Microbiology sampling in non-cystic fibrosis bronchiectasis cases from northern Alberta.

Non-cystic fibrosis bronchiectasis (NCFB) is a chronic respiratory disease resulting in chronic cough, thick sputum, and lower airway microbial colonization, akin to patients with cystic fibrosis (CF). NCFB is a common, yet under recognized entity which inflicts significant morbidity and mortality particularly to older individuals, with a rising prevalence in the developed world. Given that sputum cultures are a non-invasive method to characterize the lower airway microbiota in NCFB patients, for which pathogenic organisms are associated with worsened outcomes, we sought to characterize the microbiological pattern and clinical outcomes associated with sputum culture in a cohort of NCFB patients from Western Canada. A total of 20 subjects were prospectively recruited from various bronchiectasis clinics across the Greater Edmonton area. A retrospective chart review and a symptoms questionnaire was performed, gathering information not limited to symptoms, comorbidities, exacerbations, hospitalizations, sputum production, and sputum culture results over the prior 5 years. Subjects reported frequent hospitalization alongside a significant burden of symptoms. A large majority of sputum cultures grew pathogenic organisms such as Haemophilus influenzae and Pseudomonas aeruginosa. We also note the considerable waste and inefficiency associated with sputum cultures, outlining areas for which this important diagnostic modality can be improved. Accurate characterization of the airway microbiota alongside efficient delivery of health services are key to ensuring the proper treatment of individuals with NCFB, given their high disease burden and frequent hospitalization.

Neurologic Complications in Hereditary Hemorrhagic Telangiectasia with Pulmonary Arteriovenous Malformations: A Systematic Review.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant multi-organ condition occurring with a 1 in 3800 prevalence in Alberta. This genetic disorder leads to vascular malformations in different organs including the lungs and brain, commonly affecting pulmonary vasculature leading to pulmonary arteriovenous malformations (PAVMs). PAVMs lead to right-to-left shunts, which may be associated with neurologic complications. We aimed to evaluate and summarize the reported neurologic manifestations of individuals with HHT with pre-existing PAVMs. METHODS: We performed a qualitative systematic review to determine available literature on neurological complications among patients with PAVMs and HHT. Published studies included observational studies, case studies, prospective studies, and cohort studies including search terms HHT, PAVMs, and various neurologic complications using MEDLINE and EMBASE. RESULTS: A total of 449 manuscripts were extracted including some duplicates of titles, abstracts, and text which were screened. Following this, 23 publications were identified for inclusion in the analysis. Most were case reports (n = 15). PAVMs were addressed in all these articles in association with various neurological conditions ranging from cerebral abscess, ischemic stroke, hemorrhagic stroke, embolic stroke, and migraines. CONCLUSION: Although HHT patients with PAVMs are at risk for a variety of neurological complications compared to those without PAVMs, the quality and volume of evidence characterizing this association is low. Individuals with PAVMs have a high prevalence of neurological manifestations such as cerebral abscess, transient ischemic attack, cerebral embolism, hemorrhage, and stroke. Mitigating stroke risk by implementing proper standardized screening techniques for PAVMs is invaluable in preventing increased mortality.

Indoor partitioning and potential thirdhand exposure to carbonyl flavoring agents added in e-cigarettes and hookah tobacco.

Flavoring agents added to the e-cigarettes and hookah tobacco have increased the attractiveness of novel nicotine products. Many widely used flavorings are carbonyls, which are toxic to humans. In an indoor environment, residents can be exposed to such harmful flavorings previously emitted to the surrounding environment, through a process termed thirdhand exposure. The recent discovery of a large volume of indoor reservoirs emphasizes the importance of indoor partitioning, which is responsible for thirdhand exposure. Indoor partitioning can be expressed with partitioning coefficients, such as Henry's law solubility constant (H). However, reliable H values for many key flavorings are currently lacking. To better understand their environmental behavior, this study experimentally determined the effective Henry's law constant (Hcps,eff) using the inert gas stripping (IGS) method. Further, the influence of the hydration process for target flavorings was quantified using proton nuclear magnetic resonance (1H NMR) spectroscopy. We found that hydration of α-dicarbonyls (diacetyl and 2,3-pentanedione) enhanced their Hcps,eff from their intrinsic Henry's law constant (Hcps) by a factor of 3.52 and 2.88, respectively. The two-dimensional partitioning plots were employed to simulate the indoor phase distribution and evaluate the pathways of human exposure. Our findings show that the indoor partitioning of many harmful flavorings is highly sensitive to temperature and the size of indoor reservoirs, indicating that residents are likely to experience third-hand exposure.

