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Tracheomalacia and tracheobronchomalacia may be primary abnormalities of the large airways or associated with a wide variety of congenital and acquired conditions. The evidence on diagnosis, classification and management is scant. There is no universally accepted classification of severity. Clinical presentation includes early-onset stridor or fixed wheeze, recurrent infections, brassy cough and even near-death attacks, depending on the site and severity of the lesion. Diagnosis is usually made by flexible bronchoscopy in a free-breathing child but may also be shown by other dynamic imaging techniques such as low-contrast volume bronchography, computed tomography or magnetic resonance imaging. Lung function testing can provide supportive evidence but is not diagnostic. Management may be medical or surgical, depending on the nature and severity of the lesions, but the evidence base for any therapy is limited. While medical options that include bronchodilators, anti-muscarinic agents, mucolytics and antibiotics (as well as treatment of comorbidities and associated conditions) are used, there is currently little evidence for benefit. Chest physiotherapy is commonly prescribed, but the evidence base is poor. When symptoms are severe, surgical options include aortopexy or posterior tracheopexy, tracheal resection of short affected segments, internal stents and external airway splinting. If respiratory support is needed, continuous positive airway pressure is the most commonly used modality either via a face mask or tracheostomy. Parents of children with tracheobronchomalacia report diagnostic delays and anxieties about how to manage their child's condition, and want more information. There is a need for more research to establish an evidence base for malacia. This European Respiratory Society statement provides a review of the current literature to inform future study. Copyright © ERS 2019

This study explores how hostages are murdered during a kidnapping for ransom. A multi-dimensional scaling procedure was used to explore the homicidal behavior of kidnappers. Three styles of homicide, labeled as execution, manual, and slaughter, were identified. Each varied in the degree of expressive/instrumental aggression and planned or spontaneous violence. Classification of the sample data found that 46.4% of kidnapping homicides were characterized by instrumental violence labeled as execution style, whereas 42.9% were characterized by hostile violence that was spontaneous and less reliant on using a weapon (manual style). These observations related to the type of group conducting the kidnapping for ransom.

Water and land management decisions require consideration of multiple factors. Multicriteria decision analysis (MCDA) provides a structured, auditable and transparent tool that helps inform and add rigour to multioption decisions. MCDA was used in a payment for ecosystem services (PES) project to evaluate options for delivering good ecological status in Tortworth Brook, Gloucestershire, UK. Following a process of stakeholder engagement, final options considered were: (1) doing nothing; (2) modifying existing sewage treatment works; (3) a single integrated constructed wetland (ICW) targeting multiple ecosystem service outcomes; and (4) catchment wide multiple ICWs. The analysis concluded that the ‘do nothing’ option and modifying the existing works are both likely to provide poor utility and value for money. Both ICW options offered the greatest utility in terms of optimising the benefits to all stakeholders.

Paper presented at Symposium on the Application of Technology to Education, Washington, D.C., September 9-10, 1968.

The aim of this review was to evaluate the clinical effectiveness of fractional exhaled nitric oxide (FeNO) measured in a clinical setting for the management of asthma in adults.\ud \ud 13 electronic databases were searched and studies were selected against predefined inclusion criteria. Quality assessment was conducted using QUADAS-2. Class effect meta-analyses were performed.\ud \ud Six studies were included. Despite high levels of heterogeneity in multiple study characteristics, exploratory class effect meta-analyses were conducted. Four studies reported a wider definition of exacerbation rates (major or severe exacerbation) with a pooled rate ratio of 0.80 (95% CI 0.63–1.02). Two studies reported rates of severe exacerbations (requiring oral corticosteroid use) with a pooled rate ratio of 0.89 (95% CI 0.43–1.72). Inhaled corticosteroid use was reported by four studies, with a pooled standardised mean difference of −0.24 (95% CI −0.56–0.07). No statistically significant differences for health-related quality of life or asthma control were found.\ud \ud FeNO guided management showed no statistically significant benefit in terms of severe exacerbations or ICS use, but showed a statistically significant reduction in exacerbations of any severity. However, further research is warranted to clearly define which management protocols (including cut-off points) offer best efficacy and which patient groups would benefit the most.

