Norfolk Academy

To assess the impact of low dose inhaled fluticasone furoate on growth velocity in prepubertal patients with well-controlled asthma.The study included 477 prepubertal (Tanner Stage 1) boys from 5 to <9 years of age and girls from 5 to <8 years of age with height, weight, and BMI between the third and 97th percentile. Inclusion criteria included bone age within 2 years of chronological age, asthma symptoms for ≥6 months, prebronchodilator forced expiratory flow in 1 second of ≥60%, Asthma Control Test > 19. Participants also had to receive ≥1 prescription of inhaled corticosteroids (ICS) or oral corticosteroids within ≤1 year, but could not have received ICS in ≤6 weeks or oral corticosteroids in ≤12 weeks before screening.The study was a randomized, double-blind, parallel-group, placebo-controlled trial. To minimize risk of poorly controlled asthma, all study participants were on age appropriate montelukast and either placebo or fluticasone furoate 50 ug once daily as the intervention. There was a 16-week run-in period on leukotriene receptor antagonists alone to determine baseline adherence, symptoms, and obtain baseline growth measurements, followed by a 52-week treatment period, and an 8-week follow-up period with montelukast monotherapy. The growth measurements were compared with baseline, including height SD scores, proportion of participants in the <3 percentile growth velocity values, and changes in growth velocity quartiles from baseline to endpoint.The study showed a reduction in growth velocity on fluticasone furoate of −0.16 cm per year compared with the placebo, but this crossed the confidence interval. Treatment compliance was high based on diary entry and dose counting. The change in height from baseline was similar in the treatment group versus placebo group.The height and growth velocity reduction with low dose fluticasone furoate was unlikely to be clinically significant. Limitations of the study included the duration of 1 year, whereas patients being treated for asthma as a chronic disease are usually prescribed long-term inhaled corticosteroids, and the dose used clinically can vary in comparison with the dose studied here.This study, examining the effects of low dose fluticasone furoate on growth velocity, showed safety in well controlled asthma without a statistically significant difference and, is unlikely, to be clinically relevant reduction in growth velocity and not affecting height over a short study period. The dose used in this study was a lower dose compared with most ICS used in clinical practice. This supports ICS use in pediatric asthma, emphasizing safety with ICS to treat the inflammatory component of asthma, and provides important safety information regarding appropriate prescribing of therapy for asthmatics.

To determine the rate of asthma controller medication prescriptions at the time of hospital discharge following admission for asthma and its impact on hospital readmissions. The study also measured the impact of community prescriptions for asthma controller medications on readmissions.Pediatric patients (age 3–18) discharged with the diagnosis of wheezing or asthma were enrolled from multiple tertiary, mixed metropolitan, and regional hospitals in Australia. Patients with congenital heart disease, chronic lung disease, or neuromuscular conditions were excluded.An observational cohort study of children enrolled between September 2017 and August 2018 evaluated whether they were given an asthma controller medication at discharge from the hospital, refilled a previously prescribed controller within 3 days of discharge, or filled controller medication within the subsequent 12 months. Controller medications included inhaled corticosteroid, inhaled corticosteroid-long acting beta agonist, and leukotriene receptor antagonists. The primary outcome measured the effectiveness of asthma controller dispensing for preventing childhood asthma readmissions within 12 months.Of the 767 study participants (mean age 6.2 years, 62.8% male), 34.3% of the patients were readmitted to the hospital with asthma within 12 months. At the initial admission, 16% of patients were on controller medications. At discharge, 10.5% more patients were prescribed a controller, and 16% continued the controller they had already been prescribed. Less than half (45%) of those picked up their newly prescribed or previously prescribed controllers within 3 days of discharge. There was no protective effect from dispensing a controller medication at discharge on asthma hospital readmissions within 12 months (odds ratio 1.17, 95% confidence interval [CI] 0.69 to 1.97, P = .57). However, of the 566 children not prescribed asthma controller medications at discharge, 269 (47.5%) had 1 or more prescriptions dispensed in follow-up appointments from a subsequent provider within 12 months. The median cumulative days the controller was available at home (protected period) was under 98 days (60–167). Participants in the protected period had reduced risk of an asthma hospital readmission (hazard ratio 0.61, 95% CI 0.36 to 1.02, P = .06), including preschool children (hazard ratio 0.48, 95% CI 0.25, 0.93, P = .03).Almost three-fourths of patients discharged from the hospital with a diagnosis of asthma or wheezing were not prescribed asthma controller therapy. For those who did receive a prescription, less than 50% filled the medication. Asthma controller adherence and regular follow-ups in the community are essential if asthma readmission rates are to be reduced.It is concerning that most patients were not sent home with specific plans for asthma controller therapy across multiple hospital settings. This study further corroborates trends of poor medication fill rates for asthma controller medicines. Even when prescribed a controller medicine, readmission rates were not impacted. This study’s only factor leading to positive outcomes is when the community provider manages the prescription with subsequent asthma follow-ups. This may be because of patients having more trust in longitudinal physicians rather than the brief time they spent with the inpatient team. Consistent usage of asthma medicines is paramount to improving disease burden and preventing future exacerbations, including death. Although theoretically strong discharge education and asthma management seem important, outpatient providers who can promote adherence to asthma guidelines, additional teaching, controller medication prescriptions, and monitoring are more important.

