[Therapeutic patient education in respiratory rehabilitation]. / Éducation thérapeutique du patient au cours de la réadaptation respiratoire.

INTRODUCTION: Therapeutic patient education (TPE) is an essential component of pulmonary readaptation in chronic respiratory diseases. Numerous and varied patient education projects offer heterogeneous contents and methods, which render them difficult to analyze and to compare. The objective of this review was to provide perspective on the main principles of patient education, using a non-exhaustive approach. STATE OF KNOWLEDGE: This review is focused on patient education using a patient-centered approach, physician-patient partnership and self-management, which are presented at once pragmatically and conceptually. One of the main objectives of TPE is the acquisition of self-management skills by patients with a chronic disease, which will be considered from a clinical standpoint. Lastly, TPE will be assessed in the overall framework of patient-centered pulmonary readaptation. PERSPECTIVES: TPE needs to be structured in view of assessing its effects. It is consequently essential for caregivers to receive continuous training so as to more clearly understand the methods employed, the objective being to build evaluable contents contributing to performance of multicentric trials. CONCLUSION: Current literature on TPE emphasizes the extent to which the patient remains the central actor in his or her care pathway. If patients are called upon to modify their behaviors, it is equally necessary that caregivers proceed likewise, adopting postures favoring the acquisition and appropriation by the patient of skills that shall be required as he or she learns to live with chronic disease.

[Physical activity and pulmonary rehabilitation in adults with asthma]. / Apports de l'activité physique et de la réadaptation respiratoire dans l'asthme de l'adulte.

Physical activity is reduced in people with asthma compared to the general population, especially in situations where patients have uncontrolled asthma symptoms, persistent airflow obstruction and other long-term medical problems, in particular obesity and anxiety. Exertional dyspnea, which is of multifactorial origin, is the main cause of reduced physical activity reduction and draws patients into a vicious circle further impairing quality of life and asthma control. Both the resumption of a regular physical activity, integrated into daily life, adapted to patients' needs and wishes as well as physical and environmental possibilities for mild to moderate asthmatics, and pulmonary rehabilitation (PR) for severe and/or uncontrolled asthmatics, improve control of asthma, dyspnea, exercise tolerance, quality of life, anxiety, depression and reduce exacerbations. A motivational interview to promote a regular programme of physical activity in mild to moderate asthma (steps 1 to 3) should be offered by all health professionals in the patient care pathway, within the more general framework of therapeutic education. The medical prescription of physical activities, listed in the Public Health Code for patients with long-term diseases, and pulmonary rehabilitation should be performed more often by specialists or the attending physician. Pulmonary rehabilitation addresses the needs of severe asthma patients (steps 4 and 5), and of any asthmatic patient with poorly controlled disease and/or requiring hospitalized for acute exacerbations, regardless of the level of airflow obstruction, and/or with associated comorbidities, and before prescribing biological therapies.

[How to improve patient's access to Respiratory Rehabilitation?] / Comment améliorer l'accès des patients à la réadaptation respiratoire ?

Despite effectiveness and clear international guidelines, respiratory rehabilitation remains underutilized: less than 15% of suitable patients in France and worldwide receive this treatment. The factors of this lack of referral and uptake have been studied and are not limited to a problem of quantitative adequacy of supply and demand. The lack of knowledge of health professionals, patients, payers, heterogeneous programs which does not necessary correspond to the needs of the patient (modalities, geography, duration), the lack of trained and available professionals, the profile of patients and prescribers and the quality of the programs are identified as potentially hindering the completion of a rehabilitation program. It is essential to analyze these barriers and to find solutions to the greatest number of respiratory patients can benefit optimal healthcare and integrate into a coherent care planning.

Influence of DISC behavioral profile on the short- and long-term outcomes of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease.

