CAT Score Research Articles

Impact of modified pulmonary rehabilitation on morbidity due to chronic obstructive pulmonary disease in rural area

Background: Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease which leads to a significant reduction in the quality of life of patients. Pulmonary rehabilitation (PR) is a multidisciplinary intervention to improve the quality of life of COPD patients. In our study, we have tried to see the effect of modified PR program to improve the quality of life in COPD patients of rural area with limited resources. Objective: The aim of this study was to study the effect of modified PR on the lung functions and quality of life of COPD patients. Materials and Methods: It was an analytical and interventional study where 30 patients of COPD were included. The total duration of study was of 12 weeks which was divided in two phases. The first phase (pharmacotherapy-[PT] Phase) comprises 6 weeks when patients were given only PT as per the Global Initiative for chronic obstructive lung disease guidelines, and subsequent phase (PT plus PR phase) comprises the next 6 weeks when patients were provided PT plus modified PR which included once a week supervised chest physiotherapy at hospital, dietary advice, and psychiatric evaluation followed by the same advice at home and were checked through the telephone weekly. Between the two phases, the severity of dyspnea (COPD assessment test [CAT] score and Modified Medical Research Council [MMRC] grade), quality of life (Saint George questionnaires [SGRQs]), psychological aspects (Patient Health Questionnaire 9 [PHQ9]), and lung functions (spirometry – forced expiratory volume in 1 s [FEV1], forced vital capacity [FVC], and FEV1/FVC) and exercise capacity (6-min walk test [6MWT]) were compared and analyzed. Results: We found a significant improvement after PR in SGRQ (P ≤ 0.001), CAT score (P ≤ 0.001), MMRC grade (P ≤ 0.001), PHQ9 score (P ≤ 0.001), and 6MWT (P ≤ 0.001) but no statistical significant improvement in spirometry parameters. Conclusion: Modified home-based PR program can be an effective therapy to improve quality of life of COPD patients in rural areas with limited resources.

Adoption and adherence to chronic obstructive pulmonary disease GOLD guidelines in a primary care setting.

Objectives:Over 380 million people in the world live with chronic obstructive pulmonary disease, and it is the third leading cause of death in the United States. Despite updated guidelines, there may be significant variations in diagnosis and management of chronic obstructive pulmonary disease at a primary care level. The aim of the study was to examine primary care physician management of chronic obstructive pulmonary disease in two community clinics.Methods:After approval from the Institutional Review Board, a retrospective chart review was done among all patients with the diagnosis of chronic obstructive pulmonary disease in two community clinics. Baseline demographics, utilization of spirometry, exacerbation history and home oxygen use were also obtained.Results:Chart reviews of 101 patients were completed (52 male and 49 female) in two outpatient primary care provider offices (Office A: 66 patients and Office B: 35 patients). None of the patients had validated measures of dyspnoea such as CAT or mMRC scores. Only 21% (22/101) of the patients had formal pulmonary function test testing done, and of those who had pulmonary function tests, 31.5% of patients were incorrectly diagnosed and mislabelled as chronic obstructive pulmonary disease. Pharmacotherapy for chronic obstructive pulmonary disease was not in alignment with GOLD guidelines, with only 42% of patients on an inhaler regimen that included a long-acting muscarinic antagonist.Conclusion:There is suboptimal use of pulmonary function test in a primary care setting for diagnosis of chronic obstructive pulmonary disease and substantial errors in diagnosis. There is virtually no use routinely of validated symptom scales for diagnosis of chronic obstructive pulmonary disease. There is substantial variance in pharmacotherapy, and regimens routinely do not follow GOLD guidelines.

Subterranean Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease.

Pulmonary rehabilitation (PR) has been recommended as an integral part of treatment for patients with chronic obstructive pulmonary disease (COPD). Climate therapy in salt mine chambers has been found of benefit in chronic respiratory diseases. The study compares long-term effects of underground PR in the Wieliczka Salt Mine with that conducted on the surface. There were 42 COPD patients enrolled in the study, with FEV1/FVC <0.7 predicted and post-bronchodilator reversibility <12%, randomized into pulmonary rehabilitation in the mine (Group I, n=23) and PR on the surface (Group II, n=19). The outcomes consisted of lung function variables, exercise performance (6-min walk test - 6MWT), dyspnea (mMRC), and compliance with the disease and quality of life (COPD Assessment Test - CAT) and BODE index, compared at baseline (P0), end (P1), and 6months after pulmonary rehabilitation (P2). The findings were that subterranean pulmonary rehabilitation significantly reduced CAT score (p<0.001), BODE index (p=0.004), and dyspnea (mMRC) (p=0.001) and increased distance in 6MWT (p<0.001), compared with its equivalent conducted on the surface. Further, beneficial effect of subterranean treatment was sustained during the following half a year as opposed to the effect noticed on patients treated on the surface. We conclude that subterranean pulmonary rehabilitative treatment reduces symptoms and improves exercise tolerance to a greater and sustained extent, compared to a similar treatment on the surface, in patients suffering from COPD.

