Experiences of patients enrolled and staff involved in the prehabilitation of elective patients undergoing cardiac surgery trial: a nested qualitative study.

The purpose of this study was to understand the views and experiences of patients enrolled and staff involved in the prehabilitation of elective patients undergoing cardiac surgery trial. This sub-study was informed by normalisation process theory, a framework for evaluating complex interventions, and used consecutive sampling to recruit patients assigned to both the intervention and control groups. Patients and all staff involved in delivering the trial were invited to participate in focus groups, which were recorded, transcribed verbatim and subjected to reflexive thematic analysis. Five focus groups were held comprising 24 participants in total (nine patients assigned to the prehabilitation; seven assigned to control; and eight staff). Five themes were identified. First, preparedness for surgery reduced fear, where participants described that knowing what to expect from surgery and preparing the body physically increased feelings of control and subsequently reduced apprehension regarding surgery. Second, staff were concerned but trusted in a safe environment, describing how, despite staff's concerns regarding the risks of exercise in this population, the patients felt safe in their care whilst participating in an exercise programme in hospital. Third, rushing for recovery and the curious carer, where patients from both groups wanted to mobilise quickly postoperatively whilst staff visited patients on the ward to observe their recovery progress. Fourth, to survive and thrive postoperatively, reflecting staff and patients' expectations from the trial and what motivated them to participate. Fifth, benefits are diluted by lengthy waiting periods, reflecting the frustration felt by patients waiting for their surgery after completing the intervention and the fear about continuing exercise at home before they had been 'fixed'. To conclude, functional exercise capacity may not have improved following prehabilitation in people before elective cardiac surgery due to concerns regarding the safety of exercise that may have hindered delivery and receipt of the intervention. Instead, numerous non-physical benefits were elicited. The information from this qualitative study offers valuable recommendations regarding refining a prehabilitation intervention and conducting a subsequent trial.

A randomised controlled trial of prehabilitation in patients undergoing elective cardiac surgery.

The feasibility, safety and efficacy of prehabilitation in adult patients awaiting elective cardiac surgery are unknown. A total of 180 participants undergoing elective cardiac surgery were allocated randomly to receive either standard pre-operative care or prehabilitation, consisting of pre-operative exercise and inspiratory muscle training. The primary outcome was change in six-minute walk test distance from baseline to pre-operative assessment. Secondary outcomes included change in inspiratory muscle strength (maximal inspiratory pressure); sarcopenia (handgrip strength); quality of life and compliance. Safety outcomes were pre-specified surgical and pulmonary complications and adverse events. All outcomes were assessed at baseline; at pre-operative assessment; and 6 and 12 weeks following surgery. Mean (SD) age was 64.7 (10.2) years; 33/180 (18%) were women. In total, 65/91 (71.4%) participants who were allocated to prehabilitation attended at least four of eight supervised in-hospital exercise classes; participants aged > 50 years were more likely than younger participants to attend (odds ratio (95%CI) of 4.6 (1.0-25.1)). Six-minute walk test was not significantly different between groups (mean difference (95%CI) -7.8 m (-30.6-15.0), p = 0.503) in the intention-to-treat analysis. Subgroup analyses based on tests for interaction indicated improvements in six-minute walk test distance were larger amongst sarcopenic patients in the prehabilitation group (p = 0.004). Change in maximal inspiratory pressure from baseline to all time-points was significantly greater in the prehabilitation group, with the greatest mean difference (95%CI) observed 12 weeks after surgery (10.6 cmH2 O (4.6-16.6) cmH2 O, p < 0.001). There were no differences in handgrip strength or quality of life up to 12 weeks after surgery. There was no significant difference in postoperative mortality (one death in each group), surgical or pulmonary complications. Of 71 pre-operative adverse events, six (8.5%) were related to prehabilitation. The combination of exercise and inspiratory muscle training in a prehabilitation intervention before cardiac surgery was not superior to standard care in improving functional exercise capacity measured by six-minute walk test distance pre-operatively. Future trials should target patients living with sarcopenia and include inspiratory muscle strength training.

