Coherence between self-reported and objectively measured physical activity in patients with chronic obstructive lung disease:a systematic review

The beneficial effects of physical activity (PA) in patients with COPD, as well as the methods of their assessment, are well known and described. As objective measures of PA, such as the use of motion sensors, video recordings, exercise capacity testing, and indirect calorimetry, are not easily obtained in the daily clinical life, the reliability of the more accessible self-reported measurements of PA is important. In this review, we systematically identified original studies involving COPD patients and at least one parameter of self-reported and objective exercise testing, and analyzed every article for coherence between the objectively and self-reported measured PA. The studies are few, small, and very diverse, both in their use of questionnaires and objective measurements. Self-reported assessments were found to generally overestimate the level of PA compared to measurements made objectively by activity monitors; however, more studies are needed to rely solely on the use of PA questionnaires in COPD patients. The most accurate and valid questionnaires appear to be the self-completed Physical Activity Scale for the Elderly and the interviewer-completed Stanford Seven-Day Physical Activity Recall Questionnaire, but the ideal questionnaire still awaits construction. The motion sensors are accurate and validated in this patient group, especially SenseWear™, but not easily accessible in clinical practice, as they have various technical and adhesive difficulties

The impact of pulmonary rehabilitation on severe physical inactivity in patients with chronic obstructive pulmonary disease:a pilot study

Introduction: In patients with COPD, severe physical inactivity (SPI, which is defined as total daily energy expenditure/resting energy expenditure; physical activity level [PAL] ratio, &lt;1.4) is associated with increased morbidity and mortality. Pulmonary rehabilitation (PR) increases physical capacity in COPD, but the impact on SPI is unknown. In this study, we aimed at elucidating the prevalence of SPI in COPD patients attending standard PR, the impact of PR on SPI prevalence, and the relationship between SPI and time spent in moderate physical activity thus whether American College of Sports Medicine (ACSM) recommendations are clinically useful in excluding SPI in COPD.Methods: This is a prospective non-interventional pilot study on patients with COPD completing PR, consenting to wear an accelerometer (Sensewear © Armband) for a week before and after completing PR to assess changes in energy expenditure, time spent in physical activity, and number of daily steps. Low level of daily physical activity was not an inclusion criterion. Results: In total, 57 patients completed the study and 31 (54%) had SPI at baseline. In patients with SPI, baseline median FEV 1 was 48 (range, 28-86) % of predicted and GOLD B, n=11 (35%)/GOLD D, n=20 (65%). Surprisingly, 31 of SPI patients (97%) spent ≥150 minutes/week in moderate physical activity. After rehabilitation, 24 (78%) did not change activity level and were persistently SPI. We observed no differences at baseline between patient responding (n=7) vs not responding (n=24) to PR. Responders increased number of daily steps and time spent in lighter but not moderate physical activity during rehabilitation. Conclusion: In this pilot study, SPI was prevalent, and PR had limited impact. Contraintui-tively, most patients with SPI complied with general recommendations of weekly hours spent in moderate physical activity. Our study highlights that increasing time spent in light activity rather than improving time spent in moderate activity is important in COPD patients with chronic dyspnea.</p

Upper airway symptoms associate with the eosinophilic phenotype of COPD

Background: There is growing evidence that upper airway symptoms coexist with lower airway symptoms in COPD. Still, the prevalence and impact of upper airway disease on the nature and course of COPD remain unclear. We aimed to describe this in a cross-sectional study. // Methods: We examined a cohort of COPD patients with pulmonary function tests, induced sputum, blood eosinophils, atopy tests and computed tomography (CT) of the paranasal sinuses. Lower airway symptoms were assessed using the COPD Assessment Test (CAT), and upper airway symptoms were assessed using the nasal subdomain of the 22-item Sino Nasal Outcome Test (SNOT22nasal). We recruited patients from five sites in Denmark and Sweden. We excluded patients with a history of asthma. // Findings: In total, 180 patients (female 55%, age 67±8 years, forced expiratory volume in 1 s (FEV1 %) 52.4±16.6, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage: A: 18%, B: 54%, C: 3%, D: 25%) were included in the study. Seventy-four patients (41%) reported high upper airway symptoms (UAS, defined as SNOT22nasal≥6) with a median score of 10 (IQR 8–13). Patients with high UAS reported higher CAT scores (17.4±7.5 versus 14.9±6.6, p<0.05) and displayed higher fractions of eosinophils in blood (median 3.0% (IQR 1.6–4.2%) versus 2.3% (IQR 1.4–3.1%), p<0.05) and in induced sputum (median 1.8% (IQR 0.3–7.1%) versus median 0.5% (IQR 0–1.7%), p<0.05). No differences in atopy, CT findings or exacerbation rates were observed. // Conclusion: COPD patients with upper airway disease showed increased evidence of eosinophilic disease and increased lower airway symptom burden

Bad news itself or just the messenger? The high mortality of Fusobacterium spp. infections is related to disseminated malignancy and other comorbidities

