Angela Morgan

Pathological features and inhaled corticosteroid response of eosinophilic and non-eosinophilic asthma

Background: Non-eosinophilic asthma is a potentially important clinicopathological phenotype since there is evidence that it responds poorly to inhaled corticosteroid therapy. However, little is known about the underlying airway immunopathology and there are no data from placebo-controlled studies examining the effect of inhaled corticosteroids. Methods: Airway immunopathology was investigated using induced sputum, bronchial biopsies, bronchial wash and bronchoalveolar lavage in 12 patients with symptomatic eosinophilic asthma, 11 patients with non-eosinophilic asthma and 10 healthy controls. The patients with non-eosinophilic asthma and 6 different patients with eosinophilic asthma entered a randomised, double-blind, placebo-controlled crossover study in which the effects of inhaled mometasone 400 μg once daily for 8 weeks on airway responsiveness and asthma quality of life were investigated. Results: Patients with non-eosinophilic asthma had absence of eosinophils in the mucosa (median 4.4 cells/mm2 vs 23 cells/mm2 in eosinophilic asthma and 0 cells/mm2 in normal controls; p = 0.03) and normal subepithelial layer thickness (5.8 μm vs 10.3 μm in eosinophilic asthma and 5.1 μm in controls, p = 0.002). Non-eosinophilic and eosinophilic asthma groups had increased mast cell numbers in the airway smooth muscle compared with normal controls (9 vs 8 vs 0 cells/mm2, p = 0.016). Compared with placebo, 8 weeks of treatment with inhaled mometasone led to less improvement in methacholine PC20 (0.5 vs 5.5 doubling concentrations, 95% CI of difference 1.1 to 9.1; p = 0.018) and asthma quality of life (0.2 vs 1.0 points, 95% CI of difference 0.27 to 1.43; p = 0.008). Conclusions: Non-eosinophilic asthma represents a pathologically distinct disease phenotype which is characterised by the absence of airway eosinophilia, normal subepithelial layer thickness and a poor short-term response to treatment with inhaled corticosteroids.

Alveolar nitric oxide in adults with asthma: evidence of distal lung inflammation in refractory asthma.

Recent studies have suggested that alveolar nitric oxide (NO) concentration is a noninvasive test of distal lung inflammation. The current study determined whether alveolar NO concentration can be measured in patients with asthma of varying severity, tested the hypothesis that there is an association between alveolar NO and bronchoalveolar lavage (BAL) eosinophil count and determined whether refractory asthma is characterised by a raised alveolar NO concentration. Finally, the present authors assessed the effect of 2 weeks of prednisolone (30 mg q.d.) on alveolar NO concentration. Alveolar NO concentration was both measurable and repeatable in patients with refractory asthma. A positive correlation was found between alveolar NO concentration and BAL eosinophil count but not with bronchial wash or sputum eosinophil count. Alveolar NO concentration was increased in patients with refractory asthma (7.1 ppb) compared with mild-to-moderate asthma (3.4 ppb) and normal controls (3.4 ppb) and reduced by treatment with prednisolone. In conclusion, these findings support the hypothesis that alveolar nitric oxide is a measure of distal airway inflammation and suggest that distal lung inflammation is present in refractory asthma.

Governmentality versus choice in contemporary special education

This article provides an understanding of childhood welfare from a radical perspective, showing how power within the special education system affects the discourse of ‘choice’ for parents. The analysis unmasks the disciplinary power operating within the special education system and explores the manner in which such power affects choice for parents. In turn, the analysis suggests that although disciplinary power offers little sites for resistance, the actions of some parents in the exercise of choice are seen as a growing challenge to that power. It remains to be seen just how resistant the system will become in the face of such opposition.

Policy Responses to Honor-Based Violence: A Cultural or National Problem?

