Understanding HCP views about delivering a rehabilitation programme for people living with atrial fibrillation

Background

People living with Atrial Fibrillation (AF) can experience symptoms such as palpitation, dyspnea, fatigue and dizziness which lead to reduced physical activity levels and quality of life [1,2]. Current management of AF mainly focus on pharmacological treatments and invasive procedures, while no routine prescription of exercise or rehabilitation programme is offered.

Purpose

To assess the views and opinions of healthcare professionals about delivering a tailored exercise/cardiac rehabilitation programme to people living with AF, and to explore the barriers in referral to this programme.

Methods

A cross-sectional survey was conducted online between April and September 2021 for healthcare professionals who are involved in the care for adults with AF in UK. A range of professions were targeted, including general practitioners, cardiac physicians, physiotherapists and nurses. The survey comprised twelve questions designed to explore healthcare professional views about rehabilitation programmes for adults with AF, factors influencing their decision to recommend rehabilitation and barriers to the referral process.

Results

Overall, n=209 participants responded from a wide range of disciplines (57% female, 43% specialist arrhythmia nurses). The majority of participants agreed that a rehabilitation programme would be beneficial to support patients to perform daily activities (127, 61%), with n=123, 58% agreeing that rehabilitation programme would be beneficial in reducing breathlessness and would reduce other symptoms such as palpitation (108, 52%).

Nearly all the healthcare professional (n=206/99%) suggested that a tailored programme should include information about AF (206, 99%), weight management and symptom management (n=197, 94%) aside from exercise. The factors that strongly influence their decision to refer to a rehabilitation programme included patients with low physical activity levels (n=166, 80%) and low exercise tolerance (n=157, 76%). The main barrier in referring to the programme was transportation problems (n=128, 62%) (Figure 1). The majority reported that home based programme would be the best way to deliver the programme (166, 79%) (Figure 2).

Conclusions

The responses indicate the enthusiasm for a programme targeting people with AF, poor activity levels was the main reason for referral.

Funding Acknowledgement

Type of funding sources: None.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Transition from paediatric surgery: how many patients do we need to plan for?

INTRODUCTION Transitional care is an NHS priority with newly published NICE guidance. Many paediatric surgical patients need quality care to continue into adulthood. We undertook an evaluation of our departmental activity to assess the magnitude of this issue. METHODS We identified all outpatients ≥ 15 years (potentially requiring imminent transition) seen over a 12 month period for all five general paediatric surgery consultants in our tertiary centre. Those patients requiring transition were highlighted and the appropriate adult team for referral recorded. RESULTS There were 2989 general paediatric surgery clinic appointments within the year; 289 (9.7%) were for young people aged 15 years or older; 62 patients (28% of those ≥ 15years) were deemed to require transition into adult care. Significantly more patients having colorectal surgery required follow-up (P = 0.0009 Chi-square test) compared with patients in other subspecialties. CONCLUSIONS More patients than expected required transition. This may be the case in other units. Current best practice includes time intensive preclinic planning, careful preparation of patient and family, followed by joint clinics. A joint clinic appointment takes 30 minutes, allowing for comprehensive handover and forging new relationships. In our department, we need at least ten transition clinics across 2 years. Coalition with adult colleagues is vital. These data enable us to plan services to provide quality care for our adolescent patients and highlights colorectal surgery as a priority.

Genetic dissection of drought tolerance in chickpea (Cicer arietinum L.)

