Recurso contra o poder conclusivo das comissões : uma análise

Estudo dos recursos ao poder conclusivo das comissões da Câmara dos Deputados, analisando dados do seu cabimento, de suas razões, sua ocorrência e a influência do Executivo. Para tanto, sistematiza as informações através da identificação e estudo dos dados que abrangem a 52ª Legislatura. Aborda os mecanismos regimentais pertinentes, além dos outros fatores intervenientes.

The Influence of the Val158Met Catechol-O-Methyltransferase Polymorphism on the Personality Traits of Bipolar Patients

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A balloon measurement of the isotopic composition of galactic cosmic ray boron, carbon, and nitrogen

The isotopic compositions of galactic cosmic ray boron, carbon, and nitrogen have been measured at energies near 300 MeV amu^-1, using a balloon-borne instrument at an atmospheric depth of ~5 g cm^-2. The calibrations of the detectors comprising the instrument are described. The saturation properties of the cesium iodide scintilla tors used for measurement of particle energy are studied in the context of analyzing the data for mass. The achieved rms mass resolution varies from ~ 0.3 amu at boron to ~ 0.5 amu at nitrogen, consistent with a theoretical analysis of the contributing factors. Corrected for detector interactions and the effects of the residual atmosphere, the results are ^(10)B/B = 0.33^(+0.17)_(-0.11), ^(13)C/C = 0.06^(+0.13)_(-0.01), and ^(15)N/N = 0.42 (+0.19)_(-0.17). A model of galactic propagation and solar modulation is described. Assuming a cosmic ray source composition of solar-like isotopic abundances, the model predicts abundances near earth consistent with the measurements.

Erro de medicação: a visão do enfermeiro neonatologista

O manejo da terapia medicamentosa em unidade de terapia intensiva neonatal é complexo e agrega inúmeras drogas. Nesse sentido, manter a atenção ao preparar e administrar corretamente os medicamentos é fundamental em todo o período de assistência ao recém-nascido. Portanto, faz-se necessário que os enfermeiros tenham o entendimento acerca do conceito do erro com medicação, para que possa identificá-lo, bem como os fatores contribuintes para sua ocorrência. Diante do exposto, esta pesquisa teve como objetivos: analisar o entendimento dos enfermeiros neonatologistas sobre o conceito do erro de medicação em uma unidade de terapia intensiva neonatal; conhecer na visão destes enfermeiros quais os fatores contribuintes para a ocorrência desse erro e discutir a partir desta visão como estes fatores podem afetar a segurança do neonato. Metodologia: trata-se de uma pesquisa qualitativa, do tipo descritiva. O cenário do estudo foi uma unidade de terapia intensiva neonatal de um hospital universitário, situado no município do Rio de Janeiro. Os sujeitos foram 14 enfermeiros entre plantonistas e residentes que atuavam no manejo da terapia medicamentosa. Para a coleta dos dados utilizou-se a entrevista semiestruturada, que foram analisadas através da análise de conteúdo de Bardin, emergindo 04 categorias: Diversos conceitos sobre erros de medicação; Fatores humanos contribuintes ao erro de medicação; Fatores ambientais contribuintes ao erro de medicação e Conhecendo como os fatores contribuintes ao erro podem afetar a segurança do paciente. Para as enfermeiras o erro de medicação significa errar um dos cinco certos na administração de medicamentos (paciente, dose, via, horário e medicamento certo), e este pode acontecer em alguma parte do sistema de medicação. Neste sentido, elas entendem que uma pessoa não pode ser considerada a única responsável pela ocorrência de um erro medicamentoso. Quanto aos fatores contribuintes ao erro de medicação elencaram aqueles relacionados à prescrição medicamentosa (letra ilegível, prescrição da dose e via incorretas), ao próprio profissional de enfermagem (como sobrecarga de trabalho, número reduzido de profissionais e os múltiplos vínculos empregatícios) e ao ambiente de trabalho (ambiente inadequado e estressante; conversas paralelas com os colegas e os ruídos no setor). Na visão das enfermeiras, os fatores contribuintes ao erro podem afetar a segurança do recém-nascido, levando às situações de danos a sua saúde, podendo trazer consequências clínicas e risco de óbito. O estudo aponta a necessidade de se buscar sistemas de medicação mais confiáveis e seguros. Neste sentido, é imprescindível desenvolver e implementar programas de educação centrados nos princípios gerais da segurança do paciente. Além disso, é de suma importância que as políticas públicas de saúde, direcionem ações para o aprimoramento de medidas na segurança do RN, do sistema de medicação e da cultura de segurança.

