Improving the uptake: Barriers and facilitators to pulmonary rehabilitation.

BACKGROUND: Pulmonary rehabilitation (PR) is a well-established therapeutic management programme for patients with chronic lung disease. Despite good clinical evidence, patient engagement can be poor. AIM: The aim of the study was to determine the number of patients who are referred to PR at a District General Hospital, explore barriers and facilitators to attending and completing and identify strategies for improvement. METHODS: All patients invited to attend PR in the calendar year 2016 were included in an analysis (N = 281). A structured questionnaire composed of barriers and facilitators was administered to patients that did not attend (non-attenders, N = 20) and those that attended but did not complete the programme (non-completers/"drop-outs," N = 13). Improvement strategies were identified and implemented followed by analysis of patients invited to attend in 2017 and 2018. RESULTS: Age, sex and smoking status are factors that affect both attendance and completion rates of patients attending PR. In our analysis, we were able to demonstrate that lack of awareness and low perceived benefits were important barriers for non-attendance. In addition, overall uptake rate was improved but at the expense of completion rate. CONCLUSION: Our local non-attendance rate in 2016 was 42%, with strategies aimed at improving patient and physician information, this was reduced to 11% (2018), below the national United Kingdom average. Unexpectedly, there was a worsening of completion rates and this raises questions about both appropriateness of referrals and whether completion rate rather than non-attendance rate should be used as a performance indicator and standard.

A retrospective analysis comparing the use of ProCore® with standard fine needle aspiration in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

Endobronchial ultrasound has become first line in the investigation of mediastinal lesions suspicious for malignancy in keeping with National Institute for Health and Care Excellence (NICE) guidelines; however, needle size and type required to maximise diagnostic sensitivity remains unclear. Previous meta-analyses have compared the use of ProCore with standard fine needle aspiration in the assessment of pancreatic masses with differences noted only in the number of passes required. We aim to assess whether a ProCore needle improves diagnostic sensitivity in EBUS-TBNA. Complete follow-up data regarding all 235 patients undergoing EBUS-TBNA in a district general hospital has been collected since the service's inception in 2012. Results were collated and retrospectively analysed allowing for calculation of test sensitivity and specificity. Comparison was then made between procedures where standard fine needle aspiration was performed and those using a ProCore needle. Overall sensitivity of EBUS-TBNA was shown to be 85% with a specificity of 100% in keeping with quoted figures from other centres. Standard fine needle aspiration produced a sensitivity of 77% (85/110) versus ProCore sensitivity of 92% (115/125) with a p value of 0.0016. Thirty percent (33/110) of patients undergoing standard fine needle aspiration required an appropriate crossover technique such as mediastinoscopy or CT-guided FNA in order to either obtain or confirm the diagnosis compared with 15% (19/125) of the ProCore group with a p value of 0.0064. Our retrospective analysis shows a statistically significant difference in the diagnostic sensitivity of sampling mediastinal lymphadenopathy using a ProCore needle compared with standard fine needle aspiration. It also shows that a significantly fewer number of patients required further procedures in order to obtain or confirm the diagnosis. This could potentially be confounded by the retrospective nature of the study design; however, due to the statistical significance demonstrated, further study is required.

Epstein - Barr virus Pneumonitis.

Epstein-Barr virus is an unusual pathogen in the aetiology of alveolitis. We describe a case of Epstein-Barr virus induced pneumonitis and its successful treatment with Aciclovir.

British thoracic society winter meeting 2008.

The 26th annual British Thoracic Society Winter Meeting was held in London from 2 to 5 December 2008. It was attended by over 2000 participants from around the world. The program presented to attendees topics of interest across respiratory clinical and scientific fields.

Isolated mediastinal adenopathy: the case for mediastinoscopy.

