C Echevarria

Validation of the DECAF score to predict hospital mortality in acute exacerbations of COPD

Background Hospitalisation due to acute exacerbations of COPD (AECOPD) is common, and subsequent mortality high. The DECAF score was derived for accurate prediction of mortality and risk stratification to inform patient care. We aimed to validate the DECAF score, internally and externally, and to compare its performance to other predictive tools. Methods The study took place in the two hospitals within the derivation study (internal validation) and in four additional hospitals (external validation) between January 2012 and May 2014. Consecutive admissions were identified by screening admissions and searching coding records. Admission clinical data, including DECAF indices, and mortality were recorded. The prognostic value of DECAF and other scores were assessed by the area under the receiver operator characteristic (AUROC) curve. Results In the internal and external validation cohorts, 880 and 845 patients were recruited. Mean age was 73.1 (SD 10.3) years, 54.3% were female, and mean (SD) FEV1 45.5 (18.3) per cent predicted. Overall mortality was 7.7%. The DECAF AUROC curve for inhospital mortality was 0.83 (95% CI 0.78 to 0.87) in the internal cohort and 0.82 (95% CI 0.77 to 0.87) in the external cohort, and was superior to other prognostic scores for inhospital or 30-day mortality. Conclusions DECAF is a robust predictor of mortality, using indices routinely available on admission. Its generalisability is supported by consistent strong performance; it can identify low-risk patients (DECAF 0–1) potentially suitable for Hospital at Home or early supported discharge services, and high-risk patients (DECAF 3–6) for escalation planning or appropriate early palliation. Trial registration number UKCRN ID 14214.

Case-based discussion from North Tyneside General Hospital: somatostatin analogues in yellow nail syndrome associated with recurrent pleural effusions

Kristian Brooks (KB): A 77-year-old man presented to accident and emergency with a 1-month history of progressive breathlessness and reduced exercise tolerance. He had no chest pain, cough or wheeze, but had bilateral leg swelling and 4 kg weight loss. He had long-standing nail dystrophy and, following presentation with recurrent lower respiratory tract infections several years previously, bronchiectasis had been confirmed on high-resolution CT. He was a lifelong non-smoker, but had significant occupational asbestos exposure. There was no relevant family history. Chest radiograph showed large bilateral pleural effusions. Blood tests, including markers of infection and inflammation, were unremarkable. An ultrasound-guided pleural tap showed a lymphocytic exudate. Stephen C Bourke (SCB): The combination of nail dystrophy, lymphocytic pleural effusions, bronchiectasis and lymphoedema is consistent with yellow nail syndrome (YNS), but coexistent malignancy or other pathology should be excluded, particularly in view of the history of weight loss and asbestos exposure. Pleural fluid should be sent for cholesterol and triglycerides, cytology and culture, including mycobacterium TB. Thoracic CT and echocardiography should be performed. Overall, the most common causes for lymphocytic effusions are malignancy or TB. In a case series of 41 patients with YNS, around half had pleural effusions, which were predominantly lymphocyte-rich and more often bilateral than unilateral.1 Chylothorax may also occur in YNS, classically appearing milky white due to high levels of triglycerides, but may be yellow or blood stained. KB: No malignant cells were seen in the pleural fluid, and TB stain and culture were negative. Thoracic CT showed bilateral effusions, segmental consolidation in the left lower lobe and bilateral pleural plaques, but no pulmonary masses or lymphadenopathy. Echocardiography showed normal biventricular function and no evidence of a pericardial effusion. Previous medical …

Heterogeneity in the measurement and reporting of outcomes in studies of electronic cigarette use in adolescents: a systematic analysis of observational studies

