Friday, 23 January 2015

Antifungal Combination Therapy: A Step Forward


Combination therapy for IA benefits the moderately ill patients most

The first large (454 participants) randomized, double-blind, placebo-controlled multicenter trial study on combination therapy shows a 10% improvement in survival at 6 weeks. All patients received voriconazole and half also received anidulafungin. All patients had hematologic malignancies or a hematopoietic cell transplant. The largest differences in outcome were seen in those with serum galactomannan levels in the low middle range of 0.5-1.5. Non-neutropenic patients also appeared to benefit (13.7% versus 33.2% mortality), whereas neutropenic patients did not.

Invasive aspergillosis in immunocompromised patients is often a fatal complication - only around 40% of patients survive. Improvements in outcome have been seen in neutropenic patients especially, with earlier diagnosis and use of voriconazole therapy.

Combination therapy has been evaluated previously - one of the first being Verweij et. al. (1994) comparing amphotericin B with or without flucytosine. Mortaliy in this study exceeded 80%. Combined amphotericin B and terbinafine increased death rates (never published) and there have been several small studies but all have been inconclusive, though some gave a encouraging results.
In the recent combination study, there was no significant difference between the outcome of the two treatments (P=0.087), there was a clear improvement (11.5 percentage points) when comparing monotherapy (voriconazole alone 27% mortality) versus combination therapy (15.5% mortality) after six weeks treatment. The results may or may not be pertinent to other patient groups such as critically ill corticosteroid treatment or solid organ transplant patients. Increasing azole resistance in northern Europe may be an argument to initiate combination therapy in certain patient groups. (ClinicalTrials.gov:  NCT00531479).

Thursday, 22 January 2015

Could fungus be the next big killer? Experts warn fungal diseases now cause more deaths than malaria and tuberculosis


The Daily Mail (UK national newspaper) recently published the following story based on four main points made by Professor Rosemary Barnes of Cardiff University:
  • Figures show fungal diseases cause hundreds of thousands of deaths
  • Death often follows severe respiratory illness and infections of the blood
  • Experts warn fungi kill more people than malaria and tuberculosis globally
  • They also destroy a third of all food crops, affecting global economies
Recent flooding across UK and the rest of Europe has exacerbated the situation.

 ‘Flooding caused by adverse weather conditions has caused a worsening situation of home dampness and indoor mould growth, which are associated with asthma, rhinitis and other respiratory problems.’ 
‘Emerging fungal diseases such as Dutch Elm, ash dieback, sweet chestnut blight and sudden oak death are also a real concern for Britain’s forests, said Professor Barnes.’ 
 ‘Five and a half million people in the UK alone are living with asthma and half of these cases are down to an allergic reaction to fungi.’ 
 ‘Deforestation from fungal pathogens increases carbon dioxide emissions and contributes to global warming.’ 
‘Other diseases attack insect populations that are crucial for plant pollination.’ 


Professor Barnes said that there needs to be more education around the impact of fungus on health, and the economy. She suggests improving diagnostic techniques, investing more into research in the area, and performing surveillance studies of the fungi and diseases.

Read the full article here


Tuesday, 13 January 2015

Poor Ventilation of Homes Causes Health Problems for the Occupants

53% of homes in the East of England are affected by mould, according to a recent survey. Although this relies on self reported impressions of owners own homes and we do not know how many were polled to form this satistic, this is still quite a shocking statistic.

Many of us would probably say that poorly maintained homes and the rental market are probably the main properties that are likely to suffer from damp problems, indeed the 2009 report from the World Health Organisation on damp in the home had this to say:
Dampness and mould may be particularly prevalent in poorly maintained
housing for low-income people. Remediation of the conditions that lead to adverse
exposure should be given priority to prevent an additional contribution
to poor health in populations who are already living with an increased burden
of disease.
However we know that only 36% of all homes in the UK are rented (ONS figures 2013) so those properties mentioned in the survey cannot be all rented. There must be many of the 15 million owner occupied homes that suffer from mould - and thus are damp. Many of these are likely to be well maintained so why are they damp?


It has been estimated that the majority of damp problems are caused by excess moisture in the air of our homes condensing on cold walls or forming 'dew' at night when the air temperature falls, especially in the cold winter months. If this moisture falls onto material that can support mould growth then all it takes is for one airborne spore to land on the surface (and there are usually at least 50-100 spores in every cubic metre of air in an average home) for mould to take root.

The problem is likely to be poor ventilation. Even the most modern home in the UK is well insulated but not likely to have enough ventilation of either passive or active kind - the focus in the UK has been on energy conservation with many government grants available for boosting insulation in the home. There is little incentive or information to ventilate, even though there are efficient mechanical devices that will remove moist air AND save the heat energy in that air, warming the incoming air.

Damp is linked to a variety of repiratory illness including asthma, allergy, reviewed here on the WHO report and several since.




Monday, 12 January 2015

The Larget Living Thing on Earth - a Fungus!

If you were asked what the largest living thing was what would you guess?

The Blue Whale? 


A Canadian Redwood?

The Blue Whale IS pretty big at 24m in length and its tongue alone is the size of an African Elephant. Canadian Redwood trees are huge at 100m in height but neither come close to the current largest living thing on earth!

You might think fungi are pretty small and certainly the mushrooms and toadstools we often see growing in the ground are only a few cm across however those are just the fruiting bodies - the equivalent of an apple on a tree. The vast majority of a fungus is far bigger and grows unseen underground - but perhaps we didn't appreciate just how much bigger it is until recently.

A single individual Armillaria solidipes has been found to be 3.8km across!!!

Note not meters, kilometers!

Armilliria solidipes


Now that's one big mushroom!


Tuesday, 23 December 2014

Energy Efficient Homes Are Also Asthma Causing Homes

The UK government have for some time been supporting (by deed and funding) the construction and renovation of our homes so that they meet very strict energy efficiency requirements. As a direct consequence insulation has been lavishly funded while there has been little or no emphasis on introducing fresh air into properties i.e. via ventilation - presumably because ventilation can cause heat loss and thus lead to higher energy consumption.
Unfortunately this one-eyed thinking has led to a housing stock that has insufficient ventilation in many cases, leading to the accumulation of moisture and other gases e.g. carbon dioxide. The UK based Institute for Specialist Surveyors and Engineers has for some years now been advocating the introduction of heat-saving mechanical ventilation to help improve ventilation while minimising costs to energy efficiency.


A new paper (summarised here in the Sunday Times) has looked at asthma rates in a range of energy efficient housing and concludes that higher rates of asthma correlates with higher energy efficiency rating - a clear indication that greater consideration needs to be given by the UK government to supporting the installation of ventilation alongside insulation rather than insulation alone.



The ISSE alongside the Institute of Buildings and Health are to take this up with government ministers and senior officials of the UK construction Industry in the very near future.

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