Bronchiectasis insanity:Doing the same thing over and over again and expecting different results?

Bronchiectasis is an increasingly common disease with a significant impact on quality of life and morbidity of affected patients. It is also a very heterogeneous disease with numerous different underlying etiologies and presentations. Most treatments for bronchiectasis are based on low-quality evidence; consequently, no treatments have been approved by the US Food and Drug Administration or the European Medicines Agency for the treatment of bronchiectasis. The last several years have seen numerous clinical trials in which the investigational agent, thought to hold great promise, did not demonstrate a clinically or statistically significant benefit. This commentary will review the likely reasons for these disappointing results and a potential approach that may have a greater likelihood of defining evidence-based treatment for bronchiectasis

A 2 × 2 factorial, randomised, open-label trial to determine the clinical and cost-effectiveness of hypertonic saline (HTS 6%) and carbocisteine for airway clearance versus usual care over 52 weeks in adults with bronchiectasis:a protocol for the CLEAR clinical trial

Background: Current guidelines for the management of bronchiectasis (BE) highlight the lack of evidence to recommend mucoactive agents, such as hypertonic saline (HTS) and carbocisteine, to aid sputum removal as part of standard care. We hypothesise that mucoactive agents (HTS or carbocisteine, or a combination) are effective in reducing exacerbations over a 52-week period, compared to usual care. Methods: This is a 52-week, 2 × 2 factorial, randomized, open-label trial to determine the clinical effectiveness and cost effectiveness of HTS 6% and carbocisteine for airway clearance versus usual care-the Clinical and cost-effectiveness of hypertonic saline (HTS 6%) and carbocisteine for airway clearance versus usual care (CLEAR) trial. Patients will be randomised to (1) standard care and twice-daily nebulised HTS (6%), (2) standard care and carbocisteine (750 mg three times per day until visit 3, reducing to 750 mg twice per day), (3) standard care and combination of twice-daily nebulised HTS and carbocisteine, or (4) standard care. The primary outcome is the mean number of exacerbations over 52 weeks. Key inclusion criteria are as follows: Adults with a diagnosis of BE on computed tomography, BE as the primary respiratory diagnosis, and two or more pulmonary exacerbations in the last year requiring antibiotics and production of daily sputum. Discussion: This trial's pragmatic research design avoids the significant costs associated with double-blind trials whilst optimising rigour in other areas of trial delivery. The CLEAR trial will provide evidence as to whether HTS, carbocisteine or both are effective and cost effective for patients with BE. Trial registration: EudraCT number: 2017-000664-14 (first entered in the database on 20 October 2017). ISRCTN.com, ISRCTN89040295. Registered on 6 July/2018. Funder: National Institute for Health Research, Health Technology Assessment Programme (15/100/01). Sponsor: Belfast Health and Social Care Trust. Ethics Reference Number: 17/NE/0339. Protocol version: V3.0 Final_14052018

Defining the optimal dietary approach for safe, effective and sustainable weight loss in overweight and obese adults

Various dietary approaches with different caloric content and macronutrient composition have been recommended to treat obesity in adults. Although their safety and efficacy profile has been assessed in numerous randomized clinical trials, reviews and meta-analyses, the characteristics of the optimal dietary weight loss strategy remain controversial. This mini-review will provide general principles and practical recommendations for the dietary management of obesity and will further explore the components of the optimal dietary intervention. To this end, various dietary plans are critically discussed, including low-fat diets, low-carbohydrate diets, high-protein diets, very low-calorie diets with meal replacements, Mediterranean diet, and diets with intermittent energy restriction. As a general principle, the optimal diet to treat obesity should be safe, efficacious, healthy and nutritionally adequate, culturally acceptable and economically affordable, and should ensure long-term compliance and maintenance of weight loss. Setting realistic goals for weight loss and pursuing a balanced dietary plan tailored to individual needs, preferences, and medical conditions, are the key principles to facilitate weight loss in obese patients and most importantly reduce their overall cardiometabolic risk and other obesity-related comorbidities. © 2018 by the authors. Licensee MDPI, Basel, Switzerland

