Asthma symptoms, spirometry and air pollution exposure in schoolchildren in an informal settlement and an affluent area of Nairobi, Kenya.

BACKGROUND: Although 1 billion people live in informal (slum) settlements, the consequences for respiratory health of living in these settlements remain largely unknown. This study investigated whether children living in an informal settlement in Nairobi, Kenya are at increased risk of asthma symptoms. METHODS: Children attending schools in Mukuru (an informal settlement in Nairobi) and a more affluent area (Buruburu) were compared. Questionnaires quantified respiratory symptoms and environmental exposures; spirometry was performed; personal exposure to particulate matter (PM2.5) was estimated. RESULTS: 2373 children participated, 1277 in Mukuru (median age, IQR 11, 9-13 years, 53% girls), and 1096 in Buruburu (10, 8-12 years, 52% girls). Mukuru schoolchildren were from less affluent homes, had greater exposure to pollution sources and PM2.5. When compared with Buruburu schoolchildren, Mukuru schoolchildren had a greater prevalence of symptoms, 'current wheeze' (9.5% vs 6.4%, p=0.007) and 'trouble breathing' (16.3% vs 12.6%, p=0.01), and these symptoms were more severe and problematic. Diagnosed asthma was more common in Buruburu (2.8% vs 1.2%, p=0.004). Spirometry did not differ between Mukuru and Buruburu. Regardless of community, significant adverse associations were observed with self-reported exposure to 'vapours, dusts, gases, fumes', mosquito coil burning, adult smoker(s) in the home, refuse burning near homes and residential proximity to roads. CONCLUSION: Children living in informal settlements are more likely to develop wheezing symptoms consistent with asthma that are more severe but less likely to be diagnosed as asthma. Self-reported but not objectively measured air pollution exposure was associated with increased risk of asthma symptoms.

Short physical performance battery as a practical tool to assess mortality risk in chronic obstructive pulmonary disease.

RATIONALE: chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and common in older adults. The BODE Index is the most recognised mortality risk score in COPD but includes a 6-minute walk test (6MWT) that is seldom available in practise; the BODE Index may be better adopted if the 6MWT was replaced. OBJECTIVES: we investigated whether a modified BODE Index in which 6MWT was replaced by an alternative measure of physical capacity, specifically the short physical performance battery (SPPB) or components, retained its predictive ability for mortality in individuals with COPD. METHODS: we analysed 630 COPD patients from the ERICA cohort study for whom UK Office for National Statistics verified mortality data were available. Variables tested at baseline included spirometry, 6MWT, SPPB and its components (4-m gait speed test [4MGS], chair stand and balance). Predictive models were developed using stratified multivariable Cox regression, and assessed by C-indices and calibration plots with 10-fold cross-validation and replication. RESULTS: during median 2 years of follow-up, 60 (10%) individuals died. There was no significant difference between the discriminative ability of BODE6MWT (C-index 0.709, 95% confidence interval [CI], 0.680-0.737), BODESPPB (C-index 0.683, 95% CI, 0.647-0.712), BODE4MGS (C-index 0.676, 95% CI, 0.643-0.700) and BODEBALANCE (C-index 0.686, 95% CI, 0.651-0.713) for predicting mortality. CONCLUSIONS: the SPPB, and its 4MGS and balance components, can potentially be used as an alternative to the 6MWT in the BODE Index without significant loss of predictive ability in all-cause mortality.

Fibrinogen does not relate to cardiovascular or muscle manifestations in COPD: cross-sectional data from the ERICA study.

Cardiovascular and skeletal muscle manifestations constitute important comorbidities in COPD, with systemic inflammation proposed as a common mechanistic link. Fibrinogen has prognostic role in COPD. We aimed to determine whether aortic stiffness and quadriceps weakness are linked in COPD, and whether they are associated with the systemic inflammatory mediator-fibrinogen. Aortic pulse wave velocity (aPWV), quadriceps maximal volitional contraction (QMVC) force and fibrinogen were measured in 729 patients with stable, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages II-IV COPD. The cardiovascular and muscular manifestations exist independently (P=0.22, χ2). Fibrinogen was not associated with aPWV or QMVC (P=0.628 and P=0.621, respectively), making inflammation, as measured by plasma fibrinogen, an unlikely common aetiological factor.

