COPD und psychische Komorbiditäten

Background

Patients with chronic obstructive pulmonary disease (COPD) suffer not only from pulmonary symptoms but also from additional extrapulmonary symptoms. These include psychological comorbidities, such as anxiety and depression, which can significantly influence the course of the disease.

Objectives

What is known about the prevalence and consequences of anxiety and depression in patients with COPD, the potential causes as well as diagnostics and treatment?

Material and methods

This article describes the identification, compilation and discussion of relevant research literature and gives a review of the current state of research.

Results

Comorbid anxiety and depression are widespread in COPD patients and their relatives and are associated with a considerably worse course of the disease. The exact causes for these findings are largely unclear but presumably include complex interactions between psychological, behavioral, peripheral physiological and neural processes. Psychological comorbidities often remain undetected and untreated in COPD patients. Several anxiolytic and antidepressive interventions seem to be effective in patients with COPD but these require further systematic study.

Conclusion

Comorbid anxiety and depression in patients with COPD are significant health problems, which require intensified future research activities. Besides an improved understanding of the underlying mechanisms and interactions, improvement of detection and treatment of these psychological comorbidities in the daily clinical routine in particular need to receive greater attention.

     

Catheter-Based Renal Denervation for Hypertension

Purpose of Review

This review was undertaken to update readers on the field of therapeutic renal denervation for hypertension during the 2016 through 2018 period.

Recent Findings

After the failure of Symplicity HTN-3 to meet its top line objective, intense scrutiny revealed several possible concerns addressed by the newer investigations into the area of renal denervation. These included better device technology, more intense subject monitoring for off-protocol antihypertensive drug usage, and deeper penetration into the renal vasculature by the interventionist.

Summary

Whether untreated by medication for hypertension or on antihypertensive medication, renal denervation shows a clear, though moderate, blood pressure reduction. The failure of roughly one out of three patients with hypertension to respond to denervation procedures argues that there is room for improvement in choosing the optimal patient for this approach to hypertension management.

     

Mindfulness-Based Stress Reduction for Residents: A Randomized Controlled Trial

Background

Burnout is highly prevalent in residents. No randomized controlled trials have been conducted measuring the effects of Mindfulness-Based Stress Reduction (MBSR) on burnout in residents.

Objective

To determine the effectiveness of MBSR in reducing burnout in residents.

Design

A randomized controlled trial comparing MBSR with a waitlist control group.

Participants

Residents from all medical, surgical and primary care disciplines were eligible to participate. Participants were self-referred.

Intervention

The MBSR consisted of eight weekly 2.5-h sessions and one 6-h silent day.

Main Measures

The primary outcome was the emotional exhaustion subscale of the Dutch version of the Maslach Burnout Inventory–Human Service Survey. Secondary outcomes included the depersonalization and reduced personal accomplishment subscales of burnout, worry, work–home interference, mindfulness skills, self-compassion, positive mental health, empathy and medical errors. Assessment took place at baseline and post-intervention approximately 3 months later.

Key Results

Of the 148 residents participating, 138 (93%) completed the post-intervention assessment. No significant difference in emotional exhaustion was found between the two groups. However, the MBSR group reported significantly greater improvements than the control group in personal accomplishment (p?=?0.028, d?=?0.24), worry (p?=?0.036, d?=?0.23), mindfulness skills (p?=?0.010, d?=?0.33), self-compassion (p?=?0.010, d?=?0.35) and perspective-taking (empathy) (p?=?0.025, d?=?0.33). No effects were found for the other measures. Exploratory moderation analysis showed that the intervention outcome was moderated by baseline severity of emotional exhaustion; those with greater emotional exhaustion did seem to benefit.

Conclusions

The results of our primary outcome analysis did not support the effectiveness of MBSR for reducing emotional exhaustion in residents. However, residents with high baseline levels of emotional exhaustion did appear to benefit from MBSR. Furthermore, they demonstrated modest improvements in personal accomplishment, worry, mindfulness skills, self-compassion and perspective-taking. More research is needed to confirm these results.