Incident fracture is associated with a period of accelerated loss of hip BMD: the Study of Osteoporotic Fractures.

Bone loss following a fracture could increase the risk of future fractures. In this study, we found that elderly women who had an upper body fracture or multiple fractures lost more bone at the hip than those who did not fracture. This suggests a possible systemic bone loss response initiated by fracture. INTRODUCTION: A prior fracture is one of the strongest predictors of subsequent fracture risk, but the etiology of this phenomenon remains unclear. Systemic bone loss post-fracture could contribute to increased risk of subsequent fractures. Therefore, in this study, we investigated whether incident fractures, including those distant to the hip, are associated with accelerated loss of hip bone mineral density (BMD) in elderly women. METHODS: We analyzed data from 3956 Caucasian women aged ≥ 65 years who were enrolled in the Study of Osteoporotic Fractures and completed hip BMD measurements at study visit 4 (year 6) and visit 6 (year 10). Clinical fractures between visits 4 and 6 were ascertained from triannual questionnaires and centrally adjudicated by review of community radiographic reports. Subjects provided questionnaire information and clinical variables at examinations for known and potential covariates. Generalized linear models were used to calculate average annual percent change in total hip BMD between visits 4 and 6 for each incident fracture type and for upper body and lower body fractures combined. A subset of women (n = 3783) was analyzed for annual total hip BMD change between study visits 4 and 5 and between study visits 5 and 6 to evaluate change in total hip BMD during these 2-year intervals. RESULTS: Women with incident upper body fracture or incident lower body fracture exhibited reductions in total hip BMD of 0.89 and 0.77% per year, respectively, while women who did not fracture exhibited reductions in total hip BMD of 0.66% per year during the 4-year period. Accelerated loss of hip BMD was isolated to the 2-year time interval that included the fracture. Loss of total hip BMD was not affected by the number of days from fracture to follow up DXA. CONCLUSIONS: Systemic bone loss following fracture may increase the risk of future fractures at all skeletal sites. There is a need for improved understanding of mechanisms leading to apparent accelerated bone loss following a fracture in order to reduce subsequent fracture risk.

The epidemiology of wrist fractures in older men: the Osteoporotic Fractures in Men (MrOS) study.

There is limited wrist fracture information on men. Our goal was to calculate frequency and identify risk factors for wrist fracture in the Osteoporotic Fractures in Men (MrOS) study. We confirmed that fracture history and certain medications are predictors, and identified novel predictors including markers of kidney function and physical performance. INTRODUCTION: To calculate the incidence of wrist fractures and their risk factors in older community-dwelling men from the US Osteoporotic Fractures in Men (MrOS) study. METHODS: Using triannual postcards, we identified incident wrist fractures (centrally confirmed by radiology) in men aged ≥ 65. Potential risk factors included the following: demographics, lifestyle, bone mineral density (BMD), selected medications, biomarkers, and physical function and performance measures. Both baseline and time-varying models were adjusted for age, race/ethnicity, MrOS geographic location, and competing mortality risks. RESULTS: We observed 97 incident wrist fractures among 5875 men followed for an average of 10.8 years. The incidence of wrist fracture was 1.6 per 1000 person-years overall and ranged from 1.0 among men aged 65-69 to 2.4 among men age ≥ 80. Significant predictors included the following: fracture history after age 50 [hazard ratio (95% CI): 2.48 (1.65, 3.73)], high serum phosphate [1.25 (1.02, 1.53)], use of selective serotonin receptor inhibitor (SSRI) [3.60 (1.96, 6.63), decreased right arm BMD [0.49 (0.37, 0.65) per SD increase], and inability to perform the grip strength test [3.38 (1.24, 9.25)]. We did not find associations with factors commonly associated with wrist and other osteoporosis fractures like falls, diabetes, calcium and vitamin D intake, and alcohol intake. CONCLUSIONS: Among these older, community-dwelling men, we confirmed that fracture history is a strong predictor of wrist fractures in men. Medications such as SSRIs and corticosteroids also play a role in wrist fracture risk. We identified novel risk factors including kidney function and the inability to perform the grip strength test.

