Multimorbidity in patients with COPD and pulmonary rehabilitation

Background: Chronic Obstructive Pulmonary Disease (COPD) is a major health challenge, with an increasing morbidity and mortality worldwide. COPD is associated with several comorbidities, including skeletal muscle loss and dysfunction and osteoporosis, which impact the patient’s quality of life and increase the risk of falls and fractures. Pulmonary rehabilitation (PR) is a core management for COPD and has been proven to improve dyspnoea, exercise capacity, and quality of life. The PR programme includes patient education, exercise training, and psychosocial/behavioural intervention that aim to reduce COPD symptoms and enhance the patient’s quality of life. COPD guidelines recommend that patients with COPD who have Medical Research Council dyspnoea score of grade 3 or worse should be referred to PR. However, the pattern of PR referral in the UK is unknown. Large primary care data may provide the opportunity to explore the patterns of PR referral among the population of patients with COPD. Furthermore, to evaluate the quality of the PR service, the clinical outcomes of patient performance after PR should be assessed. Data from a recent UK National COPD audit programme PR workstream may facilitate quality control by allowing comparisons of patients’ performances between different programmes. Method: A systematic review was undertaken to assess the impact of PR on two outcomes: survival and falls (balance). Using The Health Improvement Network (THIN) database, a large database of UK primary care records, the recording of the PR events among patients diagnosed with COPD were analysed. A survival analysis was also conducted, which compared patients with records of PR and those without. Using this large dataset, a comparison of the incidence of falls between age- and sex-matched patients with COPD and individuals without COPD was conducted. Subsequently, the UK National COPD audit programme PR workstream data were used for two investigations. First, due to the differences in the capacities of PR programmes across the UK, the effect of these variations on the clinical outcomes associated with PR was investigated. Second, the number of patients who underwent PR assessment and performed a practice exercise walk test during PR baseline assessment, along with its association with the clinical response of PR, were investigated. Results: An assessment of PR recording in THIN showed that only 9.8% of patients with COPD have ever had a coded PR record. The systematic review demonstrated some evidence of the benefits of PR on balance but it had no effect on survival. However, the survival evidence from the THIN primary care data analysis found that patients with a record of PR on at least one occasion were 22% less likely to die than those with no record [adjusted hazard ratio (aHR) 0.78; 95% CI 0.69 – 0.88]. The investigation of the incidence of falls in THIN showed that patients with COPD were 55% more likely to have a recorded incidence of a fall than the non-COPD subjects (aHR, 1.55; 95% CI, 1.50 to 1.59) The investigation of the National COPD audit programme data showed that larger PR programmes with high staff/patient ratios were better at enrolling patients within three months of referral and achieved minimal clinical importance differences in the 6-minute walk test. Only 22.6% of patients who were assessed for PR had a practice exercise walk test at assessment. The practice walk test was significantly related to better baseline exercise distance, better enrolment and completion rates, and better improvement in dyspnoea scores. Conclusion: The low incidence of PR recording among patients with COPD in UK primary care records demonstrates the need for further strategies to improve pulmonary rehabilitation recording. Moreover, the demonstrated increased risk of falls in patients with COPD in THIN suggests a need for fall risk assessments at COPD diagnosis. The audit analysis demonstrated an enrolment delay more than 90 days of referral at small PR programmes, which could worsen the patient’s condition. Furthermore, the second audit analysis found that a substantial proportion of patients who were assessed for PR had not had a practice exercise walk test at their baseline assessment. The analysis also demonstrated its role in maximising the PR benefits and suggested the importance of issues that limit its application to PR programmes

The use of the practice walk test in pulmonary rehabilitation program: National COPD Audit Pulmonary Rehabilitation Workstream

