Development, effectiveness and cost-effectiveness of a new out-patient Breathlessness Support Service:study protocol of a phase III fast-track randomised controlled trial

Background: Breathlessness is a common and distressing symptom affecting many patients with advanced disease both from malignant and non-malignant origin. A combination of pharmacological and non-pharmacological measures is necessary to treat this symptom successfully. Breathlessness services in various compositions aim to provide comprehensive care for patients and their carers by a multiprofessional team but their effectiveness and cost-effectiveness have not yet been proven. The Breathlessness Support Service (BSS) is a newly created multiprofessional and interdisciplinary outpatient service at a large university hospital in South East London. The aim of this study is to develop and evaluate the effectiveness and cost effectiveness of this multidisciplinary out-patient BSS for the palliation of breathlessness, in advanced malignant and non-malignant disease. Methods: The BSS was modelled based on the results of qualitative and quantitative studies, and systematic literature reviews. A randomised controlled fast track trial (RCT) comprising two groups: 1) intervention (immediate access to BSS in addition to standard care); 2) control group (standard best practice and access to BSS after a waiting time of six weeks). Patients are included if suffering from breathlessness on exertion or at rest due to advanced disease such as cancer, chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), interstitial lung disease (ILD) or motor neurone disease (MND) that is refractory to maximal optimised medical management. Both quantitative and qualitative outcomes are assessed in face to-face interviews at baseline, after 6 and 12 weeks. The primary outcome is patients' improvement of mastery of breathlessness after six weeks assessed on the Chronic Respiratory Disease Questionnaire (CRQ). Secondary outcomes for patients include breathlessness severity, symptom burden, palliative care needs, service use, and respiratory measures (spirometry). For analyses, the primary outcome, mastery of breathlessness after six weeks, will be analysed using ANCOVA. Selection of covariates will depend on baseline differences between the groups. Analyses of secondary outcomes will include patients' symptom burden other than breathlessness, physiological measures (lung function, six minute walk distance), and caregiver burden. Discussion: Breathlessness services aim to meet the needs of patients suffering from this complex and burdensome symptom and their carers. The newly created BSS is different to other current services as it is run in close collaboration of palliative medicine and respiratory medicine to optimise medical care of patients. It also involves professionals from various medical, nursing, physiotherapy, occupational therapy and social work background

Chronic rhinosinusitis with and without nasal polyps and asthma: Omalizumab improves residual anxiety but not depression

Abstract Background Chronic rhinosinusitis (CRS) has a high prevalence of anxiety and depression. It is currently uncertain if treatment in patients with CRS with or without nasal polyps (CRSwNP and CRSsNP) has any impact on improving mental health outcomes. The aims here were to document anxiety and depression in patients with severe CRS and asthma already treated with appropriate medical therapy. We then evaluated whether further maximal treatment with omalizumab improved anxiety and/or depression alongside improvements in CRS and coassociated asthma. Methods Hospital Anxiety and Depression Scale (HADS) scores along with measures of CRS and asthma severity were recorded according to CRSwNP and CRSsNP status in n = 95 patients with severe CRS and asthma. Of this group, a further n = 23 had omalizumab for associated allergic asthma. Follow‐up measures were collected 16 weeks after omalizumab treatment. Results HADS anxiety and depression prevalence in CRS were 49.47 % and 38.95%, respectively. Within the CRSwNP and CRSsNP group 53.06% and 45.66% had raised HADS‐anxiety scores. Abnormal HADS‐depression scores were present in 40.82% and 36.95% of the CRSwNP and CRSsNP groups, respectively. Correlations for sinonasal outcome test‐22 (SNOT‐22) versus HADS total was r = 0.59 p < 0.0001, HADS‐anxiety r = 0.56 p < 0.0001 and HADS‐depression r = 0.49 p < 0.0001. Omalizumab improved anxiety in CRS (p < 0.0001) regardless of nasal polyp status (CRSwNP p = 0.0042 and CRSsNP p = 0.0078). Depression scores did not improve in either group. SNOT‐22 (p = 0.0006), asthma control questionnaire‐7 (p = 0.0019) and mini‐asthma quality of life questionnaire including emotional function (p = 0.0003 and p = 0.0009, respectively) all improved in both subgroups. Conclusion In CRS and asthma, anxiety scores but not depression improved after omalizumab treatment. Anxiety may be closely related to airway disease severity, but depression may be independent of airway disease itself. If so, a separate mental health care pathway is needed for CRS patients with depression

Effect of diet quality on mussel biomarker responses to pollutants

International audienceThe effect of the quality of two microalgal species on select biological and biochemical responses used as indicators of pollution were assessed. Mussels were conditioned for 6 weeks with the diatom Chaetoceros neogracile and the dinoflagellate Heterocapsa triquetra, chosen for being two clearly different types of primary production quality that differ in both biometric and biochemical characteristics. After dietary conditioning, the mussels were exposed to a polycyclic aromatic hydrocarbon, fluoranthene (FLU), for 1 week followed by 1 week of depuration. Results showed higher FLU accumulation in mussels fed on C. neogracile compared to those fed on H. triquetra. Concomitantly, a greater impact of this toxicant was observed in the biomarker responses of mussels fed on C. neogracile. These mussels showed an increase in the percentage of dead hemocytes, an activation of phagocytosis and ROS production of hemocytes after exposure. Some enzymatic activities also increased upon FLU exposure (superoxide dismutase −SOD-, catalase −CAT-, and glutathione reductases −GR-) and after depuration (glutathione-s-transferase −GST-). Results suggest that FLU exposure as well as food quality influence biomarker responses, with higher values of SOD, CAT and GR in non-exposed mussels fed on C. neogracile. In addition, upon exposure to the same FLU concentration, GR response varied according to dietary conditioning, suggesting that diet could act as a confounding factor in biomarker responses to pollution. Consequently, trophic conditions should be considered in marine pollution monitoring programs for a better interpretation of biomarker responses

Effect of diet quality on mussel biomarker responses to pollutants

The effect of the quality of two microalgal species on select biological and biochemical responses usedas indicators of pollution were assessed. Mussels were conditioned for 6 weeks with the diatom Chaeto-ceros neogracile and the dinoflagellate Heterocapsa triquetra, chosen for being two clearly different typesof primary production quality that differ in both biometric and biochemical characteristics. After dietaryconditioning, the mussels were exposed to a polycyclic aromatic hydrocarbon, fluoranthene (FLU), for1 week followed by 1 week of depuration. Results showed higher FLU accumulation in mussels fed onC. neogracile compared to those fed on H. triquetra. Concomitantly, a greater impact of this toxicant wasobserved in the biomarker responses of mussels fed on C. neogracile. These mussels showed an increase inthe percentage of dead hemocytes, an activation of phagocytosis and ROS production of hemocytes afterexposure. Some enzymatic activities also increased upon FLU exposure (superoxide dismutase −SOD-, catalase −CAT-, and glutathione reductases −GR-) and after depuration (glutathione-s-transferase−GST-). Results suggest that FLU exposure as well as food quality influence biomarker responses, withhigher values of SOD, CAT and GR in non-exposed mussels fed on C. neogracile. In addition, upon exposureto the same FLU concentration, GR response varied according to dietary conditioning, suggesting that dietcould act as a confounding factor in biomarker responses to pollution. Consequently, trophic conditionsshould be considered in marine pollution monitoring programs for a better interpretation of biomarker responses.Versión del edito