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Studies have shown that chronic obstructive pulmonary disease (COPD) and smoking are associated with increased suicide risk. To date there are no prospective studies examining suicide risk among smokers along a spectrum of pulmonary disease ranging from completely normal spirometry to severe COPD.Which clinical variables predict death by suicide or overdose of indeterminate intent in a large cohort of heavy smokers within the COPDGene study?We studied data from 9,930 participants involved in COPDGene, a multisite, prospective cohort study of current and former smokers. Primary cause of adjudicated deaths was identified using death certificates, family reports, and medical records. We examined time to death by suicide/overdose as the primary outcome in Cox regression adjusted for age, sex, race, BMI, pack-years, current smoking status, airflow limitation (%predicted FEVThe cohort was 47% female, 33% Black (67% White), had a mean (SD) age of 59.6 (9.0) years, and mean FEVIn this well-characterized cohort of current and former smokers with and without COPD, we identified risk factors for suicide/overdose that emphasize the subjective experience of illness over objective assessments of lung function.

Individuals with Chronic Obstructive Pulmonary Disease (COPD) often develop anxiety and depression, which worsen illness management and prognosis. Physical and psychological symptoms, contextual and illness-related factors display complex reciprocal interactions, which give rise to heterogeneous presentations. Examining the patterns of association between specific physical and psychological symptoms in patients with COPD may help to focus on the precision of the patient-centred care.We used network analyses to examine the links between symptoms of COPD, depression and anxiety.Data from 1587 individuals with COPD from the COPDGene study were included. We estimated a Bayesian Gaussian Graphical Model to highlight the unique associations between symptoms of COPD (assessed with the COPD Assessment Test), depression and anxiety (assessed with the Hospital Anxiety and Depression Scale (HADS), while examining the role of sociodemographic characteristics, lung function tests, and health status.Unique Variable Analysis reduced 14 HADS items to Tension/worry (chronic anxiety), Fear/panic (acute anxiety), Restlessness, Anhedonia, Sadness and Slowing. In network analyses, chest-tightness was related to acute anxiety, while cough and weakness were connected with core depressive symptoms (sadness and lack of pleasure). Chronic anxiety was linked with acute anxiety and depressive symptoms. Findings were confirmed accounting for the role of confounders, including lung function, sex, ethnicity and lifestyle factors. A simulation based on our model yielded distinct predictions about anxiety and depression in two participants with similar COPD severity, but different symptom profiles.Network analyses highlighted specific associations between symptoms of COPD, depression and anxiety. Accounting for symptom-level interactions may help to promote personalized treatment approaches.

We examined the prevalence of comorbid depression and anxiety in patients with chronic obstructive pulmonary disease (COPD) and their response to eight-weeks of pulmonary rehabilitation (PR).Seven hundred thirty four patients with clinically stable COPD completed an eight-week outpatient multidisciplinary PR, comprising 2-h (1-h exercise and 1-h education) per/week. Depression and anxiety, exercise capacity, quality of life (QOL), and dyspnea were measured pre- and post-PR by the incremental shuttle walk test (ISWT), St. George's Respiratory Questionnaire (SGRQ), and modified Medical Research Council (mMRC) scale, respectively. The Depression Anxiety Stress Scale (DASS-21) was completed and patients classified as having clinically significant comorbid anxiety and depression, anxiety alone, depression alone, or with neither.The mean (SD) age of patients was 71 (8.8) years, and 51% were men. Prevalence of pre-PR comorbid depression and anxiety was 34%, anxiety alone 20%, depression alone 5% and neither 41%. The prevalence of stress was 59%. In patients with anxiety and depressive symptoms, total SGRQ score improved from 64.9 (13.8) pre-PR to 50.1 (17.2) post PR (p 0.001), mMRC score improved from 3.4(1.0) pre-PR to 2.8 (1.1) post PR (p 0.001), and ISWT distance walked increased from 188.6 (117.6) pre-PR to 248.6 (149.1) post PR, p 0.001.One in three patients with COPD suffer from comorbid depression and anxiety with a high level of disease burden, reflected by symptoms of elevated dyspnea and impaired QOL. PR improves QOL and exercise capacity, and reduces dyspnea in patients with COPD and comorbid depression and anxiety.

Pulmonary rehabilitation (PR) improves exercise capacity in patients with COPD in the short term.In patients with COPD, does 8 weeks of PR confer long-term benefits on symptoms of dyspnea, anxiety, and depression, and on quality of life, 2 years after completion?One hundred and sixty-five patients with COPD completed an 8-week, community-based, comprehensive PR program, comprising 2-h sessions twice weekly. Sessions included aerobic exercise and an educational program. Patients were encouraged to perform daily walking exercise up to 30 min at home. We evaluated a number of outcome measures at baseline, 8 weeks, and 2 years, including the following: dyspnea measured with the modified Medical Research Council (mMRC) questionnaire, quality of life assessed with the St. George's Respiratory Questionnaire (SGRQ), and anxiety measured with the Anxiety Inventory for Respiratory Disease (AIR) and the Depression Anxiety Stress Scale (DASS). In addition, we measured exercise capacity, using the Incremental Shuttle Walk Test (ISWT), at baseline and 8 weeks.Mean age (SD) was 72 (8.6) years; 55% were men. At 8 weeks, improvements in mMRC, SGRQ, ISWT, DASS, and AIR were all statistically significant (P .001). During the 2-year follow-up, changes observed at 8 weeks were maintained for anxiety symptoms, and for symptoms, impact, and total SGRQ scores. In multivariate analysis, initial elevated levels of dyspnea, depression, anxiety, and decreased exercise capacity predicted greater quality of life improvement at 2 years (all P .001).Over a 2-year period, an effective 8-week PR program provides sustained improvement in anxiety and quality of life. Short-term improvements in dyspnea, depression, and stress symptoms at 8 weeks were not maintained at 2 years.