The Threatened Status of Steller Sea Lions, Eumetopias jubatus, under the Endangered Species Act: Effects on Alaska Groundfish Fisheries Management

In April 1990, the Steller sea lion, Eumetopias jubatus, was listed as threatened under the U.S. Endangered Species Act by emergency action. Competitive interactions with the billion-dollar Alaska commercial groundfish fisheries have been suggested as one of the possible contributing factors to the Steller sea lion population decline. Since the listing, fisheries managers have attempted to address the potential impacts of the groundfish fisheries on Steller sea lion recovery. In this paper, we review pertinent Federal legislation, biological information on the Steller sea lion decline, changes in the Alaska trawl fishery for walleye pollock, Theragra chalcogramma, since the late 1970's, andpossible interactions between fisheries and sea lions. Using three cases, we illustrate how the listing of Steller sea lions has affected Alaska groundfish fisheries through: I) actions taken at the time of listing designed to limit the potential for directhuman-related sea lion mortality, 2) actions addressing spatial and temporal separation of fisheries from sea lions, and 3) introduction of risk-adverse stock assessment methodologies and Steller sea lion conservation considerations directly in the annual quota-setting process. This discussion shows some of the ways that North Pacific groundfish resource managers have begun to explicitly consider the conservation ofmarine mammal and other nontarget species.

Genetic improvement of freshwater prawn, Macrobrachium rosenbergii (de Man) in India. Phase two: annual report for period January to December 2012

Macrobrachiurn rosenbergii is one of the widely cultured freshwater prawn species globally. India was the third largest producer of this species in 2007 and its aquaculture production rose to 43,000 metric tons (t) in 2005 froin less than 500 t in 1995. However, since then production has been declining and in 2008-09 it was 12,856 t, a reduction of more than 70% compared to 2005. There are several contributing factors to this decline, such as slow growth rate, poor survival, disease outbreaks, increase in cost of production, and availability of low risk alternative fish species. However, there is a consensus that poor seed quality leading to unsatisfactory growth and survival rates in ponds is one of the major reasons. Hence, the development of a systematic selective breeding program aimed at improving growth rate and ensuring high survival rate of this species was deemed a high priority. The Central Institute of Freshwater Aquaculture (CIFA), Bhubaneswar, India in collaboration with the WorldFish Center, Malaysia initiated a selective breeding program for this species in 2007.

An uncommon period of cold and change of lapse rate in the Rocky Mountains of Colorado and Wyoming

EXTRACT (SEE PDF FOR FULL ABSTRACT): Temperature and lapse rate show extreme departures from mean values for May 1981 through October 1986 at the high-elevation station D1 on Niwot Ridge in the Front Range, Colorado. If the D1 record is accurate, this period may present an opportunity to identify factors that influence temperature at high elevations, but not necessarily at low elevations. This paper focuses on four questions: (1) Is the D1 temperature record accurate? (2) What is the geographical extent of this anomalous cold period? (3) Are there any identifiable contributing factors or physical events relating to this period? (4) Is there evidence of a similar anomalous period in the past?