The use of low-cost Android tablets to train community health workers in Mukono, Uganda, in the recognition, treatment and prevention of pneumonia in children under five: a pilot randomised controlled trial.

BACKGROUND: Since 2012, The World Health Organization and UNICEF have advocated for community health workers (CHWs) to be trained in Integrated Community Case Management (iCCM) of common childhood illnesses, such as pneumonia. Despite the effectiveness of iCCM, CHWs face many barriers to accessing training. This pilot study compares traditional training with using locally made videos loaded onto low-cost Android tablets to train CHWs on the pneumonia component of iCCM. METHODS: We conducted a pilot randomised controlled trial with CHWs in the Mukono District of Uganda. The unit of randomisation was the sub-county level, and the unit of analysis was at the level of the individual CHW. Eligible CHWs had completed basic iCCM training but had not received any refresher training on the pneumonia component of iCCM in the preceding 2 years. CHWs in the control group received training in the recognition, treatment, and prevention of pneumonia as it is currently delivered, through a 1-day, in-person workshop. CHWs allocated to the intervention group received training via locally made educational videos hosted on low-cost Android tablets. The primary outcome was change in knowledge acquisition, assessed through a multiple choice questionnaire before and after training, and a post-training clinical assessment. The secondary outcome was a qualitative evaluation of CHW experiences of using the tablet platform. RESULTS: In the study, 129 CHWs were enrolled, 66 and 63 in the control and intervention groups respectively. CHWs in both groups demonstrated an improvement in multiple choice question test scores before and after training; however, there was no statistically significant difference in the improvement between groups (t = 1.15, p = 0.254). There was a statistically significant positive correlation (Pearson's r = 0.26, p = 0.03) linking years of education to improvement in test scores in the control group, which was not present in the intervention group. The majority of CHWs expressed satisfaction with the use of tablets as a training tool; however, some reported technical issues (n = 9). CONCLUSION: Tablet-based training is comparable to traditional training in terms of knowledge acquisition. It also proved to be feasible and a satisfactory means of delivering training to CHWs. Further research is required to understand the impacts of scaling such an intervention. TRIAL REGISTRATION: Registered on 23/11/2016 at clinicaltrials.gov ( NCT02971449 ).

Patient agenda setting in respiratory outpatients: A randomized controlled trial.

Soliciting a patient's agenda (the reason for their visit, concerns and expectations) is fundamental to health care but if not done effectively outcomes can be adversely affected. Forms to help patients consider important issues prior to a consultation have been tested with mixed results. We hypothesized that using an agenda form would impact the extent to which patients felt their doctor discussed the issues that were important to them. Patients were randomized to receive an agenda form to complete whilst waiting or usual care. The primary outcome measure was the proportion of patients agreeing with the statement 'My doctor discussed the issues that were important to me' rated on a four-point scale. Secondary outcomes included other experience and satisfaction measures, consultation duration and patient confidence. There was no significant effect of agenda form use on primary or secondary outcomes. Post hoc exploratory analyses suggested possible differential effects for new compared to follow-up patients. There was no overall benefit from the form and a risk of detrimental impact on patient experience for some patients. There is a need for greater understanding of what works for whom in supporting patients to get the most from their consultation.

Evaluating the role of inflammation in chronic airways disease: the ERICA study.

Extrapulmonary manifestations are recognized to be of increasing clinical importance in Chronic Obstructive Pulmonary disease. To investigate cardiovascular and skeletal muscle manifestations of COPD, we developed a unique UK consortium funded by the Technology Strategy Board and Medical Research Council comprising industry in partnership with 5 academic centres. ERICA (Evaluating the Role of Inflammation in Chronic Airways disease) is a prospective, longitudinal, observational study investigating the prevalence and significance of cardiovascular and skeletal muscle manifestations of COPD in 800 subjects. Six monthly follow up will assess the predictive value of plasma fibrinogen, cardiovascular abnormalities and skeletal muscle weakness for death or hospitalization. As ERICA is a multicentre study, to ensure data quality we sought to minimise systematic observer error due to variations in investigator skill, or adherence to operating procedures, by staff training followed by assessment of inter- and intra-observer reliability of the four key measurements used in the study: pulse wave velocity (PWV), carotid intima media thickness (CIMT), quadriceps maximal voluntary contraction force (QMVC) and 6-minute walk distance (6MWT). This report describes the objectives and methods of the ERICA trial, as well as the inter- and intra-observer reliability of these measurements.

