Peter Branagan

Diagnosis and Management of Asthma in Older Adults

Despite comprehensive guidelines established by the European Global Initiative for Asthma and the U.S. National Asthma Education and Prevention Program on the diagnosis and management of asthma, its mortality in older adults continues to rise. Diagnostic and therapeutic problems contribute to older patients being inadequately treated. The diagnosis of asthma rests on the history and characteristic pulmonary function testing (PFT) with the demonstration of reversible airway obstruction, but there are unique problems in performing this test in older patients and in its interpretation. This review aims to address the difficulties in performing and interpreting PFT in older patients because of the effects of age‐related changes in lung function on respiratory physiology. The concept of “airway remodeling” resulting in “fixed obstructive” PFT and the relevance of atopy in older people with asthma are assessed. There are certain therapeutic issues unique to older patients with asthma, including the increased probability of adverse effects in the setting of multiple comorbidities and issues surrounding effective drug delivery. The use of beta 2‐agonist, anticholinergic, corticosteroid, and anti‐immunoglobulin E treatments are discussed in the context of these therapeutic issues.

Radiological abnormalities associated with Aspergillus colonization in a cystic fibrosis population

OBJECTIVE To determine if sputum colonization with Aspergillus species in patients with cystic fibrosis (PWCF) correlates with radiological abnormalities and/or a reduction in pulmonary function (FEV1). METHODS We prospectively evaluated 32 PWCF utilizing high resolution computed tomography (HRCT) of the thorax and pulmonary function testing (PFT). The cohort was assessed as two groups: Aspergillus positive (n=16) and Aspergillus negative (n=16) based on sputum culture for Aspergillus species. A modified Bhalla scoring system was applied to each HRCT scan by two blinded radiologists. RESULTS Aspergillus positive patients had more severe and significant bronchiectasis compared to those Aspergillus negative (p<0.05). This was most marked in the right upper and lower lobes (RUL, RLL). Total Bhalla score was clinically significant in both groups and approached statistical significance between groups (p=0.063). No difference in pulmonary function between the groups was detected. CONCLUSION PWCF colonized by Aspergillus species have greater radiological abnormalities undetectable by PFTs. Early radiological evaluation of Aspergillus colonized PWCF is therefore warranted.

Toll-like receptors as therapeutic targets in cystic fibrosis

Background: Toll-like receptors (TLRs) are pattern recognition receptors that act as a first-line of defence in the innate immune response by recognising and responding to conserved molecular patterns in microbial factors and endogenous danger signals. Cystic fibrosis (CF)-affected airways represent a milieu potentially rich in TLR agonists and the chronic inflammatory phenotype evident in CF airway epithelial cells is probably due in large part to activation of TLRs. Objective/methods: To examine the prospects of developing novel therapies for CF by targeting TLRs. We outline the expression and function of TLRs and explore the therapeutic potential of naturally-occurring and synthetic TLR inhibitors for CF. Results/conclusion: Modulation of TLRs has therapeutic potential for the inflammatory lung manifestations of CF.

A deceiving wheeze

Abstract‘Wheeze’ is a common symptom in both paediatric and adult populations. Unexplained wheeze is concerning and warrants investigation. We present a case of a young girl with childhood asthma suffering with ‘persistent wheeze’. This was explained by the presence of a dual aortic arch which only became apparent during her teenage years. This report serves as a reminder to all clinicians that “not all that wheezes is asthma”.

265 Complications of diabetes in an adolescent Cystic Fibrosis population

Introduction: Cystic fibrosis related diabetes (CFRD) is increasing. We aim to determine HbA1C ranges and incidence of complications in CFRD pts when age/sex matched to non-CF diabetic controls. Methods: 11 CFRD patients (mean age 23.5 SE 1.49, 7M/4F) were age/sex matched to non-CF, type I diabetics (mean age 23.6 SE 1.52, 7M/4F). The HbA1C range (over 3 y), length from dx and all complications of DM recorded. Results: CFRD had comparable ranges of HbA1C than age/sex matched controls (range 4.8 15.1%, mean 7.90% SE 0.41, and 5.0 14.6%, mean 8.73% SE 0.41, respectively) [p-value 0.05]. Duration of DM differed b/w the gps; CFRD (mean 3.56 yrs/median 3 yrs) and non-CF diabetics (mean 9.61 yrs/median 8 yrs) [p-value <0.05]. Both groups experienced hypoand hyperglycemia. Only the control group (n 2, 18.1%) experienced microvascular complications. Neither group had macrovascular complications. DKAs were isolated to the control group; 45.0% (n 5). One CFRD had steroid induced diabetes, and one control patient developed autoimmune hypothyroidism. Other complications included recurrent urinary tract (n 3) and fungal nail infections (n 1). Conclusions: CFRD are similarly controlled compared to age/sex matched counterparts reflected by HbA1C levels. Poorer nutritional status in CF can explain differing mean HbA1C levels. Absence of microvascular complications in CFRD reflects later onset/shorter duration of DM. Both groups receive insulin, and the absence of DKAs among CFRD suggests presence of residual endogenous insulin secretion. Although HbA1C is regularly used to monitor glycaemic control in both groups, it must not be used for diabetic screening. A formal OGTT carried out regularly (yearly after age 10) is the gold standard for a diagnosis of DM in all CF patients. 7. Metabolic complications of CF