中国卧龙自然保护区不同海拔川滇高山栎(Quercus aquifolioides)群体的遗传变异

海拔梯度造成的环境异质性，如崎岖的地形、复杂的植被结构以及花期延迟等可能会极大地影响到物种的形态和遗传变异格局。理解物种形态和遗传变异的海拔格局对于物种多样性的管理和保护是非常重要的。尽管植物群体遗传学是一个飞速发展的研究领域，然而与海拔相关的形态变异、遗传变异及群体间遗传差异的研究却很少。到目前为止，还不清楚遗传变异与海拔之间是否必然的相关性。 川滇高山栎是一种重要的生态和经济型树种，广泛分布于中国西南的四川、西藏、贵州和云南省的高海拔地区，在保持水土、调节气候方面起着十分重要的作用。尽管主要受阳光限制而仅分布于阳坡，但其海拔梯度范围较大，表明川滇高山栎对不同的环境具有很强的适应性。本文通过叶型及生理响应、微卫星分子标记和扩增性片段长度多态性方法，试图探索川滇高山栎叶沿海拔梯度的形态和生理响应及其沿海拔梯度的遗传变异格局，为川滇高山栎的保护和利用提供进一步的遗传学理论依据和技术指导。 对叶形、含氮量及碳同位素的试验结果表明，平均比叶面积、气孔密度、气孔长度和气孔指数等气孔参数随海拔的升高呈非线性变化。在海拔大于2800 m时，川滇高山栎的比叶面积、气孔长度和气孔指数都随海拔升高而降低，但是在海拔小于2800 m时，这些指标都随海拔的升高而增大。相对而言，单位叶面积的含氮量和碳同位素则表现出相反的变化模式。另外，比叶面积是决定碳同位素沿海拔梯度变化的最重要参数。本研究结果表明，海拔2800 m附近是川滇高山栎生长和发育的最适地带，在这里生长的植物叶片厚度更薄、气孔更大、叶碳同位素值更小。 利用六对微卫星引物对五个不同海拔川滇高山栎群体遗传多样性进行研究，结果表明，群体内表现出较高的遗传多样性，平均每位点等位基因数11.33个，平均期望杂合度达0.820。群体间差异较小，分化仅为6.6％。聚类分析也并没有显示出明显的海拔格局。然而低频率等位基因却与海拔呈显著性正相关(R2=0.97, P < 0.01)，表明在高海拔处，川滇高山栎以更多的稀有基因来适应恶劣的环境条件。本试验结果表明由海拔梯度形成的选择性压力对川滇高山栎群体的遗传变异影响并不明显。 为了进一步探讨川滇高山栎群体遗传变异与海拔之间的相互关系，我们还对其进行了扩增性片段长度多态性分析。结果表明：(1)随海拔的升高(从群体WL2到群体WL5)，群体内遗传变异降低，而群体间遗传差异增加；(2)低海拔群体WL1表现出最低的遗传变异性(HE = 0.181)，同时与其余四个群体间呈现出最大的遗传差异性(平均FST = 0.0596)；(3)在除去低海拔群体WL1后，Mantel检测表明群体间遗传距离与海拔距离之间表现出正相关性。另外，研究结果还表明，遗传变异受生境条件(过度的湿热环境)及人为干扰(火烧、砍伐和放牧)的影响，这一点至少在低海拔群体WL1上发生了作用。 通过叶形态、生理及DNA分子水平的研究，结果表明叶形态特征和碳同位素与海拔紧密相关，与海拔之间呈非线性变化，海拔2,800 m附近是川滇高山栎生长和发育的最适地带。海拔梯度在一定程度上会影响到川滇高山栎群体的遗传变异结构，但在这样一个狭窄的地理分布区域里，这种影响并不足以导致群体间较大的遗传分化。同时生境条件及人为干扰也是影响遗传变异的限制性因子，不容忽视。 Altitudinal gradients impose heterogeneous environmental conditions, such as rugged topography, a complex pattern of vegetation and flowering delay, and they likely furthermore markedly affect the morphological and genetic variation pattern of a species. Understanding altitudinal pattern of morphological and genetic variation at a species is important for the management and conservation of species diversity. Although plant population genetics is a fast growing field of research, there are only few recent investigations, which analyzed the genetic differentiation and changes of intra-population variation along altitudinal gradients. At present, it is still unclear whether there are some common patterns of morphological and genetic variation with altitude. Quercus aquifolioides Rehder & E.H. Wilson, which is an important ecological and economical endemic woody plant species, is widely distributed in the Yunnan and Sichuan provinces, Southwest China. Its large range of habitat across different altitudes implies strong adaptation to different environments, although it is mainly restricted to sunny, south facing slopes. It plays a very important role in preventing soil erosion, soil water loss and regulating climate, as well as in retaining ecological stability. In this paper, we tried to understand the altitudinal pattern of morphological and genetic variation along altitudinal gradients through the experiments of leaf morphological and physiological responses, microsatellite analysis and AFLP markers. In leaf morphological and physiological responses experiment, we measured leaf morphology, nitrogen content and carbon isotope composition (as an indicator of water use efficiency) of Q. aquifolioides along an altitudinal gradient. We found that these leaf morphological and physiological responses to altitudinal gradients were non-linear with increasing altitude. Specific leaf area, stomatal length and index increased with increasing altitude below 2,800 m, but decreased with increasing altitude above 2,800 m. In contrast, leaf nitrogen content per unit area and carbon isotope composition showed opposite change patterns. Specific leaf area seemed to be the most important parameter that determined the carbon isotope composition along the altitudinal gradient. Our results suggest that near 2,800 m in altitude