Medical Trainees' Knowledge and Attitudes Towards Electronic Cigarettes and Hookah: A Multinational Survey Study.

BACKGROUND: The rising prevalence of electronic cigarette (e-cigarette) and hookah use among youth raises questions about medical trainees' views of these products. We aimed to investigate medical trainees' knowledge and attitudes toward e-cigarette and hookah use. METHODS: We used data from a large cross-sectional survey of medical trainees in Brazil, the United States, and India. We investigated demographic and mental health aspects, history of e-cigarettes and tobacco use, knowledge and attitudes toward e-cigarettes and hookah, and sources of information on e-cigarettes and hookah. Although all medical trainees were eligible for the original study, only senior students and physicians-in-training were included in the present analysis. RESULTS: Of 2,036 senior students and physicians-in-training, 27.4% believed e-cigarette use to be less harmful than tobacco smoking. As for hookah use, 14.9% believed it posed a lower risk than cigarettes. More than a third of trainees did not acknowledge the risks of passive e-cigarette use (42.9%) or hookah smoking (35.1%). Also, 32.4% endorsed e-cigarettes to quit smoking, whereas 22.5% felt ill equipped to discuss these tobacco products with patients. Fewer than half recalled attending lectures on these topics, and their most common sources of information were social media (54.5%), Google (40.8%), and friends and relatives (40.3%). CONCLUSIONS: Medical trainees often reported incorrect or biased perceptions of e-cigarettes and hookah, resorted to unreliable sources of information, and lacked the confidence to discuss the topic with patients. An expanded curriculum emphasis on e-cigarette and hookah use might be necessary because failing to address these educational gaps could risk years of efforts against smoking normalization.

A critical interpretive synthesis of the lived experiences and health and patient-reported outcomes of people living with COPD who isolated during the COVID-19 pandemic.

AIMS: To determine the lived experiences of people with COPD who isolated at home during the coronavirus disease 2019 (COVID-19) pandemic, and explore how these experiences affected health and patient-reported outcomes. METHODS: Keyword searches were performed in five bibliographic databases. Critical interpretative synthesis (CIS) methods were used to interrogate and understand patterns across studies. RESULTS: 23 studies were identified; three employed qualitative methods and 20 quantitative methods. Application of CIS methods highlighted a core synthetic concept that appeared to underpin experiences and outcomes, that of a heightened perception of risk. Using the Risk Perception Model as a framework, we found that cognitive factors such as knowledge of underlying health status and the transmissibility of COVID-19; experiential factors including previous episodes of breathlessness and hospitalisation; and sociocultural factors such as access to trusted sources of information, influenced perceptions of risk. In turn, this influenced behaviour, which translated to outcomes such as reduced hospitalisations, deconditioning and social isolation as people avoided "high-risk" situations and settings. CONCLUSIONS: Patients with COPD who isolated at home during the COVID-19 pandemic had a heightened perception of risk which was influenced by cognitive, experiential and sociocultural factors. The consequences of this were varied and included both positive (reduced exacerbations and hospitalisations) and negative (social isolation, deconditioning, diminished capacity for self-care) outcomes. Understanding risk and the impacts it can have could help clinicians to support people with COPD return to their pre-pandemic way of living and enable better communication of ongoing risk from respiratory viral illness.

Medical education through an invasion: insights from an elective programme for Ukrainian medical students at the University of Cambridge.

Medical students in Ukraine have faced extraordinary disruption to their clinical studies with both the COVID-19 pandemic and subsequent Russian military invasion forcing a majority of their learning to be conducted remotely. Over the summer of 2022, the School of Clinical Medicine, University of Cambridge hosted 20 medical students from Kharkiv National Medical University for a seven-week intensive clinical elective programme. The aim was to provide an immersive clinical placement that would help students to attain the necessary knowledge and experience to become competent and confident practising doctors. This perspective piece aims to support the development of future equivalent exchanges through outlining the placement's context, its planning and implementation, evidence of placement impact, and finally reflections and learning points.

