Paradoxical movement of the lower ribcage at rest and during exercise in COPD patients

Paradoxical inward displacement of the costal margin during inspiration is observed in many chronic obstructive pulmonary disease patients at rest but its importance is unclear.The current authors studied 20 patients (forced expiratory volume in one second 32.6 +/- 11.7, functional residual capacity 186 +/- 32% predicted) and 10 healthy controls at rest and during symptom-limited incremental exercise. With optoelectronic plethysmography, the phase shift between pulmonary and abdominal ribcage volumes and the percentage of inspiratory time the ribcage compartments moved in opposite directions were quantified, using control data to define the normal range of movement.Eight patients showed lower ribcage inspiratory paradox at rest (P+), while 12 patients did not (P-). This was unrelated to resting lung function or exercise tolerance. Total end-expiratory chest wall volume (EEVcw) increased immediately when exercise began in P+ patients, but later in exercise in P- patients. This difference in EEVcw was mainly due to a greater increase of end-expiratory pulmonary ribcage volume in P+ patients. During exercise, dyspnoea increased similarly in the two groups, while leg effort increased more markedly in the patients without paradox.In conclusion, lower ribcage paradox at rest is reproducible and associated with early-onset hyperinflation of the chest wall and predominant dyspnoea at end-exercise. When paradox is absent, the sense of leg effort becomes a more important symptom limiting exercise.British Lung FoundationEuropean Respiratory Society (ERS)ERS COEDPolitecn Milan, TBM Lab, Dipartimento Bioingn, I-20133 Milan, ItalyUniv Liverpool, Ctr Clin Sci, Univ Hosp Aintree, Liverpool L69 3BX, Merseyside, EnglandUniversidade Federal de São Paulo, São Paulo, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilEuropean Respiratory Society (ERS): 69Web of Scienc

Predicting Young Adults’ Intentions and Involvement in Alcohol-Influenced Aquatic Activity

Globally, alcohol consumption is a public health issue and a risk factor for drownings among young adults. While studies have identified a prominence of alcohol in youth drownings, little is known about the factors that influence young adults’ involvement in alcohol-influenced aquatic activity. The current study aimed to identify the predictors of young adults’ intention to participate, and past participation, in alcohol-influenced aquatic activity. A reliable and valid survey, informed by the Theory of Planned Behavior, was distributed to young adults (aged 18-24 years) educated in the UK and Australia. Cumulative odds ordinal logistic regressions with proportional odds were conducted to establish predictors. Overall, 182 participants completed the survey. Subjective norms (Wald χ2 (2) = 8.43, p = .015), cognitive attitudes (Wald χ2 (2) = 6.40, p = .041) and previous involvement (χ2 (1) = 8.98, p = .003) were significant predictors of intention, whilst the influence of friends (Wald χ2 (2) = 10.99, p = .004) and intention (Wald χ2 (2) = 10.80, p = .005) were significant predictors of behavior. Practitioners should enhance risk awareness and norm perceptions in prevention programs to encourage informed decision making in social aquatic situations

Does roflumilast decrease exacerbations in severe COPD patients not controlled by inhaled combination therapy? the REACT study protocol.

Many patients with chronic obstructive pulmonary disease (COPD) continue to suffer exacerbations, even when treated with maximum recommended therapy (eg, inhaled combinations of long-acting β(2)-agonist and high dose inhaled corticosteroids, with or without a long-acting anticholinergic [long-acting muscarinic antagonist]). Roflumilast is approved to treat severe COPD in patients with chronic bronchitis - and a history of frequent exacerbations - as an add-on to bronchodilators.PURPOSE:The REACT (Roflumilast in the Prevention of COPD Exacerbations While Taking Appropriate Combination Treatment) study (identification number RO-2455-404-RD, clinicaltrials. gov identifier NCT01329029) will investigate whether roflumilast further reduces exacerbations when added to inhaled combination therapy in patients still suffering from frequent exacerbations.PATIENTS AND METHODS:REACT is a 1-year randomized, double-blind, multicenter, phase III/IV study of roflumilast 500 μg once daily or placebo on top of a fixed long-acting β(2)-agonist/inhaled corticosteroid combination. A concomitant long-acting muscarinic antagonist will be allowed at stable doses. The primary outcome is the rate of moderate or severe COPD exacerbations. Using a Poisson regression model with a two-sided significance level of 5%, a sample size of 967 patients per treatment group is needed for 90% power. COPD patients with severe to very severe airflow limitation, symptoms of chronic bronchitis, and at least two exacerbations in the previous year will be recruited.CONCLUSION:It is hypothesized that because roflumilast (a phosphodiesterase-4 inhibitor) has a different mode of action to bronchodilators and inhaled corticosteroids, it may provide additional benefits when added to these treatments in frequent exacerbators. REACT will be important to determine the role of roflumilast in COPD management. Here, the design and rationale for this important study is described

