Clinical utility of exhaled nitric oxide

Lower airway inflammation is generally classified as eosinophilic or neutrophilic. In conditions where eosinophilic inflammation predominates such as asthma in children, corticosteroids are usually beneficial. Traditionally, lower airway eosinophilia is measured using cellular count (through bronchoalveolar lavage or induced sputum). Both methods have limited applicability in children. When instruments to measure fractional exhaled nitric oxide (FeNO) became available, it presented an attractive option as it provided a non-invasive method of measuring eosinophilic inflammation suitable for children and adult. Not surprisingly, proposals have been made that FeNO measurement can be clinically used in many scenarios including monitoring the response to anti-inflammatory medications, to verify the adherence to treatment, and to predict upcoming asthma exacerbations. This thesis addresses the utility of FeNO levels in various scenarios, specifically in relation to asthma control and cough, a contentious aspect of the diagnosis of asthma. The thesis consists of a series of systematic reviews (related to the main question) and original studies in children. The over-arching aim of the thesis is to determine if FeNO is a clinically useful tool in the management of asthma and common asthma symptoms. The specific aims of the thesis were, to: 1. Determine if children with asthma have more severe acute respiratory symptoms at presentation with an asthma exacerbation and at days 7, 10 and 14 using validated scales. We also examined if children with asthma were more likely to have a persistent cough on day 14 than children with protracted bronchitis and/or controls. 2. Evaluate the efficacy of tailoring asthma interventions based on sputum analysis in comparison to clinical symptoms (with or without spirometry/peak flow) for asthma related outcomes in children and adults. 3. Evaluate the efficacy of tailoring asthma interventions based on exhaled nitric oxide in comparison to clinical symptoms (with or without spirometry/peak flow) for asthma related outcomes in children and adults. 4. Determine if adjustment of asthma medications based on FeNO levels (compared to management based on clinical symptoms) reduces severe exacerbations in children with asthma. 5. Examine the relationship between FeNO and exercise induced broncho-constriction and cough in children The aims above are addressed in respective chapters and all but one has been published/submitted. A synopsis of the findings are: In study-1 (Aim 1), we found that children with protracted bronchitis had the most severe acute respiratory infection symptoms and higher percentage of respiratory morbidity at day 14 in comparison to children with asthma and healthy controls. The systematic review of study-2 (Aim 2) included 246 randomised adult participants (no children) with 221 completing the trials. In the meta-analysis, a significant reduction in number of participants who had one or more asthma exacerbations occurred when treatment was based on sputum eosinophils in comparison to clinical symptoms. In the systematic review of study-3 (Aim 3), we found no significant difference between the intervention group (treatment adjusted based on FeNO) and control group (treatment adjusted based on clinical symptoms) for the primary outcome of asthma exacerbations or for the other outcomes (clinical symptoms, FeNO level and spirometry). In post-hoc analysis, a significant reduction in mean final daily dose ICS per adult was found in the group where treatment was based on FeNO in comparison to clinical symptoms. In contrast, in the paediatric studies, there was a significant increase in ICS dose in the FeNO strategy arm. Thus, controversy remains of the benefit or otherwise of utilising exhaled nitric oxide (FeNO) in routine clinical practice. FeNO levels are dependent on atopy and none of the 7 published trials have considered atopic status in FeNO levels when medications were adjusted. In study-4 (Aim 4), 64 children with asthma were recruited. Their asthma medications were adjusted according to either FeNO levels or usual clinical care utilising a management hierarchy taking into account atopy. It was concluded that tailoring of asthma medications in accordance to FeNO levels (compared to usual management), taking into account atopy status, reduced the number of children with severe exacerbations. However, a FeNO-based strategy resulted in higher daily ICS doses and had no benefit on asthma control. In study-5 (Aim 5), 33 children with cough and 17 controls were recruited. They were randomised to undertake an exercise challenge on day 1, or dry powder mannitol challenge on day 1 (with alternative challenge being done on day 2). In addition, a 24 hour cough meter, skin prick test, capsaicin cough sensitivity test and cough diary were undertaken. The change in cough frequency post exercise was significantly increased in the children with cough. FeNO decreases post exercise regardless of whether EIB is present or not. Limitations in the studies were addressed in the respective chapters. In summary, the studies from this thesis have provided new information on: • The severity of respiratory symptoms was increased in the early phase of the asthma exacerbation but not in the later recovery phase when compared with controls. • The utility of FeNO in the management of children with asthma. • The relationship of FeNO, cough and EIB in children. • Systematic reviews on the efficacy of tailoring asthma interventions based on eosinophilic inflammatory markers (sputum analysis and FeNO) in comparison to clinical symptoms.

