Real-world experience of nintedanib for progressive fibrosing interstitial lung disease in the UK

Background

Nintedanib slows progression of lung function decline in patients with progressive fibrosing (PF) interstitial lung disease (ILD) and was recommended for this indication within the United Kingdom (UK) National Health Service in Scotland in June 2021 and in England, Wales and Northern Ireland in November 2021. To date, there has been no national evaluation of the use of nintedanib for PF-ILD in a real-world setting.

Methods

26 UK centres were invited to take part in a national service evaluation between 17 November 2021 and 30 September 2022. Summary data regarding underlying diagnosis, pulmonary function tests, diagnostic criteria, radiological appearance, concurrent immunosuppressive therapy and drug tolerability were collected via electronic survey.

Results

24 UK prescribing centres responded to the service evaluation invitation. Between 17 November 2021 and 30 September 2022, 1120 patients received a multidisciplinary team recommendation to commence nintedanib for PF-ILD. The most common underlying diagnoses were hypersensitivity pneumonitis (298 out of 1120, 26.6%), connective tissue disease associated ILD (197 out of 1120, 17.6%), rheumatoid arthritis associated ILD (180 out of 1120, 16.0%), idiopathic nonspecific interstitial pneumonia (125 out of 1120, 11.1%) and unclassifiable ILD (100 out of 1120, 8.9%). Of these, 54.4% (609 out of 1120) were receiving concomitant corticosteroids, 355 (31.7%) out of 1120 were receiving concomitant mycophenolate mofetil and 340 (30.3%) out of 1120 were receiving another immunosuppressive/modulatory therapy. Radiological progression of ILD combined with worsening respiratory symptoms was the most common reason for the diagnosis of PF-ILD.

Conclusion

We have demonstrated the use of nintedanib for the treatment of PF-ILD across a broad range of underlying conditions. Nintedanib is frequently co-prescribed alongside immunosuppressive and immunomodulatory therapy. The use of nintedanib for the treatment of PF-ILD has demonstrated acceptable tolerability in a real-world setting.

251 PREVALENCE AND CHARACTERISTICS OF SWALLOWING/COMMUNICATION IMPAIRMENTS IN FRAIL OLDER ADULTS ATTENDING THE EMERGENCY DEPARTMENT: A RETROSPECTIVE COHORT STUDY

Background

The presentation of frail older adults to the Emergency Department (ED) may be complicated by swallowing and/or communication impairment. Adults with communication impairment may experience difficulty accessing healthcare. Dysphagia is associated with frailty irrespective of age and/or number of chronic diseases [1]. This study aims to determine the prevalence and characteristics of swallowing and/or communication impairments among frail older adults attending the ED.

Methods

A retrospective cohort study of consecutive ED attendees aged ≥ 75 years assessed by an interdisciplinary Gerontological ED team between October 2021 – February 2022 was conducted. A swallow/communication screening tool determined requirement for Speech and Language Therapy (SLT) referral. Data related to demographics and SLT interventions was extracted. Data analysis was completed using STATA Version 12. Ethical approval was obtained.

Results

Among 518 patients, 118 (23%) (mean age 82.4 (+/-6.4) years, 54% male) required SLT assessment. These patients had high rates of frailty (Median CFS= 6 (IQR 5-7), suspected delirium (4AT ≥ 4 in 45%), suspected malnutrition (MNA score 0-11 in 75%), and probable sarcopenia (SARC-F= ≥ 4 in 75%). Therapy Outcome Measurement Scales and the Functional Oral Intake Scale were used in this first episode of SLT care. Oropharyngeal dysphagia was identified for 43% (27% mild, 10% moderate, 3% moderate-severe, 3% severe), with 6% presenting with signs/symptoms of oesophageal dysphagia. Changes in baseline communication was identified for 57%; cognitive communication difficulties (38%), dysarthria (11%), dysphonia (8%). SLT intervention and management approaches were initiated in the ED.

Conclusion

Findings indicate a high prevalence of swallowing/communication impairment in frail older adults attending the ED. Future research should explore SLT outcomes at point of discharge to refine these swallowing/communication presentations.

Reference

1. Bahat G et al. Association between dysphagia and frailty in community-dwelling older adults. The Journal of Nutrition, Health & Ageing. 2019:23, 571–577.

Measurement and prevalence of adult physical activity levels in Arab countries

OBJECTIVES

This study aims to examine the reported prevalence of sufficient physical activity among adults in Arab countries and to determine the use of validated instruments for assessing physical activity.

STUDY DESIGN

This is a systematic literature review.

