Pre-operative cardiopulmonary exercise testing predicts adverse post-operative events and non-progression to adjuvant therapy after major pancreatic surgery.

BACKGROUND: Surgery followed by chemotherapy is the primary modality of cure for patients with resectable pancreatic cancer but is associated with significant morbidity. The aim of the present study was to evaluate the role of cardiopulmonary exercise testing (CPET) in predicting post-operative adverse events and fitness for chemotherapy after major pancreatic surgery. METHODS: Patients who underwent a pancreaticoduodenectomy or total pancreatectomy for pancreatic head lesions and had undergone pre-operative CPET were included in this retrospective study. Data on patient demographics, comorbidity and results of pre-operative evaluation were collected. Post-operative adverse events, hospital stay and receipt of adjuvant therapy were outcome measures. RESULTS: One hundred patients were included. Patients with an anaerobic threshold less than 10 ml/kg/min had a significantly greater incidence of a post-operative pancreatic fistula [International Study Group for Pancreatic Surgery (ISGPS) Grades A-C, 35.4% versus 16%, P = 0.028] and major intra-abdominal abscesses [Clavien-Dindo (CD) Grades III-V, 22.4% versus 7.8%, P = 0.042] and were less likely to receive adjuvant therapy [hazard ratio (HR) 6.30, 95% confidence interval (CI) 1.25-31.75, P = 0.026]. A low anaerobic threshold was also associated with a prolonged hospital stay (median 20 versus 14 days, P = 0.005) but not with other adverse events. DISCUSSION: CPET predicts a post-operative pancreatic fistula, major intra-abdominal abscesses as well as length of hospital stay after major pancreatic surgery. Patients with a low anaerobic threshold are less likely to receive adjuvant therapy.

Beyond the BMI: Validity and Practicality of Postpartum Body Composition Assessment Methods during Lactation: A Scoping Review.

The assessment of body composition during lactation is an important indicator of maternal nutritional status, which is central to the overall health of the mother and child. The lactating woman's nutritional status potentially impacts on breastmilk composition and the process of lactation itself. The purpose of this scoping review was to synthesize comparative studies that sought to validate various body composition assessment techniques for use in lactating women in the postpartum period. Using the PRISMA-ScR guidelines, a comprehensive, systematic literature search was conducted using Scopus, Web of Science, and PubMed. Eight comparative studies were included in the review, with data from 320 postpartum women. The design methodologies varied substantially across studies, and included a range of simple techniques to advanced multi-compartment models for assessing body composition. The validity and reliability of measurement tools must be considered alongside issues of safety, practicality, and appropriateness to guide the research design when applied to lactating women.

Human Milk Oligosaccharide Profiles and Associations with Maternal Nutritional Factors: A Scoping Review.

Human milk oligosaccharides (HMOs) are complex unconjugated glycans associated with positive infant health outcomes. This study has examined current knowledge of the effect of maternal diet and nutritional status on the composition of HMOs in breast milk. Using the PRISMA-ScR guidelines, a comprehensive, systematic literature search was conducted using Scopus, Web of Science, Global Health (CABI), and MEDLINE. Titles and abstracts were screened independently by two reviewers against predefined inclusion and exclusion criteria. Fourteen studies met the inclusion criteria and reported on maternal dietary intake (n = 3), maternal body composition indices (n = 9), and dietary supplementation interventions (n = 2). In total, data from 1388 lactating mothers (4011 milk samples) were included. Design methodologies varied substantially across studies, particularly for milk sample collection, HMO analysis, dietary and body composition assessment. Overall, this review has identified potential associations between maternal dietary intake and nutritional status and the HMO composition of human milk, though an abundance and sufficiency of evidence is lacking. Standardised procedures for human milk sample collection and HMO analysis, along with robust and validated nutrition assessment techniques, should be employed to further investigate the impact of maternal nutritional factors on HMO composition.

