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Pulmonary Medicine
Pulmonary Vasculitis (Necrotizing granulomatous vasculitis, Churg-Strauss syndrome, Microscopic polyanitis)
What every physician needs to know:
- Are you sure your patient has pulmonary vasculitis? What should you expect to find?
- What are the most common findings associated with pulmonary vasculitis?
Beware: there are other diseases that can mimic pulmonary vasculitis:
How and/or why did the patient develop pulmonary vasculitis?
Which individuals are at greatest risk of developing pulmonary vasculitis?
- What laboratory studies should you order to help make the diagnosis, and how should you interpret the results?
- What imaging studies will be helpful in making or excluding the diagnosis of pulmonary vasculitis?
What non-invasive pulmonary diagnostic studies will be helpful in making or excluding the diagnosis of pulmonary vasculitis?
- What diagnostic procedures will be helpful in making or excluding the diagnosis of pulmonary vasculitis?
What pathology/cytology/genetic studies will be helpful in making or excluding the diagnosis of pulmonary vasculitis?
- If you decide the patient has pulmonary vasculitis, how should the patient be managed?
What is the prognosis for patients managed in the recommended ways?
What other considerations exist for patients with pulmonary vasculitis?
What's the evidence?
What every physician needs to know:
The pulmonary vasculitides are a group of diseases characterized by their destructive effects on the pulmonary vasculature with subsequent tissue necrosis. These disorders can be divided into primary (idiopathic) and secondary (associated) disorders. Primary pulmonary vasculitis is thought to be autoimmune in nature, although the pathophysiology is not clearly defined. Secondary pulmonary vasculitis can be associated with a number of diverse etiologies, including infection, drug reactions, connective tissue disease, and malignancy.
In the 1980s, the identification of antineutrophil cytoplasmic antibodies (ANCA), led to significant advances in the diagnosis and characterization of vasculitis, particularly the primary, small-vessel, pulmonary vasculitides. This identification allowed small-vessel vasculitis to be divided into ANCA-associated vasculitides (AAV) and immune-complex mediated vasculitides.
The AAV include necrotizing granulomatous vasculitis (NGV, formerly known as Wegener's granulomatosis), Churg-Strauss syndrome (CSS), and microscopic polyangitis (MPA). The immune complex mediated vasculitides are Goodpasture's syndrome, Henoch-Schönlein purpura, IgA nephrophathy, Behçet's disease, and essential cryoglobulinemia. Because the small-vessel vasculitides, particularly AAV, are most commonly encountered in pulmonary medicine, they are the focus of this chapter.
The diagnosis of vasculitis is a challenge because of the significant overlap in clinical, radiographic, and laboratory features with multiple disease processes, particularly infection and drug reactions. The complex nature of these disorders requires the clinician to utilize clinical, radiographic, laboratory, and pathologic data to recognize common patterns of vasculitis, rather than relying on strict clinical diagnostic guidelines. Once a diagnosis of vasculitis is established, immunosuppressive therapy is usually required.
The intensity of the immunosuppressive therapy is determined by the disease's severity and the degree of organ damage at the time of diagnosis. Therapy is initially geared toward inducing remission, followed by maintenance therapy with frequent evaluations for drug toxicity, infectious complications, and disease relapse.
Table 1
The Vasculitides.
|Primary Vasculitis
|Small-vessel vasculitis • Necrotizing granulomatous vasculitis (NGV) • Microscopic polyangiitis (MPA) • Churg-Strauss syndrome (CSS)
|Medium-vessel vasculitis • Polyarteritis nodosa • Kawasaki disease
|Large-vessel vasculitis • Takayasu arteritis • Giant cell arteritis
|Immune-complex mediated vasculitis
|• Goodpasture's syndrome • Henoch-Schönlein purpura • Behçet's disease • Essential cryoglobulinemia • IgA nephropathy
|Secondary vasculitis
|Autoimmune Disease
|Rheumatoid arthritis
|Antiphospholipid antibody syndrome
|Infection Drug-induced Inflammatory bowel disease
|Hypocomplementemic urticarial vasculitis
Are you sure your patient has pulmonary vasculitis? What should you expect to find?
The diagnosis of vasculitis poses a significant challenge because of the considerable overlap its presentation has with other entities, including infection, rheumatologic/connective tissue disease, malignancy, drug toxicity, and venous thromboembolic disease. Further complicating the diagnosis is the fact that individuals may present with diverse multi-system manifestations. The absence of well differentiated clinical criteria and a single diagnostic test amplifies the difficulty; however, certain clinical presentations can alert the clinician to consider the diagnosis of pulmonary vasculitis.
Constitutional Symptoms
Fatigue, fevers, weight loss, myalgias, and arthralgias are common nonspecific features of vasculitis. In fact, constitutional symptoms precede the development of renal failure by months in most patients with MPA.
Rapidly Progressive Glomerulonephritis (RPGN)
RPGN is a nephritic syndrome characterized by a 50 percent loss of renal function in less than three months and by histopathology revealing crescents in a least half of glomeruli. When renal failure and hematuria are appreciated, it is critical to evaluate a fresh urine sample microscopically for dysmorphic red cells and red cell casts that are suggestive of glomerulonephritis. Disorders that present with RPGN include AAV, SLE, Goodpasture's syndrome, post-infectious glomerulonephritis, Honoch-Schönlein purpura, membranoproliferative glomerulonephritis, idiopathic pauci-immune glomerulonephritis, essential cryoglobulinemia, and IgA nephropathy.
Diffuse Alveolar Hemorrhage (DAH)
The classic clinical syndrome of DAH includes hemoptysis, diffuse alveolar infiltrates, and a decrease in hematocrit. However, only two-thirds of patients have clinically recognized hemoptysis. The differential diagnosis in any patient with unexplained bilateral alveolar infiltrates includes alveolar hemorrhage. Bronchoalveolar lavage is diagnostic when serial lavage samples reveal persistently or increasingly bloody return. An increase in diffusion capacity (30% above baseline) can suggest the diagnosis if the patient is stable enough to perform breath-holding maneuvers in a pulmonary function laboratory. When DAH occurs in the setting of RPGN, the differential diagnosis includes the pulmonary renal syndromes associated with AAV, Goodpasture's syndrome, and SLE.
Cavitary or Nodular Lung Disease
Nodular or cavitary lung diseases are most commonly caused by infection or malignancy. However, in the right clinical setting, these findings may suggest pulmonary vasculitis, particularly AAV. Evidence that nodular or cavitary lung disease is not the result of malignancy or infection significantly raises the possibility of vasculitis.
Upper Airway Disease
Upper airway disease, including otitis, sinusitis, and rhinitis, are relatively common findings in patients with AAV. Disease that is refractory to conventional medical therapy, and ulcerative or destructive lesions should alert the clinical to the possibility of vasculitis. Tracheobronchial and endobronchial lesions occur in 10-50 percent of patients with NGV.
Neurologic Abnormalities
Mononeuritis multiplex, defined by the presence of peripheral nerve abnormalities in two or more distributions, is of particular concern in suggesting an AAV. Other nervous system abnormalities include parasthesias, weakness, pain, and functional deficiencies, such as footdrop.
Palpable Purpura
Palpable purpura is a finding of non-blanching purplish discolorations that signify a cutaneous vasculitis. Palpable purpura is a nonspecific finding, as it can be associated with AAV, as well as drug reactions, cryoglobulinemia, infections, rheumatologic disorders, and malignancy.
Adult Onset Asthma
Mature onset of asthma with or without eosinophilia is a universal finding in CSS that often presents several years prior to the diagnosis of vasculitis. Asthma that is steroid-dependent or refractory to standard medical therapy can suggest the diagnosis.
What are the most common findings associated with pulmonary vasculitis?
Necrotizing Granulomatous Vasculitis
Among the AAV syndromes, NGV is the most common. The syndrome is classically characterized by a combination of upper and lower respiratory tract disease along with renal disease. Constitutional symptoms (fatigue, fevers, and weight loss), and musculoskeletal (30-70%), skin (45-60%), eye (25-50%), and peripheral and central nervous system (10-30%) manifestations are common. The upper and lower respiratory manifestations occur in 75-95 percent of patients at onset of disease.
Renal disease is present in 40 percent of patients at the time of presentation, but 70-80 percent of patients eventually develop renal involvement. Upper airway disease with sinusitis, otitis, epistaxis, and subglottic and/or tracheal stenosis occurs in 70-95 percent of patients. The presence of ulcerating or destructive lesions is highly suggestive.
Churg-Strauss Syndrome
CSS is characterized by a classic triad of asthma, eosinophilia, and necrotizing vasculitis. CSS is unique among the AAVs, based on its clinical manifestations. The presence of asthma and eosinophilia causes significant overlap with many disorders common to pulmonary medicine, including eosinophilic pneumonia syndromes, allergic bronchopulmonary mycosis, steroid-dependent asthma, drug reactions, hypereosinophilic syndromes, and parasitic infections.
