ROYAL ACADEMY OF MEDICINE IN IRELAND 2013 Annual Scientific Meeting of the Irish Thoracic Society (ITS) IRISH JOURNAL OF MEDICAL SCIENCE
Irish Thoracic Society Annual Scientific Meeting 2013 15th–16th November 2013 Millennium Forum, Derry
Irish Journal of Medical Science Volume 182 Supplement 10 DOI 10.1007/s11845-013-1023-x
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486
Disclosure Statement The operational costs of the Irish Thoracic Society Annual Scientific Meeting 2013 are funded with the support of a number of commercial bodies through unrestricted educational grants. These are listed overleaf.
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Welcome from the Local Organiser It is my great pleasure to welcome you to Derry, host to the 2013 Irish Thoracic Society Annual Scientific Meeting. We are delighted to be bringing the meeting to the Walled City, in this its year as UK City of Culture and have put together a programme that reflects the best of respiratory medicine and healthcare throughout the island and beyond. Thank you to all those who submitted abstracts and case studies this year—we received over 200 for presentation, reflecting the high quality and innovative work taking place in research centres throughout the island. I would also like to thank the abstract review committee and judges for their time and expertise in what is never an easy task due to the increasingly high standard of submissions received. Special features of this year’s meeting include Guest Lectures on the topics ‘Understanding IPF: Genetics and genomic approaches’, ‘Bronchiectasis: update and therapeutic options’ and ‘Intensive Care and the Lung’—all featuring distinguished international speakers. Welcome also to the patient and professional organisations represented. Networking and sharing information on the wealth of activities taking place across the respiratory healthcare community has become an integral part of the meeting. I would like to extend a particular welcome to the exhibitors and sponsors of this year’s meeting. We are very grateful for their continued support. Thanks also to the Derry Visitor and Convention Bureau and the Lord Mayor of Derry for their support in organizing the meeting. We invite you to take some extra time to explore the city’s world renowned attractions and in particular to savour some of the events taking place as part of ‘City of Culture.’ Yours sincerely,
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President’s Welcome On behalf of the Irish Thoracic Society, I am delighted to welcome you to the ITS Annual Scientific Meeting 2013. I would like to thank Dr Martin Kelly and his colleagues for their great work, in conjunction with the ITS office, in organising what promises to be an excellent meeting. 2013 has been a busy and productive year for the ITS and I would like to take this opportunity to update you on some key developments. The Irish Lung Health Alliance, established last year, continues to make progress in raising awareness of lung disease amongst policy makers and the public. The group met with the Joint Oireachtas Committee for Health and Children in February to outline the scale of lung disease in Ireland and the key challenges in terms of both lung disease in general and individual conditions. Our presentations received strong support from Committee members and several issues have been advanced as a result. The group was also represented at the ERS Congress in Barcelona in September where it attracted interest as a good model for advancing collaboration and advocacy amongst patient organisations and the clinical and scientific community. Membership of the Alliance continues to grow and now includes: the Alpha One Foundation, the Cystic Fibrosis Association of Ireland, the Asthma Society of Ireland, the Irish Lung Fibrosis Association, the Irish Cancer Society, COPD Support Ireland, the Irish Sleep Apnoea Trust, the Irish Sarcoidosis Network, ASH Ireland, the Pulmonary Hypertension Association, ANAIL, the Irish Association of Respiratory Scientists and the National Programmes for COPD and Asthma, as well as the Irish Thoracic Society. Thanks to the support of Allen and Hanburys, Boehringer Ingelheim and Novartis, through unrestricted educational grants, the Irish Thoracic Society has been able to continue offering much needed funding for research in respiratory medicine. This has resulted in the submission of a proposal for consideration for matched funding under the MRCG/HRB Joint Funding Scheme. It followed a highly competitive and rigorous grant review process with a total of six very high quality grants received. The submission which received the highest average score and was forwarded to the MRCG/HRB for consideration. The winning project will be announced during the meeting. 2012 saw the launch of the Asthma Society of Ireland/Irish Thoracic Society Joint Research Bursary. This was awarded to a research team led by Dr. John Faul and Mr. Conor Kerley, Connolly Hospital Blanchardstown, Dublin to support research on the importance of Vitamin D deficiency in asthma. We are delighted to report that, thanks to the continued support of the Asthma Society of Ireland, we will be announcing the recipient of the 2013 Award over the course of the Annual Scientific Meeting. A landmark development to take place in 2013 was the establishment of COPD Support Ireland. We are all aware of how patients with COPD are disproportionately disadvantaged due to the lack of a dedicated patient support and advocacy body. Thanks to a generous grant from Novartis Ireland, the Irish Thoracic Society in conjunction with the National COPD Advisory and Working Groups, has been involved in recruiting an Executive Director to develop much needed supports and advocate on behalf of our patients with COPD. We wish every success to this new organisation. The ITS Spring Meeting 2013 took place in Newcastle in April in collaboration with the North East Thoracic Society (NETS). This meeting was highly successful, both educationally and socially, and a great opportunity to renew the strong links and friendships that exist between Ireland and Newcastle. Many thanks to Boehringer Ingelheim for their support for the meeting through an unrestricted educational travel grant. Finally, the success of all these initiatives is only possible thanks to the support and engagement of our members, partner organisations and our partners from the pharmaceutical and medical equipment sectors. This support is hugely appreciated and we look forward to continued collaboration in 2014 and beyond. Have a great meeting!