Diagnostic practices for patients with shortness of breath and presumed obstructive airway disorders: a cross-sectional analysis.

BACKGROUND: Dyspnea is a common symptom that has many causes, including obstructive airway disorders. We sought to examine previous diagnosis of obstructive airway disorders and other conditions in patients receiving treatment with inhaled medications for shortness of breath in a community setting. METHODS: This cross-sectional study included consecutive patients aged 18 years and older receiving treatment for shortness of breath with inhaled medications for a minimum of 6 months. Study participants were recruited through community pharmacies in Edmonton and Saskatoon, Canada, between February 2009 and February 2012. Previous diagnosis of obstructive airway disorders by a primary care provider was assessed by patient self-report and review of health records. We conducted an assessment (as per guidelines from the American Thoracic Society and the European Respiratory Society), including pulmonary function tests; diagnoses were adjudicated by an expert physician panel (2 respirologists and 1 emergency physician). The agreement between diagnoses derived from pulmonary function tests and diagnoses from primary care providers was evaluated. RESULTS: A total of 328 patients (median age 50 yr, 57.3% female) underwent assessment; 134 (40.9%) of patients reported ever having a pulmonary function test performed. After adjudication, 138 (42.1%) were diagnosed with asthma only, 86 (26.2%) with chronic obstructive pulmonary disease only and 11 (3.4%) with both. Some patients (93, 28.4%) had no evidence of obstructive airway disorders and 20 (6.1%) had evidence of other conditions that cause shortness of breath, such as heart failure and pulmonary hypertension. Overall, 62 (18.9%) patients could not be assigned a diagnosis. INTERPRETATION: In a group of community-based patients with shortness of breath being treated with inhalers, less than half ever had pulmonary function tests performed, and a considerable proportion had no evidence of lung disease or other conditions. These findings highlight the need for confirmatory testing, including pulmonary function tests, before prescribing inhalers for patients with presumed obstructive airway disorders.

Sarcoidosis: a prospective observational cohort from Northern Alberta.

INTRODUCTION: Sarcoidosis is a multi-system disease reported to occur with a higher incidence in Alberta than many other health jurisdictions within and outside of Canada. The reasons for this higher incidence are currently not known. Exposure to beryllium can result in a clinically and radiologically identical disease to sarcoidosis. The purpose of our study was to identify patterns with potential occupational or environmental exposures to beryllium amongst individuals with sarcoidosis in Alberta through a tertiary referral center. METHODS: A prospective observational study was carried out at the University of Alberta Hospital. Patients with confirmed sarcoidosis (stages 0-4) were recruited from subspecialty clinics (Respirology, Cardiology, Neurology and Occupational Health). A predetermined list of industries thought to involve potentially relevant exposures for the development of sarcoidosis was used to capture current and previous exposure history. Results were entered into a database and where possible verified by comparing with existing electronic medical records (including histories, physical examination, diagnostic imaging and physiology). RESULTS: A total of 45 patients were recruited, 25 men and 20 women. Of these, 84% of participants reported working in or being exposed to an industry/environment suspected of contributing to development of sarcoidosis over their lifetime. The most frequently reported exposures were within farming and agriculture (27%), oil and gas (20%), metalworking and handling animals (18%). CONCLUSIONS: Amongst this cohort, a high proportion reported working with a potentially relevant exposure. Individuals being assessed for sarcoidosis should have their most responsible physician elicit a detailed work and environmental history. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (4): e2020014).

Routine use of post-bronchodilator testing in pulmonary function testing labs.

