Prednisolone response in patients with chronic obstructive pulmonary disease: results from the ISOLDE study

BACKGROUND: A trial of corticosteroids has been recommended for all patients with chronic obstructive pulmonary disease (COPD), with the subsequent "response" determining the treatment selected. This approach assumes that patients can be reliably divided into responder and non-responder groups. We have assessed whether such a separation is statistically valid, which factors influence the change in forced expiratory volume in 1 second (FEV(1)) after prednisolone, and whether the prednisolone response predicts 3 year changes in FEV(1), health status, or number of exacerbations during placebo or fluticasone propionate treatment. METHODS: Oral prednisolone 0.6 mg/kg was given for 14 days to 524 patients with COPD before randomised treatment for 3 years with fluticasone propionate or placebo. Factors relating to change in FEV(1) after prednisolone were investigated using multiple regression. The response to prednisolone was entered into separate mixed effects models of decline in FEV(1) and health status during the 3 years of the study. RESULTS: The post-bronchodilator FEV(1) increased by a mean 60 ml (CI 46 to 74) after prednisolone with a wide unimodal distribution. Current smoking was the factor most strongly associated with the change in FEV(1) after prednisolone, with an increase of 35 ml in current smokers and 74 ml in confirmed ex-smokers (p<0.001). There was no relationship between the change in FEV(1) after prednisolone and the response to inhaled bronchodilators, baseline FEV(1), atopic status, age, or sex. The response to prednisolone, however expressed, was unrelated to the subsequent change in FEV(1) over the following 3 years on either placebo or fluticasone propionate. Regression to the mean effects explained much of the apparent prednisolone response. The significant effect of treatment on decline in health status was not predicted by the prednisolone response. CONCLUSION: Patients with COPD cannot be separated into discrete groups of corticosteroid responders and non-responders. Current smoking reduces the FEV(1) response to prednisolone. Prednisolone testing is an unreliable predictor of the benefit from inhaled fluticasone propionate in individual patients.     

Effects of exercise training on physical impairment,arterial stiffness and health-related quality of life in patients with chronic kidney disease: a pilot study

Background  

Patients with chronic kidney disease (CKD) have impaired performance in physical tasks, lower health-related quality of life and high cardiovascular morbidity and mortality. Moderate intensity exercise has been shown to provide cardiovascular and metabolic benefits in healthy individuals and patients without CKD. Long-term exercise training is recommended as a vital component in the management of a number of chronic diseases. This randomized controlled pilot project examined the effects of exercise in predialysis CKD patients.     

Non-volitional assessment of skeletal muscle strength in patients with chronic obstructive pulmonary disease

BACKGROUND: Although quadriceps weakness is well recognised in chronic obstructive pulmonary disease (COPD), the aetiology remains unknown. In disabled patients the quadriceps is a particularly underused muscle and may not reflect skeletal muscle function as a whole. Loss of muscle function is likely to be equally distributed if the underlying pathology is a systemic abnormality. Conversely, if deconditioning and disuse are the principal aetiological factors, weakness would be most marked in the lower limb muscles. METHODS: The non-volitional technique of supramaximal magnetic stimulation was used to assess twitch tensions of the adductor pollicis, quadriceps, and diaphragm muscles (TwAP, TwQ, and TwPdi) in 22 stable non-weight losing COPD patients and 18 elderly controls. RESULTS: Mean (SD) TwQ tension was reduced in the COPD patients (7.1 (2.2) kg v 10.0 (2.7) kg; 95% confidence intervals (CI) -4.4 to -1.4; p<0.001). Neither TwAP nor TwPdi (when corrected for lung volume) differed significantly between patients and controls (mean (SD) TwAP 6.52 (1.90) N for COPD patients and 6.80 (1.99) N for controls (95% CI -1.5 to 0.97, p=0.65; TwPdi 23.0 (5.6) cm H(2)O for COPD patients and 23.5 (5.2) cm H(2)O for controls (95% CI -4.5 to 3.5, p=0.81). CONCLUSIONS: The strength of the adductor pollicis muscle (and the diaphragm) is normal in patients with stable COPD whereas quadriceps strength is substantially reduced. Disuse may be the principal factor in the development of skeletal muscle weakness in COPD, but a systemic process preferentially affecting the proximal muscles cannot be excluded.     