A diverse range of response options was evaluated in terms of their utility for sustaining ecosystem services in the UK. Robustness of response options was investigated by applying a ‘stress-testing’ method which evaluated expected performance against combined scenarios of socioeconomic and climate change. Based upon stakeholder feedback, a reference scenario representing current trends in climate and socioeconomic drivers (‘business-as-usual’) was used as a dynamic baseline against which to compare results of other scenarios. The robustness of response options was evaluated by their utility in different environmental and social contexts as represented by the scenarios, and linked to their adaptability to adjust to changing conditions. Key findings demonstrate that adaptability becomes increasingly valuable as the magnitude and rate of future change diverges from current trends. Stress-testing also revealed that individual responses in isolation are unlikely to be robust meaning there are advantages from integrating cohesive combinations (bundles) of response options to maximise their individual strengths and compensate for weaknesses. This identifies a role for both top-down and bottom-up responses, including regulation, spatial targeting, incentives and partnership initiatives, and their use in combination through integrated assessment and planning consistent with the adoption of an Ecosystem Approach. Stress-testing approaches can have an important role in future-proofing policy appraisals but important knowledge gaps remain, especially for cultural and supporting ecosystem services. Finally, barriers and enablers to the implementation of more integrated long-term adaptive responses were identified drawing on the ‘4 Is’ (Institutions, Information, Incentives, Identity) conceptual framework. This highlighted the crucial but usually understated role of identity in promoting ownership and uptake of responses.

This study explores how violence is used to manipulate a victim during a kidnapping for ransom. A particular interest was to understand the degree of intensity, its pattern, and its function during the offense. To investigate, 181 kidnapping cases were examined from 32 countries, and 34 variables were identified that characterized violence toward the victim. A multidimensional scaling procedure was used to explore the structure of violence. Cruelty was found to be systematic and varied in the degree of intensity and focus. Kidnappers directed their attacks on the body or the psyche of the victim, and did so in a strategically calculated manner. This suggested that violence toward a victim is not random but a highly systemized form of torture.

Background Tiotropium is a once-daily, long-acting anticholinergic bronchodilator with the potential to alleviate airway obstruction in cystic fibrosis. Our objective was to evaluate the efficacy and safety of 2.5 and 5 µg once-daily tiotropium delivered via the Respimat Soft Mist Inhaler vs. placebo in people with cystic fibrosis. Methods This phase 2, 12-week, randomized, double-blind, placebo-controlled parallel-group study of tiotropium Respimat as add-on to usual cystic fibrosis maintenance therapy included people with cystic fibrosis with pre-bronchodilator forced expiratory volume in 1 second (FEV1) ≥25% predicted. Co-primary efficacy end points were change from baseline in percent-predicted FEV1 area under the curve from 0 to 4 hours (FEV1 AUC0–4h), and trough FEV1 at the end of week 12. Findings A total of 510 subjects with cystic fibrosis aged 5–69 years were randomized. Both doses of tiotropium resulted in significant improvement compared with placebo in the co-primary efficacy end points at the end of week 12 (change from baseline in percent-predicted FEV1 AUC0–4h: 2.5 µg: 2.94%, 95% confidence interval 1.19–4.70, p = 0.001; 5 µg: 3.39%, 95% confidence interval 1.67–5.12, p = 0.0001; in percent-predicted trough FEV1∶2.5 µg: 2.24%, p = 0.2; 5 µg: 2.22%, p = 0.02). There was a greater benefit with tiotropium 5 vs. 2.5 µg. No treatment-related adverse events or unexpected safety findings were observed in patients taking tiotropium. Conclusions Tiotropium significantly improved lung function in people with cystic fibrosis. The improvement was greater with the higher dose than the lower dose, with no difference in adverse events. Trial Registration ClinicalTrials.gov NCT00737100 EudraCT 2008-001156-43.