Lisette van den Bemt

The risk for depression comorbidity in patients with COPD.

INTRODUCTIONnPatients with COPD are believed to have a high risk for the development of depression. However, it remains unclear whether or not there is a temporal relation between COPD and depression, and if the higher risk for depression is a result of having a chronic disease, or is specific for COPD. The aim of this study is to compare the risk for physician-diagnosed depression in patients with COPD, patients with diabetes mellitus (DM), and control subjects without chronic conditions.nnnMETHODSnThe study was a prospective cohort study based on the Continuous Morbidity Registration database. Cox proportional hazards analysis was used to identify the risk of a first episode of depression in patients with COPD compared to patients with DM and matched control subjects without chronic conditions. The following covariates were added to the model: age, the general practice the patient was listed with, socioeconomic status, comorbidity, and gender. All patients with a diagnosis of depression preceding the date of first diagnosis of COPD or DM (dummy date in control subjects) were excluded.nnnRESULTSnThe hazard ratios for a first episode of depression in the COPD group compared to the DM group and healthy controls subjects were 1.80 (95% confidence interval [CI], 1.16 to 2.81) and 1.68 (95% CI, 1.20 to 2.35), respectively.nnnDISCUSSIONnWe found a temporal relation between COPD and physician-diagnosed depression. Patients with COPD are more likely to have depression diagnosed than patients with DM and control subjects without chronic conditions.

Multidimensional prognostic indices for use in COPD patient care. A systematic review.

BackgroundA growing number of prognostic indices for chronic obstructive pulmonary disease (COPD) is developed for clinical use. Our aim is to identify, summarize and compare all published prognostic COPD indices, and to discuss their performance, usefulness and implementation in daily practice.MethodsWe performed a systematic literature search in both Pubmed and Embase up to September 2010. Selection criteria included primary publications of indices developed for stable COPD patients, that predict future outcome by a multidimensional scoring system, developed for and validated with COPD patients only. Two reviewers independently assessed the index quality using a structured screening form for systematically scoring prognostic studies.ResultsOf 7,028 articles screened, 13 studies comprising 15 indices were included. Only 1 index had been explored for its application in daily practice. We observed 21 different predictors and 7 prognostic outcomes, the latter reflecting mortality, hospitalization and exacerbation. Consistent strong predictors were FEV1 percentage predicted, age and dyspnoea. The quality of the studies underlying the indices varied between fairly poor and good. Statistical methods to assess the predictive abilities of the indices were heterogenic. They generally revealed moderate to good discrimination, when measured. Limitations: We focused on prognostic indices for stable disease only and, inevitably, quality judgment was prone to subjectivity.ConclusionsWe identified 15 prognostic COPD indices. Although the prognostic performance of some of the indices has been validated, they all lack sufficient evidence for implementation. Whether or not the use of prognostic indices improves COPD disease management or patients health is currently unknown; impact studies are required to establish this.

How does asthma influence the daily life of children? Results of focus group interviews

BackgroundHealth-related quality of life (HRQL) brings together various aspects of an individuals subjective experience that relate both directly and indirectly to health, disease, disability, and impairment. Although asthma is the most common chronic disease in childhood, information on pediatric patients views on asthma-specific HRQL has not been described before. The aim of this study was to establish the components of asthma-specific HRQL, as experienced by primary school-aged asthmatic children. The generated components will be used to develop an individualized HRQL instrument for childhood asthma.MethodsPrimary school-aged asthmatic children were invited to participate in three consecutive focus group sessions. A total of five focus groups were formed. Two reviewers independently 1) identified trends in the statements and relations between HRQL components, 2) clustered the components into a small number of domains and, 3) made a model on asthma-specific HRQL based on the transcribed statements of the children. The results were compared between the two reviewers and resulted in a final model.ResultsAsthma influenced the life of the children physically, emotionally and socially. The most important components of HRQL were the effects on, and consequences of asthma on peer relationships (e.g., being bullied), the dependence on medication, shortness of breath, cough, limitations in activities and limitations due to the response on cigarette smoke exposure.ConclusionThe outcome of the focus group meetings indicates that asthma influences the life of children in various ways. Not all essential components of HRQL, according to the children, are part of existing asthma-specific HRQL instruments.