Dr Edward McKone President, the Irish Thoracic Society
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Ir J Med Sci (2013) 182 (Suppl 10):S427–S486
Exhibitors at the Irish Thoracic Society Annual Scientific Meeting 2013 Pharmaceutical and Medical Device Suppliers Actelion Pharmaceuticals UK Ltd
Home Healthcare Ltd
A Menarini Pharmaceuticals Ireland
Meda Health Sales Ireland
Medicare Health & Living Ltd
Mundipharma Pharmaceuticals Ltd
Novartis Ireland Ltd
Cruinn Diagnostics Ltd
Pfizer Healthcare Ireland (Anti-infectives)
Cardiac Services Group
Pfizer Healthcare Ireland (Champix)
Direct Medical Ltd
Eli Lilly and Company Ltd
Forest Laboratories UK Ltd
Sword Medical Ltd
Glaxo Smith Kline
Vertex Pharmaceuticals (UK) Ltd
Intermune UK & Ireland
Patient and Professional Groups ASH Ireland The Alpha One Foundation The Asthma Society of Ireland The British Lung Foundation COPD Support Ireland The Cystic Fibrosis Association of Ireland The Irish Hospice Foundation The Irish Lung Fibrosis Association The Irish Sarcoidosis Support Network The Irish Sleep Apnoea Trust
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Thursday 14th November 12.30–17.30
Specialist Registrar (SpR) Training: Letterkenny General Hospital, Letterkenny Supported by an unrestricted educational grant from Astra Zeneca
ITS Case Study Forum—followed by dinner and prize for Best Case Presentation 2013—City Hotel Derry Supported by an unrestricted educational grant from Astra Zeneca M. Kelly, Altnagelvin Hospital, Derry T. O’Connor, Mercy University Hospital, Cork M. Harrison, Cork University Hospital J. Lindsay, Northern Ireland Respiratory SpR Programme
Case Study Poster Review—Corinthian Lobby, City Hotel
Case Study Oral Presentations—Corinthian Ballroom, City Hotel
An Unusual Foreign Body M. Kooblall, S. Lane, E. Moloney Respiratory Department, Tallaght Hospital, Dublin 24
Hermansky-Pudlak Syndrome with Pulmonary Manifestations in an Irish Male McElvaney OJ, Fitzgerald SJ, Meurling IJ, Bolger K, O’Brien ME, Gunaratnam C, O’Neill SJ, McElvaney NG Respiratory Division, Department of Medicine, Beaumont Hospital, Dublin 9
Two lungs are better than three—A congenital foregut malformation with a bronchus presenting as an aggressive tumour on imaging Cullen P, Mulligan T, Rae D, Hone S, Russell J, McGuinness J Department of Cardiothoracic Surgery, Our Lady’s Children’s Hospital, Crumlin, Dublin 12
Complete tracheal transection secondary to blunt trauma: Securing the airway via flexible bronchoscopy Moore P, McManus T Department of Respiratory Medicine, South West Acute Hospital Enniskillen
Pro Con Debate Does a clinical trial lead or mislead? Lessons from some recent clinical trials Dr Ian Counihan, Beaumont Hospital, Dublin TBA
Dinner and prize giving
Friday 15th November—Millennium Forum Conference Centre, Derry 07.30–08.30
Tea and coffee/Exhibition viewing – Piazza and East Wall Bar
Poster Review and Parallel Discussions Supported by GlaxoSmithKline through an unrestricted educational grant
Poster Review: Auditorium
Parallel Poster Discussions 1. COPD (Basic Science and Clinical)—Auditorium
R. Sharkey, Altnagelvin Hospital, Derry V. Keatings, Letterkenny General Hospital, Co Donegal 2. Lung Cancer, TB and other Infections—Millennium Room
N. Magee, Belfast City Hospital, Belfast R. Convery, Craigavon Area Hospital, Co Armagh 3. Asthma, Sleep and Pulmonary Hypertension—Danske Bank Studio
T. McManus, South West Acute Hospital, Enniskillen, Co Fermanagh L. Doherty, Bons Secours Hospital, Cork
Tea and Coffee/Exhibition viewing—Piazza and East Wall Bar
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Oral Presentations I—Auditorium
C. O’Kane, Queens University Belfast A. O’Brien, Mid Western Regional Hospital, Limerick
Is emphysema a fibrotic lung disease? A Fabre1, Mj Narski2, D Healy2,3, ILawrie3, M Keane4, J Egan3, M Butler4 1 Department of Histopathology, 2Department of Thoracic surgery, 4Department of Respiratory Medicine, St Vincent’s University Hospital, Dublin 4, 3National Lung Transplant Programme, Mater Misericordiae Hospital, Dublin 7
Adherence to inhalers after discharge from Hospital following an exacerbation of COPD Deering B, MacCormack N, Kerrigan K, D’Arcy S, Costello RW Beaumont Hospital, Dublin
Rare Alpha-1 Antitrypsin Mutations in the Irish Population T.P. Carroll1, L. Fee1, C. O’Connor1, P. O’Brien2, I. Ferrarotti3, S. Ottaviani3, M. Luisetti3, and N. G. McElvaney1 1 Alpha One Foundation, RCSI Education & Research Centre, Beaumont Hospital, Dublin 9. 2Department of Biochemistry, Beaumont Hospital, Dublin 9. 3Department of Biochemistry and Clinical Genetics, University of Pavia, Italy
Alpha-1 antitrypsin inhibits leukotriene B4 mediated respiratory inflammation O’ Dwyer CA, Banville N, McElvaney NG and Reeves EP Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland
Reducing Iatrogenic CO2 Narcosis in COPD Admissions: An Enhanced Early Warning Patient Safety Initiative Elaine Mulligan, Royanne Dickson, Naomi Chapman & Rory Convery. Respiratory Medicine, Craigavon Hospital. SHSCT
The potential role for Suppressor of Cytokine Signalling 1 in the attenuation of persistent airway inflammation in asthma subtypes Emma Doran1, David F Choy2, Aarti Shikotra3, Claire A Butler1, James A Johnston1, Peter Bradding3, Joseph R Arron2, Liam G Heaney1. 1The Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast. 2ITGR Biomarker Group, Genentech Inc., South San Francisco, California. 3Glenfield Hospital, Leicester, UK
An audit of nationwide nurse—led asthma clinics by the Asthma Society of Ireland Frances Guiney, Mary Llewellyn, Deirdre Donaghy, Catherine Carrick, Orlaith Behan Asthma Society of Ireland, 42-43, Amiens Street. Dublin 1
Bronchial thermoplasty for severe persistent asthma P Riddell1; I Lawrie1; S Zaidi1; S Lane2; JJ Egan1 1 Advanced lung disease and transplant programme, Mater Misericordiae University Hospital, Dublin 2 Department of Respiratory Medicine, Adelaide and Meath Hospital, Dublin