Analysis of phenotypic data for 20 drought tolerance traits in 1-7 seasons at 1-5 locations together with genetic mapping data for two mapping populations provided 9 QTL clusters of which one present on CaLG04 has a high potential to enhance drought tolerance in chickpea improvement. Chickpea (Cicer arietinum L.) is the second most important grain legume cultivated by resource poor farmers in the arid and semi-arid regions of the world. Drought is one of the major constraints leading up to 50% production losses in chickpea. In order to dissect the complex nature of drought tolerance and to use genomics tools for enhancing yield of chickpea under drought conditions, two mapping populations-ICCRIL03 (ICC 4958 × ICC 1882) and ICCRIL04 (ICC 283 × ICC 8261) segregating for drought tolerance-related root traits were phenotyped for a total of 20 drought component traits in 1-7 seasons at 1-5 locations in India. Individual genetic maps comprising 241 loci and 168 loci for ICCRIL03 and ICCRIL04, respectively, and a consensus genetic map comprising 352 loci were constructed ( http://cmap.icrisat.ac.in/cmap/sm/cp/varshney/). Analysis of extensive genotypic and precise phenotypic data revealed 45 robust main-effect QTLs (M-QTLs) explaining up to 58.20% phenotypic variation and 973 epistatic QTLs (E-QTLs) explaining up to 92.19% phenotypic variation for several target traits. Nine QTL clusters containing QTLs for several drought tolerance traits have been identified that can be targeted for molecular breeding. Among these clusters, one cluster harboring 48% robust M-QTLs for 12 traits and explaining about 58.20% phenotypic variation present on CaLG04 has been referred as "QTL-hotspot". This genomic region contains seven SSR markers (ICCM0249, NCPGR127, TAA170, NCPGR21, TR11, GA24 and STMS11). Introgression of this region into elite cultivars is expected to enhance drought tolerance in chickpea.

The tyranny of distance: telemedicine for the critically ill in rural Australia

A case of severe sepsis with multi-organ failure needing complex support was deemed too ill for transfer to a major centre. Telemedicine allowed direct patient review, collaborative advice and collegial support with maintained healthcare standards while avoiding long distance transfer from his home and family.

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

BACKGROUND

Patients with Chronic Heart Failure (CHF) develop similar symptoms of exertional breathlessness and fatigue as patients with COPD. Although pulmonary (exercise based) rehabilitation (PR) is an integral part of the management of COPD, the potential for exercise rehabilitation (ER) to assist patients with CHF may not be as readily appreciated. We investigated whether combined ER for patients with CHF and COPD was feasible and effective using the model of PR.

METHODS

57 patients with CHF were randomized 2:1 to 7 weeks ER (CHF-ER) or 7 weeks of usual care (CHF-UC). As a comparator 55 patients with COPD were simultaneously recruited to the same ER program (COPD-ER). The primary outcome measure was the Incremental Shuttle Walk Test (ISWT) and the secondary outcome measures were the Endurance Shuttle Walk Test (ESWT), isometric quadriceps strength and health status.

RESULTS

27 CHF and 44 COPD patients completed ER and 17 patients with CHF completed UC. The CHF-ER group made significant improvements, compared to CHF-UC, in the mean (95%CI) ISWT distance; 62(35-89)m vs -6(-11 to 33)m p < 0.001. The CHF-ER group also made statistically significant improvements in health status. The improvements in exercise performance and health status were similar between patients with CHF and COPD, treated with ER.

CONCLUSION

Patients with CHF who undergo ER improve similarly in their exercise performance and health status to COPD. Combined training programs for COPD and CHF are effective and feasible, such that service provision could be targeted around common disability rather than the primary organ disease.

Plasma ammonia response to incremental cycling and walking tests in COPD

OBJECTIVE

It is well documented that plasma ammonia accumulates during exercise under conditions of metabolic stress. Metabolic stress (when skeletal muscle ATP supply fails to meet demand) occurs at low work rates during cycling in patients with COPD, but not been described during walking. Walking is an important activity for many patients with COPD and is commonly prescribed in pragmatic outpatient pulmonary rehabilitation programmes. In this study we explored whether metabolic stress occurs during incremental walking at the low work rates these patients achieve.

METHODS

Twenty-nine subjects with stable COPD [mean(SD) age 68(7)years, FEV(1) 50(19)% predicted] performed maximal cardiopulmonary exercise tests on a cycle ergometer and treadmill. Plasma ammonia concentration was measured at rest, 1 and 2min of exercise, peak exercise and 2min recovery.