A comprehensive approach to evaluating and classifying sun-protective clothing.

BACKGROUND: National standards for clothing designed to protect the wearer from the harmful effects of solar ultraviolet radiation (UVR) have been implemented in Australia/New Zealand, Europe and the U.S.A. Industry standards reflect the need to protect the skin by covering a considerable proportion of the potentially exposed body surface area (BSA) and by reducing UVR-transmission through fabric (the Ultraviolet Protection Factor; UPF). OBJECTIVES: This research aimed to develop a new index for rating sun-protective clothing that incorporates the BSA coverage of the garment in addition to the UPF of the fabric. METHODS: A mannequin model was fixed to an optical bench and marked with horizontal lines at 1-cm intervals. An algorithm (the Garment Protector Factor; GPF) was developed based on the number of lines visible on the clothed vs. unclothed mannequin and the UPF of the garment textile. This data was collected in 2015/16 and analysed in 2016. RESULTS: The GPF weights fabric UPF by BSA coverage above the minimum required by international sun-protective clothing standards for upper-body, lower-body and full-body garments. The GPF increases with BSA coverage of the garment and fabric UPF. Three nominal categories are proposed for the GPF: 0 ≤ GPF < 3 for garments that 'meet' minimum standards; 3 ≤ GPF < 6 for garments providing 'good' sun protection; and GPF ≥ 6 indicating 'excellent' protection. CONCLUSIONS: Adoption of the proposed rating scheme should encourage manufacturers to design sun-protective garments that exceed the minimum standard for BSA coverage, with positive implications for skin cancer prevention, consumer education and sun-protection awareness.

Costs of potentially inappropriate medication use in residential aged care facilities.

BACKGROUND: The potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care. METHODS: Participants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults. RESULTS: Of all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted ß = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (±SD) of medication costs that were spent on PIMs in 1 year was 17.5% (±17.8) (AUD$410.89 ± 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care. CONCLUSIONS: The use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.

Sun protection policies of Australian primary schools in a region of high sun exposure.

Queensland, Australia has the highest rates of skin cancer globally. Predetermined criteria were used to score the comprehensiveness of sun protection policies (SPP) of primary schools across Queensland. SPP were sought for schools in 10 regions (latitude range 16.3°S-28.1°S) from 2011 to 2014. Of the 723 schools sampled, 90.9% had a written SPP available publicly. Total SPP scores were low {mean 3.6 [95% CI: 3.4-3.9]; median 2 [interquartile range (IQR) 2, 4]}, with only 3.2% of schools achieving the maximum score of 12. Median SPP scores were higher in Northern and Central Queensland [both 2 (IQR 2, 6) and (IQR 2, 5), respectively] than in Southern Queensland [2 (IQR 2, 3); P = 0.004]. Clothing and hat-wearing were addressed in most policies (96% and 89%) while few schools used their SPP to plan outdoor events (5.2%) or reschedule activities to minimize sun exposure (11.7%). The SunSmart Schools program has been operating in Queensland for 17 years, and while most primary schools now have a written SPP, most are not comprehensive. Incentive-based approaches (5-star-rating award scheme and grants) may assist in addressing this issue, to reduce sun exposure of students and teachers. These data provide a baseline from which improvements in the comprehensiveness of school SPPs can be evaluated.

The AusD Study: a population-based study of the determinants of serum 25-hydroxyvitamin D concentration across a broad latitude range.

