Michael Steiner

Blood Eosinophils and Outcomes in Severe Hospitalized Exacerbations of COPD

BACKGROUNDnPatients with moderate exacerbations of COPD and the eosinophilic phenotype have better outcomes with prednisolone. Whether this outcome is similar in patients hospitalized with a severe exacerbation of COPD is unclear. We investigated the rate of recovery of eosinophilic and noneosinophilic exacerbations in patients participating in a multicenter randomized controlled trial assessing health outcomes in hospitalized exacerbations.nnnMETHODSnPatients were recruited at presentation to the hospital with an exacerbation of COPD. They were stratified into groups according to eosinophilic exacerbations if the peripheral blood eosinophil count on admission wasxa0≥ 200 cells/μL and/orxa0≥ 2%xa0of the total leukocyte count. Admission details, serum C-reactive protein levels, length of stay, and subsequent rehospitalization data were compared between groups.nnnRESULTSnA total of 243 patients with COPD (117 men) with a mean age of 71 years (range, 45-93 years) were recruited. The inpatient mortality rate was 3%xa0(median time to death, 12xa0days; range, 9-16xa0days). The median absolute eosinophil count was 100 cells/μL (range, 10-1,500 cells/μL), and 25%xa0met our criteria for an eosinophilic exacerbation; in this population, the mean length of stay (in days) was shorter than in patients with noneosinophilic exacerbations (5.0 [range, 1-19] vsxa06.5 [range, 1-33]; Pxa0= .015) following treatment with oral corticosteroids and independent of treatment prior to admission. Readmission rates at 12xa0months were similar between groups.nnnCONCLUSIONSnThe study patients presenting to the hospital with a severe eosinophilic exacerbation of COPD had a shorter length of stay. The exacerbations were usually not associated with elevated C-reactive protein levels, suggesting that better treatment stratification of exacerbations can be used.nnnTRIAL REGISTRYnhttp://www.isrctn.com/ISRCTN05557928.

A self-management programme for COPD: a randomised controlled trial

Studies of programmes of self-management support for chronic obstructive pulmonary disease (COPD) have been inconclusive. The Self-Management Programme of Activity, Coping and Education (SPACE) FOR COPD is a 6-week self-management intervention for COPD, and this study aimed to evaluate the effectiveness of this intervention in primary care. A single-blind randomised controlled trial recruited people with COPD from primary care and randomised participants to receive usual care or SPACE FOR COPD. Outcome measures were performed at baseline, 6 weeks and 6 months. The primary outcome was symptom burden, measured by the self-reported Chronic Respiratory Questionnaire (CRQ-SR) dyspnoea domain. Secondary outcomes included other domains of the CRQ-SR, shuttle walking tests, disease knowledge, anxiety, depression, self-efficacy, smoking status and healthcare utilisation. 184 people with COPD were recruited and randomised. At 6 weeks, there were significant differences between groups in CRQ-SR dyspnoea, fatigue and emotion scores, exercise performance, anxiety, and disease knowledge. At 6 months, there was no between-group difference in change in CRQ-SR dyspnoea. Exercise performance, anxiety and smoking status were significantly different between groups at 6 months, in favour of the intervention. This brief self-management intervention did not improve dyspnoea over and above usual care at 6 months; however, there were gains in anxiety, exercise performance, and disease knowledge. A brief self-management programme for COPD improves some patient outcomes; however, more support may be required http://ow.ly/AbCpm

Individualised risk in patients undergoing lung volume reduction surgery (LVRS): The Glenfield BFG Score

Lung volume reduction surgery (LVRS) has been shown to be beneficial in patients with chronic obstructive pulmonary disease, but there is low uptake, partly due to perceived concerns of high operative mortality. We aimed to develop an individualised risk score following LVRS. This was a cohort study of patients undergoing LVRS. Factors independently predicting 90-day mortality and a risk prediction score were identified. Reliability of the score was tested using area under the receiver operating characteristic curve (AUROC). 237 LVRS procedures were performed. The multivariate analysis factors associated independently with death were: body mass index (BMI)<18.5u2005kg·m−2 (OR 2.83, p=0.059), forced expiratory volume in 1u2005s (FEV1)<0.71u2005L (OR 5.47, p=0.011) and transfer factor of the lung for carbon monoxide (TLCO) <20% (OR 5.56, p=0.031). A risk score was calculated and total score assigned. AUROC for the risk score was 0.80 and a better predictor than individual components (p<0.01). The score was stratified into three risk groups. Of the total patients, 46% were classified as low risk. Similar improvements in lung function and health status were seen in all groups. The score was introduced and tested in a further 71 patients. AUROC for 90-day mortality in this cohort was 0.84. It is possible to provide an individualised predictive risk score for LVRS, which may aid decision making for both clinicians and patients. An individualised risk score for lung volume reduction surgery may aid decision making around surgery http://ow.ly/4lxm30b3n05

