Minimal versus specialist equipment for the delivery of pulmonary rehabilitation in COPD

Background: Evidence for pulmonary rehabilitation(PR)largely comes from trials where the intervention used specialist aerobic and/or resistance equipment.Limited data exist to demonstrate the efficacy of PR in community settings with minimal equipment. Aims: To compare completion rates and outcomes in COPD patients undergoing PR in a community setting with minimal equipment(PR-min)with a matched sample undergoing PR in a gym setting with specialist aerobic and resistance equipment(PR-gym). Methods: Using propensity score matching,318 patients with COPD referred for 8 weeks of PR-min were matched 1:1 with a control group of 318 patients who undertook 8 weeks of PR-gym. Completion rate(attendance≥8 supervised sessions)and changes in incremental shuttle walk(ISW),Chronic Respiratory Disease Questionnaire(CRQ)and quadriceps maximal voluntary contraction(QMVC)were compared. Results: Groups were matched for age(70.8v70.7years),FEV1%predicted(46.8v45.8),ISW(192v195m),%current smoking status(19v20)and depression scores(6.5v6.6).No between group differences were seen in ISW,CRQ or QMVC change. Completion rates were better in the PR-gym(73%)as opposed to the PR-min(64%);p=0.01. Conclusion: This case-control study shows that PR-min had similar benefits to PR-gym.A randomised non-inferiority trial is needed to confirm the findings of this study

Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study

BACKGROUND: Frailty is an important clinical syndrome that is consistently associated with adverse outcomes in older people. The relevance of frailty to chronic respiratory disease and its management is unknown. OBJECTIVES: To determine the prevalence of frailty among patients with stable COPD and examine whether frailty affects completion and outcomes of pulmonary rehabilitation. METHODS: 816 outpatients with COPD (mean (SD) age 70 (10) years, FEV1% predicted 48.9 (21.0)) were recruited between November 2011 and January 2015. Frailty was assessed using the Fried criteria (weight loss, exhaustion, low physical activity, slowness and weakness) before and after pulmonary rehabilitation. Predictors of programme non-completion were identified using multivariate logistic regression, and outcomes were compared using analysis of covariance, adjusting for age and sex. RESULTS: 209/816 patients (25.6%, 95% CI 22.7 to 28.7) were frail. Prevalence of frailty increased with age, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Medical Research Council (MRC) score and age-adjusted comorbidity burden (all p≤0.01). Patients who were frail had double the odds of programme non-completion (adjusted OR 2.20, 95% CI 1.39 to 3.46, p=0.001), often due to exacerbation and/or hospital admission. However, rehabilitation outcomes favoured frail completers, with consistently better responses in MRC score, exercise performance, physical activity level and health status (all p<0.001). After rehabilitation, 71/115 (61.3%) previously frail patients no longer met case criteria for frailty. CONCLUSIONS: Frailty affects one in four patients with COPD referred for pulmonary rehabilitation and is an independent predictor of programme non-completion. However, patients who are frail respond favourably to rehabilitation and their frailty can be reversed in the short term

Identification of landmarks on lower limb joint from CT images for kinematics studies. A totally semi-automatic procedure

The identification of an accurate, reliable and patient specific coordinate system for a bone is fundamental to analyze the kinematics of a human joint. The accuracy in the localization of anatomical landmarks of joint surfaces is extremely important because even a small variation in their positions could induce a high variation in the definition of anatomical axes and further on the kinematics output. The aim of this study was to develop and validate a semi-automatic, accurate, and reproducible routine able to identify the position of anatomical landmarks on joint surfaces. This routine, starting form a CT of a femoral bone, used as input, is able to identify semi-automatically the femoral head and the medial and lateral distal femoral condyles. Moreover it allows the identification of the following anatomical landmarks: the Femoral Hip Center (FHC), the Femoral Medial Epicondyle (FME) and the Femoral Lateral Epicondyle (FLE). From these points a standard coordinate system of the femur is univocally determined according to previous literature works. Compared to other commercial process, extensive used in this field, one peculiarity of this routine is that it is not necessary to generate the 3D model of the joint in order to define the anatomical landmarks. Usually, to generate a 3D lower limb model, with the commercial process, 4 to 5 hours are needed, with this approach we can significantly reduce this time. To validate the routine we analyze ten different CT of lower limbs. Two different tests were performed. The first test was performed to verify and check the output geometry of the model; the second test was aimed to estimate the repeatability and reproducibility of the procedure. For such task five different operators identified for each model the three anatomical landmarks, three times each. The Intra-Class Correlation coefficient (ICC) values (intra and inter) obtained for the landmarks were always higher than 0.996. Comparing the results obtained with this routine with the results obtained using largely used commercial software we found a significant reduction of the error as regards the evaluation of landmarks in terms of inter and intra-observer variability. For example, in the worst condition, on the identification of the femoral lateral condyle point (FLE), the same operator found an average and maximum distance between the real point and the landmark found of respectively 3.5 and 8.8 mm with the use of the commercial software and of respectively 0.8 and 0.9 mm with the use of our routine