BackgroundHearing and vision impairments are among the most common and disabling comorbidities in people living with dementia. Intervening to improve sensory function could be a means by which the lives of people living with dementia may be improved. However, very few studies have tried to ameliorate outcomes in dementia by improving sensory function. This paper describes the multi-step development of a new intervention designed to support hearing and vision function in people living with dementia in their own homes. At the end of the development programme, it is anticipated that a ‘sensory support’ package will be ready for testing in a full scale randomised controlled trial.MethodsThis programme is based on the process of ‘intervention mapping’ and comprises four integrated steps, designed to address the following: (1) scoping the gaps in understanding, awareness and service provision for the hearing and/or vision impairment care needs of people with dementia using a systematic literature review and Expert Reference Group; (2) investigating the support care needs through a literature search, stakeholder surveys, focus groups, semi-structured interviews and an Expert Reference Group, leading to a prototype sensory support package; (3) refining the prototype by additional input from stakeholders using focus groups and semi-structured interviews; and (4) field testing the draft intervention using an open-labelled, non-randomised feasibility study, integrating feedback from people with dementia and their significant others to develop the final intervention ready for full scale definitive trialling. Input from the ‘patient and public voice’ is a cornerstone of the work and will interlink with each step of the development process. The programme will take place in study centres in Manchester, Nicosia and Bordeaux.DiscussionQuantitative and qualitative data analyses will be employed, dependent upon the sub-studies in question. Data from the steps will be integrated with consideration given to weighting of evidence for each step of the programme. This programme represents the logical development of a complex intervention to fulfil an unmet need. It is based on a theoretical framework and will lead to a subsequent full scale efficacy trial. The challenges in integrating the data and addressing the contextual issues across study sites will be scrutinised.

Background There is insufficient evidence about the long-term course of depressive symptom trajectories and their impact among patients with COPD. Methods We analysed 3-year data obtained from patients with COPD participating in the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints study. Patients were split into four groups on the basis of Center for Epidemiologic Studies Depression Scale score ( Results A total of 1,589 patients with COPD completed the 3-year follow-up. Of these, 55% (n = 869) were classified as never depressed, 24% (n = 377) were classified as persistently depressed, 14% (n = 226) developed new onset of depression, and 7% (n = 117) had depression that remitted. Female sex and history of stroke were associated with substantial increases in the odds of persistent depression (OR, 2.95; 95% CI, 2.05-4.24 and OR, 3.09; 95% CI, 1.43-6.67, respectively). Odds of new onset depression increased with worse health status (OR, 1.10; 95% CI, 1.04-1.17 per 4-point increase in St. George's Respiratory Questionnaire score) and moderate to severe dyspnea (OR, 1.57; 95% CI, 1.07-2.31 for modified Medical Research Council score ≥ 2 vs 0 or 1). During follow-up, patients with persistent or new-onset depression experienced more exacerbations and more pronounced loss in performance as assessed by reduction in the 6-min walk distance (6MWD) test score. Conclusions About one in four patients with COPD had persistent depressive symptoms over 3 years. Clinicians should be aware of the characteristics of persistent and new onset depressive symptoms, which are associated with risk of exacerbations and loss of performance on the 6MWD test. Interventions that ameliorate the course of depression are needed. Trial Registry ClinicalTrials.gov; No.: NCT00292552; URL: www.clinicaltrials.gov.

Objective : To translate The Manchester Respiratory Activities of Daily Living (MRADL) questionnaire into Portuguese and to create a version of the MRADL that is cross-culturally adapted for use in Brazil. Methods : The English-language version of the MRADL was translated into Portuguese by two health care researchers who were fluent in English. A consensus version was obtained by other two researchers and a pulmonologist. That version was back-translated into English by another translator who was a native speaker of English and fluent in Portuguese. The cognitive debriefing process consisted in having 10 COPD patients complete the translated questionnaire in order to test its understandability, clarity, and acceptability in the target population. On the basis of the results, the final Portuguese-language version of the MRADL was produced and approved by the committee and one of the authors of the original questionnaire. Results : The author of the MRADL questioned only a few items in the translated version, and some changes were made to the mobility and personal hygiene domains. Cultural differences regarding the domestic activities domain were found, in particular regarding the item "Do you have the ability to do a full clothes wash and hang them out to dry?", due to socioeconomic and climatic issues. The item "Do you take care of your garden?" was questioned by the participants who lived in apartments, being modified to "Do you take care of your garden or plants in your apartment?" Conclusions : The final Portuguese-language version of the MRADL adapted for use in Brazil was found to be easy to understand and easily applied.