A three-phase presentation has been described to consist of a prodromal phase of asthma, rhinitis, and sinusitis, followed by an eosinophilic phase and a vasculitis phase. Asthma is virtually universal and is often steroid-dependent. Between 20 percent and 70 percent of patients have upper respiratory symptoms. Cardiac involvement is more common in CSS than in the other AAVs, occurring in 15-50 percent of patients, and it is disproportionately associated with high mortality. Mononeuritis multiplex and skin involvement are common (50-70%), as is gastrointestinal involvement with pain, infarction, hemorrhage, and viscus perforation.21
Microscopic Polyangiitis
Classically, MPA patients present after weeks to months of constitutional symptoms that include fever, night sweats, arthralgias, and weight loss. These symptoms are often followed by rapidly progressive glomerulonephritis. In comparison to NGV and CSS, RPGN occurs in virtually all patients, while the pulmonary involvement that occurs most commonly with DAH is less common (10-30%). Palpable purpura occurs in 50-70 percent of patients, peripheral nervous system in 10-50 percent, upper airway disease in 5-30 percent, and gastrointestinal manifestations with ischemia, pain, and/or bleeding in 35-55 percent. Cardiac disease with pericarditis and CHF have been described but are thought to be rare.21
Beware: there are other diseases that can mimic pulmonary vasculitis:
Signs and symptoms of vasculitis can overlap significantly with other disease processes, including infection, malignancy, connective tissue disease, drug toxicity, and venous thromboembolic disease. Diffuse alveolar hemorrhage has myriad etiologies, and pulmonary capillaritis (suggestive of vasculitis) must be differentiated from diffuse alveolar damage and bland hemorrhage (e.g., coagulopathy, mitral stenosis, inhalation injury, drug-associated disease). (See the DAH chapter.)
How and/or why did the patient develop pulmonary vasculitis?
It is difficult to ascertain the true incidence and prevalence of primary systemic vasculitis because of the limitations in the available data. Studies have not been able to incorporate the geographic and ethnic variance of disease and have included varying diagnostic criteria. In addition, case findings of AAV have increased significantly with the advent of ANCA testing in the last twenty to thirty years. With regard to specific AAV, NGV has an annual incidence of 4.9-10.5 per million, CSS from 0.5-4.2 per million, and MPA from 2.7 to 11.6 per million.1
NGV and CSS occur most often in more northern and more southern latitudes, perhaps because of decreased UV light exposure.2 NGV has an average age of onset of 55-65 years, while MPA increases in frequency with advancing age. MPA is more common than other AAV in Japanese and Chinese populations. NGV and CSS affect both sexes equally, while MPA more commonly affects men.
Which individuals are at greatest risk of developing pulmonary vasculitis?
Specific risk factors are poorly understood. Beyond an increased prevalence of disease in the more northern and southern latitudes and the increased risk of MPA in Asian populations, no clinically identified risks are universally recognized for AAV. As secondary vasculitis can complicate a number of disorders, including autoimmune or connective tissue disease, infection, drug reactions, inflammatory bowel disease, and malignancy, the presence of the primary disease raises the risk of vasculitis.
What laboratory studies should you order to help make the diagnosis, and how should you interpret the results?
Routine Testing
When the diagnosis of vasculitis is entertained, initial testing should be directed at excluding competing diagnoses and evaluating the degree of organ involvement. Particularly important is the exclusion of infection using blood cultures and cultures of tissue or fluid from affected organs. Routine laboratory tests include complete blood count with differential, chemistries, renal function, and liver function tests. Urinalysis on a freshly obtained sample should include microscopic examination for red cell casts and/or dysmorphic red cells.
Serologic Testing
Evaluation with antinuclear antibodies, rheumatoid factor, and disease-specific antibodies (e.g., anti-CCP, anti-SSA/anti-SSB, anti-RNP, anti-JO-1, anti-dsDNA, anti-SCL-70) can suggest a diagnosis of connective tissue disease. In the proper clinical setting, anti-glomerular basement membrane antibodies, cryoglobulins, hepatitis serologies, and antiphospholipid antibodies should be considered. EKG should be performed to evaluate for conduction abnormalities in all patients with vasculitis.
Antinuclear Cytoplasmic Antibodies
Our understanding of the role that ANCA testing plays in the diagnosis of vasculitis has advanced immensely since the 1980s. Immunofluorescent staining of ethanol-fixed neutrophils shows a diffuse pattern in the cytoplasm of patients with NGV, while a perinuclear pattern is most commonly noted in patients with MPA and pauci-immune glomerulonephritis. These staining patterns are referred to as cytoplasmic (c-ANCA) and perinuclear (p-ANCA).
c-ANCA is most commonly directed against a proteinase (PR3) in azuophilic granules, while p-ANCA is most commonly directed against myeloperoxidase (MPO) and is known to have a more diverse group of intracellular targets (i.e., lactoferrin, cathepsin, elastase, lysozyme, bacterial permeability protein) than c-ANCA has.
The detection of PR3 and MPO can be obtained by enzyme-linked immunosorbent assay (ELISA). A positive ANCA has high sensitivity and low specificity and should be confirmed with ELISA. Therefore, specific ELISA for PR3 and MPO should be obtained along with ANCA at the time a diagnosis of vasculitis is entertained. c-ANCA/anti-PR3 is commonly seen with NGV, while p-ANCA/anti-PR3 is most commonly associated with CSS and MPA.
The use of ANCA testing as a screening tool to a large population has a low positive-predictive value. However, utilization of ANCA testing in at-risk patients based on clinical guidelines increases the positive predictive value without sacrificing sensitivity. 3 When applied to at risk populations, c-ANCA has a sensitivity of 85-90 percent and specificity of 90-95 percent in active systemic NGV. In organ-limited disease, the sensitivity decreases to 65-86 percent.4 False-positive c-ANCA results are rare but have been described in other autoimmune diseases and in pseudomonas infections.
p-ANCA/anti-MPO has a much lower sensitivity and specificity for generalized MPA and CSS compared to c-ANCA/anti-PR3 in NGV, and p-ANCA has a higher association with other disorders, including Goodpasture's syndrome, ulcerative colitis, infective endocarditis, rheumatoid arthritis, and other autoimmune disorders. p-ANCA/anti-MPO has a sensitivity of 50-75 percent in active MPA and a 35-50 percent sensitivity for CSS. However, in CSS patients with a peripheral eosinophilia, ANCA is positive in 40-70 percent.5,20 A negative ANCA does not exclude the diagnosis, as ANCA is not always positive even in the presence of active disease.
What imaging studies will be helpful in making or excluding the diagnosis of pulmonary vasculitis?
Imaging is critical to the diagnosis and monitoring of pulmonary vasculitis. Specifically, imaging should be performed on organs that are implicated in the disease process and on those that are likely to contribute to the morbidity or mortality of the specific disease. When a diagnosis of pulmonary vasculitis is being considered, high-resolution CT of the chest should be obtained (see below); transthoracic echocardiogram, and CT of the sinuses may also provide helpful information. CT angiography or MRI of the affected organs/regions can be useful if a large-vessel or medium-vessel vasculitis is suspected.
Necrotizing Granulomatous Vasculitis
Chest imaging reveals at least one abnormality in nearly all patients. HRCT can reveal the presence of nodules (solitary or multiple), cavities, endobronchial disease, and pulmonary infiltrates (alveolar, interstitial, or mixed). The variable imaging findings and their overlap with infection and malignancy require careful evaluation in order to discern their etiology.
Churg-Strauss Syndrome
Chest imaging with HRCT is abnormal in 90 percent of patients, and parenchymal opacities, which are frequently migratory, are common. Similar to asthma, bronchial wall thickening with hyperinflation and air trapping can be seen. Nodules are less common, and pleural effusions are seen in 10 percent of patients.
Microscopic Polyangiitis
Chest imaging is highly variable in MPA, ranging from normal to bilateral heterogeneous ground-glass abnormalities suggestive of alveolar hemorrhage. Pulmonary fibrosis is rare, but it is associated with high mortality rates.
What non-invasive pulmonary diagnostic studies will be helpful in making or excluding the diagnosis of pulmonary vasculitis?
Pulmonary functioning testing is rarely useful in the diagnosis of pulmonary vasculitis. However, the finding of an elevated diffusion capacity for carbon monoxide (DLCO) to 30 percent above baseline can suggest the diagnosis of alveolar hemorrhage, although it is also occasionally seen in asthmatics. Pulmonary function testing can be followed once the diagnosis is made to evaluate for progression of disease (i.e., fibrosis).
What diagnostic procedures will be helpful in making or excluding the diagnosis of pulmonary vasculitis?
Bronchoscopy plays several important roles in the diagnosis of pulmonary vasculitis, including evaluation for DAH, malignancy, infection, and eosinophilia and assessing for ulcerative and stenotic upper airway and endobronchial disease. Lower respiratory samples can be obtained by bronchoalveolar lavage and should be sent for culture, cytology, and cell count with differential. The decision to obtain endobronchial or transbronchial biopsy specimens is dependent on the clinical, laboratory, and radiographic differential. These biopsies can be useful in excluding infections and malignancy, but they only rarely provide a positive diagnosis of vasculitis. For example, in a study by Schnabel et al., transbronchial biopsies supported a diagnosis of NGV in only two of seventeen patients.6
Tissue biopsy
While the high sensitivity and specificity of c-ANCA-anti-PR3 in the clinical setting of a high pretest probability of NGV can occasionally obviate the need for invasive biopsy, the same cannot often be said for p-ANCA/anti-MPO. Therefore, diagnostic tissue biopsy is often necessary in order to diagnose vasculitis definitively. Considerations regarding the site of biopsy include the accessibility of involved organs, the morbidity/mortality associated with the procedure, and the likelihood of obtaining diagnostic tissue.
