Cost-effectiveness of the COPD Patient Management European Trial home-based disease management program

Purpose

Efficient management of COPD represents an international challenge. Effective management strategies within the means of limited health care budgets are urgently required. This analysis aimed to evaluate the cost-effectiveness of a home-based disease management (DM) intervention vs usual management (UM) in patients from the COPD Patient Management European Trial (COMET).

Methods

Cost-effectiveness was evaluated in 319 intention-to-treat patients over 12 months in COMET. The analysis captured unplanned all-cause hospitalization days, mortality, and quality-adjusted life expectancy. Costs were evaluated from a National Health Service perspective for France, Germany, and Spain, and in a pooled analysis, and were expressed in 2015 Euros (EUR). Quality of life was assessed using the 15D health-related quality-of-life instrument and mapped to utility scores.

Results

Home-based DM was associated with improved mortality and quality-adjusted life expectancy. DM and UM were associated with equivalent direct costs (DM reduced costs by EUR −37 per patient per year) in the pooled analysis. DM was associated with lower costs in France (EUR −806 per patient per year) and Spain (EUR −51 per patient per year), but higher costs in Germany (EUR 391 per patient per year). Evaluation of cost per death avoided and cost per quality-adjusted life year (QALY) gained showed that DM was dominant (more QALYs and cost saving) in France and Spain, and cost-effective in Germany vs UM. Nonparametric bootstrapping analysis, assuming a willingness-to-pay threshold of EUR 20,000 per QALY gained, indicated that the probability of home-based DM being cost-effective vs UM was 87.7% in France, 81.5% in Spain, and 75.9% in Germany.

Conclusion

Home-based DM improved clinical outcomes at equivalent cost vs UM in France and Spain, and in the pooled analysis. DM was cost-effective in Germany with an incremental cost-effectiveness ratio of EUR 2,541 per QALY gained. The COMET home-based DM intervention could represent an attractive alternative to UM for European health care payers.

Spontaneous regression of metastatic squamous cell lung cancer

Spontaneous regression (SR) of cancer is a rare but confirmed spectacular phenomenon, and it is even rarer in the context of advanced NSCLC. It is essential to understand this phenomenon in order to elucidate the nature of neoplastic disease and develop new treatment methods.

Design of a numerical model of lung by means of a special boundary condition in the truncated branches

BACKGROUND

The need for a better understanding of pulmonary diseases has led to increased interest in the development of realistic computational models of the human lung.

METHODS

To minimize computational cost, a reduced geometry model is used for a model lung airway geometry up to generation 16. Truncated airway branches require physiologically realistic boundary conditions to accurately represent the effect of the removed airway sections. A user-defined function has been developed, which applies velocities mapped from similar locations in fully resolved airway sections. The methodology can be applied in any general purpose computational fluid dynamics code, with the only limitation that the lung model must be symmetrical in each truncated branch.

RESULTS

Unsteady simulations have been performed to verify the operation of the model. The test case simulates a spirometry because the lung is obliged to rapidly perform both inspiration and expiration. Once the simulation was completed, the obtained pressure in the lower level of the lung was used as a boundary condition. The output velocity, which is a numerical spirometry, was compared with the experimental spirometry for validation purposes.

CONCLUSIONS

This model can be applied for a wide range of patient-specific resolution levels. If the upper airway generations have been constructed from a computed tomography scan, it would be possible to quickly obtain a complete reconstruction of the lung specific to a specific person, which would allow individualized therapies.

Monitoring Noninvasive Ventilation in Patients with Obesity Hypoventilation Syndrome: Comparison between Ventilator Built-in Software and Respiratory Polygraphy

<b><i>Background:</i></b> Polygraphy (PG) remains the standard method of assessing noninvasive ventilation (NIV) effectiveness. Built-in software (BIS) of recent NIV equipment provides estimates of some ventilator parameters, but their usefulness is unclear. <b><i>Objectives:</i></b> To assess the reliability of BIS compared with PG in a cohort of obesity hypoventilation syndrome (OHS) patients on NIV. <b><i>Methods:</i></b> Thirty stable OHS patients on NIV were evaluated in an outpatient setting with simultaneous PG and BIS recordings. The automated apnea-hypopnea event index (EI_AUT) provided by Rescan and manual scoring based on available traces obtained from the software (EI_BIS) were compared with manual PG scoring (EI_PG). Each manual scoring was separately performed by 2 trained operators. Agreement between the 2 operators was assessed using the kappa coefficient. Pearson correlation and Bland-Altman plots were used to evaluate agreement between EI_AUT, EI_BIS, and EI_PG. <b><i>Results:</i></b> Twenty-six cases were valid for analysis (age ±61 years, 17 men). All patients were ventilated in the spontaneous/timed mode (mean inspiratory positive airway pressure 17 ± 3 cm H₂O, mean expiratory positive airway pressure 10 ± 3 cm H₂O). Cohen's kappa agreement between the operators was 0.7 for EI_BIS and 0.84 for EI_PG. EI_BIS showed good correlation with EI_PG (<i>r</i>² = 0.79 <i>p</i> < 0.001), better than scoring provided by the automated analysis (<i>r</i>² = 0.71, <i>p</i> < 0.006 for EI_AUT vs. EI_PG). <b><i>Conclusions:</i></b> In stable OHS patients on NIV, unattended home-based monitoring using Rescan is reproducible and reliable to assess quality of ventilation when compared with PG. In addition, manual scoring of events using data obtained with this device is more consistent than software-based automated analysis.