Human rhinovirus up-regulates transient receptor potential channels in a human neuronal cell line: implications for virus induced cough reflex sensitivity Abdullah H., Heaney L., Cosby S.L. and McGarvey L Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7AE, UK
Parallel Business Meetings/Forums 11.00–13.00
Forum of the Respiratory Nurses Association of Ireland (ANAIL) Millennium Room
Forum of Chartered Physiotherapists in Respiratory Care (CPRC)—Green Room
COPD Outreach Forum—Millennium Room
IICMS, Faculty of Respiratory—Diamond Room
5. Irish Thoracic Society Paediatric Forum—Diamond Room
B. Linnane, Mid Western Regional Hospital, Limerick D. Cox, Our Lady’s Children’s Hospital, Crumlin, Dublin
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Congenital thoracic malformations—The Northern Ireland experience from 1994 to 2011 E.A. Gorman1, S Thavagnanam2, J.P. Houghton1, A Dick2, A Patterson2 & M.D. Shields1,2 1 School of Medicine, Queen’s University Belfast 2 Royal Belfast Hospital for Sick Children
Is a single overnight pulse oximetry recording at home adequate for hypoxaemia screening? C Hunter 1,2, R Verma1, B Maxwell 1, D O’Donoghue 1,2 and MD Shields1,2 1 Royal Belfast Hospital for Sick Children, 2Queen’s University Belfast
The Diagnosis and Treatment of Sleep Related Breathing Disorders in Children in Ireland 2007-2011: Recognition of an Unmet Healthcare Need Walsh A, Phelan F, Phelan M, Ryan M, Healy F, Slattery D, ElNazir B, Greally P, Linnane B, Ni Chroinin M, Mullane D, Herzig M, Cox D, Javadpour S, McNally P Our Lady’s Children’s Hospital Crumlin, Temple Street Children’s University Hospital, The Adelaide and Meath Hospital Incorporating the National Children’s Hospital, Mid –Western Regional Hospital Limerick, Cork University Hospital, Galway University Hospital
Accommodating Interruptions: A Grounded Theory of Adolescent Asthma Hughes, M. (2013) Doctoral Candidate, Lecturer Practitioner, School of Nursing and Midwifery University College Cork
Evaluation of the effectiveness of a pilot transition year asthma e-learning programme Hughes, M. (2013) Research and Education Consultant, Asthma Society of Ireland, 42-43, Amiens Street, Dublin 1
A prospective, randomised, open labelled trial to examine the clinical efficacy of an oral nutritional supplement (ONS) with regards to improving the nutritional status of undernourished children (2-10 years) over 6 weeks M. O’ Reilly1, S. Boland1, D. Slattery2, and F. Ward1, 1Dept. of Nutrition & Dietetics, Children’s University Hospital Temple Street, Ireland 2Respiratory Dept., Children’s University Hospital Temple Street, Ireland
Outpatient Parenteral Anti-Microbial Therapy (O.P.A.T) a report of three years experience in an Irish Paediatric Respiratory Unit A. Murphy, S. Connor, O Ameerheen, F Healy, D.M Slattery Respiratory Unit, Children’s University Hospital Temple Street, Dublin 1, Rep of Ireland
Prevalence and Treatment of Pseudomonas aeruginosa in children with Cystic Fibrosis attending Cork University Hospital E. Barry, D. Mullane Dept of Paediatrics and Child Health, University College Cork Paediatric Department, Cork University Hospital (CUH)
A 4 year review of bronchoalveolar lavage (BAL) surveillance carried out in preschool aged children with cystic fibrosis B Treston1, D Clarke1,2, R Millar1.2, F Ringholz1,2, D Cox1,2, A Zaid1, B Elnazir3, P Greally3, B Linnnane2,4, P McNally1,2 1 Department of pediatric respiratory medicine, Our Lady’s Children’s Hospital, Crumlin (OLCHC), Dublin 12, 2National Children’s Research Centre, Our Lady’s Children’s Hospital Crumlin, Dublin 12, 3The Adelaide and Meath Hospital Dublin, Incorporating The National Children’s Hospital, Dublin 24, 4University Hospital Limerick, Co Limerick
Tea and coffee
Pulmonary aspiration of gastric contents in preschool children with Cystic Fibrosis (CF) Gorman I1,2, Clarke D2,5, Ringholz F2,5, Linnane B2,3,4, McNally P1,2,5 1 Trinity College Dublin, 2National Children’s Research Centre, Crumlin, Dublin 12, 3University Hospital Limerick, 4University of Limerick, 5Our Lady’s Children’s Hospital, Crumlin, Dublin 12
Annual Modified Shuttle Walk Test in Clinically Stable Children with Cystic Fibrosis M Gilbourne, K Ingoldsby, P McNally Cystic Fibrosis Centre, Department of Respiratory Medicine, Our Lady’s Children’s Hospital Crumlin, Dublin
Resolvin D1 restores airway surface liquid hydration and attenuates IL8 secretion in Cystic Fibrosis (CF) bronchial epithelial cells F.C. Ringholz1, A. Moukachar2, G. Higgins1, P. McNally1,3, V. Urbach1,4 1 Respiratory Research, National Children’s Research Centre, Crumlin, Dublin, 2Universite´ Pierreet MarieCurie, Paris VI, France 3 Respiratory Medicine, Our Lady’s Children’s Hospital, Crumlin, Dublin, 4INSERM, U845, Faculte´de Me´decine Paris Descartes, Paris, France
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Prospective audit examining the resting energy expenditure (REE) of children with Cystic Fibrosis (CF) M. O’Reilly, C. Dempsey, A. Murphy, F. Healy, DM. Slattery Department of Respiratory Medicine, Children’s University Hospital, Temple St Dublin
Sweat tests in Ireland 2011 Valerie Tsang1, Andreea Roman1, R. Ghori1, S. Whelan1, P. Mayne3, G Boran2, O. Blake1. B. Linnane1, 1 Paediatric Cystic Fibrosis Unit and Department of Biochemistry, Mid-Western Regional Hospital (MWRH), Limerick, Ireland, 2 Department of Clinical Chemistry, Tallaght Hospital, Dublin, 3. Department of Biochemistry, Children’s University Hospital, Temple St, Dublin
Irish Thoracic Society Paediatric Forum Guest Lecture Recurrent Pulmonary Aspiration Professor Michael Shields Clinical Professor, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast
Meeting of ITS Paediatric Special Advisory Panel
Oral Presentations II—Auditorium
M. Henry, Cork University Hospital, Cork J. Rendall, Belfast City Hospital, Belfast