INTRODUCTION: Pulmonary rehabilitation (PR) programs are commonly prescribed for patients with severe respiratory disorders, but little is known about how the patient's personality traits influence PR outcomes. We analyzed the response of patients with chronic obstructive pulmonary disease (COPD) to a home-based PR program according to their predominant behavioral profiles using the Dominance - Influence - Steadiness - Conscientiousness (DISC) tool. METHODS: This was a retrospective observational study of 335 COPD patients referred by their pulmonologists between January 2010 and December 2015. The DISC behavioral profile was determined at the beginning of the program. Patients received individual supervised sessions at home once a week for 8 weeks, which consisted of exercise training and psychosocial, motivational, and educational support, all tailored to the participant's DISC profile. Exercise tolerance (6-minute stepper test, 6MST), anxiety and depression (Hospital anxiety and depression scale, HADS), and quality of life (Visual simplified respiratory questionnaire, VSRQ) were evaluated immediately before and after the PR program (T0 and T2, respectively) and then 6 and 12 months later (T8 and T14, respectively). Responders were defined as patients who exhibited at least minimal clinically important differences (improvements) from baseline. RESULTS: Of the 335 COPD patients, 102 (30.4%), 98 (29.3%), 82 (24.5%), and 53 (15.8%) were classified as having predominant D, I, S, and C behavioral traits, respectively. All four patient groups showed significantly (P<0.01) improved performance in the 6MST, HADS, and VSRQ evaluations at T2 (n=300), T8 (n=262), and T14 (n=231) compared with T0, and the proportion of responders in all groups at T8 and T14 was high (∼60%). The percentage of responders differed significantly between groups only at T2, when the S group contained fewer responders on the HADS anxiety subscale. Most patients who did not complete the study were classified as D type (42/102, 41.2%), followed by I (28/98, 28.6%), S (22/82, 26.8%), and C (12/53, 22.6%) types. CONCLUSION: The personality profile of COPD patients influenced their adherence to, but not their benefit from, a home-based PR program. The high proportion of patients in all personality groups showing significant improvements in outcomes supports a personalized approach to the design of PR programs.

Long-term effects of pulmonary rehabilitation on daily life physical activity of patients with stage IV sarcoidosis: A randomized controlled trial.

INTRODUCTION: Pulmonary rehabilitation (PR) is known to improve exercise tolerance, mood, and quality of life in patients with chronic respiratory diseases. The aim of this work was to determine whether PR provides long-term benefits in increasing daily life physical activity in patients with chronic sarcoidosis. METHODS: This randomized prospective study (registered ClinicalTrials.gov NCT02044939) of 38 patients with stage IV chronic sarcoidosis was performed between 2012 and 2016. Patients were assigned to participate in a 2-month PR program (n=20) or receive counseling (n=18). Assessments were performed at baseline, 2 months (end of the PR program), 6months, and 12months, and included daily life physical activity parameters (measured for 5 consecutive days), exercise tolerance, dyspnea, anxiety, depression, fatigue, and quality of life. The primary outcome was the 12-month change in time spent in activities above an estimated energy expenditure of 2.5metabolic equivalents (METs). Secondary daily life physical activity outcomes included number of steps per day, total daily energy expenditure, and total energy expenditure above 2.5METs. RESULTS: The primary outcome did not differ between the two groups; mean between-group differences were -13.2min (95% confidence interval [CI]: -76.3 to 49.8) at 6 months and -18.1min (95% CI: -55.7 to 19.4) at 12months. Although PR had no effect on secondary daily life physical activity outcomes, it did significantly increase exercise tolerance at 6 and 12 months and decrease the dyspnea score at 6 months and the fatigue score at 12months. CONCLUSION: This trial failed to demonstrate a beneficial effect of PR on daily life physical activity in sarcoidosis patients, suggesting that long-term behavioral programs may be necessary to complement PR.

Ultrastructure and intercellular contact-mediated communication in cultured human early stage follicles exposed to mTORC1 inhibitor.

