David J Berlowitz

A randomised trial of domiciliary, ambulatory oxygen in patients with COPD and dyspnoea but without resting hypoxaemia

Background Patients with chronic obstructive pulmonary disease (COPD) who are not severely hypoxaemic at rest may experience significant breathlessness on exertion, and ambulatory oxygen is often prescribed in this circumstance despite a lack of conclusive evidence for benefit. This study aimed to determine whether such patients benefit from domiciliary ambulatory oxygen and, if so, which factors may be associated with benefit. Methods This was a 12 week, parallel, double-blinded, randomised, placebo-controlled trial of cylinder air versus cylinder oxygen, provided at 6 l/min intranasally, for use during any activity provoking breathlessness. Patients underwent baseline measurements of arterial blood gases and lung function. Outcome measures assessed dyspnoea, health-related quality of life, mood disturbance, functional status and cylinder utilisation. Data were analysed on an intention-to-treat basis, p≤0.05. Results 143 subjects (44 female), mean±SD age 71.8±9.8 years, forced expiratory volume in 1 s (FEV1)1.16±0.51 lites, Pao2 9.5±1.1 kPa (71.4±8.5 mm Hg) were randomised, including 50 patients with exertional desaturation to ≤88%. No significant differences in any outcome were found between groups receiving air or oxygen. Statistically significant but clinically small improvements in dyspnoea and depression were observed in the whole study group over the 12 weeks of the study. Conclusion In breathless patients with COPD who do not have severe resting hypoxaemia, domiciliary ambulatory oxygen confers no benefits in terms of dyspnoea, quality of life or function. Exertional desaturation is not predictive of outcome. Intranasal gas (either air or oxygen) may provide a placebo benefit. Clinical trial number ACTRN12605000457640.

Bridging the gap between research and practice: review of a targeted hospital inpatient fall prevention programme

Objective: Falls among older inpatients are frequent and have negative consequences. In this study, the effectiveness of a fall prevention programme in reducing falls and fall injuries in an acute hospital was studied. Design: Retrospective audit. Setting: The Northern Hospital, an acute, metropolitan, hospital in Australia. Intervention: A multi-factorial fall prevention programme that included establishment of a multidisciplinary committee, risk assessment of all patients on “high-risk” wards and targeted interventions for patients identified as high risk. Main outcome measures: Fall and fall injury rates per 1000 occupied bed-days were analysed using generalised additive models (GAM) and, because of the presence of autocorrelation, generalised additive mixed models (GAMM), respectively. Results: During the 9-year observation of 271 095 patients, there were 2910 falls and 843 fall injuries. The GAM predicted rate of falls was stable in the 3 years after the programme was implemented, increased in 2006, then decreased between October 2006 and December 2007 from 4.13 (95% CI 3.65 to 4.67) to 2.83 (95% CI 2.24 to 3.59; p = 0.005). The GAMM predicted rate of fall injuries reduced from 1.66 (95% CI 1.24 to 2.21) to 0.61 (95% CI 0.43 to 0.88) after programme implementation (p<0.001). Conclusions: The falls rate varied throughout the observation period, and no significant change in the rate from preprogramme to postprogramme implementation was observed. The finding of no reduction in falls during the observation period may be explained by improved reporting throughout the observation period. The reduction in fall injuries was substantial and sustained. Identification of a local problem, use of a fall risk assessment to guide the delivery of simple interventions, integration of processes into daily clinical practice and creating systems that demand accountability of staff are factors that appear to have contributed to the programme’s success.