Detection of high sensitivity troponin in outpatients with stable pulmonary hypertension identifies a subgroup at higher risk of adverse outcomes AK Roy 1,2, BN McCullagh 1,2, C Mc Gorrian 1,2, E Keane3, J Keaney 1,2, M Fitzgibbon1, NG Mahon 1,2, PT Murray1, 2 and SP Gaine 1,2 1 Mater Misericordiae University Hospital, 2 University College Dublin, 3 Beaumont Hospital Dublin
Lung function Abnormalities and Structural Lung Disease in Adult Survivors of Bronchopulmonary Dysplasia S Caskey1, S Gillespie2, J Clarke2, H Halliday3, M Shields1, L McGarvey1 1 Centre for Infection and Immunity, Queen’s University Belfast, Belfast, N. Ireland, 2 Imaging Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, 3Regional Neonatal Unit, Royal Maternity Hospital, Belfast Health and Social care Trust
CXCR3 is required for the IL-13 mediated upregulation of IL-13Ra2 in pulmonary fibroblasts Jennifer C. Barnes1, Robert V. Lumsden1, Sine´ad M. Walsh1, Julie C. Worrell1, John A. Belperio4, Aurelie Fabre3, Denise Boylan1, Rosemary Kane1, and Michael P. Keane1,2 * UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland. 2 Dept. of Respiratory Medicine, St. Vincent’s University Hospital and School of Medicine and Medical Science, Elm Park, Dublin 4, Ireland. 3Dept. Pathology, St. Vincent’s University Hospital and School of Medicine and Medical Science, Elm Park, Dublin 4, Ireland. 4Division of Pulmonary and Critical Care Medicine, Dept of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
The CXCR3 Ligands CXCL9, CXCL10 and CXCL11 up-regulate IL-13Ra2 in NIH-3T3 Fibroblasts J. C. Worrell1, R.V. Lumsden1, J.C. Barnes1, S.M. Walsh2, D.A. Boylan1, R. Kane1 and M.P. Keane2 1 UCD Conway Institute of Biomolecular and Biomedical research, University College Dublin, Belfield, Dublin 4, Ireland. 2Dept. of Respiratory Medicine, St Vincent’s University Hospital and School of Medicine and Medical Science, UCD Conway Institute, University College Dublin, Belfield, Dublin 4, Ireland
Judicious use of Immunohistochemistry for Lung Cancer Diagnosis Fives C1, McCarthy J1, Mayer N1, Kennedy M2, Henry MT2, O’Connor TM3, Curran D3, Burke L1 1 Department of Histopathology, Cork University Hospital, Cork, 2Department of Respiratory Medicine, Cork University Hospital, Cork, 3Department of Respiratory Medicine, Mercy University Hospital, Cork
Unexpected findings on PET/CT in the investigation of suspected lung cancer C McKinney, M Doherty, M Kelly, T Mc Manus, A Aziz, RA Sharkey, M McCloskey Respiratory Department, Altnagelvin Hospital, Derry, N Ireland, BT 47 6SB
Minimally invasive (VATS) Lobectomy: 80 Consecutive Cases R Motyer, DG Healy St Vincent’s & Mater Misericordiae University Hospitals, Dublin, Ireland
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Developing a training programme for pleural ultrasound in a territory referral centre: When a high workload could equal high reward D. Ryan1, J. Scott 1, C. Deneshvar 1, D P. Breen 1 1 Department of Interventional Pulmonology, Galway University Hospital (GUH), Galway
Outcomes from lung cancer at Beaumont Hospital 2012 T McEnery, E Keane, C Higgins, JM Clince, RK Morgan, SJ Linnane Beaumont Hospital, Beaumont Rd, Beaumont, Co. Dublin
Resolvin D1 restores airway surface liquid hydration and attenuates IL8 secretion in Cystic Fibrosis (CF) bronchial epithelial cells F.C. Ringholz1, A. Moukachar2, G. Higgins1, P. McNally1,3, V. Urbach1,4 1 Respiratory Research, National Children’s Research Centre, Crumlin, Dublin, 2Universite´ Pierreet MarieCurie, Paris VI, France, 3 Respiratory Medicine, Our Lady’sChildren’sHospital, Crumlin, Dublin, 4INSERM, U845, Faculte´de Me´decine Paris Descartes, Paris, France
The CF-able Score: a 2-year Evaluation of a 4-year Prognostic Tool IJ Meurling, C McCarthy, C Gunaratnam, NG McElvaney, SJ O’Neill Department of Respiratory Medicine, Beaumont Hospital, Dublin 9, Ireland
A Prospective Study of the CF Gut: Prevalence, Ribotyping and Toxigenic Capability of Clostridium difficile in Adult CF Harrison MJ1, 2, Burke D4, Fleming C1, McCarthy M1, Shortt C1, O’Callaghan G1, 2, Murphy DM1,2, Shanahan F3, Hill C3, Ross P3,4, Stanton C 3,4, Eustace JA2, Rea MC4, Plant BJ1, 2 1 Cork Adult CF Centre, Dept of Respiratory Medicine, Cork University Hospital, Cork, 2Health Research Board, Clinical Research Facility, 3Alimentary Pharmabiotic Centre, 4University College Cork. Teagasc Food Research Centre, Moorepark, Fermoy, Cork
Tea and Coffee/Exhibition viewing—Piazza and East Wall Bar
Irish Thoracic Society Guest Lecture—Auditorium Supported by an unrestricted educational grant from Boehringer Ingelheim Ireland
E. McKone, St Vincent’s University Hospital, Dublin M. Kennedy, Cork University Hospital, Cork Understanding IPF: Genetics and Genomic Approaches Professor David A. Schwartz MD, Professor of Medicine and Immunology, Chair, Dept of Medicine, University of Colorado
The Irish Thoracic Society AGM—Millennium Room
Drinks Reception—Corinthian Lobby, City Hotel, Derry Hosted by the Lord Mayor of Derry and featuring the ‘Singing for Health’ British Lung Foundation Northern Ireland Community Choir
Gala Dinner—Corinthian Ballroom, City Hotel, Derry Sponsored by Mundipharma
Saturday 16th November—Millennium Forum Conference Centre 07.30–08.30
Registration, tea and coffee—Piazza and East Wall Bar
Poster Review and Parallel Discussions Supported by GlaxoSmithKline through an unrestricted educational grant
Poster Review: Auditorium
Parallel Poster Discussions 7. COPD Clincial—Auditorium
K. Cullen, Royal Victoria Hospital, Belfast D. Breen, Galway University Hospital
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8. ILD, CF and rarer respiratory disorders—Millennium Room Chairs
A. O’Regan, Galway University Hospital, Galway E. McGrath, St Vincent’s University Hospital, Dublin
9. Treatment, policy and management—challenges and novel approaches—Danske Bank Studio Chairs
