function, airway inflammation, allergen sensitization, and indoor allergen concentration.

METHODS

One hundred and thirty-two children aging 10-14 years and living in a Southern Mediterranean area were evaluated by parental questionnaires. Spirometry, exhaled nitric oxide (FeNO), skin prick tests, total, and specific serum IgE analyses were performed along with the evaluation of home dust samples for the content in Der p 1 allergen. Three clusters were created on the basis of the presence/absence of wheeze in the last 12 months (Wh12m) and Der p 1-specific IgE level.

RESULTS

Cluster 1 (Wh12m+/high Der p 1 IgE) presented higher FeNO and poorer pulmonary function (lower FEV₁ and FEF_25%-75% ), while its symptom score was not different from Cluster 2 (Wh12m+/low Der p 1 IgE). Cluster 3 (Wh12m-/low IgE) showed the lowest FeNO values and pulmonary function similar to Cluster 2. Within Cluster 1, both Der p 1-specific IgE and FeNO were positively correlated with dust Der p 1.

CONCLUSIONS

Similar asthma phenotypes may occur in children despite differences in their atopic state. In atopic children, sensitizing allergens in the indoor environment may increase airway inflammation worsening pulmonary function. Moreover, environmental exposures may contribute to the development of asthma-like symptoms also in the absence of atopic sensitization, thus contributing to asthma overdiagnosis.

Respiratory medicine training in Malta

In Malta, respiratory medicine is quite a popular speciality. It is attractive because of the interesting case mix and the interventional element of the speciality.

Health status of COPD patients undergoing pulmonary rehabilitation: A comparative responsiveness of the CAT and SGRQ

The St. George’s Respiratory Questionnaire (SGRQ) and chronic obstructive pulmonary disease (COPD) assessment test (CAT) are the measures used to assess health status. This study aims to examine the responsiveness of these tools by severity of dyspnoea category in patients with COPD. Forty-nine COPD patients who underwent a 12-week pulmonary rehabilitation (PR) programme were assessed at baseline, 12 weeks and at 28-week follow-up. Patients were categorized into two groups by severity of dyspnoea category (i.e. mild to moderate (modified Medical Research Council (mMRC) 1–2) and severe to very severe (mMRC 3–4)) using the mMRC dyspnoea scale. Effect size (ES) was computed as estimates of responsiveness. The SGRQ demonstrated greater responsiveness by total sample (SGRQ, ES = 0.87; CAT, ES = 0.75) and for the mMRC 3–4 category (SGRQ, ES = 0.91; CAT, ES = 0.76) on completion of PR. At 28-week follow-up, overall comparable responsiveness of the CAT and SGRQ was identified by total sample (SGRQ, ES = 0.75; CAT, ES = 0.74) and by severity of dyspnoea category. The symptom, impact and activity domains of the SGRQ showed good responsiveness, with greater ESs obtained overall for the mMRC 3–4 category. On completion of PR, the SGRQ demonstrates a greater responsiveness with COPD patients, especially in relation to the mMRC 3–4 category, while both the CAT and SGRQ show comparable responsiveness on follow-up.

Predictors of correct technique in patients using pressurized metered dose inhalers

BACKGROUND

Corret inhaler technique is recommended by guidelines for optimum asthma care. The objective of the study is to determine real life predictors of correct pressurized metered dose inhaler (pMDI) technique in Asthma and COPD patients.

METHODS

Two hundred eight adult patients aged 18+ from respiratory outpatients (69.2%) and the community on regular pMDI for a diagnosis of Asthma (78.9%) or COPD, were recruited. A questionnaire containing 31 possible predictors was administered and pMDI technique with or without spacer was observed by trained researchers on 12 point steps, of which 4 were considered critical.