     

Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification

Background

Pancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention.

Aim

To introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature.

Methods

We performed an extensive review of the literature on pancreatic fistulae and leaks.

Results

In this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment.

Conclusions

A proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients.

     

Diabetes und Hypertonie

Background

Diabetes mellitus is a disease which leads to vascular damage resulting in subsequent severe cardiovascular complications, such as myocardial infarction and stroke. This process is aggravated by coexisting hypertension.

Objective

This analysis gives a review of the latest study results on prognosis, blood pressure targets, drug therapy and interventional therapy in patients with diabetes and hypertension. Selected studies published in recent years with practical relevance for patients with diabetes and hypertension are presented.

Summary

Patients with simultaneous diabetes and hypertension have a poorer prognosis and a higher cardiovascular risk compared to patients with diabetes but without hypertension. Patients with diabetes and hypertension benefit from interventional blood pressure therapy

     

Mortality Rate in Veterans with Multiple Chronic Conditions

Background

Among patients with multiple chronic conditions, there is increasing appreciation of the complex interrelatedness of diseases. Previous studies have focused on the prevalence and economic burden associated with multiple chronic conditions, much less is known about the mortality rate associated with specific combinations of multiple diseases.

Objective

Measure the mortality rate in combinations of 11 chronic conditions.

Design

Cohort study of veteran health care users.

Participants

Veterans between 55 and 64 years that used Veterans Health Administration health care services between October 1999 and September 2000.

Measurements

Patients were identified as having one or more of the following: COPD, diabetes, hypertension, rheumatoid arthritis, osteoarthritis, asthma, depression, ischemic heart disease, dementia, stroke, and cancer. Mutually exclusive combinations of disease based on these conditions were created, and 5-year mortality rates were determined.

Results

There were 741,847 persons included. The number in each group by a count of conditions was: none?=?217,944 (29.34%); 1?=?221,111 (29.8%); 2?=?175,228 (23.6%); 3?=?86,447 (11.7%); and 4+?=?41,117 (5.5%). The 5-year mortality rate by the number of conditions was: none?=?4.1%; 1?=?6.0%; 2?=?7.8%; 3?=?11.2%; 4+?=?16.7%. Among combinations with the same number of conditions, there was significant variability in mortality rates.

Conclusions

Patients with multiple chronic conditions have higher mortality rates. Because there was significant variation in mortality across clusters with the same number of conditions, when studying patients with multiple coexisting illnesses, it is important to understand not only that several conditions may be present but that specific conditions can differentially impact the risk of mortality.

     

Psychische Rauchstoppbarrieren

Background

The lifetime prevalence of tobacco smoking among chronic obstructive pulmonary disease (COPD) patients is 80?%. This exceeds the population average considerably. Cigarette smoking constitutes the aetiological key factor for COPD. About 80 to 90?% of COPD morbidity is due to tobacco smoking. In the long term, about one in two heavy smokers develop COPD.

COPD and Comorbidity

The majority of COPD incidence could be reduced or the long-term prognosis could be significantly improved by means of effective prevention of tobacco smoking. However, only a small proportion of symptomatic COPD patients are able to successfully complete smoking cessation programmes. Co-occurring psychological comorbidity in COPD patients (lifetime prevalence of clinical depression > 30?%; prevalence of subthreshold depressive symptoms up to 60?%) is far above average.

Discussion

This article discusses potential interrelations among depressiveness and tobacco smoking in patients with COPD and provides recommendations for clinical practice.

     

Biomarkers of Airway Type-2 Inflammation and Integrating Complex Phenotypes to Endotypes in Asthma

Purpose of Review

Over the past decade, the most important advance in the field of asthma has been the widespread recognition that asthma is a heterogeneous disease driven by multiple molecular processes.

