Predictors of Pulmonary Rehabilitation Completion in the UK

Aim Determine characteristics of people with COPD associated with completion of pulmonary rehabilitation (PR).Methods Cross-sectional analysis of 7060 people with COPD enrolled in PR between 03/01/2017 and 31/03/2017. Data were from a UK national audit of COPD care. Factors associated with PR completion were determined using mixed-effects logistic regression with a random intercept for PR service. Factors chosen for assessment based on clinical judgement and data availability were: age, gender, country, SES, Body Mass Index (BMI), referral location, programme type, start within 90 days, smoking status, oxygen therapy, GOLD stage, MRC grade, any exercise test, and any health status questionnaire.Results 4635 (66%) people with COPD completed a PR programme. People that were 60 years or older, resident in Wales, referred within 90 days, an ex- or never smoker, received an exercise test, or received a health status questionnaire had significantly greater odds of completing PR. People that were in the most deprived quintile, underweight or very severely obese, enrolled in a rolling rather than a cohort programme, had a higher GOLD stage, and had a higher MRC grade had significantly lower odds of completing PR.Conclusion People with COPD were more likely to complete PR when best-practice guidelines were followed. People with more severe COPD symptoms and those enrolled in rolling rather than cohort programmes were less likely to complete PR. Referring people with COPD in the earlier stages of disease, ensuring programmes follow best-practice guidelines, and favouring cohort over rolling programmes could improve rates of PR completion.</div

Lung volume reduction eligibility in patients with COPD completing pulmonary rehabilitation: results from the UK National Asthma and COPD Audit Programme

Objectives To establish what proportion of patients completing a UK pulmonary rehabilitation (PR) programme meet the 2018 National Institute for Health and Care Excellence (NICE) chronic obstructive pulmonary disease (COPD) guideline (NG115) criteria to have a respiratory review to establish whether referral to a lung volume reduction multidisciplinary team would be appropriate. This respiratory review would include evaluation of the presence of hyperinflation and the presence of emphysema on CT scan. The NICE criteria include measures of breathlessness and exercise capacity but these parameters are not completely defined.Design Observational study.Setting PR programmes across the UK in 2015 (210 centres) and 2017 (184 centres) entering data into the Royal College of Physicians’ National Asthma and COPD Audit Programme.Participants 8295 (55.7%) of 14 889 patients in programmes using incremental shuttle walk test (ISWT) or 6-minute walk test (6MWT) as an outcome measure completed PR, and 4856 (32.6%) had complete data recorded (6MWT/ISWT, baseline spirometry, Medical Research Council (MRC) dyspnoea score).Results Depending on the walking test safety threshold adopted for the ISWT (≥140 m or ≥ 80 m) and the MRC dyspnoea score threshold used (MRC score ≥3 or ≥4 at the end of PR), between 4.9% and 18.1% of PR completers met the NICE criteria for a lung volume reduction-focused respiratory review.Conclusions Lung volume reduction therapies are beneficial in appropriately selected patients with COPD, but few procedures are performed, and treatment pathways are unclear. These data help to inform the feasibility of the approach recommended by NICE and highlight the need for future systematic pathways to reduce inequalities in patients being considered for effective treatments.</div

The Use of Genetic Information to Define Idiopathic Pulmonary Fibrosis in UK Biobank

To the Editor: Idiopathic pulmonary fibrosis (IPF) is a rare disease with prevalence of 50 in 100,000 cases in the UK.1 Genome-wide association studies have identified 20 independent single nucleotide polymorphisms (SNPs) that are associated with IPF risk to date.2, 3, 4 A single common SNP in the MUC5B gene promoter region (rs35705950) has a large effect on IPF risk with each copy of the T allele that is associated with a 4- to 5-fold increased risk of IPF.4,5 Most datasets for genetic studies of IPF were derived from dedicated IPF cohort studies, registries, and clinical trials, which are usually modest in size. Large general population cohorts, such as UK Biobank, represent a valuable resource for increasing IPF case sample sizes for molecular epidemiologic studies. However, observed effect size estimates for rs35705950 on IPF risk in general population cohorts, for which cases are defined with the use of the International Classification of Diseases, revision 10 (ICD-10)6 J84.1 code, are smaller than those that are estimated in clinically-derived datasets.7 Although this attenuation could be explained by misclassification of IPF cases, the misclassification may be mitigated by the substantial gain in statistical power that can be leveraged from very large biobanks. However, more accurate classification of cases and control subjects in biobanks could provide more accurate effect estimates for use in further analyses. Given this, we proposed that the IPF risk effect size of rs35705950 could be used to evaluate and refine the choice of codes to define IPF cases. We applied this approach in UK Biobank.</p

