Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016.

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

The IRYSS-COPD appropriateness study: objectives, methodology, and description of the prospective cohort

<p>Abstract</p> <p>Background</p> <p>Patients with chronic obstructive pulmonary disease (COPD) often experience exacerbations of the disease that require hospitalization. Current guidelines offer little guidance for identifying patients whose clinical situation is appropriate for admission to the hospital, and properly developed and validated severity scores for COPD exacerbations are lacking. To address these important gaps in clinical care, we created the IRYSS-COPD Appropriateness Study.</p> <p>Methods/Design</p> <p>The RAND/UCLA Appropriateness Methodology was used to identify appropriate and inappropriate scenarios for hospital admission for patients experiencing COPD exacerbations. These scenarios were then applied to a prospective cohort of patients attending the emergency departments (ED) of 16 participating hospitals. Information was recorded during the time the patient was evaluated in the ED, at the time a decision was made to admit the patient to the hospital or discharge home, and during follow-up after admission or discharge home. While complete data were generally available at the time of ED admission, data were often missing at the time of decision making. Predefined assumptions were used to impute much of the missing data.</p> <p>Discussion</p> <p>The IRYSS-COPD Appropriateness Study will validate the appropriateness criteria developed by the RAND/UCLA Appropriateness Methodology and thus better delineate the requirements for admission or discharge of patients experiencing exacerbations of COPD. The study will also provide a better understanding of the determinants of outcomes of COPD exacerbations, and evaluate the equity and variability in access and outcomes in these patients.</p

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

Outcome measures used in pulmonary rehabilitation in patients with acute exacerbation of chronic obstructive pulmonary disease: a systematic review

Conflicting results about the effects of community-based pulmonary rehabilitation in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) exist, possibly because the variety of outcome measures used and the lack of appropriate measurement properties hinder the development of pulmonary rehabilitation guidelines. PURPOSE: The purpose of this study was to identify and review the measurement properties of patient-reported outcome measures (PROMs) and clinical outcome measures of AECOPD that are used in pulmonary rehabilitation and that can be easily applied in a community setting. DATA SOURCES: PubMed, Web of Science, Scopus, and CINAHL were searched up to July 1, 2016. STUDY SELECTION: Phase 1 identified outcome measures used in pulmonary rehabilitation for AECOPD. Phase 2 reviewed the measurement properties of the identified outcome measures. DATA EXTRACTION: One reviewer extracted the data and 2 reviewers independently assessed the methodological quality of the studies and the measurement properties of the outcome measures by using the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations. DATA SYNTHESIS: Twenty-three PROMs and 18 clinical outcome measures were found. The outcome measures most used were the St George Respiratory Questionnaire (n = 15/37 studies) and the 6-minute walk test (n = 21/37 studies). Thirty-two studies described the measurement properties of 22 PROMs and 7 clinical outcome measures. The methodological quality of the studies was mostly poor, and the measurement properties were mostly indeterminate. The outcome measure exhibiting more robust properties was the COPD Assessment Test. LIMITATIONS: A number of studies were published without the validated search strategy used and were included a posteriori ; the fact that 3 studies presented combined results for patients who were stable and patients with exacerbation, affected the conclusions that can be drawn. CONCLUSIONS: A large variety of outcome measures have been used; however, studies on their measurement properties are needed to enhance the understanding of community pulmonary rehabilitation for AECOPD

Bacteria isolated in the sputum of exacerbated patients with chronic obstructive airways disease and sensitivy to common antibiotics

