Use of mortality within 30 days of a COPD hospitalisation as a measure of COPD care in UK hospitals.

Mortality rate has been proposed as a metric of hospital chronic obstructive pulmonary disease (COPD) care in light of variation seen in national COPD audits. Using Hospital Episode Statistics (hospital 'coding') we examined 30-day mortality after COPD hospitalisation in 150 UK hospitals during 2006-2007 and 2007-2008. Mean and median 30-day mortalities were similar each year but the coefficient of variation was >20% and hospitals could change from a low or high quartile to the median by chance. We could not detect any reasons for hospitals being at the extremes. 30-day mortality after COPD hospitalisation is a complex variable and unlikely to be useful as a primary annual COPD metric.

Effect of bronchodilation on expiratory flow limitation and resting lung mechanics in COPD.

Bronchodilator drugs produce variable improvements in forced expiratory volume in 1 s (FEV(1)), but larger changes in end-expiratory lung volume (EELV) in chronic obstructive pulmonary disease (COPD), which were suggested to be related to the presence of expiratory flow limitation (EFL) at rest. We tested this concept in 42 COPD patients (FEV(1) 42.3+/-13.8% predicted) during spontaneous breathing before and after 5 mg nebulised salbutamol. EFL was detected by within-breath changes in respiratory system reactance measured by a multifrequency forced oscillation method, while changes in EELV were assessed by inspiratory capacity (IC). Bronchodilation (BD) increased IC (from 1.8+/-0.5 to 2.1+/-0.6 L, p<0.001) and reduced inspiration resistance ((insp)) at 5 Hz (from 5.1+/-1.6 to 4.2+/-1.5 cmH(2)OxsxL(-1), p<0.001). (insp) identified BD responders with a discriminative power of 80.1%. In total, 20 patients were flow-limited before BD. They showed worse spirometry and higher residual volume, but significant improvements in IC were seen in all patients irrespective of flow limitation. Changes in (insp) were confined to flow-limited patients, as were reactance changes. BD reduced the degree of heterogeneity in the respiratory system, a change best seen with inspiratory values. BD has complex effects on lung mechanics in COPD, and EFL affects both this and the response of some respiratory variables to treatment. However, changes in EELV are consistently seen, irrespective of the presence of flow limitation at rest.

Lower limb activity and its determinants in COPD.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) walk less than healthy older people and their self-reported activity predicts exacerbation risk. The relationship between lower limb activity and total daily activity is not known, nor are there any data which relate objectively assessed daily activity to laboratory assessments made before and after rehabilitation. METHODS: Lower limb activity was measured by leg actigraphy over 3 days in 45 patients with moderate to severe COPD and 18 controls of similar age. Thirty-three patients with COPD entered an 8-week rehabilitation programme in which the change in leg activity was measured and related to other outcomes. RESULTS: In patients with COPD the mean level of activity measured by whole body and leg activity monitors was closely related (r = 0.92; p<0.001), but leg activity was consistently reduced compared with controls of similar age (p = 0.001). Mean leg activity, mean intensity of leg activity and the time that patients spent mobile at home were all related to forced expiratory volume in 1 s (FEV(1)) (r = 0.57, p = 0.001; r = 0.5, p = 0.003; and r = 0.51, p = 0.002, respectively), but intensity of activity and time spent mobile were not related. Subjects completing pulmonary rehabilitation showed significant improvements in mean activity (p = 0.001) and spent more time moving (p = 0.014). These changes were unrelated to improvement in muscle strength or walking distance but correlated with baseline FEV(1) (r = 0.8, p<0.001). CONCLUSIONS: Total daily activity in patients with COPD is closely related to leg activity which is reduced compared with controls of similar age. Individuals differ in the time spent mobile during the day, but subjective and objectively assessed activity improves after rehabilitation and is predicted by FEV(1). The change in activity is unrelated to improvements in corridor walking and health status.

Factors involved in clearance of genital warts.

Consecutive patients with first presentation of external anogenital warts had the location, duration at presentation, number of warts and wart area, age, smoking and sun bed use, and presence of coexistent sexually transmitted infections (STIs) recorded. The number of treatment episodes, and number of weeks, to clear the warts were documented. Number of warts and wart area at presentation were associated with time and number of treatments to clear. Those with 1-3 warts required significantly fewer treatment episodes and less time to clear than those with 11-41 warts, as did those with warts area 2-19 mm(2) compared with wart area 100-1038 mm(2). Using survival analysis, the number of warts was significant for the number of treatments and weeks to clear. The hazard ratio for clearance with double the number of warts after 4 treatments was 0.53 (95% confidence interval [CI] 0.37-0.76), and at 4 weeks was 0.70 (0.45-0.86). The clearance rates in non-smokers compared with smokers were higher, but not significantly different. Wart burden at presentation is an indicator of time to clearance. The number of warts is the best predictor - fewer warts results in earlier clearance.

Effect of primary-care spirometry on the diagnosis and management of COPD.

Primary-care spirometry has been promoted as a method of facilitating accurate diagnosis of chronic obstructive pulmonary disease (COPD). The present study examined whether improving rates of diagnosis lead to improvements in pharmacological and nonpharmacological management. From 1999 to 2003, the current authors provided an open-access spirometry and reversibility service to a local primary-care area, to which 1,508 subjects were referred. A total of 797 (53%) had pre-bronchodilator airflow obstruction (AFO). Of the subjects who underwent reversibility testing, 19.3% were no longer obstructed post-bronchodilator. The results and records of a subgroup of 235 subjects with post-bronchodilator AFO were examined. Of the 235 subjects, 130 received a new diagnosis, most commonly COPD. The patients with COPD were significantly undertreated before spirometry and testing led to a significant increase in the use of anticholinergics (37 versus 18%), long-acting beta-agonists (25 versus 8%) and inhaled steroids (71 versus 52%). More than three quarters of smokers received smoking cessation advice but very few were referred for pulmonary rehabilitation. In conclusion, primary-care spirometry not only increases rates of chronic obstructive pulmonary disease diagnosis, but it also leads to improvements in chronic obstructive pulmonary disease treatment. The use of bronchodilator reversibility testing in this setting may be important to avoid misdiagnosis.

Upper airways abnormalities and tracheal problems in Morquio's disease.

Morquio's disease is a metabolic disorder that can cause various respiratory abnormalities. Patients who live into adulthood are likely to develop upper airway problems and respiratory failure. With advances in home ventilation, these patients are increasingly likely to be referred to specialist respiratory units. We describe our experiences with two such patients.

Vaginal yeasts in the era of "over the counter" antifungals.

OBJECTIVE: To establish whether there has been any rise in the prevalence of non-albicans Candida species isolated from vaginal swabs since the introduction of "over the counter" antifungal treatments. METHOD: A retrospective review looking at all positive vaginal yeast isolates collected from women attending one genitourinary medicine clinic during the 6 year period from 1993 to 1998 inclusive. All positive vaginal yeast isolates were included, regardless of whether or not the patients were symptomatic. Isolates from HIV positive women were excluded from the analysis. RESULTS: No increase in non-albicans vaginal yeast isolates was shown during the period studied. The proportion of non-albicans yeasts remained constant at approximately 5% of the total yeasts isolated. The most common non-albicans yeast isolated was C glabrata. CONCLUSION: There is no evidence from this study to suggest that the increasing use of "over the counter" antifungal treatment has selected for atypical, possibly inherently azole resistant, strains of vaginal yeasts in HIV seronegative women.