RESULTS

23.1% of patients had no errors in inhaler technique and 32.2% had no critical errors. Patients had a median of 10 correct steps (IQR9-11), and 3(IQR2-4) correct critical steps. Using binary logistic regression the predictors of 10 correct steps were, other healthcare professional (pharmacist, nurse, physiotherapist) explained OR 3.73(1.63-8.54, p = 0.001), male gender 2.70(1.35-5.39, p = 0.004), self-score 1-10 1.21(1.05-1.39, p = 0.007), spacer use 0.38(0.19-0.79, p = 0.007), inhaled steroid 3.71(1.34-10.25, p = 0.01), heart disease 0.31(0.13-0.77, p = 0.01), pneumococcal vaccine 2.48(1.0-6.15, p = 0.043), education level 1-4 1.44(1.00-2.06, p = 0.05) and respiratory physician explained 0-7 times, 1.11(0.99-1.26, p = 0.08). Using ordinal logistic regression, predictors for correct critical steps 0-4, were: technique self-score 1-10 1.2(1.05-1.42, p = 0.006), inhaled corticosteroid use 2.78(1.1-7.31, p = 0.03) and education level 1-4 1.41(1.02-1.95, p = 0.03 Times respiratory physician explained inhaler technique 0-7 1.1(0.98-1.24, p = 0.1), married status 1.55(0.85-2.82, p = 0.15), hypercholesterolaemia 0.52(0.25-1.01, p = 0.054) and male gender 1.76(0.97-3.18, p = 0.06).

CONCLUSIONS

Known predictors of correct pMDI use, such as gender and education level were confirmed, while age and concomitant use of dry powder inhaler were not. Pneumococcal vaccination and awareness of steroid side effects were possible novel positive predictors, while the use of a spacer and co-morbidity with heart disease were found to be negative predictors. Patients' self-assessment correlated well with actual performance. This information may be useful in defining approaches to optimize inhaler techniques which are so susceptible to human error.

Continuous Positive Airway Pressure: Is it a route for infection in those with Obstructive Sleep Apnoea?

INTRODUCTION

Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnoea (OSA), with limited data about the prevalence of respiratory infections and microbial colonization in these patients.

OBJECTIVES

The aim of this study was to determine if CPAP use is associated with respiratory infections and to identify the organisms that colonize or infect these patients.

METHOD

A retrospective, case-controlled study in patients diagnosed with OSA was carried out. 137 patients were recruited and interviewed using a questionnaire. A nasal swab was taken from each patient. Patients using CPAP machines had swabs taken from masks and humidifiers.

RESULTS

66 (48.2%) patients received CPAP treatment with 60.6% of them having a heated humidifier. 78.8% were male, with the majority using a full face mask (63.6%). No significant difference was seen in the prevalence of rhinosinusitis, lower respiratory tract infections and hospital admissions for pneumonia between CPAP and non-CPAP treated patients. The presence of a humidifier did not influence the prevalence of infections. Commensal flora was predominantly cultured from nasal swabs from both patient groups. Coagulase Negative Staphylococci and Diphtheroids were the main organisms cultured from masks and humidifiers respectively.

CONCLUSIONS

This study shows that the use of CPAP, choice of mask and humidifier have no significant impact on the prevalence of infections and micro-organisms isolated. This is very reassuring to the physician prescribing CPAP therapy and users.

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

A diagnostic dilemma in a case of pulmonary inflammatory myofibroblastic tumour

An 18-year-old man presented to the local hospital in Malta, with dyspnoea, cough, mild haemoptysis, chest pain and night sweats. CT revealed a right hilar mass. Pleural tap, bronchoscopy and open lung biopsy were inconclusive. Biopsies obtained at repeat bronchoscopy and endobronchial ultrasound (EBUS) revealed a likely diagnosis of inflammatory myofibroblastic tumour (IMT). The patient subsequently underwent right pneumonectomy, and histology revealed the presence of two further nodules apart from the main tumour. Follow-up with positron emission tomography (PET)/CT showed the development of a right basal paracardial lesion due to recurrence and the presence of lymph node, pleural and skeletal disease. Despite radiotherapy to the recurrent nodule and chemotherapy, there was skeletal disease progression. Treatment with an anaplastic lymphoma kinase inhibitor, ceritinib, resulted in very good metabolic response. This case report highlights the importance of keeping IMT in mind when the diagnosis of lung tumours is difficult, as delayed diagnosis may lead to worsened prognosis.

Association of prevalence of rhinitis, atopic eczema, rhinoconjunctivitis and wheezing with mortality from infectious diseases and with antibiotic susceptibility at a country level

BACKGROUND

It was previously reported that there is a positive correlation between incidence of type 1 diabetes and prevalence of asthma and atopic eczema. A negative correlation between the prevalence of type 1 diabetes and mortality from infectious diseases as well as a positive correlation with antibiotic susceptibility at a country level have also been reported.

OBJECTIVE

The aim of this study was to investigate the association between country prevalence of rhinitis, atopic eczema, rhinoconjunctivitis, and wheezing with mortality from infectious diseases and also with antibiotic susceptibility at a country level.

