Budesonide/Formoterol or Budesonide/Albuterol as Anti-Inflammatory Reliever Therapy for Asthma.

Overuse of reliever as short-acting beta-agonist and associated underuse of controller as inhaled corticosteroid (ICS) administered via separate inhalers results in worse asthma outcomes. Such discordance can be obviated by combining both controller and reliever in the same inhaler. So-called anti-inflammatory reliever (AIR) therapy comprises the use of a single inhaler containing an ICS such as budesonide (BUD) in conjunction with a reliever as either albuterol (ALB) or formoterol (FORM), to be used on demand, with variable dosing driven by asthma symptoms in a flexible patient-centered regimen. Global guidelines now support the use of BUD-ALB as AIR therapy to reduce exacerbations, either on its own in mild asthma or in conjunction with fixed-dose maintenance ICS-long-acting beta-agonist in moderate to severe asthma. Using BUD-FORM on its own allows patients to seamlessly move in an intuitive flexible fashion between AIR and maintenance and reliever therapy, by stepping up and down the dosing escalator across a spectrum of asthma severities. Head-to-head clinical studies are indicated to compare BUD-FORM versus BUD-ALB as AIR in mild asthma, and also BUD-FORM as maintenance and reliever therapy versus BUD-ALB as AIR plus maintenance ICS-long-acting beta-agonist in moderate to severe asthma. Patients should be encouraged to make an informed decision in conjunction with their health care professional regarding the best therapeutic option tailored to their individual needs, which in turn is likely to result in long-term compliance and associated optimal asthma control.

Should Airway Hyper-Responsiveness Be Included in the Definition of Clinical Remission With Biologic Therapy in Severe Asthma.

Airway hyper-responsiveness (AHR) is a tenet of the persistent asthma phenotype along with reversible airway obstruction and type 2 (T2) inflammation. Indirect acting challenges such as mannitol are more closely related to the underlying T2 inflammatory process as compared with direct challenges. In this review article, we summarise the current literature and explore the future role of mannitol AHR in clinical remission with biologics.

Phenotypic associations of medical polypectomy and revision surgery following endoscopic sinus surgery: a retrospective study of a single-centre experience in Scotland.

BACKGROUND: Some chronic rhinosinusitis with nasal polyps patients undergo revision surgery at some point following initial functional endoscopic sinus surgery. This review aimed to identify the predictive factors for recurrence of nasal polyps requiring oral corticosteroids or revision surgery in chronic rhinosinusitis with nasal polyps following functional endoscopic sinus surgery. METHOD: A retrospective analysis of 221 patients who underwent functional endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps in a tertiary rhinology centre, between January 2015 and December 2018, was undertaken. RESULTS: Forty-four (21.6 per cent) patients underwent medical polypectomy, 19 (9 per cent) underwent revision surgery and 51 (24.3 per cent) underwent combined polypectomy during the mean follow-up time of 5.3 years. Patients aged less than 55 years of age, with a history of previous functional endoscopic sinus surgery, peripheral blood eosinophil counts of 300 cells/µl or higher, a Lund-Mackay score of more than 17 and concomitant aspirin-exacerbated respiratory disease had significantly increased odds for medical polypectomy, revision surgery and combined polypectomy. CONCLUSION: Knowing these predictive factors, clinicians can better identify patients with an increased likelihood of severe polyp recurrence and therefore arrange closer follow-up to optimise therapy.

Opsoclonus-myoclonus paraneoplastic syndrome in nasopharyngeal carcinoma.

Nasopharyngeal carcinoma can present with epistaxis, cervical lymphadenopathy, audiological symptoms secondary to eustachian tube dysfunction, pain, or neurological symptoms from tumours directly invading the skull base. It is unusual for patients to present with indirect systemic manifestations. Paraneoplastic neurological syndrome can precede clinically overt malignancy by up to 5 years; therefore, a combination of thorough clinical, laboratory and radiological investigations is required to reach a diagnosis. Intravenous immunoglobulin and steroids might improve neurological symptoms initially and prevent irreversible neuronal damage, but treatment of the underlying cancer is important for long-term resolution. Our case adds to a small but growing body of literature related to anti-Ri antibodies, opsoclonus-myoclonus syndrome presentations, and is the first reported association of this combination with nasopharyngeal carcinoma.

Targeting Downstream Type 2 Cytokines or Upstream Epithelial Alarmins for Severe Asthma.

Biologics, including omalizumab, mepolizumab, benralizumab, and dupilumab, targeting downstream IgE, cytokines IL-5, and IL-4/13, respectively, have shown promising effects in terms of reduction in annualized asthma exacerbation rates (AER), oral corticosteroid-sparing effects, improvements in forced expiratory volume in 1 second, and improved Asthma Control Questionnaire scores. However, despite these welcome advances, approximately 30% of patients with severe asthma receiving biologics tailored to their specific downstream type 2 biomarkers, including total IgE, peripheral blood eosinophils, and fractional exhaled nitric oxide, do not experience meaningful improvements in their AER. Instead of blocking downstream cytokines, targeting upstream epithelial alarmins, including IL-33, thymic stromal lymphopoietin, and IL-25, has been proposed to tackle the immunologic heterogeneity of asthma. This review article aims to pragmatically summarize the latest key clinical data on antialarmin therapies in severe asthma and put these findings into context with regard to currently available downstream cytokine blockers.

Tyrosine Kinase Inhibitor Therapy in Locally Advanced Differentiated Thyroid Cancer: A Case Report.

A 73-year-old female presenting with haemoptysis and dyspnoea was found to have a locally advanced left thyroid mass and vocal cord palsy. A CT scan of the neck and thorax and endoscopy demonstrated invasion into the tracheal lumen. Histopathology of the intraluminal tracheal mass confirmed a papillary thyroid cancer (PTC). The tumour was deemed unresectable due to local extent and patient comorbidities. TKI therapy with lenvatinib was used for 14 months. On serial scanning, a marked reduction in tumour volume from 31 × 59 × 32 mm to 17 × 28 × 22 mm was noted. This subsequently allowed a successful surgical resection with a total thyroidectomy and central neck dissection with no evidence of residual macroscopic disease. Histopathology confirmed a well-differentiated PTC with features of tumour regression. In this case, TKI therapy in a locally advanced unresectable DTC reduced tumour size and infiltration to a degree that surgical resection of macroscopic disease was possible, without requiring airway resection. This raises the possibility that TKIs may have a neoadjuvant role in selected cases of locally advanced DTC to reduce tumour volume and therefore morbidity of subsequent surgical resection.