The Utility of Fractional Exhaled Nitric Oxide Suppression in the Identification of Nonadherence in Difficult Asthma

Rationale: Nonadherence to inhaled corticosteroid therapy (ICS) is a major contributor to poor control in difficult asthma, yet it is challenging to ascertain. Objectives: Identify a test for nonadherence using fractional exhaled nitric oxide (FENO) suppression after directly observed inhaled corticosteroid (DOICS) treatment. Methods: Difficult asthma patients with an elevated FENO (>45 ppb) were recruited as adherent (ICS prescription filling >80%) or nonadherent (filling <50%). They received 7 days of DOICS (budesonide 1,600 µg) and a test for nonadherence based on changes in FENO was developed. Using this test, clinic patients were prospectively classified as adherent or nonadherent and this was then validated against prescription filling records, prednisolone assay, and concordance interview. Measurements and Main Results: After 7 days of DOICS nonadherent (n = 9) compared with adherent subjects (n = 13) had a greater reduction in FENO to 47 ± 21% versus 79 ± 26% of baseline measurement (P = 0.003), which was also evident after 5 days (P = 0.02) and a FENO test for nonadherence (area under the curve = 0.86; 95% confidence interval, 0.68-1.00) was defined. Prospective validation in 40 subjects found the test identified 13 as nonadherent; eight confirmed nonadherence during interview (three of whom had excellent prescription filling but did not take medication), five denied nonadherence, two had poor inhaler technique (unintentional nonadherence), and one also denied nonadherence to prednisolone despite nonadherent blood level. Twenty-seven participants were adherent on testing, which was confirmed in 21. Five admitted poor ICS adherence but of these, four were adherent with oral steroids and one with omalizumab. Conclusions: FENO suppression after DOICS provides an objective test to distinguish adherent from nonadherent patients with difficult asthma. Clinical trial registered with www.clinicaltrials.gov (NCT 01219036). Copyright © 2012 by the American Thoracic Society.

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.

Welcoming the World: Governing Hospitality in London's 2012 Olympic Bid

London’s successful bid for the 2012 Olympic Games presented a diverse, cosmopolitan city opening its arms and “welcoming the world.” This article explores the apparently benign gesture of hospitality contained in London’s official candidature files submitted in 2004 and asks how such a promise of inclusiveness is managed. We argue that London’s depiction of itself as hospitable to every kind of visitor relies on subtle techniques of governmentality in which the subject positions of “host” and “guest” are imagined and produced in ways that make them more governable. By this, we are not referring to acts of authority, coercion, or discipline that exclude subjects or render them docile bodies within a rigid panoptical city. Rather, we are referring to the delicate ways in which the official bid document imagines and produces the ideal subject positions of host and guest and in so doing enables, encourages, and incentivizes certain behaviors. This analysis of urban welcoming takes us beyond reductive oppositions of hospitality and hostility, inclusion and exclusion, self and other. It focuses instead on how London’s inclusive welcome produces a variety of host and guest positions (for example, the “Olympic Family,” volunteers, guest workers), segregates them within the city, and then “conducts their conduct” in the areas of planning, security, transport, accommodation, education, and training. By analyzing the techniques of governmentality at work in London’s 2004 bid document, this article foregrounds the enabling form of power driving the city’s inclusive welcome and exposes its inherent micropolitics.