The reproductive lifespan of a woman is determined by the gradual recruitment of quiescent follicles into the growing pool. In humans, ovarian tissue removal from its in vivo environment induces spontaneous activation of resting follicles. Similarly, pharmacological activation of the PI3K/Akt pathway leads to accelerated follicle recruitment, but has been associated with follicular damage. Recent findings demonstrate that everolimus (EVE), an mTORC1 inhibitor, limits primordial follicle activation. However, its potential benefit regarding growing follicle integrity remains unexplored. Ovarian cortical fragments were exposed to ± EVE for 24 h and cultured for an additional 5 days. After 0, 1 and 6 days of culture, fragments were either processed for ultrastructural analysis or subjected to follicular isolation for gene expression and immunofluorescence assessments. Data from transmission electron microscopy showed that growing follicles displayed similar ultrastructural features irrespective of the conditions and maintained close contacts between germinal and stromal compartments. Establishment of intra-follicular communication was confirmed by detection of a gap junction component, Cx43, in both groups throughout culture, whereas transzonal projections, which physically link granulosa cells to oocyte, formed later in EVE-treated follicles. Importantly, levels of GJA1 mRNA, encoding for the Cx43 protein, significantly increased from Day 0 to Day 1 in the EVE group, but not in the control group. Given that EVE-treated follicles were smaller than controls, these findings suggest that EVE might facilitate the establishment of appropriate intercellular communications without impairing follicle ultrastructure. Therefore, mTORC1 inhibitors might represent an attractive tool to delay the culture-induced primordial follicle activation while maintaining follicles in a functionally integrated state.

[Cardiopulmonary exercise testing for the diagnosis of unexplained dyspnea: a review of 194 cases]. / Épreuve fonctionnelle à l'exercice et dyspnée inexpliquée : à propos de 194 cas.

INTRODUCTION: Chronic dyspnoea that remains unexplained after resting pulmonary function and cardiovascular testing is a common problem in clinical practice. The aim of this study was to determine the utility of cardiopulmonary exercise testing (CPET) in the diagnosis of unexplained dyspnoea. METHODS: This retrospective single-centre study included consecutive patients with dyspnoea who had normal resting cardiopulmonary examinations (including chest X-ray, electrocardiography, pulmonary function tests [PFTs], and cardiac ultrasound). CPET was performed using a cycle ergometer with analysis of blood gases. The results were interpreted as being most likely due to one of the six pathophysiological mechanisms shown below. Consensus required agreement between at least three of the authors. RESULTS: Of the 194 patients included (median age 53 years, sex-ratio (M:F) 0.83, mean body mass index 27.3±5.36kg/m2), 32% of the test profiles were compatible with deconditioning, 20% with inappropriate hyperventilation (without gas exchange abnormalities), 18% with disorders of gas exchange, 13% with sub-maximal CPET, 9% with cardiovascular anomalies, and 8% with normal CPET. Of the patients with gas exchange abnormalities, the most common causes were bronchiectasis (6), emphysema (6), recent pneumonia (2), and diffuse interstitial pneumonitis (2). Ten of the patients with cardiovascular abnormalities had chronotropic insufficiencies, 5 had excessive tension responses, and 3 had disorders of rhythm or repolarisation. CONCLUSIONS: CPET may greatly facilitate the diagnosis of unexplained dyspnoea. More than 50% of the dyspnoea cases examined here were due to deconditioning or hyperventilation syndrome and would benefit from a simple pulmonary rehabilitation program.

[The DISC tool improves communication and results in pulmonary rehabilitation]. / L'outil DISC améliore la communication et les résultats de la réhabilitation respiratoire : une approche comportementale adaptée.

INTRODUCTION: Competence in personal relationships is essential for a caregiver, especially in pulmonary rehabilitation (PR). Considering the behavioral profile of patients might help to optimize their management and the results of PR. METHODS: We evaluated eight hundred and thirty-two consecutive patients with chronic respiratory disease who received eight weeks of home-based PR. Their exercise tolerance (six-minute stepper test, 6MST), mood (HAD), and quality of life (VSRQ, MRF28) were evaluated at the beginning and end of PR. For six hundred and ninety patients, a behavioral approach was implemented at the beginning of PR by using the DISC tool to identify four behavioral profiles: dominance, influence, steadiness, conscientiousness. The remaining 142 patients served as the control group. RESULTS: Subjectively, the therapeutic alliance was more easily established with the behavioral approach. Compared with the control group, patients with the "steadiness" profile were younger (60.7±12 years) and mostly female (52.8%), whereas patients with the "conscientiousness" profile were older (67.5±10.6 years) and mostly male (85.5%). The four behaviorally profiled groups showed no differences in exercise tolerance, mood, or quality of life scores at baseline. Globally, all patients improved their exercise tolerance, mood and quality of life. The percentage of responders to 6MST and VSRQ (>MCID) was 7.5% and 5.3% higher with the behavioral approach. For non-responders to 6MST and VSRQ (

Dynamics of PI3K and Hippo signaling pathways during in vitro human follicle activation.