An international randomized study of a home-based self-management program for severe COPD: the COMET

Introduction

Most hospitalizations and costs related to COPD are due to exacerbations and insufficient disease management. The COPD patient Management European Trial (COMET) is investigating a home-based multicomponent COPD self-management program designed to reduce exacerbations and hospital admissions.

Design

Multicenter parallel randomized controlled, open-label superiority trial.

Setting

Thirty-three hospitals in four European countries.

Participants

A total of 345 patients with Global initiative for chronic Obstructive Lung Disease III/IV COPD.

Intervention

The program includes extensive patient coaching by health care professionals to improve self-management (eg, develop skills to better manage their disease), an e-health platform for reporting frequent health status updates, rapid intervention when necessary, and oxygen therapy monitoring. Comparator is the usual management as per the center’s routine practice.

Main outcome measures

Yearly number of hospital days for acute care, exacerbation number, quality of life, deaths, and costs.

Poncet's disease mimicking rheumatoid arthritis in a patient with suspected Crohn's disease

Poncet's disease is a rarely reported entity with an unknown pathogenesis. However, because it has a very favorable prognosis with antituberculosis drugs, we believe it should be considered as a differential diagnosis for patients with fever and polyarthritis of unknown cause, particularly if active tuberculosis is suspected.

Community-acquired bacteremic Streptomyces atratus pneumonia in animmunocompetent adult: a case report

INTRODUCTION

Streptomyces spp. are aerobic, Gram-positive bacteria of the order Actinomycetales, known for their ability to produce antimicrobial molecules such as streptomycin. Pneumonia due to Streptomyces is considered to be rare and limited to immunocompromised patients. Streptomyces spp. are only rarely associated with invasive systemic infections. To our knowledge, we report the first documented case of community-acquired Streptomyces atratus bacteremic pneumonia in an immunocompetent patient.

CASE PRESENTATION

We describe a case of Streptomyces atratus bacteremic pneumonia in an otherwise healthy, 77-year-old Spanish man. Streptomyces identified by 16S ribosomal RNA sequencing grew in multiple blood cultures and bronchoalveolar lavage cultures. The infection resolved completely after treatment with imipenem and amoxicillin/clavulanic acid for 2 months.

CONCLUSIONS

The majority of cases reported in the literature make reference to the difficulty of determining the pathogenic role of Streptomyces spp. Usually considered a contaminant, the pathogenic role of Streptomyces spp. is easier to confirm when the species is isolated from a catheter tip and, in the case of blood cultures, in more than one sample with a high count of colonies. To our knowledge, we report the first documented case of Streptomyces atratus bacteremic pneumonia in an immunocompetent patient. As the experience is limited, further studies are needed to better understand the interpretation of the isolates of the genus Streptomyces; the predisposing factors for infection; and the course, treatment, and evolution of these infections.

Desmoplastic small round cell tumor of the lung: A case report and literature review

Desmoplastic small round cell tumor (DSRCT) is a rare, aggressive and malignant tumor that is characterized by nests of small tumor cells surrounded by a cellular and vascular collagenous stroma and predominantly affects young adolescent males. This tumor most commonly originates in the abdomen; however, in rare cases, DSRCT can originate in other body regions. The main manifestations of DSRCT are chest pain and respiratory symptoms, and patients' average survival after diagnosis is less than two years. In this report, we describe a case involving DSRCT of the lung that proved to be difficult to diagnose, and we conduct a literature review.