BACKGROUND: We report our experience with mediastinoscopy at Auckland city hospital, a tertiary referral centre. We wished to examine correlations between clinical diagnosis and that made by histological sampling of enlarged mediastinal nodes particularly in patients with isolated mediastinal adenopathy. METHODS: We retrospectively reviewed clinical records of all patients who underwent mediastinoscopy in a five year period, mediastinoscopy was performed in the presence of enlarged lymph nodes (short axis > 1cm) found at CT. Mediastinoscopy was indicated for diagnostic staging of mediastinal adenopathy related to a parenchymal lung mass, diagnosis of isolated mediastinal adenopathy and diagnosis of mediastinal adenopathy with other CT findings. Data relating to indication, pre-test diagnosis, node stations sampled, histology, and operative complications were collected. RESULTS: Mediastinoscopy was performed in 137 consecutive patients. Seventy five patients had a lung mass, 47 had isolated mediastinal adenopathy and 15 had other CT findings. One operative complication occurred. In those patients with isolated adenopathy the following diagnoses were reached; sarcoidosis 23, TB 15, lymphoma 4, carcinoma 4, no diagnosis 1. Final diagnosis was significantly associated with patient's ethnicity. There was high sensitivity and specificity on comparison of clinical and histological diagnosis for both TB and sarcoidosis cases. CONCLUSIONS: Mediastinoscopy proved to be safe and effective in nodal assessment of the mediastinum. In carefully selected cases procedural morbidity and mortality may be avoided by application of features related to patient's ethnicity and radiological findings.

Respiratory viral infection in exacerbations of COPD.

BACKGROUND: Patients with COPD have frequent exacerbations. The role of respiratory viral infection is just emerging. We wished to determine prospectively the incidence of viral infection in exacerbated and stable COPD patients as well as smokers who do not have airways obstruction. METHODS: Stable and exacerbated COPD patients were recruited along with a group of patients who had smoked but who did not have any airways obstruction. Spirometry was performed and sputum specimens were tested for a range of 12 different respiratory viruses using PCR. RESULTS: One hundred and thirty-six patients with exacerbations of COPD, 68 stable COPD patients and 16 non-obstructed smokers were recruited. A respiratory virus was detected in 37% of exacerbations, 12% of stable COPD patients and 12% of non-obstructed smokers, p<0.0005. Rhinovirus was most frequently detected. The symptom of fever was associated with virus detection, p<0.05. Infection with more than one virus was only found in the exacerbated COPD patients. CONCLUSION: Respiratory viral infection is associated with exacerbations of COPD. Rhinovirus was the most common infecting agent identified and in two cases human metapneumovirus was also detected. Dual infections were only seen amongst those patients admitted to hospital with acute exacerbations of COPD. Viruses were more commonly detected in those with more severe airways disease.

Exudative bronchiolitis after lung transplantation.

BACKGROUND: After lung transplantation patients frequently develop small airways disease. Exudative bronchiolitis (EB) has not been described previously in this population. We describe a case series of patients who have developed EB after lung transplantation. METHODS: We reviewed the clinical records and radiologic data of 99 patients who underwent single and bilateral lung transplantation. Data relating to ethnicity, transplant indication, human leukocyte antigen (HLA) status, complications and survival were recorded. The EB cohort, defined by high-resolution computed tomographic (HRCT) evidence of the disease, was compared with a group of patients who had not developed EB. RESULTS: The majority of patients had chronic obstructive pulmonary disease (COPD; n = 51), followed by cystic fibrosis (CF; n = 22), pulmonary fibrosis (n = 8), pulmonary hypertension (n = 7), bronchiectasis (n = 5), lymphangioleiomyomatosis (n = 3) and Eisenmenger's syndrome (n = 3). Thirteen patients were found to have developed EB. EB was more commonly seen in Maori and Pacific Island patients (p < 0.05). EB was significantly associated with early infection post-transplant (p < 0.05) and a history of Aspergillus infection (p < 0.005) or diabetes (p < 0.05). The patients with EB were also significantly more likely to develop bronchiolitis obliterans syndrome (p < 0.0005), bronchiectasis (p < 0.0005) or small airways disease (p < 0.05). Patients with EB had a varied response to treatment, with the majority showing improvement. CONCLUSIONS: EB was noted to occur after lung transplantation in a significant proportion of patients, but will not be detected unless HRCT is used routinely. It has been associated with patients' ethnicity, donor haplotype, infection and the development of airways disease. EB may be a prominent indicator of the likelihood of developing BOS.