Objective To examine consistency between cross-sectional studies of conventional and electronic cigarette use among adolescents in terms of the measurement, analysis and reporting of parameters. Design A systematic analysis of cross-sectional studies of conventional and electronic cigarette use in adolescents, to identify measured and reported parameters. Data sources Studies examining use of electronic and conventional cigarette use in adolescents were identified by searching the SCOPUS database in August 2015. Study selection The selection criteria for studies were: cross-sectional studies, in English, on e-cigarette use in adolescents. Two reviewers independently selected relevant studies from the search. 60 abstracts were identified, from which 31 papers were eligible for review (23 unique studies). Data extraction Measured and reported parameters were identified and tabulated. These included the prevalence of cigarette and/ or electronic cigarette use, and the definitions of terms. Data were extracted independently by two reviewers. Data synthesis With regards basic parameters of ‘ever’ or ‘current’ use of electronic or conventional cigarettes, there were 31 unique measured parameters across 23 studies. Of 16/23 studies in which authors collected information on dual current use, prevalence was reported in 11/16, with six different definitions of ‘dual use’. Conclusions There are substantial differences in measurement and reporting of parameters across observational studies of electronic and conventional cigarette use in adolescents. These studies are at risk of reporting bias, and results are difficult to interpret. A core outcome set that should be measured and reported in all observational studies is required, using structured consensus techniques.

Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation

Background Previous models of Hospital at Home (HAH) for COPD exacerbation (ECOPD) were limited by the lack of a reliable prognostic score to guide patient selection. Approximately 50% of hospitalised patients have a low mortality risk by DECAF, thus are potentially suitable. Methods In a non-inferiority randomised controlled trial, 118 patients admitted with a low-risk ECOPD (DECAF 0 or 1) were recruited to HAH or usual care (UC). The primary outcome was health and social costs at 90 days. Results Mean 90-day costs were £1016 lower in HAH, but the one-sided 95% CI crossed the non-inferiority limit of £150 (CI −2343 to 312). Savings were primarily due to reduced hospital bed days: HAH=1 (IQR 1–7), UC=5 (IQR 2–12) (P=0.001). Length of stay during the index admission in UC was only 3 days, which was 2 days shorter than expected. Based on quality-adjusted life years, the probability of HAH being cost-effective was 90%. There was one death within 90 days in each arm, readmission rates were similar and 90% of patients preferred HAH for subsequent ECOPD. Conclusion HAH selected by low-risk DECAF score was safe, clinically effective, cost-effective, and preferred by most patients. Compared with earlier models, selection is simpler and approximately twice as many patients are eligible. The introduction of DECAF was associated with a fall in UC length of stay without adverse outcome, supporting use of DECAF to direct early discharge. Trial registration number Registered prospectively ISRCTN29082260.

S116 Hot decaf: a rct comparing home treatment and inpatient care in copd exacerbations selected by low risk decaf score

Background The DECAF score is a robust predictor of early mortality in patients admitted with an acute exacerbation of COPD (AECOPD),1 and should be routinely documented on admission.2 Of importance, 45–53% of admitted patients are low risk by DECAF (0–1), therefore potentially suitable for hospital at home (HAH). Compared to existing criteria, selection by DECAF would allow inclusion of substantially more patients, some with higher medical dependency. Methods In a randomised controlled trial (RfPB PB-PG-0213-30105), patients admitted with an AECOPD were allocated to HAH or usual care (UC). Readmissions for AECOPD within 90 days were managed according to the allocated arm, provided they were low risk (DECAF = 0–1). Eligibility criteria included: primary diagnosis AECOPD, DECAF score 0–1, age 35 or more, 10 or more cigarette pack-year history and obstructive spirometry (FEV1/VC less than 70%). Total bed days and readmissions over 90 days, and 14 and 90 day mortality were captured. At day 14, patients were asked for their preferred place of care during future exacerbations of similar severity. Abstract S116 Table 1 Outcome by allocated group Outcome UCn = 58 HAHn = 60 Bed days, n (IQR) 5 (2–12) 1 (1–7) Readmission*† 23 (39.7%) 22 (36.7%) 14 day mortality* 0 0 90 day mortality* 1 (1.7%) 1 (1.6%) Preference for HAH 51/57 54/60 *All cause. †One or more readmissions. Results Between June 2014 to January 2016 118 of 207 eligible patients were randomised: female = 56/118 (52.5%), mean age (SD) = 69.8 (10.2), mean FEV1% predicted (SD) = 43.9 (17.6) and coexistent pneumonia = 24/118 (20.3%). At 14 days, 105/117 (90%) patients expressed a preference for HAH. Median bed days were 4 days lower in the HAH arm (p = 0.001), with no difference in mortality or readmissions. Conclusions Selection for HAH by low risk DECAF score is safe, clinically effective, preferred by most patients, reduces total bed days and is a suitable option for up to 50% of admitted patients. References Steer J, et al. The DECAF Score: predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease. Thorax 2012;67(11):970–6. BTS national audit report 2015.

