The Utility of Cardiopulmonary Exercise Testing in Difficult Asthma

Background: Unexplained persistent breathlessness in patients with difficult asthma despite multiple treatments is a common clinical problem. Cardiopulmonary exercise testing (CPX) may help identify the mechanism causing these symptoms, allowing appropriate management.

Methods: This was a retrospective analysis of patients attending a specialist-provided service for difficult asthma who proceeded to CPX as part of our evaluation protocol. Patient demographics, lung function, and use of health care and rescue medication were compared with those in patients with refractory asthma. Medication use 6 months following CPX was compared with treatment during CPX.

Results: Of 302 sequential referrals, 39 patients underwent CPX. A single explanatory feature was identified in 30 patients and two features in nine patients: hyperventilation (n = 14), exercise-induced bronchoconstriction (n = 8), submaximal test (n = 8), normal test (n = 8), ventilatory limitation (n = 7), deconditioning (n = 2), cardiac ischemia (n = 1). Compared with patients with refractory asthma, patients without “pulmonary limitation” on CPX were prescribed similar doses of inhaled corticosteroid (ICS) (median, 1,300 µg [interquartile range (IQR), 800-2,000 µg] vs 1,800 µg [IQR, 1,000-2,000 µg]) and rescue oral steroid courses in the previous year (median, 5 [1-6] vs 5 [1-6]). In this group 6 months post-CPX, ICS doses were reduced (median, 1,300 µg [IQR, 800-2,000 µg] to 800 µg [IQR, 400-1,000 µg]; P < .001) and additional medication treatment was withdrawn (n = 7). Patients with pulmonary limitation had unchanged ICS doses post CPX and additional therapies were introduced.

Conclusions: In difficult asthma, CPX can confirm that persistent exertional breathlessness is due to asthma but can also identify other contributing factors. Patients with nonpulmonary limitation are prescribed inappropriately high doses of steroid therapy, and CPX can identify the primary mechanism of breathlessness, facilitating steroid reduction.

Age-related changes in energy efficiency of gait, activity, and participation in children with cerebral palsy

Aim
The aim of this study was to use a prospective longitudinal study to describe age-related trends in energy efficiency during gait, activity, and participation in ambulatory children with cerebral palsy (CP).

Method
Gross Motor Function Measure (GMFM), Paediatric Evaluation of Disability Inventory (PEDI), and Lifestyle Assessment Questionnaire-Cerebral Palsy (LAQ-CP) scores, and energy efficiency (oxygen cost) during gait were assessed in representative sample of 184 children (112 male; 72 female; mean age 10y 9mo; range 4–16y) with CP. Ninety-four children had unilateral spastic CP, 84 bilateral spastic CP, and six had other forms of CP. Fifty-seven were classified as Gross Motor Function Classification System (GMFCS) level I, 91 as level II, 22 as level III, and 14 as level IV). Assessments were carried out on two occasions (visit 1 and visit 2) separated by an interval of 2 years and 7 months. A total of 157 participants returned for reassessment.

Results
Significant improvements in mean raw scores for GMFM, PEDI, and LAQ-CP were recorded; however, mean raw oxygen cost deteriorated over time. Age-related trends revealed gait to be most inefficient at the age of 12 years, but GMFM scores continued to improve until the age of 13 years, and two PEDI subscales to age 14 years, before deteriorating (p<0.05). Baseline score was consistently the single greatest predictor of visit 2 score. Substantial agreement in GMFCS ratings over time was achieved (?lw=0.74–0.76).

Interpretation
These findings have implications in terms of optimal provision and delivery of services for young people with CP to maximize physical capabilities and maintain functional skills into adulthood.

E-Participation and E-Participants: solving the patent ‘crisis’

One of the major planks of some visions for E-Gov is that there is a willing participatory group who are more than happy to be involved in new forms of democracy and will be active and useful suppliers of input to e-consultation or e-participation processes. This group is different from that which goes online to the government site web and signs a petition asking the prime minister to resign. It is becoming clear, though, that the commitment to e-participation may well be there in theory, but difficult to access in practice. Further, the participation which is most welcome can frequently require training and expertise which is not widely available or there may be differences in opinion as to the point of participation. In this paper I will look to the attempts to encourage participation in the patent system. The UK is about to initiate a trial system utilising New York Law School’s Peer To Patent project, but has also attempted to involve participants in previous consultation exercises. I will use these as demonstrations of the sorts of problems which e-participation has met, and consider whether this new form of E-Gov is perhaps being oversold. The interesting question is whether participation is a growing tool which can ensure better public services from the State. My conclusion is that consultation and participatory projects can demonstrate involvement and are certainly educative but e-participatory projects are most likely incapable of achieving the goals set by their more optimistic advocates. The paper emphasises the patents field, but the lessons from it can – I suggest – be viewed as indicators having wider governance relevance. The primary point being made is that the technocratic view is always over-optimistic.