The skin and sinuses, which are often involved, are frequently the most accessible biopsy sites. However, the pathologic findings from biopsies obtained from these sites are less specific than biopsies obtained from lung or kidney, as skin biopsies often show a leukocytoclastic vasculitis, a nonspecific result. Upper airway specimens reveal the classic combination of necrosis, granulomatous inflammation, and vasculitis only 15-20 percent of the time7 so skin and upper respiratory sites are useful in supporting the diagnosis of vasculitis but may not allow for definitive diagnosis.
Percutaneous renal biopsy is performed in the setting of acute glomerulonephritis. The histopathologic finding of a segmental, necrotizing glomerulonephritis is highly suggestive of vasculitis. Immunofluorescence should be performed to evaluate for immune-deposition that would suggest immune-complex mediated vasculitis (e.g., IgA deposits in HSP, linear IgG in Goodpasture's syndrome, and clumped IgG in SLE). The absence of immune deposits defines pauci-immune glomerulonephritis, which, in the right clinical setting, is consistent with AAV.
Surgical lung biopsy in patients with small-vessel vasculitis identifies diagnostic features in up to 90 percent of patients.8 The procedure is most commonly performed via video-assisted thorascopic surgical (VATS) techniques, which significantly decrease the risk of complications and the recovery time compared to those of open surgical lung biopsy. Although VATS carries a slightly higher morbidity/mortality risk than renal, skin, or upper respiratory biopsies, the procedure has a high diagnostic yield, and it should be considered early in the course of disease.
Tissue should be evaluated by conventional histopathology for evidence of vasculitis, such as granulomatous inflammation or vascular necrosis. Frozen sections of tissue should also be evaluated for immune deposits by immunofluorescence and placed in saline for culture.
What pathology/cytology/genetic studies will be helpful in making or excluding the diagnosis of pulmonary vasculitis?
There are no genetic tests currently available that assist in the diagnosis of vasculitis. Cytology from bronchoalveolar lavage can be helpful if the differential includes malignancy. Pathologic specimens should be evaluated by conventional histopathology for evidence of vasculitis (e.g., granulomatous inflammation, vascular necrosis, necrotizing glomerulonephritis), as well as by immunofluoresence for evidence of immune-complex deposition. As infection is always in the differential, tissue obtained by biopsy should also be sent for culture.
If you decide the patient has pulmonary vasculitis, how should the patient be managed?
Therapy for pulmonary vasculitis generally involves immunosuppressive treatment with corticosteroids and cytotoxic agents, with escalating intensity based on disease severity. The European Vasculitis Study Group (EUVAS) has outlined a grading system that is useful in categorizing disease severity to guide therapy: (1) limited, (2) early generalized, (3) active generalized, (4) severe, and (5) refractory. Initial therapy is geared toward achieving remission, followed by maintenance therapy. Treatment considerations must take into account the risk of treatment complications, weighed against prevention of further organ dysfunction. Close monitoring for adverse effects of medications, infectious complications, and disease relapse are critical.
Induction Therapy
Limited disease ,the first of the EUVAS categories, includes patients who lack constitutional symptoms and who have normal renal function (Cr < 1.4 mg/dL). Disease is localized to the upper airway. Therapy is usually limited to monotherapy with corticosteroids, azathioprine, or methotrexate. Trimethoprim-sulfamethoxazole in limited disease has been debated, and its role remains unclear. Escalation of therapy is recommended with progressive or refractory disease.
The early generalized disease category refers to patients who have constitutional symptoms but no specific threat to organ function. Historically, treatment recommendations have included cyclophosphamide and corticosteroids, but this recommendation was modified with the publication of the Non-renal Alternative with Methotrexate (NORAM) trial, which compared the use of methotrexate with cyclophosphamide for induction therapy.9 Cyclophosphamide was associated with an earlier time to remission (three months vs. five months) and a lower relapse rate (42% vs. 74%), although methotrexate was better tolerated. Therefore, methotrexate can be considered as an alternative to cyclophosphamide in certain clinical scenarios.
Other therapies considered for induction of remission include azathioprine and mycophenolate mofetil. A randomized clinical trial that compares mycophenolate mofetil to cyclophosphamide for remission induction in ANCA-associated vasculitis (MYCYC) is currently enrolling and may lead to additional alternative agents to consider in this group of patients.
The active generalized disease category includes patients with evidence of renal dysfunction (Cr < 5.7 mg/dL) and threatened organ function. Cyclophosphamide and corticosteroids are used to treat patients this group. Historically, daily oral cyclophosphamide has been used, but the CYCLOPS trial compared daily oral (2mg/kg/d) with pulse intravenous cyclophosphamide (15mg/kg every 2-3 weeks) in newly diagnosed patients with active generalized AAV10 (all patients were also treated with prednisone) and found no significant difference in the time to remission or percentage of patients who obtained remission. These findings, combined with a lower rate of side effects and decreased cumulative cyclophosphamide dose in the pulse group, suggests that the intravenous route of delivery may be preferred.
The severe disease category includes patients with severe renal disease (Cr > 5.7 mg/dL), DAH, or other organ-threatening disease. Like patients with active generalized disease, they are usually treated with cyclophosphamide and corticosteroids, although consideration should be given to the addition of plasma exchange therapy in this group of patients. A study that compared plasma exchange to high-dose intravenous methylprednisolone found that 69 percent of the plasma exchange group was alive and independent of dialysis compared to only 49 percent in the high-dose intravenous corticosteroid group.11
The role for plasma exchange is less clear in patients with evidence of disease that threatens an organ other than the kidney. However, several reports and case series have suggested that the addition of plasma exchange may be beneficial in the setting of DAH. Rarely, patients with severe respiratory failure may require extracorporeal membrane oxygenation while awaiting the beneficial effects of immunosuppressive therapy.
In the refractory category are patients who do not respond to conventional therapy with cytotoxic medications, corticosteroids, and plasma exchange. Rituximab, a monoclonal B cell-depleting antibody, has shown significant promise as an additional therapy for AAV. In July 2010, two large randomized, controlled trials found that rituximab was not inferior to standard cyclophosphamide treatment for induction of remission in severe AAV.
The data also suggest that rituximab may be superior to cyclophosphamide for induction of remission in relapsing disease, although this endpoint requires further studies.12,13 Currently, rituximab is a suitable alternative to cyclophosphamide for initial therapy or in the setting of relapsed disease, particularly if there are contraindications to the use of cyclophosphamide.
Multiple other agents have been utilized for the treatment of refractory disease. Anithymocyte globulin has been studied for such treatment, but questions regarding efficacy and safety remain. Intravenous immunoglobulin (IVIg) acutely reduces disease activity, but the effect is not durable. IVIg may have a role where acute disease is present and conventional therapy is contraindicated because of severe infection. Tumor necrosis factor antagonist therapy has been evaluated with infliximab and etanercept, but high infectious complication rates in initial studies point to the need for further investigation prior to their routine clinical use for AAV.
Maintenance Therapy
Following the induction of remission, patients are transitioned to maintenance therapy, the goal of which is to sustain remission with medications associated with less severe side effects. Historically, patients have been transitioned off of the induction agent to methotrexate, azathioprine, or leflunomide after twelve months of therapy.
However, the Cyclophosphamide versus Azathioprine for Remission in Generalized Vasculitis (CYCAZAREM) trial revealed that an earlier transition to azathioprine maintenance therapy is acceptable.14 In this study, no increase in the rate of relapse or worsening in renal function was found when most patients were transitioned to maintenance at between three and six months. Hiemstra et al. compared mycophenolate mofetil to azathioprine for maintenance therapy and found that mycophenolate mofetil was less effective than azathioprine at maintaining disease remission in AAV.15 Therefore, azathioprine is the preferred agent for maintenance therapy.
The role of trimethoprim-sulfamethoxazole or nasal mupirocin use for reduction of Staphylococcus aureus carriage in the prevention of relapse in unclear at this time. Currently, trimethoprim-sulfamethoxazole is recommended as Pneumocystis jirovecci prophylaxis while patients are on systemic immunosuppression; an added benefit may be a reduction in the rate of relapse based on eradication of nasal Staphylococcus aureus. Most experts recommend that maintenance therapy be continued for about two years before discontinuation is considered. When relapse occurs, reinduction therapy is typically required.
What is the prognosis for patients managed in the recommended ways?
The survival rate of patients with pulmonary vasculitis has improved dramatically with the initial studies by Fauci that introduced the therapy with cyclophosphamide and prednisone. 16Despite these advances, however, relapse is common, as two-thirds of patients with NGV and a third of patients with MPA have at least one relapse within five years of diagnosis. The majority of deaths can be attributed to vasculitis itself, followed by infectious complications as the etiology in 13-26 percent of patients. Therefore, careful monitoring for infectious complications (which can mimic disease relapse) is critical in the longitudinal management of patients with pulmonary vasculitis.
The five-year survival rate among appropriately managed patients with NGV is 75 percent. The survival rate decreases with advancing age, severe renal dysfunction, pulmonary involvement (DAH), low albumin, and high anti-PR3 levels. CSS carries a higher five-year survival rate of 70-100 percent, while MPA has a lower five-year survival rate of 45-75 percent.17
Guillevin et al. developed a validated five-factor prognostic scoring system for CSS and MPA 18 that consists of proteinuria (>1g/24 hours), elevated serum creatinine (>1.58 mg/dL), and clinically significant cardiac, gastrointestinal, or central nervous system involvement. In CSS, the mortality rate increases significantly when two or more organs are involved, with a relative-risk of 1.36. In MPA, a clinical severity score of 0 confers an 88 percent five-year survival rate, while a score of two or higher is associated with 54 percent survival rate.
