A shared decision-making intervention for individuals living with chronic obstructive pulmonary disease who are considering the menu of pulmonary rehabilitation treatment options; a feasibility study.

OBJECTIVES: Shared Decision Making (SDM) has potential to support Pulmonary Rehabilitation (PR) decision-making when patients are offered a menu of centre- and home-based options. This study sought to evaluate the feasibility and acceptability of a three-component PR SDM intervention for individuals with Chronic Obstructive Pulmonary Disease (COPD) and PR healthcare professionals. METHODS: Participants were recruited from Dec 2021-Sep 2022. Healthcare professionals attended decision coaching training and used the consultation prompt during consultations. Individuals received the Patient Decision Aid (PtDA) at PR referral. Outcomes included recruitment capability, data completeness, intervention fidelity, and acceptability. Questionnaires assessed patient activation and decisional conflict pre and post-PR. Consultations were assessed using Observer OPTION-5. Optional interviews/focus groups were conducted. RESULTS: 13% of individuals [n = 31, 32% female, mean (SD) age 71.19 (7.50), median (IQR) MRC dyspnoea 3.50 (1.75)] and 100 % of healthcare professionals (n = 9, 78% female) were recruited. 28 (90.32%) of individuals completed all questionnaires. SDM was present in all consultations [standardised scores were mean (SD) = 36.97 (21.40)]. Six healthcare professionals and five individuals were interviewed. All felt consultations using the PtDA minimised healthcare professionals' bias of centre-based PR, increased individuals' self-awareness of their health, prompted consideration of how to improve it, and increased involvement in decision-making. DISCUSSION: Results indicate the study processes and SDM intervention is feasible and acceptable and can be delivered with fidelity when integrated into the PR pathway.

Genetic dissection of drought tolerance in chickpea (Cicer arietinum L.).

KEY MESSAGE: Analysis of phenotypic data for 20 drought tolerance traits in 1-7 seasons at 1-5 locations together with genetic mapping data for two mapping populations provided 9 QTL clusters of which one present on CaLG04 has a high potential to enhance drought tolerance in chickpea improvement. Chickpea (Cicer arietinum L.) is the second most important grain legume cultivated by resource poor farmers in the arid and semi-arid regions of the world. Drought is one of the major constraints leading up to 50% production losses in chickpea. In order to dissect the complex nature of drought tolerance and to use genomics tools for enhancing yield of chickpea under drought conditions, two mapping populations-ICCRIL03 (ICC 4958 × ICC 1882) and ICCRIL04 (ICC 283 × ICC 8261) segregating for drought tolerance-related root traits were phenotyped for a total of 20 drought component traits in 1-7 seasons at 1-5 locations in India. Individual genetic maps comprising 241 loci and 168 loci for ICCRIL03 and ICCRIL04, respectively, and a consensus genetic map comprising 352 loci were constructed ( http://cmap.icrisat.ac.in/cmap/sm/cp/varshney/). Analysis of extensive genotypic and precise phenotypic data revealed 45 robust main-effect QTLs (M-QTLs) explaining up to 58.20% phenotypic variation and 973 epistatic QTLs (E-QTLs) explaining up to 92.19% phenotypic variation for several target traits. Nine QTL clusters containing QTLs for several drought tolerance traits have been identified that can be targeted for molecular breeding. Among these clusters, one cluster harboring 48% robust M-QTLs for 12 traits and explaining about 58.20% phenotypic variation present on CaLG04 has been referred as "QTL-hotspot". This genomic region contains seven SSR markers (ICCM0249, NCPGR127, TAA170, NCPGR21, TR11, GA24 and STMS11). Introgression of this region into elite cultivars is expected to enhance drought tolerance in chickpea.

The Responsiveness of Exercise Tests in COPD: A Randomized Controlled Trial.

