Association between lung function and dyspnoea and its variation in the multinational Burden of Obstructive Lung Disease (BOLD) study.

BACKGROUND: Dyspnoea is a common symptom of respiratory disease. However, data on its prevalence in general populations and its association with lung function are limited and are mainly from high-income countries. The aims of this study were to estimate the prevalence of dyspnoea across several world regions, and to investigate the association of dyspnoea with lung function. METHODS: Dyspnoea was assessed, and lung function measured in 25,806 adult participants of the multinational Burden of Obstructive Lung Disease study. Dyspnoea was defined as ≥2 on the modified Medical Research Council (mMRC) dyspnoea scale. The prevalence of dyspnoea was estimated for each of the study sites and compared across countries and world regions. Multivariable logistic regression was used to assess the association of dyspnoea with lung function in each site. Results were then pooled using random-effects meta-analysis. RESULTS: The prevalence of dyspnoea varied widely across sites without a clear geographical pattern. The mean prevalence of dyspnoea was 13.7 % (SD=8.2 %), ranging from 0 % in Mysore (India) to 28.8 % in Nampicuan-Talugtug (Philippines). Dyspnoea was strongly associated with both spirometry restriction (FVC

Scientific echosounder data provide a predator's view of Antarctic krill (Euphausia superba).

Raw acoustic data were collected in East Antarctica from the RSV Aurora Australis during two surveys: the Krill Availability, Community Trophodynamics and AMISOR Surveys (KACTAS) and the Krill Acoustics and Oceanography Survey (KAOS) in the East Antarctic (centre coordinate 66.5° S, 63° E). The KACTAS survey was conducted between 14th to 21st January and 2001, and the KAOS survey was conducted between 16 January and 1 February 2003. We examine the Antarctic krill (Euphausia superba) component of these surveys and provide scientific echosounder (EK500 and EK60) data collected at 38, 120 and 200 kHz, cold water (-1 °C) echosounder calibration parameters and accompanying krill length frequency distributions obtained from trawl data. We processed the acoustic data to apply calibration values and remove noise. The processed data were used to isolate echoes arising from swarms of krill and to estimate metrics for each krill swarm, including internal density and individual swarm biomass. The krill swarm data provide insights to a predators' views of krill distribution and density.

Out-of-office blood pressure measurement for the diagnosis of hypertension in pregnancy: Survey of Canadian Obstetric Medicine and Maternal Fetal Medicine specialists.

BACKGROUND: Multiple hypertension guidelines recommend out-of-office measurements for the diagnosis of hypertension in non-pregnant adults, whereas pregnancy guidelines recommend in-office blood pressure measurements. The objective of our study was to determine how Canadian Obstetric Medicine and Maternal Fetal Medicine specialists measure blood pressure in pregnancy. METHODS: An email survey was sent to 69 Canadian Obstetric Medicine and Maternal Fetal Medicine specialists in academic centers across Canada to explore the practice patterns of blood pressure measurement in pregnant women. RESULTS: The response rate was 48%. The majority of respondents (63.6%) preferred office blood pressure measurement for diagnosing hypertension, but relied on home blood pressure readings for ongoing monitoring and management of hypertension during pregnancy (59.4%). The preferred method of out-of-office blood pressure measurement was home monitoring; 24-hour ambulatory blood pressure monitoring was not used due to limited availability and cost. CONCLUSIONS: There is wide practice variation in methods of measuring blood pressure among Canadian specialists managing hypertension in pregnancy.

The characteristics of krill swarms in relation to aggregating Antarctic blue whales.

We model the presence of rare Antarctic blue whales (Balaenoptera musculus intermedia) in relation to the swarm characteristics of their main prey species, Antarctic krill (Euphausia superba). A combination of visual observations and recent advances in passive acoustic technology were used to locate Antarctic blue whales, whilst simultaneously using active underwater acoustics to characterise the distribution, size, depth, composition and density of krill swarms. Krill swarm characteristics and blue whale presence were examined at a range of spatiotemporal scales to investigate sub meso-scale (i.e., <100 km) foraging behaviour. Results suggest that at all scales, Antarctic blue whales are more likely to be detected within the vicinity of krill swarms with a higher density of krill, those found shallower in the water column, and those of greater vertical height. These findings support hypotheses that as lunge-feeders of extreme size, Antarctic blue whales target shallow, dense krill swarms to maximise their energy intake. As both Antarctic krill and blue whales play a key role in the Southern Ocean ecosystem, the nature of their predator-prey dynamics is an important consideration, not only for the recovery of this endangered species in a changing environment, but for the future management of Antarctic krill fisheries.