could be the optimum zone for growth and development of Q. aquifolioides, and highlight the importance of the influence of altitude in research on plant physiological ecology. Genetic variation and differentiation were investigated among five natural populations of Q. aquifolioides occurring along an altitudinal gradient that varied from 2,000 to 3,600 m above sea level in the Wolong Natural Reserve of China, by analyzing variation at six microsatellite loci. The results showed that the populations were characterized by relatively high intra-population variation with the average number of alleles equaling 11.33 per locus and the average expected heterozygosity (HE) being 0.779. The amount of genetic variation varied only little among populations, which suggests that the influence of altitude factors on microsatellite variation is limited. However, there is a significantly positive correlation between altitude and the number of low-frequency alleles (R2=0.97, P < 0.01), which indicates that Q. aquifolioides from high altitudes has more unique variation, possibly enabling adaptation to severe conditions. F statistics showed the presence of a slight deficiency of heterozygosity (FIS=0.136) and a low level of differentiation among populations (FST=0.066). The result of the cluster analysis demonstrates that the grouping of populations does not correspond to the altitude of the populations. Based on the available data, it is likely that the selective forces related to altitude are not strong enough to significantly differentiate the populations of Q. aquifolioides in terms of microsatellite variation. To further elucidate genetic variation pattern of Q. aquifolioides populations under sub-alpine environments, genetic variation and differentiation were investigated along altitudinal gradients using AFLP markers. The altitudinal populations with an average altitude interval of 400 m, i.e. WL1, WL2, WL3, WL4 and WL5, correspond to the altitudes 2,000, 2,400, 2,800, 3,200 and 3,600 m, respectively. Our results were as follows: (i) decreasing genetic variation (ranging from 0.253 to 0.210) and increasing genetic differentiation with altitude were obtained from the WL2 to the WL5 population; (ii) the WL1 population showed the lowest genetic variation (HE = 0.181) and the highest genetic differentiation (average FST = 0.0596) with the other four populations; (iii) the positive correlation was obtained using Mantel tests between genetic and altitude distances except for the WL1 population. Our results suggest that altitudinal gradients may have influenced the genetic variation pattern of Q. aquifolioides populations to some extent. In addition, habitat environments (unfavorable wet and hot conditions) and human disturbances (burning, grazing and felling) were possible influencing factors, especially to the low-altitude WL1 population. The present study shows that there were close correlations between morphological features and carbon isotope composition in our data. This indicates that a coordinated plant response modified these parameters simultaneously across different altitudes. Around 2,800 m altitude there seems to be an optimum zone for growth and development of Q. aquifolioides, as indicated by thinner leaves, larger stomata and more negative d13C values. All available evidence indicates altitudinal gradients may have influenced the genetic variation pattern of Q. aquifolioides to some extent. Decreasing genetic variation and increasing genetic differentiation with altitude was obtained except for the WL1 population. And the environment of habitats and human disturbances were also contributing factors, which impact genetic variation pattern, especially to the low-altitude WL1 population.