Hidden morbidity: The results of a collaborative community chronic obstructive pulmonary disease screening initiative.

Chronic obstructive pulmonary disease (COPD) often goes unrecognised resulting in people living with the disease without a diagnosis. We investigated the characteristics, symptom burden and flow of participants in a community COPD screening initiative. Screening was undertaken during four events over 2-weeks. Participants completed symptom questionnaires and FEV-1/FEV-6 measurement. Patients with FEV-1 <80% predicted or FEV-1 ≥ 80% predicted and FEV-1/FEV-6 <0.72 were considered 'screen-positive' and invited to attend a 1-stop diagnostic clinic. Two hundred and fifty-seven individuals participated (mean ± SD age 58 ± 16, 24% current smokers). Seventy-seven were screen-positive with 27 ultimately attending a 1-stop clinic and 18 having confirmed COPD. The CAT score of participants with COPD was 19.3 ± 11.4. Two-thirds had moderate airflow obstruction on spirometry. The diagnosis rate in this screening initiative was comparable to trials of systematic case finding. Further research is required to explore the broader clinical impact of COPD screening.

Using Patient-reported Outcomes Measurement Information System Measures to Understand the Relationship Between Improvement in Physical Function and Depressive Symptoms.

This investigation determined whether improved physical function and decreased pain would reduce depressive symptoms using the Patient-reported Outcomes Measurement Information System (PROMIS). This cohort study analyzed PROMIS Depression, Physical Function, and Pain Interference CAT scores from 3,339 patients presenting to a tertiary orthopaedic center. Patients demonstrating at least a-five point (effect size, 0.5) improvement in PROMIS Physical Function between consecutive visits were eligible for inclusion. Patients presented, on average, with Physical Function and Pain Interference scores nearly one SD worse than population averages and Depression scores that approximated the normal population. Improved Physical Function and Pain Interference scores demonstrated no correlation with change in Depression scores (r = -0.13; r = 0.25). Substantial early improvement in PROMIS Physical Function scores is not associated with change in PROMIS Depression scores. PROMIS Depression scores likely reflect underlying mental health rather than situational depressive symptoms. Prognostic, level III.

Physical function computer adaptive test outcomes in diabetic lumbar spine surgical patients

BACKGROUND CONTEXTDiabetes is a highly prevalent comorbid condition among patients undergoing spine surgery. Several studies have used legacy patient-reported outcome measures to implicate diabetes as a predictor of increased disability, pain, and decreased physical function and quality of life following spine surgery. The effect of diabetes on postoperative physical function has not yet been studied using the PROMIS Physical Function Computer Adaptive Test (PF CAT). PURPOSETo understand the effect of diabetes on physical function outcomes among patients undergoing lumbar spine surgery, as reported by the PF CAT. STUDY DESIGN/SETTINGA retrospective cohort study was performed at a single university-based spine clinic. PATIENT SAMPLEPatients who underwent lumbar spine surgery between October 1, 2013 and April 26, 2018 with both PF CAT and Oswestry Disability Index (ODI) scores available for review. OUTCOME MEASURESPROMIS PF CAT. Secondary measures of disability included the ODI. METHODSPF CAT and ODI questionnaires were administered to patients via electronic tablets. Data from these questionnaires were collected prospectively, and retrieved from a university database. Wilcox tests, Exact Wilcox tests, linear regression models, and descriptive analytics were applied. RESULTSPatients meeting inclusion criteria included 233 nondiabetic patients and 65 diabetic patients. Mean PF CAT scores among diabetics were lower than those of nondiabetics at all time-points from preoperative through 12 months postoperative, with significance found at both 6 months (p=.035) and 12 months (p=.039) postoperative. Mean ODI scores among diabetics were significantly higher than those of nondiabetics at 3 months (p=.018) and 12 months (p=.027) postoperative. By 12 months postoperative, a smaller proportion of diabetics reached PF CAT and ODI minimum clinically important difference thresholds when compared to nondiabetics. CONCLUSIONSDiabetes is associated with lower PF CAT scores up to one year following lumbar spine surgery. However, many of these patients achieve meaningful improvement in physical function during this time. The PF CAT is consistent with legacy outcome measures in assessing outcomes in diabetic patients undergoing lumbar spine surgery, with an added benefit of decreased patient burden.

The relationship between steps of 6MWT and COPD severity: a cross-sectional study.