An observational cohort study of exercise and education for people with chronic obstructive pulmonary disease not meeting criteria for formal pulmonary rehabilitation programmes.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. Pulmonary rehabilitation (PR) is offered to patients with functional breathlessness. However, access to PR is limited. The objective of this study was to evaluate whether a 4-week education and exercise programme offered to COPD patients with Medical Research Council (MRC) dyspnoea 1-2 improves disease self-management. Patients were recruited by their GP to attend four weekly 2-h sessions provided by a multidisciplinary team. Patients completed outcome measures before and after the program. Forty-two patients entered the programme and 26 out of 42 (61.9%) completed all sessions. The Bristol COPD Knowledge Questionnaire and Patient Activation Measure improved (both p ≤ 0.001). Disease burden was not reduced according to the COPD assessment test. All patients accepted a referral for ongoing exercise. Fourteen current smokers (81.3%) accepted a referral for smoking cessation, three patients with anxiety or depression (37.5%) accepted a psychological therapies referral. The programme improved COPD disease knowledge, patient activation and stimulated referrals to further services supporting disease management. Randomised controlled trials are warranted for similar interventions for COPD patients with early stage disease.

Cost Savings Analysis of Early Extubation Following Congenital Heart Surgery.

The clinical benefit of early extubation following congenital heart surgery has been demonstrated; however, its effect on resource utilization has not been rigorously evaluated. We sought to determine the cost savings of implementing an early extubation pathway for children undergoing surgery for congenital heart disease. We performed a cost savings analysis after implementation of an early extubation strategy among children undergoing congenital heart surgery at British Columbia Children's Hospital (BCCH) over a 2.5-year period. All patients undergoing one of the eight Society of Thoracic Surgeons (STS) benchmark operations, ASD repair, or bidirectional cavopulmonary anastomosis were included in the analysis (n = 370). We compared our data to aggregate STS multi-institutional data from a contemporary cohort. We estimated daily costs for ICU care, ward care, medications, imaging, additional procedures, and allied health care using an administrative database. Direct costs, indirect costs, and cost savings were estimated. Simulation methods, Monte Carlo, and bootstrapping were used to calculate the 95% credible intervals for all estimates. The mean cost savings per procedure was $12,976 and the total estimated cost savings over the study period at BCCH was $4.8 million with direct costs accounting for 91% of cost savings. Sensitivity analysis demonstrated a mean cost savings range of $11,934-$14,059 per procedure. Early extubation is associated with substantial cost savings due to reduced hospital resource utilization. Implementation of an early extubation strategy following congenital heart surgery may contribute to improved resource utilization.

Work Practices and Respiratory Health Status of Appalachian Coal Miners With Progressive Massive Fibrosis.

OBJECTIVE: The aim of this study was to characterize workplace practices and respiratory health among coal miners with large opacities consistent with progressive massive fibrosis (PMF) who received care at a federally funded black lung clinic network in Virginia. METHODS: Participants were interviewed about their workplace practices and respiratory health. Medical records were reviewed. RESULTS: Nineteen former coal miners were included. Miners reported cutting rock, working downwind of dust-generating equipment, nonadherence to mine ventilation plans (including dust controls), improper sampling of respirable coal mine dust exposures, working after developing respiratory illness, and suffering from debilitating respiratory symptoms. CONCLUSION: Consistent themes of suboptimal workplace practices contributing to development of PMF emerged during the interviews. Some of the practices reported were unsafe and unacceptable. Further research is needed to determine the prevalence of these factors and how best to address them.

Dust control by air-blocking shelves and dust collector-to-bailing airflow ratios for a surface mine drill shroud.