Phonon modes of MgB2 : Super-lattice structures and spectral response

Micrometre-sized MgB2 crystals of varying quality, synthesized at low temperature and autogeneous pressure, are compared using a combination of Raman and Infra-Red (IR) spectroscopy. These data, which include new peak positions in both spectroscopies for high quality MgB2, are interpreted using DFT calculations on phonon behaviour for symmetry-related structures. Raman and IR activity additional to that predicted by point group analyses of the P6/mmm symmetry are detected. These additional peaks, as well as the overall shapes of calculated phonon dispersion (PD) models are explained by assuming a double super-lattice, consistent with a lower symmetry structure for MgB2. A 2x super-lattice in the c-direction allows a simple correlation of the pair breaking energy and the superconducting gap by activation of corresponding acoustic frequencies. A consistent physical interpretation of these spectra is obtained when the position of a phonon anomaly defines a super-lattice modulation in the a-b plane.

An analytical framework for quantifying aquifer response time scales associated with transient boundary conditions

A major challenge in studying coupled groundwater and surface-water interactions arises from the considerable difference in the response time scales of groundwater and surface-water systems affected by external forcings. Although coupled models representing the interaction of groundwater and surface-water systems have been studied for over a century, most have focused on groundwater quantity or quality issues rather than response time. In this study, we present an analytical framework, based on the concept of mean action time (MAT), to estimate the time scale required for groundwater systems to respond to changes in surface-water conditions. MAT can be used to estimate the transient response time scale by analyzing the governing mathematical model. This framework does not require any form of transient solution (either numerical or analytical) to the governing equation, yet it provides a closed form mathematical relationship for the response time as a function of the aquifer geometry, boundary conditions, and flow parameters. Our analysis indicates that aquifer systems have three fundamental time scales: (i) a time scale that depends on the intrinsic properties of the aquifer; (ii) a time scale that depends on the intrinsic properties of the boundary condition, and; (iii) a time scale that depends on the properties of the entire system. We discuss two practical scenarios where MAT estimates provide useful insights and we test the MAT predictions using new laboratory-scale experimental data sets.

BIM support for disaster response

The introduction of Building Information Modelling (BIM) to the design, construction and operation of buildings is changing the way that the building construction industry works. BIM involves the development of a full 3D virtual model of a building which not only contains the 3D information necessary to show the building as it will appear, but also contains significant additional data about each component in the building. BIM represents both physical and virtual objects in a building. This includes the rooms and spaces within and around the building. The additional data stored on each part of the building can support building maintenance opera- tions and, more importantly from the perspective of this paper, support the generation and running of simula- tions of the operation of the building and behaviour of people within it under both normal and emergency scenarios. The initial discussion is around the use of BIM to support the design of resilient buildings which references the various codes and standards that define current best practice. The remainder of the discussion uses various recent events as the basis for discussion on how BIM could have been used to support rapid recovery and re- building.

A case study in flood fatality : Beijing July 2012 flood

Background The aim of this study is to examine the flood fatality with a view to identifying risks which may inform public policy responses to future flood. On July 21st, 2012, Beijing suffered the heaviest rain since 1963. The average rainfall was 215 mm over a 24 hour period in the central city (301mm in Fangshan District). The rain resulted in a flood that caused severe health, social and financial impact. Results This flood caused 79 deaths. Of the 71 deaths for which a specific cause could be identified, 5 were rescue team members, 42 were killed by drowning (11 in the car), and the others by electricity shock, fallen house, falling items and lightning. The total financial cost was estimated to be US$ 1.7 billion. The causations of the deaths inform the risks associated with the flood. Discussion This flood had a catastrophic impact on Beijing, mainly due to the intensity of the rain (the rain was the heaviest in the modern Beijing history; possibly due to global warming and urban heat island effect), the vulnerability of the infrastructure (poor standards of drainage, disorganized water management systems and decreased permeability of the earth as a result of the city’s rapid development), and the capacity of the response system (mainly dependent on the awareness of the citizens, warning systems and the capacity of the emergency rescue). Implication Many risk management measures have been implemented as a result of this flood, including water level warning marks, flood safety education and warnings sent to mobile phones, a project to move about 74,500 farmers away from the flood-prone areas within 5 years. However, further measures targeted at the fundamental issues identified by this analysis are necessary, especially those targeting at health issues. These may include better planning, improved drainage systems and ecological development to increase permeability etc..

Demand Response for Residential Appliances in a Smart Electricity Distribution Network: Utility and Customer Perspectives

This thesis introduces advanced Demand Response algorithms for residential appliances to provide benefits for both utility and customers. The algorithms are engaged in scheduling appliances appropriately in a critical peak day to alleviate network peak, adverse voltage conditions and wholesale price spikes also reducing the cost of residential energy consumption. Initially, a demand response technique via customer reward is proposed, where the utility controls appliances to achieve network improvement. Then, an improved real-time pricing scheme is introduced and customers are supported by energy management schedulers to actively participate in it. Finally, the demand response algorithm is improved to provide frequency regulation services.