STUDY QUESTION: How does biochemical stimulation or inhibition of the PI3K/Akt/mTOR pathway affect the activation and the growth of human primordial follicles in vitro? SUMMARY ANSWER: The PI3K/Akt activators act synergistically with the Hippo signaling pathway, disrupted by tissue fragmentation, to accelerate primordial follicles recruitment while mTORC1 inhibitor partially prevents the massive spontaneous activation. WHAT IS KNOWN ALREADY: Hippo disruption caused by ovarian fragmentation and exposure to PI3K/Akt activators have been successfully used to activate resting follicles prior to grafting in patients with premature ovarian insufficiency. Outside this indication, massive and premature activation is considered deleterious as it leads to the depletion of the follicular pool and developmental defects in vitro. STUDY DESIGN, SIZE, DURATION: One hundred and twelve frozen-thawed ovarian cortex fragments from four patients were exposed to dimethylsulfoxide (DMSO-control group), everolimus (inhibitor group) or bpV (HOpic) and 740Y-P (activators group) during the first 24 and 48 h, respectively, and cultured for additional 5 days. PARTICIPANTS/MATERIALS, SETTING, METHODS: The ovarian fragments (4×2×1 mm3) were analyzed at Days 0, 1, 3 and 5 of culture. Cortex were either directly processed for immunohistological or western blot analysis or subjected to follicular isolation for assessment of gene expression. The follicle number and the developmental stage were evaluated in sections of ovarian fragments to assess the early follicular development. Survival and developmental potential were evaluated using TUNEL labeling, GDF9 and Ki67 immunostainings, Kit ligand mRNA relative expression and measurement of 17ß-estradiol (E2) levels in the culture medium. qPCR and western blotting were used to explore the expression of PI3K/Akt and Hippo pathways (TSC1, mTOR, LATS1, BIRC1 and CCN2 genes and PTEN/p-PTEN, Akt/p-Akt and rpS6/p-rps6 proteins), and localization of YAP in human ovarian tissue was performed by immunofluorescence. MAIN RESULTS AND THE ROLE OF CHANCE: Around 80% of the follicles spontaneously activated during the culture period, triggered by the activation of the PI3K/Akt/mTOR signaling. Moreover, ovarian fragmentation immediately promoted translocation of the Hippo effector YAP into the nucleus of granulosa cells, leading to upregulation of BIRC1 and CCN2 downstream targets at Day 0 and an increase of follicular growth near the cutting site. Short term exposure of thawed human ovarian fragments to PI3K/Akt activators had significant (P < 0.05 at D1 and D3; P < 0.001 at D6) but limited and potentially negative effects on follicular activation compared to spontaneous follicular growth as suggested by impaired E2 secretion. In contrast, transient incubation with an mTORC1 inhibitor partially prevented spontaneous activation by limiting growing follicle counts (P < 0.01 at D6), granulosa cell proliferation, and Kit ligand expression while ensuring appropriate steroidogenesis. LARGE SCALE DATA: N/A. LIMITATIONS, REASONS FOR CAUTION: Impact of in vitro culture might cover up the potential benefit of the everolimus on growing follicles morphology after 6 days. WIDER IMPLICATIONS OF THE FINDINGS: Our results demonstrate the synergistic effects of Hippo and PI3K/Akt/mTOR signaling, contributing to the acceleration of early primordial follicle recruitment in thawed human ovarian fragments, and suggest a beneficial effect of the mTORC1 inhibitor. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by a grant from the Fond National de la Recherche Scientifique de Belgique (Grant Télevie Nos. 7.6516.16 F and 7.4578.14 F) and the Fonds Erasme. No competing interests declared.

Six-minute stepper test: a valid clinical exercise tolerance test for COPD patients.

