Geertjan Wesseling

Nutritional depletion in relation to respiratory and peripheral skeletal muscle function in out-patients with COPD

Although increasing attention has been paid to nutritional aspects in chronic obstructive pulmonary disease (COPD), limited information is available regarding the prevalence and consequences of nutritional depletion in a random out-patient COPD population. We studied body composition in relation to respiratory and peripheral skeletal muscle function in 72 COPD patients (mean (SD) forced expiratory volume in one second (FEV1) 53 (15) % predicted), who came to the lung function laboratory for routine lung function measurements. Patients were characterized by the degree of body weight loss and fat-free mass depletion. According to this definition, 14% of the group suffered from both loss of body weight and depletion of fat-free mass, whereas 7% had one of these conditions. We found that tissue depletion was concomitant with lower values for respiratory and peripheral skeletal muscle strength (46.0 (27.2) vs 77.1 (29.8) kg), and a significantly lower transfer coefficient for carbon monoxide (KCO 64.9 (16.2) vs 81.9 (24.5) % pred). Stratification by KCO (< 60% vs > 80%) also revealed significantly lower values for fat-free mass and higher values for intrathoracic gas volumes, total lung capacity (TLC) and residual volume (RV) in the group with a KCO < 60% pred. Analysis of covariance, taking fat-free mass as covariate, indicated an independent contribution of KCO on maximal inspiratory mouth pressure (PImax) but not on peripheral skeletal muscle strength. It is concluded that a substantial number of COPD out-patients suffer from nutritional depletion, preferentially affecting peripheral skeletal muscle function.

Detecting patients at a high risk of developing chronic obstructive pulmonary disease in general practice: cross sectional case finding study

Abstract Objectives: To investigate the effectiveness of case finding of patients at risk of developing chronic obstructive pulmonary disease, whether the method is suitable for use in general practice, how patients should be selected, and the time required. Design: Cross sectional study. Setting: Two semirural general practices in the Netherlands. Participants: 651 smokers aged 35 to 70 years. Main outcome measures: Short standardised questionnaire on bronchial symptoms for current smokers, lung function with a spirometer, and the quality of the spirometric curve. Results: Of the 201 smokers not taking drugs for a pulmonary condition, 169 produced an acceptable curve (fulfilling American Thoracic Society criteria). Of these, 30 (18%, 95% confidence interval 12% to 24%) had a forced expiratory volume in one second (FEV1) <80% of predicted. When smokers were preselected on the basis of chronic cough, the proportion with an FEV1 <80% of predicted increased to 27% (17 of 64; 12% to 38%). Chronic cough was a better predictor of airflow obstruction than other symptoms, such as wheeze and dyspnoea. The presence of two symptoms was a slightly better predictor than cough only (odds ratio 3.02 (1.37 to 6.64) v 2.50 (1.14 to 5.52)). Age was also a good predictor of obstruction; smokers over 60 with cough had a 48% chance of having an obstruction. The mean time needed for spirometry was four minutes. Detecting one smoker with an FEV1 <80% of predicted cost €5 to €10. Conclusions: Trained practice assistants could check all patients who smoke for chronic obstructive pulmonary disease at little cost to the practice. Cough and age are the most important predictors of the disease. By testing one smoker a day, an average practice could identify one patient at risk a week.

Efficacy of confronting smokers with airflow limitation for smoking cessation

The objective of the present study was to test whether confronting smokers with previously undetected chronic obstructive pulmonary disease (COPD) increases the rate of smoking cessation. In total, 296 smokers with no prior diagnosis of COPD were detected with mild-to-moderate airflow limitation by means of spirometry and randomly allocated to: confrontational counselling by a nurse with nortriptyline for smoking cessation (experimental group); regular counselling by a nurse with nortriptyline (control group 1); or “care as usual” for smoking cessation by the general practitioner (control group 2). Only the experimental group was confronted with their abnormal spirometry (mean forced expiratory volume in one second (FEV1) post-bronchodilator 80.5% predicted, mean FEV1/forced vital capacity post-bronchodilator 62.5%). There was no difference in cotinine-validated prolonged abstinence rate between the experimental group (11.2%) and control group 1 (11.6%) from week 5–52 (odds ratio (OR) 0.96, 95% confidence interval (CI) 0.43–2.18). The abstinence rate was approximately twice as high in the experimental group compared with control group 2 (5.9%), but this difference was not statistically significant (OR 2.02, 95% CI 0.63–6.46). The present study did not provide evidence that the confrontational approach increases the rate of long-term abstinence from smoking compared with an equally intensive treatment in which smokers were not confronted with spirometry. The high failure rates (≥88%) highlight the need for treating tobacco addiction as a chronic relapsing disorder.

