The use of computed tomography to assess asthma severity

PURPOSE OF REVIEW: Chronic inflammation in asthma can also lead to airway remodeling, which contributes to airway narrowing. It may be possible to assess and quantify the extent of airway remodeling in vivo using computed tomography. This review examines recent developments in the evaluation of asthma severity using computed tomography, and the effect of treatment assessed by computed tomography. RECENT FINDINGS: Asthma patients have thicker airways on computed tomography scans than do healthy control individuals, and the degree of thickening is related to the severity of disease, airflow obstruction, and airway reactivity. Recent studies have indicated that patients with severe asthma and irreversible airflow obstruction had longer disease duration, a greater inflammatory process and more airway abnormalities, assessed by high-resolution computed tomography, suggestive of airway remodeling. Other studies have shown that high-resolution computed tomography lung density correlates with airflow limitation and lung volume (but not with lung transfer factor), and also correlates with patient age and severity of asthma. More recently, two publications demonstrated the effect of treatment on airway wall thickness and lung density assessed by computed tomography in patients with asthma. SUMMARY: High-resolution computed tomography is one of the most useful tools for imaging airways and parenchyma. Computed tomography scanning may be useful in determining which patients might benefit from more or less treatment. With additional advances in technology, it is likely that quantitative assessment by computed tomography will ultimately be a valuable tool for the study and treatment of chronic airway diseases.     

Endometriosis: a new approach is needed.

Endometriosis is generally regarded and treated as an endocrine and/or a surgical disease. Endocrine and surgical approaches to treatment are effective only in treating the symptoms of the disease and not its pathophysiology. Consequently, the success of such therapy is at best short-lived, and probably non-existent in mild disease. This thesis therefore argues for a new therapeutic approach towards endometriosis. In view of increasing evidence in favour of an immunological aetiology for this condition, it is suggested that such an approach may involve immunological rather than endocrine manipulation. It is also proposed that so-called unexplained infertility may in many cases represent a precursor stage of endometriosis, since immunological abnormalities in both of these conditions are so similar. Large-scale, prospective, multicentre clinical trials of immunotherapy in unexplained infertility and endometriosis appear to be indicated at this time if endometriosis is to lose its importance as one of the major contributors to female infertility.     

Visual analog scales can assess the severity of rhinitis graded according to ARIA guidelines

BACKGROUND: The allergic rhinitis and its impact on asthma (ARIA) guidelines provide a new classification of allergic rhinitis, but a quantitative analysis for severity assessment is lacking. OBJECTIVE: To study whether a visual analog scale (VAS) for global rhinitis symptoms could be used to assess the disease severity according to ARIA. METHODS: Three thousand fifty-two allergic rhinitis patients seen in primary care were tested. Fifty three per cent had an objective diagnosis of allergy and 58% of the patients were treated. Patients were categorized according to ARIA guidelines. The severity of nasal symptoms was assessed using a VAS. Quality of life was measured using the rhinoconjunctivitis quality of life questionnaire (RQLQ). RESULTS: Severity had more impact on VAS levels than duration: mild intermittent rhinitis (3.5, 2.4-5.0 cm), mild persistent rhinitis (4.5, 3.2-5.6 cm), moderate/severe intermittent rhinitis (6.7, 5.3-7.7 cm) and moderate/severe persistent rhinitis (7.2, 6.1-8.2 cm). The receiver operating characteristic curve results showed that patients with a VAS of under 5 cm could be classified as 'mild' rhinitis (negative predictive value: 93.5%) and those with a VAS of over 6 cm as 'moderate/severe' rhinitis (positive predictive value: 73.6%). Receiver operating characteristic curves and a logistic regression showed that current treatment and allergy diagnosis have no effect on the assessment of rhinitis severity using VAS. Visual analog scale and the RQLQ global score were significantly correlated (rho = 0.46; P < 0.0001). CONCLUSION: A simple and quantitative method (VAS) can be used for the quantitative evaluation of severity of allergic rhinitis.     

