Severe asthma assessment, management and the organisation of care in Australia and New Zealand: expert forum roundtable meetings.

Severe asthma imposes a significant burden on individuals, families and the healthcare system. Treatment is complex, due to disease heterogeneity, comorbidities and complexity in care pathways. New approaches and treatments improve health outcomes for people with severe asthma. However, emerging multidimensional and targeted treatment strategies require a reorganisation of asthma care. Consensus is required on how reorganisation should occur and what areas require further research. The Centre of Excellence in Severe Asthma convened three forums between 2015 and 2018, hosting experts from Australia, New Zealand and the UK. The forums were complemented by a survey of clinicians involved in the management of people with severe asthma. We sought to: (i) identify areas of consensus among experts; (ii) define activities and resources required for the implementation of findings into practice; and (iii) identify specific priority areas for future research. Discussions identified areas of unmet need including assessment and diagnosis of severe asthma, models of care and treatment pathways, add-on treatment approaches and patient perspectives. We recommend development of education and training activities, clinical resources and standards of care documents, increased stakeholder engagement and public awareness campaigns and improved access to infrastructure and funding. Further, we propose specific future research to inform clinical decision-making and develop novel therapies. A concerted effort is required from all stakeholders (including patients, healthcare professionals and organisations and government) to integrate new evidence-based practices into clinical care and to advance research to resolve questions relevant to improving outcomes for people with severe asthma.

Using teledentistry to provide interceptive orthodontic services to disadvantaged children.

INTRODUCTION: Socially disadvantaged children have limited access to orthodontic services. We examined the feasibility of a general dental practitioner providing interceptive orthodontic services to disadvantaged children with real-time supervision from an orthodontist using teledentistry. METHODS: Pretreatment and posttreatment orthodontic study models of 30 children treated by a general dentist using teledentistry and 96 children treated by orthodontic residents directly supervised by orthodontic faculty were scored with the peer assessment rating (PAR) index. RESULTS: Both groups had significant improvements in PAR scores: 35.6% in the teledentistry group and 44.1% in the direct supervision group (P <0.001). There were no significant differences between the groups before treatment or after interceptive orthodontic treatment. CONCLUSIONS: The results of this study suggest that interceptive orthodontic treatments provided by sufficiently prepared general dentists and supervised remotely by orthodontic specialists through teledentistry are a viable approach to reducing the severity of malocclusions in disadvantaged children when referral to an orthodontist is not feasible.

Phase 3 randomized study of the efficacy and safety of inhaled dry powder mannitol for the symptomatic treatment of non-cystic fibrosis bronchiectasis.

BACKGROUND: Inhaled dry powder mannitol enhanced mucus clearance and improved quality of life over 2 weeks in non-cystic fibrosis bronchiectasis. This study's objective was to investigate the efficacy and safety of dry powder mannitol over 12 weeks. METHODS: Patients with bronchiectasis confirmed by high-resolution CT (HRCT) scan, aged 15 to 80 years, with FEV1≥50% predicted and ≥1 L participated in a randomized, placebo-controlled, double-blind study. Patients with a negative mannitol provocation test were randomized to inhale 320 mg mannitol (n=231) or placebo (n=112) bid for 12 weeks. To further assess safety, the same mannitol dose/frequency was administered to a patient subset in an open-label extension over 52 weeks. Primary end points were changes from baseline at 12 weeks in 24-h sputum weight and St. George's Respiratory Questionnaire (SGRQ) score. RESULTS: There was a significant difference of 4.3 g in terms of change in sputum weight over 12 weeks (95% CI, 1.64-7.00; P=.002) between mannitol and placebo; however, this was largely driven by a decrease in sputum weight in the placebo group. This was associated, in turn, with more antibiotic use in the placebo group (50 of 112 [45%]) than in the inhaled mannitol group (85 of 231 [37%]). There was no statistical difference between the groups (P=.304) in total SGRQ score (mannitol, -3.4 points [95% CI, -4.81 to -1.94] vs placebo, -2.1 points [95% CI, -4.12 to -0.09]). In a subgroup study (n=82), patients receiving mannitol showed less small airway mucus plugging on HRCT scan at 12 weeks compared with patients receiving placebo (P=.048). Compliance rates were high, and mannitol was well tolerated with adverse events similar to those of placebo. CONCLUSION: Because the difference in sputum weights appears to be associated with increased antibiotic use in the placebo group, a larger controlled study is now required to investigate the long-term mannitol effect on pulmonary exacerbations and antibiotic use. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT0027753; URL: www.clinicaltrials.gov.

A época de tratamento das más oclusões de Classe II em crianças: uma revisão da literatura / The timing of treatment for Class II malocclusions in children: a literature review

Admite-se a existência de duas condutas básicas para a época do tratamento das más oclusões de classe II em crianças: 1) a correção alcançada em duas fases: uma durante a pré-adolescência (tratamento precoce) e a outra durante a adolescência; 2) a correção realizada em uma única fase de tratamento ativo durante a adolescência. A eficácia, os riscos e os benefícios destas condutas não foram ainda bem definidos. A maioria dos estudos clínicos que investigam estes tópicos expressa inúmeras deficiências de metodologia, tais como o caráter retrospectivo, a deficiência de controles adequados e a avaliação apenas de casos tratados com sucesso. Nos últimos anos, porém, apesar da falta de dados objetivos, os ortodontistas têm demonstrado um sólido interesse no tratamento em duas fases. O presente artigo revisa os principais itens do tratamento de classe II em duas fases e conclui expondo diversas questões clínicas importantes que poderiam ser elucidadas por estudos prospectivos cuidadosamente controlados