Vaping and Hookah Use Among Medical Trainees: A Multinational Survey Study.

The increased use of E-cigarettes and hookah among young consumers represents a public health concern. This study aimed to investigate the frequency and patterns of use of E-cigarettes and hookah among medical trainees. This cross-sectional multinational online survey included medical students, residents, and fellows in Brazil, the U.S., and India between October 2020 and November 2021. Information on sociodemographics; mental health; and E-cigarettes, hookah, tobacco, marijuana, and alcohol use were collected. Generalized structural equation models were used in 2022 to explore the factors associated with current vaping and current hookah use (ongoing monthly/weekly/daily use). People reporting previous sporadic/frequent use or those who never used/only tried it once were the reference group. Overall, 7,526 participants were recruited (Brazil=3,093; U.S.=3,067; India=1,366). The frequency of current vaping was 20% (Brazil), 11% (U.S.), and <1% (India), and current hookah use was 10% (Brazil), 6% (U.S.), and 1% (India). Higher family income (OR=6.35, 95% CI=4.42, 9.12), smoking cigarettes (OR=5.88, 95% CI=4.88, 7.09) and marijuana (OR=2.8, 95% CI=2.35, 3.34), and binge drinking (OR=3.03, 95% CI=2.56, 3.59) were associated with current vaping. The same was true for hookah use: higher family income (OR=2.69, 95% CI=1.75, 4.14), smoking cigarettes (OR=3.20, 95% CI=2.53, 4.06), smoking marijuana (OR=4.17, 95% CI=3.35, 4.19), and binge drinking (OR=2.42, 95% CI=1.96, 2.99). In conclusion, E-cigarettes and hookah were frequently used by Brazilian and American trainees, sharply contrasting with data from India. Cultural aspects and public health policies may explain the differences among countries. Addressing the problems of hookah and E-cigarette smoking in this population is relevant to avoid the renormalization of smoking.

Preterm birth, birth weight, infant weight gain and their associations with childhood asthma and spirometry: a cross-sectional observational study in Nairobi, Kenya.

BACKGROUND: In sub-Saharan Africa, the origins of asthma and high prevalence of abnormal lung function remain unclear. In high-income countries (HICs), associations between birth measurements and childhood asthma and lung function highlight the importance of antenatal and early life factors in the aetiology of asthma and abnormal lung function in children. We present here the first study in sub-Saharan Africa to relate birth characteristics to both childhood respiratory symptoms and lung function. METHODS: Children attending schools in two socioeconomically contrasting but geographically close areas of Nairobi, Kenya, were recruited to a cross-sectional study of childhood asthma and lung function. Questionnaires quantified respiratory symptoms and preterm birth; lung function was measured by spirometry; and parents were invited to bring the child's immunisation booklet containing records of birth weight and serial weights in the first year. RESULTS: 2373 children participated, 52% girls, median age (IQR), 10 years (8-13). Spirometry data were available for 1622. Child immunisation booklets were available for 500 and birth weight and infant weight gain data were available for 323 and 494 children, respectively. In multivariable analyses, preterm birth was associated with the childhood symptoms 'wheeze in the last 12 months'; OR 1.64, (95% CI 1.03 to 2.62), p=0.038; and 'trouble breathing' 3.18 (95% CI 2.27 to 4.45), p<0.001. Birth weight (kg) was associated with forced expiratory volume in 1 s z-score, regression coefficient (ß) 0.30 (0.08, 0.52), p=0.008, FVC z-score 0.29 (95% CI 0.08 to 0.51); p=0.008 and restricted spirometry, OR 0.11 (95% CI 0.02 to 0.78), p=0.027. CONCLUSION: These associations are in keeping with those in HICs and highlight antenatal factors in the aetiology of asthma and lung function abnormalities in sub-Saharan Africa.

Physiological effects and subjective tolerability of prone positioning in COVID-19 and healthy hypoxic challenge.