RESULTS

Subjects achieved mean(SD) cycle work rate of 57(20)W with VO(2max) 15.5(4.6)ml/min per kg, and treadmill distance 284(175)m with VO(2peak) 16.8(4.2)ml/min per kg. Plasma ammonia concentration rose significantly (p<0.001) with walking [mean(SEM) change 24.7(3.8)micromol/l] and cycling [mean(SEM) change 35.2(4.3)micromol/l], but peak exercise ammonia was lower in walking (p<0.01). In a subgroup of subjects (n=7) plasma ammonia did not rise during either cycling or walking despite similar lactate rise and peak exercise indices.

CONCLUSION

Our data indicate that failure of muscle ATP re-synthesis to meet demand and development of metabolic stress can occur during walking in COPD patients at the low work rates these patients achieve. This may therefore be a factor contributing to exercise limitation independent of ventilatory limitation.

Upper critical field, superconducting energy gaps and the Seebeck coefficient in La(0.8)Th(0.2)FeAsO

We report the synthesis and characterization of a new electron-doped La-oxypnictide superconductor by partial substitution of lanthanum by thorium. The superconducting transition temperature at about 30.3 K was observed in La(0.8)Th(0.2)FeAsO, which is the highest in La-based oxypnictide superconductors synthesized at ambient pressure. We find that the decrease in lattice parameters with Th doping in LaOFeAs is more drastic as compared to that obtained by high pressure (6 GPa) synthesis of oxygen-deficient LaOFeAs. The resistivity and magnetic susceptibility measurements yield an upper critical field H(c2)(0) of 47 T. Partial substitution of Th in place of La induces electron doping, as shown by a negative Seebeck coefficient. The temperature-dependent magnetic penetration depth data provides strong evidence for a nodeless low energy gap of 1.4 meV.

Minimum clinically important improvement for the incremental shuttle walking test

BACKGROUND

The incremental shuttle walking test (ISWT) is used to assess exercise capacity in patients with chronic obstructive pulmonary disease (COPD) and is employed as an outcome measure for pulmonary rehabilitation. This study was designed to establish the minimum clinically important difference for the ISWT.

METHODS

372 patients (205 men) performed an ISWT before and after a 7-week outpatient pulmonary rehabilitation programme. After completing the course, subjects were asked to identify, from a 5-point Likert scale, the perceived change in their exercise performance immediately upon completion of the ISWT. The scale ranged from "better" to "worse".

RESULTS

The mean (SD) age was 69.4 (8.4) years, forced expiratory volume in 1 s (FEV(1)) 1.06 (0.53) l and FEV(1)/forced vital capacity (FVC) ratio 50.8 (18.1)%. The baseline shuttle walking test distance was 168.5 (114.6) m which increased to 234.7 (125.3) m after rehabilitation (mean difference 65.9 m (95% CI 58.9 to 72.9)). In subjects who felt their exercise tolerance was "slightly better" the mean improvement was 47.5 m (95% CI 38.6 to 56.5) compared with 78.7 m (95% CI 70.5 to 86.9) in those who reported that their exercise tolerance was "better" and 18.0 m (95% CI 4.5 to 31.5) in those who felt their exercise tolerance was "about the same".

CONCLUSION

Two levels of improvement were identified. The minimum clinically important improvement for the ISWT is 47.5 m. In addition, patients were able to distinguish an additional benefit at 78.7 m.