职业倦怠与自我和谐、人际信任的关系研究：中学校长与一般教师的对比

Job Burnout has been a focus of the Occupational Stress Research. As a typical,helping occupation, teacher has attracted widely attention and researches in the areas of pedagogy and psychology. The special subgroup of teacher, headmasters who are the elites of the Basic Education, is ignored. The research about principals’ Job Burnout is nearly blank after analyzing related documents and information. With the development of the society, people pay more and more attention to the education and put more demands on the headmasters, especially middle-school principals. They are required not only to be good educators, who are equipped with all the inner qualities as a teacher, but also good managers. So the main purpose of this research was to compare the principal group with ordinary teacher group, and reveal underling factors, such as background variables and psychological protection variables. A representative sample of Wenzhou middle school principals sized 192 and a sample of middle school teacher sized 302 were sampled from various schools. The educational version of burnout inventory, self consistency scale, and interpersonal trust scale were administrated to the two samples, together with some demographic variables of interest. The applicability and equivalence of the three instruments used in this study were checked. Based on well-established reliability and cross-sample congruence of measures, the difference between principals and teachers was test. Then the contributing factors were analysis gradually. The five background variables were examined one by one in the two samples separately. A multiple covariance analysis was conducted to test whether there remained any difference between these two samples on the variables of interest. Regression analysis was used to further control the effect of self harmony and interpersonal trust to test the difference between two samples. Mediating analysis was conducted to build the relationship among the three constructs. The main results of the research were stated as following: 1. The internal consistency coefficients of all the scales were good, and no difference exited between the two groups. The measurement equivalence of three instruments was established well. The measures could be applied to and comparing the two samples. 2. The self-harmony, and interpersonal trust of principals were better than the ordinary middle-school teachers. Job Burnout of principals was significant lower than teachers. 3. Demographic variables like the gender, age groups, income levels, disricts, and the type of school, were important influencing factors. The difference patterns of the variables on these five variables in two samples had similarity and distinction. 4. After controlling the background variables, there remained significant difference between principals and teachers on the variables of interest. 5. Job Burnout negatively correlated with self-harmony and interpersonal trust. That is to say，the lower the degree of self-harmony and interpersonal are, the serious of the Job Burnout is, The correlation between the self-harmony and the interpersonal trust was positive. 6. After statistically controlling the background variables and psychological variables, there still exited significant difference between two groups of this study. Also, self harmony and interpersonal trust were significant protection predictors to different aspect of job burnout. 7. Mediating analysis was conducted to the residual score of the three constructs after controlling the five variables and group membership. Self harmony partially mediated the relationship between interpersonal trust and job burnout. That is, interpersonal trust had indirect effect to burnout mediated by self harmony, also had direct effect to burnout.

A multi-technology approach to identifying the reasons for lateral drift in professional and recreational darts

This work performs an extensive charterisation of precision targeted throwing in professional and recreational darts. The goal is to identify the contributing factors for lateral drift or throwing inaccuracy in the horizontal plane. A multitechnology approach is adopted whereby a custom built body area network of wireless inertial measurement devices monitor tilt, force and timing, an optical 3D motion capture system provides a complete kinematic model of the subject, electromyography sensors monitor muscle activation patterns and a force plate and pressure mat capture tactile pressure and force measurements. The study introduces the concept of constant throwing rhythm and highlights how landing errors in the horizontal plane can be attributable to a number of variations in arm force and speed, centre of gravity and the movements of some of the bodies non throw related extremities.

