Cough hypersensitivity syndrome is an important clinical concept:a pro/con debate

The major etiologies of chronic cough are generally accepted to consist of upper airway cough syndrome (formerly postnasal drip syndrome), eosinophilic airway inflammation (asthma, nonasthmatic eosinophilic bronchitis), and gastroesophageal reflux disease (GERD). However, only a small percentage of patients with these very common conditions suffers from chronic cough. Furthermore, acute cough due to viral upper respiratory tract infection (URI) is almost always a transient, self-limited condition, yet in a small subgroup of patients, URI heralds the onset of chronic, refractory cough. The cough hypersensitivity syndrome has been proposed to explain the occurrence of chronic cough in a subgroup of patients exposed to the same putative triggers as the vast majority of the population in whom chronic cough does not result. Although conceptually the cough hypersensitivity syndrome may be intellectually satisfying, differences of opinion remain as to whether this newly recognized entity is of clinical significance, i.e., useful for the treatment of patients suffering from chronic cough. The Third American Cough Conference, held in New York in June 2011, provided an ideal forum for the debate of this issue between two internationally recognized authorities in the field of cough.

Patterns of cough in the clinic

Current guidelines for the management of cough highlight the value of a taking a careful history to establish specific features of the cough in particular its duration, typical triggers or aggravants and associated symptoms. Unfortunately the diagnostic yield from a history alone is poor and there is a need to understand the pattern of clinical cough in a more precise way. As the technology to record cough in ambulatory settings becomes more sophisticated so the possibility that precise measurement of the cough frequency, intensity and acoustic characteristics may offer diagnostically valuable information in individual patients becomes a reality. In this article the current knowledge of the clinical patterns of cough is discussed and the potential for new technology to record cough patterns in a meaningful way is considered.

The management of cough:a clinical year in review

As the number of published articles in the field of cough increases year on year, it is sometimes helpful to pause and review what might have passed us by. This "Clinical Year in Review" provides an opportunity to reflect on a number of important studies reported in the area of both adult and pediatric cough. It would be impossible to cover all the important published literature; therefore, this effort has been confined to selected topics published in the last 12 months with direct relevance to the clinical management, measurement, and treatment of cough. While this article reflects a personal commentary of the literature, it is hoped that it will contribute to improving "evidence-based" care for the many individuals burdened with a troublesome cough.

Clinical cough II:therapeutic treatments and management of chronic cough

Chronic cough is a common and frequently disruptive symptom which can be difficult to treat with currently available medicines. Asthma/eosinophilic airway disease and gastro-oesophageal reflux disease are most commonly associated with chronic cough but it may also trouble patients with chronic obstructive pulmonary disease, pulmonary fibrosis and lung cancer. Over the last three decades there have been a number of key advances in the clinical approach to cough and a number of international guidelines on the management of cough have been developed. Despite the undoubted benefit of such initiatives, more effective treatments for cough are urgently needed. The precise pathophysiological mechanisms of chronic cough are unknown but central to the process is sensitization (upregulation) of the cough reflex. One well-recognized clinical consequence of this hypersensitive state is bouts of coughing triggered by apparently trivial provocation such as scents and odours and changes in air temperature. The main objective of new treatments for cough would be to identify ways to downregulate this heightened cough reflex but yet preserve its crucial role in protecting the airway. The combined efforts of clinicians, scientists and the pharmaceutical industry offer most hope for such a treatment breakthrough. The aim of this chapter is to provide some rationale for the current treatment recommendations and to offer some reflections on the management of patients with chronic cough.

Does idiopathic cough exist?

Despite a meticulous protocol involving diagnostic testing and trials of empirical therapy, there may be no obvious cause for a chronic cough in up to 42% of cases referred for specialist evaluation. In some cases, failure to consider causes that include the asthma/eosinophilic airway syndromes such as eosinophilic bronchitis and atopic cough, or nonacid gastroesophageal reflux disease may explain diagnostic failure. However, a distinct group of patients may be considered to have true idiopathic cough. Current published evidence suggests a certain patient phenotype, namely, middle-aged females with prolonged nonproductive cough and cough reflex hypersensitivity. Almost nothing else is known about this clinical entity and currently no specific therapy exists.