The National Institute for Occupational Safety and Health (NIOSH) recently developed a series of validated models utilizing computational fluid dynamics (CFD) to study the effects of air-blocking shelves on airflows and respirable dust distribution associated with medium-sized surface blasthole drill shrouds as part of a dry dust collector system. Using validated CFD models, three different air-blocking shelves were included in the present study: a 15.2-cm (6-in.)-wide shelf; a 7.6-cm (3-in.)-wide shelf; and a 7.6-cm (3-in.)-wide shelf at four different shelf heights. In addition, the dust-collector-to-bailing airflow ratios of 1.75:1, 1.5:1, 1.25:1 and 1:1 were evaluated for the 15.2-cm (6-in.)-wide air-blocking shelf. This paper describes the methodology used to develop the CFD models. The effects of air-blocking shelves and dust collector-to-bailing airflow ratios were identified by the study, and problem regions were revealed under certain conditions.

Exercise and the multidisciplinary holistic approach to adolescent dysautonomia.

AIM: To determine whether an eight-week strength training programme as part of a multidisciplinary approach would minimise symptoms and improve quality of life in patients with dysautonomia. METHODS: Adolescents referred to a tertiary-level cardiology service from May 2014-December 2015 with symptoms of dysautonomia were eligible. Participants completed an exercise test and a quality of life (QoL) questionnaire (PedsQL) prior to the intervention. Participants were asked to complete exercises five times per week. After eight weeks, participants returned for follow-up testing. Parents completed a proxy report of their child's QoL at both time points. RESULTS: A total of 17 participants completed the study protocol with an adherence rate of up to 50%. Post-intervention, QoL scores improved across all levels in the participants [total 65.2 (50.4-74.7) vs 48.9 (37.5-63.0); p = 0.006; psychosocial 65.8 (56.1-74.6) vs 50.0 (41.7-65.8); p = 0.010; physical 62.5 (37.5-76.6) vs 43.8 (25-68.5); p = 0.007] and their parent proxy reports [total 63.5 (48.7-81.3) vs 50.0 (39.3-63.0); p = 0.004; psychosocial 62.1 (52.1-81.3) vs 50.0 (39.6-59.2); p = 0.001; physical 62.5 (51.6-80.0) vs 50.0 (27.5-70.3); p = 0.003]. Treadmill time also improved (9.1 vs 8.0 minutes; p = 0.005). CONCLUSION: Following an eight-week strength training programme, dysautonomia patients report a significant improvement in both their quality of life and endurance time.

Diagnosing liver fibrosis: a narrative review of current literature for dermatologists.

Chronic liver disease is a growing problem worldwide due to obesity, alcohol-related liver disease and viral hepatitis. Liver fibrosis is generally asymptomatic and patients may not present until they have advanced cirrhosis, when the scope for reversibility is limited. Identification of asymptomatic individuals at an early stage is fundamental to reversing the rising toll of liver-related morbidity and mortality. Awareness of liver disease and the techniques for diagnosis is important for dermatologists, not only due to the burden of disease in the general population but also because some dermatology cohorts may have an elevated risk. For example, there is an increased prevalence of metabolic syndrome and excess alcohol use in those with psoriasis and hidradenitis suppurativa. In isolation, standard liver function tests lack sensitivity to detect advanced fibrosis and cirrhosis and are of limited value. Traditionally diagnosis has relied on liver biopsy, which remains the gold standard but is both costly and invasive. There have been several recent advances in the development of noninvasive alternatives. These include scoring systems combining clinical and conventional laboratory parameters for use as screening tools, direct serum biomarkers of fibrogenesis and tissue elastography using both ultrasound (Fibroscan) and magnetic resonance. This review summarizes current and future noninvasive diagnostic techniques for evaluation of liver fibrosis.

Opisthorchis felineus negatively associates with skin test reactivity in Russia-EuroPrevall-International Cooperation study.