Observational studies suggest that people with a high serum 25-hydroxyvitamin D (25(OH)D) concentration may have reduced risk of chronic diseases such as osteoporosis, multiple sclerosis, type 1 diabetes, cardiovascular disease, and some cancers. The AusD Study (A Quantitative Assessment of Solar UV Exposure for Vitamin D Synthesis in Australian Adults) was conducted to clarify the relationships between ultraviolet (UV) radiation exposure, dietary intake of vitamin D, and serum 25(OH)D concentration among Australian adults residing in Townsville (19.3°S), Brisbane (27.5°S), Canberra (35.3°S), and Hobart (42.8°S). Participants aged 18-75 years were recruited from the Australian Electoral Roll between 2009 and 2010. Measurements were made of height, weight, waist:hip ratio, skin, hair, and eye color, blood pressure, and grip strength. Participants completed a questionnaire on sun exposure and vitamin D intake, together with 10 days of personal UV dosimetry and an associated sun-exposure and physical-activity diary that was temporally linked to a blood test for measurement of 25(OH)D concentration. Ambient solar UV radiation was also monitored at all study sites. We collected comprehensive, high-quality data from 1,002 participants (459 males, 543 females) assessed simultaneously across a range of latitudes and through all seasons. Here we describe the scientific and methodological issues considered in designing the AusD Study.

Depressive symptoms and rates of bone loss at the hip in older men.

UNLABELLED: In this prospective cohort study, depressive symptoms were associated with higher rates of bone loss in older men. Poorer performance on physical function tests partly explained the association between depressive symptoms and bone loss, suggesting that efforts to increase exercise and improve physical performance in depressed men may be beneficial. INTRODUCTION: The aim of this study was to ascertain whether depressive symptoms are associated with increased rates of bone loss at the hip in older men. METHODS: A population-based prospective cohort study of 2,464 community-dwelling men, aged 68 and older, enrolled in the Osteoporosis in Men Sleep Ancillary Study had depressive symptoms assessed by the Geriatric Depression Scale (GDS). Subjects were categorized as depressed if GDS ≥6 at the initial examination. Bone mineral density (BMD) at the hip was measured using dual-energy X-ray absorptiometry at the initial and follow-up examination (average 3.4 years between exams). Use of antidepressant medications was assessed by interview and verified from medication containers at the two examinations. A computerized dictionary was used to categorize type of medication. RESULTS: In a base model adjusted for age, race/ethnicity, and clinic site, the mean total hip BMD decreased 0.70 %/year in 136 men with a GDS score of ≥6 compared to 0.39 %/year in 2,328 men with a GDS score of <6 (p = 0.001). Walking speed and timed chair stand partly explained the association between depressive symptoms and rates of bone loss. CONCLUSION: Depression, as defined by a score of 6 or greater on the Geriatric Depression Scale, is associated with an increased rate of bone loss at the hip in this cohort of older men. Adjustment for walking speed and timed chair stand attenuated the strength of the association, suggesting that differences in physical functioning do partially explain the observed association.

Longitudinal Associations between Concurrent Changes in Phenotypic Frailty and Lower Urinary Tract Symptoms among Older Men.

BACKGROUND: Lower urinary tract symptoms (LUTS) are associated with prevalent frailty and functional impairment, but longitudinal associations remain unexplored. OBJECTIVES: To assess the association of change in phenotypic frailty with concurrent worsening LUTS severity among older men without clinically significant LUTS at baseline. DESIGN: Multicenter, prospective cohort study. SETTING: Population-based. PARTICIPANTS: Participants included community-dwelling men age ≥65 years at enrollment in the Osteoporotic Fractures in Men study. MEASUREMENTS: Data were collected at 4 visits over 7 years. Phenotypic frailty score (range: 0-5) was defined at each visit using adapted Fried criterion and men were categorized at baseline as robust (0), pre-frail (1-2), or frail (3-5). Within-person change in frailty was calculated at each visit as the absolute difference in number of criteria met compared to baseline. LUTS severity was defined using the American Urologic Association Symptom Index (AUASI; range: 0-35) and men with AUASI ≥8 at baseline were excluded. Linear mixed effects models were adjusted for demographics, health-behaviors, and comorbidities to quantify the association between within-person change in frailty and AUASI. RESULTS: Among 3235 men included in analysis, 48% were robust, 45% were pre-frail, and 7% were frail. Whereas baseline frailty status was not associated with change in LUTS severity, within-person increases in frailty were associated with greater LUTS severity (quadratic P<0.001). Among robust men at baseline, mean predicted AUASI during follow-up was 4.2 (95% CI 3.9, 4.5) among those meeting 0 frailty criteria, 4.6 (95% CI 4.3, 4.9) among those meeting 1 criterion increasing non-linearly to 11.2 (95% CI 9.8, 12.6) among those meeting 5 criteria. CONCLUSIONS: Greater phenotypic frailty was associated with non-linear increases in LUTS severity in older men over time, independent of age and comorbidities. Results suggest LUTS and frailty share an underlying mechanism that is not targeted by existing LUTS interventions.