Positive drivers and potential barriers to implementation of hospital at home selected by low risk decaf score

Background Despite endorsement in guidelines, many hospitals do not offer hospital at home (HAH) for COPD exacerbation (AECOPD), partly reflecting the previous lack of a robust prognostic score to guide selection. The DECAF score addresses this concern, and should be routinely scored on admission.1 In a RCT we have shown that HAH selected by DECAF score 0–1 is safe and effective. Up to 50% of admitted patients are suitable. Our population included patients with higher medical dependency than earlier trials and HAH was supported by 24/7 specialist on-call. In an embedded qualitative study, we identified positive drivers for, and potential barriers to, use of HAH to inform service implementation. Methods Patients, carers, clinicians and managers were purposely selected to ensure diversity. Semi-structured interviews were conducted and Thematic-Construct Analysis employed.2 Results 44 patients (HAH/inpatient care/declined randomisation), 15 carers, 14 consultants, 11 specialist nurses and 4 managers were interviewed. ‘Positive drivers’ were divided into two sub-constructs: ‘Feeling more at ease and comfortable in own home environment’; and ‘Feeling safe, reassured and appreciated through continuity of hospital care’. Positive influences on independence, perceived rate of recovery, sleep quality, mood and contact with friends and family were noted. At 14 days post-presentation, 90% of patients stated they would prefer HAH over inpatient care for subsequent exacerbations of similar severity. Counter-intuitively, carers reported greater convenience rather than increased burden. ‘Potential Barriers’ were grouped into two sub-constructs: ‘Personal preferences’; and ‘Resistance to change’. Some patients highlighted fear of being alone at night and dislike of strangers visiting their home; nurses cited higher workload and greater responsibility (with experience, viewed positively); whilst operational concerns included keeping medical records in a patient’s home and inability to capture activity within current payment systems. Conclusions HAH selected by DECAF allows the inclusion of more patients than existing models, and is preferred to inpatient care by most patients and their families. During the trial few barriers to implementation were identified, and were effectively overcome. Hospitals planning to implement HAH selected by DECAF should pre-emptively address these issues. References National COPD Audit Report, 2015. Dismore. J Health psychol, 2016.

Potentiators for cystic fibrosis – targeting the underlying molecular defect

Sanjay Patel *, Ian P. Sinha , Kerry Dwan , Carlos Echevarria , Michael Schechter , Kevin W. Southern a Department of Women’s and Children’s Health, University of Liverpool, Liverpool, UK Department of Biostatistics, University of Liverpool, Liverpool, UK c Institute of Cellular Medicine, Newcastle University, Newcastle, UK Division of Pulmonary Medicine, Virginia Commonwealth University, Richmond, Virginia, USA

M24 Mortality prediction by CURB65 in pneumonia with and without complicating COPD