BACKGROUND: COPD is characterized by reduced exercise tolerance, and improving physical performance is an important therapeutic goal. A variety of exercise tests commonly are used to assess exercise tolerance, including laboratory and field-based tests. The responsiveness of these tests to common COPD interventions is yet to be compared, but the results may inform test selection in clinical and research settings. RESEARCH QUESTION: What exercise test possesses the greatest sensitivity to change from before to after intervention in patients with COPD? STUDY DESIGN AND METHODS: One hundred fifty-four patients with symptomatic COPD were recruited and randomized (2:1:1) to 6 weeks of long-acting muscarinic antagonist (LAMA), pulmonary rehabilitation (PR), or usual care. Before and after intervention, participants performed a ramp-incremental cycle exercise test (ICET) and constant work rate cycle test (CWRCT), incremental shuttle walk test (ISWT) and endurance shuttle walk test (ESWT), 6-min walk test (6MWT), and 4-m gait speed test. RESULTS: One hundred three participants (mean ± SD age, 67 ± 8 years; 75 male participants [73%]; FEV1, 50.6 ± 16.8% predicted) completed the study. Significant improvements in the ICET, CWRCT, ISWT, ESWT, and 6MWT results were observed after PR (P < .05), with the greatest improvements seen in the constant work rate protocols (percentages change: CWRCT, 42%; ESWT, 41%). INTERPRETATION: The ESWT and CWRCT seemed to be the most responsive exercise test protocols to LAMA and PR therapy. The magnitude of change was much greater after a program of rehabilitation compared with bronchodilator therapy. TRIAL REGISTRY: ISRCTN; No. 64759523.

A qualitative assessment of the pulmonary rehabilitation decision-making needs of patients living with COPD.

Pulmonary rehabilitation (PR) is highly evidenced but underutilised in patients living with chronic obstructive pulmonary disease (COPD). A menu of centre and home-based programmes is available to facilitate uptake but is not routinely offered. An appraisal of the current PR referral approach compared to a menu-based approach was warranted to explore the decision-making needs of patients living with COPD when considering a referral to PR. Face-to-face or telephone, semi-structured interviews were conducted with patients diagnosed with COPD and referred to PR and referring HCPs. Interviews were audio-recorded, transcribed verbatim and analysed using the enhanced critical incident technique. 14 HCPs and 11 patients were interviewed (n = 25). Interview data generated 276 critical incidents which informed 28 categories (30 sub-categories). Five high-level themes captured patients' decision-making needs for PR: Understanding COPD, understanding PR, perceived ability to access PR, a desire to accept PR, and supporting the offer. A menu-based approach would further support patients' PR decision-making, however, insufficient knowledge of the programmes would limit its perceived feasibility and acceptability. The development of shared decision making interventions (e.g., a patient decision aid) to elicit patient-centred, meaningful discussions about the menu is suggested.

Upper critical field, superconducting energy gaps and the Seebeck coefficient in La(0.8)Th(0.2)FeAsO.

We report the synthesis and characterization of a new electron-doped La-oxypnictide superconductor by partial substitution of lanthanum by thorium. The superconducting transition temperature at about 30.3 K was observed in La(0.8)Th(0.2)FeAsO, which is the highest in La-based oxypnictide superconductors synthesized at ambient pressure. We find that the decrease in lattice parameters with Th doping in LaOFeAs is more drastic as compared to that obtained by high pressure (6 GPa) synthesis of oxygen-deficient LaOFeAs. The resistivity and magnetic susceptibility measurements yield an upper critical field H(c2)(0) of 47 T. Partial substitution of Th in place of La induces electron doping, as shown by a negative Seebeck coefficient. The temperature-dependent magnetic penetration depth data provides strong evidence for a nodeless low energy gap of 1.4 meV.

Minimum clinically important improvement for the incremental shuttle walking test.

BACKGROUND: The incremental shuttle walking test (ISWT) is used to assess exercise capacity in patients with chronic obstructive pulmonary disease (COPD) and is employed as an outcome measure for pulmonary rehabilitation. This study was designed to establish the minimum clinically important difference for the ISWT. METHODS: 372 patients (205 men) performed an ISWT before and after a 7-week outpatient pulmonary rehabilitation programme. After completing the course, subjects were asked to identify, from a 5-point Likert scale, the perceived change in their exercise performance immediately upon completion of the ISWT. The scale ranged from "better" to "worse". RESULTS: The mean (SD) age was 69.4 (8.4) years, forced expiratory volume in 1 s (FEV(1)) 1.06 (0.53) l and FEV(1)/forced vital capacity (FVC) ratio 50.8 (18.1)%. The baseline shuttle walking test distance was 168.5 (114.6) m which increased to 234.7 (125.3) m after rehabilitation (mean difference 65.9 m (95% CI 58.9 to 72.9)). In subjects who felt their exercise tolerance was "slightly better" the mean improvement was 47.5 m (95% CI 38.6 to 56.5) compared with 78.7 m (95% CI 70.5 to 86.9) in those who reported that their exercise tolerance was "better" and 18.0 m (95% CI 4.5 to 31.5) in those who felt their exercise tolerance was "about the same". CONCLUSION: Two levels of improvement were identified. The minimum clinically important improvement for the ISWT is 47.5 m. In addition, patients were able to distinguish an additional benefit at 78.7 m.