BACKGROUND: Prone positioning has a beneficial role in coronavirus disease 2019 (COVID-19) patients receiving ventilation but lacks evidence in awake non-ventilated patients, with most studies being retrospective, lacking control populations and information on subjective tolerability. METHODS: We conducted a prospective, single-centre study of prone positioning in awake non-ventilated patients with COVID-19 and non-COVID-19 pneumonia. The primary outcome was change in peripheral oxygenation in prone versus supine position. Secondary outcomes assessed effects on end-tidal CO2, respiratory rate, heart rate and subjective symptoms. We also recruited healthy volunteers to undergo proning during hypoxic challenge. RESULTS: 238 hospitalised patients with pneumonia were screened; 55 were eligible with 25 COVID-19 patients and three non-COVID-19 patients agreeing to undergo proning - the latter insufficient for further analysis. 10 healthy control volunteers underwent hypoxic challenge. Patients with COVID-19 had a median age of 64 years (interquartile range 53-75). Proning led to an increase in oxygen saturation measured by pulse oximetry (SpO2) compared to supine position (difference +1.62%; p=0.003) and occurred within 10 min of proning. There were no effects on end-tidal CO2, respiratory rate or heart rate. There was an increase in subjective discomfort (p=0.003), with no difference in breathlessness. Among healthy controls undergoing hypoxic challenge, proning did not lead to a change in SpO2 or subjective symptom scores. CONCLUSION: Identification of suitable patients with COVID-19 requiring oxygen supplementation from general ward environments for awake proning is challenging. Prone positioning leads to a small increase in SpO2 within 10 min of proning though is associated with increased discomfort.

Minute ventilation/carbon dioxide production in patients with dysfunctional breathing.

Dysfunctional breathing refers to a multi-dimensional condition that is characterised by pathological changes in an individual's breathing. These changes lead to a feeling of breathlessness and include alterations in the biomechanical, psychological and physiological aspects of breathing. This makes dysfunctional breathing a hard condition to diagnose, given the diversity of aspects that contribute to the feeling of breathlessness. The disorder can debilitate individuals without any health problems, but may also be present in those with underlying cardiopulmonary co-morbidities. The ventilatory equivalent for CO2 (V eqCO2 ) is a physiological parameter that can be measured using cardiopulmonary exercise testing. This review will explore how this single measurement can be used to aid the diagnosis of dysfunctional breathing. A background discussion about dysfunctional breathing will allow readers to comprehend its multidimensional aspects. This will then allow readers to understand how V eqCO2 can be used in the wider diagnosis of dysfunctional breathing. Whilst V eqCO2 cannot be used as a singular parameter in the diagnosis of dysfunctional breathing, this review supports its use within a broader algorithm to detect physiological abnormalities in patients with dysfunctional breathing. This will allow for more individuals to be accurately diagnosed and appropriately managed.

Ethical principles and a practical approach to support policy making through the next phases of the COVID-19 pandemic and beyond.

There is an urgent need for an ethical framework to help us address the local and national challenges that we face as clinicians during the COVID-19 pandemic. We propose four key commitments from which a practical and consistent ethical approach can be derived. These commitments are to articulate the needs, rights and interests of the different stakeholders affected by any policy; to be accountable and transparent, recognising that people are autonomous individuals with values and concerns of their own; to consider the impact of our actions on the sustainability of the NHS, infrastructure, service demands and staff welfare; and to treat everybody equitably, with all deserving of consideration and care. Implementing these commitments will require a number of specific actions. We must put in place frameworks enabling clear advocacy for each competing objective; communicate policy and practice effectively to the public; promote integration of decision-making among social, primary, secondary and tertiary care and reduce or stop unnecessary or inefficient interventions; minimise health inequalities; and build spare capacity into the system.In this article, we expand on these actions, and note the legal context in which this would be delivered.

Understanding the Influences of COPD Patient's Capability on the Uptake of Pulmonary Rehabilitation in the UK Through an Inclusive Design Approach.