D. Downey, Belfast City Hospital TBA, St Vincent’s University Hospital, Dublin
Tea and Coffee/Exhibition viewing—Piazza East Wall Bar
Irish Thoracic Society Guest Lecture I Supported by an unrestricted educational grant from Vertex
M. Kelly, Altnagelvin Hospital, Derry G. Daly, Altnagelvin Hospital, Derry Bronchiectasis: Microbiomes, Mycobacteria and Macrolides Professor Stuart Elborn, Director, Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast
Irish Thoracic Society Guest Lecture II
TBA, Galway University Hopsital, Galway D McAuley, Intensive Care and the Lung Professor John Simpson, Professor of Respiratory Medicine, University of Newcastle
Prize giving and close Prize for Best Oral Presentation Supported by Boehringer Ingelheim through an unrestricted educational grant Prize for Best Poster Presentation Prize for Best Online SpR Case Study (http://www.irishthoracicsociety.com) Supported by Astra Zeneca through an unrestricted educational grant Presentation of ANAIL Award for Best Posters Presented by a Respiratory Nurse Presentation of the Irish Thoracic Society Research Grant in Respiratory Medicine 2013 Supported by Boehringer Ingelheim and Novartis through an unrestricted educational grant
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Irish Thoracic Society Poster Review and Discussion Friday 15th November 2013
1. COPD (Basic Science and Clinical) Chairs
R. Sharkey, Altnagelvin Hospital, Derry V. Keatings, Letterkenny General Hospital, Co Donegal
1.1. The Alpha-1 Antitrypsin Deficiency National Targeted Detection Programme L. Fee1, T.P. Carroll1, C. O’Connor1, P. O’Brien2, I. Ferrarotti3, S. Ottaviani3, M. Luisetti3, and N.G. McElvaney1 1 Alpha One Foundation, RCSI Education & Research Centre, Beaumont Hospital, Dublin 9, Ireland, 2Department of Biochemistry, Beaumont Hospital, Dublin 9, Ireland, 3Department of Biochemistry and Clinical Genetics, University of Pavia, Pavia, Italy
AAT deficiency (AATD) is a genetic disorder caused by mutations within the AAT gene. The Z mutation is the most common cause of AATD, with S linked to a milder deficiency. Classically presenting with emphysema and liver disease, AATD is under-diagnosed and prolonged delays in diagnosis are common. ATS/ERS guidelines advocate screening all COPD, poorly-controlled asthma, and cryptogenic liver disease patients, as well as first degree relatives of known AATD patients. Over 10,000 individuals have been screened to date by following ATS/ERS guidelines in a national targeted detection programme. Sequencing of the SERPINA1 gene was performed to identify rare mutations. We have identified 204 ZZ, 147 SZ, 49 SS, 1462 MZ, and 1065 MS phenotypes, as well as numerous clinically significant rare phenotypes (e.g. IZ, FZ, IS, Null, Mmalton). There appears to be a cluster of ZZ cases in the northwest of the island. A number of rare and novel SERPINA1 mutations have also been identified. One in 25 Irish people carry the Z variant. Results from the national screening programme highlight the need for increased awareness and early detection of AATD. All COPD patients should be tested for AATD as per ATS/ERS guidelines regardless of age or smoking history.
1.2. Identification of Novel Truncated Alpha-1 Antitrypsin Protein in a Q0bolton Deficient Patient D.A. Bergin1, M. Henry2, P. Meleady2, M. Clynes2, E.P. Reeves1, N.G. McElvaney1 1
Department of Medicine, Beaumont Hospital, RCSI, Dublin, Ireland, National Institute for Cellular Biotechnology, DCU, Dublin, Ireland
Alpha-1-antitrypsin (AAT) is the most abundant circulating protease inhibitor and is essential for normal protease:anti-protease homeostasis. A major physiological role of AAT is to protect the lung from the destructive effects of neutrophil elastase. AAT deficiency (AATD) is associated with early onset emphysema, COPD and liver disease. Of particular interest are the class of rare AAT mutations, called null (Q0) mutations, which yield no detectable serum AAT. The null family include mutations that introduce a premature stop codon, yielding no detectable serum AAT protein by routine
S439 quantitative methods such as nephelometry and isoelectric focusing (IEF). The total absence of AAT leads to more severe pulmonary disease within null homozygotes. The aim of this study was to employ an alternative state of the art chromatographic technique involving Alpha-1 Select Resin to evaluate plasma levels of truncated protein in a Q0 homozygote. Ethical approval for this study was obtained from the Beaumont Hospital Ethics Review Board. Plasma samples were collected from control individuals homozygous for the M allele (normal AAT) and an AATD patient homozygous for the null bolton allele (Q0bolton). Samples were phenotyped for AAT utilising the routine IEF gel electrophoresis system (Sebia). AAT was purified from plasma using Alpha-1 Chromographic Select Resin (GE Healthcare). SDS-PAGE and Western blot analysis was performed on purified AAT employing polyclonal goat antibody. Mass spectrometry was used to confirm the identity of purified AAT protein by trypsin digest of excised protein bands from Coomassie stained SDS-PAGE gels. No AAT protein was detected in plasma from the Q0bolton homozygote using IEF. In contrast, by utilising the Alpha-1 Select Resin we purified a low molecular weight protein of approximately 48 kDa from Q0bolton patient plasma compared to the 52 kDa native AAT protein from healthy controls. By Western blot analysis and mass spectrometry the purified truncated protein from the null Bolton AATD patient was identified as AAT. This is the first ever documentation of the presence of AAT protein in the plasma of a null AATD patient. Further work is required to characterise the activity of this truncated AAT protein which may also lead to the development of novel therapeutic treatments for individuals with rare AATD null mutations.