Recent Findings

The most well-established molecular mechanism in asthma is increased airway type-2 inflammation, and consequently, non-invasive biomarkers of increased airway type-2 inflammation, such as blood eosinophil counts or blood periostin levels, have proven important in stratifying asthma patients in clinical trials of type-2 cytokine inhibitors. However, it remains ambiguous how well these non-invasive biomarkers represent airway measures of type-2 inflammation in asthma. As a result, the utility of these biomarkers to assist with asthma management or as research tools to better understand asthma pathogenesis remains unclear.

Summary

This article reviews primary data assessing biomarkers of airway type-2 inflammation in asthma and describes how the use of biomarkers can advance a precision medicine approach to asthma treatment.

     

AIMAR survey on complex forms of bronchial asthma and COPD,their management and perception of critical issues

Background

The management of patients with complex forms of bronchial asthma and COPD is not usually addressed in the major international guidelines and management documents which exclusively address pure forms. AIMAR thus undertook a survey to obtain information about: a) the perceived frequency of complex forms of asthma/COPD in adult patients and in the elderly; b) patient management regarding the complex forms (focus on therapeutic goals and consequent treatment); c) the management problems perceived in diagnosis, management, monitoring, indices of appropriateness in pharmacological treatment and adherence to treatment.

Methods

The survey consisted of 18 multiple choice questions, completed by means of a web-based electronic form published in internet. All the data and responses inserted in the system were checked on-line for coherence and completeness directly during the phase of insertion and each participant had one only possibility of participating. The data thus collected were memorized directly within a relational database, based on consolidated open-source MySQL technology, and thus were immediately available for examination also during the course of the survey. Access to the data, mediated by a “back office” system of interrogation and report, enabled constant monitoring of the survey as it was being carried out, as well as extractions and verification, even on smaller data sets.

Results

The survey was carried out in the full month of December 2013 and first half of January 2014. A total of 252 questionnaires were collected from the following physician groups: pneumologists (n?=?180), general practitioners (GPs) (n?=?32), allergologists (n?=?8), internal medicine specialists (n?=?20), other specialists (n?=?12).

Conclusions

Complex forms of bronchial asthma and COPD are frequently observed and considered present in variable percentages ranging from about 10% to about 50% of patients visited and considered typical of patients with a previous history of asthma. Risk factors such as smoking, obesity, bronchial hyperreactivity and genetic predisposition are considered important. Diagnosis is difficult solely on the basis of symptoms in approximately 50% of cases, and a previous history of asthma, history of spirometry and presence of allergy are of help. Treating inflammation and reducing exacerbations are considered the key therapeutic goals and the combination of inhaled corticosteroid (ICS) and long acting β₂-agonist (LABA) and monotherapy with ICS are considered the fundamental pharmacological mode for treating patients with mixed forms of bronchial asthma and COPD. Treating with only a bronchodilator is considered to be moderately risky for this type of patient. The identification and management of mixed forms result more impeded by “logistic” aspects, e.g. long waiting lists and integration with the GP, than by aspects intrinsic to the disease management itself, e.g. selecting the assessment or interpreting the outcome of the instrumental examinations. Treatment continuity and the integration between GP and specialist are the factors that most limit the management of mixed forms in the stable phase.

     

Die Rolle der Selbsthilfegruppen in der Onkologie

Background

Little is known about self-help associations and their possibilities. Obstacles often prevent early contacts between affected people.

Objectives

The psychosocial support given by self-help associations in different phases is evaluated.

Materials and methods

Based on the experience of the Deutsche ILCO and from cooperation with other organizations and institutions, various dimensions of self-help groups are investigated.

Results

On the professional side, there is a lack of knowledge and of attitude. Suitable structures are rare.

Conclusions

The removal of barriers and development of effective structures are overdue.

     

Association Between Vitamin D Metabolism Gene Polymorphisms and Risk of Tunisian Adults’ Asthma

Introduction

Several studies have shown a strong correlation between the serum vitamin D level and asthma severity and deficits in lung function.