METHODS

This review follows recommendations outlined in the Meta-Analysis of Observational Studies in Epidemiology guidelines. The protocol for this study was preregistered with PROSPERO. Cross-sectional, cohort and intervention studies with a minimum of 300 adults aged ≥18 years assessing physical activity using a questionnaire or other self-report measure in the Arabic language were identified from seven electronic databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, CINAHL, PsycINFO, SPORTDiscu and PubMed). Databases were searched from 1st January 2008 to 17th September 2018. Descriptive analysis was performed using frequency and percentages. The prevalence of physical activity was calculated as the average prevalence for the reported percentages from the studies with similar tools.

RESULTS

Fifty studies involving 298,242 participants were included in this review. The mean (range) sample size was 5964.8.1 (323-197,681). Data were collected from participants in 16 of the 22 Arab countries. Great variation exists across the studies in determining whether adults were sufficiently active or not. Twenty studies reported usable data from the Global Physical Activity Questionnaire and the International Physical Activity Questionnaire (moderate & high categories). In these studies, prevalence of physical activity ranged from 34.2 to 96.9%. It was not possible to compare the other studies owing to variation in instruments used to assess physical activity and in the case definition used for 'physically active'.

CONCLUSIONS

This study highlights the need for wider reporting of physical activity and the adoption of valid and reliable instruments to support the development of evidence-informed policy and programmes at both country and regional level. International tools need to be correctly validated, or context-specific tools must be developed to accurately measure physical activity.

A Cross-Sectional Comparison of Direct Medical Care Costs among COPD and Asthma Patients Living in the Community in Northern Ireland

INTRODUCTION

Asthma and COPD are known to have significant health and economic consequences. Little is known about the costs of the latter in the UK. In this study we report the results of a comparison of the direct medical costs associated with COPD and asthma, where diagnoses are based on a robust prevalence study of a random sample of the Northern Ireland population.

METHODS

A two-stage survey was used to identify individuals with COPD and asthma. The diagnoses of asthma and COPD were based on patient history and lung function. Patients completed a detailed questionnaire covering healthcare utilization over the past 12 months, socioeconomic characteristics, impact of the disease on quality of life, and activities of daily living.

RESULTS

Forty-nine patients were diagnosed with COPD and 57 with asthma. Three asthma patients were excluded from the main analysis because they were thought to have atypical inpatient stays or other resource use. The mean direct healthcare cost for each COPD patient was estimated at pound171.69 ($US309; year 2000 value) per annum, significantly less than the average cost of asthma among the 54 analyzed of pound544.54 ($US980) [p < 0.05]. A correlation analysis revealed that among COPD patients, disease severity, defined by lung function, was a significant predictor of costs.

CONCLUSION

Community-based costs for asthma are greater than those for COPD; this may relate in part to a relative under-diagnosis of COPD (73.5% COPD vs 15.8% asthma). As anticipated, the cost of COPD increases as FEV(1) decreases. Further analysis will enable modeling of the cost consequences of both increased diagnosis and better management of COPD.

Prevalence of obstructive lung disease in a general population sample: the NICECOPD study

BACKGROUND

There are little data available on the prevalence of chronic obstructive pulmonary disease (COPD) in the United Kingdom. The Northern Ireland Cost and Epidemiology of Chronic Obstructive Pulmonary Disease (NICECOPD) study is a two-stage survey to examine the prevalence of obstructive lung disease in a general population sample in the Greater Belfast area.

METHODS

In stage one 4000 subjects aged 40-69 years were selected at random from the general population. They were posted a short screening questionnaire concerning respiratory symptoms. Respondents were divided into 'symptomatic' and 'asymptomatic' groups according to their responses. In stage two, a sample of symptomatic and asymptomatic subjects completed a more intensive assessment that included a detailed questionnaire on medical history, spirometry, skin allergy testing and serial peak flow measurements. Spirometric criteria for airflow obstruction were FEV1/FVC ratio of <70% with FEV1 < 80% predicted. Subjects were assigned diagnoses according to a pre-arranged protocol.

RESULTS

The survey was conducted from May 1999 to May 2001. There was a 67% response rate to the stage 1 screening questionnaire and 1330 responders were identified as being eligible to take part in stage 2. In total, 722 subjects completed a detailed assessment (50.8% Male, symptomatic, n = 326; asymptomatic, n = 396). COPD was diagnosed in 12.3% (8.8, 15.8) of the symptomatic and 2.2% (0.8, 3.6) of the asymptomatic group. The estimated prevalence of obstructive lung disease in the total population age 40-69 years was 14.4%: 6.3% COPD; 7.2% asthma; 0.9% with indeterminate airflow obstruction. In men, the prevalence of COPD varied from 4.9% in those aged 40-49 years to 12.3% in those aged 60-69 years and in women, varied from 1.4% in 40-49 years of age to 4.5% in 60-69 years.

CONCLUSION

The data suggest that COPD and asthma are common conditions in the general population and should inform future plans to address the burden of disease.

