Coinciding with World TB Day, new consensus statements have been drafted to address the growing problem of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis.These statements - published in the European Respiratory Journal - are significant, because this is the first time that doctors treating patients with these new strains of tuberculosis (TB) have reached a consensus on patient management. The major obstacle to developing guidelines for treatment of these forms of TB has been a lack of clinical evidence. (Source: Health News from Medical News Today)

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Guidance on handheld inhalers in asthma and COPD guidelines.

Respir Med. 2014 Mar 1;

Authors: Dekhuijzen PN, Bjermer L, Lavorini F, Ninane V, Molimard M, Haughney J

Abstract
BACKGROUND: Inhaled therapy is the cornerstone of pharmacotherapy in patients with asthma and chronic obstructive pulmonary disease (COPD). Appropriate inhalation device selection is as important as drug choice but device-specific guidance appears to be lacking.
METHODS: To quantify the level of inhalation-device recommendations in clinical guidelines, a review was conducted by hand-searching national and international asthma and COPD guidelines (Global Initiative for Asthma [GINA] and Global initiative for chronic Obstructive Lung Disease [GOLD] guidelines) and an international guideline on device selection (the American College of Chest Physicians/American College of Asthma, Allergy, and Immunology [ACCP/ACAAI]). For each guideline, the number of pages, tables/figures and references relating to inhalation devices was identified.
RESULTS: GINA and GOLD guidelines contain very little inhalation device-specific guidance beyond recommendations for demonstrating and testing correct inhalation technique: <2% of pages or references and <3% of tables/figures are dedicated to devices. Device-related content in the ACCP/ACAAI device selection guideline was considerably higher with 54% of pages, 88% of tables/figures and 82% of references, respectively. Results in national guidelines reflect those on international guidelines.
CONCLUSIONS: These results indicate that there is a considerable lack of clear and specific guidance regarding inhalation devices in current asthma/COPD guidelines. More robust studies on the impact of inhalation devices are needed to increase the number of evidence statements and recommendations regarding inhalation devices.

PMID: 24636812 [PubMed - as supplied by publisher]

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Current evidence and future research needs for FeNO measurement in respiratory diseases.

Respir Med. 2014 Feb 15;

Authors: Bjermer L, Alving K, Diamant Z, Magnussen H, Pavord I, Piacentini G, Price D, Roche N, Sastre J, Thomas M, Usmani O

Abstract
Although not yet widely implemented, fraction of exhaled nitric oxide (FeNO) has emerged in recent years as a potentially useful biomarker for the assessment of airway inflammation both in undiagnosed patients with non-specific respiratory symptoms and in those with established airway disease. Research to date essentially suggests that FeNO measurement facilitates the identification of patients exhibiting T-helper cell type 2 (Th2)-mediated airway inflammation, and effectively those in whom anti-inflammatory therapy, particularly inhaled corticosteroids (ICS), is beneficial. In some studies, FeNO-guided management of patients with established airway disease is associated with lower exacerbation rates, improvements in adherence to anti-inflammatory therapy, and the ability to predict risk of future exacerbations or decline in lung function. Despite these data, concerns regarding the applicability and utility of FeNO in clinical practice still remain. This article reviews the current evidence, both supportive and critical of FeNO measurement, in the diagnosis and management of asthma and other inflammatory airway diseases. It additionally provides suggestions regarding the practical application of FeNO measurement: how it could be integrated into routine clinical practice, how its utility could be assessed and its true value to both clinicians and patients could be established. Although some unanswered questions remain, current evidence suggests that FeNO is potentially a valuable tool for improving the personalised management of inflammatory airway diseases.

PMID: 24636813 [PubMed - as supplied by publisher]

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Common variable immunodeficiency and bronchiectasis: an easily missed common association.

Chest. 2014 Mar 1;145(3 Suppl):123A

Authors: Sherani K, Upadhyay H, Vakil A, Cervellione K, Thurm C

Abstract
SESSION TITLE: Infectious Disease Case Report Posters ISESSION TYPE: Case Report PosterPRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PMINTRODUCTION: The etiology of bronchiectasis is varied with abnormal host defenses being one of the causes. We report the case of a 49-year-old male presenting with recurrent pneumonias. Imaging studies revealed bronchiectasis. Work up for bronchiectasis showed low immunoglobulin levels consistent with common variable immunodeficiency (CVID). The aim of this case report is to heighten awareness among physicians for the possibility of immunoglobulin deficiency in patients presenting especially with bronchiectasis, recurrent infections and sinus disease.
CASE PRESENTATION: A 49-year-old nonsmoker male presented with fever and productive cough for 1 week. He had multiple similar episodes in the past treated with systemic antibiotic therapy at another hospital. He also reported having recurrent sinusitis and was being considered for sinus surgery by ENT physician. As a child he reported having recurrent ear infections leading to chronic hearing loss. He denied any significant family history and had 3 healthy children. Physical exam revealed bronchial breath sounds in left lower lobe. Review of old radiologic studies revealed progressively worsening bronchiectasis predominantly involving left lower lobe (fig 1a), tree-in-bud opacities with loss of volume on the left (fig 2) and mediastinal adenopathy (fig 1b). In view of history and presentation immunoglobulin levels were sent. These showed IgG &lt; 270 mg/dl, IgA &lt; 40 mg/dl and Ig M &lt; 25 mg/dl - consistent with CVID. Immunoglobulin therapy was started preventing further recurrence of infections and sinusitis in this patient.
DISCUSSION: Patients presenting with bronchiectasis, recurrent infections and sinus disease should be considered for immunoglobulin deficiency, ciliary disorders and cystic fibrosis. As demonstrated in this patient, CVID is known to be associated with bronchiectasis (11 %). It is also known to be associated with granulomatous and lymphocytic infiltrative diseases, sarcoidosis, follicular bronchiolitis, lymphoid hyperplasia, lymphoid interstitial pneumonia and lymphoma. The proposed mechanisms for the cause of bronchiectasis in CVID include recurrent infections and unregulated inflammation. In CVID, immunoglobulin replacement may slow progression of lung disease, although this has not been conclusively established.
CONCLUSIONS: Among the various etiologies of bronchiectasis, the potentially treatable ones like CVID should never be missed. Appropriate and early institution of treatment can potentially improve survival, prevent deterioration of lung function and improve quality of life.Reference #1: Busse PJ, Farzan S, Cunningham-Rundles C, "Pulmonary complications of common variable immunodeficiency" Ann Allergy Asthma Immunol. 2007;98(1):1Reference #2: Park JH, Levinson AI,"Granulomatous-lymphocytic interstitial lung disease (GLILD) in common variable immunodeficiency (CVID)" Clin Immunol. 2010;134(2):97DISCLOSURE: The following authors have nothing to disclose: Khalid Sherani, Hineshkumar Upadhyay, Abhay Vakil, Kelly Cervellione, Craig ThurmNo Product/Research Disclosure Information.

PMID: 24638297 [PubMed - in process]