Identification of connective tissue disease autoantibodies and a novel autoantibody anti-annexin A11 in patients with "idiopathic" interstitial lung disease.

BACKGROUND: Autoantibodies are a hallmark feature of Connective Tissue Diseases (CTD). Their presence in patients with idiopathic interstitial lung disease (ILD) may suggest covert CTD. We aimed to determine the prevalence of CTD autoantibodies in patients diagnosed with idiopathic ILD. METHODS: 499 patient sera were analysed: 251 idiopathic pulmonary fibrosis (IPF), 206 idiopathic non-specific interstitial pneumonia (iNSIP) and 42 cryptogenic organising pneumonia (COP). Autoantibody status was determined by immunoprecipitation. RESULTS: 2.4% of IPF sera had a CTD-autoantibody compared to 10.2% of iNSIP and 7.3% of COP. 45% of autoantibodies were anti-synthetases. A novel autoantibody targeting an unknown 56 kDa protein was found in seven IPF patients (2.8%) and two NSIP (1%) patients. This was characterised as anti-annexin A11. CONCLUSION: Specific guidance on autoantibody testing and interpretation in patients with ILD could improve diagnostic accuracy. Further work is required to determine the clinical significance of anti-annexin A11.

"Life-changing": the experience of super-responders to biologics in severe asthma.

BACKGROUND: There is limited information on the patient's perspective of how biologic treatments impact their lives. We conducted a qualitative study to explore the patient's experience of being considered a super-responder from a quality of life perspective. METHODS: Patients with severe asthma identified as super-responders were invited to semi-structured interviews conducted online. Participants could bring a family member/friend to the interview. The interviews explored experiences of biologic treatment, were transcribed and underwent thematic analysis. RESULTS: Twenty-five participants took part in this study. Themes emerged on the impact of biologic treatment for participants and for their friends/family: (i) Words used to describe their often life-changing experiences and (ii) the positive changes noted. Biologic treatment stopped the disruption of family life and social life caused by exacerbations. Improvements in mental health were also noted. Marked individual variations in the way it affected their lives were noted. Most participants noticed improvements 2-3 months after starting their biologic, but some noticed improvement within a few days and others after 6 months. CONCLUSIONS: Super-responders reported profound but heterogeneous improvements following biologic treatment beyond asthma symptoms and exacerbations including important benefits to social and family life. Improvements may be underestimated as social and family benefits are not reliably measured in current studies with implications for health economic evaluations. Not all patients are super-responders, and excellent responses may be lost in group mean data in trials. Individual time course and response patterns need further elucidation to identify who will respond best to biologics.

Takotsubo cardiomyopathy findings on cardiac magnetic resonance imaging following immersion pulmonary oedema.

Immersion pulmonary oedema (IPO) can affect sea swimmers, snorkelers, and scuba divers. It can be fatal and cases are often mistaken for drowning. There has been an association between IPO and the development of takotsubo cardiomyopathy. We present a case study of a diver rescued from the water with IPO, who was subsequently found to have takotsubo cardiomyopathy on cardiac magnetic resonance imaging (CMR). This case demonstrates CMR findings as well as follow- up investigation results. The diver's and instructor's perspective during the initial dive incident are also described.

Platypnoea-orthodeoxia syndrome due to a right-to-left interatrial shunt following pneumonectomy.

A 62-year-old man presents with breathlessness 6 months following right pneumonectomy for lung adenocarcinoma. Previous investigations had not yielded a diagnosis and his symptoms were progressing. The patient described worsened symptoms when stood up (platypnoea), with profound hypoxia until laid supine (orthodeoxia). Platypnoea-orthodeoxia syndrome due to a right-to-left interatrial shunt was diagnosed on contrast-enhanced transoesophageal echocardiography with the patient undergoing successful percutaneous patent foramen ovale closure. Patent foramen ovale is often asymptomatic with a population prevalence of around 20%-30%. Anatomical shifts postpneumonectomy can open, or worsen a previously closed interatrial communication leading to right-to-left shunting of blood. Platypnoea-orthodeoxia is under-recognised, impairing quality of life and patient outcome. Investigations can be falsely reassuring, or poorly sensitive for the causative pathology. Percutaneous closure is safe with high success rates and this case highlights the need for a high index of suspicion for shunts, particularly in postpneumonectomy patients.

Improving access to contraception through integration of family planning services into a multidrug-resistant tuberculosis treatment programme.

OBJECTIVES: Multidrug-resistant tuberculosis (MDR-TB) is a global public health priority. The advent of the World Health Organisation's Short Course regimen for MDR-TB, which halves treatment duration, has transformed outcomes and treatment acceptability for affected patients. Bedaquiline, a cornerstone of the Short Course regimen, has unknown teratogenicity and the WHO therefore recommends reliable contraception for all female MDR-TB patients in order to secure eligibility for bedaquiline. We were concerned that low contraceptive uptake among female patients in our rural South African MDR-TB treatment programme could jeopardise their access to bedaquiline. We therefore conducted a service delivery improvement project that aimed to audit contraceptive use in female MDR-TB patients, integrate family planning services into MDR-TB care, and increase the proportion of female patients eligible for bedaquiline therapy. METHODS: Contraceptive use and pregnancy rates were audited in all female patients aged 13-50 years initiated on our MDR-TB treatment programme in 2016. We then implemented an intervention consisting of procurement of depot-medroxyprogesterone acetate (DMPA) for the MDR-TB unit and training of specialist MDR-TB nurses in administration of DMPA. The audit cycle was repeated for all female patients aged 13-50 years initiated on the programme in January-October 2017 (post-intervention). RESULTS: The proportion of women on injectable contraceptives by the time of MDR-TB treatment initiation increased significantly in the post-intervention cohort (77.4% vs 23.9%, p<0.0001). CONCLUSION: By integrating contraceptive services into our MDR-TB programme we significantly increased contraceptive uptake, protecting women from the obstetric risks associated with pregnancy during MDR-TB treatment and maximising their eligibility for bedaquiline therapy.