The plasma ammonia response to cycle exercise in COPD

The plasma ammonia response to exercise in chronic obstructive pulmonary disease (COPD) was examined and the relationship between plasma ammonia concentration and muscle adenine nucleotide metabolism was explored. In total, 25 stable COPD patients and 13 similar-aged controls underwent incremental and constant-work rate cycle exercise tests. Arterialised venous blood was sampled at rest, at 1-min intervals during exercise and <or=5 min after exercise for ammonia and lactate concentration. Peak incremental work rate was significantly less in COPD subjects (67+/-21 W) than similar-aged controls (156+/-46 W). In COPD and control subjects, plasma ammonia concentration increased during incremental exercise until 2 min post-exercise and then declined by 5 min post-exercise. However, two distinct patterns were seen in COPD subjects. In one group (n = 16), ammonia increased (42.8+/-3.3 micromol x L(-1)) by a similar magnitude as the controls (55.5+/-7.0 micromol x L(-1)). In the second COPD group (n = 9), no ammonia increase was observed despite a similar lactate increase. Ammonia change with incremental and constant-work rate exercise strongly correlated in COPD subjects. Plasma ammonia increase correlated with muscle inosine-5'-monophosphate formation after constant-work rate exercise. Plasma ammonia concentration increases during incremental and constant-work rate cycle exercise in chronic obstructive pulmonary disease subjects at lower absolute work rates compared with similar-aged controls. The plasma ammonia response may provide useful information about adenine nucleotide metabolism and, therefore, muscle fatigue during exercise in patients with chronic obstructive pulmonary disease.

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

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

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

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

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

BACKGROUND

The evidence of benefit for pulmonary rehabilitation (PR) programmes is established. However, the optimal duration of a PR programme is not known. A randomised controlled trial was undertaken in patients with chronic obstructive pulmonary disease (COPD) to assess whether a 4 week PR programme was equivalent to our conventional 7 week PR programme at equivalent time points of 7 weeks and 6 months.

METHODS

One hundred patients (56 men) with stable COPD of mean (SD) age 70 (8) years and forced expiratory volume in 1 second (FEV1) 1.13 (0.50) litres were randomised to either a 7 week (n = 50) or 4 week (n = 50) supervised PR programme. Patients were assessed at baseline, at completion of the supervised PR programme, and 6 months later. Patients randomised to the 4 week group were also assessed at the 7 week time point. Outcome measures were the Incremental Shuttle Walk Test, Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire-Self Reported, and the Breathing Problems Questionnaire.

RESULTS

Forty one patients in each group completed the PR programme. Patients made significant within group improvements after supervised rehabilitation. There were no statistically significant differences between the groups for any other measure at the 7 week or 6 month time points, except that patients in the 4 week group attained higher ESWT times (mean difference 124 seconds (95% CI 17.00 to 232.16), p = 0.024) at the 7 week time point.

CONCLUSIONS

A shortened 4 week supervised PR programme is equivalent to a 7 week supervised PR programme at the comparable time points of 7 weeks and 6 months.

A profile of daily activity in chronic obstructive pulmonary disease

BACKGROUND

Little information exists about the pattern of daily activity in patients with chronic obstructive pulmonary disease (COPD), especially in those who are on long-term oxygen therapy (LTOT). The aim of this study was to explore the regular level of domestic physical activity in patients with COPD and to explore differences in activity in those on LTOT.

METHODS

Daily activity was recorded using an activity monitor for 7 consecutive days in 4 groups. Group 1 had severe COPD (FEV1 0.66 [0.42] L) receiving LTOT (n = 9). Group 2 had severe COPD (FEV1 1.07 [0.43] L) and had full knowledge of the activity monitor and the purpose of the study (n = 10). Group 3 had severe COPD (FEV1 1.16 [0.27] L) but were unaware of the precise nature of the study (n = 10). Group 4 (n = 10) were the healthy control group. Participants also completed health status questionnaires.

RESULTS

There were statistically significant differences in the level of daily activity between all groups (P < .001) except between groups 2 and 3. There were no significant differences between days within groups. The activity counts compared to the healthy groups were reduced by 49% in groups 2 and 3 and by 79% in those on LTOT.

CONCLUSION

Patients with COPD demonstrate reduced levels of spontaneous physical activity compared with healthy controls. Furthermore, patients receiving LTOT have an even lower level of domestic activity compared with that of those not on LTOT but with COPD of similar severity.