PURPOSE: Pulmonary function tests (PFTs), including spirometry with and without post-bronchodilator (post-BD) testing, are frequently performed in the assessment of asthma, along with other obstructive airway disorders. Multiple publications over the past 15 years have noted that one in three physician-diagnosed asthma cases are not in fact asthma. In this quality assurance project, we assess whether PFT labs in Alberta have policies on post-BD testing, as extraneous and unnecessary use of post-BD testing can lead to wasted staff and patient time and unnecessary expenses to the health care system. METHODS: We reviewed, in collaboration with the College of Physicians and Surgeons of Alberta and Alberta Medical Association, all PFT labs in the province of Alberta (hospital-based private not-for-profit [NFP] and private for-profit [FP] labs). This health policy study of PFT labs involved identifying the proportions and regional distribution of NFP and private FP labs in the province of Alberta while assessing post-BD policies. Each PFT lab was asked for their policy regarding spirometry and asthma diagnosis from May 1 to August 31, 2017. RESULTS: A total of 92 PFT labs were identified in Alberta, 74 of which were private FP (independent) labs, while 18 were private NFP (public) hospital-based labs. Policies were as follows: (i) post-BD policy existed (and if so routinely performed / not routinely done); (ii) no post-BD policy; and (iii) lab chose not to participate. All 18 hospital labs responded: 10 had no policy; six had a policy or algorithm; one did not perform post-BD testing (exercise testing) and one had multiple testing sites. Of the private FP labs, three had relevant policies and/or algorithm and 10 had none. No information was provided from 61 labs. Access to PFT labs in Northern Alberta was limited. CONCLUSIONS: Lab policies surrounding post-BD testing were found to be heterogeneous in Alberta. Low response rates, despite the use of a systems approach and requests in writing and in person from FP labs, were notable. Development of a standardized policy across the province would be beneficial. Further higher-level review of the appropriateness of post-BD use in both FP and NFP PFT labs is needed.

Psychiatric co-morbidity and asthma: A pilot study utilizing a free use tool to improve asthma care.

PURPOSE: To assess the prevalence of co-morbid psychiatric disorders in asthmatic patients in a Western Canadian Regional Severe Asthma Center. METHODS: A prospective study was completed of patients evaluated through the Edmonton Regional Severe Asthma Clinic (ERSAC). A standardised evaluation, the Mini International Neuropsychiatric Interview (MINI) screen was used to identify possible psychiatric disorders. RESULTS: Twenty-four individuals with moderate to severe asthma, who presented for treatment at ERSAC, were recruited and underwent assessment with the MINI screen. The average patient age was 48 years (range 18-81 years). Nine patients were male and fifteen were female. Twenty subjects (83%) screened positive for a possible psychiatric co-morbidity using the MINI screen. The most common psychiatric co-morbidities identified were post-traumatic stress disorder (50% of the sampled population), depressive episode or persistent depressive disorder (42%), substance/alcohol abuse (33%), generalized anxiety disorder (335), manic episode (25%), agoraphobia (21%), panic disorder (21%) and obsessive-compulsive disorder (17%). Some individuals had more than one concomitant possible psychiatric co-morbidity identified by the MINI screen. CONCLUSIONS: Psychiatric co-morbidity was confirmed to be common in patients with moderate-severe asthma. In individuals with asthma, the MINI screen appeared to be a simple and useful clinical tool to screen for untreated/sub-optimally-managed psychiatric co-morbidities that may impact management.

Links Between Strokes and Hereditary Hemorrhagic Telangiectasia: A Population-Based Study.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a disease of abnormal vasculature where patients are predisposed to strokes of multiple etiologies. We assessed yearly stroke incidence among Albertans with HHT and compared with the general population. Given the tendency for stroke in HHT patients, we expected HHT patients to have higher stroke incidence, in particular at younger ages. METHODS: Population-based administrative health data on inpatient and ambulatory admissions were extracted over a 16-year period using International Classification of Diseases (ICD)-9 and ICD-10, Canada codes. We analyzed overall occurrence of strokes in Alberta by age, gender, stroke subtype, and diagnosis of HHT. RESULTS: The age-standardized incidence rate of stroke in HHT was 450 per 100,000 compared with 260 per 100,000 in the general population with a rate ratio of 1.73 (95% confidence interval (CI) [1.046-2.842]). This study found a higher HHT prevalence in Alberta (1 in 3800) compared to the world average of 1 in 5000. Women were also more likely to be diagnosed with HHT, with a 3.25:1 female gender preponderance in the yearly incidence.InterpretationThis study not only shows that HHT patients are at higher risk of having a stroke but also quantifies that risk using an age-adjusted metric in Alberta. This province has a higher than expected disease burden of HHT, with the majority of cases affecting women. Our study found that acute ischemic strokes and transient ischemic attacks are far more common than hemorrhage in HHT. As HHT is a rare, multi-system, chronic disease, these patients should be referred to an HHT Centre of Excellence.

