Irish Thoracic Society Annual Scientific Meeting, 9-11 November 2017

All news reports by Paul Mulholland

Emerging trends in occupational health identified

Recent changes to the composition of paint and metal-working fluid pose a potential risk to people’s health, the Irish Thoracic Society Annual Scientific Meeting 2017, which was held in the Strand hotel, Limerick from 9-11 November, heard.

In his talk on ‘Occupational Lung Disease: A Medley’, Prof Paul Cullinan, Professor in Occupational and Environmental Respiratory Disease at Imperial College (NHLI) and Royal Brompton Hospital, London, UK, outlined the case of a woman who developed a severe rash on her face after her office was repainted.

She proved to be allergic to a preservative used in the paint and developed the allergy because the preservative is also used in many personal care products, such as deodorants.

The woman suffered the effects of ‘off-gassing’, which refers to the release of airborne particulates or chemicals – dubbed volatile organic compounds (VOCs) – from common household products.

“It is a nice example of how you can get a rash without touching anything,” Prof Cullinan told the Medical Independent (MI).

“This is a brand new problem, that has arisen because the paint manufacturers have been asked to cut the amount of solvent they use in their paints as a result of a directive from the EU. And they have developed water-based paints…. The problem is that water-based paints breed bacteria. So to stop that happening, you have to put a preservative in them. There is quite an epidemic now, of people becoming sensitised to this preservative. It is not difficult to diagnose if you know. If you have never heard of it before, and most people haven’t, then you would be flummoxed.”

According to Prof Cullinan, hypersensitivity pneumonitis (HP), an inflammation of the alveoli within the lung, as a result of metal-working fluid (a lubricant used by engineering firms in cutting metal) is another emerging issue.

“It gets aerosolised, it gets into the air when it is contaminated and people breathe it in and they get this very unpleasant and incurable condition,” Prof Cullinan said.

“Not enough doctors are aware of this at the moment. There are lots of cases that are being missed. They have moved in engineering away from oil-based fluids to water-based fluids. Very like the paint issue, water-based fluids are a breeding ground for bacteria. And it is the bacteria in the fluid that gives this nasty disease.”

During his talk, Prof Cullinan discussed how medical professionals still have difficulties in identifying whether patients have worked with asbestos.

Overall, he said occupational health has developed in recent years, despite the perception of the field being “old fashioned”.

“It is better than it was because more people are getting interested in it,” he said. “But it is still a bit of an orphan. And it still has an air of being rather old fashioned and all about diseases that disappeared years ago, which is not the case at all.”

Ultrasound useful in measuring the performance of diaphragm

Ultrasound provides a good means of evaluating diaphragm performance and can be applied in a hospital’s intensive care unit, according to a leading US respiratory physician.

Prof Dennis McCool, Memorial Hospital of Rhode Island and Alpert Medical School of Brown University, delivered a lecture at the Irish Thoracic Society Scientific Meeting 2017 on understanding of diaphragm performance.

“Diaphragm strength should be considered in the framework of diaphragm force-length, force-velocity and mechanical advantage,” Prof McCool told delegates.

He discussed a number of recent studies he was involved in that sought to assess the potential of ultrasound in evaluating diaphragm performance.

Two decades ago one of his studies demonstrated that 2-D ultra-sonography could be used to accurately and reproducibly measure diaphragm thickness in the lateral region of the zone of apposition (ZOA) of the diaphragm.

A study, published in Thorax in 2014, evaluated if ultrasound-derived measures of diaphragm thickening, rather than diaphragm motion, could be used to predict extubation success or failure. It found that ultrasound measures of diaphragm thickening in the ZOA may be useful to predict extubation success or failure during spontaneous breathing (SB) or pressure support (PS) weaning trials.

Overall, the capability of ultrasound to specifically evaluate diaphragm function provides the clinician with valuable and immediate information on a traditionally inaccessible organ system, which may be used on daily rounds, according to Prof McCool.

In his talk, he also referred to how polio epidemics prompted work from the 1950s to the 1980s, which resulted in a better understanding of respiratory mechanics.

IPF research wins Best Oral award

Dr Lucy Bergin from Trinity College Dublin won the award for Best Oral Presentation at the Irish Thoracic Annual Scientific Meeting 2017.

The title of Dr Bergin’s paper was ‘Characterisation of the effect of interleukin (IL-17A) on toll-like receptor 3 (TLR3) function in idiopathic pulmonary fibrosis (IPF): A candidate novel mechanism for action’.

Previously, her laboratory team had demonstrated that defective TLR3 function was associated with a significantly greater risk of mortality and an accelerated rate of decline in lung function in IPF patients.