BACKGROUND: Fusobacterium species are pleomorphic, obligate anaerobic gram-negative bacilli. They are difficult to culture and grow slowly. If antibiotic treatment is initiated prior to blood cultures, the bacteria might evade detection. This is a comprehensive report on mortality in non-bacteraemia fusobacterial infection.METHODS: Data were collected retrospectively in adults having a positive culture with Fusobacterium spp. admitted during 2000-2012 at the medical department. Data on culture specimens, number of cultures, admission and culture dates, patient age, gender, clinical disease, Charlson's index of co-morbidity, CRP level and survival were obtained. For comparison, we traced 60 consecutive, similarly obtained cultures from 2009 to 2010 containing Staphylococcus aureus.RESULTS: Within a 12-year period, we identified 28 patients with a positive culture of Fusobacterium spp. in a medical ward serving a population of 220,000. Only a minority (39%) had a positive blood culture, and 54% had focus in respiratory tract or pleura. Overall 6-month mortality was 32%, and unrelated to subspecies, treatment or anatomic location but significantly related to age &gt;60 years, admission for severe, acute illness, and comorbidity, especially metastatic malignancy. Comparison between infection with Fusobacterium spp. and S. aureus showed that Fusobacterium spp. infections were predominantly community acquired, while S. aureus were both community and hospital acquired. Overall mortality for both bacterial infections increased significantly with age and current malignant disease. S. aureus-infected patients carried a significantly higher mortality.CONCLUSION: Our data support that Fusobacterium spp. infection is a marker for significant, chronic disease rather than carrying a poor prognosis per se.</p

Lemierre&amp;rsquo;s syndrome: current perspectives on diagnosis and management

This is a systematic review of cases with Lemierre’s syndrome (LS) in the past 5 years. LS is characterized by sepsis often evolving after a sore throat or tonsillitis and then complicated by various septic emboli and thrombosis of the internal jugular vein. Symptoms include sepsis, pain, and/or swelling in the throat or neck, as well as respiratory symptoms. Laboratory findings show elevated infectious parameters and radiological findings show thrombosis of the internal jugular vein and emboli in the lungs or other organs. The syndrome is often associated with an infection with Fusobacterium necrophorum. We found a total of 137 cases of LS, of which 47 were infected with F. necrophorum and others with Staphylococcus and Streptococcus. Complications of this rare but severe disease included osteomyelitis, meningitis, and acute respiratory distress syndrome. Mortality was extremely high in the pre-antibiotic era but has diminished with the advent of antibiotics. This review showed a mortality rate of only 2% of which none of the cases involved fusobacteria. Duration of treatment varied; a 4–6-week course of carbapenem or piperacillin/tazobactam in combination with metronidazole was optimum. Other treatment options included anticoagulants in 46% of cases, which is unwarrantedly high, as to date, no evidence of the positive effects of anticoagulants in LS exists. Only two cases had ligation of the internal jugular vein performed. This review confirms the rare, but severe aspects of LS. Mortality from LS in this day and age appears to be low, however the syndrome is difficult to recognize, and still requires the full attention of the clinician

Experiences in responders and non-responders to pulmonary rehabilitation among people with chronic obstructive pulmonary disease:a clinical study with convergent mixed analysis

Purpose: This study aims to investigate the experienced and measured development in physical capacity in people with Chronic Obstructive Pulmonary Disease (COPD) undergoing a standard pulmonary rehabilitation programme with a focus on the diverging experiences of responders and non-responders. Methods: Twenty-one participants in standard pulmonary rehabilitation were included in the study. We measured the participants’ change in the six-minute walk test (6MWT) during rehabilitation participation. We investigated their experiences of the changes in their physical capacity by combined participant observations and interviews. A convergent mixed analysis was conducted of the coherent data. Results: Standard pulmonary rehabilitation had a different physical impact on people with COPD. Responders were delighted by a positive physical change, which improved their daily functioning and capability of fulfilling personal priorities. However, non-responders experienced decreased capacity and a lack of trust in their future. All participants found it challenging to exercise and achieve sustainable exercise habits. Conclusion: In this qualitative study, we found that absence of expected improvement to pulmonary rehabilitation seems to confer distress and feelings of hopelessness. The achievement of sustainable change in daily exercise behaviour appears yet to be insufficient. Thus, new and more individualized models of physiotherapists’ guidance in exercise are imperative.Implications for rehabilitation It is vital to acknowledge differential response to people with the chronic obstructive pulmonary disease following eight-week standard pulmonary rehabilitation. Especially noteworthy feelings of distress and hopelessness are prominent to non-responders because of the absence of the promised improvements. Both responders and non-responders require intensive physiotherapist guidance to exercise. It is recommended to ensure individualised support to people with chronic obstructive pulmonary disease in rehabilitation programmes.</p

Metastases or benign adrenal lesions in patients with histopathological verification of lung cancer: Can CT texture analysis distinguish?