Adenine nucleotide loss in the skeletal muscles during exercise in chronic obstructive pulmonary disease

BACKGROUND

Skeletal muscle adenine nucleotide loss has been associated with fatigue during high intensity exercise in healthy subjects but has not been studied in patients with chronic obstructive pulmonary disease (COPD). Changes in adenine nucleotides and other metabolites in the skeletal muscles were measured in patients with COPD and age matched healthy volunteers by obtaining biopsy samples from the quadriceps muscle at rest and following a standardised exercise challenge.

METHODS

Eighteen patients with COPD (mean (SD) forced expiratory volume in 1 second 38.1 (16.8)%) and eight age matched healthy controls were studied. Biopsy samples were taken from the vastus lateralis muscle at rest and immediately after a 5 minute constant workload cycle test performed at 80% peak work achieved during a maximal incremental cycle test performed previously.

RESULTS

The absolute workload at which exercise was performed was substantially lower in the COPD group than in the controls (56.7 (15.9) W v 143.2 (26.3) W, p<0.01). Despite this, there was a significant loss of adenosine triphosphate (mean change 4.3 (95% CI -7.0 to -1.6), p<0.01) and accumulation of inosine monophosphate (2.03 (95% CI 0.64 to 3.42), p<0.01) during exercise in the COPD group that was similar to the control group (-4.8 (95% CI -9.7 to 0.08), p = 0.053 and 1.6 (95% CI 0.42 to 2.79), p<0.01, respectively).

CONCLUSIONS

These findings indicate that the ATP demands of exercise were not met by resynthesis from oxidative and non-oxidative sources. This suggests that significant metabolic stress occurs in the skeletal muscles of COPD patients during whole body exercise at low absolute workloads similar to those required for activities of daily living.

Mortality due to constipation and short-segment Hirschsprung's disease

We report a case of mortality secondary to constipation. A 12-year-old child with a history of constipation from the age of 9 years presented in moribund condition with intestinal obstruction secondary to idiopathic constipation. He underwent laparotomy and died within 24 h of operation. At postmortem there was no evidence of abnormalities of the enteric nervous system. A 2nd case of early neonatal death from Hirschsprung's disease is presented to demonstrate that short-segment aganglionosis can be detected at postmortem. Enterocolitis can rapidly progress and be fatal in short-segment Hirschsprung's disease.

Small bowel volvulus due to giant mesenteric lipoma

We report on a 14-year-old girl with acute intestinal obstruction due to volvulus of the small bowel caused by a giant mesenteric lipoma. To the best of our knowledge, this presentation of a mesenteric lipoma is unknown in the previous paediatric literature.

Nutritional enhancement of exercise performance in chronic obstructive pulmonary disease: a randomised controlled trial

BACKGROUND

Pulmonary rehabilitation is effective in improving exercise performance and health status in chronic obstructive pulmonary disease (COPD). However, the role of nutritional support in the enhancement of the benefits of exercise training has not been explored. A double blind, randomised, controlled trial of carbohydrate supplementation was undertaken in patients attending outpatient pulmonary rehabilitation.

METHODS

85 patients with COPD were randomised to receive a 570 kcal carbohydrate rich supplement or a non-nutritive placebo daily for the duration of a 7 week outpatient pulmonary rehabilitation programme. Primary outcome measures were peak and submaximal exercise performance using the shuttle walk tests. Changes in health status, body composition, muscle strength, and dietary macronutrient intake were also measured.

RESULTS

Patients in both the supplement and placebo groups increased shuttle walking performance and health status significantly. There was no statistically significant difference between treatment groups in these outcomes. Patients receiving placebo lost weight whereas supplemented patients gained weight. In well nourished patients (BMI >19 kg/m(2)) improvement in incremental shuttle performance was significantly greater in the supplemented group (mean difference between groups: 27 (95% CI 1 to 53) m, p<0.05). Increases in incremental shuttle performance correlated with increases in total carbohydrate intake.