They also detected increased levels of IL-17A in bronchoalveolar lavage (BAL) fluid and lung tissue from IPF patients.

IL-17A has also previously been shown to promote viral persistence in infected cells.

In the new research, it was established that IL-17A can modulate TLR3-function in IPF lung fibroblasts in order to reduce production of the anti-viral mediators, RANTES and IFN- ß.

IL-17A can also concomitantly increase TLR3-induced pro-inflammatory production from IPF lung fibroblasts.

Overall, the results of the project support a novel role for IL-17 A in promoting disease progression in IPF via its modulation of TLR3 function in IPF fibroblasts.

In addition, the study reveals IL-17A G197A as a potentially novel biomarker in IPF. 

The other award winners at the meeting included: Ms Chloe Carpenter, Beaumont Hospital, Dublin, for Best Poster Presentation; Ms Geraldine Nolan, St Vincent’s University Hospital, Dublin for Best Poster presented by a Respiratory Physiologist; and Ms Ashley Sullivan, University College Cork and Dr Padraig Hawkins, Beaumont Hospital, Dublin, who received ITS GSK British Thoracic Society Travel Bursaries.

‘Rapid diagnostics a necessity in reducing antibiotic use’

 A clinical scientist working in the Royal Victoria Hospital, Belfast, has called for urgent investment to be made in rapid diagnostics as a means to reduce unnecessary prescriptions and antibiotic use.

Dr Tanya Curran, who delivered a talk on the laboratory diagnosis of respiratory infections at the ITS Scientific Meeting 2017, said that health services have reached a “crossroads” in terms of antibiotic use.

“We are all very familiar with antibiotic stewardship and the things we do to conserve our antibiotic usage,” according to Dr Curran.

“But we don’t really think enough about rapid diagnostics. If we can tell quickly that a patient has, or more importantly sometimes doesn’t have an infection, then that’s going to influence how we prescribe. And that is what is really, really important. I think it is imperative we do something pretty quickly.”

Dr Curran referred to the 2015 UK report Rapid diagnostics: Stopping unnecessary use of antibiotics, which recommended a market-based revenue stream for developers of products that match a recognised area of need.

She said investment was required in the area, but that ultimately savings could be made by avoiding unnecessary prescriptions.

“We will have to spend more money, we will have to use more expensive diagnostic tests, because this is a money issue a lot of the time.”

In terms of laboratory diagnostic practice, Dr Curran stated that there continued to be an over-reliance on culture, and that more use needs to be made of innovations, such as molecular screening.

The clinical scientist is involved in a number of projects examining molecular screening for bacterial meningitis, bone and joint infections, and for respiratory conditions.

Point-of-care testing is also needed in order to get faster diagnostic results, according to Dr Curran.

“We need to have a test in the hospital wards that can give you a result within less than three hours,” she said. “They have to be reliable and sensitive and should and will change how we manage patients.”

Self-management plans bring benefits to asthma and COPD patients

The establishment of the joint Asthma Society of Ireland (ASI) and COPD Support Ireland Adviceline in July 2016 has led to a significant increase in the use of personalised management plans, according to new research.

The results of a HSE evaluation, examining if it was achieving proposed service objectives and patient outcomes, were presented to the 2017 Irish Thoracic Society Annual Scientific Meeting by ASI Health Promotion Officer Ms Ashling Jennings.

According to the survey conducted for the evaluation, the majority of users (79-88 per cent) agreed or strongly agreed that they were confidant in managing their condition and had an improved understanding regarding medications.

They also said they had improved knowledge about what to do in the event of an exacerbation and improved knowledge of the importance of engaging with a health professional.

The use of self-management plans increased as a result of service use; 56 per cent of users had no prior plan, but used one post-call. The use of these plans was found to maximise service effectiveness.

Other research concerning self-management plans presented at the meeting was conducted by the respiratory department in St Michael’s Hospital, Dun Laoghaire.

A total of 30 COPD patients were assessed in an outpatient department, 60 per cent of whom had a self-management plan in place.

The main triggers for activating their plan were sputum (55 per cent; breathlessness (28 per cent); and a cough (17 per cent).

Also, 83 per cent of patients followed up with their GP as soon as possible after commencing a rescue prescription and 89 per cent reported feeling very confident to initiate their self-management plan independently.

“Healthcare professionals involved with COPD patients should continue to include self-management plans as part of the ongoing treatment of the condition and should also consider the suitability of patients for rescue prescriptions for prompt management of exacerbations,” according to the study authors.