1.3. The Classification of the SZ Phenotype of Alpha-1 Antitrypsin Deficiency in Ireland O. El Kawkgi*, Y. Hamadi*, E.P. O’Connor, C. McCarthy, M.E. O’Brien, T.P. Carroll, N.G. McElvaney *denotes joint first authorship Respiratory Research Division, Department of Medicine, Royal College of Surgeons In Ireland, Beaumont Hospital, Dublin, Ireland Alpha-1 antitrypsin deficiency (AATD) is characterised by early onset emphysema and liver disease in the severe ZZ phenotype. The SZ phenotype, which is a prevalent intermediate of AATD, has a less delineated relationship in the development of lung disease. The aim of this study was to determine the prevalence of lung disease in SZ individuals. SZ individuals were identified through the national alpha-1 antitrypsin patient registry and the targeted detection programme. Smoking history, pulmonary function and HRCT results were recorded. Data was collected for 54 SZ patients. Mean age was 54 years, 43 patients had spirometry; the mean FEV1 was 90 %. 35 % of patients (15/43) had airflow obstruction. HRCT results were available for 31 individuals, 29 of whom had detailed smoking histories available. 16 % of patients had evidence of emphysema on HRCT; however this only occurred in those who smoked. 36 % of SZ-smokers had emphysema. Bronchiectasis was evident on HRCT in 54 % of SZ smokers and 44 % of SZ never-smokers; however there was no statistical significance in the difference between these two groups. Individuals with the SZ phenotype are at risk of developing emphysema if they smoke, however the rate of bronchiectasis in this population is high, regardless of smoking history.
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1.4. Alpha-1 Antitrypsin from Deficient Individuals is more Fucosylated than Healthy Controls: an Indication of on-going Inflammation 1
C. McCarthy , R. Saldova , M.E. O’Brien , D.A. Bergin , T.P. Carroll1, J. Keenan3, P. Meleady3, M. Henry3, M. Clynes3, P.M. Rudd2, E.P. Reeves1, N.G. McElvaney1 1
Respiratory Research Division, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland, 2NIBRT GlycoScience Group, The National Institute for Bioprocessing Research and Training, University College Dublin, Dublin 4, Ireland, 3 National Institute for Cellular Biotechnology, Dublin City University, Dublin, Ireland
1.5. Alpha-1 Antitrypsin Binds Complement C3: A Novel Immune Regulatory Role M.E. O’Brien1, C. McCarthy1, M. Henry1, D.A. Bergin1, P. Meleady2, E.P. Reeves1, M. Clynes2, N.G. McElvaney1 1 Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland, 2 National Institute for Cellular Biology, Dublin City University, Dublin, Ireland
Alpha 1-antitrypsin (AAT) is a serine protease inhibitor found in human plasma and is the main inhibitor of neutrophil-derived proteases. The anti-inflammatory effects of AAT beyond protease inhibition are increasingly recognized. We set out to identify all proteins that bind to AAT as it circulates in the plasma in order to elucidate novel anti-inflammatory properties. To examine AAT’s interaction with potential linker proteins, permeation chromatography of plasma through Superdex 200 10/300 GL was performed. Two-step protein purification was performed using AAT select resin. Protein profiles were visualized by Coomassie blue staining of SDS-PAGE gels and western blotting. In-gel digestion of the visualized bands was performed and mass spectrometry (LC MS/MS) analysis carried out to identify high molecular weight AAT binding partners. Complement C3 was identified as a binding partner to AAT at the predicted molecular weight peak of 246 kDa. C3 binding to AAT was confirmed in plasma by immunoprecipitation through a Hitrap NHS activated HP column and in vitro by FACS analysis of protein:protein interactions. We hypothesize that, under an increased proteolytic burden, AAT can prevent the dysregulated degradation of C3. Alterations in C3 activity was investigated in plasma of AAT-deficient individuals. The novel identification of C3 binding to AAT uncovers a potential new function for AAT in the regulation of complement activation during inflammation and may have important implications for the pathophysiology of pulmonary disease in AATD and other conditions with an increased protease burden.
