A controlled study of community-based exercise training in patients with moderate COPD.

BackgroundThe effectiveness of clinic-based pulmonary rehabilitation in advanced COPD is well established, but few data exist for less severe patients treated in alternative settings. The purpose of this study was to investigate whether a novel, community-based exercise program (CBE) was feasible and effective for patients with moderate COPD.MethodsNineteen patients with moderate COPD (mean FEV1 62%) and self-reported exercise impairment were randomized to 12-weeks of progressive endurance and strength training at a local health club under the guidance of a certified personal trainer, or to continuation of unsupervised habitual physical activity. Outcomes assessed at baseline and 12 weeks included session compliance, intensity adherence, treadmill endurance time, muscle strength, dyspnea, and health status.ResultsCompliance was 94% and adherence was 83%. Comparisons between CBE and control groups yielded the following mean (SEM) differences in favor of CBE: endurance time 134 (74) seconds versus -59 (49) seconds (P=0.041) and TDI 5.1 (0.8) versus -0.2 (0.5) (P<0.001). The CBE group increased muscle strength (weight lifted) by 11.8 kilograms per subject per week of training (P<0.001). SGRQ was not significantly changed.ConclusionsWe demonstrated the feasibility and effectiveness of a novel community-based exercise program involving health clubs and personal trainers for patients with moderate COPD.Trial registrationClinicalTrials.gov Identifier NCT01985529

New Spirometry Indices for Detecting Mild Airflow Obstruction.

The diagnosis of chronic obstructive pulmonary disease (COPD) relies on demonstration of airflow obstruction. Traditional spirometric indices miss a number of subjects with respiratory symptoms or structural lung disease on imaging. We hypothesized that utilizing all data points on the expiratory spirometry curves to assess their shape will improve detection of mild airflow obstruction and structural lung disease. We analyzed spirometry data of 8307 participants enrolled in the COPDGene study, and derived metrics of airflow obstruction based on the shape on the volume-time (Parameter D), and flow-volume curves (Transition Point and Transition Distance). We tested associations of these parameters with CT measures of lung disease, respiratory morbidity, and mortality using regression analyses. There were significant correlations between FEV1/FVC with Parameter D (r = -0.83; p < 0.001), Transition Point (r = 0.69; p < 0.001), and Transition Distance (r = 0.50; p < 0.001). All metrics had significant associations with emphysema, small airway disease, dyspnea, and respiratory-quality of life (p < 0.001). The highest quartile for Parameter D was independently associated with all-cause mortality (adjusted HR 3.22,95% CI 2.42-4.27; p < 0.001) but a substantial number of participants in the highest quartile were categorized as GOLD 0 and 1 by traditional criteria (1.8% and 33.7%). Parameter D identified an additional 9.5% of participants with mild or non-recognized disease as abnormal with greater burden of structural lung disease compared with controls. The data points on the flow-volume and volume-time curves can be used to derive indices of airflow obstruction that identify additional subjects with disease who are deemed to be normal by traditional criteria

Desensitization to dyspnea in COPD with specificity for exercise training mode

Patients with chronic obstructive pulmonary disease (COPD) exhibit improved exercise capacity after physical training due to reconditioning and improved ventilatory efficiency. Other possible effects are improved ventilatory muscle function and desensitization to dyspnea. We compared general physical training (GPT), consisting of walking and stair climbing exercises, with inspiratory muscle training (IMT), consisting of targeted breathing through inspiratory resistances, in two groups with severe COPD. Seven subjects; age 60 (8) years, forced expiratory volume in one second (FEV1) 0.84 (0.35) L, arterial oxygen tension (PaO2) 11.1 (0.8) kPa, arterial carbon dioxide tension (PaCO2) 4.9 (0.3) kPa, had GPT and nine subjects; age 60 (9) years, FEV1 0.83 (0.31) L, PaO2 10.4 (0.8) kPa, PaCO2 4.4 (0.5) kPa had IMT. Each group trained daily for 30 minutes for eight weeks and 70% of the sessions were supervised. Six minute walking distance increased in both groups: 32 m (6.9% P < 0.05) with GPT and 23 m (4.8%; P < 0.05) with IMT but significant improvements in symptom-limited incremental cycle exercise performance were not detected. Breathlessness by visual analog scale was reduced following 6-minute walks after GPT (P < 0.05) but not after IMT. Following maximal incremental tests, breathlessness scores were unchanged for both groups. COPD patients performing regular physical exercise report reductions in breathlessness which are specific to the exercise training mode

Effect of Natriuretic Peptide-Guided Therapy on Hospitalization or Cardiovascular Mortality in High-Risk Patients With Heart Failure and Reduced Ejection Fraction: A Randomized Clinical Trial.