BACKGROUND: Most studies on the relationship between helminth infections and atopic disorders have been conducted in (sub)tropical developing countries where exposure to multiple parasites and lifestyle can confound the relationship. We aimed to study the relationship between infection with the fish-borne helminth Opishorchis felineus and specific IgE, skin prick testing, and atopic symptoms in Western Siberia, with lifestyle and hygiene standards of a developed country. METHODS: Schoolchildren aged 7-11 years were sampled from one urban and two rural regions. Skin prick tests (SPT) and specific IgE (sIgE) against food and aeroallergens were measured, and data on allergic symptoms and on demographic and socioeconomic factors were collected by questionnaire. Diagnosis of opisthorchiasis was based on PCR performed on stool samples. RESULTS: Of the 732 children included, 34.9% had opisthorchiasis. The sensitization to any allergen when estimated by positive SPT was 12.8%, while much higher, 24.0%, when measured by sIgE. Atopic symptoms in the past year (flexural eczema and/or rhinoconjunctivitis) were reported in 12.4% of the children. SPT was positively related to flexural eczema and rhinoconjunctivitis, but not to wheezing. Opisthorchiasis showed association with lower SPT response, as well as borderline association with low IgE reactivity to any allergen. However, the effect of opisthorchiasis on SPT response was not mediated by IgE, suggesting that opisthorchiasis influences SPT response through another mechanism. Opisthorchiasis also showed borderline association with lower atopic symptoms. CONCLUSIONS: There is a negative association between a chronic helminth infection and skin prick test reactivity even in a developed country.

Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus.

The purpose of this review is to assess the most recent evidence in the management of primary hyperparathyroidism (PHPT) and provide updated recommendations for its evaluation, diagnosis and treatment. A Medline search of "Hyperparathyroidism. Primary" was conducted and the literature with the highest levels of evidence were reviewed and used to formulate recommendations. PHPT is a common endocrine disorder usually discovered by routine biochemical screening. PHPT is defined as hypercalcemia with increased or inappropriately normal plasma parathyroid hormone (PTH). It is most commonly seen after the age of 50 years, with women predominating by three to fourfold. In countries with routine multichannel screening, PHPT is identified earlier and may be asymptomatic. Where biochemical testing is not routine, PHPT is more likely to present with skeletal complications, or nephrolithiasis. Parathyroidectomy (PTx) is indicated for those with symptomatic disease. For asymptomatic patients, recent guidelines have recommended criteria for surgery, however PTx can also be considered in those who do not meet criteria, and prefer surgery. Non-surgical therapies are available when surgery is not appropriate. This review presents the current state of the art in the diagnosis and management of PHPT and updates the Canadian Position paper on PHPT. An overview of the impact of PHPT on the skeleton and other target organs is presented with international consensus. Differences in the international presentation of this condition are also summarized.

Changing trend in the utilisation rate of donated corneas for keratoplasty in the UK: The North East England Study.

PurposeTo report the changing trend in the utilisation rate of donated corneas for keratoplasty and to examine the reasons for unutilised corneas in the North East of England.MethodsRelevant data were retrospectively collected from a local eye retrieval database and the UK Transplant Registry for two separate years; namely, 2006 and 2010.ResultsThe utilisation rate of donated corneas for keratoplasty improved from 57% (52/92) in 2006 to 71% (220/312) in 2010 (P=0.012). Over the same period, there was a marked reduction of failed serological test results from 24% (22/92) to 5% (14/312) (P<0.001). The leading reasons for unutilised corneas were failed serological test results (22/92, 24%) in 2006 and inadequate tissue quality (23/312, 7%) in 2010. The rate of tissue contamination remained similar between 2006 (4%) and 2010 (6%) (P=0.80). Eleven (4%) corneas were not transplanted due to recipient-related factors in 2010. Donor corneas of inadequate tissue quality were associated with older age (P=0.04) but not with gender, donation site, consent method, death-to-enucleation interval, death-to-processing interval, and storage time in the eye bank.ConclusionThere was a substantial improvement in the utilisation rate of corneas donated in the North East of England between 2006 and 2010. The principal reason was a reduction in failed serological test results. High donor age was associated with increased chance of corneas not being used. Utilisation rate of corneas can be further improved if potential modifiable factors are addressed, such as recipient-related factors and microbial contamination.

Prevalence of food sensitization and probable food allergy among adults in India: the EuroPrevall INCO study.