Awake tracheal intubation with the ProVu™ video stylet: a case series.

Management of the difficult airway is integral to peri-operative practice. The development of devices to simplify airway handling are changing our approach to tracheal intubation. We report a case series of three patients who underwent awake tracheal intubation with the ProVu™ video stylet (Flexicare Medical Ltd, Mountain Ash, UK). All three patients had predicted difficult airways, including: limited mouth opening secondary to radiotherapy; previous exenteration, hemi-maxillectomy and scapular free flap formation; and cervical fixation. Awake tracheal intubation was performed successfully in all three cases, with no complications reported. This is the first reported case series of the ProVu™ video stylet as an awake tracheal intubation device. The benefits and limitations of this video stylet are discussed.

Keratinocyte skin cancer risks for working school teachers: Scenarios and implications of the timing of scheduled duty periods in Queensland, Australia.

Relative keratinocyte skin cancer risks attributable to lifetime occupational and casual sunlight exposures of working school teachers are assessed across the state of Queensland for 1578 schools. Relative risk modeling utilizing annual ultraviolet exposure assessments of teachers working in different geographic locations and exposed during periods of measured daily playground duty times for each school were made for local administrative education districts by considering traditional school opening and closing hours, and playground lunchtime schedules. State-wide, basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) relative risk estimates varied by 24% for BCC and 45% for SCC. The highest relative risk was calculated for the state's north (sunshine) coast education district which showed that risk could increase by as much as 32% for BCC and 64% for SCC due to differences in teacher duty schedules. These results highlight the importance of playground duty scheduling as a significant risk factor contributing to the overall burden of preventable keratinocyte skin cancers in Queensland.

Body-site distribution of melanocytic nevi in young Australian children.

OBJECTIVE: To investigate the body-site distribution of melanocytic nevi (MN) with respect to habitually and intermittently sun-exposed surfaces. DESIGN: Cross-sectional survey of MN prevalence. SETTING: Townsville (19.16 degrees S), Queensland, Australia. PARTICIPANTS: Random sample of 506 1- to 6-year-old white children who were born and raised in Townsville (response, 87.6%). MAIN OUTCOME MEASURES: Site-specific counts and densities (number per square meter) of MN. RESULTS: Densities of MN of all sizes were highest on the outer forearms, followed by the outer upper arms, neck, and face. The feet had the lowest density of MN. Densities of MN of 2 mm or greater were highest on the upper arms and trunk. Boys had higher densities of MN of all sizes on the neck than girls (P = .002). Girls had higher densities of MN of 2 mm or greater on the lower legs (P = .006) and thighs (P = .005) than boys. Habitually sun-exposed body sites had higher densities, particularly of small MN, than relatively sun-protected sites, and larger MN were most prevalent on the intermittently exposed skin of the trunk. CONCLUSIONS: These children have higher total body and site-specific MN counts and densities than children from elsewhere, and their MN are distributed over the body in a way that implicates exposure to sunlight. As sun exposure in childhood and MN are risk factors for melanoma, intervention studies are required to determine if MN can be prevented.