The recognition and management of somatization. What is needed in primary care training.

This article addresses the medical education issues associated with teaching primary care residents about somatization. Specific training designed to recognize and manage somatization involves a hierarchical series of five knowledge domains with associated discrete skills. As a foundation, a biopsychosocial model must be embraced by the medical leadership of the training program. Second, because psychosocial stresses play a critical etiologic role in somatization, the ability to identify relevant psychosocial issues during medical interviewing is a fundamental skill. Third, basic psychiatric diagnostic areas (depression and anxiety) must be mastered as a prerequisite for identifying somatization. Specific interviewing and management techniques are reviewed, along with two current programmatic approaches. Finally, the concept of physician countertransference also must be explicitly addressed as part of the curriculum. Without assuring that these building blocks are in place, residents are likely to become overwhelmed by the management of somatizing patients and continue the pattern of frustration associated with these patients.     

A comparison of 16 systems to diagnose schizophrenia.

Sixteen diagnostic classification systems were compared to determine the degree of agreement on the diagnosis of schizophrenia. Data were collected by a structured interview method with 284 patients, 52 first admissions, and 196 readmissions. The kappa coefficient was used to calculate interrater reliability and concordance of the systems. Adequate reliability was found for 12 of the systems. However, concordance was generally low; 11 of 120 combinations reached kappa of .40 or higher for the total sample, 16 of 120 for first admissions, and only 6 of 120 for readmissions. These results indicate the restriction of generalization and raise questions as to the empirical validity of the construct of schizophrenia.     

Genome sequencing is a sensitive first-line test to diagnose individuals with intellectual disability

PurposeIndividuals with intellectual disability (ID) and/or neurodevelopment disorders (NDDs) are currently investigated with several different approaches in clinical genetic diagnostics.MethodsWe compared the results from 3 diagnostic pipelines in patients with ID/NDD: genome sequencing (GS) first (N = 100), GS as a secondary test (N = 129), or chromosomal microarray (CMA) with or without FMR1 analysis (N = 421).ResultsThe diagnostic yield was 35% (GS-first), 26% (GS as a secondary test), and 11% (CMA/FMR1). Notably, the age of diagnosis was delayed by 1 year when GS was performed as a secondary test and the cost per diagnosed individual was 36% lower with GS first than with CMA/FMR1. Furthermore, 91% of those with a negative result after CMA/FMR1 analysis (338 individuals) have not yet been referred for additional genetic testing and remain undiagnosed.ConclusionOur findings strongly suggest that genome analysis outperforms other testing strategies and should replace traditional CMA and FMR1 analysis as a first-line genetic test in individuals with ID/NDD. GS is a sensitive, time- and cost-effective method that results in a confirmed molecular diagnosis in 35% of all referred patients.     

National guidelines needed to manage rhinitis and prevent complications.

OBJECTIVES: Rhinitis is an extremely common disease worldwide and nasal allergies are one of the major causes of the condition. Allergic rhinitis not only produces a range of nasal and non-nasal symptoms, but it has been closely associated with other chronic airways diseases, such as asthma and sinusitis. This review was undertaken to evaluate the relationship of allergic rhinitis to these diseases and to provide support for proposing national guidelines for managing rhinitis. DATA SOURCES: Relevant studies in English were searched for using MEDLINE, bibliographies from obtained articles, and consultation with experts. STUDY SELECTION: All major studies related to the epidemiology and effects of allergic rhinitis and the relationship between allergic rhinitis and asthma, sinusitis, and other airways diseases were reviewed. DATA SYNTHESIS: There is substantial scientific and clinical evidence that allergic rhinitis frequently coexists with asthma, and sinusitis and may be a predisposing factor for both. In addition, a number of studies have demonstrated that nasal inflammation and obstruction directly affect pulmonary function and clinical symptoms of asthma. Finally, it has been clearly demonstrated that treating allergic rhinitis with antihistamines, nasal corticosteroids, immunotherapy, and allergen avoidance have a significant, positive effect on lung function and asthma symptomology. CONCLUSIONS: The prevalence of allergic rhinitis, asthma, and sinusitis are increasing. Asthma and sinusitis can be debilitating conditions. Asthma alone can be life threatening and costly to treat. The timely and optimal treatment of allergic rhinitis may help prevent these conditions or, at least, prevent them from worsening. Consequently, there is an immediate need to establish national, evidence-based, practice guidelines to assist primary care physicians in diagnosing and managing rhinitis and in evaluating and managing rhinitis and in evaluating and managing allergic rhinitis coexisting with other airways diseases.     