Persistent income poverty and deprivation in the European Union: An analysis of the first three waves of the European Community Household Panel

Poverty research has increasingly focused on persistent income poverty, both as a crucial social indicator and as a target for policy intervention. Such an approach can lead to an identification of a sub-set of poor individuals facing particularly adverse circumstances and/or distinctive problems in escaping from poverty. Here we seek to establish whether, in comparison with cross-sectional measures, persistent poverty measures also provide a better measure of exclusion from a minimally acceptable way of life and relate with other important variables in a logical fashion. Our analysis draws upon the first three waves of the ECHP and shows that a persistent poverty measure does constitute a significant improvement over its cross-sectional counterpart in the explanation of levels of deprivation. Persistent poverty is related to life-style deprivation in a manner that comes close to being uniform across countries. The measure of persistence also conforms to our expectations of how a poverty measure should behave in that, unlike relative income poverty lines, defining the threshold level more stringently enables us to identify progressively groups of increasingly deprived respondents. Overall the persistent poverty measure constitutes a significant advance on cross-sectional income measures. However, there is clearly a great deal relating to the process of accumulation and of erosion of resources, which is not fully captured in the persistent poverty measure. In the absence of such information, there is a great deal to be said for making use of both types of indictors in formulating and evaluating policies while we continue to improve our understanding of longer-term processes.

Multiple deprivation and persistent poverty in the European Union

The literature on Social exclusion has focused attention on the processes leading to exposure to multiple disadvantage. Despite the influence this perspective has had on both academic and policy discussions, conceptual analysis has remained imprecise and empirical evidence modest. We have made use of the European Community Household Panel (ECHP) in order to examine the extent to which persistent income poverty results in multiple deprivation. Our analysis shows that only a modest proportion of the persistently poor can he characterized as being exposed to such deprivation. While persistent poverty and multiple deprivation combine to produce extremely high levels of economic strain, there is no evidence that they interact in a significant fashion. We argue that understanding deprivation is not facilitated by focusing on a cleavage between a multiply deprived minority and a comfortable majority, and we consider the policy implications of this argument.

Persistent and consistent poverty in the 1994 and 1995 waves of the European Community Household Panel Survey

This paper focuses on the mismatch between income and deprivation measures of poverty. Using the first two waves of the European Community Household Panel Survey, a measure of relative deprivation is constructed and the overlap between the relative income poor and relatively deprived is examined, There is very limited overlap with the lowest relative income threshold. The overlap increases as the income threshold is raised, but it remains true that less than half those below the 60 percent relative income line are among the most deprived. Relative deprivation is shown to be related to the persistence of income poverty, but also to a range of other resource and need factors. Income and deprivation measures each contain information that can profitably be employed to enhance our understanding of poverty and a range of other social phenomena. This is illustrated by the manner in which both income poverty and relative deprivation are associated with self-reported difficulty making ends meet.

Demarcation laser therapy in the management of macular-sparing persistent subretinal fluid after scleral buckling procedures