Monitoring of patients with COPD: A review of current guidelines’ recommendations

BACKGROUNDnThe goals for the management of COPD are to delay the process of disease progression and alleviate its manifestations. The follow-up of the patients physical and mental condition is part of best practice management when monitoring routines results in information that contributes to the achievement of management goals. However, the recommendations on monitoring procedures may differ between guidelines and may not be based on scientific evidence. The aim of this article is to review the current guideline recommendations on monitoring routines for COPD.nnnMETHODSnClinical practice guidelines on the management of COPD were identified by a Medline search, Internet search and expanded by experts in the respiratory field. Guidelines on the management of COPD were analysed on recommended monitoring routines, recommended frequency of monitoring.nnnRESULTSnEighteen clinical practice guidelines on the management of COPD were analysed. The follow-up of lung function indices was the most frequently recommended monitoring routine. Moreover, monitoring of symptoms, exercise tolerance, comorbidity, and smoking habits were recommended regularly. In none of the guidelines, the recommended monitoring routines were evidence based. Only one guideline provides a different set of monitoring parameters for advanced COPD compared to mild and moderate COPD.nnnCONCLUSIONnSome monitoring routines were recommended frequently, especially follow-up of lung function indices. However, evidence to support the guideline recommendations for the monitoring of patients with COPD is missing. The effect of monitoring on care process and outcomes should be assessed.

Diagnostic accuracy of pre-bronchodilator FEV1/FEV6 from microspirometry to detect airflow obstruction in primary care: a randomised cross-sectional study

Background:Forced expiratory volume in 1s/forced expiratory volume in 6u2009s (u2009FEV1/FEV6) assessment with a microspirometer may be useful in the diagnostic work up of subjects who are suspected of having COPD in primary care.Aim:To determine the diagnostic accuracy of a negative pre-bronchodilator (BD) microspirometry test relative to a full diagnostic spirometry test in subjects in whom general practitioners (GPs) suspect airflow obstruction.Methods:Cross-sectional study in which the order of microspirometry and diagnostic spirometry tests was randomised. Study subjects were (ex-)smokers aged ⩾50 years referred for diagnostic spirometry to a primary care diagnostic centre by their GPs. A pre-BD FEV1/FEV6 value <0.73 as measured with the PiKo-6 microspirometer was compared with a post-BD FEV1/FVC (forced vital capacity) <0.70 and FEV1/FVC<lower limit of normal (LLN) from diagnostic spirometry.Results:One hundred and four subjects were analysed (59.6% males, 42.3% current smokers). Negative predictive values from microspirometry for airflow obstruction based on the fixed and LLN cut-off points were 94.4% (95% confidence interval (CI), 86.4–98.5) and 96.3% (95% CI, 88.2–99.3), respectively. In all, 18% of positive microspirometry results were not confirmed by a post-BD FEV1/FVC <0.70 and 44% of tests were false positive compared with the LLN criterion for airflow obstruction.Conclusions:Pre-bronchodilator microspirometry seems to be able to reliably preselect patients for further assessment of airflow obstruction by means of regular diagnostic spirometry. However, use of microspirometry alone would result in overestimation of airflow obstruction and should not replace regular spirometry when diagnosing COPD in primary care.

Low body mass index, airflow obstruction, and dyspnoea in a primary care COPD patient population.

AIMnThe objective of our study was to explore the existence/co-existence of factors - as per American Thoracic Society (ATS)/European Respiratory Society (ERS) standards - for staging patients in a primary care COPD population.nnnMETHODnA representative sample of COPD patients in primary care was studied. Cross-sectional information on airflow obstruction, body mass index (BMI), and dyspnoea (Modified Medical Research Council [MMRC] score) were collected. The existence/co-existence of these prognostic factors is described.nnnRESULTSnThe study sample consisted of 2,023 patients. BMI was low in 11.7%, MMRC score > or =2 was found in 28.7%, and 53.9% fulfilled the criteria of relevant airflow obstruction. Only 3.4% of this population scored on all three prognostic factors.nnnCONCLUSIONnModerate dyspnoea and moderate airflow obstruction were rather prevalent in this primary care population, but coexistence of factors was low. Therefore, it seems that the assessment of BMI and dyspnoea represent additional information on primary care COPD patients.