Levalbuterol in the treatment of patients with asthma and chronic obstructive lung disease

Effective asthma control requires long-term (anti-inflammatory) controller medications for patients with mild-persistent to severe-persistent disease, and quick-relief bronchodilator medication for all patients with asthma to control intermittent symptoms of cough, wheeze, and bronchoconstriction, as well as acute exacerbations. For patients with chronic obstructive pulmonary disease, quick-relief and long-acting bronchodilators are primarily used in the maintenance and treatment of associated symptoms, including shortness of breath. For many years, the most widely used bronchodilator has been racemic (R, S)-albuterol, a short-acting beta2-adrenergic agonist, commonly dispensed as an inhaled aerosol or solution. Until the introduction of levalbuterol inhalation solution (Xopenex) in 1999, all marketed forms of albuterol (including Ventolin and Proventil brands) were racemic mixtures composed of a 1:1 ratio of (R)- and (S)-stereoisomers. Administered as a proportionally equivalent nebulized dose, levalbuterol [(R)-albuterol] provides greater bronchodilation than racemic albuterol and, in the appropriate clinical setting, offers the possibility for improving clinical outcomes in patients with asthma and other obstructive airway diseases. Additionally, levalbuterol can be given at lower doses than racemic albuterol to provide comparable bronchodilation, with the potential for reduced beta-mediated adverse effects in adults and children. Only since the past decade has the technology to separate stereoisomers become available, and thus the biologic activities of the albuterol stereoisomers had not been established. Binding studies have demonstrated that (R)-albuterol binds to the beta2-adrenergic receptor with a high affinity, whereas (S)-albuterol binds with 100-fold less affinity than (R)-albuterol. Other evaluations have suggested that (R)-albuterol possesses the bronchodilatory, bronchoprotective, and ciliary-stimulatory properties of racemic albuterol, while (S)-albuterol does not contribute beneficially to the therapeutic effects of the racemate and was originally assumed to be inert. However, preclinical evaluations have shown that (S)-albuterol has effects that work in opposition to (R)-albuterol and may diminish the therapeutic effects of (R)-albuterol.     

Safety and tolerability of local treatment with iloprost, a prostacyclin analogue, in patients with Peyronie's disease: a phase I study

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Peyronie's disease (PD) is an acquired curvature of the penis attributable to progressive fibromatosis of the tunica albuginea (TA). It is frequently associated with Dupuytren's contracture and those of Ledderhose. More recently it was found that patients suffering from PD also often suffer from diabetes mellitus and gout. Cigarette smoking and the intake of large amounts of alcohol are considered risk factors for PD.The exact aetiology of the disease is unknown, however, the trauma hypothesis is shared by most authors. According to this theory, repeated sexual microtrauma in people genetically predisposed could cause PD. The inflammatory process leads to the formation of fibrosis and plaques. Plaque can lead to penile curvature and may reduce its functionality. Pain is the most common symptom of early‐stage disease. In the late stages the pain disappears, but erectile dysfunction may occur. Surgical treatment is available, but this exposes the patient to a greater risk of erectile dysfunction and it is most frequently associated with a reduction in the length of the penis. The rationale for local medical therapy is to use a treatment that acts on the initial phase of the disease by reducing and stopping the processes that lead to fibrosis, thus stabilizing the disease. Systemic medical therapy is usually accompanied by high rates of recurrence. Many authors consider local drug therapy more appropriate. Local treatment consists of several types of medication, but results are often sub‐optimal. Anti‐inflammatory or immunoregulatory therapy, either systemic or topical, has shown some efficacy when administered early in the disease by modulating the inflammatory response and attenuating the alteration of tissue repair. Unfortunately, in most cases, patients are first seen when the plaque is chronically inflamed, stabilized and sometimes already calcified. We have tested a biological drug for intralesional administration for the first time. We chose iloprost, an analogue of prostacyclin I2, for its theoretically favourable properties. If used i.v., it has been shown to be effective in treating vascular ischaemic disease such as thromboangioitis obliterans, peripheral arterial occlusive disease, Raynaud's phenomenon and systemic sclerosis. The rationale for the therapeutic use of iloprost in the late stages of PD is based on the assumption that activation of fibrinolysis induced by the drug would be able to determine a regression of the plaque with a consequent reduction of the curvature on erection. The main purpose of this phase I study was to evaluate the safety and tolerability of this drug injected in the context of the fibrous plaque on a small number of patients before designing a large‐scale randomized trial. According to the results,therapy with intralesional iloprost in Peyronie's disease seems to be safe and tolerated and is a possible alternative to surgery.