The UK government has consistently sidelined honor-based violence from mainstream political discourse and has chosen to present the issue as a problem that is embedded in the culture of minority communities. This inevitably leads to a sense of heightened cultural sensitivity and the pressure to be viewed as culturally competent. It is argued that for honor-based violence to be managed effectively, it must first be dissociated from culture and from mainstream domestic violence discourse and recognized as a national problem that requires serious and specific policy intervention. Although it is acknowledged that all policy responses to complex social problems should reflect multicultural sensitivity, we argue in this critical review that this should not become an excuse for nonintervention.

'You're nothing without me!': the positive role of education in regaining self-worth and 'moving on' for survivors of domestic abuse

This research paper shows the ways in which survivors of domestic abuse can move on with their lives and take action to prevent their re‐victimisation by returning to education. The primary aim was to explore the role of education as an agent of change, effecting positive and empowering changes to survivors’ lives, thereby enhancing their life chances and preventing future re‐victimisation. A qualitative approach was adopted in which in‐depth life‐history interviews were conducted with the target population and semi‐structured interviews conducted with key workers from domestic abuse support agencies and educational service providers. A measure of social capital was used to assess the level of social support available to participants at two points in time. Findings suggest a relationship between social support networks and a need for long‐term one‐to‐one support in achieving personal and educational development—a primary motivation to living abuse‐free lives.

Success of a sports-club led-community X-PERT Diabetes Education Programme

Abstract This study examined the effectiveness of a sports-club-led X-PERT Diabetes Programme, measuring changes to participants’ physical condition, knowledge of diabetes, psychological well-being, activity level, diabetes self-management and participants’ rating of the programme. In this mixed-method, repeated measures evaluative study, data were gathered at baseline (T0), six weeks (T1) and 6 months (T2) using the Diabetes Health Profile, General Practice Physical Activity Questionnaire, Diabetes Empowerment Scale – Short Form, Participant Evaluation Questionnaire and focus groups. Over three years, 260 individuals with type 2 diabetes provided data for the evaluation. The sports-club-led X-PERT Diabetes Education Programme was successful in achieving its targets with improvement in clinical outcomes including significant reductions in BMI, waist circumference, total cholesterol, LDL cholesterol, triglycerides and glycated haemoglobin by T2. Positive changes were also evident in relation to participants’ health profile, self-management and empowerment. This study illustrates the important role that European sports stadia can play in community health through delivering targeted programmes beyond general health promotion activities.

Pulmonary nodules: bringing order out of chaos

Picture the scene: a lung cancer multidisciplinary team (MDT) meeting, somewhere in the UK, January 2015. CT images from a patient with suspected colorectal cancer, whom no one present has ever met, are discussed at the request of the colorectal team. An abnormality is present in the right lower lobe of lung. A week earlier, following two clicks and a drag from the colorectal radiologists mouse, a 5 mm incidental pulmonary nodule was identified and is now destined to take its unwitting host on an unpredictable journey, which may span years. Imperfectly remembered advice from multiple professional society guidelines, some a decade old, will be proffered and contested in repeated meetings. How should the nodule be measured, how often, by whom? What is the risk that it is malignant? Is now (ever?) the right time for a biopsy? This scenario, which is likely familiar to many readers, has often served to relegate nodule follow-up to a tedious chore shared widely to ease the burden. Help is at hand. With this issue of Thorax, David Baldwin, Mat Callister and colleagues publish the British Thoracic Society (BTS) guidelines for the investigation and management of pulmonary nodules,1 together with their own clear summary,2 which will support good, evidence-based patient care, effective resource use and audited outcomes. The precise and detailed distillation of a burgeoning evidence base—one-third of the 360 references are from 2012 or later—into four graphic algorithms represents a huge step from chaos towards order. It offers chest physicians everywhere the opportunity to channel the growing number of patients with incidental pulmonary nodules into a consistent and systematic process of investigation and, where appropriate, treatment. A number of helpful simplifications emerge. Data from several large screening studies, including the Dutch NELSON study,3 provide clear evidence that nodules …