Background and objectiveThe distance of 6-minute walk test (D6MWT) has been widely used in the assessment of functional status in patients with COPD, while very little attention has been paid to the role of steps of 6-minute walk test (S6MWT). The purpose of this study was to investigate the relationship between S6MWT and other physiologic parameters of COPD.Patients and methodsSeventy patients with stable COPD were enrolled consecutively in this cross-sectional study. Pulmonary function tests, including spirometry, impulse oscillometry (IOS) and the single-breath diffusing capacity of the lungs for carbon monoxide (DLCO), were carried out at rest. Quality of life was assessed by health-related quality of life (HRQoL) questionnaires, including modified Medical Research Council dyspnea scale (mMRC), St George’s Respiratory Questionnaire, Chronic Obstructive Pulmonary Disease Assessment Test (CAT) and Clinical Chronic Obstructive Pulmonary Questionnaire. Both steps and distance were measured in the following 6-minute walk test (6MWT).ResultsBoth S6MWT and D6MWT showed significant correlation with spirometry, IOS, DLCO parameters and HRQoL questionnaires score. Both pre- and post-6MWT inspiratory capacity showed significant correlation with S6MWT (ρ=0.338, P=0.004; ρ=0.359, P=0.002, respectively), whereas did not correlate with D6MWT (ρ=0.145, P=0.230; ρ=0.160, P=0.189, respectively). In stepwise multiple regression analysis, mMRC grade, age and CAT score remained as significant predictors in the final model for D6MWT (adjusted R2=0.445, P<0.01). DLCO and CAT score remained as significant predictors in the final model for S6MWT (adjusted R2=0.417, P<0.01).ConclusionS6MWT is efficient in the evaluation of functional status and quality of life in COPD and has significant correlation with various parameters indicating disease severity. Additionally, S6MWT might be better in predicting lung hyperinflation in COPD compared with D6MWT.

Exploratory Study Examining A Composite Index Measuring Sarcopenia and Anxiety in COPD – Relationship with Frailty, Disease Severity, Exertional Dyspnea and Quality of Life.

Recent models of palliative care for COPD shifted from care-provision at the end of life, to emphasizing early integration when symptom burden significantly impairs quality of life (QOL). Sarcopenia was recently shown to associate with reduced exercise capacity, functional performance and health status. Similarly, anxiety is related with poorer QOL, more exacerbations, more re-hospitalizations, prolonged length of stay and higher mortality in COPD. We hypothesize that a bi-dimensional index comprising measurement of sarcopenia and anxiety – SARA score, can identify frailer patients with high symptom burden and significantly diminished QoL, for early palliative care. A feasibility study comprising 33 subjects with stage 2-4 COPD are recruited. The SARA scale comprises the SARC-F questionnaire that measures sarcopenia, as well as the anxiety domain of the Hospital Anxiety and Depression Scale (HADS). A composite score derived from the two indices forms the SARA score that ranges 2-6 points. Correlational analyses examined relationships between SARA and markers of frailty (Fried Index, FRAIL questionnaire), exertional dyspnea (eMRCD scale), QoL (Chronic Respiratory Questionnaire, CRQ) and disease severity (CAT score). Univariate analyses were employed to compare the mean score of the above variables between 2 groups (SARA 3 vs SARA <3). Subjects had a mean age of 70. 25 (75.8%) have stage 3 and 4 COPD. SARA score demonstrates moderate correlation with eMRCD, CAT, FRAIL and Fried scores, as well as the fatigue, emotional function and mastery domain of the CRQ (all p<0.05). Additionally, it highly correlated with the depression domain of HADS (HADS-D) (p<0.001). Univariate analyses demonstrate that SARA 3 is significantly associated with greater eMRCD, CAT score, FRAIL, Fried’s index, HADS-D and the three domain of CRQ listed above. Preliminary analysis suggest that the SARA may help identify subjects with greater frailty, more severe disease, higher psychological morbidity and poorer QoL, for early palliative multi-disciplinary interventions.

Influence of comorbid heart disease on dyspnea and health status in patients with COPD - a cohort study.

PurposeThe aim of this study was to examine the changing influence over time of comorbid heart disease on symptoms and health status in patients with COPD.Patients and methodsThis is a prospective cohort study of 495 COPD patients with a baseline in 2005 and follow-up in 2012. The study population was divided into three groups: patients without heart disease (no-HD), those diagnosed with heart disease during the study period (new-HD) and those with heart disease at baseline (HD). Symptoms were measured using the mMRC. Health status was measured using the Clinical COPD Questionnaire (CCQ) and the COPD Assessment Test (CAT; only available in 2012). Logistic regression with mMRC ≥2 and linear regression with CCQ and CAT scores in 2012 as dependent variables were performed unadjusted, adjusted for potential confounders, and additionally adjusted for baseline mMRC, respectively, CCQ scores.ResultsMean mMRC worsened from 2005 to 2012 as follows: for the no-HD group from 1.8 (±1.3) to 2.0 (±1.4), (P=0.003), for new-HD from 2.2 (±1.3) to 2.4 (±1.4), (P=0.16), and for HD from 2.2 (±1.3) to 2.5 (±1.4), (P=0.03). In logistic regression adjusted for potential confounding factors, HD (OR 1.71; 95% CI: 1.03–2.86) was associated with mMRC ≥2. Health status worsened from mean CCQ as follows: for no-HD from 1.9 (±1.2) to 2.1 (±1.3) with (P=0.01), for new-HD from 2.3 (±1.5) to 2.6 (±1.6) with (P=0.07), and for HD from 2.4 (±1.1) to 2.5 (±1.2) with (P=0.57). In linear regression adjusted for potential confounders, HD (regression coefficient 0.12; 95% CI: 0.04–5.91) and new-HD (0.15; 0.89–5.92) were associated with higher CAT scores. In CCQ functional state domain, new-HD (0.14; 0.18–1.16) and HD (0.12; 0.04–0.92) were associated with higher scores. After additional correction for baseline mMRC and CCQ, no statistically significant associations were found.ConclusionHeart disease contributes to lower health status and higher symptom burden in COPD but does not accelerate the worsening over time.

