Effectiveness of Pulmonary Rehabilitation in Patients With Chronic Obstructive Pulmonary Disease With Different Degrees of Static Lung Hyperinflation.

OBJECTIVE: To evaluate the effect of pulmonary rehabilitation (PR) on exercise performance and quality of life in patients with chronic obstructive pulmonary disease (COPD) with different degrees of static lung hyperinflation (LH). DESIGN: Retrospective cohort study. SETTING: PR network. PARTICIPANTS: A cohort of 1981 patients with COPD (55% men; age: 66.8±9.3y; forced expiratory volume in the first second%: 50.7±19.5; residual volume [RV]%: 163.0±49.7). INTERVENTION: An interdisciplinary PR program for patients with COPD consisting of 40 sessions. MAIN OUTCOME MEASURES: Participants were stratified into 5 quintiles according to baseline RV and were evaluated on the basis of pre- and post-PR 6-minute walk distance (6MWD), constant work rate test (CWRT), and Saint George's Respiratory Questionnaire (SGRQ), among other clinical parameters. RESULTS: With increasing RV quintile, patients were younger, more frequently women, had lower forced expiratory volume in the first second%, lower body mass index and fat-free mass index, shorter 6MWD, shorter CWRT, and worse SGRQ scores (P<.01). All RV strata improved after PR in all 3 outcomes (P<.001). Nevertheless, higher, compared to lower RV categories, had lower ΔCWRT (P<.01) but similar Δ6MWD (P=.948) and ΔSGRQ (P=.086) after PR. CONCLUSIONS: LH in COPD is related to younger age, female sex, lower body weight, worse exercise capacity and health status, but did not prevent patients from benefitting from PR. LH, however, influences walking and cycling response after PR differently.

Social-aware Event Handling within the FallRisk Project.

OBJECTIVES: With the uprise of the Internet of Things, wearables and smartphones are moving to the foreground. Ambient Assisted Living solutions are, for example, created to facilitate ageing in place. One example of such systems are fall detection systems. Currently, there exists a wide variety of fall detection systems using different methodologies and technologies. However, these systems often do not take into account the fall handling process, which starts after a fall is identified or this process only consists of sending a notification. The FallRisk system delivers an accurate analysis of incidents occurring in the home of the older adults using several sensors and smart devices. Moreover, the input from these devices can be used to create a social-aware event handling process, which leads to assisting the older adult as soon as possible and in the best possible way. METHODS: The FallRisk system consists of several components, located in different places. When an incident is identified by the FallRisk system, the event handling process will be followed to assess the fall incident and select the most appropriate caregiver, based on the input of the smartphones of the caregivers. In this process, availability and location are automatically taken into account. RESULTS: The event handling process was evaluated during a decision tree workshop to verify if the current day practices reflect the requirements of all the stakeholders. Other knowledge, which is uncovered during this workshop can be taken into account to further improve the process. CONCLUSIONS: The FallRisk offers a way to detect fall incidents in an accurate way and uses context information to assign the incident to the most appropriate caregiver. This way, the consequences of the fall are minimized and help is at location as fast as possible. It could be concluded that the current guidelines on fall handling reflect the needs of the stakeholders. However, current technology evolutions, such as the uptake of wearables and smartphones, enables the improvement of these guidelines, such as the automatic ordering of the caregivers based on their location and availability.

Differential response to pulmonary rehabilitation in COPD: multidimensional profiling.

The aim of the present study was to profile a multidimensional response to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD).Dyspnoea, exercise performance, health status, mood status and problematic activities of daily life were assessed before and after a 40-session pulmonary rehabilitation programme in 2068 patients with COPD (mean forced expiratory volume in 1 s of 49% predicted). Patients were ordered by their overall similarity concerning their multidimensional response profile, which comprises the overall response on MRC dyspnoea grade, 6MWD, cycle endurance time, Canadian Occupational Performance Measure performance and satisfaction scores, Hospital Anxiety and Depression Scale anxiety and depression, and St George's Respiratory Questionnaire total score, using a novel non-parametric regression technique.Patients were clustered into four groups with distinct multidimensional response profiles: n=378 (18.3%; "very good responder"), n=742 (35.9%; "good responder"), n=731 (35.4%; "moderate responder"), and n=217 (10.5%; "poor responder"). Patients in the "very good responder" cluster had higher symptoms of dyspnoea, number of hospitalisations <12 months, worse exercise performance, worse performance and satisfaction scores for problematic activities of daily life, more symptoms of anxiety and depression, worse health status, and a higher proportion of patients following an inpatient PR programme compared to the other three clusters.A multidimensional response outcome needs to be considered to study the efficacy of pulmonary rehabilitation services in patients with COPD, as responses to regular outcomes are differential within patients with COPD.