CONTEXTE: La maladie de Rendu-Osler-Weber (MROW) est une maladie caractérisée par une anomalie du système vasculaire. Les patients qui en sont atteints deviennent prédisposés à être victimes d'AVC présentant de multiples étiologies. À cet égard, nous avons cherché à évaluer l'incidence annuelle d'AVC au sein de patients albertains atteints de la MROW comparativement à l'incidence annuelle d'AVC au sein de la population de cette province. Étant donné la prédisposition évoquée ci-haut, nous nous attendions à ce que l'incidence d'AVC chez des patients atteints de cette maladie soit plus élevée, particulièrement à un plus jeune âge. MÉTHODES: Des données administrative liées à la santé et basées sur une population déterminée ont été extraites au moyen des codes ICD-9 et ICD-10-CA. Elles concernaient des patients hospitalisés et ambulatoires au cours d'une période de 16 ans. Nous avons ensuite analysé l'incidence d'ensemble des AVC en Alberta en fonction de l'âge, du sexe, des sous-types d'AVC et de l'établissement préalable d'un diagnostic de MROW. RÉSULTATS: Le taux d'incidence normalisé selon l'âge des AVC chez les patients atteints de la MROW était de 450 pour 100 000 comparativement à 260 pour 100 000 au sein de la population générale. Le ratio des taux, lui, était de 1,73 (IC 95 % [1,046;2,842]). Notre étude a aussi constaté une prévalence plus élevée de la MROW en Alberta (1 sur 3 800) comparativement à la moyenne mondiale, qui est de 1 sur 5 000. Fait à souligner, les femmes étaient plus susceptibles de recevoir un diagnostic de MROW (prépondérance féminine de 3,25:1 sur une base annuelle). INTERPRÉTATION: Cette étude a montré que les patients atteints de la MROW étaient non seulement plus à risque d'être victimes d'un AVC mais a aussi quantifié ce risque au moyen d'un outil de mesure ajusté pour l'Alberta en fonction de l'âge. Cette province donne à voir une incidence plus élevée de MROW que ce à quoi on pouvait s'attendre, la majorité des patients étant de sexe féminin. Notre étude a en outre montré que les AVC ischémiques aigus et les accidents ischémiques transitoires (AIT) sont nettement plus courants que les hémorragies lorsqu'on est atteint de la MROW. Considérant qu'il s'agit d'une maladie chronique rare de nature multi-systémique, ceux et celles qui en sont atteints devraient être dirigés vers un centre d'excellence spécialisé dans son traitement.

Common bleeding disorders affecting individuals with Hereditary Hemorrhagic Telangiectasia.

PURPOSE: Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disorder affecting vasculature in different organ systems; seen at a rate of approximately 1:5000 in North America. Complications, with significant increases in health service utilization, arise from bleeding and shunts, and are particularly problematic in the lung and liver. Although these patients tend to chronically bleed from the GI tract and nasal cavities, a single bleed from arterio-venous malformations in the lungs or brain can have serious health implications and may be fatal. Bleeding due to vascular wall fragility in HHT patients can be further complicated with a concomitant bleeding disorder. METHODS: The proportion of adult patients seen in the Edmonton HHT center with a concomitant bleeding disorder, as assessed by blood test results for Factor VIII and related factors (Ristocetin Cofactor), Factor IX and Factor XI, was determined in a retrospective, single centre study. RESULTS: Of 77 individuals with HHT, four had below normal values of von Willebrand Factor, Ristocetin Cofactor or Factor VIII. Two patients had laboratory parameters diagnostic of a bleeding disorder, accounting for 2.6% of confirmed HHT subjects. These results indicate that establishing screening for bleeding disorders in HHT centers is important in managing bleeding symptomatology. CONCLUSIONS: In individuals with HHT, the presence of a second bleeding disorder can have significant clinical implications on patient management and health care utilizations. This paper highlights areas that need to be reviewed with respect to best practice protocols for the management of HHT patients.