One-year treatment with mometasone furoate in chronic obstructive pulmonary disease

Many patients with chronic obstructive pulmonary disease (COPD) are treated with twice daily (BID) inhaled corticosteroids (ICS). This study evaluated whether daily PM mometasone furoate administered via a dry powder inhaler (MF-DPI) was equally effective compared to twice daily dosing

Reduction of exacerbations by the PDE4 inhibitor roflumilast - the importance of defining different subsets of patients with COPD

<p>Abstract</p> <p>Background</p> <p>As chronic obstructive pulmonary disease (COPD) is a heterogeneous disease it is unlikely that all patients will benefit equally from a given therapy. Roflumilast, an oral, once-daily phosphodiesterase 4 inhibitor, has been shown to improve lung function in moderate and severe COPD but its effect on exacerbations in unselected populations was inconclusive. This led to the question of whether a responsive subset existed that could be investigated further.</p> <p>Methods</p> <p>The datasets of two previous replicate, randomized, double-blind, placebo-controlled, parallel-group studies (oral roflumilast 500 μg or placebo once daily for 52 weeks) that were inconclusive regarding exacerbations were combined in a post-hoc, pooled analysis to determine whether roflumilast reduced exacerbations in a more precisely defined patient subset.</p> <p>Results</p> <p>The pooled analysis included 2686 randomized patients. Roflumilast significantly decreased exacerbations by 14.3% compared with placebo (p = 0.026). Features associated with this reduction were: presence of chronic bronchitis with or without emphysema (26.2% decrease, p = 0.001), presence of cough (20.9% decrease, p = 0.006), presence of sputum (17.8% decrease, p = 0.03), and concurrent use of inhaled corticosteroids (ICS; 18.8% decrease, p = 0.014). The incidence of adverse events was similar with roflumilast and placebo (81.5% vs 80.1%), but more patients in the roflumilast group had events assessed as likely or definitely related to the study drug (21.5% vs 8.3%).</p> <p>Conclusions</p> <p>This post-hoc, pooled analysis showed that roflumilast reduced exacerbation frequency in a subset of COPD patients whose characteristics included chronic bronchitis with/without concurrent ICS. These observations aided the design of subsequent phase 3 studies that prospectively confirmed the reduction in exacerbations with roflumilast treatment.</p> <p>Trials registration</p> <p>ClinicalTrials.gov identifiers: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00076089">NCT00076089</a> and <a href="http://www.clinicaltrials.gov/ct2/show/NCT00430729">NCT00430729</a>.</p

Relationship between FEV1 change and patient-reported outcomes in randomised trials of inhaled bronchodilators for stable COPD: a systematic review.

BACKGROUND: Interactions between spirometry and patient-reported outcomes in COPD are not well understood. This systematic review and study-level analysis investigated the relationship between changes in FEV1 and changes in health status with bronchodilator therapy. METHODS: Six databases (to October 2009) were searched to identify studies with long-acting bronchodilator therapy reporting FEV1 and health status, dyspnoea or exacerbations. Mean and standard deviations of treatment effects were extracted for each arm of each study. Relationships between changes in trough FEV1 and outcomes were assessed using correlations and random-effects regression modelling. The primary outcome was St George's Respiratory Questionnaire (SGRQ) total score. RESULTS: Thirty-six studies (≥ 3 months) were included. Twenty-two studies (23,654 patients) with 49 treatment arms each contributing one data point provided SGRQ data. Change in trough FEV1 and change in SGRQ total score were negatively correlated (r = -0.46, p < 0.001); greater increases in FEV1 were associated with greater reductions (improvements) in SGRQ. The correlation strengthened with increasing study duration from 3 to 12 months. Regression modelling indicated that 100 mL increase in FEV1 (change at which patients are more likely to report improvement) was associated with a statistically significant reduction in SGRQ of 2.5 (95% CI 1.9, 3.1), while a clinically relevant SGRQ change (4.0) was associated with 160.6 (95% CI 129.0, 211.6) mL increase in FEV1. The association between change in FEV1 and other patient-reported outcomes was generally weak. CONCLUSIONS: Our analyses indicate, at a study level, that improvement in mean trough FEV1 is associated with proportional improvements in health status