Background: Persistent or recurrent macular-sparing subretinal fluid (SRF) can sometimes occur following scleral buckling procedures. Observation and reoperation have been used in the management of such cases. Demarcation laser therapy (DLT) has been used to treat macular-sparing retinal detachments in the context of cytomegalovirus retinitis and as primary treatment for selected rhegmatogenous retinal detachments. There are, however, scarce data in the literature regarding its use following primary scleral buckling procedures. The current study explores the use of DLT under the latter circumstances. Methods: The medical records of all consecutive patients with persistent SRF sparing the macula following primary rhegmatogenous retinal detachment repair using a scleral buckling procedure were retrospectively reviewed. Only those patients in whom the breaks were localised to the area of indentation and, thus, seemed to be well supported by the buckle were included. Demographics, clinical characteristics of the retinal detachment prior to scleral buckling, extension of the residual SRF observed postoperatively, details of the laser procedure, anatomical and functional outcomes and complications were evaluated. Results: Seven patients, all females, with a mean age of 47.9 years (range: 20-81) were included in the study. The retinal detachments were superior (n=3), inferior (n=3) and subtotal, affecting both superior and inferior retina (n=1). Scleral buckling procedures were used to treat the retinal detachments in all cases. Following demarcation laser therapy, the area of SRF remained stable in two patients, and flattened in four. In one patient, extension of SRF occurred requiring further surgery. Conclusions: Demarcation laser therapy appears to be a reasonable option in the management of patients with persistent or recurrent SRF sparing the macula following scleral buckling surgery. © Springer-Verlag 2006.

Rhinovirus upregulates transient receptor potential channels in a human neuronal cell line: Implications for respiratory virus-induced cough reflex sensitivity

ABSTRACT (250 words)
BACKGROUND: The mechanism underlying respiratory virus-induced cough hypersensitivity is unknown. Up-regulation of airway neuronal receptors responsible for sensing physical and chemical stimuli is one possibility and the transient receptor potential (TRP) channel family are potential candidates. We have used an in vitro model of sensory neurones and human rhinovirus (HRV-16) to study the effect of virus infection on TRP expression.
METHODS: IMR32 neuroblastoma cells were differentiated in culture to express three TRP channels, TRPV1, TRPA1 and TRPM8. Flow cytometry and qRT-PCR were used to measure TRP channel protein and mRNA levels following inoculation with live virus, inactivated virus, virus- induced soluble factors or pelleted virus particles. Multiplex bioassay was used to determine nerve growth factor (NGF), interleukin (IL)-1ß, IL-6 and IL-8 levels in response to infection.
RESULTS: Early up-regulation of TRPA1 and TRPV1 expression occurred 2 to4 hours post infection. This was independent of replicating virus as virus induced soluble factors alone were sufficient to increase channel expression 50 and 15 fold, respectively. NGF, IL-6 and IL-8 levels, increased in infected cell supernatants, represent possible candidates. In contrast, TRPM8 expression was maximal at 48 hours (9.6 fold) and required virus replication rather than soluble factors
CONCLUSIONS We show for the first time that rhinovirus can infect neuronal cells. Furthermore, infection causes up-regulation of TRP channels by channel specific mechanisms. Increase in TRPA1 and TRPV1 levels can be mediated by soluble factors induced by infection whereas TRPM8 requires replicating virus. TRP channels may be novel therapeutic targets for controlling virus-induced cough.

The effects of global climate change on the cycling and processes of persistent organic pollutants (POPs) in the North Sea

The fate and cycling of two selected legacy persistent organic pollutants (POPs), PCB 153 and gamma-HCH, in the North Sea in the 21st century have been modelled with combined hydrodynamic and fate and transport ocean models
(HAMSOM and FANTOM, respectively). To investigate the impact of climate variability on POPs in the North Sea in the 21st century, future scenario model runs for three 10-year periods to the year 2100 using plausible levels of both in
situ concentrations and atmospheric, river and open boundary inputs are performed. This slice mode under a moderate scenario (A1B) is sufficient to provide a basis for further analysis. For the HAMSOM and atmospheric forcing, results of the IPCC A1B (SRES) 21st century scenario are utilized, where surface forcing is provided by the REMO downscaling of the ECHAM5 global atmospheric model, and open boundary conditions are provided by the MPIOM global ocean model.
Dry gas deposition and volatilization of gamma-HCH increase in the future relative to the present by up to 20% (in the spring and summer months for deposition and in summer for volatilization). In the water column, total mass of
gamma-HCH and PCB 153 remain fairly steady in all three runs. In sediment,
gamma-HCH increases in the future runs, relative to the present, while PCB 153 in sediment decreases exponentially in all three runs, but even faster in the future, due to the increased number of storms, increased duration of gale wind conditions and increased water and air temperatures, all of which are the result of climate change. Annual net sinks exceed sources at the ends of all periods.
Overall, the model results indicate that the climate change scenarios considered here generally have a negligible influence on the simulated fate and transport of the two POPs in the North Sea, although the increased number and magnitude of storms in the 21st century will result in POP resuspension and ensuing revolatilization events. Trends in emissions from primary and secondary sources will remain the key driver of levels of these contaminants over time.