METHODS

Data for prevalence of rhinitis, eczema, rhinoconjunctivitis, and wheezing was obtained from the International Study of Asthma and Allergies in Childhood study (ISAAC). ISAAC Phase one was a multicentre multicountry cross sectional study involving over 700,000 children in 2 age groups of school children, 13-14 years old (adolescents) and 6-7 years old (children) in 156 centres from 56 countries. Mortality from infectious diseases was taken from World Health Organisation data. The Alexander project was used to identify antibiotic susceptibilities to common bacteria.

RESULTS

There were significant positive correlations between atopic eczema and mortality from all infectious diseases studied, diarrhoeal illness, tropical infections, and childhood infections. A negative correlation exists between the prevalence of rhinitis and Streptococcus pneumoniae susceptibility to penicillin and to erythromycin, rhinitis and Haemophilus influenzae susceptibility to ampicillin and between rhinoconjunctivitis and H. influenzae susceptibility to ampicillin.

CONCLUSION

Th1/Th2 responses might influence the pathogenesis of infectious disease mortality, while antibiotic overprescription could explain the negative association between atopy and antibiotic susceptibility.

Systemic and venous thromboembolism: think about paradoxical embolism

Patent foramen ovale (PFO) is one of the most important causes of paradoxical embolism; it is found in about 25-30% of the population. In most patients, it is asymptomatic and diagnosis is usually made during routine echocardiography. In a small proportion of patients, PFO is diagnosed after paradoxical embolism is suspected. We present a case of a middle-aged smoker who was admitted with lower limb deep vein thrombosis and pulmonary embolism, who developed acute upper limb ischaemia during his inpatient stay. Since doctors might dismiss such cases as routine, this report highlights the importance of detailed history taking and examination in patients with venous thromboembolism. Paradoxical embolism should always be considered as a possible diagnosis when managing patients with concomitant venous and arterial embolism.

Potential impact of fireworks on respiratory health

The world-wide use of fireworks with their consequent detrimental effect on the air quality is widely recognized with elevated ambient air levels of particulate matter and its several metallic components and gases identified in several studies carried out during such events. Exposed individuals may be at risk following inhalation of such produced pollutants. This review focuses on the impact of fireworks on air quality and the potential effect of fireworks on the respiratory system of healthy individuals as well as those suffering from underlying respiratory diseases, particularly asthma and chronic obstructive pulmonary disease (COPD). This applies not only to spectators including children but also to pyrotechnicians themselves. An extensive Medline search revealed that a strong evidence of the impact of fireworks on respiratory health is lacking in susceptible as well as healthy individuals with no formal studies on COPD or asthma, other than a few case reports in the latter. The implementation of global strategies to control the use of fireworks and hence improve air quality could possibly reduce their likely detrimental effect on human respiratory health in exposed individuals, but clearly a more targeted research is needed.

A delayed diagnosis of Mounier-Kuhn syndrome

Following a provisional diagnosis of asthma of several years' duration by his general practitioner, a 43-year-old otherwise healthy man who was a non-smoker was referred to a pulmonologist with worsening productive cough and exertional breathlessness. A thoracic CT scan revealed dilated airways (tracheal diameter 35 mm, left bronchial diameter 20 mm, right bronchial diameter 18 mm). Inflamed and easily collapsible airways were seen on bronchoscopy. The patient remained stable and was followed up with regular spirometry. A follow-up CT scan 7 years later showed tracheobronchomegaly (tracheal diameter 42 mm, left bronchial diameter 25 mm, right bronchial diameter 23 mm) with large cystic spaces consistent with Mounier-Kuhn syndrome. Repeat bronchoscopy showed a massively dilated trachea and generalised collapse on expiration with a dilated thin-walled bronchial tree. He was deemed ineligible for lung transplantation due to the extent of airway involvement making it difficult to anastomose donor lung to native tissue.

A local perspective to asthma management in the accident and emergency department in Malta

AIM

This study was performed to assess the management of adult patients presenting to the Mater Dei Hospital Accident and Emergency (A&E) department with acute asthma.

SUBJECTS AND METHODS

Asthmatic patients age 14 or older who presented to A&E department between January and October 2010 with asthma exacerbations were included. Data were collected from the clinical notes and analyzed.