The effect of exercise combined with bailing capsules on chronic stationary obstructive pulmonary disease

Objective To observe and compare the effect of Cordyceps sinensis (bailing) capsules combined with weight-bearing breathing exercises, and weight-bearing breathing exercises combined with tiotropium bromide and seretide, on patients with stable but moderate-to-severe chronic obstructive pulmonary disease (COPD). Methods Sixty-three patients with moderate-to-severe COPD were randomly divided into an observation group and a control group. Both groups performed weight-bearing breathing exercises, supplemented in the observation group with the oral administration of bailing capsules. The control group instead inhaled tiotropium bromide and seretide. Six-minute walking distance, the COPD assessment test (CAT scores) and concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-α (TNF-α) were observed after 1 (T1), 30 (T2) and 58 (T3) days of the treatments. Results At T1 there were no significant differences between the two groups in any of the measurements (P≤0.05). At T2, there were still no significant differences except that a significant decrease in IL-8 and TNF-α levels was observed in the control group. At T3 the average CAT scores had decreased significantly in both groups compared to before the treatment but there was no significant difference between the two groups. In the observation group, the average 6MWT distance had increased significantly compared to before the treatment and compared to the control group, where there was no significant improvement. The average IL-6, IL-8 and TNF-α readings of the control group were significantly lower than those of the observation group at T3 and compared to before the treatment. No significant changes in those indicators were observed in the observation group at T3. Conclusions Bailing capsules combined with weight-breathing exercises are more effective for relieving dyspnea symptoms and improving exercise capacity than weight-breathing exercises combined with tiotropium bromide and seretide. However, in controlling airway inflammation and airway hyper-responsiveness, the triple inhalation combined with weight-bearing breathing exercises is more effective. Key words: Bailing capsules; Tiotropium bromide; Seretide; Pulmonary rehabilitation training; Chronic obstructive pulmonary disease

Preliminary study on the evaluation of pneumoconiosis

Objective: Select the appropriate disease assessment indicators, formulate the comprehensive evaluation group of pneumoconiosis patients, and explore the role of the comprehensive evaluation grouping in the clinical evaluation of pneumoconiosis, and provide the basis for the prognosis of pneumoconiosis. Methods: Combined with clinical symptoms, pulmonary function, pneumoconiosis stage, acute exacerbation and complications, a comprehensive assessment of pneumoconiosis patients was established.138 newly diagnosed pneumoconiosis patients were divided into low risk group, middle risk group and (very) high risk group. The patients were followed up by telephone to record their health status and quality of life within one year after discharge from hospital. Analysis of the relationship between the comprehensive assessment group of patients with pneumoconiosis and symptom score, pulmonary function, pneumoconiosis stage, acute exacerbation and complications. The relationship between the comprehensive assessment group of pneumoconiosis patients and the risk events (the number of visits, hospitalization, mechanical ventilation, death cases in one year) and CAT score were analyzed. Results: There were significant differences in clinical symptoms, pulmonary function injury, pneumoconiosis stage, acute exacerbation and complications among patients in low risk group, middle risk group and (very) high risk group (P<0.01) . With the increase of comprehensive assessment score, CAT score increased, the risk events increased, the difference was statistically significant (P<0.01) . Spearman correlation analysis showed that the comprehensive assessment group was significantly correlated with the number of visits, hospitalization, mechanical ventilation, deaths and CAT score in one year. Conclusion: Combined with clinical symptom assessment, pulmonary function assessment, chest imaging assessment, acute exacerbation assessment, and complication assessment, the pneumoconiosis patients' comprehensive assessment group formulated can evaluate the severity of pneumoconiosis patients, and make a more accurate and comprehensive judgement of the disease.

Effect on Ubiquinone MDA Level of Plasma, FEV1% and CAT Score Stable COPD Patients