Modelling the fate of persistent organic pollutants (POPs) in the North Sea system

The environmental fate of selected persistent organic pollutants (POPs) in the North Sea system is modelled with a high resolution Fate and Transport Ocean Model (FANTOM) that uses hydrodynamic model output from the Hamburg Shelf Ocean Model (HAMSOM). Large amounts of POPs enter the North Sea from the surrounding highly populated, industrialised and agricultural countries. Major pathways to the North Sea are atmospheric deposition and river inputs, with additional contributions coming from bottom sediments and adjacent seas. The model domain covers the entire North Sea region, extending northward as far as the Shetland Islands, and includes adjacent basins such as the Skagerrak, Kattegat, and the westernmost part of the Baltic Sea. Model resolution (for both models) is 1.5’ latitude x 2.5’ longitude (approximately 3 km horizontal resolution) with 30 vertical levels. The POP model also has 20 sediment layers. Important model processes controlling the fate of POPs in the North Sea system are discussed. Results focus on Lindane gamma- HCH or gamma-hexachlorocyclohexane) and PCB 153.

The persistent activity of Jupiter-family comets at 3-7 AU

We present an analysis of comet activity based on the Spitzer Space Telescope component of the Survey of the Ensemble Physical Properties of Cometary Nuclei. We show that the survey is well suited to measuring the activity of Jupiter-family comets at 3-7 AU from the Sun. Dust was detected in 33 of 89 targets (37 ± 6%), and we conclude that 21 comets (24 ± 5%) have morphologies that suggest ongoing or recent cometary activity. Our dust detections are sensitivity limited, therefore our measured activity rate is necessarily a lower limit. All comets with small perihelion distances (q <1.8 AU) are inactive in our survey, and the active comets in our sample are strongly biased to post-perihelion epochs. We introduce the quantity ɛfρ, intended to be a thermal emission counterpart to the often reported Afρ, and find that the comets with large perihelion distances likely have greater dust production rates than other comets in our survey at 3-7 AU from the Sun, indicating a bias in the discovered Jupiter-family comet population. By examining the orbital history of our survey sample, we suggest that comets perturbed to smaller perihelion distances in the past 150 yr are more likely to be active, but more study on this effect is needed.

A worldwide survey of chronic cough: A manifestation of enhanced somatosensory response:A manifestation of enhanced somatosensory response

Reports from individual centres suggest a preponderance of females with chronic cough. Females also have heightened cough reflex sensitivity. Here we have reviewed the age and sex of unselected referrals to 11 cough clinics. To investigate the cause of any observed sex dimorphism, functional magnetic resonance imaging of putative cough centres was analysed in normal volunteers. The demographic profile of consecutive patients presenting with chronic cough was evaluated. Cough challenge with capsaicin was undertaken in normal volunteers to construct a concentration-response curve. Subsequent functional magnetic resonance imaging during repeated inhalation of sub-tussive concentrations of capsaicin observed areas of activation within the brain and differences in the sexes identified. Of the 10 032 patients presenting with chronic cough, two-thirds (6591) were female (mean age 55 years). The patient profile was largely uniform across centres. The most common age for presentation was 60-69 years. The maximum tolerable dose of inhaled capsaicin was lower in females; however, a significantly greater activation of the somatosensory cortex was observed. Patients presenting with chronic cough from diverse racial and geographic backgrounds have a strikingly homogeneous demographic profile, suggesting a distinct clinical entity. The preponderance of females may be explained by sex-related differences in the central processing of cough sensation.