Budesonide/formoterol combination therapy as both maintenance and reliever medication in asthma

Asthma control is improved by combining inhaled corticosteroids with long-acting beta2-agonists. However, fluctuating asthma control still occurs. We hypothesized that in patients receiving low maintenance dose budesonide/formoterol (bud/form), replacing short-acting beta2-agonist (SABA) reliever with as-needed bud/form would provide rapid symptom relief and simultaneous adjustment in antiinflammatory therapy, thereby reducing exacerbations. In this double-blind, randomized, parallel-group study, 2,760 patients with asthma aged 4-80 years (FEV1 60-100% predicted) received either terbutaline 0.4 mg as SABA with bud/form 80/4.5 microg twice a day (bud/form + SABA) or bud 320 microg twice a day (bud + SABA) or bud/form 80/4.5 microg twice a day with 80/4.5 microg as-needed (bud/form maintenance + relief). Children used a once-nocte maintenance dose. Bud/form maintenance + relief prolonged time to first severe exacerbation (p < 0.001; primary endpoint), resulting in a 45-47% lower exacerbation risk versus bud/form + SABA (hazard ratio, 0.55; 95% confidence interval, 0.44, 0.67) or bud + SABA (hazard ratio, 0.53; 95% confidence interval 0.43, 0.65). Bud/form maintenance + relief also prolonged the time to the first, second, and third exacerbation requiring medical intervention (p < 0.001), reduced severe exacerbation rate, and improved symptoms, awakenings, and lung function compared with both fixed dosing regimens.     

Surface Dyslexia in Semantic Dementia: A Comparison of the Influence of Consistency and Regularity

Abstract

This study addressed the question of exactly which aspects of spelling-sound consistency influence accuracy of reading aloud in surface dyslexic patients with semantic dementia. Oral reading data were obtained from twelve patients on three sets of words that varied in regularity (defined according to grapheme-phoneme correspondences) and consistency (defined according to the pronunciation of word body neighbours). The patients were less accurate for irregular/inconsistent words, which they commonly pronounced in line with sound-spelling regularities, as expected in surface dyslexia. They produced plausible but incorrect responses for some regular as well as many irregular words, suggesting that their reading performance was influenced by sound-spelling relationships not captured by grapheme-phoneme correspondences. On a set of items that varied consistency and regularity independently, the patients showed a large effect of regularity and a smaller but significant effect of consistency in reading aloud. In addition, there was a correlation between degree of semantic impairment and level of reading accuracy for inconsistent items. These findings are discussed in terms of two influential models of reading: the dual-route-cascaded model (Coltheart et al., 2001 Coltheart, M, Rastle, K, Perry, C, Langdon, R and Ziegler, J. 2001. DRC: A dual route cascaded model of visual word recognition and reading aloud. Psychological Review, 108: 204–56. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]) and the triangle model (Plaut et al., 1996 Plaut, DC. 1997. Structure and function in the lexical system: Insights from distributed models of word reading and lexical decision. Language and Cognitive Processes, 12: 765–805. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]). It is argued that the triangle model provides a more straightforward account of the relationship between word comprehension and consistency effects in reading.     

Sexual Offences: Help for the forgotten victims

Societies which do not safeguard and give prime support for the relations between men and women for procreation and child rearing undermine our propensity for and fundamental need of secure attachment. Without attachment, and the nurture it brings, well-being is displaced by destructiveness and despair; these then tend to develop a debilitating cultural history. Contemporary sex education is seriously flawed in that it is rarely set within a sufficient model of human nature. Now governed extensively by fear within a culture of transient, disposable relationships, sex education is subject to ambivalent social policies and confused values. This paper offers a more constructive and defensible scenario rooted in the ethical and educational implications of what we now know about human nature and of the psychosocial and other risks to our species.     

The involvement of parents in healthcare decisions where adult children are at risk of lacking decision‐making capacity: a qualitative study of treatment decisions in epilepsy

Background Patients with intellectual disabilities (ID) receive health care by proxy. It is family members and/or paid support staff who must recognise health problems, communicate with clinicians, and report the benefits, if any, of a particular treatment. At the same time international and national statutes protect and promote the right of people with disabilities to access the highest attainable standards of health on the basis of free and informed consent. Methods To consider the role of parent‐proxies in the management of epilepsy in adult children with ID who are at risk of lacking capacity to make decisions about their health care we interviewed 21 mothers. Findings These mothers are not pursuing changes in treatment that might improve their son or daughter's epilepsy, nor are they willing to countenance changes in treatment. Clinicians concerned to build and sustain therapeutic alliances with these mothers, our evidence suggests, may well avoid going against their wishes. Discussion Our research highlights the interactional contingencies of a hitherto neglected three‐way clinical relationship comprising parent‐proxy, an adult at risk of lacking decision‐making capacity, and a treating clinician. This is a relationship, our findings suggest, where little importance is attached to either patient consent, or involvement in treatment decisions.     

Pilonidal sinus surgery: could we predict postoperative complications?

Pilonidal sinus surgery could, as of now, be considered a surgery tailored more to the surgeon than to the patient. In an attempt to give to surgeons an objective instrument of decision, we have evaluated which variables could be considered predictive of postoperative complications after pilonidal sinus surgery. A prospective electronic database of all patients treated for sacrococcygeal pilonidal disease was analysed. Sex, age, obesity, smoking, recurrent disease, the presence of multiple orifices and the distance between the most lateral orifice and midline were recorded and correlated with the occurrence of postoperative complications (infection and recurrence); 1006 patients were evaluated. Excision with primary mid‐line closure was performed on all the patients. Mean follow‐up was 7·3 ± 3·6 years. A total of 158 patients with postoperative complications (infection and/or recurrence) were recorded during this period. A multivariate analysis showed that, after adjusting for major clinical and demographic characteristics, only a recurrent disease [odds ratio (OR): 3·41, 95% confidence interval (CI): 1·89–6·15, P < 0·001] and the distance of lateral orifice from midline (OR: 26·3, 95% CI: 12·2–56·7, P < 0·001) were independent predictors of overall postoperative complications. Focussing on the distance from midline, the receiver operative characteristic (ROC) analysis showed that the distance of lateral orifice from midline predicted 79·2% of complications and the Youden's test identified the best cut‐off as 2·0 cm for this variable. An evidence‐based tool for deciding on the type of surgical intervention could be developed and validated by further ad hoc prospective studies evaluating our results in comparison to other different types of surgical techniques. Our results support the use of these variables as an effective way to tailor pilonidal sinus surgery to the patient, so as to obtain the best results in patient care.