Background: Oxidation stress showed clinical evidence of increased in patients with COPD and contribute functionally to expiratory air flow&#x0D; resistance, so the body requires exogenous antioxidants to inhibit oxidative stress. This study was conducted to assess whether there is influence&#x0D; on levels of MDA plasma ubiquinone, FEV1% and patients with stable COPD CAT score.&#x0D; Methods: This study is a clinical trial experimental with pretest and post-test design which aims to determine the effect of plasma MDA, FEV1%&#x0D; and patients with stable COPD CAT score. Subjects consist of 30 patients with stable COPD who came to Pulmonary outpatient clinic of Moewardi&#x0D; hospital Surakarta during June to August 2016. The sample was taken by consecutive sampling. Subjects were divided into two group, the&#x0D; treatment group (n=15) received additional therapy ubiquinone 1x150mg/day and the control group (n=15) received standard therapy. MDA&#x0D; plasma levels, FEV1% and CAT scores were measured at the time of control pulmonary outpatient clinic.&#x0D; Results: Giving ubiquinone can significantly lower CAT score better in the treatment group compared to the control group. There were no&#x0D; statistically significant difference (p=0.744) in plasma MDA treatment group (1.37 ± 0.11) compared to controls (1,39 ± 0.16). There were no&#x0D; statistically significant difference between (p=0.276) the decline in FEV1% treatment group (43.28 ± 20.59) and the control group (36.01 ± 14.73).&#x0D; Conclusion : The use of Ubiquinone in decreasing CAT score for stable COPD patients. There was lowering effect in MDA plasma but there&#x0D; was no excalation value in FEV1%.

Effects of Mangosteen pericarp Extract to Clinical Improvements, The Plasma Level of IL-6 and Malondialdehyde in Acute Exacerbation of COPD Patients

Background: Amplification of inflammation in acute exacerbation of chronic obstructive pulmonary disease (COPD) increases inflammatory&#x0D; mediators and oxidative stress in the airways, pulmonary and systemic circulation that are characterized by increased plasma level of IL-6&#x0D; and MDA, resulting in worsening of clinical symptoms. Xanthones in mangosteen pericarp have anti-inflammatory and antioxidant effects,&#x0D; potentially as an adjuntive therapy in acute exacerbations of COPD.&#x0D; Methods: The aim of this study was to determine the effect of mangosteen pericarp extract to clinical improvements, plasma level of IL-6 and&#x0D; MDA of acute exacerbation COPD patients. A clinical trial of experimental with pretest and posttest was conducted on 34 acute exacerbation&#x0D; of COPD patients in Dr. Moewardi Hospital Surakarta and Dr. Ario Wirawan Lung Hospital Salatiga from April until May 2016. The sample&#x0D; was taken by consecutive sampling. Subjects were divided by randomized double blind technique into the treatment group (n=17) received&#x0D; mangosteen pericarp extract 2x1100mg/day and control group (n = 17) received placebo. Clinical improvements were measured in CAT&#x0D; score and length of stay. CAT score, plasma level of IL-6 and MDA were measured on admission and at discharge. Length of stay based&#x0D; on the number of days of care in hospitals.&#x0D; Results: There was significant difference (p=0,011) towards decreased of IL-6 plasma level between treatment group (-2,17 ± 3,46 pg/&#x0D; mL) and control group (+1,67 ± 6,81 pg/mL). There were no significant difference towards decreased of length of stay (p=0,34) between&#x0D; treatment group (4,12 ± 1,54 days) and control group (5,24 ± 2,49 days), towards decreased of CAT score (p=0,252) between treatment&#x0D; group (-19,18 ± 3,96) and control group (-18,24 ± 2,75), and towards decreased of MDA plasma level (p=0,986) between treatment group&#x0D; (+0,03 ± 0,36μmol/L) and control group (+0,35 ± 1,58).&#x0D; Conclusions: The addition of mangosteen pericarp extract 2x1100mg/day during hospitalization was significantly lowered plasma levels&#x0D; of IL-6, but were not significant in lowering the CAT score, shortening the length of stay, and reducing the increase in plasma level of MDA.

The Effect of Opiocephalus striatus Extract on Leptin, Adiponectin and COPD Assessment Test Scores on Stable COPD Patients Experiencing Muscle Wasting

Background: Muscle wasting is one of extrapulmonary manifestations that occur in 20-40% of patients with COPD as a result of an&#x0D; imbalance of protein synthesis and degradation, where it is thought to be a consequence of chronic inflammation. One of the factor that affect&#x0D; muscle wasting is nutritional factor. The purpose of this study is to prove that nutrition therapy can improve inflammation (measured by levels&#x0D; of leptin, adiponectin) further improve muscle wasting and improve the quality of life of patients COPD with muscle wasting.&#x0D; Method: The clinical study design is pre and post auto control quasi experimental in stable COPD patients with comorbid muscle wasting.&#x0D; The experiment was conducted in Pulmonary Outpatient Clinic Dr. Saiful Anwar Hospital and Physiology Laboratory of Medical Faculty&#x0D; Brawijaya University. Chronic obstructive pulmonary disease was diagnosed based on 2014 GOLD criteria. Muscle wasting was diagnosed&#x0D; through examination of the BIA. Levels of leptin and adiponectin was measured using ELISA method, and quality of life was assessed&#x0D; using CAT score. We measured BIA, Leptin, Adiponectin and CAT in 32 COPD patients with muscle wasting, before and after 12 weeks&#x0D; supplementation of Opiocephalus striatus extract 3x1000mg/day.&#x0D; Results: There were significant increased of BMI (p = 0.046), no significant increase of FFMI (p = 0506), a significant decrease in leptin&#x0D; levels (p = 0.000) and a significant increase in adiponectin levels (p = 0.048) and improvement of quality of life (score CAT) (p = 0.000) ) after&#x0D; administration of opiocephalus striatus extract for 12 weeks.&#x0D; Conclusion: Suplementation of Opiocephalus striatus extract for 12 weeks can improve BMI, decrease levels of leptin and increase level&#x0D; of adiponectin resulting in improvement of quality of life in stable COPD patients with muscle wasting.