Auditing a new lung cancer service

The Adelaide and Meath Hospital (AMNCH) is a new hospital, with the respiratory service established in 1999. We report on our experience with lung cancer in this short time. We conducted a retrospective chart audit, identifying patients from the Oncology Nurse patient list, of lung cancer cases diagnosed in 2001-2002. In 2001, 47 cases were diagnosed, with 71 cases diagnosed in 2002. Time to tissue diagnosis was 14.8, 2-46 (mean, range, one subject skewing the data) days. Diagnosis by tissue type was as follows: non-small cell carcinoma (NSCLC) n=92 (77.9%), small cell lung carcinoma (SCLC) n=17 (14.4%), mesothelioma n=2 (17%), carcinoid n=1 (0.8%) and no tissue diagnosis n=6 (5.1%). Staging of NSCLC: stage 1a n=3 (3.2%), stage 1b n=6 (6.5%), stage 2a n=5 (5.4%), stage 2b n=2 (2.2%), stage 3a n=10 (10.9%), stage 3b n=22 (23.9%) and stage 4 n=44 (47.8%). Staging of SCLC: limited stage n=5 (29.4%), extensive stage n=12 (70.6%). Positive emission tomography (PET) was employed in the staging of 22 patients. In these patients PET up-staged the disease in 8 patients, and management was unchanged in 8 patients. We conclude that 1. the relatively new respiratory service in AMNCH is handling increasing numbers of lung cancer cases, 2. cases are diagnosed within an acceptable time-frame, 3. rate of tissue diagnosis is comparable to national figures, 4. most patients present with advanced disease and 5. PET is a useful imaging modality for detection of cancer spread in selected patients.

Assessment of the quality of neonatal echocardiographic images transmitted by ISDN telephone lines

OBJECTIVE

To assess the quality of echocardiographic images from neonates transmitted over Integrated Service Digital Network 2 (ISDN2) channels.

DESIGN

Echocardiographic images were viewed live in real time either by a direct video link or by transmission over the commercial network, using one, two, or three ISDN2 channels. The order of the viewing formats was random and four observers marked each view for potential for provision of complete diagnostic information and quality.

SETTING

Cardiology department of tertiary referral centre for paediatric cardiac services. ISDN lines were positioned in two nearby rooms. Telephone connection was through the commercial network and video connection by a direct video cable.

PATIENTS

10 neonates were studied (weight 2600 to 3900 g). In each, nine echocardiographic studies were undertaken to assess imaging (M mode and cross sectional) and Doppler (spectral and colour) quality.

RESULTS

No significant differences were found in diagnostic ability between the different formats for M mode, colour, or spectral Doppler studies. For cross sectional imaging the diagnostic information and image quality increased with increasing numbers of ISDN channels. With six channels there was little difference from the directly connected images.

CONCLUSIONS

In echocardiographic assessment of the newborn, one or two ISDN2 channels will transmit images of satisfactory quality in many situations but three or more channels are necessary to ensure minimum degradation of the live image.

Influence of colour Doppler echocardiography on the ultrasonic assessment of congenital heart disease: a prospective study

OBJECTIVE

To evaluate the additional information provided by colour Doppler in the ultrasonic assessment of congenital heart disease.

PATIENTS AND METHODS

A prospective study of 215 children (age range 1 day-16 years) presenting with clinical signs of congenital heart disease.

RESULTS

Colour Doppler was essential for the diagnosis of an anomalous left coronary artery and altered the management of a patient initially diagnosed as having cardiomyopathy. Colour Doppler provided extra information, but without major impact on management, in the following: the diagnosis of ventricular septal defects associated with other defects, of multiple ventricular septal defects, of anomalous pulmonary venous drainage, and of mild mitral regurgitation; the demonstration of site of coarctation, of stenotic or hypoplastic pulmonary artery branches, of unobstructed flow through a right atrial membrane, and of left ventricle to right atrium regurgitation; the assessment of the width of the duct and of flow through the patent foramen ovale in transposition and tricuspid atresia; the differentiation of pulmonary atresia from critical pulmonary stenosis and the measurement of maximum velocity of tricuspid regurgitation.

CONCLUSIONS

Ideally all patients should undergo colour Doppler studies before cardiac surgery to ensure a more accurate diagnosis. However, since the additional information provided does not affect the management in most patients, machines without colour Doppler can provide a satisfactory service in paediatric cardiology centres in countries where resources are limited.

Two-dimensional echocardiography in infants with persistent truncus arteriosus

Two-dimensional echocardiography was used to study a consecutive series of 13 infants with persistent truncus arteriosus. In all a single great artery with the long upward course characteristic of the aorta was shown. This great artery could be identified as a persistent truncus arteriosus by the recognition of a branch arising from its ascending part (10 out of 13) or of more than three semilunar valve cusps (5/13). These criteria allowed the correct diagnosis to be reached in 12 of the 13 infants.