Introduction The CURB65 score was developed to predict mortality in community acquired pneumonia (CAP) but is often used in pneumonia complicating acute exacerbations of COPD (pAECOPD). We have previously shown that CURB65 underestimates in-hospital mortality in pAECOPD, particularly in low risk patients (observed mortality 11.2%, CURB65-predicted 1.5%).[1] Of importance, CURB65 was derived in a population with significant exclusions, notably admission from nursing home, and few patients with dementia were included, whereas in our DECAF AECOPD cohort [1] such patients were included. The higher than predicted mortality in pAECOPD may reflect additional risk conferred by co-existent COPD, a less selected population and/or clinical outcomes in participating hospitals. We have therefore investigated whether the mortality of an equivalent population with CAP, but without COPD, is similar to that found previously in pAECOPD. Methods Patients admitted with a primary diagnosis of CAP were identified from coding records. Patients with confirmed or suspected COPD were excluded; selection criteria and time frame otherwise matched the DECAF cohort. Demographic, clinical and mortality data were gathered from clinical notes. Categorical variables were compared using Fisher’s exact test. Results 115 patients with CAP were included: mean (SD) age 72.1 (16.4) years, 29.6% were admitted from institutional care and 21.7% had dementia. Median (IQR) CURB65 score was 2 (1–3) and in-hospital mortality 16.5%. Compared to the earlier cohort with pAECOPD, mortality in patients with low or intermediate risk CURB65 scores was lower. Abstract M24 Table 1. Curb65 risk score DECAF pAECOPD CAP without COPD P N died % n died % Low 89 10 11.2 30 0 0 .06 Intermediate 98 16 16.3 29 0 0 .02 High 112 34 30.4 56 19 34 .73 Total 299 60 20.1 115 19 16.5 .49 In the present study, 74% of deaths occurred in patients admitted from institutional care (mortality 35%, non-institutional care 9% p = 0.002) and/or those with dementia (mortality 36%, without dementia 11% p = 0.006). Conclusions Compared to the BTS national audit, the proportion of patients with severe pneumonia is higher (49% v 30%) and mortality lower (16.5% v 21.2%). Both dementia and admission from institutional care were associated with high mortality rates. Among patients with low or intermediate risk CURB65 scores the mortality of those with CAP without COPD was lower than we previously found in pAECOPD, confirming that the underestimation of mortality risk by CURB65 in pAECOPD was not attributable to less effective clinical care. References Steer. The DECAF score. Thorax, 2012;67:970–6.

P137 Internal validation of the DECAF score as a predictor of inpatient mortality in acute exacerbations of COPD

Introduction In patients presenting with an acute exacerbation of COPD (AECOPD), accurate prediction of in-hospital mortality may help inform the most appropriate place and level of care. The DECAF score was developed for this purpose and designed to be simple to apply at the bedside using variables that are routinely collected on admission: Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation. Whilst the performance of the tool within the derivation cohort was strong,[1] before recommending use in clinical practice further validation is required. Methods Both external and internal validation of the DECAF score are currently in progress; for each, a cohort of 840 patients consecutively admitted with AECOPD is being recruited. To optimise data capture, patients are identified by screening admissions units and coding records. Indices that comprise the DECAF score and other independent predictors of mortality and readmission are collected. Dyspnoea is assessed using the extended MRC dyspnoea score.[1] Inclusion criteria are: primary diagnosis of AECOPD, age 35 or older, 10 pack years or more smoking history, and obstructive spirometry. Exclusion criteria are: other illness likely to limit survival to less than one year (principally metastatic malignancy) and previous inclusion in the validation study. We present an analysis of the performance of DECAF in the first 623 patients recruited to the internal validation cohort. Results Abstract P137 Table 1. DECAF AUROC = 0.82 (95% 0.76 to 0.87) Derivation DECAF AUROC = 0.86 (95% CI 0.82 to 0.89) p value using Fisher’s exact test Internal validation DECAF AUROC = 0.82 (95% 0.76 to 0.87) Derivation DECAF AUROC = 0.86 (95% CI 0.82 to 0.89) Discussion As in the derivation study, DECAF is a good predictor of inpatient mortality (AUROC = 0.82), with a stepwise increase in mortality with DECAF score. The DECAF score accurately identifies low risk (DECAF score 0–1) and high risk patients (3 or greater) admitted with an exacerbation of COPD, potentially helping select patients for early supported discharge schemes, or for intensified medical treatment or early palliation. References Steer, J., J. Gibson, and S. C. Bourke, The DECAF Score: predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease. Thorax, 2012. 67(11): p. 970–6.

Profound bradycardia associated with NIV removal

A patient with lower-limb onset ALS presented with a one-month history of vasovagal episodes and a one-week history of cough productive of green sputum and lethargy. She was drowsy and in acute on chronic type-two respiratory failure. She responded to non-invasive ventilation, however she suffered recurrent episodes of profound bradycardia on removal of the mask, which gradually resolved over ten days. We have reviewed the literature and offer a potential explanation for these events.