RESULTS

A total of 244 patients (67.2% females) were included, 126 (51.6%) were admitted, 97 (39.8%) discharged and 21 (8.6%) discharged themselves against medical advice. There was a decline in the presentations between January and July, followed by an upward trend until October (P = 0.42). Pulse oximetry was performed in 207 patients (84.8%), arterial blood gases in 133 (54.5%), peak expiratory flow rate in 106 (43.4%) and chest radiography in 206 (84.4%) patients. The respiratory rate was documented in 151 (61.8%), heart rate in 204 (83.6%) and ability to complete sentences in 123 (50.4%) patients. One hundred and ninety six patients (80.3%) were given nebulized bronchodilators, 103 (42.2%) intravenous corticosteroids, 7 (2.87%) oral corticosteroids, 109 (44.7%) oxygen, 28 (11.5%) antibiotics and 9 (3.69%) magnesium. Systemic corticosteroids and antibiotics were more commonly prescribed to patients admitted (P < 0.001).

CONCLUSION

Management of acute asthma in Malta requires optimization in order to compare with international guidelines.

Aspiration of a speaking valve

Foreign body aspiration (FBA) is a relatively common and serious condition that can result in a spectrum of presentations ranging from incidental to acutely life-threatening. Described here is a case of aspiration of a tracheo-oesophageal speaking valve through a permanent tracheostomy that went unnoticed for a number of years, and an overview of the technique used for its removal. A 70-year-old ex-heavy smoker with a permanent tracheo-oesophageal fistula presented with a relatively recent history of increasing shortness of breath, sputum purulence and haemoptysis. Further investigation with a CT scan and bronchoscopy revealed the presence of a foreign body within his right lower lobe bronchus which was later removed by advancing a flexible bronchoscope over a rigid one.

The effect of cigarette smoking on allergic conditions in Maltese children (ISAAC)

Maltese children are frequently exposed to tobacco smoke through passive and personal smoking. In the phase 3 ISAAC study questionnaire, we enquired about passive smoking to the parents of 3816 (80% response rate) 5- to 8-yr-old children and about passive and personal smoking to 4139 (90% response rate) 13- to 15-yr-old participating children. Thirty-one percent of 5- to 8-yr olds were passive smokers with their father more likely to be the smoker (p < 0.0001). Maternal smoking in the first year of the child's life resulted in the children having an increased chance of wheezing 'ever' (p < 0.001), exercise-induced wheezing (p < 0.05) and being diagnosed with asthma (p < 0.0001). Current smoking by the mother also led to the child having current rhinitis (p < 0.001). Fifty-one percent of 13- to 15-yr olds were passive smokers again with the father more likely to be the smoker (p < 0.0001). Maternal (p < 0.0001) and paternal smoking (p < 0.05) resulted in the children having an increased chance of wheezing sometime in their life, exercise-induced wheezing, nocturnal cough, and being diagnosed with asthma. Current smoking by the mother was more common in children having current rhinitis (p < 0.05), while current smoking by both mother and/or father led to itchy/watery eyes accompanying rhinitis (p < 0.05). Recurrent itchy rashes were also more likely in passive smokers (p < 0.001). Personal smoking by the 13- to 15-yr olds (8.15% boys vs. 8.8% girls ns ) resulted in a higher cumulative prevalence of wheezing (p < 0.0001), rhinitis (p < 0.05), and recurrent itchy rash (p < 0.001) but only affected current prevalence of wheezing (p < 0.0001). These smokers were more likely to experience exercise-induced wheezing (p < 0.0001), nocturnal cough (p < 0.0001), and being diagnosed with asthma (p < 0.05) and eczema (p < 0.001). Children smoking more than 10 cigarettes/day persisted with wheezing (p = 0.04) had more frequent episodes of exercise-induced wheeze (p = 0.04), nocturnal cough (p < 0.0001), and rhinoconjunctivitis (p = 0.02) than milder smokers. Smoking seems to be affecting childhood allergies in Maltese children quite significantly.

Chronic cough as a complication of treatment with statins: a case report

Statins are widely used for primary and secondary prevention of cardiovascular disease. For this reason, knowledge of the side effects and interactions pertaining to this class of pharmaceuticals is of utmost importance to all physicians. In this text a case report is presented of an eighty year old gentleman, referred to the respiratory clinic at Mater Dei Hospital Malta after developing dry cough on being treated with simvastatin and fluvastatin. An attempt at switching over to a placebo was made with resolution of symptoms. This is the second described case in the literature of lone cough associated with statin therapy necessitating treatment discontinuation in our patient. Possible hypothesis are discussed as well as suggestions for further research to unravel the underlying mechanisms of this association.