Bisoprolol in patients with heart failure and moderate to severe chronic obstructive pulmonary disease: a randomized controlled trial.

AIMS: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) frequently coexist. No study has prospectively examined the effects of beta-blockade in those with both conditions. METHODS AND RESULTS: We randomized 27 patients with HF and coexistent moderate or severe COPD to receive bisoprolol or placebo, titrated to maximum tolerated dose over 4 months. The primary outcome was forced expiratory volume in 1 s (FEV(1)). The study is registered with ClinicalTrials.gov, number: NCT00702156. Patients were elderly and predominantly male. Cardiovascular comorbidity, smoking history, and pulmonary function were similar in each group (mean FEV(1) 1.37 vs. 1.26 L, P = 0.52). A reduction in FEV(1) occurred after 4 months following treatment with bisoprolol compared with placebo (-70 vs. +120 mL, P = 0.01). Reversibility following inhaled beta(2)-agonist and static lung volumes were not impaired by bisoprolol. All measures of health status exhibited a consistent non-significant improvement, including the Short Form 36 physical and mental component scores (2.6 vs. 0.5 and 0.8 vs. -0.3, respectively), Minnesota Living with Heart Failure Questionnaire (-2.5 vs. 3.5) and Chronic Respiratory Questionnaire (0.07 vs. -0.24). The mean number of COPD exacerbations was similar in the bisoprolol and placebo groups (0.50 and 0.31, respectively, P = 0.44). CONCLUSION: Initiation of bisoprolol in patients with HF and concomitant moderate or severe COPD resulted in a reduction in FEV(1). However, symptoms and quality of life were not impaired.

An observational investigation of dysfunctional breathing and breathing control therapy in a problem asthma clinic.

OBJECTIVES: Dysfunctional breathing (DB) is recognized as an associated problem in patients with asthma and may be identified by the Nijmegen questionnaire. We conducted an observational study to determine if breathing control therapy (BCT) improved Nijmegen scores or asthma-related quality of life in patients attending a problem asthma clinic. METHODS: Nijmegen and Mini Asthma Quality of Life (Mini-AQLQ) questionnaires were completed. Patients with a positive Nijmegen (> or = 23, DB) were referred for BCT and progressive exercise testing (PET) to seek confirmation of dysfunctional breathing. Follow-up questionnaire data were collected at 6 months. RESULTS: A total of 102 patients were studied. The total mean Nijmegen score was 26.4 (range 1-61). Those with a score > or = 23 (DB group, n = 65, 64%) had significantly lower Mini-AQLQ (mean 2.83) than the non-DB group (n = 37, mean 4.12, 95% CI for difference 0.87, 1.87, p < 0.0001). There was a strong relationship between Nijmegen score and Mini-AQLQ (r = -0.63, p < 0.001) at baseline; 10 of 17 DB patients who completed PET showed inappropriate hyperventilation. Follow-up data, available for Nijmegen and Mini-AQLQ in 44 and 46 patients respectively, showed no significant change in either of these parameters. CONCLUSIONS: The strong relationship between Mini-AQLQ and Nijmegen scores and poor relationship between Nijmegen scores and PET-identified inappropriate hyperventilation suggest that a positive Nijmegen score overestimates the presence of dysfunctional breathing in patients with moderate to severe asthma. We found no evidence that a moderate intensity breathing control intervention had any impact on Nijmegen scores or asthma-related quality of life in this patient group.

The meaning ascribed to wheeled mobility devices by individuals who use wheelchairs and scooters: a metasynthesis.