PELICAN: A quality of life instrument for childhood asthma: Study Protocol of two Randomized Controlled Trials in Primary and Specialized Care in the Netherlands

BackgroundAsthma is one of the major chronic health problems in children in the Netherlands. The Pelican is a paediatric asthma-related quality of life instrument for children with asthma from 6–11u2009years old, which is suitable for clinical practice in primary and specialized care. Based on this instrument, we developed a self-management treatment to improve asthma-related quality of life. The Pelican intervention will be investigated in different health care settings. Results of intervention studies are often extrapolated to other health care settings than originally investigated. Because of differences in organization, disease severity, patient characteristics and care provision between health care settings, extrapolating research results could lead to unnecessary health costs without the desired health care achievements. Therefore, interventions have to be investigated in different health care settings when possible. This study is an example of an intervention study in different health care settings. In this article, we will present the study protocol of the Pelican study in primary and specialized care.Method/designThis study consists of two randomized controlled trials to assess the effectiveness of the Pelican intervention in primary and specialized care. The trial in primary care is a multilevel design with 170 children with asthma in 16 general practices. All children in one general practices are allocated to the same treatment group. The trial in specialized care is a multicentre trial with 100 children with asthma. Children in one outpatient clinic are randomly allocated to the intervention or usual care group. In both trials, children will visit the care provider four times during a follow-up of nine months. This study is registered and ethically approved.DiscussionThis article describes the study protocol of the Pelican study in different health care settings. If the Pelican intervention proves to be effective and efficient, implementation in primary and specialized care for paediatric asthma in the Netherlands will be recommended.Trial registrationThis study is registered by clinicaltrial.gov (NCT01109745)

Megatrials for Bronchodilators in Chronic Obstructive Pulmonary Disease (COPD) Treatment: Time to Reflect

Introduction: Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality worldwide. Although (long-acting) bronchodilators are used to relieve symptoms, the impact of bronchodilators on COPD mortality remains an unresolved issue. Our aim was to explore the results and the interpretations of the results of studies of bronchodilator treatment from high-impact COPD trials. Methods: We searched PubMed and Embase for primary publications of randomized controlled trials with more than 1000 participants with COPD and that studied the effectiveness of long-acting bronchodilator treatment. We assessed population characteristics, primary outcomes, focus of outcomes, and possible bias from concomitant pulmonary medication. Results: We retrieved 5 primary publications of large trials. Participants tended to be patients with rather severe COPD who were cared for at a hospital. Only half of the primary outcomes were statistically significant. Reports tended to focus on statically significant outcomes and not necessarily on primary outcomes or outcomes of the whole study population. The relevance of study outcomes was rarely discussed. Discussion: The rather small effects of bronchodilators in a COPD population that is not representative for daily care, together with the tendency of relying on statistical rather than clinical significance, hampers translation to the large number of patients with COPD in the community.

PELICAN: a cluster-randomized controlled trial in Dutch general practices to assess a self-management support intervention based on individual goals for children with asthma

Abstract Objective: Insufficient asthma management leads to impaired health-related quality of life (HRQL). The aim of this study is to assess whether individualized self-management (ISM) support will improve HRQL in children with asthma compared to enhanced usual care (EUC) in Dutch general practices. Methods: A cluster-randomized controlled trial with 9-month follow-up. ISM is a nurse-led intervention that is optimized to the needs of children, leading to a written action plan. Power calculation demanded inclusion of 170 children (aged 6–11u2009years) diagnosed with asthma and active medication use. Results: Outcomes were HRQL of the child (Paediatric Asthma Quality of Life Questionnaire, PAQLQ-s) and several secondary outcomes. Data of 29 children (mean age 8.6u2009years, SD 1.7) were analyzed; ISM (nu2009=u200915) or EUC (nu2009=u200914). Logistic regression analysis (minimal clinical important difference; MCIDu2009≥u20090.5) and descriptive analyses were performed. Despite high PAQLQ-s score at baseline (median ISM 6.35, EUC 6.02), a substantial number of subjects from both groups showed MCID of HRQL (ISM 33%, EUC 57%). Treatment differences on HRQL were not significant (OR 0.38, 95% CI 0.08, 1.69). Secondary outcomes did not show significant differences either, with exception of PAQLQ-s symptoms domain score in favor of EUC. Conclusion: Due to recruitment problems and underpowered analyses, no firm conclusions on the effectiveness of ISM support for childhood asthma in primary care could be drawn. Still, this study can be considered a valuable pilot study and in the future, there might be better capacity in general practices to commit to such treatment.

PELICAN: Content evaluation of patient‐centered care for children with asthma based on an online tool

We assessed the content of an intervention which integrates individual goals in outpatient clinic asthma management (based on self management principles) of children 6–12 years of age.