The association between tobacco and the risk of asthma, rhinoconjunctivitis and eczema in children and adolescents: analyses from Phase Three of the ISAAC programme

BACKGROUND

Exposure to parental smoking is associated with wheeze in early childhood, but in 2006 the US Surgeon General stated that the evidence is insufficient to infer a causal relationship between exposure and asthma in childhood and adolescents.

AIMS

To examine the association between maternal and paternal smoking and symptoms of asthma, eczema and rhinoconjunctivitis.

METHODS

Parents or guardians of children aged 6-7 years completed written questionnaires about symptoms of asthma, rhinoconjunctivitis and eczema, and several risk factors, including maternal smoking in the child's first year of life, current maternal smoking (and amount) and paternal smoking. Adolescents aged 13-14 years self completed the questionnaires on these symptoms and whether their parents currently smoked.

RESULTS

In the 6-7-year age group there were 220 407 children from 75 centres in 32 countries. In the 13-14-year age group there were 350 654 adolescents from 118 centres in 53 countries. Maternal and paternal smoking was associated with an increased risk of symptoms of asthma, eczema and rhinoconjunctivitis in both age groups, although the magnitude of the OR is higher for symptoms of asthma than the other outcomes. Maternal smoking is associated with higher ORs than paternal smoking. For asthma symptoms there is a clear dose relationship (1-9 cigarettes/day, OR 1.27; 10-19 cigarettes/day, OR 1.35; and 20+ cigarettes/day, OR 1.56). When maternal smoking in the child's first year of life and current maternal smoking are considered, the main effect is due to maternal smoking in the child's first year of life. There was no interaction between maternal and paternal smoking.

CONCLUSIONS

This study has confirmed the importance of maternal smoking, and the separate and additional effect of paternal smoking. The presence of a dose-response effect relationship with asthma symptoms suggests that the relationship is causal, however for eczema and rhinoconjunctivitis causality is less certain.

Two cases of aspiration of calcium tablets

Two clinical cases of aspiration are reported in elderly ladies with differing presentations following inhalation of the same brand of calcium tablet. One of the patients distinctly recalled the choking episode, whereas the other failed to do so making the diagnosis of aspiration difficult. One of the aspirated tablets was successfully retrieved during rigid bronchoscopy after the patient reported several months of cough requiring multiple courses of antibiotics. The other aspirated tablet was coughed up by the patient after the successful treatment of a pneumonia complicated by a parapneumonic effusion.

Correlation of worldwide incidence of type 1 diabetes (DiaMond) with prevalence of asthma and atopic eczema (ISAAC)

INTRODUCTION

Environmental factors play a role in pathogenesis of both type 1 diabetes and atopic disease but they remain incompletely understood. T cell-mediated responses primarily of the T helper type 1 (Th1) are involved in type 1 diabetes while T helper type 2 (Th2) responses favour allergic disease. This TH 1/TH 2 paradigm is currently the source of much controversy in various studies.

OBJECTIVE

The aim of the study was to compare the reported country incidence of type 1 diabetes with the prevalence of atopic disease.

METHODS

The prevalence of wheeze, rhinitis, rhinoconjunctivitis and atopic eczema in the preceding 12 months in the 13- to 14-year-old age group was taken from The International Study of Asthma and Allergies in Childhood phase 1 study. These were compared to the age specific incidence of type 1 diabetes in children per 100 000 per year obtained from the Diabetes Mondiale Project Group study from those countries participating in both studies. Data collected from these 31 countries together with latitude was analysed using a Pearson correlation and significance analysis. A multiple regression analysis determined the confounding effect of latitude.

RESULTS

The incidence of type 1 diabetes was found to have a positive correlation with both wheezing (P = 0.009) and atopic eczema (P < 0.01). There was a no correlation between the incidence of type 1 diabetes and the prevalance of rhinitis (r = 0.02, P = 0.88) or of rhinoconjunctivitis (r = 0.026, P = 0.88). Latitude correlated negatively with type 1 diabetes and positively with rhinitis and rhinoconjnctuvits; it was not significantly correlated with wheeze or eczema. Regression analysis showed that latitude is a significant confounding factor in the correlation of rhinitis (P value < 0.0008) and rhinoconjunctivitis (P value < 0.0003) with diabetes.

CONCLUSIONS

The study suggests that common environmental and/or genetic factors predispose to type 1 diabetes, wheezing and atopic eczema while factors predisposing to rhinitis and rhinoconjunctivitis appear to be distinct from those predisposing to type 1 diabetes.

