Temperature-controlled Laminar Airflow (TLA) in symptomatic severe asthma - a post hoc analysis of severe exacerbations, quality of life and health economics.

PURPOSE: Uncontrolled severe asthma constitutes a major economic burden to society. Add-ons to standard inhaled treatments include inexpensive oral corticosteroids and expensive biologics. Nocturnal treatment with Temperature-controlled Laminar Airflow (TLA; Airsonett®) could be an effective, safe and cheaper alternative. The potential of TLA in reducing severe asthma exacerbations was addressed in a recent randomised placebo-controlled trial (RCT) in patients with severe asthma (Global Initiative for Asthma (GINA) step 4/5), but the results were inconclusive. We re-analysed the RCT with severe exacerbations stratified by the level of baseline asthma symptoms and Quality of Life. METHODS: More uncontrolled patients, defined by Asthma Control Questionnaire 7 (ACQ7) > 3, EuroQoL 5-Dimension Questionnaire Visual Analogue Scale (EQ5D-VAS) ≤ 65 and Asthma Quality of Life Questionnaire (AQLQ) ≤ 4 were selected for re-analysis. The rates of severe asthma exacerbations, changes in QoL and health-economics were analysed and compared between TLA and placebo. RESULTS: The study population included 226 patients (113 TLA / 113 placebo.) The rates of severe asthma exacerbations were reduced by 33, 31 and 25% (p = 0.083, 0.073, 0.180) for TLA compared to placebo, dependent on selected control measures (ACQ7, EQ5D-VAS, AQLQ, respectively). For patients with less control defined by AQLQ≤4, the difference in mean AQLQ0-12M between TLA and placebo was 0.31, 0.33, 0.26 (p = 0.085, 0.034, 0.150), dependent on selected covariate (AQLQ, EQ5D-VAS, ACQ7, respectively). For patients with poor control defined by ACQ7 > 3, the difference in EQ5D-5 L utility scores between TLA and placebo was significant at 9 and 12 months with a cost-effective ICER. The results from the original study did not demonstrate these differences. CONCLUSION: This post hoc analysis demonstrated an effect of TLA over placebo on severe exacerbations, asthma control and health economics in a subgroup of patients with more symptomatic severe allergic asthma. The results are consistent with the present recommendations for TLA. However, these differences were not demonstrated in the full study. Several explanations for the different outcomes have been outlined, which should be addressed in future studies. FUNDING: NIHR Health Technology Assessment Programme and Portsmouth Hospitals NHS Trust.

Mind the gap.

This article looks at the provision of professional indemnity in the UK, what the different products are and the importance of making choices appropriate to your needs to fulfil the statutory and ethical obligation to have appropriate indemnity as a registered dentist.

Tier 2 NHS services in primary dental care - where are the risks?

NHS England and the Office of the Chief Dental Officer have set out plans for the accreditation of Tier 2 services in primary care, the first of which will be endodontics. This Opinion article examines the unintended consequences of the development of this service whose need has arisen for a number of reasons including the current UDA activity-based NHS dental contract, undergraduate training and the quality and quantity of endodontic services being delivered in primary dental care.

Long Sun-Exposures Influencing High Sub-Cutaneous Synthesis of Vitamin-D3 may be Associated with Exacerbation of Symptoms in Allergic-Asthma.

OBJECTIVES: Does excessive sun-exposure, non-use of sunscreen and/or high doses of vitamin-D3 supplements provoke exacerbation of asthma? DESIGN: Clinical examinations, retrospective records-access and questionnaire surveys were distributed to a convenience sample of allergic-asthma patient (n=183). SETTING: Patients (19-89 years) attending the outpatient respiratory clinics at Maidstone Hospital were enrolled. RESULTS: 90.3% of patients (total IgE levels ≥75 kU/L ; n=103) exposed to direct sunlight of ≥ 15 minutes per day continuously for 6-7 days presented with wheeze (χ2(1) = 7.46; p< 0.05) compared to only 9.7% patients of similar atopy-status, presenting with wheeze if exposed to sunlight of < 15 minutes per day for 6-7 days. 68.9% patients (with IgE levels ≥ 75 kU/L ; n=103), non-users of sunscreen (SPF 30 and above), exposed to direct sunlight of ≥ 15 minutes per day continuously for 6-7 days developed a wheeze, compared to fewer users of sunscreen (9.7%, n=103), exposed to the same duration of sunlight who developed asthma symptoms (p< 0.05). Vitamin-D3 supplementation in asthma-patients with clinical signs of hypovitaminosis-D (n=21), produced symptoms of morning chest-tightness (76.2%), allergic rhinitis (61.9%) and wheeze (100%), 2 weeks after initiation of treatment. CONCLUSIONS: Our results advocate direct sunlight exposure < 15 minutes per day and use of sunscreen as a novel approach to preventing atopic-asthma symptoms in allergic-asthma patients.. Activated vitamin-D3 is well-recognised to shift the immune-balance towards Th2 predominance, favouring allergic asthma. These results suggest that limiting subcutaneous synthesis of vitamin-D3 in asthma patients and re-addressing dosage of vitamin-D3 supplementation is necessary may contribute to prevent exacerbation of symptoms.

Electronic clinical dental records: unintended consequences.

Record keeping is an essential component of delivering safe and appropriate care. In an ever increasing climate of litigation and complaints contemporaneous record keeping has assumed increasing importance, but is time consuming to do well and cover the aspects of care necessary. Practitioners have started using templates and copy and paste notes which, whilst useful, have their limitations and create problems of their own.

How the vision of a clinician and an educator brought the MA Dental Law and Ethics course to life.