Transcriptional pathway signatures predict MEK addiction and response to selumetinib (AZD6244)

Selumetinib (AZD6244, ARRY-142886) is a selective, non-ATP-competitive inhibitor of mitogen-activated protein/extracellular signal-regulated kinase kinase (MEK)-1/2. The range of antitumor activity seen preclinically and in patients highlights the importance of identifying determinants of response to this drug. In large tumor cell panels of diverse lineage, we show that MEK inhibitor response does not have an absolute correlation with mutational or phospho-protein markers of BRAF/MEK, RAS, or phosphoinositide 3-kinase (PI3K) activity. We aimed to enhance predictivity by measuring pathway output through coregulated gene networks displaying differential mRNA expression exclusive to resistant cell subsets and correlated to mutational or dynamic pathway activity. We discovered an 18-gene signature enabling measurement of MEK functional output independent of tumor genotype. Where the MEK pathway is activated but the cells remain resistant to selumetinib, we identified a 13-gene signature that implicates the existence of compensatory signaling from RAS effectors other than PI3K. The ability of these signatures to stratify samples according to functional activation of MEK and/or selumetinib sensitivity was shown in multiple independent melanoma, colon, breast, and lung tumor cell lines and in xenograft models. Furthermore, we were able to measure these signatures in fixed archival melanoma tumor samples using a single RT-qPCR-based test and found intergene correlations and associations with genetic markers of pathway activity to be preserved. These signatures offer useful tools for the study of MEK biology and clinical application of MEK inhibitors, and the novel approaches taken may benefit other targeted therapies.

How does Nepal Television (NTV) frame natural disasters? A qualitative content analysis of news scripts using news frames and PPRR cycle

Introduction- This study investigates the prevailing status of Nepalese media portrayal of natural disasters. It is contributing to the development of a disaster management model to improve the effectiveness and efficiency of news production throughout the continuum of prevention, preparedness, response and recovery (PPRR) phases of disaster management. Theoretical framework- Studies of media content often rely on framing as the theoretical underpinning of the study, as it describes how the press crafts the message. However there are additional theoretical perspectives that underline an understanding of the role of the media. This article outlines a conceptual understanding of the role of the media in modern society, the way that this conceptual understanding is used in the crafting of media messages and how those theoretical considerations are applied to the concepts that underpin effective disaster management. (R.M. Entman, 2003; Liu, 2007; Meng & Berger, 2008). Methodology- A qualitative descriptive design is used to analyse the disaster news of Nepal Television (NTV). However, this paper presents the preliminary findings of Nepal Television (a government owned Television station) using qualitative content analysis of 105 natural disaster related news scripts (June 2012-March 2013) based on the framing theory and PPRR cycle. Results- The preliminary results indicate that the media focus while framing natural disasters is dominated by human interest frame followed by responsibility frame. News about response phase was found to be most prominent in terms of PPRR cycle. Limited disaster reporting by NTV has impacted the national disaster management programs and strategies. The findings describe natural disasters are being reported within the limited understanding of the important principles of disaster management and PPRR cycle. Conclusion- This paper describes the current status of the coverage of natural disasters by Nepal Television to identify the frames used in the news content. It contributes to determining the characteristics of effective media reporting of natural disasters in the government owned media outlets, and also leads to including communities and agencies involved in disasters. It suggests the frames which are best suited for news making and how media responds to the different phases of the disaster cycle.

Potentiation of the early visual response to learned danger signals in adults and adolescents

The reinforcing effects of aversive outcomes on avoidance behaviour are well established. However, their influence on perceptual processes is less well explored, especially during the transition from adolescence to adulthood. Using electroencephalography, we examined whether learning to actively or passively avoid harm can modulate early visual responses in adolescents and adults. The task included two avoidance conditions, active and passive, where two different warning stimuli predicted the imminent, but avoidable, presentation of an aversive tone. To avoid the aversive outcome, participants had to learn to emit an action (active avoidance) for one of the warning stimuli and omit an action for the other (passive avoidance). Both adults and adolescents performed the task with a high degree of accuracy. For both adolescents and adults, increased N170 event-related potential amplitudes were found for both the active and the passive warning stimuli compared with control conditions. Moreover, the potentiation of the N170 to the warning stimuli was stable and long lasting. Developmental differences were also observed; adolescents showed greater potentiation of the N170 component to danger signals. These findings demonstrate, for the first time, that learned danger signals in an instrumental avoidance task can influence early visual sensory processes in both adults and adolescents.

Kari Gislason's response to the Ottoman Motel by Christopher Currie [The Art of Vanishing Parents]

A review of The Ottoman Hotel by Christopher Currie (Text Publishing, 2011). There is more than one moment in life when parents disappear. Teenagers routinely wish them away. Young adults at university return to find they have been abandoned, their possessions boxed, labelled and stored, their bedrooms turned into guest accommodation sometimes featuring lavender. You call your parents and they're not home. Your mother doesn't accept your friend request...