Cost-effectiveness of FDG-PET in staging non-small cell lung cancer: the PLUS study.

Currently, up to 50% of the operations in early-stage non-small cell lung cancer (NSCLC) are futile owing to the presence of locally advanced tumour or distant metastases. More accurate pre-operative staging is required in order to reduce the number of futile operations. The cost-effectiveness of fluorine-18 fluorodeoxyglucose positron emission tomography ((18)FDG-PET) added to the conventional diagnostic work-up was studied in the PLUS study. Prior to invasive staging and/or thoracotomy, 188 patients with (suspected) NSCLC were randomly assigned to conventional work-up (CWU) and whole-body PET or to CWU alone. CWU was based on prevailing guidelines. Pre-operative staging was followed by 1 year of follow-up. Outcomes are expressed in the percentage of correctly staged patients and the associated costs. The cost price of PET varied between 736 and 1,588 depending on the (hospital) setting and the procurement of (18)FDG commercially or from on-site production. In the CWU group, 41% of the patients underwent a futile thoracotomy, whereas in the PET group 21% of the thoracotomies were considered futile ( P=0.003). The average costs per patient in the CWU group were 9,573 and in the PET group, 8,284. The major cost driver was the number of hospital days related to recovery from surgery. Sensitivity analysis on the cost and accuracy of PET showed that the results were robust, i.e. in favour of the PET group. The addition of PET to CWU prevented futile surgery in one out of five patients with suspected NSCLC. Despite the additional PET costs, the total costs were lower in the PET group, mainly due to a reduction in the number of futile operations. The additional use of PET in the staging of patients with NSCLC is feasible, safe and cost saving from a clinical and from an economic perspective.

Staging of non-small-cell lung cancer and application of FDG-PET. A cost modeling approach.

BACKGROUND: The presence of (distant) metastases affects the therapy (operation) and prognosis of patients with non-small-cell lung cancer (NSCLC). Fifty percent of the operations are futile due to the presence of a locally advanced tumor or distant metastases. Therefore, more accurate preoperative staging is required with respect to the outcomes (reduction of futile operations) and costs. This study examines current staging procedures and assesses possible situations for incorporating positron emission tomography (PET). METHODS: A retrospective analysis was performed to assess actual clinical practice in the staging procedure of 337 patients with NSCLC in two Dutch hospitals. Consequently, by combining these data of actual clinical practice with a literature review, a model was developed to determine the influence of PET on the staging outcomes and the costs. In this model the accuracy and costs of PET can be varied as well as the extent of substitution of conventional diagnostic tests by PET. RESULTS: Practice variation was found between the two hospitals with regard to the setting in which the diagnostic staging took place (hospitalization, outpatient setting) and the extent of the use of mediastinoscopy. This was reflected in the costs and in the number of (futile) operations. CONCLUSION: Hospitalization is the major cost driver in these patients. From a cost viewpoint, the evaluation of PET in a strategy after diagnostic imaging but prior to invasive staging seems most optimal.

Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial.

BACKGROUND: Up to 50% of curative surgery for suspected non-small-cell lung cancer is unsuccessful. Accuracy of positron emission tomography (PET) with 18-fluorodeoxyglucose (18FDG) is thought to be better than conventional staging for diagnosis of this malignancy. Up to now however, there has been no evidence that PET leads to improved management of patients in routine clinical practice. We did a randomised controlled trial in patients with suspected non-small-cell lung cancer, who were scheduled for surgery after conventional workup, to test whether PET with 18FDG reduces number of futile thoracotomies. METHODS: Before surgery (mediastinoscopy or thoracotomy), 188 patients from nine hospitals were randomly assigned to either conventional workup (CWU) or conventional workup and PET (CWU+PET). Patients were followed up for 1 year. Thoracotomy was regarded as futile if the patient had benign disease, explorative thoracotomy, pathological stage IIIA-N2/IIIB, or postoperative relapse or death within 12 months of randomisation. The primary outcome measure was futile thoracotomy. Analysis was by intention to treat. FINDINGS: 96 patients were randomly assigned CWU and 92 CWU+PET. Two patients in the CWU+PET group did not undergo PET. 18 patients in the CWU group and 32 in the CWU+PET group did not have thoracotomy. In the CWU group, 39 (41%) patients had a futile thoracotomy, compared with 19 (21%) in the CWU+PET group (relative reduction 51%, 95% CI 32-80%; p=0.003). INTERPRETATION: Addition of PET to conventional workup prevented unnecessary surgery in one out of five patients with suspected non-small-cell lung cancer.