Background: Pulmonary rehabilitation (PR) is recommended for patients with COPD to improve their symptoms and quality of life. However, in the UK, only one in ten of those who need PR receive it and this might be inaccessible to people with disabilities. This study aims to inform improvements to PR service by identifying barriers to the uptake of PR in the COPD care journey in relation to patients' capabilities that can affect their access to PR. Methods: An Inclusive Design approach with mixed methods was undertaken. Firstly, patients and healthcare professionals were interviewed to gather insight into their experiences of COPD care and map patients' care journey. Secondly, an Exclusion Calculator was used to estimate service demand on patients' capability and the proportion of population excluded from the service. Thirdly, a framework analysis was applied to guide data analysis to identify the challenges of accessing PR. Finally, proposed recommendations were refined with patients and healthcare professionals. Results: The overall capability-related exclusion number was very high (62.5%), and exclusion caused by limited mobility was the highest (50%) among the interviewees and even higher based on the population database. This suggests the importance of considering COPD patients' capability-related needs to improve their access to care. Capability-related challenges for patients accessing PR such as poor mobility to transport and low vision impairing ability to read inhaler instructions were identified, as well as non-capability-related challenges such as patients' perception about COPD and inability to access proper information. Recommendations were proposed to help patients to self-manage their COPD and access to PR. Conclusion: Lack of attention to COPD patients' capability level in the delivery of PR may affect its uptake. Considering the capability-related needs of COPD patients and providing patients with reassurance, information, and support on their care journey could improve the uptake of PR.

Admission COVID-19 clinical risk assessment for guiding patient placement and diagnostic testing strategy.

INTRODUCTION: Without universal access to point-of-care SARS-CoV-2 testing, many hospitals rely on clinical judgement alone for identifying cases of COVID-19 early. METHODS: Cambridge University Hospitals NHS Foundation Trust introduced a 'traffic light' clinical judgement aid to the COVID-19 admissions unit in mid-March 2020. Ability to accurately predict COVID-19 was audited retrospectively across different stages of the epidemic. RESULTS: One SARS-CoV-2 PCR positive patient (1/41, 2%) was misallocated to a 'green' (non-COVID-19) area during the first period of observation, and no patients (0/32, 0%) were mislabelled 'green' during the second period. 33 of 62 (53%) labelled 'red' (high risk) tested SARS-CoV-2 PCR positive during the first period, while 5 of 22 (23%) 'red' patients were PCR positive in the second. CONCLUSION: COVID-19 clinical risk stratification on initial assessment effectively identifies non-COVID-19 patients. However, diagnosing COVID-19 is challenging and risk of overcalling COVID-19 should be recognised, especially when background prevalence is low.

Why, when and how do secondary-care clinicians have emergency care and treatment planning conversations? Qualitative findings from the ReSPECT Evaluation study.

BACKGROUND: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an emergency care and treatment planning (ECTP) process, developed to offer a patient-centred approach to deciding about and recording treatment recommendations. Conversations between clinicians and patients or their representatives are central to the ReSPECT process. This study aims to understand why, when, and how ReSPECT conversations unfold in practice. METHODS: ReSPECT conversations were observed in hospitals within six acute National Health Service (NHS) trusts in England; the clinicians who conducted these conversations were interviewed. Following observation-based thematic analysis, five ReSPECT conversation types were identified: resuscitation and escalation; confirmation of decision; bad news; palliative care; and clinical decision. Interview-based thematic analysis examined the reasons and prompts for each conversation type, and the level of detail and patient engagement in these different conversations. RESULTS: Whereas resuscitation and escalation conversations concerned possible futures, palliative care and bad news conversations responded to present-tense changes. Conversations were timed to respond to organisational, clinical, and patient/relative prompts. While bad news and palliative care conversations included detailed discussions of treatment options beyond CPR, this varied in other conversation types. ReSPECT conversations varied in doctors' engagement with patient/relative preferences, with only palliative care conversations consistently including an open-ended approach. CONCLUSIONS: While ReSPECT supports holistic, person-centred, anticipatory decision-making in some situations, a gap remains between the ReSPECT's aims and their implementation in practice. Promoting an understanding and valuing of the aims of ReSPECT among clinicians, supported by appropriate training and structural support, will enhance ReSPECT conversations.

Quantitative 18F-fluorodeoxyglucose positron emission tomography/computed tomography to assess pulmonary inflammation in COPD.