A systematic review of mobility instruments and their measurement properties for older acute medical patients

BackgroundIndependent mobility is a key factor in determining readiness for discharge for older patients following acute hospitalisation and has also been identified as a predictor of many important outcomes for this patient group. This review aimed to identify a physical performance instrument that is not disease specific that has the properties required to accurately measure and monitor the mobility of older medical patients in the acute hospital setting.MethodsDatabases initially searched were Medline, Cinahl, Embase, Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials without language restriction or limits on year of publication until July 2005. After analysis of this yield, a second step was the systematic search of Medline, Cinahl and Embase until August 2005 for evidence of the clinical utility of each potentially suitable instrument. Reports were included in this review if instruments described had face validity for measuring from bed bound to independent levels of ambulation, the items were suitable for application in an acute hospital setting and the instrument required observation (rather than self-report) of physical performance. Evidence of the clinical utility of each potentially suitable instrument was considered if data on measurement properties were reported.ResultsThree instruments, the Elderly Mobility Scale (EMS), Hierarchical Assessment of Balance and Mobility (HABAM) and the Physical Performance Mobility Examination (PPME) were identified as potentially relevant. Clinimetric evaluation indicated that the HABAM has the most desirable properties of these three instruments. However, the HABAM has the limitation of a ceiling effect in an older acute medical patient population and reliability and minimally clinically important difference (MCID) estimates have not been reported for the Rasch refined HABAM. These limitations support the proposal that a new mobility instrument is required for older acute medical patients.ConclusionNo existing instrument has the properties required to accurately measure and monitor mobility of older acute medical patients.

Home mechanical ventilation in australia and new zealand

This study aims to describe the pattern of home mechanical ventilation (HMV) usage in Australia and New Zealand. 34 centres providing HMV in the region were identified and asked to complete a questionnaire regarding centre demographics, patient diagnoses, HMV equipment and settings, staffing levels and methods employed to implement and follow-up therapy. 28 (82%) centres responded, providing data on 2,725 patients. The minimum prevalence of HMV usage was 9.9 patients per 100,000 population in Australia and 12.0 patients per 100,000 population in New Zealand. Variation existed across Australian states (range 4–13 patients per 100,000 population) correlating with population density (r=0.82; p<0.05). The commonest indications for treatment were obesity hypoventilation syndrome (OHS) (31%) and neuromuscular disease (NMD) (30%). OHS was more likely to be treated in New Zealand, in smaller, newer centres, whilst NMD was more likely to be treated in Australia, in larger, older centres. Chronic obstructive pulmonary disease was an uncommon indication (8.0%). No consensus on indications for commencing treatment was found. In conclusion, the prevalence of HMV usage varies across Australia and New Zealand according to centre location, size and experience. These findings can assist HMV service planning locally and highlight trends in usage that may be relevant in other countries.

Additional exercise does not change hospital or patient outcomes in older medical patients: a controlled clinical trial.

QUESTION What are the effects of additional exercise on hospital and patient outcomes for acutely-hospitalised older medical patients? DESIGN Controlled clinical trial. PARTICIPANTS 236 Patients aged 65 or older admitted to an acute care hospital with a medical illness between October 2002 and July 2003. INTERVENTION The experimental group received usual care plus an individually tailored exercise program administered twice daily from hospital admission to discharge. The control group received usual care only. OUTCOME MEASURES The primary outcome was discharge destination. Secondary outcomes were measures of activity limitation (Barthel Index, Timed Up and Go, Functional Ambulation Classification), length of stay, and adverse events. RESULTS There was no significant effect of the additional exercise program on any outcome. There were no significant differences between groups for the proportion of the patients discharged to home (RR 0.99, 95% CI 0.86 to 1.14) or inpatient rehabilitation (RR 0.76, 95% CI 0.30 to 1.51) or for measures of activity limitation at hospital discharge. A one day difference in length of stay was identified between groups but this difference was not significant (p = 0.45). There were no significant differences between groups for adverse events: 28-day readmission (RR 1.10, 95% CI 0.65 to 1.86), patient mortality (RR 1.15, 95% CI 0.16 to 8.0), intensive care admission (RR 0.16, 95% CI 0.01 to 3.13) and falls (RR 0.69, 95% CI 0.17 to 2.81). CONCLUSION Additional physiotherapy intervention during hospitalisation did not significantly improve hospital or patient outcomes.

