Severe vocal cord dysfunction resistant to all current therapeutic interventions

SummaryVocal cord dysfunction (VCD) is characterised by paradoxical vocal cord adduction during inspiration or throughout the respiratory cycle, it results in wheeze, stridor, cough and dyspnoea. Although asthma and VCD can coexist, patients with VCD are frequently misdiagnosed with refractory asthma. It can severely restrict an individual's level of activity and effective therapeutic control can be difficult to achieve. We report the case of a patient who was treated with all available therapeutic interventions, including intralaryngeal botulinum toxin injection, but failure resulted in a permanent trachesotomy

Defining and investigating difficult asthma: Developing quality indicators

SummaryBackgroundThere is no agreed definition of ‘difficult asthma’ or what investigations should be available to investigate these patients. Patients with difficult asthma remain symptomatic on high levels of treatment and are high users of medical resources.AimTo develop a set of quality indicators for the definition and investigation of difficult asthma.MethodModified RAND Appropriateness Method was used. An expert panel composed of nine hospital asthma specialists who run ‘difficult’ asthma clinics and were identified from a shortlist of key workers in the field. Indicators were rated as necessary to define and investigate difficult asthma.ResultsDifficult asthma was defined as ‘symptoms persisting beyond therapy consistent with step 4 of the British Thoracic Society (BTS) guidelines’ (high dose inhaled corticosteroids and long acting β2-agonists). Eighty-three indicators were identified (40 relating to definition and 43 relating to investigations). Of these 32 (39%) were rated as necessary: 7 out of 40 (18%) for defining difficult asthma and 23 out of 43 (53%) for investigations. Indicators of high medical resource usage were characteristic of the ‘difficult’ nature of the management of patient with difficult asthma. A framework for the investigation of these patients was created.ConclusionThe listed performance indicators identify a range of requirements that are necessary to define difficult asthma. Targeting of real needs in this group of patients will lead to better patient care and reduction of ‘waste’ in provision of healthcare

Evidence for a mixed mass composition at the `ankle' in the cosmic-ray spectrum

We report a first measurement for ultra-high energy cosmic rays of the correlation between the depth of shower maximum and the signal in the water Cherenkov stations of air-showers registered simultaneously by the fluorescence and the surface detectors of the Pierre Auger Observatory. Such a correlation measurement is a unique feature of a hybrid air-shower observatory with sensitivity to both the electromagnetic and muonic components. It allows an accurate determination of the spread of primary masses in the cosmic-ray flux. Up till now, constraints on the spread of primary masses have been dominated by systematic uncertainties. The present correlation measurement is not affected by systematics in the measurement of the depth of shower maximum or the signal in the water Cherenkov stations. The analysis relies on general characteristics of air showers and is thus robust also with respect to uncertainties in hadronic event generators. The observed correlation in the energy range around the `ankle' at $\lg(E/{\rm eV})=18.5-19.0$ differs significantly from expectations for pure primary cosmic-ray compositions. A light composition made up of proton and helium only is equally inconsistent with observations. The data are explained well by a mixed composition including nuclei with mass $A > 4$. Scenarios such as the proton dip model, with almost pure compositions, are thus disfavoured as the sole explanation of the ultrahigh-energy cosmic-ray flux at Earth.Comment: Published version. Added journal reference and DOI. Added Report Numbe