COPD is a major cause of all-cause mortality. We examined predictors of 1-year mortality in patients with severe COPD and major depression after inpatient treatment in a rehabilitation hospital.We screened 898 consecutively admitted patients. Of these, 138 patients received the diagnoses of COPD according to American Thoracic Society Guidelines and major depression by Diagnostic and Statistical Manual of Mental Disorders, 4th edition and signed consent; 67 were randomized to a treatment adherence enhancement intervention and 71 to usual care. We assessed history of falls, dyspnea-related disability, severity of depression, medical burden, and cognitive functioning. Following discharge from inpatient rehabilitation, participants were prospectively followed, and mortality was ascertained over 52 weeks from hospital notes and reports of primary care physicians and relatives.One-year, all-cause mortality was 22% (31 of 138). Multivariate Cox regression analysis showed that history of falls in the 6 months preceding hospital admission was the strongest predictor of mortality (OR, 3.05; 95% CI, 1.40-6.66; P.005). Dyspnea during activities (Pulmonary Functional Status and Dyspnea Questionnaire-Modified domain) was also associated with mortality (OR, 1.05; 95% CI, 1.02-1.08; P.002). Depression severity, medical burden, and cognitive impairment were not predictors of mortality.Recent falls and dyspnea during activities identify subgroups of depressed patients with COPD at increased risk for all-cause mortality. These subgroups are in need of clinical attention and follow-up and can serve as targets for prevention research aiming to inform clinical strategies and public health planning.

Rationale: Anxiety is a common comorbidity of chronic obstructive pulmonary disease (COPD) that is associated with higher morbidity and mortality. We evaluated three anxiety screening questionnaires: the Generalized Anxiety Disorder 7-Item Scale (GAD-7), the Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), and the Anxiety Inventory for Respiratory Disease (AIR). Objectives: To evaluate and compare the test performance characteristics of three anxiety screening questionnaires, using the Mini-International Neuropsychiatric Interview (MINI), version 7.0, as the “gold standard.” Methods: Individuals with COPD were recruited at 16 centers. The MINI and questionnaires were administered by trained research coordinators at an in-person visit and readministered by telephone 2–4 weeks later. A composite score for the presence of any Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) anxiety disorder was computed, based on the MINI as the gold standard, compared with a participant screening positive on self-report measures for these analyses. Results: Two hundred and twenty eligible individuals with COPD were enrolled; 219 completed the study. Eleven percent were identified as having a DSM-V anxiety disorder, based on the MINI. Elevated anxiety symptoms based on questionnaires were 38% for the AIR, 30% for the GAD-7, and 20% for the HADS-A. Area under the receiver operating characteristic curve (AUC) was highest for the GAD-7 (0.78; 95% confidence interval [CI], 0.69–0.87), followed by the HADS-A (0.74; 95% CI, 0.64–0.84) and the AIR (0.66; 95% CI, 0.56–0.76). The AUC for the GAD-7 was significantly greater than for the AIR (P = 0.014). Sensitivity was not statistically different among the questionnaires: 77% for the GAD-7, 63% for the HADS-A, and 66% for the AIR. The HADS-A had the highest specificity, 85%, which was significantly higher than that of the GAD-7 (77%; P

Introduction: There is strong evidence to suggest that pulmonary rehabilitaton (PR) improves exercise capacity, quality of life and psycholgical well-being in patietns with COPD in short-term follow-up. However, the benefits of the initial PR program in longer-term is inconculusive. We explored the long-term benefits of an eight week after PR with 2 years follow-up on dyspnoea, anxiety and quality of life in patients with COPD. Method: 165 COPD patients completed an 8-week community-based PR program. Patients completed at baseline, 8 weeks and 104 weeks the following outcome measures: dyspnoea measured by the Medical Research Council (nMRC), quality of life assessed by the St-Georges Respiratory Questionnaire (SGRQ) and anxiety measured by the Anxiety Inventory for Respiratory Disease (AIR). Results: The mean (SD) age was 72 (8.6) years and 55% were men. At 8 weeks nMRC, SGRQ and AIR showed statistically and clinically significant improvements all (p Conclusions: This study demonestrates that an eight week PR program is effective in improvong quality of life at 2 years. However, this effect was not sustained in reducing severity of dyspnoea and anxiety. Table 1 - Long-term benefits of pulmonary rehabilitation

Asthma is a public health problem because of increasing prevalence in children and older adults. It is estimated that over three hundred million people are living with asthma worldwide. The high burden of asthma is associated with greater functional impairment and increased healthcare utilization in older adults. This chapter examines the impact of depression and anxiety and its management in older adults with asthma. Depression and anxiety are common comorbidities in older adults with asthma. They are associated with poor asthma control, low self-esteem, acute exacerbation, frequent episodes of hospital admission, poor adherence to medical treatment, impaired quality of life and suicidal ideation. The efficacy pulmonary rehabilitation (PR), cognitive behavioural therapy (CBT) and antidepressant drug therapy for patients with depression and anxiety in asthma are explored. Our findings indicate that PR and CBT are beneficial in improving depressive and anxiety symptoms and quality of life in short-term uncontrolled intervention studies. However, the long-term efficacy of CBT and PR is unknown. To date, the efficacy of antidepressant drug therapy for depression and anxiety in patients with COPD and asthma is uncertain. Thus, healthcare professionals should devise strategies to detect anxiety and depressive symptoms in older adults with asthma and offer appropriate treatment to reduce disease burden and improve quality of life. Well-controlled randomized trials are needed to examine the efficacy of intervention with long-term follow-up.