Objective

Study the relationship between vitamin D and the severity of asthma by targeting five SNPs of vitamin D metabolism gene pathway in a Tunisian adult asthmatics population.

Methods

Our case–control study includes 154 adult asthmatic patients and 154 healthy Tunisian subjects. We genotyped many variants in three human genes encoding key components of the vitamin D metabolism, CYP2R1, CYP27B1, GC. The GC gene rs4588 and rs7041 polymorphisms were analysed using the PCR-RFLP method, while rs10741657 and rs12794714 for CYP2R1 gene and rs10877012 of CYP27B1 gene were investigated using TaqMan PCR genotyping techniques.

Results

We found that the presence of at least one copy of the rs12794714 A, allele was associated with lower risk of developing asthma (OR 0.61). Further, the rs12794714 is a protector factor against asthma severity (OR 0.5). However, the presence of rs10877012 TG genotype is a risk factor related to asthma severity (OR 1.89). When we classified the population according to sex, our results showed that rs10877012 TT genotype was a risk factor for women subjects (OR 6.7). Moreover, the expression of TT genotype was associated with a higher risk of asthma in non-smoker patients (OR 7.13). We found a significant lower VD serum levels in asthmatics than controls but no impact of the polymorphisms on VD levels.

Conclusions

We found that rs12794714 and rs10877012 SNPs were associated with asthma risk.

     

Can Nuclear Imaging Techniques Predict Patient Outcome and Guide Medical Management in Hereditary Transthyretin Cardiac Amyloidosis?

Purpose of Review

Nuclear imaging recently gained a key role in the diagnosis and prognostic assessment of transthyretin (TTR)-related cardiac amyloidosis. This review aims at summarizing the state-of-the art regarding the implementation of nuclear imaging in the management of hereditary mutated TTR-cardiac amyloidosis (mTTR-CA).

Recent Findings

Although cardiac uptake of bone tracers is acknowledged as a specific marker of TTR amyloid cardiac burden, recent studies validated the implementation of bone scan in the flow chart for non-invasive diagnosis and follow-up of CA in multicenter trials. Simultaneously, cardiac denervation evidenced by MIBG scintigraphy proved to be a strong and independent prognostic marker of poor outcome in mTTR-CA.

Summary

By its unique ability to assess both amyloid burden and cardiac denervation, nuclear imaging may prove useful as part of multimodality imaging tools to trigger treatment initiation and monitoring in patients with mTTR-CA.

     

Communication Skills Training for Physicians Improves Patient Satisfaction

BACKGROUND

Skilled physician communication is a key component of patient experience. Large-scale studies of exposure to communication skills training and its impact on patient satisfaction have not been conducted.

OBJECTIVE

We aimed to examine the impact of experiential relationship-centered physician communication skills training on patient satisfaction and physician experience.

DESIGN

This was an observational study.

SETTING

The study was conducted at a large, multispecialty academic medical center.

PARTICIPANTS

Participants included 1537 attending physicians who participated in, and 1951 physicians who did not participate in, communication skills training between 1 August 2013 and 30 April 2014.

INTERVENTION

An 8-h block of interactive didactics, live or video skill demonstrations, and small group and large group skills practice sessions using a relationship-centered model.

MAIN MEASURES

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), Jefferson Scale of Empathy (JSE), Maslach Burnout Inventory (MBI), self-efficacy, and post course satisfaction.

KEY RESULTS

Following the course, adjusted overall CGCAHPS scores for physician communication were higher for intervention physicians than for controls (92.09 vs. 91.09, p?<?0.03). No significant interactions were noted between physician specialty or baseline CGCAHPS and improvement following the course. Significant improvement in the post-course HCAHPS Respect domain adjusted mean was seen in intervention versus control groups (91.08 vs. 88.79, p?=?0.02) and smaller, non-statistically significant improvements were also seen for adjusted HCAHPS communication scores (83.95 vs. 82.73, p?=?0.22). Physicians reported high course satisfaction and showed significant improvement in empathy (116.4?±?12.7 vs. 124?±?11.9, p?<?0.001) and burnout, including all measures of emotional exhaustion, depersonalization, and personal accomplishment. Less depersonalization and greater personal accomplishment were sustained for at least 3 months.