Once-daily long-acting beta₂-agonists/inhaled corticosteroids combined inhalers versus inhaled long-acting muscarinic antagonists for people with chronic obstructive pulmonary disease.

Three classes of inhaler medication are used to manage chronic obstructive pulmonary disease (COPD): long-acting beta₂-agonists (LABA); long-acting muscarinic antagonists (LAMA); and inhaled corticosteroids (ICS). To encourage patient adherence, two classes of medication are often combined in a single medication device; it seems that once-daily dosing offers greatest convenience to patients and may markedly influence adherence. To compare a once-daily combination of inhaled corticosteroid and long-acting beta₂-agonist inhalers (ICS/LABA) versus inhaled long-acting muscarinic antagonists alone (LAMA) for people with chronic obstructive pulmonary disease (COPD). We performed an electronic search of the Specialised Register of the Cochrane Airways Group (14 May 2018), ClinicalTrials.gov (14 May 2018), and the World Health Organization International Clinical Trials Registry Platform (20 September 2017), then a search of other resources, including reference lists of included studies and manufacturers' trial registers (10 October 2017). Two pairs of review authors screened and scrutinised selected articles. We included randomised controlled trials (RCTs) comparing once-daily administered ICS/LABA and LAMA in adults with COPD. Two review authors independently extracted data and assessed risk of bias in each study. We analysed dichotomous data as random-effects odds ratios (ORs) and continuous data as mean differences (MDs), both with 95% confidence intervals (95% CIs), using Review Manager 5. We included two studies with 880 participants. We identified one ongoing trial with planned recruitment of 80 participants. Included studies enrolled participants with both partially reversible and non-reversible COPD and baseline mean per cent predicted (%pred) forced expiratory volume in one second (FEV₁) of 43.4 to 49.6. Both studies lasted 12 weeks. Both studies used the same combination of inhaled ICS/LABA (fluticasone furoate and vilanterol 100/25 mcg once daily; FF/VI) versus LAMA (18 mcg tiotropium; TIO). They were published as full articles, and neither study was at low risk of bias in all domains.Compared to the TIO arm, results for pooled primary outcomes for the FF/VI arm were as follows: mortality: OR 0.20, 95% CI 0.02 to 1.73, 880 participants (deaths reported only in the TIO arm), very low-quality evidence; COPD exacerbation (requiring short-burst oral corticosteroids or antibiotics, or both): OR 0.72, 95% Cl 0.35 to 1.50, 880 participants, very low-quality evidence; pneumonia: reported in both studies only during treatment with FF/VI: OR 6.12, 95% Cl 0.73 to 51.24, 880 participants, very low-quality evidence; and total serious adverse events: OR 0.96, 95% Cl 0.50 to 1.83, 880 participants, very low-quality evidence. None of the pneumonias were fatal. Compared to the TIO arm, we found no statistically significant difference for pooled secondary outcomes, including St George's Respiratory Questionnaire (SGRQ) mean total score change; hospital admissions (all-cause); disease-specific adverse events; mean weekly rescue medication use (results available from only one of the studies); and mean weekly percentage of rescue-free days for FF/VI. We found no statistically significant differences between ICS/LABA and LAMA for improvement in symptoms measured by the COPD Assessment Test (CAT score) nor for FEV₁ (change from baseline trough in 24-hour weighted mean on treatment day 84). Many pooled estimates lacked precision. Data for other endpoints such as exacerbations leading to intubation and physical activity measures were not available in included trials. Based on analysis of primary and secondary outcomes, we are uncertain whether once-daily ICS/LABA, combined in one inhaler, has a different efficacy or adverse effect profile compared to LAMA for treatment of people with COPD. However, the current review is based on only two trials with the main focus on primary outcomes other than those considered in this review. The short follow-up period and the very low quality of evidence limit our confidence in the result and increase uncertainty. Further trials of longer duration are needed. Current evidence is not strong enough to demonstrate important differences between inhalers in terms of effects, nor to establish that once-daily fluticasone/vilanterol 100/25 mcg and tiotropium 18 mcg are equivalent.

Health effects in COPD smokers who switch to electronic cigarettes: a retrospective-prospective 3-year follow-up.