The purpose of screening tools for anxiety and depression in patients with chronic obstructive pulmonary disease is to identify those patients with clinically relevant symptoms who are in need of further diagnostic psychiatric assessment. Identifying high numbers of false positives is costly, both financially, and in terms of wasted time for the clinician and the patient. A scale that can efficiently screen patients for anxiety and depression is characterised by a high sensitivity, specificity, which ensures that all individuals with anxiety and depression disorders are identified with the symptom. This section of the book examined the available screening tools for anxiety and depression and their suitability and psychometric properties for patients with COPD. It is clear that although all of the scales reviewed have promising reliability and validity in general medical populations or in the populations they were designed. However, few, with the exception of the Anxiety Inventory for Respiratory disease (AIR), Brief Assessment Schedule for Depression, Beck Anxiety and Depression Inventory, Generalised Anxiety Inventory and Hospital Anxiety and Depression Scale have been partially validated in patients with COPD. The AIR is the only scale that is specifically designed and validated to measure anxiety in patients with COPD. It is responsive to pulmonary rehabilitation. These screening anxiety and depression scales have been widely used in patients with COPD including with other chronic respiratory diseases. However, the efficacy of these scales in terms of their responsiveness to intervention requires further testing.

Over 40% of older chronic obstructive pulmonary disease (COPD) patients suffer from clinically significant depressive symptoms, which may interfere with their daily activities. This section focuses primarily on antidepressant drug trials that have been conducted in patients with COPD and major depression. It will also examine the benefits of anxiolytics for this patient group. Both selective serotonin reuptake inhibitor (SSRI) and tricyclic antidepressant (TCA) studies conducted in depressed COPD patients have been significantly limited by methodological weaknesses including small sample size, sample heterogeneity and variability in the scales used to diagnose and monitor the treatment of depression. For this reason, it remains unclear which SSRIs or TCAs should be favoured in the treatment of depressed COPD patients and what are appropriate dosages and duration ranges. Lower doses of opioids are beneficial in ameliorating dyspnoea in patients with COPD without series adverse events. However, only a few studies have been conducted to address this question and they are all small in sample size. Additionally, the safety of benzodiazepines for use in patients with severe COPD requires further investigation. Therefore, appropriately powered prospective randomised controlled trials are needed. General guidance and specific medical advice points are provided in how to use antidepressants and anxiolytics in patients with COPD.

Chronic respiratory diseases primarily affect the lung. Asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis, lung cancer, lung fibrosis, sleep apnoea syndrome, pneumoconiosis and pleural diseases are common respiratory diseases worldwide. They present similar symptoms such as breathlessness on exertion, excess mucous production, chronic cough and wheezing. When these conditions are not adequately treated and/or become chronic may contribute to the development of systemic inflammatory comorbid disorders such as cardiovascular, musculoskeletal, psychiatric and cerebrovascular diseases. These comorbid disorders and pathophysiological mechanisms may vary in their manifestations, despite having similar symptoms. Comorbidities have major impact in patients with chronic respiratory diseases by impairing their quality of life, decreasing exercise capacity and increasing healthcare utilization. Therefore, it is important to screen patients with chronic respiratory diseases for comorbidities and monitor regularly. In addition, those identified with comorbidities should be referred for further assessment and to receive appropriate treatment which may include pharmacological therapy and non-pharmacological therapy (including exercise therapy and cognitive behavioural therapy) using a collaborative care model. Evidence from the available literature suggests that the effects of treating comorbidities in patients with chronic respiratory diseases are beneficial in short term improving quality-of-life patients and their caregivers. However, the long-term impact on clinical outcomes (e.g. healthcare utilization) is uncertain. Thus, well-controlled randomised control trails are needed.

Over 40 % of older chronic obstructive pulmonary disease (COPD) patients suffer from clinically significant depressive symptoms, which may interfere with their daily activities. Untreated depression may increase physical disability, social isolation, hopelessness and healthcare utilization. This review examined the impact of depression on the course of COPD, and the efficacy of antidepressant drug therapy and its implications for clinical practice. The efficacy of antidepressants in published trials in patients with COPD has been inconclusive. Specifically, there has been no clear evidence that antidepressants can induce remission of depression or ameliorate dyspnoea or physiological indices of COPD. Both selective serotonin reuptake inhibitor (SSRI) and tricyclic antidepressant (TCA) studies conducted in depressed COPD patients have been significantly limited by methodological weaknesses including small sample size, sample heterogeneity and variability in the scales used to diagnose and monitor the treatment of depression. For this reason, it remains unclear which SSRIs or TCAs should be favoured in the treatment of depressed COPD patients and what are appropriate dosages and duration ranges. Simply offering antidepressant drugs to older depressed COPD patients is unlikely to improve their condition. Promising treatment strategies such as a collaborative treatment approach and cognitive behavioural therapy should be considered for depressed COPD patients, with or without antidepressant drug therapy. Further studies are needed, including large, randomized, controlled trials with long-term follow-up, to examine the efficacy of antidepressants in patients with COPD.