The impact of first pregnancy and delivery on pelvic floor dysfunction

Background: The first childbirth has the greatest impact on a woman’s pelvic floor when major changes occur. The aim of this study was to comprehensively describe pelvic floor dysfunction (PFD) in young nulliparous women, and its correlation with postnatal pathology. Methods: A prospective study was performed at Cork University Maternity Hospital, Ireland. Initially 1484 nulliparous women completed the validated Australian Pelvic Floor Questionnaire at 15 weeks’ gestation and repeatedly at one year postnatally (N=872). In the second phase, at least one year postnatally, 202 participants without subsequent pregnancies attended the clinical follow up which included: pelvic organ prolapse quantification, a 3D-Transperineal ultrasound scan and collagen level assessment. Results: A high pre-pregnancy prevalence of various types of PFD was detected, which in the majority of cases persisted postnatally and included multiple types of PFD. The first birth had a negative impact on severity of pre-pregnancy symptoms in <15% of cases. Apart from prolapse, vaginal delivery, including instrumental delivery did not increase the risk of PFD symptoms, where as Caesarean section was protective for all types of PFD. The first birth had a bigger impact on pre-existing symptoms of overactive bladder compared to stress urinary incontinence. Pelvic organ prolapse is extremely prevalent in young primiparous women, however usually it is low grade and asymptomatic. Congenital factors and high collagen type III levels play an important role in the aetiology of pelvic organs prolapse. Levator ani trauma is present in one in three women after the first pregnancy and delivery. Conclusion: The main damage to the pelvic floor most likely occurs due to an undiagnosed congenital intrinsic weakness of the pelvic floor structures. PFD is highly associated with first childbirth, however it seems that pregnancy and delivery are contributing factors only which unmask the congenital intrinsic weakness of the pelvic floor support.

Accelerating innovation in the built environment by research and education

Awareness of climate change and adaptations of building stock play a key role in the UK government’s environmental agenda. While some European countries and countries like Japan move forward by bringing their sustainability agenda to the public sector, the UK seems to be slow in embracing these ideas and long term sustainability in improved products and processes for better performance, efficiency and innovative application of renewable technology is yet to come. While funding remains a major constraint research show that a number of detrimental issues including; organisation, risk, mind sets of the stakeholders, planning constraints, reluctance to accept change and the unexploited markets are major contributing factors. Most of these barriers can be overcome with research, development and information and knowledge transfer techniques. Educating all stakeholders can act as an accelerator for innovation. This paper examines innovation in the built environment and how research and education can stimulate this process. It explores drivers and barriers for innovation and how research and education in construction, design, engineering and project management can enhance this process. It presents and discusses lessons learnt from two action research projects in relation to innovation.

Accelerating innovation in the social housing sector in UK

The UK government has been promoting innovation in the construction sector to improve the sustainability of the built environment. It has the potential and strength in developing construction research in design and engineering, but the impact of these processes seems to be slow in reaching the residential sector. While funding remains a major constraint research show that a number of detrimental issues including; organisation, risk, mind sets of the stakeholders, planning constraints,reluctance to accept change and the unexploited markets are major contributing factors. Most of these barriers can be overcome with research, development and information and knowledge transfer techniques. Educating all stakeholders can act as an accelerator for innovation. Given the large stock of existing dwellings, the situation is compounded, by issues related to climate change, to the point that this problem can no longer be ignored and requires an urgent response from all sectors involved. This paper attempts to highlight some of the key issues that are important in accelerating innovation in the housing sector. It briefly looks at the process of innovation in housing and presents lessons learnt from two research projects. The drivers and barriers and the role played by the government are examined in relation to the housing context.

An Investigation into the Link between UK Credit Union Characterisitics, Location and their Success

The unique characteristics of credit unions reduces the information asymmetry that is prevalent in credit making decisions, enabling them to provide loans where other financial institutions cannot. This makes them a potential tool in the fight against financial exclusion. Yet, the UK credit union movement is not regarded as being successful, even though there is evidence of much financial exclusion. This study is cross sectional in form, and evaluates characteristics that may contribute to the success of the UK credit union movement at national and regional level, in 2000. The findings are used to consider the impact of recent regulatory changes on the movement. The key findings are that there is a significant relationship between the success of a credit union, its size and the deprivation of the ward from which it sources its members. More specifically, larger credit unions and those located in more affluent wards, are more successful. Affiliation to the Irish League of Credit Unions and having a common bond of occupation, are also found to be contributing factors to credit union success. These results are taken as providing support for the recent changes implemented by the Financial Services Authority (FSA), which is likely to result in the emergence of larger credit unions (through mergers), run by appropriately qualified persons, serving a more mixed-income membership base. It is, however, noted that the history of the UK movement is one of missed opportunities and only time will tell whether credit unions have the wherewithal to accept current opportunities.

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.