BACKGROUND: Data are lacking regarding the prevalence of food sensitization and probable food allergy among general population in India. We report the prevalence of sensitization and probable food allergy to 24 common foods among adults from general population in Karnataka, South India. METHODOLOGY: The study was conducted in two stages: a screening study and a case-control study. A total of 11 791 adults in age group 20-54 were randomly sampled from general population in South India and answered a screening questionnaire. A total of 588 subjects (236 cases and 352 controls) participated in the case-control study involving a detailed questionnaire and specific IgE estimation for 24 common foods. RESULTS: A high level of sensitization (26.5%) was observed for most of the foods in the general population, higher than that observed among adults in Europe, except for those foods that cross-react with birch pollen. Most of the sensitization was observed in subjects who had total IgE above the median IgE level. A high level of cross-reactivity was observed among different pollens and foods and among foods. The prevalence of probable food allergy (self-reports of adverse symptoms after the consumption of food and specific IgE to the same food) was 1.2%, which was mainly accounted for cow's milk (0.5%) and apple (0.5%). CONCLUSION: Very high levels of sensitization were observed for most foods, including those not commonly consumed in the general population. For the levels of sensitization, the prevalence of probable food allergy was low. This disassociation needs to be further explored in future studies.

Impact of telephone consent and potential for eye donation in the UK: the Newcastle Eye Centre study.

AIMS: To examine the impact of telephone consent introduced in 2007 on the eye donation rate and to report the changing trend and potential for improvement in eye donation in Newcastle upon Tyne, UK. METHODS: Relevant data were retrospectively collected from the local eye retrieval database for two separate years, namely, 2006 (before the introduction of telephone consent) and 2010. All the hospitals within Newcastle were included in the study. RESULTS: From 2006 to 2010, there was a 3.5-fold increase in eye donation from 32 (of 2479 deaths) to 111 donors per year (of 2213 deaths) in Newcastle (P<0.001). Consent was obtained via face-to-face interview in all 32 (100%) and 59 (53.2%) donors in 2006 and 2010, respectively. Introduction of telephone consent increased the donation rate by an additional 88.1% (from 59 to 111 donors) in 2010 (P<0.001). In addition, there was a significant increase in medical notes of the deceased being reviewed from 27.1% (671/2479 cases) in 2006 to 62.4% (1382/2213 cases) in 2010 (P<0.001). Acceptance rate of eye donation was 45.7% (32/70) in 2006 and 49.6% (111/224) in 2010 (P=0.575). Acceptance rate was positively associated with registration on organ donor register (P<0.001) and telephone consent (P<0.001), but not with age (P=0.883), gender (P=0.234), or location of death (P=0.984) of the potential donors. CONCLUSION: There has been a substantial improvement in eye donation rate in Newcastle over the recent years. Introduction of telephone consent and high-quality eye donation service serve as effective measures for increasing eye donation.

A prospective observational study of maternal oxygenation during remifentanil patient-controlled analgesia use in labour.

Numerous studies of remifentanil patient-controlled analgesia during labour have shown high levels of maternal satisfaction, but concerns remain, especially over the side-effects of sedation and respiratory depression. We conducted a prospective observational study of maternal oxygen desaturation during remifentanil patient-controlled analgesia. Pulse oximetry values were recorded every eight s and later downloaded for analysis. A desaturation episode was defined as oxygen saturation < 90%. We collected 148 h of data in 61 women, during which we observed 176 desaturation episodes. These episodes occurred in 43 (70%) women. The median (IQR [range]) of the lowest saturation during each episode was 87 (85-89 [68-89])% with duration 16 (8-24 [8-104]) s. Supplementary oxygen reduced the time per hour spent with saturation < 90%, but not the depth or duration of individual episodes. Desaturation episodes were twice as common during the second stage of labour as compared with the first stage. Prior opioid administration, bolus size and use of nitrous oxide during patient-controlled analgesia use were not found to influence frequency, depth or duration of desaturation episodes. Although these findings suggest desaturation occurs more frequently during remifentanil patient-controlled analgesia than previously reported, the results are comparable with earlier oximetry studies of women who received nitrous oxide and pethidine during labour.

Short communication: Effect of cross ventilation with or without evaporative pads on core body temperature and resting time of lactating cows.