Our aim was to evaluate the use and impact of the practice walk test on enrolment, completion, and clinical functional response to pulmonary rehabilitation (PR) using the 2015 UK National Chronic Obstructive Pulmonary Disease (COPD) Pulmonary Rehabilitation audit data. Patients were assessed according to whether a baseline practice walk test was performed or not. Study outcomes included use of the practice walk test, baseline and change in incremental shuttle walk test distance (ISWD) or 6-minute walk test distance (6MWD), and enrolment to and completion of PR program. Of 7,355 patients, only 1,666 (22.6%) had a baseline practice test. At baseline, the practice walk test group walked further as compared to the no practice walk test group: ISWD, 17.9 m [95% confidence interval (CI) 8.2–27.5 m] and 6MWD, 34.8 m (95% CI 24.7–44.9 m). The practice walk test group were 2.2 times (95% CI 1.8–2.6) more likely to enroll and 17% (95% CI 1.03–1.34) more likely to complete PR. Although the change in ISWD and 6MWD with PR was lower in the practice walk test group, they walked further at discharge assessment. Only 22.6% of the patients in the 2015 National PR audit had a practice walk test at assessment. Those who did had better enrolment, completion, and better baseline walking distance, from which the prescription is set

Risk of fall in patients with COPD

A matched cohort study was conducted to determine the incidence of falls in patients following a diagnosis of COPD using a UK primary care database. 44 400 patients with COPD and 175 545 non-COPD subjects were identified. The incidence rate of fall per 1000 person-years in patients with COPD was higher (44.9; 95% CI 44.1 to 45.8) compared with non-COPD subjects (24.1; 95% CI 23.8 to 24.5) (P<0.0001). Patients with COPD were 55% more likely to have an incident record of fall than non-COPD subjects (adjusted HR, 1.55; 95% CI 1.50 to 1.59). The greater falls risk in patients with COPD needs consideration and modifiable factors addressed

The effect of pulmonary rehabilitation on mortality, balance, and risk of fall in stable patients with chronic obstructive pulmonary disease: a systematic review

Objectives: To evaluate the impact of pulmonary rehabilitation on survival and fall (including balance) in patients with chronic obstructive pulmonary disease (COPD) at stability. Design: Systematic Review. Methods: OVID, MEDLINE, EMBASE, and Cochrane Collaboration Library were searched for literature dating from January 1980 up to November 2014 as well as an update in October 2015. Two reviewers screened titles, abstracts and full text records, extracted data and assessed studies for risk of bias; any disagreements were resolved by a third member of the team, and consensus was always sought. Results: Initial searches yielded 3216 records but after review, only 7 studies were included and no studies focused solely on falls. Two cohort studies found some positive benefits of pulmonary rehabilitation on balance but the results were inconsistent across the studies. Regarding survival, two randomised controlled trials were conducted; one study showed significant survival benefit at 1 year while the other one showed non-significant survival benefit at 3 years. Neither were adequately powered and in both, survival was a secondary outcome. Conclusions: There was only limited inconclusive evidence to show that pulmonary rehabilitation has a significant beneficial effect on balance or survival

Spontaneous Rupture of Malarial Spleen: Report of Two Cases

Malaria is endemic in many tropical and subtropical regions of the world, including Saudi Arabia. The infection has serious consequences in those residing in non endemic regions on travelling to endemic areas, due to lack of immunity to the parasite. In this report, we describe the clinical course of two patients who travelled to a malaria endemic area. Both contracted the infection and presented with splenic rupture. They received splenectomy in addition to the appropriate antimalarial medications, with successful outcome

Thermal and mechanical properties of hemp fabric-reinforced nanoclay-cement nano-composites

The influence of nanoclay on thermal and mechanical properties of hemp fabric-reinforced cement composite is presented in this paper. Results indicate that these properties are improved as a result of nanoclay addition. An optimum replacement of ordinary Portland cement with 1 wt% nanoclay is observed through improved thermal stability, reduced porosity and water absorption as well as increased density, flexural strength, fracture toughness and impact strength of hemp fabric-reinforced nanocomposite. The microstructural analyses indicate that the nanoclay behaves not only as a filler to improve the microstructure but also as an activator to promote the pozzolanic reaction and thus improve the adhesion between hemp fabric and nanomatrix

Mechanical properties of cotton fabric reinforced geopolymer composites at 200-1000 °C