Aim: To examine sputum microbiologic profile in COPD exacerbations and its relationship with indexes of severity of disease and severity of exacerbation. The antibiotic treatment is also assessed as well as the microbial susceptibility pattern. Furthermore the outcome of COPD patients is assessed and related to sputum microbiologic profile, severity of disease and severity of exacerbation. Patients and Methods: Appropriate sputum samples, collected within 3 hours from admission, were included in the analysis and quantitative cultures were performed. COPD severity was estimated by FEV1, Medical Research Council (MRC) chronic dyspnoea scale, hospitalization the year before admission, serum albumin, body mass index (BMI) and long term oxygen treatment (LTOT). Exacerbation severity was estimated by PaCO2, Acute Physiology and Chronic Health Evaluation (APACHE) II score and the presence of purulent sputum. The outcome of patients was assessed by three-year mortality and length of hospital stay (LOS). Results: Eligible for analysis were 103 patients stratified in: group Α, 64 patients with normal flora, and group B, 39 with positive cultures. Group B was subdivided in B1, 27 patients with pathogens other than Pseudomonas aeruginosa, and B2, 12 patients with P. aeruginosa. FEV1 and BMI were higher and APACHE II score lower in group A than in group B (p<0.05). Less patients had purulent sputum in group A than in group B (p<0.05). Comparisons among all groups showed that B2 patients had the lowest FEV1 and the highest APACHE II score (p<0.05). All patients received antibiotics on admission although bacterial aetiology of the exacerbation was proved microbiologically in 37.9%, and half of them received inappropriate antibiotic treatment. In-hospital mortality was 3.9% and three-year mortality 42.2%. LOS was 8.91±0.55 days. Survival was inversely related to MRC score, PaCO2, APACHE II score, LTOT and hospitalizations and positively related to serum albumin (p values< 0.05), but the MRC score was the only independent determinant of survival (p<0.001 OR= 7.71 and 95% CI 2.36-25.212). Survival was not related to the microbiologic profile although LOS was positively related to it, as well as to the MRC score (p<0.05) which was the most important determinant of LOS (p<0.05 OR= 3.09 and 95% CI 1.16-8.26). Conclusion: Bacterial COPD exacerbations and especially those of P. aeruginosa characterize both more severe disease and more severe exacerbation. The MRC dyspnoea score at stable condition before the last exacerbation was the best predictor of length of hospital stay and survival.Σκοπός: Να εξετάσουμε τη μικροβιακή χλωρίδα των πτυέλων στις παροξύνσεις ΧΑΠ και τη σχέση της με δείκτες σοβαρότητας της υποκείμενης νόσου και δείκτες σοβαρότητας της παρόξυνσης. Μελετάμε επίσης τη λαμβανόμενη αντιβίωση και την ευαισθησία των απομονωθέντων μικροβίων σε αυτή. Tέλος εκτιμάται η έκβαση των ασθενών και συσχετίζεται με τη χλωρίδα, τη σοβαρότητα της νόσου και της παρόξυνσης. Υλικό και Μέθοδος: Κατάλληλα δείγματα πτυέλων που συλλέγησαν μέσα σε τρεις ώρες από την εισαγωγή των ασθενών συμπεριλήφθηκαν στην ανάλυση και πραγματοποιήθηκαν ποσοτικές καλλιέργειες. Η σοβαρότητα της ΧΑΠ εκτιμήθηκε με το FEV1, την κλίμακα χρόνιας δύσπνοιας Medical Research Council (MRC), την παρουσία νοσηλείας το προηγούμενο έτος, την αλβουμίνη ορού, το δείκτη μάζας σώματος (BMI) και τη χορήγηση συνεχούς