The plasma ammonia response to cycle exercise in COPD.

The plasma ammonia response to exercise in chronic obstructive pulmonary disease (COPD) was examined and the relationship between plasma ammonia concentration and muscle adenine nucleotide metabolism was explored. In total, 25 stable COPD patients and 13 similar-aged controls underwent incremental and constant-work rate cycle exercise tests. Arterialised venous blood was sampled at rest, at 1-min intervals during exercise and

Detecting oxygen desaturation in patients with COPD: incremental versus endurance shuttle walking.

BACKGROUND: There has been no direct comparison between an incremental and endurance walking test to detect the relative oxygen desaturation in patients with chronic obstructive pulmonary disease (COPD). This is of some importance as current guidelines have suggested that ambulatory oxygen should only be prescribed after a standard assessment and desaturation documented. No clear advice about the nature of the required exercise task is given. This study therefore compared the relative desaturation between the incremental shuttle walking test (ISWT) and the constant speed walking test (ESWT) and response to ambulatory oxygen. METHODS: Forty-one patients (29 male), mean (SD), age 71.18 (7.48) yrs, FEV(1) 0.85 (0.29) l with stable COPD were recruited after completion of a 7-week pulmonary rehabilitation programme. Patients completed a baseline (without carrying a cylinder) ISWT and ESWT and then, in random order in double blind fashion, completed the walk tests with a cylinder of air or a cylinder of oxygen. Measurements included distance walked, oxygen saturation, heart rate, perceived breathlessness and exertion (Borg scale). RESULTS: All patients desaturated (<4% below 90%). There was no significant difference in desaturation between the ISWT and the ESWT. There was a significant improvement in performance with supplementary oxygen compared to cylinder air (p<0.05) for both tests. However, compared to the baseline walk, supplementary oxygen did not enhance the distance walked for either test. There was a significant decrease in walking performance on both the ISWT and the ESWT when carrying an air cylinder compared with the control walk. When comparing the percentage difference between oxygen and air for responders (i.e. those that achieve a 10% or more increase), the ESWT showed a greater percentage change 42.1% compared to 26.1% for the ISWT. CONCLUSIONS: This study identifies that incremental and endurance walking provokes significant desaturation and that there is a short-term benefit of oxygen versus air in enhancing exercise performance. There was no significant difference in the level of desaturation between tests. Therefore the ISWT is a suitable exercise test that can be used to evaluate desaturation and is practically more realistic.

Transition from paediatric surgery: how many patients do we need to plan for?

INTRODUCTION Transitional care is an NHS priority with newly published NICE guidance. Many paediatric surgical patients need quality care to continue into adulthood. We undertook an evaluation of our departmental activity to assess the magnitude of this issue. METHODS We identified all outpatients ≥ 15 years (potentially requiring imminent transition) seen over a 12 month period for all five general paediatric surgery consultants in our tertiary centre. Those patients requiring transition were highlighted and the appropriate adult team for referral recorded. RESULTS There were 2989 general paediatric surgery clinic appointments within the year; 289 (9.7%) were for young people aged 15 years or older; 62 patients (28% of those ≥ 15years) were deemed to require transition into adult care. Significantly more patients having colorectal surgery required follow-up (P = 0.0009 Chi-square test) compared with patients in other subspecialties. CONCLUSIONS More patients than expected required transition. This may be the case in other units. Current best practice includes time intensive preclinic planning, careful preparation of patient and family, followed by joint clinics. A joint clinic appointment takes 30 minutes, allowing for comprehensive handover and forging new relationships. In our department, we need at least ten transition clinics across 2 years. Coalition with adult colleagues is vital. These data enable us to plan services to provide quality care for our adolescent patients and highlights colorectal surgery as a priority.

Enteropathogenicity of Aeromonas hydrophila and Plesiomonas shigelloides.

Aeromonas hydrophila was enteropathogenic in ligated ileal loops of rabbits, causing a fluid accumulation of 1-0 - 2-0 ml per cm of gut length. Gut reaction could be produced with an inoculum as low as 10-4 viable bacteria. There was no difference in the nature of the positive reactions given by strains isolated from diarrhoeal and non-diarrhoeal children and adults and from water. Plesiomonas shigelloides, on the other hand, did nt cause a significant gut reaction. A. hydrophila multiplied in the ileal loop by about 10-5 wheras P. shigelloides did so at only 10-2-3. These experiments on a animal model thus indicated the enteropathogenic nature of A. hydrophilia, but no definite conclusion could be drawn from this study on P. shigelloides.