INTRODUCTION: Distant metastases are found in the many of patients with lung cancer at time of diagnosis. Several diagnostic tools are available to distinguish between metastatic spread and benign lesions in the adrenal gland. However, all require additional diagnostic steps after the initial CT. The purpose of this study was to evaluate if texture analysis of CT-abnormal adrenal glands on the initial CT correctly differentiates between malignant and benign lesions in patients with confirmed lung cancer. MATERIALS AND METHODS: In this retrospective study 160 patients with endoscopic ultrasound-guided biopsy from the left adrenal gland and a contrast-enhanced CT in portal venous phase were assessed with texture analysis. A region of interest encircling the entire adrenal gland was used and from this dataset the slice with the largest cross section of the lesion was analyzed individually. RESULTS: Several texture parameters showed statistically significantly difference between metastatic and benign lesions but with considerable between-groups overlaps in confidence intervals. Sensitivity and specificity were assessed using ROC-curves, and in univariate binary logistic regression the area under the curve ranged from 36 % (Kurtosis 0.5) to 69 % (Entropy 2.5) compared to 73 % in the best fitting model using multivariate binary logistic regression. CONCLUSION: In lung cancer patients with abnormal adrenal gland at imaging, adrenal gland texture analyses appear not to have any role in discriminating benign from malignant lesions

Changes in systemic inflammation after pulmonary rehabilitation in patients with COPD and severe physical inactivity – an exploratory study

Background: Severe physical inactivity (SPI) in patients with COPD is associated with a poor prognosis. It is unknown whether there is a link between SPI and systemic inflammation, and if systemic inflammation in SPI changes following pulmonary rehabilitation (PR).Methods: A prospective, observational study of patients referred for at least 7 weeks of PR comprising 2 h of exercise therapy and education twice weekly. At baseline and after PR, daily physical activity level (PAL) was measured with a validated activity monitor, SenseWear? as well as systemic inflammation: b-eosinophils, p-fibrinogen, p-CRP, s-IL-6 and s-CD 163. SPI was defined as PALBackground: Severe physical inactivity (SPI) in patients with COPD is associated with a poor prognosis. It is unknown whether there is a link between SPI and systemic inflammation, and if systemic inflammation in SPI changes following pulmonary rehabilitation (PR). Methods: A prospective, observational study of patients referred for at least 7 weeks of PR comprising 2 h of exercise therapy and education twice weekly. At baseline and after PR, daily physical activity level (PAL) was measured with a validated activity monitor, SenseWear ® as well as systemic inflammation: b-eosinophils, p-fibrinogen, p-CRP, s-IL-6 and s-CD 163. SPI was defined as PAL &lt;1.4. Results: At baseline, SPI was present in 31 of the 57 patients included, and 23% (7/31) improved to non-SPI after PR. We observed no differences between patients with SPI and non-SPI, except baseline plasma fibrinogen level was slightly yet significantly higher in patients with SPI (median 13.3 [6.2–23.6] vs 11.2 [6.5–16.7] µmol/l) but change in fibrinogen levels differed insignificantly between patients who improved to non-SPI at follow-up compared to patients with persistent SPI (−0.6 [−16.9–9.9] vs −0.4 [−11.2–1.2] µmol/l). Conclusion: SPI in COPD appears not to be associated with a distinct inflammatory profile compared to less sedentary COPD patients attending pulmonary rehabilitation. Currently biomarkers have no role in the detection of SPI in COPD.</p

Attendance rate and perceived relevance related to type, content, and delivery of current rehabilitation programmes after surgical resection for non-small cell lung cancer

Background: Surgical resection is the preferred treatment for localised non-small cell lung cancer (NSCLC). Rehabilitation is central in the management of the associated impaired quality of life, high symptom burden, deconditioning, and social-existential vulnerability. Yet, optimal content and delivery of rehabilitation are not yet defined. Therefore, we aimed to investigate the current rehabilitation offers, attendance rate, and perceived relevance related to content or delivery. Moreover, we investigated the current symptom burden in the patients. Methods: We conducted an observational cohort study in patients who had undergone surgical resection for NSCLC 4–6 months earlier at Odense University Hospital, Denmark. We retrieved demographic data from patient registries, and interviewed patients via telephone concerning availability, uptake, and attendance rate of any rehabilitation offer in their local primary care setting; content and delivery; benefits of attending, experienced relevance and “symptom burden generally” (specially developed questions); and “symptom burden here and now” [Edmonton Symptom Assessment Scale (ESAS)]. Results: We approached 128 patients, reached 115, and interviewed the 100 (87%) patients who consented. In total, 88% (88/100) had received a rehabilitation offer, and 75% (66/88) had participated in programmes that either targeted NSCLC (23%) or were general cancer rehabilitation (33%), pulmonary rehabilitation (12%), online (1%), or other (33%). Disease-specific rehabilitation was significantly related to the highest attendance rate and perception of relevance. High attendance (≥75%) was, moreover, significantly related to the offer being delivered by a physiotherapist and having a focus on physical exercise. General symptoms were physically oriented [dyspnoea (65%), pain (47%), fatigue (78%)] and “mild” in ESAS scoring. No differences were observed in any baseline characteristics. Conclusions: Rehabilitation after surgical resection for localised NSCLC is delivered heterogeneously in Denmark. Disease-specific rehabilitation was positively related to attendance rate and to the perceived relevance of the offer.</p