From cytology to histology: diagnosis of a relapsed mediastinal lymphoma by endobronchial ultrasound transbronchial histological needle

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is highly accurate in diagnosing mediastinal lymphadenopathies of lung cancer and benign disorders, with the advantage that it is a minimally invasive technique, unlike open surgery and mediastinoscopy. However, the diagnostic accuracy of EBUS-TBNA for the diagnosis of lymphoma in patients with mediastinal lymphadenopathy is not well defined. The lack of tissue architecture obtained by cytological needles decreases the diagnostic accuracy for diagnosis and subtyping of de novo and relapsed mediastinal lymphomas. We present the first described case in the literature of an anaplastic large cell lymphoma relapsed, diagnosed on tissue fragments obtained by EBUS-TBNA with the particularity of using a histological needle.

Impact of environmental air pollutants on disease control in asmathic patients

PURPOSE

Asthmatics are adversely affected by the presence of air pollutants, the concentrations of which can nowadays be measured. However, the utility of this information in clinical practice has not been defined in a group of asthmatics in stable condition. Our objective was to determine what impact the level of air pollutants had on the control of their asthma and the degree of airway inflammation.

METHODS

We performed a cross-sectional study of adult asthmatics in stable condition. From the regional environmental authority, we obtained the concentrations of ambient nitric oxide (NO2), ozone (O3), suspended particulate matter up to 10 micrometers in diameter (PM10) and sulphur dioxide (SO2) at fixed geographical points. Disease control was assessed using asthma control test (ACT) scores, and airway inflammation using fraction of exhaled nitric oxide (FeNO) values. Correlation and linear regression studies were performed using ACT scores as the dependent variable.

RESULTS

The study included 99 asthmatics, aged 39 years (SD 8), 55% women. Mean ACT value was 17.2 (SD 6.5), and FeNO 33.7 (SD 16). Of the pollutants studied, only NO2 was correlated with ACT scores (CC = 0.45, p < 0.001). We found no relationship between pollutants and airway inflammation. Multivariate analysis showed that ACT score was predicted by ambient air NO2 concentration and, to a lesser extent, mean FeNO.

CONCLUSIONS

Information on the concentration of ambient NO2 in our environment can help the clinician to interpret the evolution of asthmatic patients.

Profile of patients treated with omalizumab in routine clinical practice in Spain

BACKGROUND

Omalizumab is indicated in patients with severe allergic asthma not controlled by high-dose inhaled glucocorticoids and long-acting beta-agonists. Few data are available on the profile of patients treated with this drug in routine clinical practice in Spain.

OBJECTIVE

To describe the profile of patients with severe allergic asthma treated with omalizumab and the course of the disease after a period of treatment.

METHODS

Retrospective, multicentre study, recording the data on patients of either sex and ≥12 years with uncontrolled severe allergic asthma, previously treated with omalizumab. Data were evaluated in relation to pulmonary function, symptoms, quality of life, and concomitant anti-asthma treatment before the prescription of omalizumab and at the time of the study visit.

RESULTS

214 patients were evaluable (mean age=48.2±17.7 years; mean age at the time of diagnosis=26.6±16.5 years). 90.7% had experienced exacerbations the year before receiving omalizumab, and the mean total IgE level was 273±205.4IU/ml. The mean monthly dose was 380.5±185.4mg. Compared with the baseline situation, differences were observed after treatment with omalizumab in mean FEV1 (62.7±15.9% vs. 70.8±18.7%), in the proportion of patients requiring oral corticosteroids (47.7% vs. 14.0%), and in the ACQ and AQLQ scores. 32.7% of the patients received doses not recommended by the Summary of Product Characteristics (SPC).

CONCLUSIONS

Profile of asthmatic patients treated with omalizumab predominantly corresponds to uncontrolled severe asthma cases, in accordance with SPC's indications. The results of the study suggest a favourable clinical course similar to that observed in other studies.

Spirometry. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR)

Spirometry is the main pulmonary function test and is essential for the evaluation and monitoring of respiratory diseases. Its utility transcends the field of Respiratory Medicine, is becoming increasingly important in primary care and applications have even been described outside the field of respiratory diseases. This document is therefore intended to serve as support for all health professionals who use spirometry, providing recommendations based on the best scientific evidence available. An update of the indications and contraindications of the test is proposed. The document sets out recommendations on the requirements necessary for conventional spirometers and portable office equipment, as well as on spirometer hygiene and quality control measures. Spirometric parameters that must be considered, performance of manoeuvres, criteria for acceptability and repeatability of measurements and their quality control are defined. A proposal is also established for presentation of the results and an evaluation and interpretation is proposed according to information generated in recent years. Finally, lines of adaptation and integration of spirometry in the field of new technologies are considered.