OBJECTIVE

• ? To assess the safety and tolerability of intralesional injections of iloprost (an I2 prostacyclin analogue) for its ability to suppress the production of connective tissue growth factor in fibroblasts, for the treatment of Peyronie's disease (PD).

PATIENTS AND METHODS

• ? A total of 38 patients with PD were preliminarily assessed according to symptoms, the degree of penile curvature and the size and number of plaques.
• ? Each patient received weekly intralesional injections of iloprost 200 ng in 1 mL normal saline for 5 weeks. If tolerated, the single dose was increased weekly to the maximum of 400 ng (2 mL).
• ? All the patients were preliminarily evaluated using at‐home photography and were re‐evaluated 2 months after the end of the treatment regimen.
• ? There was no placebo control group in this phase I study.

RESULTS

• ? Almost all patients showed mild side effects (burning or pain) during the treatment at the site of injection.
• ? All patients tolerated well a iloprost dose of 200 ng; 19 patients reached a 300 ng dose and 14 tolerated a 400 ng dose without showing side effects.
• ? A total of 29% of the patients showed an improvement in curvature.

CONCLUSION

• ? The results show that therapy with intralesional iloprost is a possible alternative to surgery for Peyronie's disease.

     

Operations for patients with coronary arterial obstructive disease and aortic disease

Forty three patients combined with the coronary artery obstructive disease (CAOD) and the aortic disease (AoD) were classified into 5 groups. Group I: Nine patients underwent simultaneous surgical treatment for CAOD and AoD). Two patients died from non cardiac origins. Group II: Fourteen patients underwent the coronary artery bypass graft (CABG) prior to the operation for AoD. There was no operative death. Group III: There were 12 patients who underwent surgical treatment for AoD only. There were 3 operative deaths and 2 of them died from myocardial infarction. Group IV: There were 3 patients who underwent operation for AoD prior to CABG. Two of them were diagnosed CAOD at more than 22 months after the operation for AoD. Group V: Five patients who underwent no operation for CAOD or AoD. There were three deaths during the follow up period. The causes of their deaths were cardiac or non cardiac.     

慢性阻塞性肺疾病患者延迟就医原因的质性研究

目的明确慢性阻塞性肺疾病(COPD)患者延迟就医的原因,为引导COPD患者及时就医提供参考。方法对15例延迟就医的COPD患者进行半结构式访谈,采用质性研究内容分析法对访谈资料分析与提炼。结果受访者延迟就医时间20～90 d。延迟就医原因提炼出5个主题,分别是自行处理与暂时缓解、判断疾病错误、妥协疾病症状、就医能力不足、医疗条件限制。结论 COPD患者延迟就医现象普遍,患者及家属应学会正确判断就医时机,改变不良就医习惯;医护人员及社会相关部门需重视患者及家属的健康教育,并提供必要的支持,引导COPD患者及时就医。     