RATIONALE: COPD and smoking are characterised by pulmonary inflammation. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) imaging may improve knowledge of pulmonary inflammation in COPD patients and aid early development of novel therapies as an imaging biomarker. OBJECTIVES: To evaluate pulmonary inflammation, assessed by FDG uptake, in whole and regional lung in "usual" (smoking-related) COPD patients, alpha-1 antitrypsin deficiency (α1ATD) COPD patients, smokers without COPD and never-smokers using FDG PET/CT. Secondly, to explore cross-sectional associations between FDG PET/CT and systemic inflammatory markers in COPD patients and repeatability of the technique in COPD patients. METHODS: Data from two imaging studies were evaluated. Pulmonary FDG uptake (normalised Ki; nKi) was measured by Patlak graphical analysis in four subject groups: 84 COPD patients, 11 α1ATD-COPD patients, 12 smokers and 10 never-smokers. Within the COPD group, associations between nKi and systemic markers of inflammation were assessed. Repeatability was evaluated in 32 COPD patients comparing nKi values at baseline and at 4-month follow-up. RESULTS: COPD patients, α1ATD-COPD patients and smokers had increased whole lung FDG uptake (nKi) compared with never-smokers (0.0037±0.001, 0.0040±0.001, 0.0040±0.001 versus 0.0028±0.001 mL·cm-3·min-1, respectively, p<0.05 for all). Similar results were observed in upper and middle lung regions. In COPD participants, plasma fibrinogen was associated with whole lung nKi (ß=0.30, p=0.02) in multivariate analysis adjusted for current smoking, forced expiratory volume in 1 s % predicted, systemic neutrophils and C-reactive protein levels. Mean percentage difference in nKi between the baseline and follow-up was 3.2%, and the within subject coefficient of variability was 7.7%. CONCLUSIONS: FDG PET/CT has potential as a noninvasive tool to enable whole lung and regional quantification of FDG uptake to assess smoking- and COPD-related pulmonary inflammation.

Ethical issues surrounding do not attempt resuscitation orders: decisions, discussions and deleterious effects.

Since their introduction as 'no code' in the 1980s and their later formalization to 'do not resuscitate' orders, such directions to withhold potentially life-extending treatments have been accompanied by multiple ethical issues. The arguments for when and why to instigate such orders are explored, including a consideration of the concept of futility, allocation of healthcare resources, and reaching a balance between quality of life and quality of death. The merits and perils of discussing such decisions with patients and/or their relatives are reviewed and the unintended implications of 'do not attempt resuscitation' orders are examined. Finally, the paper explores some alternative methods to approaching the resuscitation decision, and calls for empirical evaluation of such methods that may reduce the ethical dilemmas physicians currently face.

Discussion and documentation of future care: a before-and-after study examining the impact of an alternative approach to recording treatment decisions on advance care planning in an acute hospital.

OBJECTIVE: To determine whether discussion and documentation of decisions about future care was improved following the introduction of a new approach to recording treatment decisions: the Universal Form of Treatment Options (UFTO). METHODS: Retrospective review of the medical records of patients who died within 90 days of admission to oncology or respiratory medicine wards over two 3-month periods, preimplementation and postimplementation of the UFTO. A sample size of 70 per group was required to provide 80% power to observe a change from 15% to 35% in discussion or documentation of advance care planning (ACP), using a two-sided test at the 5% significance level. RESULTS: On the oncology ward, introduction of the UFTO was associated with a statistically significant increase in cardiopulmonary resuscitation decisions documented for patients (pre-UFTO 52% to post-UFTO 77%, p=0.01) and an increase in discussions regarding ACP (pre-UFTO 27%, post-UFTO 49%, p=0.03). There were no demonstrable changes in practice on the respiratory ward. Only one patient came into hospital with a formal ACP document. CONCLUSIONS: Despite patients' proximity to the end-of-life, there was limited documentation of ACP and almost no evidence of formalised ACP. The introduction of the UFTO was associated with a change in practice on the oncology ward but this was not observed for respiratory patients. A new approach to recording treatment decisions may contribute to improving discussion and documentation about future care but further work is needed to ensure that all patients' preferences for treatment and care at the end-of-life are known.