κατ’οίκον οξυγονοθεραπείας (LTOT). Η σοβαρότητα της παρόξυνσης εκτιμήθηκε με τη μερική πίεση του διοξειδίου (PaCO2), την αξιολόγηση της οξείας φυσιολογίας και χρόνιας κατάστασης της υγείας (APACHE) II score και την παρουσία πυώδους απόχρεμψης. Η έκβαση των ασθενών εκτιμήθηκε με την τριετή θνητότητα και τη διάρκεια νοσηλείας (LOS). Αποτελέσματα: Στη μελέτη συμπεριλήφθησαν 103 ασθενείς που χωρίστηκαν στην: Ομάδα Α που περιλάμβανε 64 ασθενείς με φυσιολογική χλωρίδα και στην ομάδα Β που περιλάμβανε 39 ασθενείς με θετικές καλλιέργειες. Η ομάδα B χωρίστηκε εκ νέου στις υποομάδες B1 με 27 ασθενείς με παθογόνους μικροοργανισμούς εκτός P. αeruginosa και στην υποομάδα B2 με 12 ασθενείς με P. aeruginosa. FEV1 και BMI ήταν υψηλότερα και το APACHE II score χαμηλότερο στην ομάδα A από ότι στην ομάδα B (p<0.05). Λιγότεροι ασθενείς είχαν επίσης πυώδη απόχρεμψη στην ομάδα Α (p<0.05). Συγκρίσεις μεταξύ όλων των ομάδων έδειξαν ότι η υποομάδα B2 είχε το χαμηλότερο FEV1 και το υψηλότερο APACHE II score (p<0.05). Όλοι οι ασθενείς έλαβαν αντιβιοτικά στην εισαγωγή τους αν και βακτηριακή αιτιολογία της παρόξυνσης τεκμηριώθηκε στο 37.9%, εκ των οποίων οι μισοί έλαβαν κατάλληλη αγωγή. Η ενδονοσοκομειακή θνητότητα ήταν 3.9% και η θνητότητα στην τριετία 42.2%. Η διάρκεια νοσηλείας ήταν 8.91±0.55 ημέρες. Η επιβίωση συσχετιζόταν αντίστροφα με το βαθμό δύσπνοιας MRC, το PaCO2, APACHE II score, LTOT και τις νοσηλείες και θετικά με την αλβουμίνη ορού (p values< 0.05), με το βαθμό δύσπνοιας MRC να είναι ο μόνος ανεξάρτητος καθοριστικός παράγοντας της επιβίωσης (p<0.001 OR= 7.71 και 95% CI 2.36-25.212). Η επιβίωση δε συσχετιζόταν με τη μικροβιακή χλωρίδα. Αντίθετα η LOS συσχετιζόταν με τη χλωρίδα όπως και με το βαθμό δύσπνοιας MRC (p<0.05), ο οποίος ήταν ο καθοριστικός παράγοντας της LOS (p<0.05 OR= 3.09 και 95% CI 1.16-8.26). Συμπέρασμα: Βακτηριακής αιτιολογίας παροξύνσεις ΧΑΠ και ειδικά όταν ο εμπλεκόμενος μικροοργανισμός είναι η P. aeruginosa χαρακτηρίζουν ασθενείς με πιο σοβαρή υποκείμενη νόσο και πιο σοβαρή παρόξυνση. Ο βαθμός δύσπνοιας με την κλίμακα MRC είναι ο καλύτερος προγνωστικός δείκτης της διάρκειας νοσηλείας και της επιβίωσης

Pulmonary fibrosis predating microscopic polyangiitis by seven years

A 63-year-old man, ex-smoker with renal failure of recent onset was admitted at the respiratory department with massive haemoptysis. Previous X-rays and CT scans showed pulmonary fibrosis of seven-year duration. Subsequently, he developed high fever, large haemoptysis, new infiltrates and respiratory failure despite broad-spectrum antibiotic treatment. Antineutrophilic antibodies of the perinuclear type with specificity against myeloperoxidase were detected and microscopic polyangiitis was diagnosed. Immunosuppressive treatment with methylprednisolone pulses and cyclophosphamide was started with initially favorable response, but later the patient developed a hospital-acquired pneumonia which was treated successfully with meropenem. As pulmonary haemorrhage recurred, he was transferred to intensive care for plasmapheresis which was considered the last treatment option. Unfortunately he died from septic shock. Conclusion: Asymptomatic pulmonary fibrosis can predate microscopic polyangiitis by several years and is associated with unfavorable prognosis of the vasculitis. Appreciation of this finding would lead to faster diagnosis and better management of these patients. © 2009 Elsevier Ltd