Randomized controlled trial of ambulatory oxygen and an ambulatory ventilator on endurance exercise in COPD.

In a prospective, randomized study we examined the effect of (i) ambulatory oxygen and (ii) a portable, inspiratory pressure support (IPS) device on the endurance shuttle walk test (ESWT) in patients with severe chronic obstructive pulmonary disease (COPD). Ten outpatients [median (range) FEV1 0.60 l(0.35, 1.45)] performed the ESWT under five test conditions: baseline walk (no assistance), IPS at 14 cmH2O from a portable ventilator (the HIPPY, Friday Medical, U.K.), sham IPS (< 8 cmH2O), ambulatory oxygen at 2 l min(-1), and sham oxygen (carrying the portable oxygen cylinder and breathing air). There were significant improvements in the ESWT with ambulatory oxygen, but a negative effect with the HIPPY device [mean (SD) time: baseline 172 (48) sec; oxygen 242 (62) sec; HIPPY 84 (35) sec]. The ESWT appeared sensitive to the effect of cylinder weight although differences in endurance capacity were not significant [sham oxygen 151 (45) sec]. The ESWT was sensitive to the acute application of oxygen, demonstrating a beneficial effect on endurance performance in patients with severe COPD. The ESWT could form the basis of a standardized assessment for ambulatory oxygen.

A short outpatient pulmonary rehabilitation programme: immediate and longer-term effects on exercise performance and quality of life.

Pulmonary rehabilitation is widely available in North America and parts of Europe for patients with chronic obstructive pulmonary disease (COPD). Here, we describe the feasibility and benefits of providing a comprehensive but cost effective pulmonary rehabilitation programme in a U.K. district general hospital. Two hundred and sixty-seven patients with respiratory disability were referred for pulmonary rehabilitation. Patients were assessed and recruited onto a 7 week outpatient-based pulmonary rehabilitation programme including elements of exercise and education without longer term maintenance. Exercise performance was measured by the shuttle walking test and a treadmill endurance test, and quality of life as measured by two disease specific questionnaires, the Breathing Problems Questionnaire and the Chronic Respiratory Disease Questionnaire. Of 267 patients referred between 1993 and 1996, 132 (110 with COPD) have completed rehabilitation and could be evaluated. For all graduates, shuttle distance increased by 58 m (27%) and treadmill endurance time increased by 15.9 min (294%). The Breathing Problems Questionnaire proved sensitive to changes in quality of life in some domains. The Chronic Respiratory Disease Questionnaire showed significant improvements in all domains in a sub-set of 57 patients who completed it. Longer term follow-up of 49 patients at a mean of 10.3 months following pulmonary rehabilitation revealed that previous gains in exercise performance and quality of life were maintained with improvements in shuttle walking distance of 33 m (14% over baseline) and endurance time of 16 min (280% over baseline). The Breathing Problems Questionnaire showed no overall change but the Chronic Respiratory Disease Questionnaire showed continued improvement in a small number of patients. We therefore concluded that a short outpatient based pulmonary rehabilitation programme without a maintenance element has produced significant gains in exercise performance and quality of life for 132 patients at a district general hospital in the U.K.

A comparison of three disease-specific and two generic health-status measures to evaluate the outcome of pulmonary rehabilitation in COPD.

The use of health status as an outcome measure is becoming more widespread in pulmonary rehabilitation. There are a number of health status measures but the choice remains uncertain. Three disease specific measures and two generic measures of health status were employed to observe their relative sensitivity to a 7-week course of pulmonary rehabilitation. Patients with stable chronic obstructive pulmonary disease (COPD) were recruited into a rehabilitation programme. They completed a shuttle-walking test and three disease-specific questionnaires: the Chronic Respiratory Questionnaire (CRQ), the St. George's Hospital Respiratory Questionnaire (SGRQ) and the Breathing Problems Questionnaire (BPQ). Patients also completed two generic questionnaires: a global quality-of-life scale and an activity checklist. Ninety-seven patients [58 male mean (SD) age 67 (8.7) years] completed the course over a 12-month period. The mean pre-rehabilitation (SD) FEV1 was 1.06 (0.59) l. The shuttle-walking test and the treadmill-endurance test increased significantly after rehabilitation (P<0.001). All three disease-specific questionnaires improved significantly (the CRQ and SGRQ improved beyond minimum clinically important difference). The global score improved significantly whilst the 'things people do' decreased. All three disease-specific measures were responsive to pulmonary rehabilitation. However the operator-led CRQ appears to be the most sensitive short-term outcome measure.