Increased Protease-Activated Receptor-2 (PAR-2) Expression on CD14++CD16+ Peripheral Blood Monocytes of Patients with Severe Asthma.

BACKGROUND: Protease-Activated Receptor-2 (PAR-2), a G protein coupled receptor activated by serine proteases, is widely expressed in humans and is involved in inflammation. PAR-2 activation in the airways plays an important role in the development of allergic airway inflammation. PAR-2 expression is known to be upregulated in the epithelium of asthmatic subjects, but its expression on immune and inflammatory cells in patients with asthma has not been studied. METHODS: We recruited 12 severe and 24 mild/moderate asthmatics from the University of Alberta Hospital Asthma Clinics and collected baseline demographic information, medication use and parameters of asthma severity. PAR-2 expression on blood inflammatory cells was analyzed by flow cytometry. RESULTS: Subjects with severe asthma had higher PAR-2 expression on CD14++CD16+ monocytes (intermediate monocytes) and also higher percentage of CD14++CD16+PAR-2+ monocytes (intermediate monocytes expressing PAR-2) in blood compared to subjects with mild/moderate asthma. Receiver operating characteristics (ROC) curve analysis showed that the percent of CD14++CD16+PAR-2+ in peripheral blood was able to discriminate between patients with severe and those with mild/moderate asthma with high sensitivity and specificity. In addition, among the whole populations, subjects with a history of asthma exacerbations over the last year had higher percent of CD14++CD16+ PAR-2+ cells in peripheral blood compared to subjects without exacerbations. CONCLUSIONS: PAR-2 expression is increased on CD14++CD16+ monocytes in the peripheral blood of subjects with severe asthma and may be a biomarker of asthma severity. Our data suggest that PAR-2 -mediated activation of CD14++CD16+ monocytes may play a role in the pathogenesis of severe asthma.

Prevalence of osteopenia and osteoporosis in patients with moderate to severe asthma in Western Canada.

PURPOSE: Steroids, inhaled and systemic, are used to treat airway inflammation in patients with asthma; however, steroids are recognized to cause a number of side effects, including osteoporosis. We evaluated the prevalence of osteopenia/osteoporosis in patients with moderate-severe asthma managed through the Edmonton Regional Severe Asthma Centre. METHODS: We performed a retrospective chart review and analyzed 57 charts on patients with moderate-severe asthma followed through the specialty clinic, and recorded their bone mineral density (BMD). Steroid use was reviewed and the frequency of osteopenia/osteoporosis was compared in patients requiring continuous systemic steroids (Group 1, n=15), intermittent systemic steroids (Group 2, n=15) or inhaled steroids only (Group 3, n=27). RESULTS: The mean age (mean±SD) was 50±14.8 years. Cumulative systemic steroid dose of prednisone equivalent was higher in Group 1 (12.5 mg/day) than Group 2 (3.2 mg/day) (p=0.002). The frequency of osteopenia / osteoporosis was not significantly different between patients in Group 1(67%) and Group 2 (53%, p=0.46) but was significantly greater in patients from Group 1 in comparison with Group 3 (33%, p=0.038). CONCLUSION: Patients with moderate-severe asthma have a high prevalence of reduced bone density. Many patients treated with intermittent systemic steroids for exacerbations, or who were stable on inhaled steroids, had either osteopenia or osteoporosis before the age of 50. National and international osteoporosis guidelines should emphasize earlier screening for asthma patients; and increase awareness of the detrimental effects of short-term systemic steroids and inhaled steroids on BMD, especially when started at an early age and in northern climates.