Pulmonary function testing prior to reduced intensity conditioning allogeneic stem cell transplantation in an unselected patient cohort predicts posttransplantation pulmonary complications and outcome

Pretransplant pulmonary function tests (PFTs) have been checked mostly in myeloablative allogeneic stem cell transplantation (Allo-SCT). Their value in the setting of reduced intensity conditioning Allo-SCT (Allo-RIC) has been less explored. We retrospectively evaluated the predictive value of PFTs on posttransplant pulmonary complications (PPC) and outcomes in 195 consecutive Allo-RIC patients, based on fludarabine plus busulphan or melphalan. PFT parameters included forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1/FVC ratio, total lung capacity (TLC), residual volume, and diffusion capacity for carbon monoxide (DLCo) corrected for the hemoglobin levels. Pretransplant PFTs abnormalities were observed in 130 patients (66%). The most frequent abnormalities were abnormal DLCO (n = 83, 44%), followed by FEV1/FVC (n = 75, 38%) and FVC (n = 47, 24%). The abnormalities were severe in 25 (13%) patients, moderate in 65 (33%) and mild in 40 patients (21%). Multivariate analysis showed that TLC was significantly associated with PPC, nonrelapse mortality and overall survival (OS), (HR 4.2, 95% CI. 2-8.5; HR 3.8, 95% CI. 1.7-8.5; HR 2.3, 95% CI. 1.3-4.1, respectively, P = 0.01), while abnormal FVC had a negative impact on PPC and OS (HR 1.8, 95% CI. 0.98-3.6, P = 0.06 and HR 1.7, 95% CI. 1.1-2.6, P = 0.008). This study emphasizes the valuable role of PFTs in identifying patients at risk for PPC, NRM, and lower OS in the Allo-RIC setting.

[Electrical impedance tomography in acute lung injury]

Electrical impedance tomography has been described as a new method of monitoring critically ill patients on mechanical ventilation. It has recently gained special interest because of its applicability for monitoring ventilation and pulmonary perfusion. Its bedside and continuous implementation, and the fact that it is a non-ionizing and non-invasive technique, makes it an extremely attractive measurement tool. Likewise, given its ability to assess the regional characteristics of lung structure, it could be considered an ideal monitoring tool in the heterogeneous lung with acute lung injury. This review explains the physical concept of bioimpedance and its clinical application, and summarizes the scientific evidence published to date with regard to the implementation of electrical impedance tomography as a method for monitoring ventilation and perfusion, mainly in the patient with acute lung injury, and other possible applications of the technique in the critically ill patient. The review also summarizes the limitations of the technique and its potential areas of future development.

Nocturnal home pulse oximetry: variability and clinical implications in home mechanical ventilation

BACKGROUND

Nocturnal home pulse oximetry (NHPO) provides information by measuring a series of variables: time spent with SaO(2) <90% expressed as percentage (T90) or in minutes (Tm90), mean SaO(2) (MnS), and lowest SaO(2) (LwS.) The presence of significant nocturnal desaturation has been proposed as a parameter in decision making with regard to initiating home mechanical ventilation (HMV) or monitoring HMV effectiveness. However, there is limited information on the possible variability of the test, and this could influence the interpretation of results.

OBJECTIVES

To explore the variability between 2 consecutive measurements of NHPO and to determine clinical applications in HMV.

METHODS

The patients presented diseases susceptible to HMV treatment and were enrolled in stable condition without respiratory failure. NHPO was conducted on 2 consecutive nights. The variables analyzed were: T90, Tm90, Mns, and LwS. The coefficient of variation (CV), a concordance coefficient (CC), and the Bland-Altman method were used in order to explore the variability.

RESULTS

We studied 40 cases. Two were excluded, and the remaining 38 were aged 58 ± 16 years (19 males). Eighteen were receiving HMV. CV values exceeded 100% for T90 and Tm90 and were below 5% for MnS and LwS. The CC for T90, Tm90, and LwS showed confidence intervals with lower limits below 0.5, while for MnS the value was 0.88 (0.79-0.93).

CONCLUSIONS

There is a wide variability in NHPO recordings for T90, Tm90, and LwS, so a single determination to detect nocturnal desaturation may not be valid for decision making; the parameter with the least interindividual variability and intraindividual variability was MnS.