BackgroundHealth effects of electronic cigarette (EC) use in patients with chronic obstructive pulmonary disease (COPD) are largely unexplored.AimWe present findings from a long-term prospective assessment of respiratory parameters in a cohort of COPD patients who ceased or substantially reduced conventional cigarette use with ECs.MethodsWe prospectively re-evaluated COPD exacerbations, spirometric indices, subjective assessments (using the COPD Assessment Tool [CAT] scores), physical activity (measured by the 6-minute walk distance [6MWD]), and conventional cigarette use in EC users with COPD who were retrospectively assessed previously. Baseline measurements prior to switching to EC use were compared to follow-up visits at 12, 24, and 36 months. Age- and sex-matched regularly smoking COPD patients who were not using ECs were included as reference (control) group.ResultsComplete data were available from 44 patients. Compared to baseline in the EC-user group, there was a marked decline in the use of conventional cigarettes. Although there was no change in lung function, significant improvements in COPD exacerbation rates, CAT scores, and 6MWD were observed consistently in the EC user group over the 3-year period (p<0.01). Similar findings were noted in COPD EC users who also smoked conventional cigarettes (“dual users”).ConclusionThe present study suggests that EC use may ameliorate objective and subjective COPD outcomes and that the benefits gained may persist long-term. EC use may reverse some of the harm resulting from tobacco smoking in COPD patients.

PROMIS: a valid and efficient outcomes instrument for patients with ACL tears.

The current study compares the Patient Reported Outcomes Information System Physical Function Computer Adaptive Test (PROMIS PF CAT) to traditional knee PRO instruments in a healthy population undergoing surgery for ACL injuries with the following objectives: (1) identify and determine the strength of any correlations between the scores of PROMIS PF CAT and current knee PROs or their subscales that measure physical function; (2) evaluate PROMIS PF CAT's test burden; and (3) determine if PROMIS PF CAT has any floor or ceiling effects in this population. Patients indicated for ACL surgery completed the Short Form-36 Physical Function (SF-36 PF), Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale (Marx), the EuroQol 5-dimensions Questionnaire (EQ-5D), and PROMIS PF CAT. Correlations between PROs were defined as follows: High (≥ 0.7); high-moderate (0.61-0.69); moderate (0.4-0.6); moderate-weak (0.31-0.39); and weak (≤ 0.3). Floor or ceiling effects were considered significant if 15% or more patients reported the lowest or highest possible total score, respectively. 100 patients participated with a mean age of 26years (range 11-57). The PROMIS PF CAT demonstrated high correlations with SF-36 PF (r = 0.82, p < 0.01), EQ-5D (r = - 0.70, p < 0.01) KOOS ADL (r = 0.74, p < 0.01), and KOOS Sport (r = 0.70, p < 0.01). There were no ceiling or floor effects for PROMIS PF CAT (0%). The mean number of items completed for the PROMIS PF CAT was 4.2 (median 4; range 4-11). The PROMIS PF CAT shows a high correlation with commonly employed PROs that also measure physical function with low test burden and without ceiling effects in this relatively young and healthy population.

Subtle Cavus Deformities

Category: Sports Introduction/Purpose: Lateral ankle ligament injuries are common conditions accounting for 25% of musculoskeletal injuries. Prior reports have found increased risk of failed lateral ankle reconstruction in those with a subtle cavus deformity, and therefore, correcting the deformity is often advocated. However, other studies have been unable to identify subtle cavus deformity as a clear risk factor for recurrent injury. The purpose of this study was to 1) compare PROMIS physical function (PF), pain interference (PI), and depression scores in patients with subtle cavus deformities to those without deformity who underwent lateral ankle ligament reconstruction, 2) compare PROMIS scores in allograft and modified Brostrom-Gould (BG) reconstructions in those with subtle cavus, and 3) to evaluate for any post-operative complications in those with subtle cavus. Methods: PROMIS CAT scores were prospectively obtained from patients evaluated in a specialty foot and ankle clinic between February 2015 and December 2017. Using CPT codes, 145 patients who underwent lateral ankle ligament reconstruction were identified. Exclusion criteria consisted of less than three-month follow-up, incomplete PROMIS scores, or multiple surgeries unrelated to the reconstruction during the follow-up period. A total of 78 patients were included in the study. Pre- and post-operative PROMIS PF, PI, and depression were collected. Patients were then divided into two groups: subtle cavus foot (n=23) and non-cavus foot (n=55). A foot was considered cavus based on physical exam and previously published radiographic parameters. The cavus group was further subdivided into allograft reconstruction and BG reconstruction. Post-operative complications were also recorded. Student t-tests were used to evaluate for differences in PF, PI, and depression t-scores in cavus vs. non-cavus groups as well as allograft vs. BG. Results: The average follow-up was 28.59+/-13.27 weeks in the cavus and 29.77+/-16.15 weeks in the non-cavus group (p=0.76). There were no differences in pre-operative PF, PI, or depression t-scores between the two groups (p&gt;0.05). The cavus group had significantly better post-operative PF compared to the non-cavus group (49.24+/-8.14 vs. 43.17+/-6.64, p=0.001). PI was also better in the cavus group (51.12+/-8.33) compared to the non-cavus group (55.09+/-9.45), however not statistically significant (p=0.08). There were no differences in post-operative depression (p=0.58). When subdividing the cavus group, allograft reconstruction (49.49+/-7.48) had better post-operative PI t-scores compared to BG (57.17+/-8.16, p=0.04). In the cavus group, there were no instances of recurrent instability; one patient required a repeat ankle arthroscopy for debridement. One patient in the non-cavus group developed recurrent instability. Conclusion: Patients with subtle cavus deformity undergoing lateral ankle ligament reconstruction had significantly higher post-operative PROMIS PF t-scores compared to those without deformity and a trend towards improved pain post-operatively. When subdividing the subtle cavus group, allograft reconstruction demonstrated better PI scores post-operatively, and thus may be a more favorable technique in patients who have a subtle cavus deformity. Though longer follow-up is needed, our study suggests that patients with subtle cavus deformities may not require a more complex reconstruction with osteotomies to correct their deformity in order to achieve clinically meaningful improved outcomes.