Selecting the most appropriate patients to refer for surgery is crucial for high-quality and efficient clinical care. However, there are no specific referral criteria to guide the referral of appropriate patients for rotator cuff repair surgery. The aim of the present study was to design robust surgical referral criteria for patients with degenerative rotator cuff tears using consensus methodology. A two-round Delphi questionnaire was undertaken with a nationally representative sample of 41 specialist shoulder surgeons experienced in rotator cuff repair. Surgical referral criteria for degenerative rotator cuff tear were developed where consensus of at least 70% agreement was achieved. The initial questionnaire consisted of 24 items. Consensus was reached on 14 items, including: severity of pain, functional limitation, the identification of fat atrophy, agreement that a course of physiotherapy should be attempted before surgical referral, and exclusion for those with an active frozen shoulder. However, there was no consensus with regard to the dimensions of the tear. The surgical referral criteria developed were novel and promising for patients with degenerative rotator cuff tears, and further research is required to examine their efficacy. Copyright © 2013 John Wiley & Sons, Ltd.

Summary Background The application and extent of simulation-based education use within cardiorespiratory physiotherapy postgraduate education (in-house/regional provisions) and emergency oncall services were previously unexplored. Objectives This survey aimed to investigate the extent to which simulation-based education is currently utilised by physiotherapy services in the UK. Design A national postal questionnaire-based survey. Setting All 280 National Health Service Critical/Intensive Care Units in England, Northern Ireland, Scotland and Wales, providing emergency on-call physiotherapy services were included in the survey. Participants Emergency on-call physiotherapy service leads. Method A self-administered 20-item postal questionnaire survey was designed to establish the extent to which simulation-based education was currently being used within cardio-respiratory physiotherapy post-registration training. Results A useable response rate of 55% (155/280) was achieved, representing a range of respiratory and emergency on-call service leads. Sixty-one Trusts (39%) currently use simulation within acute respiratory or emergency on-call postgraduate training. The provision of simulation equipment varied with respect to type, fidelity and accessible to the physiotherapy service. Simulation-based education featured in emergency on-call induction, updates, competency assessment, assessment skills, treatment skills and scenarios (75, 92, 39, 28, 82, 48% respectively). Conclusions Simulation is currently used to teach a wide variety of cardio-respiratory physiotherapy skills relevant to the acute respiratory and on-call environments. Adoption was dependent upon local facilities, needs and training requirements. National inconsistencies in availability, fidelity and accessibility were identified. The evidence base surrounding the current use of simulation-based education within physiotherapy is limited and evidence of transferability to the practice arena remains relatively unknown. Future research is warranted to determine the education outcomes, impact on skill performance, competency, retention and patient safety when integrating SBE within EOC training activities.

BACKGROUND: There is a growing interest in the role of comorbid anxiety in patients with COPD. Comorbid anxiety has a major impact on physical functioning, health-related quality of life, and healthcare utilization. However, the prevalence of clinical anxiety, particularly specific anxiety diagnoses, in patients with COPD remains unclear. OBJECTIVE: We performed a systematic review of studies that report the prevalence of clinical anxiety and specific anxiety disorders in patients with COPD. METHODS: We searched for articles in CINAHL, EMBASE, MEDLINE, and PsycINFO, from 1966 to January 31, 2012, with a focus on studies that utilized clinical interviews for a robust psychiatric diagnosis in patients with COPD. RESULTS: Of 410 studies identified, 10 met the inclusion criteria for review. The studies had small to modest sample sizes (n = 20–204) and included mainly male COPD subjects (71% male). The prevalence of clinical anxiety ranged from 10–55% among in-patients and 13–46% among out-patients with COPD. The reported prevalence of specific anxiety disorders ranged considerably, and included generalized anxiety disorder (6–33%), panic disorder (with and without agoraphobia) (0–41%), specific phobia (10–27%), and social phobia (5–11%). Women were significantly more likely to have a clinical anxiety disorder, particularly specific phobia and panic disorder. CONCLUSIONS: There is a high prevalence of clinical anxiety in patients with COPD. Social phobia and specific phobia appear to be particularly prevalent, yet they have received little attention within existing literature. Further research into effective management and screening for clinical anxiety disorders is warranted.