R Willson, S Makhecha, R Moore-Crouch, IM Balfour-Lynn. Arch Dis Child. doi:10.1136/archdischild-2018-316609 To assess how often acutely wheezing pediatric patients requiring oral corticosteroids (OCS) had filled their controller inhaled steroids in the preceding six months. Wheezing children in a tertiary pediatric respiratory care clinic in London, England, during a two-year period (2016–2017) who were prescribed oral steroids at that visit were included in analysis. This retrospective study reviewed charts to identify asthmatic patients who were symptomatic and prescribed an oral steroid at their office visit. Children were excluded if there was no evidence of asthma, longstanding corticosteroid use, OCS used for a trial of responsiveness, …

Upper airway obstruction is an emergency that requires quick and decisive intervention. Stridor is the sound created by airflow through a partially obstructed airway, and has been described to vary with the site and degree of obstruction. This study sought to determine the sound characteristics of stridor in the excised human larynx. Five fresh cadaver human larynges were harvested and subjected to obstructions at supraglottic, glottic, and subglottic subsites. Subglottic pressure, airflow, and audio signal were recorded. Data were analyzed on the basis of laryngeal obstruction subsite and the degree of laryngeal resistance. Visual inspection demonstrated certain trends in peak spectral energy depending on the site and, more significantly, the amount of obstruction. Statistical analysis of spectral waveforms showed better correlation with the amount of obstruction than with the site of obstruction. In summary, the frequency distribution of stridor produced in an excised human larynx was influenced by the amount of laryngeal resistance, but not by the site of airway obstruction.

Accurate knowledge of the velocity dispersion of Lamb modes is important for ultrasonic nondestructive evaluation methods used in detecting and locating flaws in thin plates and in determining their elastic stiffness coefficients. Lamb mode dispersion is also important in the acoustic emission technique for accurately triangulating the location of emissions in thin plates. In this research, the ability to characterize Lamb mode dispersion through a time-frequency analysis (the pseudo-Wigner-Ville distribution) was demonstrated. A major advantage of time-frequency methods is the ability to analyze acoustic signals containing multiple propagation modes, which overlap and superimpose in the time domain signal. By combining time-frequency analysis with a broadband acoustic excitation source, the dispersion of multiple Lamb modes over a wide frequency range can be determined from as little as a single measurement. In addition, the technique provides a direct measurement of the group velocity dispersion. The technique was first demonstrated in the analysis of a simulated waveform in an aluminum plate in which the Lamb mode dispersion was well known. Portions of the dispersion curves of the A0, A1, S0, and S2 Lamb modes were obtained from this one waveform. The technique was also applied for the analysis of experimental waveforms from a unidirectional graphite/epoxy composite plate. Measurements were made both along and perpendicular to the fiber direction. In this case, the signals contained only the lowest order symmetric and antisymmetric modes. A least squares fit of the results from several source to detector distances was used. Theoretical dispersion curves were calculated and are shown to be in good agreement with experimental results.

There are only three factors which account for the presence or the absence of fauna in any archaeological site: Ecology of the area, Economics of any associated predator population (including hominids), and Ethos of any associated hominid population. When these are incorporated into a binary equation with a presence or absence outcome, and then correlated with a locus type, a focus is provided for a more far reaching analysis of faunal richness and diversity as they relate to preference and activity patterns. Taphonomic and recovery biases, of course, enter into the analysis and are a given. The equations number 16 with 8 being equalities and 8 being inequalities. Seven of the equalities result in an absence marker. Seven of the inequalities result in a presence marker. The equations force us to think more about how and why fauna were used and the role of competing species. I have found this approach useful to better understand why goats are virtually non-existent in the early seventeenth-century Chesapeake sites, seemingly disputing the extant documentation for that time. Greater cultural understanding may unfold by incorporating this methodology into our faunal interpretation.

Among the various techniques available, ultrasonic Lamb waves offer a convenient method of evaluating composite materials. Since the Lamb wave velocity depends on the elastic properties of a structure, an effective tool exists to monitor damage in composites by measuring the velocity of these waves. Lamb wave measurements can propagate over long distances and are sensitive to the desired in-plane elastic properties of the material. This paper describes two studies which monitor fatigue damage and two studies which monitor thermal damage in composites using Lamb waves. In the fatigue studies, the Lamb wave velocity is compared to modulus measurements obtained using strain gage measurements in the first experiment and the velocity is monitored along with the crack density in the second. In the thermal damage studies, one examines samples which were exposed to varying temperatures for a three minute duration and the second includes rapid thermal damage in composites by intense laser beams. In all studies, the Lamb wave velocity is demonstrated to be an excellent method to monitor damage in composites.