What other considerations exist for patients with pulmonary vasculitis?
Longitudinal monitoring of patients with AAV requires careful evaluation for disease relapse and complications of therapy. The clinician must be cautious that signs or symptoms consistent with a flare of vasculitis may also represent signs of infection or drug toxicity. In addition, the incidence of venous thromboembolic disease in patients with AAV is several times higher than that of the general population, so it should be considered in the differential diagnosis of disease flare.
Significant concern has been raised about the use of leukotriene inhibitors and omalizumab in severe steroid-dependent asthma regarding their conversion of severe asthma to CSS. However, after the initial concerns for each of these therapies were raised, data has not supported a pathogenic role for either; instead, this effect was likely related to a withdrawal of corticosteroids in patients with pre-existing CSS.
What's the evidence?
Lane, SE, Watts, R, Scott, DG. "Epidemiology of systemic vasculitis.". Curr Rheumatol Rep. vol. 7. 2005. pp. 270.This excellent overview of the epidemiology of systemic vasculitis discusses regional and ethnic variations in the published data.
Gatenby, PA, Lucas, RM, Engelsen, O, Ponsonby, AL, Clements, M. "Antineutrophic cytoplasmic antibody-associated vasculitides: could geographic patterns be explained by ambient ultraviolet radiation?". Arthritis Rheum. vol. 61. 2009. pp. 1417.This ecological study attempts to describe and quantify a possible association between UV radiation levels and the incidence of ANCA-associated vasculitis. The authors conclude that ambient UV radiation may provide a protective immunomodulatory effect on the onset of NGV and CSS.
Mandl, LA, Solomon, DH, Smith, EL, Lew, RA, Katz, JN, Schmerlin, RH. "Using antineutrophil cytoplasmic antibody testing to diagnose vasculitis: can test-ordering guidelines improve diagnostic accuracy?". Arch Intern Med. vol. 162. 2002. pp. 1509.Mandl and colleagues used a retrospective case series from two academic medical centers to measure the diagnostic accuracy of ANCA testing and to determine how applying proposed ANCA ordering guidelines can affect test performance. The authors conclude that using guidelines for testing would decrease the false-positive rate by 27 percent and that no cases of AAV would be missed. This study adds to the data suggesting that ANCA is not a screening test and that it should be applied in appropriate clinical scenarios to reduce the number of false-positive results and expenditures.
Finkielman, JD, Lee, AS, Hummel, AM, Viss, MA, Jacob, GL, Homburger, HA. "ANCA are detectable in nearly all patients with active severe Wegener's granulomatosis.". Am J Med . vol. 120. 2007. pp. 643.Finkielman and colleagues prospectively evaluated serum samples from 180 patients using three methods to detect ANCA and stratified patients by disease activity. The authors conclude that ANCA are detectable in 96 percent of patients with severe NGV and in 83 percent of patients with limited disease if all three detection methods are used.
Choi, HK, Liu, S, Merkel, PA, Colditz, GA, Niles, JL. "Diagnostic performance of antineutrophil cytoplasmic antibody tests for idiopathic vasculitides: meta-analysis with a focus on myeloperoxidase antibodies.". J Rheumatol. vol. 28. 2001. pp. 1584.This meta-analysis focused on the diagnostic value for ANCA and anti-MPO antibody testing for idiopathic systemic vasculitis. The results suggest that immunoassays for anti-MPO and immunofluorescence for pANCA is highly specific and that both tests should be used together. The authors recommend combining anti-PR3 and anti-MPO testing with ANCA to optimize diagnostic precision.
Schnabel, A, Holl-Ulrich, K, Dalhoff, K, Reuter, M, Gross, WL. "Efficacy of transbronchial biopsy in pulmonary vasculitides.". Eur Respir J. vol. 10. 1997. pp. 2738-2743.Schnable and colleagues evaluated the role for transbronchial biopsy in patients with mild to moderate pulmonary involvement from NGV and CSS. This small case series found that transbronchial biopsies are seldom positive in NGV unless they are taken from areas that are grossly abnormal. In contrast, tracheobronchial lesion biopsies had a high rate of positive findings. CSS patients had a similar yield from upper and lower respiratory tract biopsies.
Devaney, KO, Travis, WD, Hoffman, G, Leavitt, R, Lebovics, R, Fauci, AS. "Interpretation of head and neck biopsies in Wegener's granulomatosis: a pathologic study of 126 biopsies in 70 patients.". Am J Surg Pathol . vol. 14. 1990. pp. 555.The authors propose criteria for the diagnosis of NGV based on biopsy specimens from the head and neck region based on 126 biopsies of this body region. Of note, the combination of vasculitis, necrosis, and granulomatous inflammation were seen together in only 16 percent of specimens.
Hoffman, GS, Kerr, GS, Leavitt, RY, Hallahan, CW, Lebovics, RS, Travis, WD. "Wegener's granulomatosis: an analysis of 158 patients.". Ann Intern Med . vol. 116. 1992. pp. 488.The authors prospectively studied the clincal features, pathophysiology, treatment, and prognosis in 158 patients with NGV for 1229 patient-years and concluded that the clinical course of NGV has improved significantly with the addition of cyclophosphamide and glucocorticoids. The authors raise concerns about the toxicity of long-term cyclophosphamide therapy and encourage further investigation of alternative regimens.
de Groot, K, Rasmussen, N, Bacon, PA, Tervaert, JW, Feighery, C, Gregorini, G. "Randomized trial of cyclophosphamide versus methotrexate for induction of remission in early systemic antineutrophil cytoplasmic antibody-associated vasculitis.". Arthritis Rheum . vol. 52. 2005. pp. 2461.This randomized clinical trial compared cyclophosphamide and methotrexate for induction in early AAV in an unblinded fashion. The authors conclude that methotrexate can replace cyclophosphamide for initial treatment in early disease. However, methotrexate was less effective in patients with extensive pulmonary disease.
de Groot, K, Harper, L, Jayne, DR, Flores Suarez, LF, Gregorini, G, Gross, WL. "Pulse versus daily oral cyclophosphamide for induction of remission in antineutrophil cytoplasmic antibody-associated vasculitis: a randomized trial.". Ann Intern Med . vol. 150. 2009. pp. 670.This randomized controlled trial by de Groot and colleagues has had a significant impact on dosing of cyclophosphamide in AAV. The pulse regimen was noninferior to daily oral cyclophosphamide for inducing remission of AAV, and it had a reduced cumulative dose of drug and less leukopenia.
Jayne, DRW, Gaskin, G, Rasmussen, N, Abramowicz, D, Ferrario, F, Guillevin, L. "Randomised trial of plasma exchange or high dose methylprednisolone as adjunctive therapy for severe renal vasculitis.". J Am Soc Nephrol . vol. 18. 2007. pp. 2180.The role for plasma exchange in severe AAV with renal failure has been controversial. This randomised trial in patients with AAV and renal failure found improved survival and freedom from dialysis at three months with plasma exchange in addition to standard therapy (69% vs. 33%).
Stone, JH, Merkel, PA, Spiera, R, Seo, P, Langford, CA, Hoffman, GS. "Rituximab versus cyclophosphamide for ANCA-associated vasculitis.". N Engl J Med . vol. 363. 2010. pp. 221.Stone and colleagues conducted a randomized, controlled noninferiority trial that compared rituximab to standard cyclophosphamide therapy for the induction of remission in patients with severe NGV or MPA. The results met criteria for noninferiority with a primary end point of remission of disease without the use of prednisone at six months. The data also suggests that rituximab may be superior in patients with relapsing disease.
Jones, RB, Tervaert, JW, Hauser, T, Lugmani, R, Morgan, MD, Peh, CA. "Rituximab versus cyclophosphamide in ANCA-associated renal vasculitis.". N Engl J Med . vol. 363. 2010. pp. 211.This study evaluated rituximab in AAV with renal involvement compared to therapy with cyclophosphamide. Patients who received rituximab were given two IV doses of cyclophosphamide and then were compared to patients who received cyclophosphamide for 3-6 months, followed by azathioprine therapy. Rituximab was found to be non-inferior, and both groups had high rates of sustained-remission. This study and the Stone et al. study showed no significant difference in adverse events between treatment groups.
Jayne, D, Rasmussen, N, Andrassy, K, Bacon, P, Tervaert, JW, Dadoniene, J. "A randomized trial of maintenance therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies.". N Engl J Med . vol. 349. 2003. pp. 36.Prolonged cyclophosphamide therapy can be associated with adverse effects. This study by Jayne and colleagues evaluated the role for azathioprine in reducing the exposure to cyclophosphamide in patients with generalized AAV. After remission was obtained on standard cyclophosphamide therapy (at least three months), patients were randomly assigned to continued therapy versus azathioprine. The primary end point was relapse, and no difference was noted in the two study groups, suggesting that azathiopriine may be substituted for cyclophosphamide after remission has been achieved in generalized vasculitis.