Concomitant therapy with Cineole (Eucalyptole) reduces exacerbations in COPD: A placebo-controlled double-blind trial

This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

The effect of posture on asynchronous chest wall movement in COPD

Priori R, Aliverti A, Albuquerque AL, Quaranta M, Albert P, Calverley PM. the effect of posture on asynchronous chest wall movement in COPD. J Appl Physiol 114: 1066-1075, 2013. First published February 14, 2013; doi:10.1152/japplphysiol.00414.2012.-Chronic obstructive pulmonary disease (COPD) patients often show asynchronous movement of the lower rib cage during spontaneous quiet breathing and exercise. We speculated that varying body position from seated to supine would influence rib cage asynchrony by changing the configuration of the respiratory muscles. Twenty-three severe COPD patients (forced expiratory volume in 1 s = 32.5 +/- 7.0% predicted) and 12 healthy age-matched controls were studied. Measurements of the phase shift between upper and lower rib cage and between upper rib cage and abdomen were performed with opto-electronic plethysmography during quiet breathing in the seated and supine position. Changes in diaphragm zone of apposition were measured by ultrasounds. Control subjects showed no compartmental asynchronous movement, whether seated or supine. in 13 COPD patients, rib cage asynchrony was noticed in the seated posture. This asynchrony disappeared in the supine posture. in COPD, upper rib cage and abdomen were synchronous when seated, but a strong asynchrony was found in supine. the relationships between changes in diaphragm zone of apposition and volume variations of chest wall compartments supported these findings. Rib cage paradox was noticed in approximately one-half of the COPD patients while seated, but was not related to impaired diaphragm motion. in the supine posture, the rib cage paradox disappeared, suggesting that, in this posture, diaphragm mechanics improves. in conclusion, changing body position induces important differences in the chest wall behavior in COPD patients.Politecn Milan, Dipartimento Elettron Informaz & Bioingn, I-20133 Milan, ItalyUniversidade Federal de São Paulo, Dept Med, São Paulo, BrazilUniv Liverpool, Univ Hosp Aintree, Ctr Clin Sci, Liverpool L69 3BX, Merseyside, EnglandUniversidade Federal de São Paulo, Dept Med, São Paulo, BrazilWeb of Scienc

Movement and Home Range of Nile Crocodiles in Ndumo Game Reserve, South Africa

The study of movement patterns and home range is fundamental in understanding the spatial requirements of animals and is important in generating information for the conservation and management of threatened species. Ndumo Game Reserve, in north-eastern KwaZulu-Natal, bordering Mozambique, has the third largest Nile crocodile (Crocodylus niloticus) population in South Africa. Movement patterns of 50 Nile crocodiles with a total length of between 202 cm and 472 cm were followed over a period of 18 months, using mark-resight, radio and satellite telemetry. The duration of radio transmitter attachment (131 ± 11.4 days) was significantly and negatively related to total length and reproductive status. Satellite transmitters failed after an average of 15 ± 12.5 days. Home range was calculated for individuals with 10 or more radio locations, spanning a period of at least 6 months. There was a significant relationship between home range size and total length, with sub-adults (1.5 m – 2.5 m) occupying smaller, more localised home ranges than adults (> 2.5 m). The largest home ranges were for adults (> 2.5 m). Home ranges overlapped extensively, suggesting that territoriality, if present, does not result in spatially discrete home ranges of Nile crocodiles in Ndumo Game Reserve during the dry season. Larger crocodiles moved farther and more frequently than smaller crocodiles. The reserve acts as a winter refuge and spring breeding site for an estimated 846 crocodiles, which also inhabit the Rio Maputo during the summer months. Nile crocodile movement out of the reserve and into the Rio Maputo starts in November and crocodiles return to the reserve as water levels in the floodplain recede in May. Conservation implications: Movement patterns of Nile crocodiles show the important role the reserve plays in the conservation of Nile crocodile populations within the greater Ndumo Game Reserve–Rio Maputo area