Geopolymer composites containing woven cotton fabric (0–8.3 wt%) were fabricated using the hand lay-up technique, and were exposed to elevated temperatures of 200 °C, 400 °C, 600 °C, 800 °C and 1000 °C. With an increase in temperature, the geopolymer composites exhibited a reduction in compressive strength, flexural strength and fracture toughness. When heated above 600 °C, the composites exhibited a significant reduction in mechanical properties. They also exhibited brittle behavior due to severe degradation of cotton fibres and the creation of additional porosity in the composites. Microstructural images verified the existence of voids and small channels in the composites due to fibre degradation

Multimorbidity in patients with COPD and pulmonary rehabilitation

Background: Chronic Obstructive Pulmonary Disease (COPD) is a major health challenge, with an increasing morbidity and mortality worldwide. COPD is associated with several comorbidities, including skeletal muscle loss and dysfunction and osteoporosis, which impact the patient’s quality of life and increase the risk of falls and fractures. Pulmonary rehabilitation (PR) is a core management for COPD and has been proven to improve dyspnoea, exercise capacity, and quality of life. The PR programme includes patient education, exercise training, and psychosocial/behavioural intervention that aim to reduce COPD symptoms and enhance the patient’s quality of life. COPD guidelines recommend that patients with COPD who have Medical Research Council dyspnoea score of grade 3 or worse should be referred to PR. However, the pattern of PR referral in the UK is unknown. Large primary care data may provide the opportunity to explore the patterns of PR referral among the population of patients with COPD. Furthermore, to evaluate the quality of the PR service, the clinical outcomes of patient performance after PR should be assessed. Data from a recent UK National COPD audit programme PR workstream may facilitate quality control by allowing comparisons of patients’ performances between different programmes. Method: A systematic review was undertaken to assess the impact of PR on two outcomes: survival and falls (balance). Using The Health Improvement Network (THIN) database, a large database of UK primary care records, the recording of the PR events among patients diagnosed with COPD were analysed. A survival analysis was also conducted, which compared patients with records of PR and those without. Using this large dataset, a comparison of the incidence of falls between age- and sex-matched patients with COPD and individuals without COPD was conducted. Subsequently, the UK National COPD audit programme PR workstream data were used for two investigations. First, due to the differences in the capacities of PR programmes across the UK, the effect of these variations on the clinical outcomes associated with PR was investigated. Second, the number of patients who underwent PR assessment and performed a practice exercise walk test during PR baseline assessment, along with its association with the clinical response of PR, were investigated. Results: An assessment of PR recording in THIN showed that only 9.8% of patients with COPD have ever had a coded PR record. The systematic review demonstrated some evidence of the benefits of PR on balance but it had no effect on survival. However, the survival evidence from the THIN primary care data analysis found that patients with a record of PR on at least one occasion were 22% less likely to die than those with no record [adjusted hazard ratio (aHR) 0.78; 95% CI 0.69 – 0.88]. The investigation of the incidence of falls in THIN showed that patients with COPD were 55% more likely to have a recorded incidence of a fall than the non-COPD subjects (aHR, 1.55; 95% CI, 1.50 to 1.59) The investigation of the National COPD audit programme data showed that larger PR programmes with high staff/patient ratios were better at enrolling patients within three months of referral and achieved minimal clinical importance differences in the 6-minute walk test. Only 22.6% of patients who were assessed for PR had a practice exercise walk test at assessment. The practice walk test was significantly related to better baseline exercise distance, better enrolment and completion rates, and better improvement in dyspnoea scores. Conclusion: The low incidence of PR recording among patients with COPD in UK primary care records demonstrates the need for further strategies to improve pulmonary rehabilitation recording. Moreover, the demonstrated increased risk of falls in patients with COPD in THIN suggests a need for fall risk assessments at COPD diagnosis. The audit analysis demonstrated an enrolment delay more than 90 days of referral at small PR programmes, which could worsen the patient’s condition. Furthermore, the second audit analysis found that a substantial proportion of patients who were assessed for PR had not had a practice exercise walk test at their baseline assessment. The analysis also demonstrated its role in maximising the PR benefits and suggested the importance of issues that limit its application to PR programmes