A trial was performed to assess the effect of evaporative pads on core body temperature (CBT) and lying behavior of lactating Holstein cows housed in cross-ventilated freestall facilities in a humid environment. This trial was undertaken in 2 barns equipped with (EP) or without (NP) evaporative pads. Each facility had 4 pens, 1 baffle/pen, and a nominal width of 122 m. Stocking density was higher (123.4 vs. 113.1%) and freestalls were slightly shorter (2.3 vs. 2.4 m) and narrower (1.16 vs. 1.21 m) in EP compared with NP barns. In each pen, lying behavior of 20 cows was monitored using electronic data loggers that recorded at 1-min intervals. A subset (n=14) of these cows within each pen were also fitted with temperature loggers attached to blank controlled intravaginal drug release devices to determine CBT every 5 min. Ambient conditions were collected every 15 min. Individual cow lying duration and lying bouts were assessed for each cow, as well as time spent standing and CBT within the following categories: CBT <38.6°C, and CBT >38.6, >38.9, >39.2, >39.4, and >39.7°C. These variables were analyzed using pen as the experimental unit, with cow and day as additional random effects. The average maximum ambient conditions over the 9 d were 25°C and 78.74% relative humidity. No differences were observed in lying duration and number of lying bouts over the 9-d period, with overall means of 696±31 min/d and 12.6±0.5 bouts/d. The EP cows spent 170 min/d longer with a CBT <38.6°C and 107 min/d less with CBT >39.2°C than did NP cows. Cooling with evaporative pads tended to increase time spent lying with a CBT >8.6°C and lying bouts/d for EP cows versus NP cows. Results from this trial show that even under mild heat stress, evaporative cooling in cross-ventilated facilities can decrease CBT and tended to increase lying time.

Influence of continuous mining arrangements on respirable dust exposures.

In underground continuous mining operations, ventilation, water sprays and machine-mounted flooded-bed scrubbers are the primary means of controlling respirable dust exposures at the working face. Changes in mining arrangements - such as face ventilation configuration, orientation of crosscuts mined in relation to the section ventilation and equipment operator positioning - can have impacts on the ability of dust controls to reduce occupational respirable dust exposures. This study reports and analyzes dust concentrations measured by the Pittsburgh Mining Research Division for remote-controlled continuous mining machine operators as well as haulage operators at 10 U.S. underground mines. The results of these respirable dust surveys show that continuous miner exposures varied little with depth of cut but are significantly higher with exhaust ventilation. Haulage operators experienced elevated concentrations with blowing face ventilation. Elevated dust concentrations were observed for both continuous miner operators and haulage operators when working in crosscuts driven into or counter to the section airflow. Individual cuts are highlighted to demonstrate instances of minimal and excessive dust exposures attributable to particular mining configurations. These findings form the basis for recommendations for lowering face worker respirable dust exposures.

Recombinant factor VIII Fc fusion protein: extended-interval dosing maintains low bleeding rates and correlates with von Willebrand factor levels.

BACKGROUND: Routine prophylaxis with replacement factor VIII (FVIII) - the standard of care for severe hemophilia A - often requires frequent intravenous infusions (three or four times weekly). An FVIII molecule with an extended half-life could reduce infusion frequency. The A-LONG study established the safety, efficacy and prolonged pharmacokinetics of recombinant FVIII Fc fusion protein (rFVIIIFc) in previously treated adolescents and adults with severe hemophilia A. OBJECTIVE: In this post hoc analysis, we investigated the relationship between subjects' prestudy (FVIII) and on-study (rFVIIIFc) regimens. METHODS: We analyzed two subgroups of subjects: prior prophylaxis and on-study individualized prophylaxis (n = 80), and prior episodic treatment and on-study weekly prophylaxis (n = 16). Subjects' prestudy dosing regimens and bleeding rates were compared with their final rFVIIIFc regimens and annualized bleeding rates (ABRs) in the last 3 months on-study. Dosing regimen simulations based on population pharmacokinetics models for rFVIII and rFVIIIFc were performed. RESULTS: As compared with their prestudy regimen, 79 of 80 (98.8%) subjects on individualized rFVIIIFc prophylaxis decreased their infusion frequency. Overall ABRs were low, with comparable factor consumption. Longer dosing intervals, including 5-day dosing, were associated with higher baseline von Willebrand factor antigen levels. Simulated dosing regimens predicted a greater proportion of subjects with steady-state FVIII activity trough levels of ≥ 1 IU dL(-1) (1%) with rFVIIIFc than with equivalent rFVIII regimens. CONCLUSION: These results suggest that patients on rFVIIIFc prophylaxis can reduce their infusion frequency as compared with their prior FVIII regimen while maintaining low bleeding rates, affording more patients trough levels of ≥ 1 IU dL(-1) than with rFVIII products requiring more frequent dosing regimens.