CONCLUSIONS

System-wide relationship-centered communication skills training improved patient satisfaction scores, improved physician empathy, self-efficacy, and reduced physician burnout. Further research is necessary to examine longer-term sustainability of such interventions.

     

Ambient Air Pollution and Asthma-Related Outcomes in Children of Color of the USA: a Scoping Review of Literature Published Between 2013 and 2017

Purpose of Review

Given racial disparities in ambient air pollution (AAP) exposure and asthma risk, this review offers an overview of the literature investigating the ambient air pollution-asthma relationship in children of color between 2013 and 2017.

Recent Findings

AAP is likely a key contributor to the excess burden of asthma in children of color due to pervasive exposure before birth, at home, and in school. Recent findings suggest that psychosocial stressors may modify the relationship between AAP and asthma.

Summary

The effect of AAP on asthma in children of color is likely modulated by multiple unique psychosocial stressors and gene-environment interactions. Although children of color are being included in asthma studies, more research is still needed on impacts of specific criteria pollutants throughout the life course. Additionally, future studies should consider historical factors when analyzing current exposure profiles.

     

Burned Out at the Bedside: Patient Perceptions of Physician Burnout in an Internal Medicine Resident Continuity Clinic

Background

Burnout is high among resident physicians and may be associated with suboptimal patient care and reduced empathy.

Objective

To investigate the relationship between patient perceptions of empathy and enablement and physician burnout in internal medicine residents.

Design

Cross-sectional, survey-based observational study between December 2012 and March 2013 in a resident continuity clinic located within a large urban academic primary care practice in Baltimore, Maryland.

Participants

Study participants were 44 PGY1-3 residents and a convenience sample of their English-speaking adult primary care patients (N?=?244).

Main Measures

Patients rated their resident physicians using the Consultation and Relational Empathy Measure (CARE) and the Patient Enablement Instrument (PEI). Residents completed the Maslach Burnout Inventory (MBI). We tested for associations between resident burnout and patients’ perceptions of resident empathy (CARE) and enablement (PEI) using multilevel regression analysis.

Key Results

Multilevel regression analyses indicated significant positive associations between physician depersonalization scores on the MBI and patient ratings of empathy (B?=?0.28, SE?=?0.17, p?<?0.001) and enablement (B?=?0.11, SE?=?0.11, p?=?0.02). Emotional exhaustion scores on the MBI were not significantly related to either patient outcome.

Conclusions

Patients perceived residents who reported higher levels of depersonalization as more empathic and enabling during their patient care encounters. The relationship between physician distress and patient perceptions of care has important implications for medical education and requires further study.

     

Treatment of acute hepatitis C: recommendations from an expert panel of the Italian Society of Infectious and Tropical Diseases

Aim

This paper is aimed at providing practical recommendations for the management of acute hepatitis C (AHC).

Methods

This is an expert position paper based on the literature revision. Final recommendations were graded by level of evidence and strength of the recommendations.

Results

Treatment of AHC with direct-acting antivirals (DAA) is safe and effective; it overcomes the limitations of INF-based treatments.

Conclusions

Early treatment with DAA should be offered when available.

     

Subclinical Carotid Atherosclerosis in COPD Cases and Control Smokers: Analysis in Relation with COPD Exacerbations and Exacerbation-like Episodes

Purpose

It remains unclear whether there is a pathogenic link between chronic obstructive pulmonary disease (COPD) and cardiovascular diseases. Subclinical carotid atherosclerosis is a predictor of future cardiovascular events. Exacerbations increase all-cause mortality in COPD, and exacerbation-like episodes have been described in subjects without COPD. Our objectives were as follows: (1) to confirm the independent association between COPD and carotid atherosclerosis and (2) to asses the possible relationship between COPD exacerbations or exacerbation-like episodes and a higher risk of atherosclerosis.