Hiemstra, TF, Walsh, M, Mahr, A, Savage, CO, de Groot, K, Harper, L. "Mycophenolate mofetil vs. azathioprine for remission maintenance in antineutrophil cytoplasmic antibody-associated vasculitis: a randomized controlled trial.". JAMA. vol. 304. 2010. pp. 2381.Azathioprine has been shown as an effective alternative to cyclophosphamide once remission has been achieved in AAV. The IMPROVE trial tested the hypothesis that mycophenolate mofetil may be more effective than azathioprine in preventing relapses in AAV. This open-label, randomized trial found that mcyophenolate mofetil was less effective for maintaining remission than azathioprine was, and both groups had similar rates of adverse events. Therefore, based on the current literature, azathioprine should be chosen as a cyclophosphamide-sparing agent over mycophenolate mofetil to maintain remission in AAV.
Fauci, AS, Haynes, BF, Katz, P, Wolff, SM. "Wegener's granulomatosis: prospective clinical and therapeutic experience with 85 patients for 21 years.". Ann Intern Med . vol. 98. 1983. pp. 76.This seminal paper revolutionized therapy for NGV. Fauci and colleagues prospectively evaluated eighty-five patients over twenty-one years and showed that 93 percent of patients achieved complete remission with cyclophosphamide and prednisone therapy.
Phillip, R, Luqmani, R. "Mortality in systemic vasculitis: a systematic review.". Clin Exp Rheumatol. vol. 26. 2008. pp. S94.This review by Phillip and Luqmani documents the improvement in survival of patients with systemic vasculitis, as well the improvements in our diagnostic tools over time.
Guillevin, L, Cohen, P, Gayraud, M, Lhote, F, Jarrhousse, B, Casassus, P. " Churg-Strauss syndrome: clinical study and long-term follow-up of 96 patients.". Medicine . vol. 78. 1999. pp. 26.Guillevin and colleagues retrospectively evaluated clinical manifestations, prognostic factors, and long-term outcome in ninety-six patients with CSS between 1963 and 1995. The article provides an excellent overview of the clinical manifestations and course of patients with CSS.
Merkel, PA, Lo, GH, Holbrook, JT, Tibbs, AK, Allen, NB, Davis, JC. "Brief communication: high incidence of venous thrombotic events among patients with Wegener granulomatosis: The Wegener's Clinical Occurrence of Thrombosis (WeCLOT) study.". Ann Intern Med . vol. 142. 2005. pp. 260.The WeCLOT study prospectively followed a cohort of 180 patients with NGV and documented venous thrombotic events. The authors found 16 VTEs in 167 patients with a median time from enrollment (active disease) to VTE of 2.1 months. The incidence of VTE was 7 per 100 person-years. The authors comment on this high rate in comparison to patients with lupus and RA and to the general population.
Frankel, SK, Jayne, D. "The pulmonary vasculitides.". Clin Chest Med . vol. 31. 2010. pp. 519.This excellent review discusses the epidemiology, diagnosis, and therapy of patients with AAV.
Brown, KK, Cool, CD, Murray, JF, Nadel, JA. "Pulmonary vasculitis.". Murray and Nadel's textbook of respiratory medicine. Elsevier Saunders. 2010. pp. 1244-1260.The book chapter discusses the epidemiology, pathology, diagnosis, and therapy of pulmonary vasculitis.
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Eagle Eyed Hansen to Attack Track Nationals
30th January 2013
For immediate release:
Eagle Eyed Hansen to Attack Track Nationals with Renewed Focus
Natasha Hansen has unfinished business in the sport of cycling and intends to be rather busy defending four titles at the Elite Track Nationals in her home town of Invercargill starting this Thursday in a story that is typically 'Kiwi' as the 23 year old holds down a fulltime job while chasing her sporting dreams.
An Air Traffic Controller by day, the London Olympian is used to keeping her eye on incoming traffic but intends flying around the Invercargill Velodrome with renewed vigour after ending 2012 by her own admission down on form and motivation.
"Following the Olympics I took a month off the bike before getting back into training for the current season which kicked off for me late November at the Oceania Championships held in Adelaide," said Hansen.
"Training started off well in October and I was pretty excited to build on the momentum from the previous year, especially with the rise of the women's sprint programme. In particular I was looking forward to racing at another World Cup and then eventually onto my second World Championships in March 2013, where I was hoping to better my results from the Olympics."
Circumstances have since meant that Hansen won't race at the World Champs, a decision she understands and has come to terms with, working with Bike NZ to reassess her goals and focus on returning to top form and fitness, starting with the defence of the four national titles won last year.
"Now that I'm back in New Zealand I feel more focused and determined to go well at the National Championships as I not only defend my titles in the sprint, keirin, team sprint and 500m time trial, but I also hope to produce personal best times in the flying 200m and 500m time trial."
Hansen is no stranger to the high pressure environment of top level sport, with every one of her working days requiring a focus on the job at hand.
"On top of all my bike training, I work full time as an Air Traffic Controller; a combination which I believe compliments each other as the shift work enables me to spend my spare time meeting all of my training requirements.
"My main goal now is a strong finish to the New Zealand season, which will hopefully lead to a good off season and eventually selection for the Glasgow Commonwealth Games. I know I can do it, and I need to, not just for me, but to prove that the women's sprint programme is a good investment for the sport.
"Bike NZ has been great and I continue to receive great support from them, but I can't feel sorry for myself either, it is time to roll up the sleeves and get on with being the best athlete I can be."
For further information contact:
Natasha Hansen
0211 709 979
The programme is (courtesy of BikeNZ):
Thursday 31 January: Men and women individual pursuit, men and women 250m time trials. Evening finals: Under 19 and elite time trials, individual pursuit finals, Men under-19 scratch race.
Friday qualifying: Elite sprint, under-19 individual pursuit, under-19 keirin. Evening finals: Elite sprint, under 19 individual pursuit, under-19 kerin, women points race, men scratch race.
Saturday qualifying: Under 19 sprint, elite keirin, under 19 points. Evening finals: Under 19 sprint, women's under 19 points, elite women scratch, men keirin, men's points.
Sunday qualifying: Elite team pursuit, elite and under-19 team sprint. Evening finals: Elite team pursuit, under-19 and elite team sprint, men's Madison.
Full details: www.bikenz.org.nz. Live ticker cover and
results: www.cyclingsouthl.org.nz


text:
Also Called
- Mental Reality Manipulation/Warping
User can bend reality via their or others's thoughts and imagination, they can change any and all aspects of reality, allowing them to achieve nearly anything simply by willing it.
Mentifery is both Reality Warping's strongest form and purest expression, allowing the user to directly achieve any desired change on thought alone, both rational and irrational alike, unhindered by the need for templates, materials, or proxies.
Applications (General)
Applications (Detail)
- Creation
- Death Inducement
- Destruction
- Energy Manipulation
- Event Manipulation
- Event Negation
- Imagination Manifestation
- Immortality
- Invulnerability
- Matter Manipulation
- Mental Manipulation
- Mental Projection
- Physics Manipulation
- Probability Manipulation
- Psionic Manipulation
- Reality Condition
- Rule Bending
- Shapeshifting
- Space-Time Manipulation
- Superpower Manipulation
Master-Level Applications
- Potentially all Almighty Abilities including, but not limited to:
- Absolute Existence
- Absolute Will
- Absolute Wish
- Belief Warping
- Causality Manipulation
- Complete Arsenal
- Dual Warping
- Impossibility Inducement
- Logic Manipulation
- Meta Ability Creation
- Meta Power Manipulation
- Meta Probability Manipulation
- Meta Summoning
- Meta Teleportation
- Nonexistence
- Omnikinesis
- Omnificence
- Paradox Manipulation
- Possibility Inducement
- Perspective Manipulation
- Subjective Reality
- Ultipotence
- Virtual Warping
- May be less effective if the user is not at their peak mental state; i.e. fatigue, and sickness.
- The user cannot form or create what they are incapable of imagining.
- Without restraint, a single wild thought could have devastating consequences.
- Self-control tricks are thus necessary, unless the user is well prepared, or born with it.
Known Users
- Anthony Fremont (It's a Good Life)
- Minus (minus)
- SackBoy:SackGirl (LittleBigPlanet)
- Beyonder (Marvel); pre-retcon
- Franklin Richard (Marvel)
- Jim Jaspers (Marvel)
- Fred Jones (Supernatural)
- Jesse Turner (Supernatural)
- Gremmy Thoumeaux (Bleach)
- Jasdevi (D.Gray-man)
- Yugi (Tenchi in Tokyo)
- Demiurge (Valkyrie Crusade)
- Kurome (Hyperdimension Neptunia VII)
- Ancients (Skylanders)
- Brain (Skylanders)
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Best Program to lose Weight
Started by KylieY , Feb 19 2013 03:19 PM
26 replies to this topic
Posted 19 February 2013 - 03:19 PM
Hi there
I have just come home from the doctors with my blood test results. I have low Vitamin D, even lower iron, slightly high cholesterol and a fatty liver. I do not drink, so the doctor told me it is most likely my diet.
I need to lose 20 kilos. I have tried to lose weight hundreds of times. And every time I fail. Every.single.time. Now with these health issues I really need to get serious. My sister is a personal trainer, so I can exercise with her and I have recently bought a bike, so the exercise part is covered.
I need to really look at my food. This is where I get into trouble. I love food. I love reading about it, cooking it, I love menu planning, I love all cooking shows.