Background Limited health economic costs analysis has been published in relation to the use of simulation-based education (SBE) in healthcare. Whilst two research studies have previously reported the cost of delivering simulation scenarios within a physiotherapy research study, both omitted full economic costs (FEC) associated with SBE design and delivery.1,2 To date, the cost analysis of combining SBE and video-reflexive ethnography (VRE) in pre-registration physiotherapy is unreported. Methodology Cost consequence analysis has been undertaken in relation to phase 2 of a pragmatic mixed methods study of the use of SBE in cardio-respiratory physiotherapy in the UK. Phase 2 featured the use of SBE and VRE to explore performance, behaviours and personal experiences of final year pre-registration physiotherapy students.3 The transparent approach to costing (TRAC) was used to calculate FEC of 12 scenarios and respective video-reflexive interviews (debriefs). Results The value attributed by participants included an opportunity to promote skills development, increase self-awareness, placement preparation and the potential to influence patient safety.3 Whereas, the cost analysis of providing this intervention was £3706 per 24 learners, equating to £154.42 per learner. Alternatively, streaming the scenario to an entire cohort reduces costs per learner to £31.10 (saving £123.32 per learner). The cost consequence analysis related to SBE design and delivery, equity of provision, capital investment costs and associated faculty training costs. Conclusion and recommendations Further experimental studies will be required to demonstrate the value of combining different mediums, modalities and methods of SBE with VRE before comprehensive health economic evaluations relating to impact on learning outcomes and academic performance, transfer to practice and healthcare can be established. Future research will help to ascertain the value and the associated costs to inform decisions of the efficacy, viability and sustainability of SBE in physiotherapy. References Black B, Marcoux B. Feasibility of using standardized patients in a physical therapist education program: a pilot study. J Phys Ther. 2002;16:49–56. Shoemaker M, Beasley J, Cooper M, Perkins R, Smith J, Swank C. A method for providing high-volume interprofessional simulation encounters in physical and occupational therapy education programs. J Allied Health. 2011;40:15–21. Gough S, Yohannes A, Murray J. Using video-reflexive ethnography and simulation-based education to explore patient management and error recognition by pre-registration physiotherapists. Adv Simulation. 2016;1:1–16.

Introduction To date there are no studies that examined the responsiveness of the Depression, Anxiety and Stress scale – 21 items (DASS-21) in any intervention in patients with COPD. Aims We evaluated the responsiveness of the DASS-21 scale in an eight-week pulmonary rehabilitation (PR) program. Methods We recruited 192 patients with COPD who were clinically stable and had a percent predicted FEV 1 Results The mean (SD) age was 71(8.4) years. The DASS-21 scale was responsive to PR with a mean change pre versus post scores for depression [8.67 vs.7.01 t= 3.26 p< 0.001], for anxiety [8.55 vs. 7.01, t = 2.81 p

Background: Cognitive impairments are common in patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF). To date there are no meta- analyses that have investigated the prevalence of mild cognitive impairment (MCI) in patients with COPD and CHF. Aims: To examine the individual study data set using meta-analysis to estimate the prevalence of MCI in patients with COPD and CHF. Methods Data sources: We identified relevant studies for COPD and CHF by searching published literature from inception to February 2016 using the MEDLINE and Web of Science databases. Study selection: Studies were included if they documented the prevalence of MCI and CHF for patients without dementia and employed appropriate screening tool for cognitive impairment. Data extraction and synthesis: 17 studies of CHF patients (n= 29,456) and 14 studies of COPD patients (n= 23, 116) were included for the meta-analysis. Main outcome measures : Prevalence of MCI in patients with COPD and CHF. The pooled prevalence of MCI for patients with COPD was estimated at 24% (95% CI: 12%, 38%). The prevalence of MCI in patients with CHF was 35% (95% CI: 25%, 45%). In the jackknife sensitivity analysis, both pooled estimates did not substantially vary when the meta-analysis was repeated with each included study being excluded one at a time. Conclusions: Approximately, 24% COPD patients and 35% CHF patients respectively had MCI. Studies are needed to examine the efficacy of intervention on MCI.

Background Upon graduation, physiotherapists are required to manage clinical caseloads involving deteriorating patients with complex conditions. In particular, emergency on-call physiotherapists are required to provide respiratory/cardio-respiratory/cardiothoracic physiotherapy, out of normal working hours, without senior physiotherapist support. To optimise patient safety, physiotherapists are required to function within complex clinical environments, drawing on their knowledge and skills (technical and non-technical), maintaining situational awareness and filtering unwanted stimuli from the environment. Prior to this study, the extent to which final-year physiotherapy students were able to manage an acutely deteriorating patient in a simulation context and recognise errors in their own practice was unknown. Methods A focused video-reflexive ethnography study was undertaken to explore behaviours, error recognition abilities and personal experiences of 21 final-year (pre-registration) physiotherapy students from one higher education institution. Social constructivism and complexity theoretical perspectives informed the methodological design of the study. Video and thematic analysis of 12 simulation scenarios and video-reflexive interviews were undertaken. Results Participants worked within the professional standards of physiotherapy practice expected of entry-level physiotherapists. Students reflected appropriate responses to their own and others’ actions in the midst of uncertainty of the situation and physiological disturbances that unfolded during the scenario. However, they demonstrated a limited independent ability to recognise errors. Latent errors, active failures, error-producing factors and a series of effective defences to mitigate errors were identified through video analysis. Perceived influential factors affecting student performance within the scenario were attributed to aspects of academic and placement learning and the completion of a voluntary acute illness management course. The perceived value of the simulation scenario was enhanced by the opportunity to review their own simulation video with realism afforded by the scenario design. Conclusions This study presents a unique insight into the experiences, skills, attitudes, behaviours and error recognition abilities of pre-registration physiotherapy students managing an acutely deteriorating patient in a simulation context. Findings of this research provide valuable insights to inform future research regarding physiotherapy practice, integration of educational methods to augment patient safety awareness and participant-led innovations in safe healthcare practice. Electronic supplementary material The online version of this article (doi:10.1186/s41077-016-0010-5) contains supplementary material, which is available to authorized users.