Importance: The natriuretic peptides are biochemical markers of heart failure (HF) severity and predictors of adverse outcomes. Smaller studies have evaluated adjusting HF therapy based on natriuretic peptide levels ( guided therapy ) with inconsistent results. Objective: To determine whether an amino-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided treatment strategy improves clinical outcomes vs usual care in high-risk patients with HF and reduced ejection fraction (HFrEF). Design, Settings, and Participants: The Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure (GUIDE-IT) study was a randomized multicenter clinical trial conducted between January 16, 2013, and September 20, 2016, at 45 clinical sites in the United States and Canada. This study planned to randomize 1100 patients with HFrEF (ejection fraction ≤40%), elevated natriuretic peptide levels within the prior 30 days, and a history of a prior HF event (HF hospitalization or equivalent) to either an NT-proBNP-guided strategy or usual care. Interventions: Patients were randomized to either an NT-proBNP-guided strategy or usual care. Patients randomized to the guided strategy (n = 446) had HF therapy titrated with the goal of achieving a target NT-proBNP of less than 1000 pg/mL. Patients randomized to usual care (n = 448) had HF care in accordance with published guidelines, with emphasis on titration of proven neurohormonal therapies for HF. Serial measurement of NT-proBNP testing was discouraged in the usual care group. Main Outcomes and Measures: The primary end point was the composite of time-to-first HF hospitalization or cardiovascular mortality. Prespecified secondary end points included all-cause mortality, total hospitalizations for HF, days alive and not hospitalized for cardiovascular reasons, the individual components on the primary end point, and adverse events. Results: The data and safety monitoring board recommended stopping the study for futility when 894 (median age, 63 years; 286 [32%] women) of the planned 1100 patients had been enrolled with follow-up for a median of 15 months. The primary end point occurred in 164 patients (37%) in the biomarker-guided group and 164 patients (37%) in the usual care group (adjusted hazard ratio [HR], 0.98; 95% CI, 0.79-1.22; P = .88). Cardiovascular mortality was 12% (n = 53) in the biomarker-guided group and 13% (n = 57) in the usual care group (HR, 0.94; 95% CI; 0.65-1.37; P = .75). None of the secondary end points nor the decreases in the NT-proBNP levels achieved differed significantly between groups. Conclusions and Relevance: In high-risk patients with HFrEF, a strategy of NT-proBNP-guided therapy was not more effective than a usual care strategy in improving outcomes. Trial Registration: clinicaltrials.gov Identifier: NCT01685840

Methods of rehabilitation in chronic obstructive pulmonary disease

Selected aspects of pulmonary rehabilitation (PR) were examined in subjects with chronic obstructive pulmonary disease (COPD) seeking objective evidence of improvements in exercise tolerance, respiratory muscle function, symptoms and survival prospects. Each group of subjects had moderately severe airflow obstruction and every effort was made to select subjects without reversibility of airflow obstruction so as to dissociate any physiological changes accompanying bronchodilatation from those genuinely due to improvement in other modalities. Two supervised methods of physical training were compared over eight weeks. General physical training, consisting of timed walking and stair climbing, increased the six-minute walking distance by 7% in seven subjects. Respiratory muscle training consisting of targeted inspiratory resistance breathing, increased walking distance by 5% in nine subjects. A significant reduction in breathlessness was observed which appeared to be specific for walking assessment after general physical training. Acute and chronic administration of aminophyl1ine, giving mean plasma theophylline levels within the accepted therapeutic range, improved airflow obstruction despite the selection of subjects. Acute administration increased walking distance by 6% and produced evidence of increased respiratory drive. Chronic administration increased maximum exercise ventilation by 11% and maximum oxygen uptake by 10%. None of these studies produced evidence of change in respiratory muscle strength. Long-term oxygen therapy (LTOT) improved survival prospects in 72 subjects with hypoxic cor pulmonale. Pulmonary haemodynamics were stable in 45 subjects after 12 months of LTOT. The benefit was apparent soon after commencement of LTOT and the survival curves were similar for males and females. Survival was closely related to the degree of airflow obstruction but not to arterial blood gas tensions or pulmonary haemodynamics. Death rate accelerated after about ten years indicating that the benefit was temporary. In general, the changes which v/ere observed with different aspects of PR were modest reflecting wide individual variations in response. Future endeavours need to identify specific clinical or pathophysiological features which are associated with potential improvements. This approach will lead to the rational selection of subjects for particular forms of treatment and the appropriate use of resources

Clergy work-related satisfactions in parochial ministry: the influence of personality and churchmanship