Exercise in patients with chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) may incur exercise limitation by any one or combination of disturbances in breathing mechanics, oxygen transport, respiratory muscle metabolism or respiratory regulation and sensation. In spite of the increased ventilation demand/capacity ratio in these patients, the relationship between breathing mechanics, respiratory muscle fatigue, the adequacy of alveolar ventilation and the development of exertional dyspnoea is neither clearly defined nor predictable from data obtained with the patient at rest. The issue of oxygen transport during exercise has been complicated by confusion between arterial hypoxia and inadequate volume of oxygen transported to the tissues, which frequently may differ qualitatively and quantitatively. The cardiac output response to exercise in patients with COPD is therefore critical in determining oxygen transport. This response is also impossible to predict from resting lung mechanics, pulmonary arterial blood pressure, arterial oxygen tension or clinical disease profile. Without exercise testing, which includes measurement of all the variables mentioned, it is impossible to define clearly the cause of exercise-induced symptoms in patients with COPD. Exercise training with and without supplemental oxygen has been shown to improve exercise tolerance in these patients, but the precise mechanism of this improvement remains obscure.     

慢性阻塞性肺疾病患者术后肺炎的预防与处理

术后肺炎(postoperative pneumonia,PP)属医院感染性肺炎(院内肺炎),是术后常见的肺部并发症。慢性阻塞性肺疾病(chronic obstructive pul monary disease,COPD)是一种以气流受限为特征的肺部疾病,通常呈进行性发展,不完全可逆,多与肺部对有害颗粒物或有害气体的异常炎症反应有关。由于阻塞性通气功能障碍,合并全小叶肺气肿时尚有弥散量降低,因此,对心肺功能有影响的麻醉和手术均可导致呼吸功能的恶化而使病情加重。由于心肺功能的改变,使麻醉、术前、术后的管理与一般患者不同,应加强围手术期的管理,以减少PP的发生。一、COPD的特点与…     

Improved physical performance outcomes after functional restoration treatment in patients with chronic low-back pain. Early versus recent training results

Functional restoration, a medically supervised team treatment approach that addresses deficits that accompany the deconditioning process in patients with chronic low-back pain, has emerged as a viable rehabilitation alternative. While the primary emphasis of this treatment approach has remained unchanged since its inception over 6 years ago, recent rapid advances in quantification technology and understanding of the complexity of the chronic low-back pain (CLBP) syndrome have led to more sophisticated and aggressive rehabilitation efforts. In the current study, the authors examined two groups of patients with CLBP, from the treatment program's initial (n = 45) and most recent years (n = 57) of operation, respectively, to determine if the evolution of the treatment program has resulted in increased gains in physical capacity between these groups of patients. Patients in each group were assessed on measures of isokinetic trunk strength and spinal range of motion at program admission and discharge. Both groups demonstrated improved physical capacity levels, but the recent group also demonstrated considerably higher physical capacity levels than the early group, at both program admission and discharge. It was concluded that functional restoration continues to be successful with CLBP patients, and that increased preprogram training and education may facilitate a more rapid elimination of inhibitory factors (ie, pain, fear of reinjury), which often impede and slow physical training.     

Conservative treatment results of the acute and chronic mallet finger

BACKGROUND: In the treatment of the acute ligamentous mallet finger, conservative therapy with a Stack or Winterstein splint is an established approach, though there are many different conservative therapy regimes. There are even more therapy options for the chronic mallet finger (more than 4 weeks old) including different operation techniques. MATERIAL AND METHODS: In a retrospective study, 44 patients with an acute and 33 patients with a chronic ligamentous mallet finger treated with a Stack or Winterstein splint were investigated. RESULTS: The results in both groups are satisfactory (SD <10 degrees : 70.5% in the acute, 87.9% in the chronic lesions). The subjective satisfaction (scale 1-6) was high in both groups. It was even significantly higher in the group with the chronic lesions (acute: 2.55+/-1.63, chronic: 1.82+/-1.38). In both groups there was no correlation between an initially high extension deficit and a bad therapy outcome. CONCLUSIONS: Also in chronic ligamentous mallet finger, conservative therapy should be attempted before an operation, irrespective of the initial extension deficit, especially because the stress and the therapy risk for the patient with this therapy is small.     

Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study

BACKGROUND: Information about the influence of regular physical activity on the course of chronic obstructive pulmonary disease (COPD) is scarce. A study was undertaken to examine the association between regular physical activity and both hospital admissions for COPD and all-cause and specific mortality in COPD subjects. METHODS: From a population-based sample recruited in Copenhagen in 1981-3 and 1991-4, 2386 individuals with COPD (according to lung function tests) were identified and followed until 2000. Self-reported regular physical activity at baseline was classified into four categories (very low, low, moderate, and high). Dates and causes of hospital admissions and mortality were obtained from Danish registers. Adjusted associations between physical activity and hospital admissions for COPD and mortality were obtained using negative binomial and Cox regression models, respectively. RESULTS: After adjustment for relevant confounders, subjects reporting low, moderate or high physical activity had a lower risk of hospital admission for COPD during the follow up period than those who reported very low physical activity (incidence rate ratio 0.72, 95% confidence interval (CI) 0.53 to 0.97). Low, moderate and high levels of regular physical activity were associated with an adjusted lower risk of all-cause mortality (hazard ratio (HR) 0.76, 95% CI 0.65 to 0.90) and respiratory mortality (HR 0.70, 95% CI 0.48 to 1.02). No effect modification was found for sex, age group, COPD severity, or a background of ischaemic heart disease. CONCLUSIONS: Subjects with COPD who perform some level of regular physical activity have a lower risk of both COPD admissions and mortality. The recommendation that COPD patients be encouraged to maintain or increase their levels of regular physical activity should be considered in future COPD guidelines, since it is likely to result in a relevant public health benefit.     

深度呼吸联合排痰训练对稳定期COPD患者的影响

目的观察深度呼吸与排痰训练护理对稳定期COPD患者排痰及肺功能的影响。方法将57例稳定期COPD患者随机分为排痰训练组(A组)、深度呼吸训练组(B组)、深度呼吸训练与排痰训练组(C组)各19例,三组在常规药物治疗的基础上分别给予排痰训练、深度呼吸训练、深度呼吸联合排痰训练,训练4周后,对三组患者的排痰量、肺功能进行测试。结果训练后,三组排痰及肺功能情况均有改善,C组肺功能显著优于A、B组(均P0.05)。结论深度呼吸联合排痰训练可有效改善稳定期COPD患者的肺功能情况。     

Prevalence of depression in patients with chronic obstructive pulmonary disease: a systematic review

BACKGROUND—Patients with chronic obstructive pulmonary disease (COPD) have repeatedly been characterised as a population of chronically ill patients with a higher than normal prevalence of depression. Susceptibility for depression has been noted in patients with certain other chronic conditions. This systematic review was conducted to achieve a more definite answer to the question: do patients with COPD show a higher than normal prevalence of depression?METHODS—Studies in English language journals were retrieved by an electronic search over the period from 1966 to December 1997 and by an extended search of reference lists, and were included or excluded according to a system of diagnostic and methodological criteria.RESULTS—Ten studies were included, of which only four had a case-control design. Three of the case-control studies reported an increased prevalence of depression among patients with COPD which was statistically significant in only one. The fourth controlled study found a significantly increased depression score among COPD patients. Of the remaining six uncontrolled studies three found a high baseline prevalence of depression among their study group.CONCLUSIONS—An association between COPD and depression was found in the four controlled studies. The two methodologically best conducted studies that did not detect a statistically significant higher prevalence lacked power. The two studies that did find a significant association used a questionable depression measure. The prevalence of depression was high compared with general population figures in three of six non-controlled studies. The empirical evidence for a significant risk of depression in patients with COPD remains inconclusive, due to the poor methodological quality of most of the published studies, the lack of studies with an adequate sample size, and variability in instruments and cut off scores used to measure depression.     

