Sputum Type 2 Markers Could Predict Remission in Severe Asthma Treated With Anti-IL-5.

BACKGROUND: Biotherapies targeting IL-5 allow a tangible improvement of asthma. However, all patients do not respond the same way to these treatments. Even if high blood eosinophil counts seem to be associated with a reduction in exacerbations with treatment targeting IL-5, we lack biomarkers for the prediction of remission after these very expensive treatments. RESEARCH QUESTION: Are there biomarkers of remission after therapy targeting IL-5 in the sputum of patients with severe eosinophilic asthma? STUDY DESIGN AND METHODS: This observational study included 52 patients with severe asthma initiated with anti-IL-5 therapy and recruited from the asthma clinic of the Centre Hospitalier Universitaire of Liege, Belgium. Remission was defined as patients who combined the following at 1 year after therapy: no chronic treatment with oral corticosteroids; no exacerbation; asthma control questionnaire score < 1.5, asthma control test score > 19, or both; FEV1 of ≥ 80% predicted, improvement of FEV1 of ≥ 10%, or both; and a blood eosinophil count < 300 cells/µL. Eosinophil peroxidase (EPX), IgE, IL-3, IL-4, IL-5, IL-13, IL-25, IL-33, granulocyte-macrophage colony-stimulating factor, thymic stromal lymphopoietin (TSLP), and eotaxin-1 levels were measured in the sputum of these patients before anti-IL-5 treatment. RESULTS: Among the 52 patients, 11 were classified as being in remission. These patients were characterized by higher sputum eosinophil, macrophage, and lymphocyte counts, whereas the sputum neutrophil percentage was lower than in the nonremission group. In addition, the sputum eotaxin-1, TSLP, IL-5, EPX, and IgE protein levels were higher at baseline in the remission group compared with the nonremission group. Univariate regression analysis revealed that male vs female sex, sputum neutrophil percentage, eotaxin-1, IL-5, and EPX were potential predictors of remission. INTERPRETATION: Sputum type 2 markers seemed to be potentially predictive of remission after anti-IL-5 therapy in a cohort of patients with severe eosinophilic asthma. These results need validation on a larger cohort.

The end of religious exemptions from immunisation requirements?

The purpose of this paper is to propose a middle ground in the debate over religious exemptions from measles vaccination requirements. It attempts to strike a balance between public health concerns on the one hand and religious objections on the other that avoids two equally serious errors: (1) making religious liberty an absolute and (2) disregarding religious beliefs altogether. Some think that the issue is straightforward: science has spoken and the benefits to public health outweigh any other concerns. The safety of the community, they say, demands that everybody be vaccinated so that measles outbreaks can be prevented, but such voices often ignore the freedom of religion, which is a mistake. Using Martha Nussbaum's work on religious liberty, this paper claims that the exemptions should be preserved if a certain level of vaccination rates can be maintained.

Surrogate decision making and intellectual virtue.

Patients can be harmed by a religiously motivated surrogate decision maker whose decisions are contrary to the standard of care; therefore, surrogate decision making should be held to a high standard. Stewart Eskew and Christopher Meyers proposed a two-part rule for deciding which religiously based decisions to honor: (1) a secular reason condition and (2) a rationality condition. The second condition is based on a coherence theory of rationality, which they claim is accessible, generous, and culturally sensitive. In this article, I will propose strengthening the rationality condition by grounding it in a theory of intellectual virtue, which is both rigorous and culturally sensitive.

Cultural sensitivity in paediatrics.

In a recent Journal of Medical Ethics article, 'Should Religious Beliefs Be Allowed to Stonewall a Secular Approach to Withdrawing and Withholding Treatment in Children?', Joe Brierley, Jim Linthicum and Andy Petros argue for rapid intervention in cases of futile life-sustaining treatment. In their experience, when discussions of futility are initiated with parents, parents often appeal to religion to 'stonewall' attempts to disconnect their children from life support. However, I will argue that the intervention that the authors propose is culturally insensitive.

Jehovah's Witnesses and autonomy: honouring the refusal of blood transfusions.

This paper explores the scriptural and theological reasons given by Jehovah's Witnesses (JWs) to refuse blood transfusions. Julian Savulescu and Richard W Momeyer argue that informed consent should be based on rational beliefs and that the refusal of blood transfusions by JWs is irrational, but after examining the reasons given by JWs, I challenge the claim that JW beliefs are irrational. I also question whether we should give up the traditional notion of informed consent.

Success of clinical pathways for total joint arthroplasty in a community hospital.

Clinical pathways for total joint arthroplasty have been implemented successfully during the past decade. We report the results of pathway use for primary elective total hip and total knee arthroplasty in a community teaching hospital. We evaluated pathway efficacy using patient data forms and the hospital's financial database. Before instituting the pathway, the average length of stay was 4.41 days for patients having total hip arthroplasty and 3.92 days for patients having total knee arthroplasty. The average length of stay for patients having total hip arthroplasty decreased to 3.24 days and to 2.98 days for patients having total knee arthroplasty. Press Ganey Survey results showed high patient satisfaction rates before and after pathway initiation. Pathway implementation did not lead to increased complication rates or readmissions. Despite higher expected increases in the overall healthcare cost during the time of implementation (3 years), direct cost increases were limited to 3.48%. The key elements contributing to pathway success included preoperative patient education, standardized orders derived from evidence-based medicine, and a nurse practitioner who championed the pathway and ensured compliance. We recommend clinical pathways for patients having total joint arthroplasties to reduce length of stay, facilitate effective resource use, and preserve quality of care without compromising patient satisfaction or safety.