The aim of this study was to test several hypotheses that clergy work-related satisfaction could be better explained by a multidimensional rather than a unidimensional model. A sample of 1071 male stipendiary parochial clergy in the Church of England completed the Clergy Role Inventory, together with the short-form Revised Eysenck Personality Questionnaire. Factor analysis of the Clergy Role Inventory identified five separate clergy roles: Religious Instruction, Administration, Statutory Duties (conducting marriages and funerals), Pastoral Care, and Role Extension (including extra-parochial activities). Respondents also provided an indication of their predispositions on the catholic-evangelical and liberal-conservative dimensions. The significant associations of the satisfactions derived from each of the roles with the demographic, personality, and churchmanship variables were numerous, varied, and, with few exceptions, small in magnitude. Separate hierarchical regressions for each of the five roles indicated that the proportion of total variance explained by churchmanship was, in general, at least as great as that explained by personality, and was greater for three roles: Religious Instruction, Statutory Duties, and Role Extension. It was concluded that clergy satisfactions derived from different roles are not uniform and that churchmanship is at least as important as personality in accounting for clergy work satisfaction

Educating novice practitioners to detect elder financial abuse: A randomised controlled trial

© 2014 Harries et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.This article has been made available through the Brunel Open Access Publishing Fund.Background - Health and social care professionals are well positioned to identify and intervene in cases of elder financial abuse. An evidence-based educational intervention was developed to advance practitioners’ decision-making in this domain. The objective was to test the effectiveness of a decision-training educational intervention on novices’ ability to detect elder financial abuse. The research was funded by an E.S.R.C. grant reference RES-189-25-0334. Methods - A parallel-group, randomised controlled trial was conducted using a judgement analysis approach. Each participant used the World Wide Web to judge case sets at pre-test and post-test. The intervention group was provided with training after pre-test testing, whereas the control group were purely given instructions to continue with the task. 154 pre-registration health and social care practitioners were randomly allocated to intervention (n78) or control (n76). The intervention comprised of written and graphical descriptions of an expert consensus standard explaining how case information should be used to identify elder financial abuse. Participants’ ratings of certainty of abuse occurring (detection) were correlated with the experts’ ratings of the same cases at both stages of testing. Results - At pre-test, no differences were found between control and intervention on rating capacity. Comparison of mean scores for the control and intervention group at pre-test compared to immediate post-test, showed a statistically significant result. The intervention was shown to have had a positive moderate effect; at immediate post-test, the intervention group’s ratings had become more similar to those of the experts, whereas the control’s capacity did not improve. The results of this study indicate that the decision-training intervention had a positive effect on detection ability. Conclusions - This freely available, web-based decision-training aid is an effective evidence-based educational resource. Health and social care professionals can use the resource to enhance their ability to detect elder financial abuse. It has been embedded in a web resource at http://www.elderfinancialabuse.co.uk.ESR

Design of the Subpopulations and Intermediate Outcome Measures in COPD (SPIROMICS) AIR Study.

IntroductionPopulation-based epidemiological evidence suggests that exposure to ambient air pollutants increases hospitalisations and mortality from chronic obstructive pulmonary disease (COPD), but less is known about the impact of exposure to air pollutants on patient-reported outcomes, morbidity and progression of COPD.Methods and analysisThe Subpopulations and Intermediate Outcome Measures in COPD (SPIROMICS) Air Pollution Study (SPIROMICS AIR) was initiated in 2013 to investigate the relation between individual-level estimates of short-term and long-term air pollution exposures, day-to-day symptom variability and disease progression in individuals with COPD. SPIROMICS AIR builds on a multicentre study of smokers with COPD, supplementing it with state-of-the-art air pollution exposure assessments of fine particulate matter, oxides of nitrogen, ozone, sulfur dioxide and black carbon. In the parent study, approximately 3000 smokers with and without airflow obstruction are being followed for up to 3 years for the identification of intermediate biomarkers which predict disease progression. Subcohorts undergo daily symptom monitoring using comprehensive daily diaries. The air monitoring and modelling methods employed in SPIROMICS AIR will provide estimates of individual exposure that incorporate residence-specific infiltration characteristics and participant-specific time-activity patterns. The overarching study aim is to understand the health effects of short-term and long-term exposures to air pollution on COPD morbidity, including exacerbation risk, patient-reported outcomes and disease progression.Ethics and disseminationThe institutional review boards of all the participating institutions approved the study protocols. The results of the trial will be presented at national and international meetings and published in peer-reviewed journals

Design of Materials for IR Detectors Using High Z Elements for High Energy Radiation Environment

There is a strong need for rad hard and high operating temperature IR detectors for space environment. Heavy metal Selenides (high Z and large density) have been investigated for more than half century for high operating temperature mid wave infrared (MWIR) applications. Most of the efforts have been devoted to make detector arrays on high-resistivity Si substrates for operating wavelengths in the 1.5 to 5.0 m region using physical vapor transport grown poly crystalline materials. For most of the biological spectral and imaging applications, short wave infrared (SWIR) detectors have shown better performance. Recent growth materials have shown variation in morphology with slight change in growth conditions and hence variation in performance parameters such as bandgap, mobility and resistivity from sample to sample. We have performed growth and optical characterization of binary materials CdSe-PbSe to determine the suitability for IR detector. We have determined bandgap using several theoretical models for different morphologies observed during growth on silicon wafers