Objective This study sought to elicit and describe the first-hand experiences of anxiety in community patients with stable chronic obstructive pulmonary disease (COPD). Anxiety is common among patients with COPD. Clinical anxiety affects up to two thirds of patients, leading to reduced quality of life and physical functioning. There has been little research exploring the experiences of anxiety in patients with COPD, particularly in individuals with stable respiratory symptoms. Methods We interviewed 14 community patients with stable COPD and self-reported symptoms of anxiety. Data were analyzed using thematic network analysis to develop basic, organizing, and global themes. Results Patients reported intense thoughts of fear, hopelessness, and confusion that were associated with the anxiety and panic attacks. Self-management was important, particularly self-talk coping strategies. Conclusions Unmanaged anxiety seems to be particularly distressing for patients with COPD. Self-management strategies can be highly effective in preventing and managing anxiety.

Background Hydrotherapy is frequently indicated for the rehabilitation of patients with rheumatoid arthritis (RA); nevertheless, there has been inadequate appraisal of its effectiveness. The potential benefits of hydrotherapy for patients with RA are to improve and/or maintain functional ability and quality of life. Objectives The aim of this systematic review was to evaluate the effectiveness of hydrotherapy in the management of patients with RA. Method AMED, CINAHL, EMBASE, MEDLINE, PubMed, Science Direct and Web of Science were searched between 1988 and May 2011. Keywords used were rheumatoid arthritis, hydrotherapy, aquatic physiotherapy, aqua therapy and water therapy. Searches were supplemented with hand searches of references of selected articles. Randomized controlled trials were assessed for their methodological quality using the Physiotherapy Evidence Database (PEDro) scale. This scale ranks the methodological quality of a study scoring 7 out of 10 as ‘high quality’, 5–6 as ‘moderate quality’ and less than 4 as ‘poor quality’. Results Initially, 197 studies were identified. Six studies met the inclusion criteria for further analysis. The average methodological quality for all studies was 6.8 using the PEDro scale. Most of the studies reported favourable outcomes for a hydrotherapy intervention compared with no treatment or other interventions for patients with RA. Improvement was particularly noted in reducing pain, joint tenderness, mood and tension symptoms, and increasing grip strength and patient satisfaction with hydrotherapy treatment in the short term. Conclusions There is some evidence to suggest that hydrotherapy has a positive role in reducing pain and improving the health status of patients with RA compared with no or other interventions in the short term. However, the long-term benefit is unknown. Further studies are needed. Copyright © 2012 John Wiley & Sons, Ltd.

Aims A questionnaire survey of primary care musculoskeletal extended-scope physiotherapists (ESPs) was undertaken to determine information about their conversion rates and referral barriers, with regard to radiological and consultant referrals. Method A sample of 200 musculoskeletal ESPs classified as having a speciality in orthopaedics and working in primary care were recruited via the ‘ESP Professional Network’. Results A total of 100 (50%) responses were received. Forty-seven per cent of primary care ESPs indicated that they recorded their conversion rates, but only 31 participants submitted conversion rate data. Overall, the average conversion rate for all participants was 74% (range 30–95%). Forty-three per cent of respondents identified that they had experienced barriers when referring for radiological investigations and 38% that they experienced barriers when referring patients to secondary care for a consultant opinion. Commissioning barriers such as poorly commissioned care pathways were the most common theme in both areas. Fifty per cent of respondents identified that they used a referral criteria when referring patients to secondary care. Commonly, these criteria had been developed in conjunction with secondary care consultants or commissioners. Conclusion ESPs in primary care have reported similar conversion rates to those working in secondary care. There is a need for further empirical conversion rate studies in primary care to validate these self-reported findings and to enable ESPs to demonstrate clinical efficiency and benchmark their performance. Copyright © 2012 John Wiley & Sons, Ltd.

“...this technology should be rigorously evaluated in terms of the cost–benefit analysis, improving quality of life of patients with chronic obstructive pulmonary disease and reducing the care burden to family and caregivers.”

Advanced chronic obstructive pulmonary disease (COPD) patients are likely to develop comorbidities that may contribute to a substantial burden of symptoms such as intolerable dyspnea, fatigue and poor-health status. Evidence from the available literature suggests that advanced COPD patients are less likely to receive palliative care and/or supportive care compared with cancer patients. Factors that contribute to this disparity are multifactorial, including diagnostic uncertainty of when to provide palliative care, patients’ unwillingness to discuss advanced care planning with their general practitioners, lack of appropriate guidelines regarding when to refer patients to palliative care and lack of adequate resources. A few unblinded studies of palliative-care provision that included advanced COPD patients with other life-threatening diseases demonstrated some benefits in reducing healthcare utilization, improving quality of life and greater patient and caregiver satisfaction with the service. Therefore, further studies are required employing randomized controlled trials to show the benefits of a patient-centred multidisciplinary palliative care program and its cost–effectiveness for this patient group.