Physical frailty and pulmonary rehabilitation in COPD:a prospective cohort study

BACKGROUND: Frailty is an important clinical syndrome that is consistently associated with adverse outcomes in older people. The relevance of frailty to chronic respiratory disease and its management is unknown. OBJECTIVES: To determine the prevalence of frailty among patients with stable COPD and examine whether frailty affects completion and outcomes of pulmonary rehabilitation. METHODS: 816 outpatients with COPD (mean (SD) age 70 (10) years, FEV(1)% predicted 48.9 (21.0)) were recruited between November 2011 and January 2015. Frailty was assessed using the Fried criteria (weight loss, exhaustion, low physical activity, slowness and weakness) before and after pulmonary rehabilitation. Predictors of programme non-completion were identified using multivariate logistic regression, and outcomes were compared using analysis of covariance, adjusting for age and sex. RESULTS: 209/816 patients (25.6%, 95% CI 22.7 to 28.7) were frail. Prevalence of frailty increased with age, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Medical Research Council (MRC) score and age-adjusted comorbidity burden (all p≤0.01). Patients who were frail had double the odds of programme non-completion (adjusted OR 2.20, 95% CI 1.39 to 3.46, p=0.001), often due to exacerbation and/or hospital admission. However, rehabilitation outcomes favoured frail completers, with consistently better responses in MRC score, exercise performance, physical activity level and health status (all p<0.001). After rehabilitation, 71/115 (61.3%) previously frail patients no longer met case criteria for frailty. CONCLUSIONS: Frailty affects one in four patients with COPD referred for pulmonary rehabilitation and is an independent predictor of programme non-completion. However, patients who are frail respond favourably to rehabilitation and their frailty can be reversed in the short term

J Can Acad Child Adolesc Psychiatry

Objective: Anxiety-based school refusal in adolescence is a complex, sometimes difficult to treat disorder that can have serious academic and psychiatric consequences. The objective of this qualitative study was to explore how teens with this problem and their parents experience the psychiatric care received. Methods: This qualitative multicenter study took place in France, where we conducted semi-structured interviews with adolescents receiving psychiatric care for anxiety-based school refusal and with their parents. Data collection by purposive sampling continued until we reached theoretical sufficiency. Data analysis was thematic. Results: This study included 20 adolescents aged 12 to 18 years and 21 parents. Two themes emerged from the analysis: (1) the goals of psychiatric care with two sub-themes, "self-transformation" and problem solving; and, (2) the therapeutic levers identified as effective with two sub-themes: time and space and relationships. Conclusion: Our results show a divergence between parents and teens in their representations of care and especially of its goals. Therapeutic and research implications about the terms of return to school within psychiatric care and also the temporality of care are discussed

A common reference frame for describing rotation of the distal femur: a CT-based kinematic study using cadavers

The understanding of rotational alignment of the distal femur is essential in total knee replacement to ensure that there is correct placement of the femoral component. Many reference axes have been described, but there is still disagreement about their value and mutual angular relationship. Our aim was to validate a geometrically-defined reference axis against which the surface-derived axes could be compared in the axial plane. A total of 12 cadaver specimens underwent CT after rigid fixation of optical tracking devices to the femur and the tibia. Three-dimensional reconstructions were made to determine the anatomical surface points and geometrical references. The spatial relationships between the femur and tibia in full extension and in 90 of flexion were examined by an optical infrared tracking system. After co-ordinate transformation of the described anatomical points and geometrical references, the projection of the relevant axes in the axial plane of the femur were mathematically achieved. Inter- and intra-observer variability in the three-dimensional CT reconstructions revealed angular errors ranging from 0.16 to 1.15 for all axes except for the trochlear axis which had an interobserver error of 2. With the knees in full extension, the femoral transverse axis, connecting the centres of the best matching spheres of the femoral condyles, almost coincided with the tibial transverse axis (mean difference -0.8 degrees, SD 2.05). At 90 of flexion, this femoral transverse axis was orthogonal to the tibial mechanical axis (mean difference -0.77 degrees, SD 4.08). Of all the surface-derived axes, the surgical transepicondylar axis had the closest relationship to the femoral transverse axis after projection on to the axial plane of the femur (mean difference 0.21 degrees, SD 1.77). The posterior condylar line was the most consistent axis (range -2.96 degrees to -0.28 degrees, SD 0.77) and the trochlear anteroposterior axis the least consistent axis (range -10.62 degrees to +11.67 degrees, SD 6.12). The orientation of both the posterior condylar line and the trochlear anteroposterior axis (p = 0.001) showed a trend towards internal rotation with valgus coronal alignment