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.

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.

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.

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.

Have we underestimated the efficacy of pulmonary rehabilitation in improving mood?

BACKGROUND: Patients with COPD have a high prevalence of anxiety and depression. The efficacy of pulmonary rehabilitation (PR) in treating more severe anxiety and depression is unknown. The study aimed to explore the effectiveness of PR in reducing symptoms of anxiety and depression across a spectrum of severities. METHODS: The study used principles of comparative effectiveness research. Data was analysed from 518 patients with COPD [57.5% male, mean (SD) age 69.2 years (± 8.8 years)]. Patients were categorised into 3 groups based on their hospital anxiety and depression scale (HADS) scores pre PR ('none' 0-7, 'probable' 8-10 and 'presence' 11-21). A responder was defined as achieving a change of ≥ 48 m on the incremental shuttle walk test (ISWT). Patients were categorised as 'completers' if they attended their discharge assessment for PR. RESULTS: Anxiety and depression did not reduce following PR in patients with no symptoms (p > 0.05). Patients with a 'probable' or 'presence' of symptoms had significant reductions (both p < 0.001). There was a difference between sub-groups in change for anxiety and depression with patients scoring highest on the HADS having the greatest reductions (p < 0.001). There was no correlation between anxiety or depression and completion of PR (p > 0.05). Responders and non-responders did not differ in their anxiety or depression levels (p > 0.05). CONCLUSION: PR is effective in reducing symptoms of anxiety and depression. Previous studies may have underestimated the effectiveness of the PR programme in improving mood.

Generic, symptom based, exercise rehabilitation; integrating patients with COPD and heart failure.

BACKGROUND: Patients with Chronic Heart Failure (CHF) develop similar symptoms of exertional breathlessness and fatigue as patients with COPD. Although pulmonary (exercise based) rehabilitation (PR) is an integral part of the management of COPD, the potential for exercise rehabilitation (ER) to assist patients with CHF may not be as readily appreciated. We investigated whether combined ER for patients with CHF and COPD was feasible and effective using the model of PR. METHODS: 57 patients with CHF were randomized 2:1 to 7 weeks ER (CHF-ER) or 7 weeks of usual care (CHF-UC). As a comparator 55 patients with COPD were simultaneously recruited to the same ER program (COPD-ER). The primary outcome measure was the Incremental Shuttle Walk Test (ISWT) and the secondary outcome measures were the Endurance Shuttle Walk Test (ESWT), isometric quadriceps strength and health status. RESULTS: 27 CHF and 44 COPD patients completed ER and 17 patients with CHF completed UC. The CHF-ER group made significant improvements, compared to CHF-UC, in the mean (95%CI) ISWT distance; 62(35-89)m vs -6(-11 to 33)m p < 0.001. The CHF-ER group also made statistically significant improvements in health status. The improvements in exercise performance and health status were similar between patients with CHF and COPD, treated with ER. CONCLUSION: Patients with CHF who undergo ER improve similarly in their exercise performance and health status to COPD. Combined training programs for COPD and CHF are effective and feasible, such that service provision could be targeted around common disability rather than the primary organ disease.

Plasma ammonia response to incremental cycling and walking tests in COPD.

OBJECTIVE: It is well documented that plasma ammonia accumulates during exercise under conditions of metabolic stress. Metabolic stress (when skeletal muscle ATP supply fails to meet demand) occurs at low work rates during cycling in patients with COPD, but not been described during walking. Walking is an important activity for many patients with COPD and is commonly prescribed in pragmatic outpatient pulmonary rehabilitation programmes. In this study we explored whether metabolic stress occurs during incremental walking at the low work rates these patients achieve. METHODS: Twenty-nine subjects with stable COPD [mean(SD) age 68(7)years, FEV(1) 50(19)% predicted] performed maximal cardiopulmonary exercise tests on a cycle ergometer and treadmill. Plasma ammonia concentration was measured at rest, 1 and 2min of exercise, peak exercise and 2min recovery. RESULTS: Subjects achieved mean(SD) cycle work rate of 57(20)W with VO(2max) 15.5(4.6)ml/min per kg, and treadmill distance 284(175)m with VO(2peak) 16.8(4.2)ml/min per kg. Plasma ammonia concentration rose significantly (p<0.001) with walking [mean(SEM) change 24.7(3.8)micromol/l] and cycling [mean(SEM) change 35.2(4.3)micromol/l], but peak exercise ammonia was lower in walking (p<0.01). In a subgroup of subjects (n=7) plasma ammonia did not rise during either cycling or walking despite similar lactate rise and peak exercise indices. CONCLUSION: Our data indicate that failure of muscle ATP re-synthesis to meet demand and development of metabolic stress can occur during walking in COPD patients at the low work rates these patients achieve. This may therefore be a factor contributing to exercise limitation independent of ventilatory limitation.

Within-day repeatability of the endurance shuttle walk test.