PURPOSE: To synthesize qualitative study findings on the meaning ascribed to wheelchairs and wheeled mobility devices (WMD) by WMD users. METHOD: Bibliographic databases were systematically searched up to January 2015 to identify relevant papers. Reviewers selected studies, assessed methodological quality and thematically synthesized findings using a metasynthesis process described by Thomas and Harden (2008). RESULTS: Twenty articles were included. Four descriptive themes emerged: physical environment interaction; sociocultural experiences; participation in activities and occupations; and WMD-self relationship. WMD use was found to be a complex experience that can fluctuate through interaction with aspects of the environment and opportunities for participation. The analytic theme, dynamic duality of WMD experience, addressed the simultaneous enabling and disabling aspects of WMD use. CONCLUSIONS: Metasyntheses enable researchers to gain a deeper understanding of issues by examining findings across studies. Findings of this study provide a framework for understanding the complexity of WMD use. The framework has practical applications for clinicians and users of WMD in understanding the experience of WMD to be neither singular nor static. Implications for Rehabilitation The meaning of wheeled mobility device (WMD) use is dynamically influenced by the environment and opportunities afforded for occupational and social participation. A duality of experiences can emerge for WMD users, where wheeled mobility use can be at the same time positive and negative, based on the interaction with the environment. Clinicians need to determine the meaning that each individual user ascribes to the WMD, and to consider how that meaning may change over time. By understanding the meaning ascribed to WMD use by individuals, clinicians can be better prepared to work with the WMD users to address negative reinforcers of the experience in physical and sociocultural environments as well as highlighting the positive experiences.

Effects of formoterol on exercise tolerance in severely disabled patients with COPD.

OBJECTIVE: We wished to evaluate the effects of inhaled formoterol, a long-acting beta(2)-adrenergic agonist, on exercise tolerance and dynamic hyperinflation (DH) in severely disabled chronic obstructive pulmonary disease (COPD) patients. DESIGN: In a two-period, crossover study, 21 patients with advanced COPD (FEV(1)=38.8+/-11.7% predicted, 16 patients GOLD stages III-IV) were randomly allocated to receive inhaled formoterol fumarate 12 microg twice daily for 14 days followed by placebo for 14 days, or vice versa. Patients performed constant work-rate cardiopulmonary exercise tests to the limit of tolerance (Tlim) on a cycle ergometer: inspiratory capacity (IC) was obtained at rest and each minute during exercise. Baseline and transitional dyspnoea indices (BDI and TDI) were also recorded. RESULTS: Eighteen patients completed both treatment periods. Formoterol treatment was associated with an estimated increase of 130 s in Tlim compared with placebo (P=0.052): this corresponded to a 37.8% improvement over placebo (P=0.012). Enhanced exercise tolerance after bronchodilator was associated with diminished DH marked by higher inspiratory reserve and tidal volumes at isotime and exercise cessation (P<0.05). There was no significant difference between formoterol and placebo on exercise dyspnoea ratings; however, all domains of the TDI improved (P

How do patients use their nebuliser in the community?

BACKGROUND: Nebulised therapy is commonly used in the management of patients with asthma and chronic obstructive pulmonary disease (COPD). There are guidelines setting out standards for maintenance of the compressor and replacement and care of consumables. This study surveys patients using nebulisers to ascertain the reported use and maintenance of the nebulisers and any side effects related to therapy. METHODS: An anonymous postal questionnaire, requesting information on nebuliser use and maintenance, and side effects was sent to 200 patients who had been maintained on nebuliser therapy and had been in contact with the nebuliser service at Glasgow Royal Infirmary within the last year. RESULTS: One hundred and seventeen (58.5%) questionnaires were returned completed or partially completed for analysis. The majority of patients who replied were female (median age of 69 years). The most commonly reported diagnosis was COPD (87/117); 92/117 (79%) were smokers or ex-smokers. The most commonly reported side effects associated with treatment are dry mouth, tremor and chest tightness. The responses to questions on servicing, maintenance and replacement of consumables indicate that patients comply poorly with these activities. Additionally compliance with the prescribed drug regimen occurs in less than 50% of the patient cohort. CONCLUSIONS: The results of this study indicate that compliance with instructions given on the care and maintenance of home nebulisers may be suboptimal. Additionally patients reported poorer compliance than was predicted. These areas may be improved with the introduction of a new patient information leaflet.