Rheumatoid arthritis and idiopathic pulmonary fibrosis: a bidirectional Mendelian randomisation study

BackgroundA usual interstitial pneumonia (UIP) pattern of lung injury is a key feature of idiopathic pulmonary fibrosis (IPF) and is also observed in up to 40% of individuals with rheumatoid arthritis (RA)-associated interstitial lung disease (RA-ILD). The RA-UIP phenotype could result from either a causal relationship of RA on UIP or vice versa, or from a simple co-occurrence of RA and IPF due to shared demographic, genetic or environmental risk factors.MethodsWe used two-sample bidirectional Mendelian randomisation (MR) to test the hypothesis of a causal effect of RA on UIP and of UIP on RA, using variants from genome-wide association studies (GWAS) of RA (separately for seropositive (18 019 cases and 991 604 controls) and seronegative (8515 cases and 1 015 471 controls) RA) and of IPF (4125 cases and 20 464 controls) as genetic instruments. Sensitivity analyses were conducted to assess the robustness of the results to violations of the MR assumptions.FindingsIPF showed a significant causal effect on seropositive RA, with developing IPF increasing the risk of seropositive RA (OR=1.06, 95% CI: 1.04 to 1.08, p</p

Device-assessed sleep and physical activity in individuals recovering from a hospital admission for COVID-19: a multicentre study

Background The number of individuals recovering from severe COVID-19 is increasing rapidly. However, little is known about physical behaviours that make up the 24-h cycle within these individuals. This study aimed to describe physical behaviours following hospital admission for COVID-19 at eight months post-discharge including associations with acute illness severity and ongoing symptoms. Methods One thousand seventy-seven patients with COVID-19 discharged from hospital between March and November 2020 were recruited. Using a 14-day wear protocol, wrist-worn accelerometers were sent to participants after a five-month follow-up assessment. Acute illness severity was assessed by the WHO clinical progression scale, and the severity of ongoing symptoms was assessed using four previously reported data-driven clinical recovery clusters. Two existing control populations of office workers and individuals with type 2 diabetes were comparators. Results Valid accelerometer data from 253 women and 462 men were included. Women engaged in a mean ± SD of 14.9 ± 14.7 min/day of moderate-to-vigorous physical activity (MVPA), with 12.1 ± 1.7 h/day spent inactive and 7.2 ± 1.1 h/day asleep. The values for men were 21.0 ± 22.3 and 12.6 ± 1.7 h /day and 6.9 ± 1.1 h/day, respectively. Over 60% of women and men did not have any days containing a 30-min bout of MVPA. Variability in sleep timing was approximately 2 h in men and women. More severe acute illness was associated with lower total activity and MVPA in recovery. The very severe recovery cluster was associated with fewer days/week containing continuous bouts of MVPA, longer total sleep time, and higher variability in sleep timing. Patients post-hospitalisation with COVID-19 had lower levels of physical activity, greater sleep variability, and lower sleep efficiency than a similarly aged cohort of office workers or those with type 2 diabetes. Conclusions Those recovering from a hospital admission for COVID-19 have low levels of physical activity and disrupted patterns of sleep several months after discharge. Our comparative cohorts indicate that the long-term impact of COVID-19 on physical behaviours is significant.</p

Genetic Associations and Architecture of Asthma-COPD Overlap

Background Some people have characteristics of both asthma and COPD (asthma-COPD overlap), and evidence suggests they experience worse outcomes than those with either condition alone. Research Question What is the genetic architecture of asthma-COPD overlap, and do the determinants of risk for asthma-COPD overlap differ from those for COPD or asthma? Study Design and Methods We conducted a genome-wide association study in 8,068 asthma-COPD overlap case subjects and 40,360 control subjects without asthma or COPD of European ancestry in UK Biobank (stage 1). We followed up promising signals (P Results We selected 31 independent variants for further investigation in stage 2, and discovered eight novel signals (P Interpretation We identified eight signals for asthma-COPD overlap, which may represent loci that predispose to type 2 inflammation, and serious long-term consequences of asthma.</p