CONCLUSIONS

When universally prescribed, carbohydrate supplementation does not enhance the rehabilitation of patients with COPD. This study suggests that exercise training results in negative energy balance that can be overcome by supplementation and that, in selected patients, this may improve the outcome of training. The finding of benefit in well nourished patients may suggest a role for nutritional supplementation beyond the treatment of weight loss in COPD.

Health status measurement: sensitivity of the self-reported Chronic Respiratory Questionnaire (CRQ-SR) in pulmonary rehabilitation

BACKGROUND

A self-reported CRQ (CRQ-SR) has recently been developed and found to be a reproducible and reliable measure of health status. This study explores both the sensitivity of the CRQ-SR and relative sensitivity compared with the conventional interviewer led CRQ (CRQ-IL) in patients undergoing pulmonary rehabilitation.

METHODS

Eighty patients with stable chronic obstructive pulmonary disease who had been referred for pulmonary rehabilitation completed the CRQ-SR at initial assessment and at the end of the 7 week programme. A further 35 patients completed both the CRQ-SR and the CRQ-IL, administered 1 week apart, before starting rehabilitation and again at the end of the programme.

RESULTS

There were large statistically and clinically significant changes in mean score per dimension following rehabilitation in all dimensions of the CRQ-SR (dyspnoea mean difference 0.87 (95% CI 0.61 to 1.14); fatigue 0.76 (0.53 to 1.0); emotion 0.60 (0.35 to 0.86); mastery 0.76 (0.52 to 1.0); p<0.001). Similar results were found in the comparison of the sensitivity of the CRQ-SR and the CRQ-IL, with large changes in mean score per dimension following rehabilitation for both versions of the questionnaire (p<0.005). No significant differences were seen in the magnitude of change between the two formats of the questionnaire (p>0.05).

CONCLUSION

The self-reported CRQ is as sensitive to change as the interviewer led CRQ in patients undergoing pulmonary rehabilitation but has the advantage of being less time consuming to administer.

Gastroschisis: determinants of neonatal outcome

This retrospective study elicits information regarding the dependence of neonatal outcome in gastroschisis upon: (1) the mode of delivery, (2) place of birth, (3) time for birth to surgery, (4) method of closure, (5) time from operation to commencement of first enteral feeds. The neonatal intensive care database from five major tertiary centres was used to identify 181 neonates with gastroschisis from 1990 to 2000. There were 8 deaths. There were no significant differences in outcome for infants delivered vaginally (102) versus Caesarean section (79), those born near the tertiary centre (133) as compared to infants born away (48), ones operated within 7 hours (125) compared with those operated after 7 hours (56), with delayed closure (30) versus primary closure (151). Neonates fed within 10 days of operation (85) had significantly lower incidence of sepsis, duration of TPN and hospital stay when compared to those fed after 10 days (96). Early commencement of feeds decreases the incidence of sepsis, duration of total parenteral nutrition (TPN) and hospital stay. Place of delivery, mode of delivery, time to surgery and type of closure do not influence neonatal outcome.

Hirschsprung's disease: the Australian Paediatric Surveillance Unit's experience

Hirschsprung's disease (HD) was introduced into the Australian Paediatric Surveillance Unit (APSU) system in 1996 with the objective to collect data on demographics, incidence, family history, associated anomalies, clinical features, investigation, and surgical treatment in Australia. Children under 15 years of age with HD (confirmed by biopsy) were entered into a database maintained at The Children's Hospital at Westmead in Sydney. Nationwide, 127 children with HD were reported from January 1997 to December 2000, and near-complete information was available on 126. Neonatal presentation was seen in 114 cases (90%), whereas 12 (10%) presented post-neonatally. There was a history of delayed passage of meconium (more than 24 h) in 65 of the 114 patients (57%) who presented in the neonatal period. In those presenting post-neonatally there was no history of delayed passage of meconium. Primary pull-through was performed in 42 of the 82 patients (51%) operated upon. The Soave procedure was performed in 53 of the total 82 (65%) operations and 29 of 42(69%) primary pull-through operations. Pre-operative enterocolitis was seen in 15 of 126 (12%) and postoperative enterocolitis in 17 of 82 (21%) children. The majority of children with HD are diagnosed in the neonatal period (90%). Primary pull-through is becoming more popular (51%). The Soave procedure is the most commonly performed operation (65%) in Australia. Pre- and post-operative enterocolitis is still a significant problem.