Confiabilidade do teste da caminhada de seis minutos em pacientes com miastenia gravis generalizada

Este estudo objetivou determinar a confiabilidade do teste da caminhada de seis minutos (TC6M) como um teste de capacidade funcional em pacientes com miastenia gravis generalizada (MG). Foram selecionados 11 pacientes com MG - 5 homens, 6 mulheres - com idade de 55±9 anos, avaliados inicialmente quanto à função fulmonar, que se submeteram a três TC6M em dias diferentes. Durante e/ou após cada teste foram medidas freqüência cardíaca e saturação de oxigênio (por oxímetro portátil), sensação de dispnéia (pela escala de Borg) e distância percorrida. Nos três testes as distâncias percorridas foram 498 m, 517 m e 520 m (respectivamente 99%, 103% e 104% do valor predito). Em média, a freqüência cardíaca, dispnéia e saturação de oxigênio mostraram comportamento constante nos três testes. Foram encontradas alta confiabilidade relativa, com coeficiente de correlação interclasse maior que 0,90 entre os testes (TC6M1-TC6M2, 0,960; TC6M1-TC6M3, 0,945; e TC6M2-TC6M3, 0,970) e confiabilidade absoluta de 4%, 3,5% e 4,8%, com reprodutibilidade de 11%, 9,8% e 13,4%, respectivamente para o primeiro, segundo e terceiro testes. Os limites superiores e inferiores de concordância e o valor médio das médias das diferenças (bias) calculados pelo teste de Bland-Altman mostraram-se clinicamente aceitáveis. Conclui-se que o TC6M se mostrou seguro, confiável e reprodutível, podendo ser aplicado para avaliação e seguimento da tolerância ao exercício em pacientes com MG generalizada.

[Economic cost of treating the patient with asthma in Spain: the AsmaCost study]

OBJECTIVE

This analysis of the cost of asthma in Spain includes both direct health care costs and indirect costs arising from illness.

PATIENTS AND METHODS

Prospective, 12-month observational cohort study of adult patients with asthma diagnosed according to the guidelines of the Global Initiative for Asthma (GINA) and the adapted Spanish criteria (GEMA). We recorded information on health care resources utilized (medications, medical visits, emergency care, hospital admissions, and tests) and indirect costs (patient travel or transfer costs and workdays lost).

RESULTS

A total of 627 patients throughout Spain were studied. Of these, 21.2% had intermittent asthma, 24.6% mild asthma, 27.6% moderate asthma, and 26.6% severe asthma. The total societal cost of asthma (including indirect costs) was euro1726 (95% confidence interval [CI], euro1314-euro2154) per patient annually. Indirect costs accounted for 11.2% of the total. The cost to the National Health Service was euro1533 (95% CI, euro1133-euro1946) per patient annually. The cost of asthma was higher for patients older than 65 years (euro2079) and for those with more severe disease (euro959 for intermittent asthma; euro1598, mild asthma; euro1553, moderate asthma; and euro2635 severe asthma). Based on these findings, the total annual cost of asthma in Spain is estimated to be euro1480 million (95% CI, euro382-euro2565 million) for patients with demonstrated bronchial hyperreactivity and euro3022 million (95% CI, euro2472-euro3535 million) for patients diagnosed based on symptoms alone.

CONCLUSIONS

The average annual cost of asthma in adults in Spain comes to euro1726 per patient, considering both direct and indirect costs. The average annual cost per patient to the National Health Service is euro1533.

Carbon dioxide rebreathing in non-invasive ventilation. Analysis of masks, expiratory ports and ventilatory modes

BACKGROUND AND AIM

Carbon dioxide (CO2) rebreathing is a complication of non-invasive ventilation (NIV). Our objectives were to evaluate the ability of masks with exhaust vents (EV) to avoid rebreathing while using positive pressure (PP) NIV with different levels of expiratory pressure (EPAP). Concerning volume-cycled NIV, we aimed to determine whether cylindrical spacers located in the circuit generate rebreathing.

MATERIALS AND METHODS

5 healthy volunteers were evaluated. Bi-level PP was used with 3 nasal and 2 facial masks with and without EV. Spacers of increasing volume attached to nasal hermetic masks were evaluated with volume NIV. Inspired CO2 fraction was analyzed.

RESULTS

Rebreathing was zero with all nasal masks and EPAP levels. Using facial masks 1 volunteer showed rebreathing. There was no rebreathing while using all the spacers.

CONCLUSIONS

In healthy volunteers, nasal and facial masks with EV prevent rebreathing. In addition, the use of spacers did not generate this undesirable phenomenon.

[High frequency of anemia in COPD patients admitted in a tertiary hospital]

INTRODUCTION

Anemia is related to chronic and inflammatory diseases. Moreover, it is a factor of worse outcome in heart failure or myocardial infarction. Despite the importance of hemoglobin as a globular oxygen carrying protein, there are few studies on anemia and chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To determine the frequency and the characteristics of the anemia in COPD patients admitted to a tertiary hospital within a one year period.

METHODS

Anthropometric and clinical data, tobacco habit, lung function tests, arterial blood gases and a basic study of anemia (BSA) were collected from digital clinical files.

RESULTS

A total of 177 patients were enrolled. Mean age was 70 (range 44-95), FEV1 was 35 (15%) and hemoglobin (Hb) 136(22) g/dl. Sixty-six (37%) patients had chronic respiratory failure (CRF) and 59 (33%) were receiving long-term oxygen therapy. A total of 56 (31%) had anemia (Hb < 130 g/dl in men or < 120 g/dl in women) with a mean Hb of 111(13). Anemia was normocytic normochromic in 32 cases (58%). BSA was obtained in 24 patients (42.85%) and showed that 10 patients (41%) had anemia of chronic disease, 6 patients (25%) had iron deficiency and 8 (34%) had other causes. It should be mentioned that 35 patients (53%) had CRF had anemia but only 8 patients had erythrocytosis (4.5%).

CONCLUSION

Anemia was frequent in these patients and was an underdiagnosed comorbidity.

[Risk factors for mortality in chronic obstructive pulmonary disease]

OBJECTIVE

Although the factors predictive of survival in patients with chronic obstructive pulmonary disease (COPD) have been widely studied, full consensus has yet to be reached. The objective of this study was to further clarify how lung function parameters, exercise tolerance, and quality of life influence survival in patients with COPD.

PATIENTS AND METHODS

This prospective study included 60 patients diagnosed with COPD. At the start of the study, patients underwent respiratory function tests, exercise testing, and 6-minute walk test. They also answered a chronic respiratory disease questionnaire to measure health-related quality of life. Follow-up lasted 7 years.

RESULTS

Five of the 60 patients withdrew from the study. Twenty-six of the remaining 55 patients (47%) died during the study. Univariate Cox regression analysis showed a correlation between survival and age, degree of obstruction, inspiratory capacity, carbon monoxide diffusing capacity, and peak exercise tolerance. No correlation was found between survival and body mass index, PaO2, PaCO2, total lung capacity, residual volume, maximal respiratory pressures, 6-minute walk distance, or health-related quality of life. Age, degree of obstruction (measured as the ratio of forced expiratory volume in 1 second to forced vital capacity after administration of bronchodilator), and maximum minute ventilation in the exercise test were introduced initially in the multivariate Cox stepwise regression analysis, but only maximum minute ventilation remained in the final model (relative risk, 0.926; P< .001).

CONCLUSIONS

Our findings show that peak exercise tolerance is the best predictor of survival in patients with COPD.

Airway inflammation in the elite athlete and type of sport

BACKGROUND

The prevalence of asthma and bronchial hyper-responsiveness is greater in elite athletes than in the general population, and its association with mild airway inflammation has recently been reported.

OBJECTIVE

To study the relationship between the type of sport practised at the highest levels of competition (on land or in water) and sputum induction cell counts in a group of healthy people and people with asthma.

MATERIAL AND METHODS

In total, 50 athletes were enrolled. Medical history, results of methacholine challenge tests and sputum induced by hypertonic saline were analysed

RESULTS

Full results were available for 43 athletes, who were classified by asthma diagnosis and type of sport (land or water sports). Nineteen were healthy (10 land and 9 water athletes) and 24 had asthma (13 land and 11 water athletes). Although the eosinophil counts of healthy people and people with asthma were significantly different (mean difference 3.1%, 95% CI 0.4 to 6.2, p = 0.008), analysis of variance showed no effect on eosinophil count for either diagnosis of asthma or type of sport. However, an effect was found for neutrophil counts (analysis of variance: F = 2.87, p = 0.04). There was also a significant correlation between neutrophil counts and both duration of training and bronchial hyper-responsiveness among athletes exposed to water (Spearman's rank correlations, 0.36 and 0.47, p = 0.04 and 0.04, respectively).

CONCLUSIONS

Elite athletes who practice water sports have mild neutrophilic inflammation, whether or not asthma is present, related to the degree of bronchial hyper-reactivity and the duration of training in pool water.

Diagnostic utility of inflammatory biomarkers in asthma: exhaled nitric oxide and induced sputum eosinophil count

BACKGROUND

Even though an inflammatory process is known to be the underlying cause of asthma, diagnosis is based on clinical history, reversible airway obstruction and bronchial hyperresponsiveness according to international guidelines. The fraction of exhaled nitric oxide (FE(NO)) and induced sputum eosinophil count (Eos%) have been used as non-invasive inflammatory biomarkers.

OBJECTIVES

The aim of this study was to compare the sensitivity and specificity of FE(NO), Eos% and spirometry and to assess whether their combined use in clinical practice would improve diagnostic yield.

METHODS

In 50 patients with asthma symptoms we performed spirometry, a methacholine challenge test, FE(NO) measurement and assessment of Eos% in induced sputum. The standard diagnosis of asthma followed the guidelines of the Global Initiative for Asthma.

RESULTS

Twenty-two of the 50 patients were diagnosed with asthma. The sensitivity and diagnostic accuracy were higher for FE(NO) measurement (77%; area under the receiver operating curve [AUC], 0.8) than for spirometry (22%; AUC, 0.63). The sensitivity and specificity of Eos% in induced sputum were 40% and 82%, respectively, and the diagnostic accuracy of Eos% was lower (AUC, 0.58). When both inflammatory biomarkers were used together specificity increased to 76%.

CONCLUSIONS

The diagnostic accuracy of FE(NO) measurement was superior to that of the standard diagnostic spirometry in patients with symptoms suggestive of asthma. The use of FE(NO) measurement and induced sputum Eos% together to diagnose asthma in clinical practice is more accurate than spirometry or FE(NO) assessment alone and easier to perform.

[Measurement of fraction of exhaled nitric oxide with the portable NIOX-MINO monitor in healthy adults]

Measurement of the fraction of exhaled nitric oxide (FENO) provides a noninvasive way to monitor asthma treatment in clinical practice. The aim of this study was to determine FENO reference values for measurements recorded with the portable NIOX MINO monitor in a group of healthy volunteers. We also assessed the association between values recorded by the portable monitor and the N-6008 chemiluminescence analyzer used in our pulmonary function laboratory. The FENO values obtained with the portable monitor were consistently higher than those recorded by the N-6008 analyzer; the cutoff value for the portable monitor was 34 ppb (mean + 2 SD). We detected a direct correlation (r=0.92) between the FENO measurements recorded by the 2 monitors (P=.001). The following equation expresses the relationship between measurements from the 2 devices: FENO(NIOX MINO) = 10 + [1.5 FENO(N-6008)]. We did not observe statistically significant correlations between FENO measurements and age, sex, body mass index, or spirometry.

Anti-inflammatory effects of high-dose inhaled fluticasone versus oral prednisone in asthma exacerbations

The objective of the present study was to investigate the kinetics of high doses of inhaled steroid fluticasone in comparison with oral steroid prednisone on plasma protein leakage and bronchial eosinophilia in adults with moderate asthma exacerbations. The study design was a randomised, double-blind, placebo-controlled prospective trial. In total, 45 patients treated at the emergency department for moderate asthma exacerbations were recruited and 39 were assigned to receive fluticasone and placebo of prednisone (19 patients), or prednisone and placebo of fluticasone (20 patients). Medication was administered to all patients via a metered-dose inhaler and spacer (16 puffs; 4,000 microg.day(-1) or placebo) plus one pill (prednisone 30 mg.day(-1) or placebo). Spirometry and induced sputum for differential cell counts, albumin and alpha(2)-macroglobulin levels and blood eosinophils, interleukin-5 and granulocyte-macrophage colony-stimulating factor levels were obtained before treatment and at 2, 6 and 24 h after treatment. Symptoms clearly improved after 24 h in both groups. No differences were seen between groups in peak expiratory flow or forced expiratory flow in one second, which improved progressively but then decayed slightly after 24 h. Eosinophil counts in sputum also improved over time in both groups. The effect was faster with fluticasone than with prednisone, but was partially lost at 24 h. However, plasma proteins in sputum and eosinophil count in blood both decreased until 24 h, with no significant differences between groups. There was no correlation between eosinophil counts and plasmatic protein levels. In conclusion, both treatments improved symptoms, airway obstruction and inflammation, and plasma protein leakage at 24 h. Prednisone reduced blood eosinophil counts, while fluticasone reduced airway eosinophil counts, suggesting that the anti-inflammatory performance of fluticasone is exerted locally.

[Monitoring of breathing pattern at rest by electrical impedance tomography]

OBJECTIVE

Electrical impedance tomography (EIT) involves the application of a small alternating current to produce a series of chest images that can be used to monitor breathing pattern. The relation between chest images and tidal volume has not been sufficiently validated. The aim of the present study was to analyze the correlation between EIT images and the volume-time signal measured with a pneumotachometer in 13 healthy volunteers.

MATERIAL AND METHODS

The following measurement devices were used: a) MedGraphics preVent Pneumotach, with special software for recording the volume-time signal (reference test), and b) EIT-4, a fourth-generation prototype unit designed by the Department of Electronic Engineering at the Universidad Politécnica de Cataluña, Spain that records the volume-time signal and produces a graphic depiction of a cross section of the thorax at the sixth intercostal space.

RESULTS

The mean (SD) tidal volume measured by the pneumotachometer and the EIT-4 was 0.523 (0.102) L and 0.527 (0.106) L, respectively (P value not significant). The linear correlation coefficient between the 2 measurements was 0.923 (P=.001), and the mean of the differences between the 2 procedures was -0.003 L (95% confidence interval, -0.045 to 0.038). The greatest differences were associated with female gender, body mass index, and chest circumference. In view of these differences, a different equation based on these variables was needed for calibration of the EIT-4.