1.6. The Prevalence of Liver Abnormalities in Individuals with ZZ Alpha-1 Antitrypsin Deficiency O.F. McElvaney, T.P. Carroll, C. O’Connor, L. Fee, N.G. McElvaney
Respiratory Research, Department of Medicine, RCSI Education and Research Centre, Beaumont Hospital, Dublin, Ireland
1.7. Supplemental Dietary Nitrate for COPD: a Randomized, Double-blind, placebo-controlled, Crossover Trial C.P. Kerley1,2, K. Cahill1, K. Bolger1, K. Fennell1, A. O’Brien1, A. McGowan1, C. Burke1, J.L. Faul1, L.J. Cormican1 1
Respiratory & Sleep Diagnostics Department, Connolly Hospital, Dublin 15, Ireland, 2 School of Medicine, University College Dublin, Ireland Nitric oxide (NO) is a systemic- and pulmonary-vasodilator. The conversion of nitrite (derived from dietary nitrate) to NO can occur independent of NO synthase in a process that is upregulated in hypoxic conditions. Because COPD patients commonly suffer hypoxaemia, we hypothesized that dietary nitrate supplementation might improve exercise capacity in COPD patients. We compared the effect of beetroot juice (BRJ; 14 mmol nitrate) compared to a matched placebo (PL; \ 0.5 mmol nitrate) on exercise capacity (incremental shuttle walk test; ISWT) and blood pressure (BP) in COPD patients. Twelve COPD subjects (6 male) (Gold stages 2–4) had serum nitrate/nitrite, BP and exercise capacity (ISWT) assessed at baseline and after 3-h after randomization to BRJ or PL. After 7-d, the protocol was repeated with the crossover beverage. Subjects who took BRJ had significant elevations in serum-nitrate (+646 ± 587 vs. +3 ± 12.4 lM; p \ 0.01) and -nitrite (+ 646 ± 587 vs. + 9.9 ± 70 nM; p \ 0.01), increased ISWT distance (+23 ± 9 vs. -13 ± 5 m; p \ 0.01), and decreased mean arterial BP (-5 ± 5 vs. +5 ± 15 mmHg; p \ 0.05) compared to PL. Acute consumption of dietary nitrate can improve exercise tolerance, and lower blood pressure in COPD patients.
1.8. Grip Strength in a Chronic Respiratory Disease Cohort (TILDA Experience) C. Condon, O. Donoghue, R.A. Kenny, E.K. Stokes Trinity College Dublin, Dublin 2, Ireland Sacropenia and muscle weakness are common features of chronic lung disease either as a consequence of inflammation or disuse atrophy (1). Muscle weakness is a factor in loss of mobility and reduced functional independence. This study compared the best-achieved grip strength of a community dwelling chronic obstructive pulmonary disease (COPD) cohort against age and sex-matched controls using data from wave 1 of the Irish Longitudinal Study on Ageing (TILDA). The highest score of grip strength, using a handgrip dynamometer was used for analysis. Descriptive and Mann–Whitney tests were used to compare grip strength between groups. Inter quartile ranges, using TILDA population norms (2), are shown for comparison only. 337 people (145 males) reported a diagnosis of chronic lung disease (COPD or emphysema) from a population of 8,405 (4 %). 229 people within this COPD cohort also completed a physical health assessment at home or at a center. 2,200 males and 2,915
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females in the non-COPD cohort also completed a physical assessment. Maximal Grip Strength
patients without a prescription, 52 % (n = 13) were found to be at risk of hypercapnic respiratory failure, and only one of these patients (7.69 %) was found to have an oxygen saturation within the recommended limits of 88–92 %. In conclusion, the prescription of oxygen in Tallaght Hospital is not satisfactory or in compliance with the BTS Guidelines. Also, the use of oxygen for those at risk of hypercapnic respiratory failure is not within the recommended guidelines. Reference: 1. O’ Driscoll BR, Howard LS, Davison AG (2008) British Thoracic Society guideline for the emergency oxygen use in adult patients. Thorax 63(Suppl. VI):vi1–vi68
Age range (n)
COPD NonMann– Mean COPD Whitney grip ± SD Mean test (kg) grip ± SD (kg)
51–60 (ii = 32)
37.9 ± 6.5 37.8 ± 7.9 p = 0.87
61–70 (n = 36)
35.4 ± 8.8 34.5 ± 7.0 p = 0.93
[71 (n = 37)
28.6 ± 7.5 28.8 ± 7.4 p = 0.86
Females 51–60 (n = 43)
20.1 ± 5.1 21.9 ± 5.1 p = 0.03*
1.10. Auditing the Launch of Formal Oxygen Prescribing Practice
61–70 (n = 47)
18.8 ± 5.1 20.5 ± 4.7 p = 0.03*
G. Patterson, S. Graham, E. McRory, R. Convery
[71 (n = 34)
17.9 ± 5.2 17.3 ± 4.5 p = 0.94
Respiratory Medicine, Craigavon Area Hospital, Portadown, County Armagh, UK
The result shows that the mean male grip strength in the COPD group is comparable with agematched peers. However, females with COPD between 50 and 70 had lower mean grip strength than their peers and, compared to normative ranges (2), these females were at the lower end of the range and are at risk of possible greater functional decline. References: 1. Ansari K, Keaney N, Taylor I, Burns G, Farrow M (2012) Muscle weakness, health status and frequency of exacerbations in chronic obstructive pulmonary disease. Postgrad Med J 2. Kenny RA, Coen RF, Frewen J, Donoghue OA, Cronin H, Savva GM (2013) Normative values of cognitive and physical function in older adults: findings from the Irish Longitudinal Study on Ageing. J Am Geriatr Soc 61(Suppl 2):S279–S290. PubMed PMID: 23662720. Epub 2013/05/17. eng
1.9. An Audit of the Prescription of Oxygen on Inpatients in a Dublin Academic Teaching Hospital C. Casey1, A. Mulkerins1, S. Lane2, E. Moloney2, A. Sahadevan2
The 2008 British Thoracic Society (BTS) guidelines on the use of oxygen were published to ensure that oxygen was prescribed according to a target saturation range, rather than device and flow rate. In response, we conducted an audit on the prescription of oxygen in Craigavon Area Hospital (CAH). Using the BTS Emergency Oxygen Audit 2012 template, we conducted an initial and subsequent re-audit, following MDT oxygen training sessions conducted by ourselves, during May and July 2013 respectively. We collected data from 10 wards auditing kardexes of patients who were on oxygen at the time of data collection. In the first audit 38/287 patients were on oxygen at the time of data collection. 9/38 (24 %) were prescribed oxygen on their kardex; 2/9 (22 %) of these patients had oxygen correctly signed for on medication rounds. On re-auditing following staff training, we saw an 11 % increase in the number of patients prescribed oxygen, and a 7 % improvement in the number of kardexes signed. This audit has shown that with appropriate education, formal oxygen prescribing practice has improved in CAH. As a result we have facilitated a move towards better oxygen prescribing amongst the oxygen sensitive population, in keeping with BTS guidelines. References: 1. O’Driscoll BR, Howard LS, Davison AG (2008) British thoracic society guideline for emergency oxygen use in adult patients. Thorax 63(6):1–68
Department of Physiotherapy, Tallaght Hospital, Dublin 24, Ireland, Department of Respiratory Medicine, Tallaght Hospital, Dublin 24, Ireland
The British Thoracic Society (BTS) guidelines state that oxygen therapy should be prescribed to achieve a target saturation of 94–98 % for most acutely unwell patients, or 88–92 % for those at risk of hypercapnic respiratory failure. The target saturation should be recorded in the drug chart. The purpose of this audit is to determine the compliance with these oxygen prescription guidelines in Tallaght Hospital. A prospective chart review of all inpatients on oxygen therapy was completed over a 2 week period. Data has so far been compiled on 40 patients and data collection is ongoing. Oxygen was prescribed in the drug chart in 2.5 % of cases (n = 1). However, there was a prescription recorded in the medical chart/early warning score chart in 37.5 % (n = 14) of cases. Of the
1.11. Oxygen Prescribing in MRHM I. Sulaiman, S. Ahmad, D. Kelly, M. Sheehy Mullingar Respiratory Department, Midland Regional Hospital, Mullingar, Ireland Oxygen is the commonest drug used in medical emergencies. Its only real indication is to treat hypoxemia. The dangers of too much oxygen become more relevant in patients with hypercapnic respiratory failure (i.e. Chronic Obstructive Pulmonary Disease (COPD), neuromuscular conditions) where oxygen delivery needs to be carefully titrated. The aim of this audit was to evaluate if the introduction of the Early Warning Score (EWS) and a Grand Rounds Presentation on Oxygen Prescribing can improve oxygen prescribing.