Development of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCQ)

BACKGROUND

Chronic cough is a common condition which has a significant impact on quality of life. Assessment and management are hampered by the absence of well validated outcome measures. The development and validation of the Leicester Cough Questionnaire (LCQ), a self-completed health related quality of life measure of chronic cough, is presented.

METHODS

Patients with chronic cough were recruited from outpatient clinics. The development of the LCQ consisted of three phases: phase 1 (item generation); phase 2 (item reduction, allocation of items to domains and validation of questionnaire); phase 3 (repeatability and responsiveness testing of final version of questionnaire).

RESULTS

Phase 1: Literature review, multidisciplinary team meeting and 15 structured interviews with chronic cough patients generated 44 items (LCQ1) with a 7 point Likert response scale. Phase 2: 104 chronic cough outpatients completed the LCQ1 along with an importance rating for each item. The clinical impact factor method was used for item reduction to 19 items (LCQ2: final version). These items were divided into three domains (physical, psychological and social) following expert opinion. Internal reliability, as assessed using Cronbach's alpha coefficients, varied between 0.79 and 0.89. Concurrent validity was high when the LCQ2 (n=56) was compared with a cough visual analogue score (r=-0.72). There was a moderate relationship with response to the St George's Respiratory Questionnaire (r=-0.54) and SF36 total score (r=0.46). Phase 3: Two week repeatability (n=24) was high with intraclass correlation coefficients for domains varying between 0.88 and 0.96. Responsiveness in nine patients whose cough was successfully treated varied within domains from an effect size of 0.84 to 1.75.

CONCLUSION

The LCQ is a valid, repeatable 19 item self-completed quality of life measure of chronic cough which is responsive to change. It should be a useful tool in clinical trials and longitudinal studies.

Lung volume reduction surgery – a comparison of the long term outcome of unilateral vs. bilateral approaches

OBJECTIVE

Bilateral lung volume reduction surgery (LVRS) is thought to be preferable to unilateral surgery due to greater initial benefit but the subsequent rate of decline may also be greater. We compared the long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs.

METHODS

Prospective data were collected on a consecutive series of 65 patients undergoing LVRS who were all suitable for bilateral surgery. Twenty-six patients: age 59 (8) years underwent bilateral LVRS by video-assisted thoracoscopy (VAT) or sternotomy and 39 patients: age 60 (6) years underwent unilateral VAT. The perioperative effects of LVRS on spirometry were prospectively recorded at 3, 6, 12 and 24 months.

RESULTS

The unilateral group had similar preoperative lung volumes to the bilateral patients: forced expiratory volume in 1s (FEV(1)) 26 vs. 30% predicted, RV 275 vs. 246% predicted and total lung capacity (TLC) 148 vs. 142% predicted. Unilateral LVRS was associated with significantly lower weight of lung resected: 80 (31) vs. 118 (46) g; hospital stay: 16 (10) days vs. 28 (22) days. Thirty-day mortality was 3% in the unilateral and 8% in the bilateral group (P=0.34). Postoperative ventilation occurred in 5% in the unilateral and in 42% in the bilateral group (P=0.0002). The decline of FEV(1) during the first postoperative year was significant in the bilateral group (-313 ml/y, P=0.04) but not significant in the unilateral group (-50 ml/y, P=0.18). SF 36 scores in all eight domains were similar in both groups preoperatively and at any postoperative interval.

CONCLUSION

We have found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit.