Multiple sclerosis health-related quality of life utility values from the UK MS register.

Background: New interventions for multiple sclerosis (MS) commonly require a demonstration of cost-effectiveness using health-related quality of life (HRQoL) utility values. The EQ-5D is the utility measure approved for use in the UK NHS funding decision-making. There are also MS-specific utility measures - e.g., MS Impact Scale Eight Dimensions (MSIS-8D) and MSIS-8D-Patient (MSIS-8D-P). Objectives: Provide EQ-5D, MSIS-8D and MSIS-8D-P utility values from a large UK MS cohort and investigate their association with demographic/clinical characteristics. Methods: UK MS Register data from 14,385 respondents (2011 to 2019) were analysed descriptively and using multivariable linear regression, with self-report Expanded Disability Status Scale (EDSS) scores. Results: The EQ-5D and MSIS-8D were both sensitive to differences in demographic/clinical characteristics. An inconsistency found in previous studies whereby mean EQ-5D values were higher for an EDSS score of 4 rather than 3 was not observed. Similar utility values were observed between MS types at each EDSS score. Regression showed EDSS score and age were associated with utility values from all three measures. Conclusions: This study provides generic and MS-specific utility values for a large UK MS sample, with the potential for use in cost-effectiveness analyses of treatments for MS.

COVID-19 in Multiple Sclerosis: Clinically reported outcomes from the UK Multiple Sclerosis Register.

BACKGROUND: In March 2020, the United Kingdom Multiple Sclerosis Register (UKMSR) established an electronic case return form, designed collaboratively by MS neurologists, to record data about COVID-19 infections in people with MS (pwMS). OBJECTIVES: Examine how hospital admission and mortality are affected by disability, age and disease modifying treatments (DMTs) in people with Multiple Sclerosis with COVID-19. METHODS: Anonymised data were submitted by clinical teams. Regression models were tested for predictors of hospitalisation and mortality outcomes. Separate analyzes compared the first and second 'waves' of the pandemic. RESULTS: Univariable analysis found hospitalisation and mortality were associated with increasing age, male gender, comorbidities, severe disability, and progressive MS; severe disability showed the highest magnitude of association. Being on a DMT was associated with a small, lower risk. Multivariable analysis found only age and male gender were significant. Post hoc analysis demonstrated that factors were significant for hospitalisation but not mortality. In the second wave, hospitalisation and mortality were lower. Separate models of the first and second wave using age and gender found they had a more important role in the second wave. CONCLUSIONS: Features associated with poor outcome in COVID-19 are similar to other populations and being on a DMT was not found to be associated with adverse outcomes, consistent with smaller studies. Once in hospital, no factors were predictive of mortality. Reassuringly, mortality appears lower in the second wave.

Validating the portal population of the United Kingdom Multiple Sclerosis Register.

The UK Multiple Sclerosis Register (UKMSR) is a large cohort study designed to capture 'real world' information about living with multiple sclerosis (MS) in the UK from diverse sources. The primary source of data is directly from people with Multiple Sclerosis (pwMS) captured by longitudinal questionnaires via an internet portal. This population's diagnosis of MS is self-reported and therefore unverified. The second data source is clinical data which is captured from MS Specialist Treatment centres across the UK. This includes a clinically confirmed diagnosis of MS (by Macdonald criteria) for consented patients. A proportion of the internet population have also been consented at their hospital making comparisons possible. This dataset is called the 'linked dataset'. The purpose of this paper is to examine the characteristics of the three datasets: the self-reported portal data, clinical data and linked data, in order to assess the validity of the self-reported portal data. The internet (n = 11,021) and clinical (n = 3,003) populations were studied for key shared characteristics. We found them to be closely matched for mean age at diagnosis (clinical = 37.39, portal = 39.28) and gender ratio (female %, portal = 73.1, clinical = 75.2). The Two Sample Kolmogorov-Smirnov test was for the continuous variables to examine is they were drawn from the same distribution. The null hypothesis was rejected only for age at diagnosis (D = 0.078, p < 0.01). The populations therefore, were drawn from different distributions, as there are more patients with relapsing disease in the clinical cohort. In all other analyses performed, the populations were shown to be drawn from the same distribution. Our analysis has shown that the UKMSR portal population is highly analogous to the entirely clinical (validated) population. This supports the validity of the self-reported diagnosis and therefore that the portal population can be utilised as a viable and valid cohort of people with Multiple Sclerosis for study.

Topical nasal anesthesia for flexible bronchoscopy. A comparison of four methods in normal subjects and in patients undergoing transnasal bronchoscopy.

We evaluated nasal anesthesia regimens by comparing, in seven normal men, four drug regimens: 1) 1 percent phenylephrine; 2) 4 percent lidocaine; 3) 1 percent phenylephrine + 4 percent lidocaine; and 4) 5 percent cocaine. After spraying each drug into the anterior nares, vasoconstriction, decongestion, and nasal anesthesia (measured as transnasal depth of nasogastric (NG) tube insertion before discomfort) were assessed. There were no significant differences in NG tube insertion depth between the regimens (p = 0.54). Insertion depth was significantly increased after 10 ml of 2 percent viscous lidocaine were sniffed (p less than 0.004), but again, differences between regimens were not significant (p = 0.051). One hundred bronchoscoped patients received one of the following sprayed into the nose: 1) placebo (P); 2) 1 percent phenylephrine + P; 3) 1 percent phenylephrine + 4 percent lidocaine; or 4) 5 percent cocaine + P. Each patient then sniffed viscous lidocaine. There were no significant differences between regimens for any of the following: 1) nasal resistance to bronchoscope insertion, 2) patient's nasal discomfort, or 3) bronchoscopist's perception of patient discomfort. We conclude that sprayed anesthetics contribute little to nasal anesthesia and any regimen appears acceptable when viscous lidocaine is used.

Comparison of quantitative cultures to semiquantitative loop cultures of bronchoscopic protected specimen brush samples.

STUDY OBJECTIVE: To compare quantitative growth from a calibrated loop to growth from the standard serial dilution technique of culturing bronchoscopic protected specimen brush (PSB) samples and to determine the effect of refrigeration of the PSB sample on subsequent quantitative growth. DESIGN: Laboratory stock cultures were sampled with a PSB and cultured by both standard 100-fold serial dilution as well as 1:100 mL and 1:1,000 mL calibrated loops. Stock cultures were also sampled with a PSB and growth before and after refrigeration for 24 h at 4 degrees C (both serial dilution and calibrated loops) was compared. Clinical PSB samples from seven patients suspected of having lower respiratory tract infections were cultured by both techniques as well. SETTING: Clinical research laboratory and teaching hospital. PATIENTS AND INTERVENTIONS: PSB samples from inpatients and outpatients who had clinically indicated bronchoscopy. No interventions. MEASUREMENTS AND RESULTS: Quantitative growth from the 1:1,000 mL calibrated loop was within 1 log10 of growth from the serial dilution technique for 20 of 21 organisms, including 2 yeasts. Except for Haemophilus influenzae (known to be cold intolerant), there were no important differences in growth of bacteria before and after 24 h at 4 degrees C. For quantitative bacterial growth, there was a significant correlation between serial dilution and the 1:1,000 mL loop cultures (r=0.86, p < 0.0001). CONCLUSION: In this study, quantitative growth from a single 1:1,000 mL loop culture of PSB samples was comparable to growth from the standard serial dilution technique. Our results also suggest that overnight refrigeration of PSB samples may be possible in certain clinical situations.

Bronchoscopic protected specimen brush and bronchoalveolar lavage in the diagnosis of bacterial pneumonia.

Despite marked improvements in antibiotic therapy, the accurate diagnosis and treatment of bacterial lower respiratory tract infection remain a challenge. The bronchoscopic protected specimen brush and bronchoscopic bronchoalveolar lavage combined with quantitative bacterial cultures can provide sensitive and relatively specific information about lower airway flora. Both of these methods require strict observance of the required protocol, careful processing of the obtained specimens, and the absence of prior antibiotic therapy to obtain best results. These procedures are also of some utility in sickle cell acute chest syndrome, bronchiectasis, and in the immunocompromised host.

Clinical use of cocaine. A review of the risks and benefits.

Following the isolation of cocaine from the extract of coca leaves in the late 1700s by Albert Neiman, the local anaesthetic properties of the drug have been evaluated. The anaesthetic effect of cocaine is believed to be the result of reversible blockade of nervous impulse conduction by the prevention of sodium ion movement within the cell membrane. The many undesired effects, however, are the result of adrenergic stimulation by means of prevention of noradrenaline (norepinephrine) uptake. The clinical use of cocaine in the modern era is associated primarily with surgical procedures involving the manipulation of mucous membranes, particularly those of the upper respiratory tract. Recently, based on problems with the potential for illicit use and adverse effects, alternative regimens have been investigated. In some settings these have been superior to cocaine. Further studies comparing various anaesthetic regimens are warranted.

Bronchoscope damage and repair costs: results of a regional postal survey.

Flexible fiberoptic bronchoscopy is a commonly performed procedure for which the indications, technical aspects, and potential patient complications have been well described. However, limited information is available regarding damage to the instrument itself. In order to better describe the types and causes of bronchoscope damage, repair costs, and time out of service, we performed a postal survey of hospital bronchoscopy laboratories in Alabama, Mississippi, and Louisiana. We received 43 completed surveys from laboratories that perform an average of 233 bronchoscopies per year. The respondents reported 103 episodes of bronchoscope damage, the majority of which consisted of damage to the bronchoscope cover, broken fiber bundles, malfunction of the bending apparatus, and suction channel damage. The respondents attributed 62% of all the damage to one of the three following categories: unknown, improper handling, and damage caused by biopsy forceps, brushes, or needles. Of the 103 episodes of bronchoscope damage, 66 (64%) were judged to be preventable, 13.6% not preventable, and 17.5% to be indeterminant. The average time out of service (mean, SD) for each damaged bronchoscope was 3.5 (3.9) weeks, and the average repair cost per episode of bronchoscope damage was $2,726.13 ($1,391.21). At least 19 episodes of bronchoscope damage occurred during cleaning and disinfecting procedures. We conclude that the majority of bronchoscope damage and repair costs should be potentially preventable and suggest that a program to familiarize all personnel handling bronchoscopes with proper maintenance and handling procedures should decrease the risk of bronchoscope damage.

Obstructed tracheal bronchus as a cause of post-obstructive pneumonia.

This article describes a case of obstructed supernumerary tracheal bronchus with partial atelectasis and pneumonia of the right upper lobe, diagnosed using trispiral tomograms. An obstructing broncholith, a supernumerary tracheal bronchus, and granulation tissue mass extruding from the bronchus were confirmed by resection of the pulmonary segment.

The role of bacterial super infection in extensive pulmonary tuberculosis. Data from protected brush cultures in untreated patients from the University of South Alabama Medical Center, Mobile, Alabama, USA.

Pulmonary tuberculosis (TB) and bacterial pneumonia are both characterized by fever, cough, and purulent sputum production. Although TB alone can cause these symptoms, the possibility of a concomitant bacterial pneumonia has led some clinicians to treat these patients empirically with antibacterial agents. Neither the benefit of such empiric antibiotic therapy nor transtracheal aspirate cultures from patients with pulmonary TB have yielded consistent results. Consequently, we performed a prospective study to obtain lower airway secretions via a bronchoscopic protected specimen brush (PSB) technique for quantitative aerobic and anaerobic cultures from untreated patients with extensive pulmonary TB (defined as cavitary disease or involvement of > or = 3 segments). We obtained bronchoscopic samples from 3 untreated men aged 21, 61, and 60 years with extensive pulmonary TB. There was no significant bacterial growth (aerobic or anaerobic) from the specimens obtained. These results, therefore, do not support the hypothesis that bacterial pneumonia is a common concomitant of extensive pulmonary TB.