Methods

127 COPD subjects and 80 control subjects with smoking history were studied. Carotid ultrasound examination was carried out in all subjects. Univariate and multivariate logistic regression analyses were performed in order to assess the relationship between both COPD diagnosis and previous COPD exacerbations (or exacerbation-like episodes in non-COPD subjects) and the presence of carotid atherosclerosis.

Results

The prevalence of carotid atherosclerosis was higher in COPD group (65.3 vs. 47.5%, p?=?0.01; OR?2.18, 95% CI 1.23–3.88, p?<?0.01). Diagnosis of COPD was not independently associated with atherosclerosis, after adjusting for potential confounders. Neither COPD exacerbations nor exacerbation-like episodes in control subjects were associated with a higher risk of atherosclerosis.

Conclusion

There is a higher prevalence of carotid atherosclerosis in COPD than in control smokers or ex-smokers, but the differences seem to be related to shared risk factors. We have not found evidence for an increased risk of atherosclerosis associated with COPD exacerbations or exacerbation-like events. Further longitudinal studies should be carried out to confirm these findings.

     

CAT correlates positively with respiratory rate and is a significant predictor of the impact of COPD on daily life of patients: a cross sectional study

Background

The pathophysiological changes of COPD tend to worsen with progression, triggering limiting symptoms and implying the decrease in the activities of daily living and quality of life. The COPD Assessment Test (CAT) is a questionnaire designed to measure the impact of COPD on the health status. The aim of this study was to evaluate the impact of the disease through the CAT in a Brazilian sample of COPD patients and to correlate symptoms at rest with the CAT score in these patients.

Methods

Study of cases with COPD patients was conducted by pulmonary rehabilitation program (RP). Respiratory rate (RR) and symptoms (dyspnea by Modified Borg Scale Dyspnea Index; symptoms by CAT) were analyzed at the beginning of the RP.

Results

The study analyzed 28 COPD patients, both genders, age 65.93?±?7.84 years and many patients ranging from severe and very severe disease. The majority of patients were rated by CAT with low impact-disease (n?=?13/46, 4%);medium (n?=?11/39, 3%) and the high impact-diseases were observed in a few subjects (n?=?4/14.3%). The difference between all CAT scores was significant, p?=?0.000. There was a positive correlation between respiratory rate and CAT scores impact-level (r?=?0.585, p?=?0.001). The results obtained by the Borg Scale revealed a high presence of symptoms in these COPD patients but no association with CAT.

Conclusion

The CAT is a sensitive tool to assess the current health status of COPD patients, and in Southern Brazil it is positively correlated with respiratory rate.

     

The Reemergence of the Asthma-COPD Overlap Syndrome: Characterizing a Syndrome in the Precision Medicine Era

Purpose of Review

The asthma-COPD overlap syndrome (ACOS) has reemerged in the medical literature. This review addresses our current understanding of ACOS as a clinical and biological entity and how new and existing therapies may be targeted to this group.

Recent Findings

Many studies suggest that ACOS is common and associated with more morbidity than asthma and COPD in general. However, there is no consensus on an ACOS definition, likely due to the heterogeneity of the disease. Variable definitions have led to variable results in ACOS studies. Given this clinical variability, biomarkers (e.g., eosinophils and type 2 inflammatory markers) are increasingly being used to identify an ACOS molecular phenotype which appears to be more responsive to inhaled corticosteroids.

Summary

Although ACOS has become a popular diagnosis, it is unclear whether identifying ACOS as a separate disease entity is clinically useful. Future studies should focus on identifying key clinical features and biomarkers that characterize vulnerable and treatment-responsive patients.