Latent help to and from H-2 antigens.

An optimized system for probing allo-immunity to major histocompatibility complex (MHC) antigens by means of adoptive transfer is used to confirm and extend previous work showing that naturally occurring class I MHC antigens, while capable of inducing Th activity when presented in combination with other allo-antigens, fail to do so on their own. The Th activity which they do induce develops slowly, after repeated immunizations, and can properly be described as "latent". Latency, or "cripticity" as it is also termed, may help explain how autoimmune disease is initiated.     

Cytologic criteria used to diagnose adenocarcinoma in pleural effusions.

A stepwise logistic regression analysis was employed to evaluate the usefulness of the following criteria to distinguish adenocarcinoma in pleural effusion from benign pleural effusion: increased size of nucleus, increased nuclear to cytoplasmic ratio, irregular nuclear borders, sharply defined cytoplasmic boundaries, large nucleoli, aggregates with variable size nuclei, aggregates with nuclear overlap, irregular noncentral vacuoles, aggregates with nuclear molding, multinucleation, three-dimensional aggregates, aggregates with large cytoplasmic vacuoles, atypical mitoses, nuclear vacuoles, homogeneous cytoplasm, aggregates with associated lymphocytes and neutrophils, and uniform size aggregates. A total of 223 patients with benign pleural effusion cases and 221 patients with adenocarcinoma in their pleural effusion were scored as to the presence or absence of the above criteria. The resulting data were subjected to a stepwise logistic regression analysis that chose increased nuclear/cytoplasmic ratio, irregular nuclear borders, large nucleoli, sharply defined cytoplasmic boundaries, and three-dimensional aggregates as the best criteria to differentiate adenocarcinoma in pleural effusion from benign pleural effusion. When used together, these five features had a sensitivity of 94% and a specificity of 93% for predicting adenocarcinoma.     

To cure chronic HIV infection, a new therapeutic strategy is needed.

With the advent of highly active anti-retroviral therapy (HAART) in 1997, most investigators felt that HIV infection would be cured with a few years of antiviral therapy. It is now clear that antiviral drugs alone cannot cure the infection, even when applied within a few weeks of initial symptoms. There are now several reports of the discontinuation of HAART after several years of effective suppression of detectable plasma virus. Relapse occurs universally within a few weeks. More promising results have been reported if HAART is initiated early after infection. However, even in this instance, most patients suffer a relapse within a few weeks. If diagnostic treatment interruptions are performed, some individuals appear to control plasma virus concentrations at low levels — <5000 HIV RNA molecules/ml. We have similar results from subjects who were infected chronically before HAART was initiated, so that it is clear that the previous dogma that HIV-specific immune reactivity is absent in individuals who are chronically infected is incorrect. Immune reactivity to HIV does exist, and is detectable in vivo, even when the infection becomes chronic before therapy is initiated. Consequently, we are now faced with a new therapeutic dilemma: how can a cure of this infection be achieved? This review is focused on the rationale and methods to design clinical trials directed towards achieving a cure of HIV infection.     

Autobac I procedure to assess susceptibility to Cefaclor.

Agar dilution and Autobac I tests were performed to compare the susceptibility of 1,000 bacterial isolates to cefaclor and cephalothin. The standard Autobac methodology will correctly predict resistance to cefaclor. The test methodology seems to influence in vitro results, since more strains of gram-negative bacteria were susceptible to cefaclor by the Autobac I method than by the agar dilution test.