Hospital admission and readmission for acute exacerbation of COPD. A tough nut to crack

Reducing acute hospital care for people with long-term conditions has become a key element of health policy as governments strain every sinew to contain the escalating healthcare costs arising from ageing populations. Attention has been drawn to the problem of unscheduled hospitalisation for acute exacerbations of COPD (AECOPD) because it is such a common cause of emergency admission and because there is a high readmission rate following discharge. The latter has driven the perception in many quarters that admissions to hospital should be preventable and, with regards to readmission particularly, may be due to poor quality hospital care. Clinicians are frequently caught in the crossfire of these arguments—under pressure to discharge patients quickly to free up precious hospital bed capacity but also to ensure ‘safe’ discharge to reduce the risk of further presentation. Primary care physicians are experiencing similar pressures to avoid referral to hospital while at the same time providing safe management of the episode in the patients home.nnThe impact of an AECOPD on an individual is determined by the composite effects of the severity of the acute event (eg, respiratory infection) and the underlying condition of the patient (the respiratory disease and other factors such as multimorbidity). In making clinical judgements about discharge from hospital clinicians need to also take into account the social and psychological circumstances, particularly the confidence of the patient and their carers that they are ready to leave hospital. It would be fair to say that currently, these judgements are largely subjective and do not routinely incorporate objective measurements of the risk of subsequent readmission to assist in shared decision-making.nnTwo papers published in this issue of Thorax are relevant to this debate and have the potential to impact on clinical care. Suh et al 1 used parasternal electromyography (EMG) to measure neural …

Metabolic phenotype of skeletal muscle in early critical illness

Objectives To characterise the sketetal muscle metabolic phenotype during early critical illness. Methods Vastus lateralis muscle biopsies and serum samples (days 1 and 7) were obtained from 63 intensive care patients (59% male, 54.7±18.0 years, Acute Physiology and Chronic Health Evaluation II score 23.5±6.5). Measurements and main results From day 1 to 7, there was a reduction in mitochondrial beta-oxidation enzyme concentrations, mitochondrial biogenesis markers (PGC1α messenger mRNA expression (−27.4CN (95%u2009CI −123.9 to 14.3); n=23; p=0.025) and mitochondrial DNA copy number (−1859CN (IQR −5557–1325); n=35; p=0.032). Intramuscular ATP content was reduced compared tocompared with controls on day 1 (17.7mmol/kg /dry weight (dw) (95%u2009CI 15.3 to 20.0) vs. 21.7u2009mmol/kg /dw (95%u2009CI 20.4 to 22.9); p<0.001) and decreased over 7 days (−4.8u2009mmol/kg dw (IQR −8.0–1.2); n=33; p=0.001). In addition, the ratio of phosphorylated:total AMP-K (the bioenergetic sensor) increased (0.52 (IQR −0.09–2.6); n=31; p<0.001). There was an increase in intramuscular phosphocholine (847.2AU (IQR 232.5–1672); n=15; p=0.022), intramuscular tumour necrosis factor receptor 1 (0.66u2009µg (IQR −0.44–3.33); n=29; p=0.041) and IL-10 (13.6u2009ng (IQR 3.4–39.0); n=29; p=0.004). Serum adiponectin (10.3u2009µg (95%u2009CI 6.8 to 13.7); p<0.001) and ghrelin (16.0u2009ng/mL (IQR −7–100); p=0.028) increased. Network analysis revealed a close and direct relationship between bioenergetic impairment and reduction in muscle mass and between intramuscular inflammation and impaired anabolic signaling. ATP content and muscle mass were unrelated to lipids delivered. Conclusions Decreased mitochondrial biogenesis and dysregulated lipid oxidation contribute to compromised skeletal muscle bioenergetic status. In addition, intramuscular inflammation was associated with impaired anabolic recovery with lipid delivery observed as bioenergetically inert. Future clinical work will focus on these key areas to ameliorate acute skeletal muscle wasting. Trial registration number NCT01106300.