This paper reflects on an educational development, a dental law and ethics course, as the course approaches its fifth anniversary. The authors outline their personal journey into developing and delivering this course, as well as sharing their best practice in relation to teaching dental postgraduate students who may approach the subject in different ways. It also highlights the vision behind this provision and how it is received by dental practitioners. The paper shares the learners' perception of topics such as ethics in comparison to law, and it highlights the perspective of both authors in teaching and following the students' journey in this course.

Dento-legal considerations about an MI approach.

Over the years there have been many conceptual changes in how dental disease is prevented and managed. What is now the norm and standard practice was at some earlier time considered to be at best pioneering, and at its worst, heresy or negligent. When we look, for example at how we conservatively manage periodontal disease when less than a generation ago we were wielding surgical knives far more frequently than we do now, we can see how research and evidence-based dentistry has influenced our thinking. We are very much at that tipping point now with minimum intervention (MI) dentistry. This article will discuss the impact of MI dentistry from a legal viewpoint, covering such aspects as consent and record-keeping.

Consent - an update.

Following the judgement in Montgomery in March 2015 which brought the law of consent up to speed with what the GDC 's ethical and professional guidance expected registrants to do, this article looks at how other cases have interpreted Montgomery subsequently and the impact and implications for dentists. The importance of excellent communication is emphasised in order to provide sufficient and relevant information to the particular patient you have sitting in your dental chair.

Consent - a new era begins.

The law in relation to consent has changed following the handing down of the Supreme Court judgement in Montgomery vs Lanarkshire in March this year. Legally, clinicians, including dentists, must now take reasonable care to ensure that patients are aware of any material risks involved in a proposed treatment and of reasonable alternatives. This case now brings the law in relation to the disclosure of risks when obtaining consent to treatment in line with the guidance issued by regulatory bodies such as the GMC and GDC.

Reflections on a training course reorienting dental teams towards prevention.

Prevention is a core element of routine dental practice. However, members of the dental team often lack the required knowledge and skills to deliver effective evidence-based advice and support to patients. This paper describes the development and delivery of an innovative course designed to develop the preventive capacity of dental teams working in dental foundation training practices across London. The course contents were based upon national guidelines on evidence-based preventive care delivered in primary dental care settings (Delivering better oral health). An experienced team of trainers from diverse backgrounds successfully designed and delivered the courses and the initial feedback from participants indicate strong support for the approach developed.

Risk management in clinical practice. Part 2. Getting to 'yes'--the matter of consent.

Consent is an integral part of delivering the care patients want. In order to consent to treatment, patients must have the legal capacity to give valid consent. If this three stage test is satisfied, the patient can elect to have any treatment they wish even if it is not in their best interest. Before a patient is able to consent to treatment they must have adequate knowledge about the risks, benefits and alternatives to the treatment. The amount of information provided to the patient by the dentist is determined to some degree by the legal system prevailing. The patient must voluntarily agree to treatment without being coerced by the dentist or other parties and if things change during treatment the patient needs to be advised. Written consent is very useful in the defence of cases but simply signing the consent form does not mean that the patient knows or understands the treatment to which they have agreed.

Risk management in clinical practice. Part 1. Introduction.

This paper introduces a number of concepts that will recur throughout the series. It examines firstly the rationale behind what triggers patients' complaints and explores the concepts of precipitating and predisposing factors. If patients are dissatisfied they may seek legal redress and clinical negligence is explained briefly with an explanation particularly of breach of duty and causation. Record keeping is an integral part of delivering high quality care and ten essential requirements are listed. Where patients request it or treatment is more complex than the practitioner can manage, a referral should be considered. An outline of risk management principles are given with emphasis on learning from mistakes.

Who cares for the carers?

The NHS complaints system has been overhauled again in England with the stated aim of simplifying a 'process' driven system and to give 'organisations greater flexibility to respond and encourage a culture that seeks and then uses people's experiences of care to improve quality'. The complaints system that ran from 1996 to 31 March 2009 was considered 'too prescriptive and inflexible and not meeting the needs of the person making the complaint'. Many fine words and hours of consultations have been devoted to analysing the problems with the complaints systems and the advantages of producing a new one that enables health services to listen to the patients, respond to their concerns and improve the services delivered. This patient-centred focus is the new rally cry in the modern twenty-first century NHS. Very little thought, however, appears to have been given to those against whom the complaints are invariably directed: the dentist and their teams. What will the new reforms, with one less layer of complaints management (the Healthcare Commission) do to the dynamics of complaints management? What effects on the dentist and their teams will come about as a result of the primary care trust's ability to investigate the complaint themselves if invited to do so by the patient?

Selection and behavior of CD4+ CD25+ T cells in vivo: lessons from T cell receptor transgenic models.

Despite great interest in CD4+ CD25+ suppressor T cells, many of the fundamental properties of these cells remain enigmatic. This is in part due to experimental limitations inherent to the study of polyclonal suppressor T cells, and the extensive use of in vitro assays. This review article intends to outline recent advances in our understanding of the biology of suppressor T cells that have emerged from the analysis of T cell receptor (TCR) transgenic models. Several laboratories have taken advantage of model systems in which suppressor T cells of defined antigen-specificity are naturally selected in order to characterize the selection and behavior of these cells in vivo. In addition to providing valuable insights into the mechanism of differentiation of suppressor T cells, these systems now offer new possibilities for understanding the mode of action of suppressor T cells. For example, adoptive transfer of small numbers of ex vivo isolated TCR transgenic suppressor T cells allows for the visualization of the fate of such cells when confronted with cognate antigen in a quasi-normal, nonlymphopenic environment. Characteristic features of the currently available TCR transgenic models of suppressor T cells will be highlighted, and particular issues pertaining to the differentiation, function, and homeostasis of this T cell subset that have emerged from these models will be discussed.