INTRODUCTION: Exercise tolerance testing is an integral part of the pulmonary rehabilitation (PR) management of patients with chronic obstructive pulmonary disease (COPD). The 6-minute stepper test (6MST) is a new, well-tolerated, reproducible exercise test, which can be performed without any spatial constraints. OBJECTIVE: The aim of this study was to compare the results of the 6MST to those obtained during a 6-minute walk test (6MWT) and cardiopulmonary exercise testing (CPET) in a cohort of COPD patients. METHODS: Ninety-one COPD patients managed by outpatient PR and assessed by 6MST, 6MWT, and CPET were retrospectively included in this study. Correlations between the number of steps on the 6MST, the distance covered on the 6MWT, oxygen consumption, and power at the ventilatory threshold and at maximum effort during CPET were analyzed before starting PR, and the improvement on the 6MST and 6MWT was compared after PR. RESULTS: The number of steps on the 6MST was significantly correlated with the distance covered on the 6MWT (r=0.56; P<0.0001), the power at maximum effort (r=0.46; P<0.0001), and oxygen consumption at maximum effort (r=0.39; P<0.005). Performances on the 6MST and 6MWT were significantly improved after PR (570 vs 488 steps, P=0.001 and 448 vs 406 m, respectively; P<0.0001). Improvements of the 6MST and 6MWT after PR were significantly correlated (r=0.34; P=0.03). CONCLUSION: The results of this study show that the 6MST is a valid test to evaluate exercise tolerance in COPD patients. The use of this test in clinical practice appears to be particularly relevant for the assessment of patients managed by home PR.

[Blood lactate three minutes after a graded exercise test: a criterion of maximal exercise in patients with COPD]. / Lactatémie trois minutes après une EFX : un critère de maximalité chez le patient BPCO.

INTRODUCTION: The graded exercise test (GXT) is used to measure the exercise capacity of patients with chronic obstructive pulmonary disease (COPD). To do this GXT must be maximal (exhaustive). However, the value of the blood lactate at the GXT endpoint [La(-)max] or after a recovery period of three minutes [La(-)recovery], to confirm that the GXT is maximal, remains controversial. The purpose of the present study is to determine a threshold of [La(-)max] and/or [La(-)recovery], which confirms the exhaustiveness of GXT in patients with COPD. METHODS: Thirty-six patients with COPD performed a GXT until exhaustion on a cycle ergometer. During the GXT cardiorespiratory parameters, [La(-)max] and [La(-)recovery] were measured. When at least three out of five of the most frequently used criteria to confirm exhaustion were met, GXT was considered as maximal. Conversely, GXT was considered as sub-maximal when less three criteria were observed. The receiver operating characteristic (ROC) curves were analyzed. RESULTS: For [La(-)max] the areas under the ROC curve and the areas under the diagonal were not significantly different (P=0.16). For [La(-)recovery] the ROC curve inflected itself at 5.8mmol/L (sensitivity=0.92 and specificity=0.56). CONCLUSIONS: It was not possible to use [La(-)max] to confirm exhaustion in our population. However, [La(-)recovery]<5.8mmol/L may help to confirm non-exhaustion during GXT in patients with COPD. Below this blood lactate threshold 93% patients performed a sub-maximal GXT.

[Comparison of home-based and outpatient, hospital-based, pulmonary rehabilitation in patients with chronic respiratory diseases]. / La réhabilitation respiratoire : évaluation de deux types de prise en charge, ambulatoire versus domicile.

INTRODUCTION: The comprehensive care and personalized pulmonary rehabilitation (PR) of patients with chronic respiratory disease is effective regardless of the place of performance. The objective of this prospective observational study was to compare two types of care in an outpatient rehabilitation center, versus a home-based PR. METHODS: Two hundred and eighty-six patients were supported : 137 patients were included in outpatients (age : 61.2±10.8years, BMI: 28.7±7.1), 149 in home-based PR (age: 62.9±12years, BMI: 26.1±6.6). The choice between outpatient and home was a function of distance from the center and the patient's wishes. The outpatient care was done in groups of six, four times a week for 6weeks. At home she was single, once a week for 8weeks with continued physical activity independently of the other days a week depending on individual action plan. The therapeutic education programs and psycho-social support were identical in both structures. The assessment included assessment of exercise tolerance test in 6minutes stepper (TS6), anxiety and depression and quality of life. RESULTS: There were no incidents or accidents during the PR in the two structures. The exercise intolerance was significantly higher in patients TS6 home (332.9±154.8 versus 460.2±137.9 counts, P<0.01). All the parameters studied, except for HAD score in the center, were improved significantly (P<0.001) after the course. The evolution of the different scores was not significantly different between the ambulatory versus home. CONCLUSION: The PR of chronic respiratory unselected patients is as safe and effective at home or in outpatient center on exercise tolerance and quality of life. Home-based PR is an alternative to outpatient care as long as all activities, physical training, therapeutic education and psychosocial support, are achieved.