But I have an overwhelming fear of failing yet again. I don't know what program to follow so I thought I'd come in here for suggestions. I need a diet rich in fibre and high in protein and iron. Are there any great cookbooks out there that have recipes I can follow?
Any info, I'd be grateful.
Posted 19 February 2013 - 03:27 PM
Join weight watchers, attend their meetings and track what you eat. It's a very sensible program and you'll get tonnes of support.
Posted 19 February 2013 - 03:34 PM
I would also suggest Weight Watchers. It will give you the skills and support to get yourself on track.
Posted 19 February 2013 - 03:36 PM
Honestly, I wish I knew the answer.
I lost more than 20kg using My Fitness Pal (myfitnesspal.com) to track my food and exercise but over the last two years have found that it's creeping back on again.
There is no mystery as to why I'm putting on weight - the issue is that I'm eating too much junk and not exercising enough. The problem I have is that I just find it so hard to make changes that I can keep up for the longterm.... like lots of people I've lost weight and put it back on again more times than I can count, purely because of my bad habits.
So, for me, the question is not "how can I lose weight" but "how can I change my eating habits and mindset around food so I don't spend the rest of my life yo-yo-ing".
I know this is not answering your questions, but I'd really encourage you not to just "go on a diet" but start thinking about the things that will have to change forever if you want to get to a healthier weight and stay there.
I have found a book by Gillian Riley to be quite helpful, called "Eating Less". And MFP (myfitnesspal.com) is worth a look too, it's free, easy and can be effective if you "just want to lose weight".
Posted 19 February 2013 - 03:46 PM
Thanks Happy Mummy - I have tried Weight Watchers before - I shall look into it again.
And thanks Rubybelle - I was nodding the entire time I was reading your post. I will download that app, thanks. That books sounds quite interesting. And I too am the same as you. I know it all comes down to my bad habits.
Thanks again.
Posted 19 February 2013 - 03:52 PM
I can't recommend My Fitness Pal enough. It has changed my way of thinking about food. I have learnt so much, and have never lost this much weight ever in all my weight loss attempts. (see ticker) There's also a handy app for smart phones where you can scan barcodes for nutritional info. It works everything out for you.
Best of luck!
Posted 19 February 2013 - 03:53 PM
Hi Kylie,
I have been using Michelle Bridges crunchtime cookbook. I exercise probably 3 or 4 nights a week and I've lost 5kg in 7 weeks (8.5% of my body weight) and it's SO EASY. The food is delicious, she has a 12 week meal plan so you can just follow that, or swap and change for recipes you like. There is also scope to try new flavours/variations and it doesn't feel like a "diet", but more a learning curve. I've had take away most Sunday nights, and still have the odd choccie and wine, so by no means am I being an angel, but the book teaches you about portions, what foods to eat etc so that my choices are wiser.
Oh, and I love cooking shows and meal planning too and I've found this great.
Edited by emlis22, 19 February 2013 - 03:55 PM.
Posted 19 February 2013 - 03:59 PM
Dietician - on a care plan from your GP so should be free/close to it.
exercise (walking doesn't count) 4 times a week.
Use a entree plate instead of a dinner plate whenever you eat.
Try to always leave something on your plate. Even if it's the salad to start with!!!
Stop drinking anything cold besides water - no cordial/soft drink/diet anything. Sparking water with a squeeze of REAL lime/lemon juice is OK.
And get your husband/partner/best friend on board.
And lastly, stop bothering weighing yourself. Measure around your arms/thighs/waist/hips instead. This will reduce more quickly than your weight and give you some positive feedback to help keep you motivated.
Posted 19 February 2013 - 04:10 PM
Combine MFP and the CSIRO diet.
CSIRO diet has lots of meat, so high in protein & iron, and is low carb.
MPF helps you keep track of calories, so you know how much you can eat.
Posted 19 February 2013 - 04:10 PM
Hi KylieY,
Late last year I did the michelle Bridges 12week program and it was awesome! I lost 13 kgs in 12 weeks and this was weight I had been trying to shift for about 6 years! It was so successful I found myself knocked up at the end of it but as soon as I have this baby I will be back on it.
You sign up for 12 weeks and she sends you all your meal plans and exercise for 7 days. then you get 2 videos weekly from her ( for the group) which she talks about your mindset. It was amazing as she made me think of why I was overweight and not just the food side. She has a forum also which was invaluable help but the great part was, there are facebook groups that you can join for your area and you can choose to meet up for group training to follow the program that Michelle sends you or you can do it alone. I am so not a 'group meeting strangers' person but I bit the bullet and did them and I am so glad I did as I have met some really nice people who have offered great support when I have needed it. Not I know it is not for everyone as it is pretty full on exercise wise and is a very low cal diet.
I have joined weight watchers before but I hated it as I felt they pushed way too much of 'fat free' treats and frozen meals (which is their income I know) and I do not think they encouraged you to exercise much beyond walking.Good luck
Posted 20 February 2013 - 01:27 PM
I would also recommend Michelle Bridges 12wbt. I'm doing it currently and I think it is a fantastic program which works on changing your thinking as well as your habits.
Posted 20 February 2013 - 01:35 PM
My wife and I followed the CSIRO diet. It comes with a complete menu for 12 (? - I think it was 12) weeks of the diet, including recipes for all meals.
I lost 8 kilos and that was without exercising (due to cronic knee and back problems) and I was sometimes a bit lax with the diet.
The downside was that some of the recipes we a bit involved and took a bit of preparation time.
Posted 26 February 2013 - 09:09 AM
I can not recommend the Michelle Bridges 12wbt enough. I lost 15kg on the program and have continued to lose weight. To date I have lost 20kgs. It is fantastic.
I managed to this with 3 children and did not find the program difficult to follow.
Posted 26 February 2013 - 09:17 AM
I need to lose weight too, and have been wondering about the MB plan.
What is the exercise in the Michelle Bridges 12wbt?
Posted 27 February 2013 - 08:09 AM
I have to say it depends on how self motivated you are. From what I've seen Michelle Bridges WBT is fantastic but perhaps you need a really good personal trainer who knows exercise AND food (sensible food) who can keep you accountable.
WW can also be useful for this but I tend to agree the exercise component is a bit on the soft side. Exercise is particularly important in maintaining your weight.
I also second getting your husband on board.
Posted 27 February 2013 - 08:20 AM
I have recently lost 35kg with weight watchers. I love it because you can eat whatever you choose, and since you love cooking it would suit you perfectly. Many of the WW recipes are delicious and there are heaps on their website. Or you can just cook the same food as you always have and just enter it into their online tracker, it will tell you how many points it is and you can just limit your portion sizes. So you wont have to sacrifice your love of food or cooking.
I have never had success doing it on my own, I always end up giving up after a few days. But the weekly weigh in at WW is a huge motivator and keeps you on track. Oh and I didnt exercise at all and still lost it at a reasonable pace, so if you are going to work out with your sister you will have a lot of success.
Posted 27 February 2013 - 08:45 AM
Programs like Weight Watchers and Michelle Bridges are good to help get you motivated. Dont do anything that promises quick results (especially if it involves a milkshake replacement!). Focusing on living a healthy lifestyle rather than focusing on the numbers on the scale will be a more sustainable way of gaining long term goals.
I wanted to add though that you cant "fail" at losing weight. Every time you do something healthy for yourself you get better at it. Dont ever beat yourself up just start a new day
#18 Guest_Waiting ..._*
Posted 27 February 2013 - 08:55 AM
If you can afford a "coach" (could be a dietician, GP, Personal Trainer ... even a trusted friend) that you have to "check in with" and can gain support from I believe that this makes all the difference. Most importantly you should keep your relationship with them until you have maintained the weight-loss for a goal period and instilled the new habits or it is all too easy to fall straight back off the bandwagon!
I believe that this provides the psychological support that is all too often forgotten about when we focus on what type of "diet" approach should be used and also makes you accountable to someone.
I love the Lorna Jane blog for really yummy "clean" recipes so have some fun researching new food types if this is what you enjoy! Pinterest is also great for new healthy recipes. There is no reason to stop reading, researching, cooking and loving food ... it will just be about discovering and experimenting with new choices and possibly revising serving sizes.
Good on you for making this first step forward!
Posted 27 February 2013 - 09:00 AM
Cut out preservatives, sugar, processed food. There is a great blog called "Cut out the crap" with recipes etc.
Posted 27 February 2013 - 09:08 AM
I cannot recommend the Michelle Bridges 12wbt enough! When I started I could hardly walk because of SPD after 3 babies, two rounds later I am 31.5 kg lighter and I can run! I've never been able to run!
I still have 15kg to go and I barely have to think about it anymore, my lifestyle has changed forever. Michelles mindset videos are amazing!
Good luck!
Posted 27 February 2013 - 02:36 PM
If you love food and love cooking - go to www.paleoplan.com
I'm not overweight. In fact I weigh 57kgs. BUT, until I looked into paleo eating, I could never lose that last 2 kilograms that would make me feel comfortable (I was always 59 kilograms)
Paleo cooking uses all natural veg/fruit/meat/nuts/eggs etc - eat as much as you like (well I do).
The biggest thing for me was that I'm never hungry eating paleo style foods.
Its like a religion for me now - I tell everybody they have to eat this way.
i promise the weight will drop off you - HELL, I got rid of the last 2kilograms really easily.
If you have a heap of weight to lose, it will drop of you so easily.