High prevalence of abnormal gastrointestinal permeability in moderate-severe asthma.

PURPOSE: Abnormal gastrointestinal permeability (GIP) has been implicated in a number of diseases, including chronic intestinal inflammatory disorders such as Crohn's as well as non-intestinal immunologic diseases such as diabetes and multiple sclerosis. Although evidence in the literature demonstrates mucosal abnormalities of the digestive barrier in asthma, previous studies have assessed only colonic permeability, while ignoring the mucosal-associated lymphoid tissue (MALT) rich areas of the small intestine. Alterations in GIP may lead to increased entry of allergenic proteins from the gut lumen into the systemic circulation, thus priming and activating the adaptive immune system and leading to inappropriate allergen sensitization and/or deregulated extra-intestinal inflammation. This study examines GIP in adults with moderate to severe asthma. METHODS: Patients ingested a mixed-sugar solution and urine was collected. GIP was assayed using high-performance liquid chromatography. Demographics, atopy (assessed by allergen skin testing) and sputum cell counts were also assessed. RESULTS: Fourteen patients with moderate to severe asthma were studied, half of whom were found to have abnormal GIP. Abnormal GIP did not correlate with sputum cell counts and there was no apparent association between atopy and intestinal permeability. CONCLUSION: This study demonstrated our ability to identify abnormal GIP in the MALT-rich, immunogenic small intestine of patients with asthma. The absence of a correlation between airway inflammation and increased GIP suggests that these two parameters are not causally linked, but rather define distinct entities that could separately or sequentially be involved with the development and propagation of asthma over time.

Severe asthma associated with myasthenia gravis.

Severe asthma constitutes a subgroup of approximately 10% of all asthma cases. Approximately one-half of these individuals have a refractory form of the disease in which atopy and T-helper cell 2-skewed immunological response may not be as closely linked to the disease as in other phenotypes of asthma. This suggests that not all asthma is explained by a T-helper cell 2-skewed immunological response, and that other immunological mechanisms may be important in this category of nonatopic asthma. The authors present a case involving a 55-year-old Caucasian man with nonatopic, adult-onset asthma, nonsteroidal anti-inflammatory drug sensitivity and idiopathic urticaria. This individual presented two years following his initial asthma diagnosis with diplopia and mild ptosis, and was subsequently diagnosed with seropositive myasthenia gravis.

Fragrance materials in asthma: a pilot study using a surrogate aerosol product.

OBJECTIVE: Many household products contain fragrances. Little is known about exposure to fragrances on human health, particularly within the airways. This study aimed to evaluate how common household fragrance products (i.e. air fresheners, cleaning products) affect people with asthma, who frequently report sensitivity to these products. Many of these products have volatile organic compounds or semi-volatile organic compounds. This study evaluated nine fragrance materials in an aerosol formulation to assess effects on airway physiology, airway inflammation and symptom perception in normal controls and those with asthma. METHODS: The effects of fragrances were evaluated in people without asthma, people with mild asthma and people with moderate asthma in a four-way crossover placebo-controlled study. Subjects were exposed twice to a fragranced aerosol and twice to a placebo aerosol (15 and 30 min each). Subjects completed a questionnaire for 29 symptoms during and up to 3 h after each exposure scenario. Spirometry was performed prior to and 3 h post-exposure; sputum induction was conducted 3 h post-exposure. RESULTS: Nasal symptoms showed the greatest frequency of response in all three subject groups, and moderate asthmatics reported the greatest symptom severity and symptom types. No significant differences were noted in physiology or cellular inflammation. CONCLUSION: A trend for increased symptoms was noted in moderate asthmatics, suggesting that asthma severity may play a factor in fragrance sensitivity.

Persistent elevation of peripheral blood myeloid cell counts associated with omalizumab therapy.