Acute and latent adenovirus in COPD.

INTRODUCTION: The COPD airway is infiltrated with CD8+ T cells, which has led to a virus being implicated in its pathogenesis. Some investigators have suggested a role for the persistence of the adenovirus E1A in bronchial epithelial cells. We examined respiratory tract specimens from COPD patients for the presence of E1A DNA and mRNA using real-time PCR. METHODS: Nucleic acid extraction was performed on sputum specimens from patients with COPD. Copy numbers for GAPDH, and adenovirus 5 E1A DNA and mRNA were determined using a quantitative real-time PCR assay. All samples were screened for the adenovirus hexon gene using nested PCR. RESULTS: One hundred and seventy-one patients, 80 male, aged 68.9+/-9.8 years with COPD were recruited. One hundred and thirty-six were seen during an exacerbation when admitted to hospital, 33 of whom were reviewed when clinically stable along with an additional 35 stable COPD patients. Ten patients in the exacerbation group were positive for the adenovirus hexon gene (7%), as were four in the stable group (6%). Only two patients in the exacerbation group were positive for adenovirus 5 E1A. Only one patient in the stable COPD group had detectable E1A DNA/mRNA and also tested positive for the adenovirus hexon gene. CONCLUSION: Adenovirus is detected in similar frequencies in exacerbated and stable COPD patients. Adenovirus E1A DNA is infrequently detected in respiratory secretions from patients with COPD. Our data suggest that the persistence of adenovirus 5 E1A in lung cells of sputum samples in patients with COPD occurs infrequently.

Evaluation of real-time PCR for the detection and quantification of bacteria in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) embraces a number of pathological processes including chronic bronchitis, chronic bronchiolitis and emphysema. The chronic and progressive course of COPD is often aggravated by short periods of increasing symptoms. Respiratory tract infections (RTIs) are the most common causes of COPD exacerbations. Detection and enumeration of respiratory bacteria are important techniques in diagnosing RTIs and in the validation of new treatment methods. We describe here the development and evaluation of real-time PCR assays for the simultaneous direct detection and quantification of a range of respiratory bacteria in individuals with COPD during stable periods and during acute exacerbations of the disease. Sputum samples from 30 subjects in a COPD study were analysed, and results compared with the current gold standard of culture. Real-time PCR assays proved highly sensitive, with no cross-reactivity with other species. The prevalence of bacteria detected by real-time PCR compared with that by culture was substantially higher for Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus spp. and Moraxella catarrhalis. Multiple pathogens were also found with real-time PCR but were not detected by culture. This study demonstrates the potential of such methods in the detection and enumeration of respiratory bacteria.

Organisms isolated from adults with cystic fibrosis.

BACKGROUND: Patients with cystic fibrosis [CF] have frequent pulmonary exacerbations associated with the isolation of bacterial organisms from sputum samples. It is not clear however, if there are differences in the types of additional organisms isolated from patients who are infected with Burkholderia cepacia complex [BCC] or Pseudomonas aerugionsa [PA] in comparison to those who are not infected with either of these organisms [NI]. METHODS: Adult patients attending the regional CF unit were followed over a two year period and patients were assigned to three groups depending on whether they were known to be chronically infected with BCC, PA or NI. We compared the numbers and types of organisms which were isolated in each of these groups. RESULTS: Information was available on a total of 79 patients; BCC 23, PA 30 and NI 26. Total numbers of organisms isolated, expressed as median and IQR for each group, [P = 0.045] and numbers of co-infecting organisms [P = 0.003] were significantly higher in the BCC group compared to PA, and in the PA group [P < 0.001, p = 0.007 respectively] compared to NI patients. The pattern of co-infecting organisms was similar in all three groups. CONCLUSIONS: Total numbers of organisms isolated and numbers of co-infecting organisms were significantly higher in the BCC group compared to PA, and in the PA group compared to NI patients. Types of co-infecting organisms are similar in all groups of patients.