Trends in registered incidence of oesophageal and stomach cancer in the Oxford region, 1974-88.

In the Oxford region 8,903 residents with oesophageal or gastric cancers were registered by the Oxford Cancer Registry between 1974 and 1988. For most of this time the Registry's practice was to code all adenocarcinomas of the oesophagus as adenocarcinomas of the cardia of stomach. There was a significant increase over time in the registered incidence of adenocarcinoma of the cardia, no appreciable change in the incidence of oesophageal cancers registered as such, and a decline in registered incidence of cancers of the stomach other than cardia.

Sun exposure at school.

There is strong evidence that sun exposure during childhood and adolescence plays an important role in the etiology of skin cancer, in particular cutaneous melanoma. Between the age of 6 and 18, most children and adolescents will spend around 200 days per year at school and may receive a substantial fraction of their daily total solar ultraviolet radiation (UVR) exposure while at school. This study estimated the average daily erythemally effective dose of 70 grade 8 students from a high school in Townsville during 5 school days in July 1998. Through UV measurements of shade locations at the school and a combination of frequency counts and a questionnaire of grade 8 students, it was possible to determine the fraction of solar UVR reaching under the shade structures during lunch breaks and routine outdoor activities. Also, a routinely operating UV-Biometer provided the annual variation of the daily dose that was used to calculate exposure levels for the 70 students. Our results suggest that up to 47% of the daily total dose fell within the time periods where students were outdoors during school hours. For students not seeking shade structures during the breaks (which usually was the case when involved in sport activities such as basketball or soccer), the average daily dose could have been as high as 14 SED (standard erythemal dose). Using results from the questionnaire of 70 grade 8 students, their average annual dose while at school was 414 SED or 2 SED per school day. However, the distribution of average daily erythemal effective dose per grade 8 student over the whole year showed that on 31% of all school days in 1998, this dose was exceeded. Because most previous attempts to change arguably poor sun-protective behavior of young Australian children and adolescents at school showed little success, one way of decreasing the amount of harmful UVR reaching unprotected skin is the more careful design of shade structures at schools.

Estimation of the annual solar UVR exposure dose of infants and small children in tropical Queensland, Australia.

The solar ultraviolet radiation (UVR) exposure of infants and small children was measured for 1 week using UVR-sensitive polysulfone film attached to the shoulder and chest of the subjects. For the infant study, shoulder and chest badges received similar exposures, while the 2 1/2-year-olds received higher exposures on the shoulder than on the chest. Also, the 2 1/2-year-olds generally received higher exposures than the infants. The median total daily exposures for both groups were 39 and 92 J/m2. The maximum total daily exposures measured were 640 J/m2 (chest) and 240 J/m2 (shoulder) for the infants and 2060 J/m2 (shoulder) and 840 J/m2 (chest) for the 2 1/2 year-olds. Using this exposure data, monthly and annual exposure doses were calculated for both groups and compared to similar data from the UK. The annual exposure dose for infants is 8.4 kJ/m2 or 84 standard erythemal dose (SED) for both shoulder and chest. The annual exposure dose for 2 1/2 year-old children is 39.4 kJ/m2 or 394 SED for the shoulder and 28.8 kJ/m2 or 288 SED for the chest. Apart from the generally higher annual exposure doses experienced by the infants and 2 1/2 year-old children in Townsville, the main difference to the UK is the almost nonexistent drop in monthly exposure doses between summer and winter in Townsville compared to the UK. In the UK, the winter-month exposure dose is only 0.5% of the summer-month dose. However, in Townsville it is around 40%.

Body weight-gain equivalents of selected foods.

A table of body weight-gain equivalents of selected foods has been developed to illustrate the weight gain to expect when eating single protions of a food above daily maintenance requirements for varying periods. The data were designed to discourage overeating habits, which result in obesity, and may be utilized to reinforce proper dietary habits in counseling of all individuals.

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.

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.