OBJECTIVE: To determine the need for a practice walk for the endurance shuttle walk test (ESWT) following the performance of two incremental shuttle walk tests (ISWTs) - one practice and one test - on the same day. DESIGN: Retrospective data analysis of shuttle walk test measurements. All participants had performed two ISWTs and two ESWTs at a single visit, prior to commencing pulmonary rehabilitation. SETTING: Outpatient physiotherapy department of a university hospital. PARTICIPANTS: Forty-four patients (33 males, 11 females) with a primary diagnosis of chronic obstructive pulmonary disease, referred for routine pulmonary rehabilitation. MEASUREMENTS: Shuttle walk test distance and time, Borg breathlessness score, heart rate and pulsed oxygen saturation. RESULTS: The mean age of the group was 67.6 years [standard deviation (SD) 9.0] and mean forced expiratory volume in 1 second was 37% predicted (SD 13). The mean times walked during ESWTs 1 and 2 were 195 and 207 seconds (SD 115 and 138), respectively. Using the analysis recommended by Bland and Altman, the mean of the individual differences (d) between Tests 1 and 2 was 12 seconds, with limits of agreement from -88 to +112 seconds. CONCLUSION: A practice endurance shuttle walk is unnecessary following performance of ISWTs on the same day.

Pulmonary rehabilitation is successful for COPD irrespective of MRC dyspnoea grade.

BACKGROUND: It is not clear whether the benefits of pulmonary rehabilitation (PR) apply equally to patients with Chronic Obstructive Pulmonary Disease (COPD) with different levels of starting disability. We have therefore investigated the effect of pulmonary rehabilitation stratified by the MRC dyspnoea scale in patients with COPD. METHODS: This is a retrospective, observational study of data collected from 450 consecutive patients with COPD attending outpatient PR: 247 male, mean (SD) age 69.5 (8.9) yrs and FEV(1) 44.6 (19.7)% predicted. The Incremental Shuttle Walk Test (ISWT) was performed before and after the seven-week course RESULTS: 395 patients (88%) completed the programme. The mean (SD) baseline ISWT performance was 167 (113)m. The distribution of baseline MRC grades was 2 - 15.4%, 3 - 24.9%, 4 - 27.3% and 5 - 32.4%. The mean (95% CI) improvement in ISWT after PR for each MRC scale grade was highly significant (p<0.0005); 2 - 66 (50-83)m, 3 - 63 (50-75)m, 4 - 59 (49-70)m, and 5 - 54 (43-64)m. CONCLUSIONS: Patients with COPD, of all MRC dyspnoea grades, benefit comparably from pulmonary rehabilitation achieving both statistically and clinically meaningful improvements in exercise performance. MRC grade should therefore not be used to exclude patients from pulmonary rehabilitation.

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.

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.

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

Review article: addressing the sexual health of patients with COPD: the needs of the patient and implications for health care professionals.

Sexual expression is an important part of our individual identity and yet, this area is rarely addressed by health professionals. This article will explore the possible reasons for this and will also demonstrate the importance of assessing sexuality in patients with chronic obstructive pulmonary disease (COPD).

Osmotic adjustment in chickpea (Cicer arietinum L.) results in no yield benefit under terminal drought.

Variation in osmotic adjustment (OA) among chickpea (Cicer arietinum L.) cultivars has been observed when exposed to terminal drought, but some studies suggest that this benefits yield while others suggest it does not benefit yield in water-limited environments. In the present study, parents differing in OA were crossed and a set of advanced breeding lines (ABLs) developed for yield testing. The variation in OA during podding was measured under terminal drought in the F(2), F(3), F(7), and F(8) progeny and in the parents by either rehydrating the leaves before sampling for osmotic potential (OP) or by measuring the relative water content (RWC) and OP on adjacent leaves for the calculation of the OP at full turgor. Yields were measured in the F(8) progeny under terminal drought in Australia and India. While differences in OA were measured in the chickpea lines and parents, OA varied from year to year and did not consistently benefit yield when measured in the field under terminal drought. In Australia, differences in OA were not associated with any yield benefit in any year, while in India early flowering resulted in higher yields at three of the four sites, and OA had an inconsistent effect on seed yields. A comparison of OP at full turgor measured after rehydration and from measurements of RWC and OP showed that the rehydration technique underestimated OA. The lack of contribution of OA to yield of chickpea is discussed.

How long should outpatient pulmonary rehabilitation be? A randomised controlled trial of 4 weeks versus 7 weeks.

BACKGROUND: The evidence of benefit for pulmonary rehabilitation (PR) programmes is established. However, the optimal duration of a PR programme is not known. A randomised controlled trial was undertaken in patients with chronic obstructive pulmonary disease (COPD) to assess whether a 4 week PR programme was equivalent to our conventional 7 week PR programme at equivalent time points of 7 weeks and 6 months. METHODS: One hundred patients (56 men) with stable COPD of mean (SD) age 70 (8) years and forced expiratory volume in 1 second (FEV1) 1.13 (0.50) litres were randomised to either a 7 week (n = 50) or 4 week (n = 50) supervised PR programme. Patients were assessed at baseline, at completion of the supervised PR programme, and 6 months later. Patients randomised to the 4 week group were also assessed at the 7 week time point. Outcome measures were the Incremental Shuttle Walk Test, Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire-Self Reported, and the Breathing Problems Questionnaire. RESULTS: Forty one patients in each group completed the PR programme. Patients made significant within group improvements after supervised rehabilitation. There were no statistically significant differences between the groups for any other measure at the 7 week or 6 month time points, except that patients in the 4 week group attained higher ESWT times (mean difference 124 seconds (95% CI 17.00 to 232.16), p = 0.024) at the 7 week time point. CONCLUSIONS: A shortened 4 week supervised PR programme is equivalent to a 7 week supervised PR programme at the comparable time points of 7 weeks and 6 months.