Exercise and Auricular Acupuncture for Chronic Low Back Pain: A Feasibility Randomised Controlled Trial

Objectives: To evaluate the feasibility of a randomized-controlled trial (RCT) investigating the effects of adding auricular acupuncture (AA) to exercise for participants with chronic low-back pain (CLBP). Methods: Participants with CLBP were recruited from primary care and a university population and were randomly allocated (n=51) to 1 of 2 groups: (1) "Exercise Alone (E)"-12-week program consisting of 6 weeks of supervised exercise followed by 6 weeks unsupervised exercise (n=27); or (2) "Exercise and AA (EAA)"-12-week exercise program and AA (n=24). Outcome measures were recorded at baseline, week 8, week 13, and 6 months. The primary outcome measure was the Oswestry Disability Questionnaire. Results: Participants in the EAA group demonstrated a greater mean improvement of 10.7% points (95% confidence interval, -15.3,-5.7) (effect size=1.20) in the Oswestry Disability Questionnaire at 6 months compared with 6.7% points (95% confidence interval, -11.4,-1.9) in the E group (effect size=0.58). There was also a trend towards a greater mean improvement in quality of life, LBP intensity and bothersomeness, and fear-avoidance beliefs in the EAA group. The dropout rate for this trial was lower than anticipated (15% at 6 mo), adherence with exercise was similar (72% E; 65% EAA). Adverse effects for AA ranged from 1% to 14% of participants. Discussion: Findings of this study showed that a main RCT is feasible and that 56 participants per group would need to be recruited, using multiple recruitment approaches. AA was safe and demonstrated additional benefits when combined with exercise for people with CLBP, which requires confirmation in a fully powered RCT.

UNISTEP (University Students Exercise and Physical Activity) Study: A Pilot Study of the Effects of Accumulating 10,000 Steps on Health and Fitness Among University Students.

BACKGROUND: Recent public health initiatives have promoted accumulating 10,000 steps per day. Little previous research has evaluated its effects in young adults. The aim of this study was to determine the effects of taking 10,000 steps per day on fitness and cardiovascular risk factors in sedentary university students. METHODS: Healthy, sedentary students (mean age 21.16 ± SD 6.17) were randomly allocated to take 10,000 steps per day or to a control group who maintained their habitual activity. Members of the 10,000 step group wore a pedometer and reported daily step count in a diary. Outcome measurements (20-meter multistage shuttle run, BMI, and blood pressure) were measured before and after 6 weeks. RESULTS: There were no significant differences between the groups at baseline. After 6 weeks, the 10,000 steps group were taking significantly more steps (8824.1 ± SD 5379.3 vs. 12635.9 ± SD 6851.3; P = .03).No changes were observed in fitness, or BMI (P > .05). Significant reductions in blood pressure (P = .04) in the 10,000 step group. CONCLUSIONS: A daily target of 10,000 steps may be an appropriate intervention in sedentary university students to increase their physical activity levels. The positive health benefits of simple everyday physical activity should be promoted among health professionals.

Democratic Participation, Engagement, and Freedom

It is commonly supposed that democracies should encourage greater political participation and civic engagement. This article identifies two distinct perspectives on political participation and civic engagement: a ‘freedom-centred’ model and an ‘ethical’ model. The ‘freedom-centred’ model defended here draws on the republican concept of freedom as non-domination, together with the political liberal notion of fair deliberative proceduralism, while the ethical model draws on Aristotelian, perfectionist, sources. It is argued that the ‘ethical’ model is overly concerned with the ‘moral renewal’ of modern social life, and is insensitive to problems of domination posed by its account of civic reciprocity and trust. By contrast, the ‘freedom-centred’ model developed offers a systematic account of personal and political freedom, which provides qualified support for deliberative modes of participation and engagement.