Identifying who will benefit from non-invasive ventilation in amyotrophic lateral sclerosis/motor neurone disease in a clinical cohort

Background Respiratory failure is associated with significant morbidity and is the predominant cause of death in motor neurone disease/amyotrophic lateral sclerosis (MND/ALS). This study aimed to determine the effect of non-invasive ventilatory (NIV) support on survival and pulmonary function decline across MND/ALS phenotypes. Methods Cohort recruited via a specialist, multidisciplinary clinic. Patients were categorised into four clinical phenotypes (ALS, flail arm, flail leg and primary lateral sclerosis) according to site of presenting symptom and the pattern of upper versus lower motor neurone involvement. NIV was initiated according to current consensus practice guidelines. Results Between 1991 and 2011, 1198 patients diagnosed with ALS/MND were registered. 929 patients (77.5%) fulfilled the selection criteria and their data were analysed. Median tracheostomy free survival from symptom onset was 28 months in NIV-treated patients compared to 15 months in untreated (Univariate Cox regression HR=0.61 (0.51 to 0.73), p<0.001). The positive survival effect of NIV persisted when the model was adjusted for age, gender, riluzole and percutaneous endoscopic gastrostomy use (HR=0.72 (0.60 to 0.88, p=0.001). In contrast with the only randomised controlled trial, NIV statistically significantly increased survival by 19 months in those with ALS-bulbar onset (Univariate HR=0.50 (0.36 to 0.70), multivariate HR=0.59 (0.41 to 0.83)). These data confirm that NIV improves survival in MND/ALS. The overall magnitude of benefit is 13 months and was largest in those with ALS-bulbar disease. Future research should explore the optimal timing of NIV initiation within phenotypes in order to optimise respiratory function, quality of life and survival.

Pharmacist directed home medication reviews in patients with chronic heart failure: A randomised clinical trial ☆

BACKGROUND Chronic heart failure (CHF) accounts for significant morbidity, mortality and health expenditure. Furthermore, patients with CHF are often on numerous pharmacological agents for their comorbidities. The objective of this study was to determine whether a pharmacist directed home medication review intervention had positive effects on CHF patient outcomes. METHODS A total of 120 patients hospitalised for CHF were randomised to receive a pharmacist directed post-discharge home medication review (n = 64, 53.3%) or standard care (n = 56, 46.7%). Participants were followed for 6 months. Primary outcomes were death, CHF hospitalisation and length of hospital stay. RESULTS There were no between group differences in mortality (hazard ratio = 1.41, 0.50 to 3.97; P = 0.514) or CHF hospitalizations (incidence rate ratio [IRR] = 1.74 95% CI: 0.85-3.60 P = 0.131) over the 6 month follow-up period. Days of hospital stay for CHF exacerbations in the 6 month follow-up were significantly greater in the intervention group (IRR = 2.34 95% CI: 1.80-3.05 P = 0.000). CONCLUSIONS Post-discharge pharmacy directed home medication review appeared to have no effect on mortality and health care utilisation above that achieved with standard care. The post-acute management of CHF must be a collaborative multi-disciplinary effort by the health care team as it is the additive effect of interventions that are most effective.

Effect of Singing on Respiratory Function, Voice, and Mood After Quadriplegia: A Randomized Controlled Trial

OBJECTIVE To explore the effects of singing training on respiratory function, voice, mood, and quality of life for people with quadriplegia. DESIGN Randomized controlled trial. SETTING Large, university-affiliated public hospital, Victoria, Australia. PARTICIPANTS Participants (N=24) with chronic quadriplegia (C4-8, American Spinal Injury Association grades A and B). INTERVENTIONS The experimental group (n=13) received group singing training 3 times weekly for 12 weeks. The control group (n=11) received group music appreciation and relaxation for 12 weeks. Assessments were conducted pre, mid-, immediately post-, and 6-months postintervention. MAIN OUTCOME MEASURES Standard respiratory function testing, surface electromyographic activity from accessory respiratory muscles, sound pressure levels during vocal tasks, assessments of voice quality (Perceptual Voice Profile, Multidimensional Voice Profile), and Voice Handicap Index, Profile of Mood States, and Assessment of Quality of Life instruments. RESULTS The singing group increased projected speech intensity (P=.028) and maximum phonation length (P=.007) significantly more than the control group. Trends for improvements in respiratory function, muscle strength, and recruitment were also evident for the singing group. These effects were limited by small sample sizes with large intersubject variability. Both groups demonstrated an improvement in mood (P=.002), which was maintained in the music appreciation and relaxation group after 6 months (P=.017). CONCLUSIONS Group music therapy can have a positive effect on not only physical outcomes, but also can improve mood, energy, social participation, and quality of life for an at-risk population, such as those with quadriplegia. Specific singing therapy can augment these general improvements by improving vocal intensity.