CONCLUSIONS

The EIT-4 provides an alternative means of monitoring breathing pattern, although a number of issues related to the circumference of the rib cage need to be resolved.

[Oxygen-conserving devices: a forgotten resource]

Oxygen-conserving devices include transtracheal catheters, reservoir cannulas, and demand oxygen delivery systems. They are designed to extend the amount of time portable oxygen cylinders will last and correct hypoxemia with a lower flow of oxygen. Transtracheal catheters increase the fraction of inspired oxygen by delivering oxygen directly to the trachea, bypassing the dead space of the oropharynx and improving the efficiency of the upper airway as a reservoir. Reservoir cannulas increase the fraction of inspired oxygen at the beginning of the inspiratory phase. Demand oxygen delivery systems have a valve that is activated during inspiration, meaning that oxygen is only delivered during this stage of the respiratory cycle. Each system has advantages and disadvantages arising from differing design features. Prescription should be based on individual tests in all cases to ensure optimal oxygen delivery during rest, exercise, and sleep.

Clinical outcomes of expiratory muscle training in severe COPD patients

The most common symptoms in chronic obstructive pulmonary disease (COPD) patients are breathlessness and exercise limitation. Although both general and inspiratory muscle training have shown clinical benefits, the effects of specific expiratory muscle training remain controversial.

OBJECTIVE

To investigate the effects of expiratory training on lung function, exercise tolerance, symptoms and health-related quality of life in severe COPD patients.

METHODS

Sixteen patients (FEV(1), 28+/-8% pred.) were randomised to either expiratory muscle or sham training groups, both completing a 5-week programme (30 min sessions breathing through an expiratory threshold valve 3 times per week) (50% of their maximal expiratory pressure (MEP) vs. placebo, respectively). Lung function, exercise capacity (bicycle ergometry and walking test), and clinical outcomes (dyspnoea and quality of life (St. George Respiratory Questionnaire (SGRQ)) were evaluated both at baseline and following the training period.

RESULTS

Although lung function remained roughly unchanged after training, exercise capacity, symptoms and quality of life significantly improved. The improvement in both walking distance and the SGRQ score significantly correlated with changes in MEP.

CONCLUSION

Our results confirm that a short outpatient programme of expiratory training can improve symptoms and quality of life in severe COPD patients. These effects could be partially explained by changes in expiratory muscle strength.

Lung Calcifications and Chronic Kidney Failure

Pulmonary calcification is relatively uncommon and typically asymptomatic. A number of diseases are associated with this disorder, including chronic kidney failure, infections, and lung amyloidosis. There are, moreover, a number of conditions, such as hypercalcemia, hyperphosphatemia, alkalosis, and alveolar damage, which predispose a patient to calcification. We describe a case of pulmonary calcifications associated with chronic kidney failure which had required hemodialysis and a subsequent kidney transplant.

Control of ventilation, breathlessness perception and alexithymia in near-fatal asthma

Several studies have demonstrated impaired control of ventilation in some patients with near-fatal asthma (NFA). The objective of our study was to determine a possible relationship between alexithymia (a cognitive processing disorder), control of ventilation, and breathlessness perception in patients who had an NFA attack. We analyzed data from 100 subjects: 50 with NFA, 25 asthmatics without NFA, and 25 non-asthmatic controls. Ventilatory responses to hypoxia and hypercapnia were measured by the rebreathing technique in terms of slope of ventilation and mouth occlusion pressure (P0.1). Breathlessness perception was assessed with the Borg scale and alexithymia with the Toronto Alexithymia Scale (TAS). No statistical differences were observed between groups in breathlessness perception and ventilatory responses. The mean (SD) TAS score of 63.6 (14.9) in the NFA group was significantly higher than the score of 56.4 (12.1) in the non-asthmatic group (p = 0.007). More subjects with alexithymia were identified in the NFA group (24%) than in the non-NFA group (12%) or the non-asthmatic control group (12%). Although the presence of alexithymia did not correlate with poor ventilatory responses or breathlessness perception, it was associated with a larger number of previous hospitalisations: 6.2 (8.1) in the NFA group and 2.8 (4.8) in the non-NFA group (p = 0.036). In conclusion, the prevalence of alexithymia is higher among NFA patients than among asthmatics who have not experienced NFA attacks. Neither altered breathlessness perception nor ventilatory response to hypoxia seems to play a role in NFA, although alexithymia may favor poor clinical control.