Relevance of the measure of perceived exertion for the rehabilitation of obese patients.

The most common tool used for measuring effort perception is the rating scale of perceived exertion (RPE) developed by Borg. This scale is also used for various outcomes in the general population. The validity and reliability of this scale have already been reported in obese patients. However, the relevance of measuring perceived exertion in obese patients is still poorly known. This review of the literature presents the Borg RPE scale (i.e., validity, reliability and recommendations) and its main advantages during graded exercise tests (e.g., comparison of physical capacity, predicting physiological variables, verifying exhaustion and exercise safety) and rehabilitation programs (e.g., individualized exercise intensity, evaluation of the impact of a rehabilitation program and even determining the perceptual preference) in obese patients. This review of the literature underlines the relevance and usefulness of the Borg RPE scale, which is still underused in obese patients. However, additional studies are still necessary before using this scale routinely in all obese patients (regardless of the severity of their obesity or associated complications).

Six-minute stepper test to assess effort intolerance in interstitial lung diseases.

The six-minute stepper test (6MST) is a new test for evaluating exercise tolerance. Unlike the six-minute walk test (6MWT) it can be carried out in a limited space. The aim of this study was to compare the 6MST and the 6MWT in patients with various diffuse interstitial lung disease (ILD). 6MWT and 6MST were performed the same day in 84 patients with various ILD. The covered distance during 6MWT was compared to the number of steps during the 6MST. We also compared heart rate, oxygen saturation, dyspnoea and leg tiredness on a Borg scale. All the patients successfully completed the tests, and tolerance was considered good. The number of steps completed in the 6MST was strongly correlated with the distance walked in the 6MWT (r2 = 0.5; p < 0.0001). Oxygen desaturation was less frequent and less severe (p < 0.0001), heart rate was higher (p < 0.0001) and dyspnoea and leg tiredness were more marked (p < 0.0001) in the 6MST than in the 6MWT. The 6MST is feasible for patients with ILD. It is a simple, safe, mobile test that is cheap and easy to carry out in all structures.

Home-based pulmonary rehabilitation in idiopathic pulmonary fibrosis.

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is a severe chronic lung disease. Pulmonary rehabilitation could improve the quality of life of patients with this condition. METHODS: We prospectively evaluated the impact of an 8-week home-based pulmonary rehabilitation programme over 10 months in stable patients suffering from IPF. Exercise capacity, pulmonary function, dyspnoea and quality of life were analyzed before and after the rehabilitation programme. RESULTS: Seventeen patients were included and 13 completed the study. Mean functional vital capacity (FVC) was 2.15±0.79L and mean diffusing capacity for carbon monoxide (DLCO) was 7.81±3.99mL/min/mmHg. Six patients were treated with low dose oral steroids (20mg/day of prednisone) with or without immunosuppressive treatments; six were taking part in therapeutic trials. Mean endurance time (7.4±9.1 min vs. 14.1±12.1 min; P=0.01), number of steps per minute on a stepper (322±97 vs. 456±163; P=0.026), six-minute walk distance relative to heart rate (HR) (11±6 vs. 17±12; P=0.006), exercise dyspnoea (P=0.026), sensation of physical limitation on the SF-36 (25%±26 vs. 49%±38; P=0.047) and four out of seven visual analogue scales were significantly improved after rehabilitation. In contrast, no significant difference was observed in resting pulmonary function or in other items on quality of life questionnaires. CONCLUSION: A home-based programme of pulmonary rehabilitation is feasible in IPF patients. It significantly improved endurance parameters and physical limitation in this patient group without changing pulmonary function.

Validity, reliability, and responsiveness of a new short Visual Simplified Respiratory Questionnaire (VSRQ) for health-related quality of life assessment in chronic obstructive pulmonary disease.