Patient experience of lung volume reduction procedures for emphysema: a qualitative service improvement project

The aim of this service improvement project was to gain understanding of the patient experience of lung volume reduction surgery (LVRS) and endobronchial valve (EBV) placement, from referral through to post-discharge care. Focus group interviews were carried out in two tertiary centres in London and Leicester, UK. Sixteen patients who had undergone lung volume reduction surgery (LVRS), endobronchial valve (EBV) placement, or both, were recruited. Prior to participation in each focus group, participants completed a questionnaire to guide and focus discussion. Thematic analysis identified common themes to the participant experience of receiving lung volume reduction interventions. Themes included patient focus on declining health and the need to “fight” for a referral; consequences of having procedures and potential unexpected complications; and vulnerability post discharge and limited continuity of care. Participants were clear that the benefits of having had either LVRS or EBV procedures outweighed any difficulties experienced. Participants were keen to have further similar interventions if appropriate. These data confirm the need to develop more systematic lung volume reduction pathways, provide appropriate information, and ensure that post-discharge care is optimal. Patients feel they have to fight to get a lung volume reduction procedure; a more systematic approach is needed http://ow.ly/82Oy30cLORk

The influence of South Asian ethnicity on the incremental shuttle walk test in UK adults

The objective of this study was to compare incremental shuttle walking test (ISWT) performance between South Asian and Caucasian British adults, identify predictors of ISWT distance and produce ethnicity-specific reference equations. Data from a mixed gender sample aged 40–75 years from Leicestershire, United Kingdom, were selected for analyses. Analysis of covariance determined differences in ISWT performance between South Asian and Caucasian British ethnic groups. Linear regressions identified predictors of ISWT distance, which determined the reference equations. In total, 144 participants took part in the study (79 South Asian (54 ± 8 years, 71% female) and 65 Caucasian British (58 ± 9 years, 74% female)). Distance walked for the ISWT was shorter for South Asian individuals compared with Caucasian British (451 ± 143 vs. 575 ± 180 m, p < 0.001). The ethnicity-specific reference equations for ISWT distance explained 33–50% of the variance (standard error of the estimate (SEE): 107–119 m) for South Asians and explained 14–58% of the variance (SEE: 121–169 m) for Caucasian British. Ethnicity univariately explained 12.9% of the variance in ISWT distance and was significantly associated with ISWT distance after controlling for age, gender, height, weight, dyspnoea and lung function (B = −70.37; 1 = Caucasian British, 2 = South Asian), uniquely explaining 3.7% of the variance. Predicted values for ISWT performance were lower in South Asian people than in Caucasian British. Ethnicity-specific reference equations should account for this.

Prospective risk of osteoporotic fractures in patients with advanced chronic obstructive pulmonary disease

Despite the high prevalence of osteoporosis in chronic obstructive pulmonary disease (COPD) patients, the fracture risk prediction tools are not routinely undertaken in the management of COPD. We quantified fracture risk using a validated risk prediction tool (Fracture Risk Assessment (FRAX®)) and determined potential bone-protection treatment needs in patients with advanced COPD. The 10-year probability of major osteoporotic or hip fracture was calculated using the FRAX tool in a cohort of patients attending a hospital complex COPD service. Patients were identified to be at low, intermediate and high risk based on their FRAX scores, in accordance with the National Osteoporosis Guideline Group recommendations, to assess the number of patients requiring bone mineral density (BMD) testing or bone protection therapy. Two hundred forty-seven patients [mean (standard deviation (SD)) age 66 (9.1) years, 26% current smokers, 40% women and median (interquartile range (IQR)) Medical Research Council (MRC) breathlessness scale 4 (0)] had a 10-year probability of 9.5% (6.1) and 3.8% (4.6) for major osteoporotic and hip fractures, respectively. Thirty-six percentage of patients were identified to be at intermediate risk of developing fragility fracture, requiring BMD assessment, while 9% were at high risk, requiring treatment. Thirty-two percentage of high-risk patients were on bisphosphonates. The FRAX score can be used to assess the fracture risk within the COPD cohort and assist with decision-making about BMD measurement and provision of bone protection therapy.

CELEB trial: Comparative Effectiveness of Lung volume reduction surgery for Emphysema and Bronchoscopic lung volume reduction with valve placement: a protocol for a randomised controlled trial

Introduction Although lung volume reduction surgery and bronchoscopic lung volume reduction with endobronchial valves have both been shown to improve lung function, exercise capacity and quality of life in appropriately selected patients with emphysema, there are no direct comparison data between the two procedures to inform clinical decision-making. Methods and analysis We describe the protocol of the CELEB study, a randomised controlled trial which will compare outcomes at 1u2009year between the two procedures, using a composite disease severity measure, the iBODE score, which includes body mass index, airflow obstruction, dyspnoeaand exercise capacity (incremental shuttle walk test). Ethics and dissemination Ethical approval to conduct the study has been obtained from the Fulham Research Ethics Committee, London (16/LO/0286). The outcome of this trial will provide information to guide treatment choices in this population and will be presented at national and international meetings and published in peer-reviewed journals. We will also disseminate the main results to all participants in a letter. Trial registration number ISRCTN19684749; Pre-results.