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Outdoor air pollution and respiratory health in patients with COPD

Objectives

Time series studies have shown adverse effects of outdoor air pollution on mortality and hospital admissions in patients with chronic obstructive pulmonary disease (COPD) but panel studies have been inconsistent. This study investigates short-term effects of outdoor nitrogen dioxide, ozone, sulfur dioxide, particulate matter (PM10) and black smoke on exacerbations, respiratory symptoms and lung function in 94 patients with COPD in east London.

 Methods

Patients were recruited from an outpatient clinic and were asked to complete daily diary cards (median follow-up 518 days) recording exacerbations, symptoms and lung function, and the amount of time spent outdoors. Outdoor air pollution exposure (lag 1 day) was obtained from local background monitoring stations.

 Results

Symptoms but not lung function showed associations with raised pollution levels. Dyspnoea was significantly associated with PM10 (increase in odds for an IQR change in pollutant: 13% (95% CI 4% to 23%)) and this association remained after adjustment for other the pollutants measured. An IQR increase in nitrogen dioxide was associated with a 6% (0–13%) increase in the odds of a symptomatic fall in peak flow rate. The corresponding effect sizes for PM10 and black smoke were 12% (2–25%) and 7% (1–13%), respectively.

 Conclusion

It is concluded that outdoor air pollution is associated with important adverse effects on symptoms in patients with COPD living in London.

Airway remodelling and its relationship to inflammation in cystic fibrosis

Pulmonary disease is the most important cause of morbidity and mortality in cystic fibrosis (CF). Most patients with CF die from respiratory failure with extensive airway destruction. Airway remodelling, defined as structural airway wall changes, begins early in life in CF but the sequence of remodelling events in the disease process is poorly understood. Airway remodelling in CF has traditionally been thought to be solely the consequence of repeated cycles of inflammation and infection. However, new evidence obtained from developmental, physiological and histopathological studies suggests that there might instead be multiple mechanisms leading to airway remodelling in CF including (1) changes related to infection and inflammation; (2) changes specific to CF as a result of CF transmembrane conductance regulator (CFTR) dysfunction in the airway wall, independent of infection and inflammation; and (3) protective responses to (1) and/or (2). Recent advances in bronchoscopic techniques have allowed airway mucosal (endobronchial) biopsies to be taken in children and even infants. Endobronchial biopsy studies may provide insight into the role and relative contribution of the different mechanisms of airway remodelling in CF, with the main limitation that they assess only changes in proximal large airways and not in peripheral small airways from where CF disease is thought to originate. Findings from biopsy studies could encourage the development of novel therapeutic strategies targeting structural changes in addition to infection and inflammation.

Lung function impairment, COPD hospitalisations and subsequent mortality

Background

Hospitalisations and their sequelae comprise key morbidities in the natural history of chronic obstructive pulmonary disease (COPD). A study was undertaken to examine the associations between lung function impairment and COPD hospitalisation, and COPD hospitalisation and mortality.

 Methods

The analysis included a population-based sample of 20 571 participants with complete demographic, lung function, smoking, hospitalisation and mortality data, with 10-year median follow-up. Participants were classified by prebronchodilator lung function according to the modified Global Initiative on Obstructive Lung Disease (GOLD) criteria. Hospitalisations were defined by the presence of a COPD discharge diagnosis (ICD-9 codes 490–496). Incidence rate ratios (IRR) of COPD admissions and hazard ratios (HR) of mortality with respective 95% CI were calculated, adjusted for potential confounders.

 Results

The prevalence of modified GOLD categories was normal (36%), restricted (15%), GOLD stage 0 (22%), GOLD stage 1 (13%), GOLD stage 2 (11%) and GOLD stages 3 or 4 (3%). Adjusted IRRs (and 95% CI) indicated an increased risk of COPD hospitalisation associated with each COPD stage relative to normal lung function: 4.7 (3.7 to 6.1), 2.1 (1.6 to 2.6), 3.2 (2.6 to 4.0), 8.0 (6.4 to 10.0) and 25.5 (19.5 to 33.4) for the restricted, GOLD stage 0, GOLD stage 1, GOLD stage 2 and GOLD stages 3 or 4, respectively. Hospitalisation for COPD increased the risk of subsequent mortality (HR 2.7, 95% CI 2.5 to 3.0), controlling for severity, number of prior hospitalisations and other potential confounders. The increase in mortality associated with admission was very similar across the modified GOLD stages.

 Conclusions

COPD severity was associated with a higher rate of severe exacerbations requiring hospitalisation, although severe exacerbations at any stage were associated with a higher risk of short-term and long-term all-cause mortality.

Multidrug-resistant tuberculosis: resistance rates to first and reserve antituberculosis drugs in the UK in 2008/9 and the role of rapid molecular tests for drug resistance

At the Health Protection Agency National Mycobacterium Reference Laboratory (HPA NMRL) between January 2008 and December 2009, we evaluated in patients with multidrug-resistant tuberculosis (MDRTB; isolates resistant to rifampicin and isoniazid) the rate of resistance to other first-line drugs (ethambutol and pyrazinamide) and to reserve drugs and the role of rapid molecular tests for rifampicin (and MDRTB) resistance.

MDRTB is difficult to manage—drugs are toxic, less effective and costly. Further problems arise from extensively drug-resistant tuberculosis (XDRTB); MDRTB isolates resistant to a quinolone and any of the injectable drugs (amikacin, capreomycin, kanamycin). Effective management of MDRTB/XDRTB depends on drug sensitivity test (DST) results to the remaining first-line and reserve drugs.

We have previously demonstrated that our national ‘fastrack’ molecular tuberculosis and rifampicin resistance identification service significantly reduces time for detection compared with bacteriological culture. Overall, Mycobacterium tuberculosis complex is detected 15.2 days earlier than gold standard automated liquid culture methods...

Seasonality and attendance at a pulmonary rehabilitation programme

Pulmonary rehabilitation (PR) programmes have been shown to reduce symptoms, improve exercise tolerance and reduce readmission rates in chronic obstructive pulmonary disease (COPD).1 2 PR has the potential to reduce the economic burden of COPD upon the NHS but, if poor attendance results in groups running at less than capacity, the cost-effectiveness of the service is markedly reduced. Understanding and responding to the factors that influence attendance is vital to ensuring maximum benefit is gained from PR programmes. The role of seasonality in attendance at PR programmes has not previously been evaluated, and there is conflicting evidence regarding the role of seasonality from other outpatient settings.3 4

We reviewed attendance rates between 2007 and 2010 at our PR programme in a central London borough. We collected data on attendance at initial assessments and subsequent biweekly PR sessions and examined the data...

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