Current physiotherapy practice in Greek intensive care units: a national study

Background: The purpose of the study was to investigate the responsibilities and frequency of clinical procedures that physiotherapists perform within the intensive care unit (ICU) in Greece, along with the level of education and training of these physiotherapists. Methods: Physiotherapists who work in general ICUs of hospitals were invited to complete a developed questionnaire. The questionnaire consisted of 83 items, of closed and opened–ended format. Items for service provision and physiotherapists’ employment were included, along with participants’ involvement in respiratory care, early mobilisation and the use of the ICU equipment. Results: One hundred forty physiotherapists completed the questionnaire. Seventy-three respondents (52%) reported working in ICU in Athens and 67 (48%) in other cities of Greece. Almost all the physiotherapists’ performed early mobilisation and respiratory techniques; although the frequency of procedures and use of equipment were variable. Sixty-one (44%) and 70 (50%) respondents participated in the weaning procedure and mobilised the patient whilst using the ventilator, respectively. Conclusion: The physiotherapists are from ICUs all over Greece. The results reflect the differences among the procedures that physiotherapists perform, regarding early mobility and respiratory physiotherapy. The results indicate the need for a national up-to-date job description of the physiotherapy services in ICUs in Greece

Current physiotherapy practice in Greek intensive care units: a national study

Background: The purpose of the study was to investigate the responsibilities and frequency of clinical procedures that physiotherapists perform within the intensive care unit (ICU) in Greece, along with the level of education and training of these physiotherapists. Methods: Physiotherapists who work in general ICUs of hospitals were invited to complete a developed questionnaire. The questionnaire consisted of 83 items, of closed and opened–ended format. Items for service provision and physiotherapists’ employment were included, along with participants’ involvement in respiratory care, early mobilisation and the use of the ICU equipment. Results: One hundred forty physiotherapists completed the questionnaire. Seventy-three respondents (52%) reported working in ICU in Athens and 67 (48%) in other cities of Greece. Almost all the physiotherapists’ performed early mobilisation and respiratory techniques; although the frequency of procedures and use of equipment were variable. Sixty-one (44%) and 70 (50%) respondents participated in the weaning procedure and mobilised the patient whilst using the ventilator, respectively. Conclusion: The physiotherapists are from ICUs all over Greece. The results reflect the differences among the procedures that physiotherapists perform, regarding early mobility and respiratory physiotherapy. The results indicate the need for a national up-to-date job description of the physiotherapy services in ICUs in Greece. © 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group

Experimental hypogonadism: Insulin resistance, biochemical changes and effect of testosterone substitution

We sought to clarify the role of testosterone substitution in terms of insulin resistance and metabolic profile dysregulation in hypogonadism. Twenty-nine male Wistar rats aged 11-12 weeks were divided in three groups: control (C, n = 10), sham operation; orchiectomy (ORX, n = 9); and orchiectomy + testosterone substitution (ORX+T, n = 10). Blood samples were obtained at day 1 (operation), after 10 days (intramuscular T injection 100 μg/100 g b.w.), 25 days (second T injection) and 40 days (sacrifice). Hormonal replacement significantly attenuated the negative effect of orchiectomy on insulin resistance as indicated by the successive changes in both insulin levels (1.44 ± 2.94 vs. 4.10 ± 2.47 vs. 1.78 ± 0.68 ng/mL, for D1, D10 and D40, respectively; p = 0.028 and p = 0.022, respectively) and HOMA-IR index (1.36 ± 2.75 vs. 3.68 ± 1.87 vs. 1.74 ± 0.69 ng/mL, for D1, D10 and D40, respectively; p = 0.024 and p = 0.026, respectively) in the ORX+T group. Irisin levels peaked at the 10th postoperative day and were decreased at the end of the experiment (0.27 ± 0.11 vs. 0.85 ± 0.54 vs. 0.02 ± 0.07 ng/mL for D1, D10 and D40, respectively; p = 0.028 in both cases), whereas resistin levels did not differ. Experimental hypogonadism results in an unfavorable lipid profile and insulin resistance, which is not observed when the ORX animals are substituted for T. © 2019 Walter de Gruyter GmbH, Berlin/Boston

Coronary artery disease and endothelial dysfunction: Novel diagnostic and therapeutic approaches

Coronary artery disease is the leading cause of morbidity and mortality worldwide. The most common pathophysiologic substrate is atherosclerosis which is an inflammatory procedure that starts at childhood and develops throughout life. Endothelial dysfunction is associated with the initiation and progression of atherosclerosis and is characterized by the impaired production of nitric oxide. In general, endothelial dysfunction is linked to poor cardiovascular prognosis and different methods, both invasive and non-invasive, have been developed for its evaluation. Ultrasound evaluation of flow mediated dilatation of the branchial artery is the most commonly used method to assessed endothelial function while intracoronary administration of vasoactive agents may be also be used to test directly endothelial properties of the coronary vasculature. Endothelial dysfunction has also been the subject of therapeutic interventions. This review article summarizes the knowledge about evaluation of endothelial function in acute coronary syndromes and stable coronary artery disease and demonstrates the current therapeutic approaches against endothelial dysfunction. © 2020 Bentham Science Publishers