PURPOSE: A case of persistent hematologic abnormalities in a patient receiving long-term omalizumab therapy for severe asthma is reported. SUMMARY: During the course of her treatment at an asthma clinic, a 24-year-old woman was noted to have increased white blood cell counts, with elevated myeloid cell counts; the blood abnormalities were first documented more than 12 months previously. The woman had been taking omalizumab for more than 2 years and was also receiving immune globulin therapy for common variable immunodeficiency. Based on the results of bone marrow aspiration and biopsy, she was diagnosed as having mild neutrophilia, possibly related to past corticosteroid therapy, but there was no evidence of a malignancy, a hemophagocytic syndrome, or an infectious, myeloproliferative, or lymphoproliferative process. Pursuant to a multidisciplinary medication review, the use of omalizumab was identified as a potential factor in the myeloid cell elevations and discontinued. About 1 month after omalizumab therapy was halted, the patient's myeloid cell counts normalized. The temporal association of omalizumab use and blood abnormalities in this case, coupled with the lack of data on the drug's long-term hematologic effects, suggests a need for cautious use and close monitoring of omalizumab therapy, particularly in younger patients. CONCLUSION: A patient with asthma and common variable immunodeficiency developed an elevation of peripheral blood myeloid cells that was first noticed 29 months after the initiation of monthly omalizumab injections. Omalizumab was discontinued, and the abnormality persisted for 1 month after the last dose. The patient's blood count results remained within normal limits 3 months after the last dose.

Screening for right-to-left shunts with contrast transcranial Doppler in hereditary hemorrhagic telangiectasia.

BACKGROUND AND PURPOSE: Contrast transthoracic echocardiography (TTCE) is used to screen hereditary hemorrhagic telangiectasia (HHT) patients for right-to-left shunts (RLS) associated with increased stroke risk. We hypothesized that contrast transcranial Doppler (TCDc), shown to be highly sensitive for detecting RLS in patent foramen ovale, will be as comparable to TTCE for screening HHT patients. METHODS: We compared TTCE and TCDc for detecting RLS in 12 patients with HHT who also underwent CT pulmonary studies to determine pulmonary arteriovenous malformation (PAVM) presence. The sensitivity and specificity of TTCE and TCDc in detecting PAVM were determined and the agreement between TTCE and TCDc in detecting RLS was assessed. RESULTS: Both TTCE and TCDc had 100% sensitivity in detecting underlying PAVM; the specificity was 25% and 38%, respectively. The agreement in detecting RLS between TTCE and TCD was high (κ=0.76). TCD was well-tolerated with no immediate adverse or embolic events over the next 3 months. CONCLUSIONS: TCDc offers a simple office-based alternative to TTCE for screening RLS associated with PAVM in HHT patients.

Perceptions about self-management among people with severe asthma.

AIM: The purpose of this study was to explore the perceptions about self-management among people who were being followed up in a severe asthma clinic by asthma specialists for confirmed, overall severe asthma. Such insight informs how best to tailor programs for this difficult to treat patient population. METHOD: In-depth tape-recorded interviews of eight adults with severe asthma were transcribed and analyzed for salient themes using content analysis. RESULTS: To self-manage their illness, over time participants sought asthma information from a variety of sources that they often viewed as inadequate due to lack of scope and or plain language. The most valued sources of asthma information were encountered after referral to an asthma specialist and were health professionals and a pulmonary rehabilitation program. CONCLUSION: There is a need to examine the content of asthma information sources for their relevance to and influence on the behavior of patients with severe asthma.

The efficacy of tiotropium as a steroid-sparing agent in severe asthma.

People with severe asthma account for 5% to 10% of all asthmatic patients; however, this small group uses the majority of health care resources. Novel methods are needed to cope with the burden that this minority of patients places on the health care system. A severe asthma clinic patient, who was monitored through the University of Alberta's Virtual Asthma Clinic (Edmonton, Alberta) is presented. Despite optimization of his disease and individualized asthma education (provided by a certified asthma educator), the patient remained on oral glucocorticosteroids (OGS) to control his disease. Following optimization and stabilization, a further reduction in the dose of his OGS by the addition of the long-acting anticholinergic agent tiotropium bromide, was demonstrated. The role of tiotropium as a potential 'steroid-sparing agent' in severe refractory asthma is discussed, noting that if patients who are on OGS are not monitored for active inflammation, they may overuse the amount of prescribed systemic steroids, which can result in long-term steroid-related sequelae.