Posted 28 February 2013 - 06:51 PM
Rubybelle makes a lot of sense. You need to think of this as an eating and exercise plan for life. I have been using my fitness pal to track energy intake and output, basically reducing portion sizes and doing things like not putting butter under spreads on toast, only having a muffin at morning tea once a week etc.
I also allow myself a bit of a blowout at weekends, as this is for life, not a short term 'diet'.
I run twice a week, do weights twice a week and swim once a week. I also walk when I can and take the stairs.
Yes, it's dull, yes it has no fancy book or gimmicks and yes it has taken me eight months to lose eight kilos, but it's not creeping up and I feel that this is sustainable. I don't feel I am depriving myself.
Edited to over come iPad itis...
Edited by Canberra chick, 28 February 2013 - 07:25 PM.
Posted 28 February 2013 - 06:55 PM
Please do not part with your money and join the likes of WW or lite n easy! Clean eating its the easiest thing you can do and you will get amazing results!
Posted 07 March 2013 - 05:34 PM
I hated Michelle's 12wbt. I personally found it to be ultra competitive, and totally focused on the numbers on the scales. I found there were so many people doing it that the forums get flooded, your questions get moved to pages down and often go unanswered. There wasn't the support there that I'd been hoping for.
I found her mindset video's hard to relate to. She's never been overweight a day in her life. She can try and be as empathetic as she likes, but she has no clue what it's like to be overweight, to try and change a lifetime of bad eating habits.
Posted 07 March 2013 - 06:01 PM
I joined Weight Watchers online program a few weeks ago, and it suits me to a tee. I love cooking and love trying new recipes, and the tracker has a recipe builder you can add your recipes to, and works out the points value for you.
It makes you accountable for what goes into your mouth......I have a LOT of weight to lose and it's coming off slowly but surely. I am just eating my regular meals but have removed butter and oil from them, and have cut down on the amount of bread I eat considerably. The portions are smaller....a recipe for 4 now is 5 or 6 servings.
No junkfood, no high calorie treats, but I'm not missing out on anything because I've found replacements (Bulla 98% fat free ice cream etc) and fruit.
I don't go to meeting because I'm just not a meetings person, but I weigh myself weekly and record the weight on the tracker and it's on a gradual downward slope.
My exercise is walking for 30 minutes per night but I'll increase that as my fitness levels increase.
WW don't "push" anything, even on the community forums have never seen anyone recommend a WW branded product over something else. They have loads of recipes to try too.
My weight loss program isn't a diet, it's a lifestyle change and I'm in the headspace that this is forever. And I'm happy with that.
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Here are some ideas for getting that budget in shape, ready for being a one income family.
Baby Names
Need some ideas?
See what names are trending this year.


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Run for Shelter
Two area homeless ministries split $20,000 thanks to last month's inaugural Run for Shelter 5K.
Rusty Marsh, of Augusta Rescue Mission, and Roger Gardner, of New Hope Bridge Ministry, at right, were on hand with supporters for a ceremony outside Augusta Rescue Mission on Walker Street.
The April 28 race drew an estimated 250 runners and netted $10,000 for each ministry.
Since 1965, Augusta Rescue Mission has served homeless men in Augusta with an overnight shelter that offers meals, clothing and chapel services. The ministry runs a long-term resident worker program to help men find jobs.
The Bridge Ministry of New Hope Worship Center in Grovetown holds weekly services under the John C. Calhoun Expressway bridge at 15th Street. Every Saturday, homeless men and women are offered hot meals, clothing, food and hygiene kits. Learn more at augustarescuemission.org or nhwc.org.
Be A Fan drive
The annual Be A Fan drive of Area Churches Together Serving, an Aiken nonprofit, kicked off Friday and continues today in Aiken.
The drive collects fans to be given to low-income residents of Aiken County this summer. To participate, buy a new box fan at Lowe's, 2470 Whiskey Road, and give it to ACTS volunteers who will be stationed at the store from 10 a.m. to 6 p.m. today. Fans cost $16 each. Receipts for tax purposes will be available.
For more information, see actsofaiken.org.
Revien in concert
St. Andrew Presbyterian Church, 3551 Wheeler Road, will play host to Athens-based group Revien in a concert called Sweet Music IV at 3 p.m. May 20.
The trio features Phil Snyder on cello, Kyle Dawkins on guitars and electronics, and Brian Smith on guitars and electronics. Tickets cost $10.
Call (706) 736-4575 for more information or see revientrio.tumblr.com. Dessert will be served.
Women's ministry
The Augusta area Magnificat Ministry for women will have a meal and meeting at 9:30 a.m. May 19 at St. Mary on the Hill Catholic Church Parish Hall, 1420 Monte Sano Ave. Amy Parris, parishioner at Holy Trinity Catholic Church, will speak.
The cost is $10. For more information, call (706)
– Kelly Jasper, staff writer


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Aside from looking amazing in trousers and sometimes having Fido Dido hair, Tilda Swinton stands out a mile in any Hollywood identity parade. She's well known for boasting one of the most eclectic, intriguing bodies of work of any actor currently working, an Academy Award and a determination to do things her own way. After all, among all the battle-hardened Method actors and wet-behind-the-ears starlets, it's pretty rare to hear a movie star confessing that, all things being equal, they'd just as happily be doing something else. Swinton, though, is a pretty rare movie star. "Acting," she's said, "is something that I have relatively little interest in". God help us when she finds something she is interested in. Until then, we're happy to watch her light up the work of directors like Jarmusch, Fincher, Jarman and the Coen brothers. Now with We Need To Talk About Kevin, she's united with fellow Scot Lynne Ramsay, to wow and disturb festival crowds with a powerful adaptation of Lionel Shriver's novel. It's time to talk about Tilda.
ESSENTIAL VIEWING: Michael Clayton (2007)
Every thriller needs a decent baddie, someone to hatch evil schemes, organise assassinations and sign the cheques. Tilda Swinton provides a nasty addition to the canon in Tony Gilroy's '70s-flavoured thriller, picking up an Oscar in the process. As Karen Crowder, she's the well-groomed face of corporate corruption, clad in a suit Condoleezza Rice would kill for and an air of anything-for-a-buck amorality. Legal counsel for U-North, an agribusiness giant with a dark secret to keep, she's obliged to get her hands dirty, arranging the murder of Tom Wilkinson's loose cannon attorney. But playing nasty is the easy bit. What marks Swinton's performance out is the way she humanises Crowder, making her believable, even relatable. Behind a façade of power suits and froideur, she's struggling to keep it together. Think of Max von Sydow in Sydney Pollack's Three Days Of The Condor, John Lithgow in Blow Out or any of the Parallax Corporation's nameless goons: Swinton's lawyer rivals them all for ruthlessness, but watch her sweating off a pot belly on the treadmill and try not to feel at least a pang of empathy, too.
ESSENTIAL VIEWING: Orlando (1992)
Never afraid to clock on for sexy time, Swinton makes a bold move through gender and time in Sally Potter's colourful adaptation of Virginia Woolf's novel. She's mesmerising as the title character: a time traveller, shapeshifter and walking origin story for anyone who's agonising about the significance of sexuality, gender and upbringing. When we meet Orlando he's an Elizabethan courtier engaged in an affair with the Fairie Queen herself - or 'himself', considering she's played by Quentin Crisp - that flickers and burns like a chamber candle. A switch of epochs – and genders – eventually finds her living as a 19th century woman, hobnobbing with poets and having an affair with a seafaring Billy Zane. She's basically Highlander in a wig. It's a metaphysical delight that charms and confounds in equal measure, and Swinton is its swooning heart. It's no common film that has a woman playing a man having an affair with a man playing a woman ('Some Like It Smock'?) but then we did say she did things her own way.
ESSENTIAL VIEWING: I Am Love (2009)
For a polymath with an IQ higher than your phone number, Tilda Swinton wears her smarts lightly. In Luca Guadagnino's refined Italian drama she flaunts her impressive Italian as Russian émigrée Emma Recchi, an outsider married into an ailing Milanese family pitched somewhere between the Addams and the Friedmans on the dysfunction scale. Swinton's natural restraint serves her character perfectly, with Recchi's thin tissue of gentility masking deep pools of passion that fizz to the surface when she embarks on a high-risk affair with her son's friend Antonio (Edoardo Gabbriellini). Here Swinton's exploration of female sexuality – mined previously her collaborations with Derek Jarman and films like Orlando and Female Perversions – zones in on the darker, scarier conflict between duty and desire, a battle where the craving for love (and a good bonk) usually wins out in a life full of empty pleasures. So it proves here, with Swinton evoking the dual life of a woman living on a knife-edge with unusual skill.
RECOMMENDED: Edward II (1992)
If Derek Jarman were still alive and turning out art-house flicks dripping in decadence and style, it's inconceivable that Tilda Swinton wouldn't be adorning them. The actress describes the seven films the pair made together as "a kind of a kindergarten", albeit one in which the toys and rattles are probably swapped for poetry tomes and the nanny has an Oedipal complex. The success of Jarman's arty biopic Caravaggio flowed on into this bold refashioning of Christopher Marlowe's play as a weirdly postmodern treat, replete with gay battalions, Sony Walkmans and Annie Lennox cameos. It's rich in anachronism and allegory (if you're looking for an inspiration for Baz Luhrmann's Romeo + Juliet, look no further) and the Hermes-clad Swinton is dynamite as the jilted French queen who can only gaze jealously on as King Edward (Steven Waddington) carries on with his dishy pal, Piers Gaveston (Andrew Tiernan). OK, so she watches and then turns into a furious, gun-toting vamp. Everyone has a breaking point.