A decrease in the prevalence and improved control of allergic conditions in 13- to 15-yr-old Maltese children (ISAAC)

The International Study of Asthma and Allergies in Childhood (ISAAC) has produced a reliable global map of childhood allergies through the use of a validated standardized questionnaire. Phase 1 of the study was carried out in the Maltese Islands in 1995 and repeated in 2002 in phase 3. To investigate the trends in prevalence and severity of childhood allergies in Maltese schoolchildren, in this article, we compare the data obtained from 4184 children, 13- to 15-yr-olds (88.7% response rate) in phase 1, to that of phase 3 when 4139 (90% response rate) children participated. The cumulative (27.9% vs. 27.4%: p=0.6) and current (16% vs. 14.6% p=0.08) prevalence rates of wheezing remained quite static but wheezers were more likely to be diagnosed with asthma in 2002 (11.1% vs. 14.1% p<0.0001). Along the 7 yrs, these asthmatics were better controlled with less wheezing attacks (p<0.01), less disturbed nights (p<0.05) and less acute severe episodes (p<0.05). Nasal problems were present in 52.7% of participants in 1995 and in 50.4% in 2002 (p<0.05), and 47.4% vs. 42.8% (p<0.0001) persisted with these symptoms and associated itchy eyes (29% vs. 21.8%: p<000001). Though prevalence decreased, the children were labelled as hayfever sufferers more often (32.3 vs. 40.7%: p<0.00001). Rhinitis symptoms seemed to interfere less with daily activities (p<0.01). In 2002, an itchy rash suggestive of eczema was also less present 'ever' (12.8% vs. 11.2%: p<0.05) or currently (10.1% vs. 8.5%: p<0.05) but again more likely to be diagnosed as eczema (p<0.001). This rash caused less sleepless nights in phase 3 of the study (p<0.05). These results indicate that asthma prevalence has reached a plateau between 1995 and 2002 while rhinitis and eczema are less common. All these allergic conditions are better controlled and more likely to be diagnosed in these schoolchildren by Maltese doctors in 2002 than in 1995.

An unusual cause of chest pain in a young man: bronchogenic cysts and their cardiac manifestations

We report a case of a 24-year-old man who presented with chest pain and electrocardiographic evidence of myocardial ischaemia. An abnormal structure located behind the heart on the urgent transthoracic echocardiogram and a computed tomography scan of the mediastinum led to prompt surgery with eventual resection of the lesion. The histology revealed fragments of connective tissue covered by squamous epithelium and ciliated epithelium, consistent with a bronchogenic cyst. The case study is accompanied by a literature review of the pathogenesis, diagnosis and management of bronchogenic cysts and their association with cardiac symptoms.

Which population level environmental factors are associated with asthma, rhinoconjunctivitis and eczema? Review of the ecological analyses of ISAAC Phase One

The International Study of Asthma and Allergies in Childhood (ISAAC) Phase One showed large worldwide variations in the prevalence of symptoms of asthma, rhinoconjunctivitis and eczema, up to 10 to 20 fold between countries. Ecological analyses were undertaken with ISAAC Phase One data to explore factors that may have contributed to these variations, and are summarised and reviewed here.In ISAAC Phase One the prevalence of symptoms in the past 12 months of asthma, rhinoconjunctivitis and eczema were estimated from studies in 463,801 children aged 13 - 14 years in 155 centres in 56 countries, and in 257,800 children aged 6-7 years in 91 centres in 38 countries. Ecological analyses were undertaken between symptom prevalence and the following: Gross National Product per capita (GNP), food intake, immunisation rates, tuberculosis notifications, climatic factors, tobacco consumption, pollen, antibiotic sales, paracetamol sales, and outdoor air pollution.Symptom prevalence of all three conditions was positively associated with GNP, trans fatty acids, paracetamol, and women smoking, and inversely associated with food of plant origin, pollen, immunisations, tuberculosis notifications, air pollution, and men smoking. The magnitude of these associations was small, but consistent in direction between conditions. There were mixed associations of climate and antibiotic sales with symptom prevalence.The potential causality of these associations warrant further investigation. Factors which prevent the development of these conditions, or where there is an absence of a positive correlation at a population level may be as important from the policy viewpoint as a focus on the positive risk factors. Interventions based on small associations may have the potential for a large public health benefit.