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Dyspnoea severity and pneumonia as predictors of in-hospital mortality and early readmission in acute exacerbations of COPD

Background

Rates of mortality and readmission are high in patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In this population, the prognostic value of the Medical Research Council Dyspnoea Scale (MRCD) is uncertain, and an extended MRCD (eMRCD) scale has been proposed to improve its utility. Coexistent pneumonia is common and, although the CURB-65 prediction tool is used, its discriminatory value has not been reported.

 Methods

Clinical and demographic data were collected on consecutive patients hospitalised with AECOPD. The relationship of stable-state dyspnoea severity to in-hospital mortality and 28-day readmission was assessed. The discriminatory value of CURB-65, MRCD and eMRCD, in the prediction of in-hospital mortality, was assessed and compared.

 Results

920 patients were recruited. 10.4% died in-hospital and 19.1% of the 824 survivors were readmitted within 28 days of discharge. During their stable state prior to admission, 34.2% of patients were too breathless to leave the house. Mortality was significantly higher in pneumonic than in non-pneumonic exacerbations (20.1% vs 5.8%, p<0.001). eMRCD was a significantly better discriminator than either CURB-65 or the traditional MRCD scale for predicting in-hospital mortality, and was a stronger prognostic tool than CURB-65 in the subgroup of patients with pneumonic AECOPD.

 Conclusions

The severity of dyspnoea in the stable state predicts important clinical outcomes in patients hospitalised with AECOPD. The eMRCD scale identifies a subgroup of patients at a particularly high risk of in-hospital mortality and is a better predictor of mortality risk than CURB-65 in exacerbations complicated by pneumonia.

Occupational exposure to organic dust increases lung cancer risk in the general population

Background

Organic dust is a complex mixture of particulate matter from microbial, plant or animal origin. Occupations with exposure to animal products have been associated with an increased lung cancer risk, while exposure to microbial components (eg, endotoxin) has been associated with a decreased risk. To date there has not been a comprehensive evaluation of the possible association between occupational organic dust exposure (and its specific constituents) and lung cancer risk in the general population.

 Methods

The SYNERGY project has pooled information on lifetime working and smoking from 13 300 lung cancer cases and 16 273 controls from 11 case–control studies conducted in Europe and Canada. A newly developed general population job-exposure matrix (assigning no, low or high exposure to organic dust, endotoxin, and contact with animals or fresh animal products) was applied to determine level of exposure. ORs for lung cancer were estimated by logistic regression, adjusted for age, sex, study, cigarette pack-years, time since quitting smoking, and ever employment in occupations with established lung cancer risk.

 Results

Occupational organic dust exposure was associated with increased lung cancer risk. The second to the fourth quartile of cumulative exposure showed significant risk estimates ranging from 1.12 to 1.24 in a dose-dependent manner (p<0.001). This association remained in the highest quartile after restricting analyses to subjects without chronic obstructive pulmonary disease or asthma. No association was observed between lung cancer and exposure to endotoxin or contact with animals or animal products.

 Conclusion

Occupational exposure to organic dust was associated with increased lung cancer risk in this large pooled case–control study.

Continuous versus intermittent inhaled corticosteroids for mild persistent asthma in children: not too much, not too little

The goal of asthma treatment is to prevent exacerbations, achieve daily asthma control and prevent adverse effects with a minimum of medication. In preschoolers, children and adolescents with mild persistent asthma, the most effective therapy remains daily use of low-dose inhaled corticosteroids.1 Why then consider intermittent therapy over maintenance inhaled corticosteroids?

 The intermittent approach is attractive to patients and families for a variety of reasons, including fear of corticosteroid side effects,2 the erroneous concept that no symptoms equate to no disease3 and ease of compliance with medications administered for symptoms rather than on a daily basis. Indeed, pharmacy records clearly show that most children with asthma infrequently renew their prescriptions for controller medications, suggesting that they may not understand, perceive or agree with the need for daily therapy, despite ongoing healthcare resources utilisation and excess use of rescue β2-agonist.4

This practice...

In search of the fibrotic epithelial cell: opportunities for a collaborative network

Idiopathic pulmonary fibrosis (IPF) is a chronic progressive disease of unknown aetiology. It has a very poor prognosis and no effective treatment. There are two major barriers to the development of novel treatments in IPF: an incomplete understanding of its pathogenesis and the fact that current models of the disease are poorly predictive of therapeutic response. Recent studies suggest an important role for the alveolar epithelium in the pathogenesis of IPF. However, practical limitations associated with isolation and culture of primary alveolar epithelial cells have hampered progress towards further elucidating their role in the pathogenesis of the disease or developing disease models that accurately reflect the epithelial contribution. The practical limitations of primary alveolar epithelial cell culture can be divided into technical, logistical and regulatory hurdles that need to be overcome to ensure rapid progress towards improved treatment for patients with IPF. To develop a strategy to facilitate alveolar epithelial cell harvest, retrieval and sharing between IPF research groups and to determine how these cells contribute to IPF, a workshop was organised to discuss the central issues surrounding epithelial cells in IPF (ECIPF). The central themes discussed in the workshop have been compiled as the proceedings of the ECIPF.

Continuous versus intermittent inhaled corticosteroid (budesonide) for mild persistent asthma in children--not too much, not too little

The clinical efficacy of inhaled corticosteroids (ICSs) in asthma has been demonstrated in long-term intervention studies,1 2 and ICSs are recommended first-line treatment of persistent asthma, even in children.3 The long-term benefits of early intervention with ICS have been well documented in adults with asthma.4 In children, early intervention with ICS has not altered the natural history of the disease.1 We have recently finalised a series of studies related to the Helsinki Early Intervention Childhood Asthma Programme.5 The programme highlights the benefits and safety aspects of intermittent treatment with an ICS, budesonide, in comparison with continuous daily ICS and non-steroidal maintenance treatment. In this study, we summarise our experiences.

 In the 18-month intervention, we compared two budesonide regimens with a control group treated with a fixed dose of disodium cromoglycate (DSCG). The study evaluated the antiasthmatic efficacy...

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