Lung volume reduction surgery--a comparison of the long term outcome of unilateral vs. bilateral approaches.

OBJECTIVE: Bilateral lung volume reduction surgery (LVRS) is thought to be preferable to unilateral surgery due to greater initial benefit but the subsequent rate of decline may also be greater. We compared the long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs. METHODS: Prospective data were collected on a consecutive series of 65 patients undergoing LVRS who were all suitable for bilateral surgery. Twenty-six patients: age 59 (8) years underwent bilateral LVRS by video-assisted thoracoscopy (VAT) or sternotomy and 39 patients: age 60 (6) years underwent unilateral VAT. The perioperative effects of LVRS on spirometry were prospectively recorded at 3, 6, 12 and 24 months. RESULTS: The unilateral group had similar preoperative lung volumes to the bilateral patients: forced expiratory volume in 1s (FEV(1)) 26 vs. 30% predicted, RV 275 vs. 246% predicted and total lung capacity (TLC) 148 vs. 142% predicted. Unilateral LVRS was associated with significantly lower weight of lung resected: 80 (31) vs. 118 (46) g; hospital stay: 16 (10) days vs. 28 (22) days. Thirty-day mortality was 3% in the unilateral and 8% in the bilateral group (P=0.34). Postoperative ventilation occurred in 5% in the unilateral and in 42% in the bilateral group (P=0.0002). The decline of FEV(1) during the first postoperative year was significant in the bilateral group (-313 ml/y, P=0.04) but not significant in the unilateral group (-50 ml/y, P=0.18). SF 36 scores in all eight domains were similar in both groups preoperatively and at any postoperative interval. CONCLUSION: We have found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit.

Insertion of an implantable venous access device in the groin using inferior epigastric vein.

BACKGROUND: Patients with cystic fibrosis (CF) need reliable venous access that can be provided by implantable venous access devices (IVAD). Such IVADs usually are placed in the upper part of the body, but placing them in this area has 3 disadvantages: a suitable vein may not be available, the portal may be conspicuous, and there may be interference with chest physiotherapy. Positioning the IVAD in the groin by using the inferior epigastric vein (IEV) is an answer to these problems. METHODS: This is a review of 29 patients from a single surgeon's practice from 1984 to 1999. A groin incision was used to implant the IVAD and to introduce the catheter via the IEV to the inferior vena cava. RESULTS: A total of 33 IVAD were inserted in 29 patients (27 with CF). The average age at first operation was 12.4 years. Infection was seen in 5. Venous thrombosis was not seen in any patient. The average longevity of IVAD is 18.5 months. Total experience is 87 IVAD years. CONCLUSION: This is a useful route of first choice for CF patients, with an overall complication rate comparable with techniques in which IVADs are placed in the upper half of body. J Pediatr Surg 36:579-581.

Adverse outcome of congenital diaphragmatic hernia is determined by diaphragmatic agenesis, not by antenatal diagnosis.

BACKGROUND/PURPOSE: The authors studied their congenital diaphragmatic hernia (CDH) cases retrospectively to ascertain if classical CDH and diaphragmatic agenesis (DA) have separate clinical manifestations, whether antenatally diagnosed cases behave differently from those not diagnosed antenatally, and if antenatal diagnosis before 25 weeks carries a worse prognosis. METHODS: The authors performed a retrospective review of 23 infants with CDH treated at their institution between January 1996 and March 1999. The patients were divided into 3 groups that were analyzed: DA and classical CDH, antenatally diagnosed and nonantenatally diagnosed, and antenatally diagnosed before 25 weeks and after 25 weeks. RESULTS: There were 8 cases of DA and 11 cases of classical CDH. Four infants died without operation and could not be classified. Neonates with DA had significantly longer mean duration of preoperative stabilization compared with classical CDH (5.25+/-2.76 days v 1.36+/-1.0 days) and postoperative mechanical ventilatory support (15.7+/-3.0 days v 4.9+/-3.0 days). Fifty percent of DA patients died; all classical CDH patients survived. Twelve cases were diagnosed antenatally, 6 before 25 weeks' gestation. Antenatally diagnosed cases had no statistically significant difference in mortality rates from those not diagnosed antenatally; 50% of those diagnosed before 25 weeks survived. CONCLUSIONS: DA cases require more preoperative preparation and postoperative ventilation and have a bad prognosis compared with classical CDH. Antenatal diagnosis of CDH does not convey a different prognosis. Fifty percent of CDH patients with antenatal diagnosis before 25 weeks survive.