Anemia is common in patients with chronic diseases. However, little is known regarding the prevalence of comorbid anemia and its impact on quality of life, healthcare utilization, and mortality in patients with COPD. We conducted a systematic review and synthesis of the literature (1966 to March 2010). The prevalence of comorbid anemia in patients with COPD ranges from 7.5% to 34%, depending upon the populations selected and diagnostic tools employed to determine the level of hemoglobin. Comorbid anemia in patients with COPD was associated with greater healthcare resource utilization, impaired quality of life, older age, and male gender. Moreover, anemia in patients with COPD is an independent prognostic predictor of premature mortality and a greater likelihood of hospitalization. The true prevalence of anemia in patients with COPD is unknown. There is a lack of consensus agreement regarding this hematological abnormality's true frequency. Based on the findings from the existing literature, more work is necessary to establish the true prevalence of anemia in COPD. Robust and prospective clinical studies are needed to improve the management of COPD patients with comorbid anemia.

OBJECTIVE: To systematically review recent evidence on the effectiveness of tiotropium versus placebo, ipratropium, and long-acting β2 agonists on outcomes relevant to patients with stable COPD, including health-related quality of life, dyspnea, exacerbations and hospitalizations. METHODS: Our inclusion criteria for trials were: ≥ 12 weeks; compared tiotropium to placebo, ipratropium, or long-acting β agonists; patients ≥ 40 y old and with stable COPD. Sixteen trials (16,301 patients) met the inclusion criteria. RESULTS: Tiotropium improved health-related quality of life (measured with St George's Respiratory Questionnaire) compared to placebo (odds ratio [OR] 1.61, 95% CI 1.38–1.88, P < .001) and ipratropium (OR 2.03, 95% CI 1.34–3.07, P = .001). Tiotropium also improved dyspnea (measured with the Transitional Dyspnea Index) compared to placebo (OR 1.96, 95% CI 1.58–2.44, P < .001) and ipratropium (OR 2.10, 95% CI 1.28–3.44, P = .003). Tiotropium decreased the likelihood of an exacerbation (OR 0.83, 95% CI 0.72–0.94, P = .004) and related hospitalizations (OR 0.89, 95% CI 0.80–0.98, P = .02) but not serious adverse events (OR 1.06, 95% CI 0.97–1.17, P = .19), compared to placebo. The cumulative incidence of dry mouth was 7.4% with tiotropium, compared to 3.9% with ipratropium, 1.6% with salmeterol, and 2.0% with placebo. CONCLUSIONS: In stable COPD, tiotropium showed superior efficacy in improving quality of life and dyspnea, compared to placebo and ipratropium. However, tiotropium's differences with salmeterol were less clear.

AIMS: We examined the management of depression by general practitioners (GPs), through the use of case vignettes, in patients with chronic obstructive pulmonary disease (COPD), severe osteoarthritis and depressive symptoms alone. BACKGROUND: Depression is common in patients with COPD. Untreated depression leads to poor compliance with medical treatment and increases health-care utilisation. METHODS: We surveyed a random sample of GPs (n = 3956) in England using a postal questionnaire. The questionnaire explored how GPs would approach the management of emotional distress in patients with and without a chronic condition and gauged their views of and experiences with depression in patients with COPD. FINDINGS: A total of 864 completed responses were received (22%). In the vignettes, a significantly greater percentage of GPs reported that they would explore or offer the diagnosis of depression in a patient with COPD (95.4%) compared with patients with either severe osteoarthritis (88.3%) or depressive symptoms alone (86.3%). In each case, the vast majority of GPs reported that they would explore a diagnosis of depression using a clinical diagnostic tool. The preferred method of treatment, if offered, in all three cases was a combination of anti-depressant drugs and psychological therapy. GPs endorsed the importance of routinely screening for depression in patients who have COPD and acknowledged that depression impairs patient self-management of COPD.In conclusion, GPs in England were able to diagnose depression from the vignettes and plan appropriate treatment strategies in patients with chronic diseases. This should be complemented with thorough physical examination by GPs to rule out other factors such as the impact of physical illness. GPs believe depression interferes with patient self-management of COPD.

Aims. To investigate the long-term benefits of a six-week comprehensive cardiac rehabilitation programme on physical activity, psychological well-being and quality of life in patients with coronary heart disease. Background. Cardiac rehabilitation (CR) in short term improves exercise capacity and quality of life in patients with cardiac disease. However, the long-term benefits of CR are inconclusive. Design. A prospective CR programme with repeated measures follow-up over 12 months. Methods. A six-week outpatient cardiac rehabilitation programme was conducted including 147 patients with coronary heart disease. Patients completed the physical activity energy expenditure (seven-day recall activity), MacNew Heart Disease Health-Related Quality of Life (MacNew) and Hospital Anxiety and Depression scale (HADs) at baseline, six weeks, six and 12 months. Results. One hundred and five (71%) patients (76 male) mean age of 61·8 (SD 9·7) completed the four-measurement points. Analysis of variance revealed that total energy expenditure (F (2, 231) = 131, p