Effect of influenza and 23-valent pneumococcal polysaccharide vaccinations on elderly with chronic obstructive pulmonary diseases: a community-based intervention study

Objective: To explore the effect of influenza and 23 valent pneumococcal polysaccharide pneumococcal vaccinations on symptom-improvement among elderly with chronic obstructive pulmonary diseases (COPD). Methods: Data was gathered from 4 communities in 3 National Demonstration Areas set for comprehensive prevention and control of chronic non- communicable diseases in Chongqing city and Ningbo city respectively, from November 2013 to October 2014. The communities were selected by cluster sampling and divided into 4 groups: (1) injected influenza vaccines; (2) injected with pneumococcal vaccines; (3) received both of the two vaccines; (4) the control group that without any intervention measures. All the subjects aged from 60 to 75 were selected to fill in demographic information questionnaire and receive (COPD assessment test, CAT) scores twice, before intervention and 1 year after the vaccination. SAS 9.4 software was used to analyze the change of symptoms and CAT scores before and after the intervention program and comparing the improvement on symptoms among the elderly people under study. Results: A total of 1 244 subjects with nearly same baseline conditions after the propensity score matching, were involved in this study. CAT scores appeared as Median=21 (IQR: 17-26) at baseline. The CAT scores appeared as Median=18 (IQR: 14-24), decreasing in all the 3 vaccinated groups, one year after the intervention program (influenza vaccines, matching t test, t=-6.531, P=0.403; pneumococcal vaccines, Wilcoxon test, H=-9 623, P<0.001; combined vaccine vaccines, matching t test, t=-10.803, P<0.001). However, in the control group, no obvious change was observed (Wilcoxon H=1 167, P=0.403). Proportions of impacts at high or very high levels all decreased in the 3 intervention groups, while little change was observed in the control group. Outcomes from the Factorial analysis suggested that influenza vaccination could improve the general conditions and symptoms including cough, chest tightness, dyspnea, physical activities, and stamina. Pneumococcal vaccination appeared more effective on all of symptoms and indicators. Conclusion: Pneumococcal and influenza vaccination seemed helpful for elderly people suffering COPD to improve the general health condition.

A modified 6-form Tai Chi for patients with COPD

Background and objective24-form Tai Chi is a traditional exercise popular among old people in China, but it has some complex movements beyond of capabilities of patients with COPD. This study was to modify and simplify 24-form Tai Chi and evaluate effects of the modified Tai Chi on lung function, exercise capacity, dyspnea symptom and health status in patients with COPD. MethodsA two-step procedure was applied: an initial qualitative research module consisting of focus group discussion, expert consultation and patient interviews was conducted to simplified and modified 24-form Tai Chi for patients with COPD. Then, a randomized controlled trial consisting of 60 patients with II to IV COPD was conducted to evaluate effects of the modified Tai Chi on lung function (FEV1%), exercise capacity (Six minutes walking distance,6MWD), dyspnea symptom (Modified Medical Research Council Scale, mMRC) and health status (COPD Assessment Test, CAT). All measures were obtained at baseline, 3-month follow-up and 9-month follow-up. ResultsA new simpler 6-form Tai Chi that combining characteristics of COPD, the experts’ wisdom and patients’ needs was developed. Patients with COPD can grasp it in about 3 h and participants showed 86.0% adherence to the Tai Chi training and no negative accidents occurred. Generalized estimating equations (GEE) showed that there were significant differences in FEV1%, 6MWD and CAT scores between modified Tai Chi (MTC) group and the control group over time (model group × time interaction χ2 = 13.68, P < 0.001; χ2 = 192.39, P < 0.001;χ2 = 6.05, P = 0.014, respectively), however, no statistical significance in mMRC scores was found between the 2 groups over time (model group × time interaction χ2 = 3.54, P = 0.06). The baseline of FEV1%,6MWD, mMRC scores and CAT scores are significant covariates for lung function, exercise capacity, dyspnea symptom and health status, respectively (χ2 = 149.43, P < 0.001; χ2 = 5.78, P = 0.016; χ2 = 66.71, P < 0.001; χ2 = 81.83, P < 0.001, respectively). ConclusionsThis modified 6-form Tai Chi routine is easy to grasp, easy to adhere to, safe to practice and effective to improve lung function, exercise capacity, health status and to prevent dyspnea symptom from getting worse for patients with COPD and it can be recommended as a suitable exercise therapy for them.