Dose dependent increased mortality risk in COPD patients treated with oral glucocorticoids

Systemic corticosteroids are often administered in COPD patients. The relationship between systemic glucocorticoids and mortality in patients with moderate to severe chronic obstructive pulmonary disease (COPD) was retrospectively analysed. Baseline characteristics of the patients, in stable clinical condition, were collected on admission to a pulmonary rehabilitation centre. Overall mortality was asessed at the end of follow-up. The Cox proportional hazards model was used to quantify the relationship between glucocorticoid use, distinguishing administration route (oral/inhalation) and oral dose, and overall mortality, adjusted for the influence of age, sex, smoking, lung function, resting arterial blood gases and body mass index. On multivariate analysis, oral glucocorticoid use at a (prednisone equivalent) dose of 10 mg x day(-1) without inhaled glucocorticoids, was associated with an increased risk (RR=2.34, 95% confidence interval (CI) 1.24-4.44) while 15 mg x day(-1) carried a relative risk of 4.03, CI = 1.99-8.15). A significant interaction was observed between inhaled and oral glucocorticoid use. Combined with inhaled glucocorticoids, the relative risk of oral glucocorticoid use appeared to be significantly smaller. It is concluded that in severe chronic obstructive pulmonary disease, maintenance treatment with oral glucocorticoids is associated with increased mortality in a dose-dependent manner. Since the present study design cannot exclude the possibility of bias by indication, further prospective studies are indicated using a broader patient characterization.

Use of out of hours services: a comparison between two organisations

Objectives: To investigate differences in numbers and characteristics of patients using primary or emergency care because of differences in organisation of out of hours care. Background: Increasing numbers of self referrals at the accident and emergency (A&E) department cause overcrowding, while a substantial number of these patients exhibit minor injuries that can be treated by a general practitioner (GP). Methods: Two different organisations of out of hours care in two Dutch cities (Heerlen and Maastricht) were investigated. Important differences between the two organisations are the accessibility and the location of primary care facility (GP cooperative). The Heerlen GP cooperative is situated in the centre of the city and is respectively 5 km and 9 km away from the two A&E departments situated in the area of Heerlen. This GP cooperative can only be visited by appointment. The Maastricht GP cooperative has free access and is located within the local A&E department. During a three week period all registration forms of patient contacts with out of hours care (GP cooperative and A&E department) were collected and with respect to the primary care patients a random sample of one third was analysed. Results: For the Heerlen and Maastricht GP cooperative the annual contact rate, as extrapolated from our data, per 1000 inhabitants per year is 238 and 279 respectively (χ2(1df)=4.385, p=0.036). The contact rate at the A&E departments of Heerlen (n=66) and Maastricht (n=52) is not different (χ2(1df)=1.765, p=0.184). Some 51.7% of the patients attending the A&E department in Heerlen during out of hours were self referred, compared with 15.9% in Maastricht (χ2(1df)=203.13, p<0.001). Conclusions: The organisation of out of hours care in Maastricht has optimised the GP’s gatekeeper function and thereby led to fewer self referrals at the A&E department, compared with Heerlen.

External validation of a COPD diagnostic questionnaire

The aim of the present study was to determine the external validity of a recently developed questionnaire for the identification of patients at increased risk of airflow limitation in smokers from the general population in the provinces of Dutch and Belgian Limburg (regions surrounding Maastricht, the Netherlands). As part of a study on the early detection of airflow limitation and subsequent smoking cessation treatment (International Standard Randomised Controlled Trial Number: 64481813), the recently developed chronic obstructive pulmonary disease (COPD) diagnostic questionnaire was used in current smokers aged 40–70 yrs, with a smoking history of ≥10 pack-yrs, who reported one or more respiratory symptom (cough, sputum production or dyspnoea), but who had no diagnosis of a respiratory disease (COPD or asthma). Spirometry performed according to American Thoracic Society/European Respiratory Society criteria served as a reference test. Of the 676 subjects who entered the analyses, 398 showed normal lung function and 278 had a diagnosis of COPD (post-bronchodilator forced expiratory volume in one second/forced vital capacity of <0.70). The ability of the COPD diagnostic questionnaire to discriminate between subjects with and without COPD was poor (area under the receiver operating characteristic curve of 0.65). In a high-risk population consisting of middle-aged current smokers with a smoking history of ≥10 pack-yrs, the chronic obstructive pulmonary disease diagnostic questionnaire is probably not useful as a diagnostic tool for the identification of patients with an increased risk of airflow limitation.

The Impact of a Primary Care Physician Cooperative on the Caseload of an Emergency Department: The Maastricht Integrated Out-of-Hours Service

AbstractOBJECTIVE: To determine the effect of an out-of-hours primary care physician (PCP) cooperative on the caseload at the emergency department (ED) and to study characteristics of patients utilizing out-of-hours care. DESIGN: A pre-post intervention design was used. During a 3-week period before and a 3-week period after establishing the PCP cooperative, all patient records with out-of-hours primary and emergency care were analyzed. SETTING: Primary care in Maastricht (the Netherlands) is delivered by 59 PCPs. Primary care physicians formerly organized out-of-hours care in small locum groups. In January 2000, out-of-hours primary care was reorganized, and a PCP cooperative was established. This cooperative is located at the ED of the University Hospital Maastricht, the city’s only hospital, which has no emergency medicine specialists. MAIN OUTCOME MEASURES: The number of patients utilizing out-of-hours care, their age and sex, diagnoses, post-ED care, and serious adverse events. RESULTS. After establishing the PCP cooperative, the proportion of patients utilizing emergency care decreased by 53%, and the proportion of patients utilizing primary care increased by 25%. The shift was the largest for patients with musculoskeletal disorders or skin problems. There were fewer hospital admissions, and fewer subsequent referrals to the patient’s own PCP and medical specialists. No substantial change in new outpatient visits at the hospital or in mortality occurred. CONCLUSIONS: In the city of Maastricht, the Netherlands, the PCP cooperative reduced the use of hospital emergency care during out-of-hours care.