Risk factors for osteoporosis in Caucasian patients with moderate chronic obstructive pulmonary disease: a case control study

The prevalence of osteoporosis is high in chronic obstructive pulmonary disease (COPD) patients. The gold standard for the diagnosis of osteoporosis is bone mineral density (BMD) measurements as assessed by dual energy absorptiometry (DXA) scanning as well as vertebral fractures as assessed by instant vertebral assessment (IVA). The aim of this study was to compare COPD GOLD II patients (that is, patients with moderate COPD, stage II, according to the GOLD classification) with osteoporosis (cases) to COPD GOLD II patients without osteoporosis (controls) to identify risk factors for osteoporosis. The diagnosis of osteoporosis was based on BMD and vertebral fractures. Cases (n=49) were matched for gender, age and forced expiratory volume in the first second to controls (n=49). We assessed pulmonary function, body composition, vitamin D, emphysema score (by high-resolution computer tomography), medical history and medication use in all patients. Variables that were significantly different between the cases and controls were included in a logistic regression analysis. COPD patients with osteoporosis had a significantly lower body mass index (BMI) and higher residual volume as the percentage of total lung capacity (RV%TLC) compared to COPD patients without osteoporosis. Decreasing BMI and increasing RV%TLC increased the odds ratio for osteoporosis. Overweight and obese BMI values were protective for osteoporosis. Screening for osteoporosis should be performed even in moderate COPD patients, especially in those with a low BMI and/or a high RV%TLC.     

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慢性阻塞性肺疾病(COPD)是一种以气流受限为特征的疾病，通常呈进行性发展，不完全可逆，多与肺部对有害颗粒物或有害气体的异常炎症反应有关。病人由于阻塞性通气功能障碍，合并全小叶肺气肿时尚有弥散量降低，为此，对心肺功能有影响的麻醉和手术均可导致呼吸功能的恶化。因此，我们要对COPD病人的围手术期处理引起足     

Immediate effects of osteopathic manipulative treatment in elderly patients with chronic obstructive pulmonary disease

CONTEXT: Osteopathic manipulative treatment (OMT) has long been advocated for patients with respiratory disorders, but little definitive evidence exists to support its use in this population. OBJECTIVE: To investigate the immediate effect of OMT on pulmonary function parameters in elderly subjects with chronic obstructive pulmonary disease. METHODS: Subjects aged 65 years or older with a forced expiratory volume in 1 second to forced vital capacity ratio of less than 70% were recruited and randomly assigned to receive either OMT or sham therapy. The OMT protocol consisted of seven standardized osteopathic manipulative techniques, while the sham therapy protocol comprised light touch applied to the same anatomic regions and for the same duration (20 min). All subjects received baseline and posttreatment pulmonary function testing. A telephone survey was conducted 1 day after the intervention to collect subjective feedback and assess the success of blinding protocols. RESULTS: Of the 35 study participants, 18 were randomly assigned to the OMT group and 17 to the sham group. Compared with the sham group, the OMT group showed a statistically significant decrease in the forced expiratory flow at 25% and 50% of vital capacity and at the midexpiratory phase; the expiratory reserve volume; and airway resistance. The OMT group also had a statistically significant increase in the residual volume, total lung capacity, and the ratio of those values compared with the sham group. Most subjects (82%, OMT group; 65%, sham group) reported breathing better after receiving their treatment. Only 53% of subjects in the OMT group and 41% in the sham group correctly guessed their group assignment. CONCLUSION: Results suggest an overall worsening of air trapping during the 30 minutes immediately following one multitechnique OMT session relative to the sham group.