RECOMMENDED: Burn After Reading (2008)
The Coen brothers' spy caper is full of cornball joys – Brad Pitt's tracksuited idiot; Frances McDormand's vain accomplice; J. K. Simmons' despairing CIA man – and Swinton is clearly having enormous fun amongst all the nitwittery. She's one half of the adulterous couple who unwittingly spark all the Bourne-meets-the-Marx-Brothers shenanigans. It probably helps that her paramour is her Michael Clayton co-star, George Clooney, an actor who's never more at home than when he's sending up his own suave persona. Still, Swinton gives a delightfully exasperated turn in a rare comic role. Admittedly she's the straight axis around which this world of lunacy spins, but she manages to keep a straight face while Clooney's pervy spook builds her a home-made sex toy in his basement, and that takes some doing.
FOR THE FAN: Constantine (2005)
Those who carp about this film's various failings of fidelity to its comic inspiration are legion (it should be Liverpudlian; Constantine should be blond and not Keanu Reeves; why is Shia LaBeouf?) but virtually no one raises a fuss over the casting of Swinton as the angel Gabriel because she seems so obviously, blindingly right as Heaven's foremost warrior angel. As in Orlando, she walks a sexually ambiguous line; as in her delightfully unexpected turn as the White Witch in the Narnia films, she exploits that strange, otherworldly presence to great effect and just seems permanently, subtly out of synch with her surroundings. Her part is surprisingly complicated too: while this angel is full of grace, it's notably short on love and mercy. Swinton herself may not hold these more commercial roles in high regard, but we'd rather like to see her in more supernatural turns that make the most of her extraordinary impact.
ONE TO MISS: The Beach (2000)
Every actor tends to have at least one turkey stinking up their IMDb page. Not Swinton. Her films aren't to all tastes – you'd struggle to find anyone to fight Female Perversions' corner – and many inspire admiration rather than love, but she's got a quality control mechanism that we'd like her to lend to, say, Nicolas Cage. If there's one movie where she's on less than stellar form it's Danny Boyle's messy Gap Yah thriller, The Beach. As the cultish leader of traveller commune, she's charged with delivering the subtle menace to hold those acolytes under her spell. She's half-decent in the part – particularly in a gruelling scene where she orders a dying Frenchman to be abandoned for no worse a crime than being munched by a shark –but she's poorly served by the ponderous horrors that unfold as the film spirals towards its fevered climax. Somehow we doubt this one has pride of place on her DVD shelf.


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The federal and Queensland governments have signed a bilateral agreement to help ensure there are no further delays for environmental approvals for major projects.
The new agreement, which clarifies the roles of the two tiers of government in the approval process, comes a week after a spat between federal Environment Minister
The agreement includes the setting of defined milestones and time frames for providing documents, feedback and approvals, including the signing-off on terms of reference and key assessment reports.
Mr Seeney said this would ensure the 30- day approval time for the commonwealth to sign off on state assessment would be met. Under the former agreement, the past 18 projects in Queensland did not meet the deadline.
"I'm confident the delays of the past will not be revisited in future projects," Mr Seeney said.
The commonwealth is assessing the Alpha Coal project, which is a joint venture between Indian group GVK Group and Gina Rinehart's Hancock Coal.
The Australian Financial Review


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Fresh broccoli florets requires insect infestation inspection. Please see "Kashrut Instructions" below:
- 1 lb. frozen cheese tortellini or vegetable-filled tortellini
- 1 cup frozen green peas
- 2 cups-finely-chopped fresh broccoli florets
- 1 (10 or 12-oz.) jar roasted red peppers, drained, marinade reserved
- ¼ cup diced red onion
- ¼ cup chopped black olives
- Reserved marinade
- 2 Tablespoons olive oil
- 2 Tablespoons red-wine vinegar
- 2 teaspoons Dijon-style mustard
- ¼ cup grated fresh Parmesan cheese
- Salt and freshly-ground pepper to taste
- Begin cooking the tortellini according to package directions.
- Layer the frozen peas and the broccoli florets in a large saucepan with 1/2-inch of water. Bring them to a simmer and steam over moderate heat, covered, until the peas are thawed and the broccoli is bright green, about 3 to 4 minutes.
- Drain the peas and broccoli and rinse them under cool water until they are at room temperature.
- In the meantime, drain the roasted peppers, reserving the juices in a small mixing bowl. Cut the peppers into strips.
- Combine the liquid from the red peppers with the olive oil, vinegar, mustard and Parmesan cheese. Whisk to combine.
- When the tortellini are done, drain and rinse under cool water until they are at room temperature.
- Combine them in a mixing bowl with the peas, broccoli, red pepper strips, black olives and dressing. Add the Parmesan cheese and toss well. Season to taste with salt and pepper and toss to coat.
Kashrut Instructions
DESCRIPTION: Broccoli is a green vegetable resembling a miniature tree. Its thick central stem divides into many smaller branches, which are crowned with tightly clustered green florets.
INFESTATION: Broccoli may be infested with a variety of insects, most prominently aphids and thrips. The aphids are green or white, but will often turn brown during the parboiling (partial cooking) that is done to prepare the vegetable for inspection (see Inspection, below). The thrips are usually black or gray.
Also present at times is the broccoli worm, a thin white or light greenish worm of about a half inch's length. This worm, when present, is difficult to discern because it looks like one of the thin stems.
Our research has indicated that infestation levels of broccoli grown domestically (USA, Canada, but not Mexico) vary by season. During the winter months, (approximately November through March), infestation level is around 10%. Broccoli grown during this season should be inspected. During the summer months (the remaining seven months of the year), broccoli can be heavily infested, and inspection is often impractical. Broccoli from Mexico is infested throughout the year. It is primarily used for frozen broccoli products.
INSPECTION: When checking broccoli, a well-lit area should be chosen. This aids in discerning an insect from the floret pieces. It should be noted that cleaning infested broccoli is not feasible. The purpose of inspection is to determine if the broccoli is infested. Once infestation is detected, the floret portion of the head must be discarded. One cannot be certain that all insects will be discovered and removed. However, the stem portion may be separated, washed and consumed.
Fresh broccoli-stems:
Broccoli stems may be used after a thorough washing. No further checking is necessary.
Fresh broccoli (whole):
- It is virtually impossible to perform a comprehensive inspection on raw broccoli. Parboil the broccoli for ten seconds to soften the florets and stems. An additional benefit of parboiling is that aphids often turn from green to brown and the florets from light to dark lush green. The contrast of colors makes the insects more easily detectable after this process. Submerge in cold water immediately after parboiling to preserve the flavor and firmness of the vegetable.
- It is important to segregate each head individually when processing more than one head of broccoli. If a section of a broccoli head shows infestation, the entire head must be discarded.
- Inspect each floret section:
- Look carefully at the under part (i.e., the branched area) of each floret. It is important to check the Y-shaped crevice between the branches.
- Spread each floret head apart and look inside the floret from the top¬ down (i.e., through the green flower buds, into the branch area).
- If one OR two insects are found, special care should be taken in examining the remaining sections of that broccoli head. Should a total of three insects be found, either in a particular section or spread among different sections of the same broccoli head, the entire head should be discarded.
Alternative method:
- While parboiling the broccoli as described above, agitate the vegetable in the boiling water and bang it against the side of the pot several times.
- After removing the broccoli and submerging it in cold water, check a sampling of the parboiled water in a glass bowl over a light box.
- If insects appear in the water, each floret must be checked meticulously.
- If no insects appear in the water, the broccoli may be used after running a strong stream of water through the head from top to bottom and from bottom to top.
Beware: Insects like company. If even one insect is found, the entire head must be checked most scrupulously.
Please note: erudite displays should not include raw broccoli due to the impossibility of properly checking raw broccoli.


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Seniors Games finish with $15K surplus
Burnaby organizers of the 2012 BC Seniors Games finished $15,565 in the black.
After a final audit expected in mid-December, half of that amount, or $7,783, will be given to the BC Seniors Games Society to fund future games, with the rest to be put towards seniors amenities in Burnaby, according to a city staff report.
The Games organizers raised more than $547,000 in revenues of which 36 per cent came from registration fees from participants. Sponsorships from corporate and individual donors accounted for 29 per cent of revenue, while the provincial government (through the BC Seniors Games Society) contributed 19 per cent, or $105,000, and the City of Burnaby committed to funding $55,000, or 10 per cent.
A variety of other funding sources, including donations, sales and grants made up the remaining six per cent.
The revenue generated "significantly exceeds" the budget estimate included in the organizing committee's original bid for the Games, the report said. That's due to sponsorship revenue exceeding expectations and the number of participants being more than expected.
Total expenditures for the event were more than $531,000. Of that, 38 per cent was spent on securing venues, including city-owned facilities, Burnaby Mountain and Byrne Creek secondary schools, Burnaby Firefighters Hall and Royal City Curling Club.
Administration of the Games, including office space, temporary office staff and equipment rental, took up 22 per cent of the costs. Other major costs included the gala banquet, sponsor recognition events, signage and printing.
The Games were held Aug. 21 to 26 and drew almost 4,000 participants from across the province who competed in 28 events.