A longitudinal study of lung function in nonsmoking patients with rheumatoid arthritis.

STUDY OBJECTIVE: s: Patients with rheumatoid arthritis (RA) have a high prevalence of pulmonary function test (PFT) abnormality, but the long-term significance of this is unknown. We performed a longitudinal study of pulmonary function in asymptomatic, nonsmoking patients with active RA requiring disease-modifying drugs. We looked for temporal change in lung function and characteristics that would predict subsequent development of PFT abnormality or respiratory symptoms. METHODS: In 1990, 52 patients (44 women; age range, 29 to 78 years; median, 56 years) underwent clinical assessment (drug history, RA severity, immunologic, and inflammatory markers) and PFTs (spirometry, body plethysmography, gas transfer). PFT results were expressed as standardized residuals (SRs). Thirty-eight patients were reassessed in 2000. A self-administered questionnaire was used to identify respiratory symptoms. RESULTS: The prevalence of pulmonary function abnormality was higher than expected compared with a reference population, but there was no significant increase in number over 10 years (8.7% in 1990 and 8.8% in 2000). When assessed by group means and compared with reference values, reduced diffusing capacity of the lung for carbon monoxide (DLCO) and increased ratio of residual volume (RV) to total lung capacity (TLC) [RV/TLC] were the only abnormalities to develop over the study period (mean DLCO in 2000, - 0.47 SR; 95% confidence interval [CI], - 0.91 to - 0.01; RV/TLC, 0.49 SR; 95% CI, 0.13 to 0.84). However, rates of change of pulmonary function variables were not significantly different from zero. Logistic regression did not identify any meaningful relationship between disease characteristics and PFT abnormality. CONCLUSIONS: Asymptomatic patients with RA have a higher prevalence of PFT abnormality than expected, but these do not increase in number over time. We did not identify any patient or disease-specific characteristic that could predict the development of respiratory disease in patients with RA. Analysis using percentage of predicted values, rather than SRs, is misleading as it exaggerates the extent of abnormality present. Abnormal lung function is a common and probably benign finding in nonsmoking, asymptomatic patients with RA.

How is cyber threat evolving and what do organisations need to consider?

Organisations and members of the public are becoming accustomed to the increasing velocity, frequency and variety of cyber-attacks that they have been facing over the last few years. In response to this challenge, it is important to explore what can be done to offer commercial and private users a reliable and functioning environment. This paper discusses how cyber threats might evolve in the future and seeks to explore these threats more fully. Attention is paid to the changing nature of cyber-attackers and their motivations and what this means for organisations. Finally, useful and actionable steps are provided, which practitioners can use to understand how they can start to address the future challenges of cyber security.

Measurement of physiological recovery from exacerbation of chronic obstructive pulmonary disease using within-breath forced oscillometry.

BACKGROUND: Within-breath reactance from forced oscillometry estimates resistance via its inspiratory component (X(rs,insp)) and flow limitation via its expiratory component (X(rs,exp)). AIM: To assess whether reactance can detect recovery from an exacerbation of chronic obstructive pulmonary disease (COPD). METHOD: 39 subjects with a COPD exacerbation were assessed on three occasions over 6 weeks using post-bronchodilator forced oscillometry, arterial blood gases, spirometry including inspiratory capacity, symptoms and health-related quality of life (HRQOL). RESULTS: Significant improvements were seen in all spirometric variables except the ratio of forced expiratory volume in 1 s (FEV(1)) to vital capacity, ranging in mean (SEM) size from 11.0 (2.2)% predicted for peak expiratory flow to 12.1 (2.3)% predicted for vital capacity at 6 weeks. There was an associated increase in arterial partial pressure of oxygen (PaO(2)). There were significant mean (SEM) increases in both X(rs,insp) and X(rs,exp) (27.4 (6.7)% and 37.1 (10.0)%, respectively) but no change in oscillometry resistance (R(rs)) values. Symptom scales and HRQOL scores improved. For most variables, the largest improvement occurred within the first week with spirometry having the best signal-to-noise ratio. Changes in symptoms and HRQOL correlated best with changes in FEV(1), PaO(2) and X(rs,insp). CONCLUSIONS: The physiological changes seen following an exacerbation of COPD comprised both an improvement in operating lung volumes and a reduction in airway resistance. Given the ease with which forced oscillometry can be performed in these subjects, measurements of X(rs,insp) and X(rs,exp) could be useful for tracking recovery.