Relationships Between Objective Sleep Indices and Symptoms in a Community Sample of People With Tetraplegia

OBJECTIVE To examine the relationships between injury severity, quality of life, sleep symptoms, objectively measured sleep, and sleep disorders in chronic tetraplegia. DESIGN Cross-sectional survey. SETTING Community. PARTICIPANTS People with tetraplegia (N=78; 59 men, 35 with motor and sensory complete tetraplegia; mean age ± SD, 43±12.1; age range 18-70y), living in the state of Victoria, Australia, who were not currently being treated for sleep disorders and who completed both questionnaires and sleep studies comprised the study cohort. INTERVENTION Questionnaire battery mailed to potential participants. Returned questionnaires were followed with full, home-based polysomnography. MAIN OUTCOME MEASURES Demographics and questionnaire responses. RESULTS Quality of life (Assessment of Quality of Life instrument) was worse in the group with complete lesions compared with incomplete lesions (P=.001; median=16; interquartile range, 9 vs 12 [12]), and the Apnea-Hypopnea Index was higher (P=.002; interquartile range, 32.0 [25.2] vs 13.2 [24.8]). Ninety-one percent of those with complete lesions had obstructive sleep apnea (Apnea-Hypopnea Index >10) versus 55.8% of those with incomplete tetraplegia. No effect of lesion level on the Apnea-Hypopnea Index was observed (r=-.04, P=.73). In the complete group, the time taken from sleep onset until the first rapid eye movement sleep period was significantly delayed at over 2 hours. Multiple regression analyses showed substantially stronger relationships between daytime sleep complaints and abnormalities observed in the sleep study in those with complete lesions. CONCLUSIONS Obstructive sleep apnea is a major problem, particularly in those with complete tetraplegia, and this single comorbidity is associated with reduced quality of life. In those with incomplete cervical lesions, the relationships between sleepiness, other sleep symptoms, and polysomnography indices are less precise.

Comparison of pedometer and activity diary for measurement of physical activity in chronic obstructive pulmonary disease.

PURPOSE Precise, inexpensive tools for measuring physical activity levels are important for developing strategies to improve symptoms and enhance quality of life in chronic obstructive pulmonary disease (COPD). Self-report questionnaires and diaries have been used in many populations with variable results. The pedometer is widely recognized as a valid and reliable objective measurement tool, but it has not been well tested in COPD. This study aimed to determine the relationship between free-living physical activity recorded in a daily diary and that measured by using a pedometer in patients with COPD. METHODS Participants with COPD (n = 80) recorded physical activity over 7 days. Cumulative pedometer readings and diary records of 4 activity categories for each 0.5 hour were compared. RESULTS Participants (n = 76) with complete data sets were included in the analysis. The diary was more reliably completed. Mean pedometer reading per week was 23,129 (SD = 17,083) “step” counts (range, 1,725–66,454). Mean diary-recorded standing and walking time per week was 98.9 (SD = 10.4) hours (range, 73–119.5). The relationship between these measures was moderate and statistically significant (r = 0.37, P = .001). CONCLUSIONS A daily diary record appears to offer more promise than the pedometer as a tool for measuring free-living physical activity in patients with COPD. Further research is required to assess the value of the 2 methods as discriminative, evaluative, and predictive tools in COPD populations.