The Visual Simplified Respiratory Questionnaire (VSRQ) was designed to assess health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD). It contains eight items: dyspnea, anxiety, depressed mood, sleep, energy, daily activities, social activities and sexual life. Psychometric properties were assessed during a clinical trial that evaluated the impact of tiotropium on HRQoL of COPD patients. These included the determination of structure, internal consistency reliability, concurrent validity with the St George's Respiratory Questionnaire (SGRQ), test - retest reliability, clinical validity and responsiveness to change over two weeks. Minimal important difference (MID) was calculated; cumulative response curves (CRC) were based on the dyspnea item. Psychometric analyses showed that VSRQ structure was unidimensional. The questionnaire demonstrated good internal consistency reliability (Cronbach's alpha = 0.84), good concurrent validity with SGRQ (Spearman = -0.70) and clinical validity, good test-retest reproducibility (ICC = 0.77), and satisfactory responsiveness (standardized response mean = 0.57; Guyatt's statistic = 0.63). MID was 3.4; CRC median value of the 'minimally improved' patients was 3.5. In conclusion, VSRQ brevity and satisfactory psychometric properties make it a good candidate for large studies to assess HRQoL in COPD patients. Further validation is needed to extend its use in clinical practice.

[Home-based pulmonary rehabilitation in idiopathic pulmonary fibrosis]. / Réhabilitation respiratoire à domicile au cours de la fibrose pulmonaire idiopathique.

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is a severe chronic lung disease. Pulmonary rehabilitation could improve the quality of life of patients with this condition. METHODS: We prospectively evaluated the impact of an 8 week home-based pulmonary rehabilitation program over 10 months in stable patients suffering from IPF. Exercise capacity, pulmonary function, dyspnea and quality of life were analyzed before and after the rehabilitation program. RESULTS: 17 patients were included and 13 completed the study. Mean FVC was 2.15+/-0.79 L and mean DLCO was 7.81+/-3.99 ml/min/mmHg. Six patients were treated with low dose oral steroids ($20 mg/day of prednisone) with or without immunosuppressive treatments; 6 were taking part in therapeutic trials. Mean endurance time (7.4+/-9.1 min vs 14.1+/-12.1 min; p<0,01), number of beats per minute on a stepper (322+/-97 vs 456+/-163; p=0.026), 6 min walking distance to heart rate ratio (11+/-6 vs 17+/-12; p=0.006), exercise dyspnea (p=0.026), sensation of physical limitation at the SF-36 (25%+/-26 vs 49%+/-38; p=0.047) and 4 out of 7 visual analog scales were significantly improved after rehabilitation. In contrast, no significant difference was observed in resting pulmonary function or in other items of quality of life questionnaires CONCLUSION: A home-based program of pulmonary rehabilitation is feasible in IPF patients. It significantly improves endurance parameters and physical limitation in this patient group without changing pulmonary function.

Effect of tiotropium on health-related quality of life as a primary efficacy endpoint in COPD.

Clinical manifestations of chronic obstructive pulmonary disease (COPD), including airflow limitation, dyspnea, and activity limitation, ultimately lead to impaired health-related quality of life (HRQoL). This 9-month, randomized, double-blind, multicenter study compared the effect of once-daily tiotropium 18 microg and placebo on HRQoL, spirometric parameters, and exacerbations in 554 patients with moderate-to-severe COPD. HRQoL was assessed using the St. George's Respiratory Questionnaire (SGRQ) and the new 8-item Visual Simplified Respiratory Questionnaire (VSRQ), which is currently being validated. The primary efficacy endpoint was the proportion of patients achieving a reduction of at least 4 units in the SGRQ total score at study end (Month 9). Mean +/- SD baseline SGRQ total score was 47.4 +/- 18.1. Significantly more tiotropium-treated patients achieved a reduction of at least 4 units in the SGRQ score vs placebo at study end (59.1% vs 48.2%, respectively; p = 0.029). Tiotropium significantly improved spirometric parameters (forced expiratory volume in 1 second [FEV1]: 0.11 +/- 0.02 L vs 0.01 +/- 0.02 L; between-group difference: 0.10 +/- 0.03 L, p = 0.0001) and reduced exacerbations vs placebo. Maintenance treatment with tiotropium provided significant and clinically relevant improvements in HRQoL, as measured by the SGRQ.