Diaphragm ultrasonography as an alternative to whole-body plethysmography in pulmonary function testing.

OBJECTIVE: Whole-body plethysmography is a common method of measuring pulmonary function. Although this technique provides a sensitive measure of pulmonary function, it can be problematic and unsuitable in some patients. The development of more accessible techniques would be beneficial. METHODS: A prospective study was performed to validate diaphragm ultrasonography as an alternative to whole-body plethysmography in patients referred for pulmonary function testing. Diaphragm movement and position were assessed by ultrasonography after standard pulmonary function testing using whole-body plethysmography. RESULTS: A wide range of lung function was observed. Standard lung volumes were as follows: total lung capacity, 5.57 +/- 1.31 L, residual volume, 2.27 +/- 0.56 L; and vital capacity, 3.30 +/- 0.98 L (mean +/- SD). The ratio of forced expiratory volume in 1 second to forced vital capacity was calculated as 0.69 +/- 0.08. Ultrasonography showed that mean diaphragm excursion values were 11.1 +/- 3.8 mm (2-dimensional), 14.7 +/- 4.1 mm during quiet breathing (M-mode), and 14.8 +/- 3.9 mm during a maximal sniff (M-mode). The velocity of diaphragm movement rose sharply during the sniff maneuver from 15.2 +/- 5.8 mm/s during quiet breathing to 104.0 +/- 33.4 mm/s. Static 2-dimensional measures of diaphragm position at the end of quiet inspiration or expiration correlated with standard measures of lung volume on plethysmography (eg, a correlation coefficient of 0.83 was obtained with end inspiration and vital capacity). All measures of diaphragm movement (whether by 2-dimensional or M-mode techniques) were poorly correlated with any lung volumes measured. CONCLUSIONS: These data suggest that dynamic measurements using diaphragm ultrasonography provide a relatively poor measure of pulmonary function in relation to whole-body plethysmography.

Clinical relevance of inter-method differences in fat-free mass estimation in chronic obstructive pulmonary disease.

BACKGROUND: Evaluation of fat-free mass (FFM) is becoming recognised as an important component in the assessment of clinical status and formulation of prognosis in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: The aim of this study was to determine whether potential differences in FFM estimation performed by air displacement plethysmography (ADP), bioelectrical impedance (BIE) and anthropometry (ANTHRO) would assume clinical significance. METHODS: Twenty-eight patients with moderate-to-severe COPD were submitted to FFM estimation by ADP, BIE and ANTHRO. FFM was then allometrically related to peak oxygen uptake (peak VO2) as determined by symptom-limited incremental cycle ergometry. RESULTS: We found that ANTHRO classified fewer patients as 'FFM-depleted' than the other two techniques (p < 0.05). Although mean biases of the BIE-ADP differences were close to zero, their 95% confidence limits extended as high as 5.9 kg (16%). The ANTHRO-based allometric exponents for peak VO2 correction of FFM, therefore, were typically higher than those obtained by the other two methods in both depleted and non-depleted patients (ANTHRO: 1.45-1.41, BIE: 0.97-1.18, ADP: 1.08-1.14, respectively). CONCLUSION: We conclude that between-method differences in FFM estimation can be sufficiently large to have practical implications in patients with moderate-to-severe COPD. A single method of body composition assessment, therefore, should be used for FFM estimation in these patients.