Chronic bronchiolitis in a 5‐yr-old child after exposure to sulphur mustard gas

Exposure to sulphur mustard (SM) gas may have extensive immediate effects on the respiratory system. However, long-term effects are far less known. This case report describes a Kurdish male child who was exposed to SM gas during a chemical attack in Iraq at 5 yrs of age. In the acute phase, the child developed severe respiratory symptoms with a chemical pneumonia. Extensive burning of the skin occurred. In the course of 10 yrs, lung function deteriorated progressively to a forced expiratory volume in one second of 30% of predicted value. Severe air-trapping occurred. The lung function abnormalities were not reversed by treatment with corticosteroids or bronchodilators. Infectious exacerbations of the childs lung disease occurred. High resolution computed tomography scan showed multiple bronchiectasis. The histological picture of an open lung biopsy was best described as a “chronic bronchiolitis”.

Low-grade adipose tissue inflammation in patients with mild-to-moderate chronic obstructive pulmonary disease

BACKGROUND Low-grade systemic inflammation is common in chronic obstructive pulmonary disease (COPD), but its source remains unclear. Adipose tissue is a potent producer of inflammatory mediators and may contribute to systemic inflammation in COPD, possibly via hypoxia. OBJECTIVE We studied the influence of COPD and exercise-induced oxygen desaturation on adipose tissue inflammation (ATI) and its contribution to systemic inflammation. DESIGN Subcutaneous adipose tissue biopsies were investigated in 28 clinically stable COPD patients [forced expiratory volume in 1 s: 58 ± 16% predicted; BMI (in kg/m(2)): 24.9 ± 2.9] and 15 age-, sex-, and body composition-matched healthy control subjects. Fat mass was measured with dual-energy X-ray absorptiometry. Patients were prestratified by oxygen desaturation assessed by incremental cycle ergometry. The adipocyte size and adipose tissue expression of 19 inflammatory and hypoxia-related genes were measured, and adipose tissue macrophages (ATMs) were histologically quantified. Systemic inflammatory markers included C-reactive protein (CRP) and a panel of 20 adipokines. RESULTS COPD patients had comparable fat mass but higher CRP and HOMA-IR than did control subjects. COPD patients and control subjects had comparable adipose tissue gene expression, adipocyte size, ATM infiltration, and systemic adipokine concentrations. Desaturating COPD patients had no different ATI status than did nondesaturating COPD patients. COPD patients with high CRP had significantly greater ATM infiltration than did patients with low CRP, which was independent of BMI and fat mass. CONCLUSIONS In COPD patients, mild-to-moderate COPD, per se, does not enhance ATI or its contribution to systemic inflammation compared with in well-matched healthy control subjects. However, to our knowledge, our study provides a first indication for a possible role of ATMs in the systemic inflammatory response in COPD that requires additional investigation. This trial was registered at www.trialregister.nl as NTR1402.

Reliability and validity of the clinical COPD questionniare and chronic respiratory questionnaire

BACKGROUND Questionnaires are often used in assessing health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). It is important that these questionnaires have good reliability, validity, and responsiveness. The aim of this study was to investigate and compare these properties in the disease specific Clinical COPD Questionnaire (CCQ) and the Chronic Respiratory Questionnaire self-reported (CRQ-SR). METHODS Two hundred ninety six participants with spirometry confirmed mild to moderate COPD were included in a smoking cessation trial. It was assumed that health-related quality of life would improve in participants who stopped smoking. The questionnaires were administered at baseline and at weeks 5, 26, and 52 after the target quit date. RESULTS At baseline, 292 (97%) participants returned the CCQ and 296 (100%) the CRQ-SR questionnaire. For both instruments, the internal consistency was good (Cronbachs alpha >70%) as was the convergent validity with each other but not with spirometry. The CCQ was responsive to improvements in respiratory symptoms at both week 26 (-1.02, SD = 0.81) and 52 (-1.04, SD = 0.91) and in the total score at week 26 (-0.54, SD = 0.50) and 52 (-0.43, SD = 0.44). The mastery domain and the total score of the CRQ-SR were responsive at week 26 (1.14, SD = 0.82; 0.67, SD = 0.97 respectively) but not at week 52 (0.04, SD = 0.93; 0.38, SD = 0.57 respectively). CONCLUSION Both the CCQ and CRQ-SR are equally reliable and valid. The long-term responsiveness of the CCQ is better. Both questionnaires can be used in future studies involving patients with mild to moderate COPD. However, when the follow-up exceeds 26 weeks, the CCQ is the recommended alternative. Netherlands Trial Register: ISRCTN 64481813.