Occurrence of Witches'-Broom, a New Phytoplasma Disease of Acid Lime (Citrus aurantifolia) in India.

In India, acid lime (Citrus aurantifolia (L.) Swingle) is one of the most important citrus fruits grown. It constitutes nearly 20% of the total citrus production. During 1995, an unusual type of disease was observed on a 6-year-old acid lime plant in an orchard in the Nagpur District in eastern Maharashtra. It was named witches'-broom disease (WBD) to reflect the most conspicuous symptom. Other symptoms included small chlorotic leaves, highly proliferated shoots, and shortened internodes. Leaves dropped prematurely and infected twigs were distorted. In advanced stages, infected branches had dieback symptoms. WBD of lime has been reported from Oman and UAE (1) and the causal phytoplasma was designated "Candidatus Phytoplasma aurantifolia" (2). Subsequent surveys in 1995-1998 revealed disease incidences as high as 5% in Maharashtra and in other major acid-lime-growing states-Andhra Pradesh, Tamilnadu, and Karnataka. After the grafting of infected acid lime shoots, disease symptoms developed on Troyer citrange, rough lemon, and Rangpur lime, but not on sweet orange (mosambi), mandarin (Nagpur), or trifoliate orange. The WBD agent was transmitted from infected acid lime to periwinkle (Catharanthus roseus) plants and vice versa by dodder (Cuscuta reflexa). Ultrathin sections of leaf midrib of infected acid lime plants were fixed on copper grids, stained with uranyl acetate and lead acetate, and examined in a JEM 100S transmission electron microscope. Numerous bodies having the characteristic morphology of phytoplasmas were observed in phloem sieve tubes of acid lime in diseased but not in healthy leaves. The phytoplasmal bodies ranged from 100 to 800 nm in diameter and were bounded by a poorly defined membrance. Freehand transverse sections of young internode regions of a WBD-infected periwinkle plant were stained in DAPI (4', 6 diamidino-2-phenylindole; 1.0 µg/ml) and were observed with a fluorescent microscope (Leica). An intense bluish-white fluorescence in the phloem elements of diseased periwinkle and its absence in healthy samples were consistent with the presence of phytoplasmas. This is the first report of phytoplasma-induced witches'-broom disease of acid lime in India. References: (1) M. Garnier et al. Plant Dis. 75:546, 1991. (2) L. Zreik et al. Int. J. Syst. Bacteriol. 45:449,1995.

Can we identify patients with different illness schema following an acute exacerbation of COPD: a cluster analysis.

INTRODUCTION: Pulmonary Rehabilitation (PR) reduces hospital admissions following an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) but adherence is known to be poor. Patients' illness perceptions may affect adherence to disease-management strategies but to date have not been explored following an exacerbation. The study aim is two-fold; firstly to prospectively explore acceptance and uptake of post-exacerbation PR and secondly to identify possible clusters of patients' illness perceptions following hospitalisation for an exacerbation of COPD. METHODS: Patients admitted to hospital with an exacerbation of COPD were recruited to a prospective observational study. Self-reported illness perceptions, mood, health status and self-efficacy were assessed. Acceptance and uptake of PR were recorded at six months. Cluster analysis of Illness Perceptions Questionnaire-Revised data was used to establish groups of patients holding distinct beliefs. RESULTS: 128 patients were recruited. Acceptance and uptake of PR following an acute exacerbation was poor with only 9% (n = 11) completing the programme. Cluster analysis revealed three distinct groups: Cluster 1 'in control' (n = 52), Cluster 2 'disengaged' (n = 36) and Cluster 3 'distressed' (n = 40). Significant between-cluster differences were observed in mood, health status and self-efficacy (p < 0.01). Acceptance and uptake of PR did not differ between clusters. CONCLUSIONS: Acceptance/uptake of post-exacerbation PR was found to be poor. Three distinct illness schema exist in patients following an acute exacerbation. This information may be useful in developing novel psychologically-informed interventions designed to reduce feelings of distress and perhaps facilitate a PR intervention for this vulnerable population.

The tyranny of distance: telemedicine for the critically ill in rural Australia.

A case of severe sepsis with multi-organ failure needing complex support was deemed too ill for transfer to a major centre. Telemedicine allowed direct patient review, collaborative advice and collegial support with maintained healthcare standards while avoiding long distance transfer from his home and family.