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For this study we identified all patients on oxygen in medical and surgical wards. We then looked through medical notes and drug cardex for the prescription of oxygen while documenting history of COPD, hypercapnia, oxygen delivery, and patient oxygen saturations. Following the introduction of the EWS chart, we looked at the incidence of prescription again. In the initial audit 100 patients were reviewed. 23 % were on oxygen. 91 % via nasal canulae, 5 % a face mask and 4 % on Noninvasive Ventilation. 75 % had a diagnosis of COPD, only 66 % of patients had an Arterial Blood Gas Done. 25 % of patients on oxygen had it prescribed. In the re-audit we reviewed 104 patients. Only 18 % were on Oxygen. 53 % had COPD, 79 % had an ABG performed. Oxygen was prescribed 79 % of the time
Early warning score sheet
Oxygen prescription has improved dramatically after a Presentation on Oxygen Prescription and the introduction of the EWS. Our recommendation is to make oxygen prescription mandatory on a separate sheet in each patient’s drug cardex. Once this is introduced oxygen prescription should be re-audited within 3 months.
1.12. The Prescription of Oxygen on Discharge Letters to Early Supported Discharge Service in Western Health and Social Care Trust K. Donnelly, J. Hughes, A.M. Kernaghan, A. Box, A. Kennedy, C. Farren, H. Patterson
1.13. Audit of Oxygen Prescribing in Medical Patients According to BTS Criteria in a Tertiary Level Teaching Hospital K. Harkin, K. Sharma, R. Rutherford Department of Respiratory Medicine, University College Hospital, Galway, Ireland Oxygen is a drug that is frequently given but not prescribed in hospital settings. Its appropriate use includes hypoxemia rather than for breathlessness or as a default panacea. Oxygen should be prescribed to achieve sats of 92–98 % in acutely hypoxaemic patients and 88–92 % in patients who are high risk of developing hypercapnic respiratory failure. Retrospective analysis on twenty patients on oxygen therapy, who had been admitted under a medical service within 24 h, were analysed to see whether oxygen therapy was appropriate and prescribed correctly. Of 20 patients, only 1 had oxygen prescribed correctly. 16 patients had no pre 02 saturation recorded. Oxygen is currently being given without prescription or documentation as to indication, delivery system, oxygen concentration and target saturation and education programs must be put in place to address this.
1.14. Long-Term Oxygen Users Beware: Contraindications and Toxicity Risk Factors concerning Potential Long-Term Azithromycin Use in a General COPD Population A. Franciosi A*, T.T. Nicholson*, S. Landers S*, T.J. McDonnell TJ, M.W. Butler These authors contributed equally to this work
Early Supported Discharge Nursing Team, Western Health and Social Care Trust, Northern Ireland The BTS guidelines (2008) for emergency oxygen use in adult patients provide guidance on with the prescription, administration and monitoring of oxygen therapy. It states ‘‘…the intentions of the clinician who initiates oxygen therapy should be communicated clearly to the person who actually administers oxygen to the patient…’’. This is further supported by the WHSCT Policy for the Prescription and administration of Emergency Oxygen in Adults (2012). We wished to examine oxygen prescription [and communication to other staff] of patients who were referred to ESD (Early Supported Discharge) team from 01/01/13–28/02/13. A data collection sheet was devised, guided by the recommendations from BTS (2008). Initial data analysis demonstrates that only 10 % of patients who were discharge on oxygen therapy had a documented prescription on their discharge letter with only 7.5 % having target saturations specified. Currently oxygen is not being prescribed in accordance with national and Trust policies. It is intended to highlight these findings to medical and pharmacy colleagues. As part of the trusts oxygen policy we are introducing oxygen prescription for all in patients and in addition the BTS oxygen education module will be a requirement for all junior medical staff.
Department of Respiratory Medicine, St Vincents University Hospital and University College Dublin, Dublin, Ireland Long-term daily azithromycin (LTDA) reduces the frequency of exacerbations in COPD in a randomised trial setting1. Concerns exist regarding arrhythmic and auditory toxicities from chronic use in the real world setting. We hypothesised that risk factors for such toxicities, and contraindications, would be more frequent than previously reported. Following ethical approval, 47 consecutive hospital-based patients (mean age 69 years ± 1.2, Male = 25, Female = 22) with physiciandiagnosed COPD (mean FEV1 45.1 ± 2.7 % predicted), and a history of either exacerbations or long-term oxygen therapy (LTOT, n = 10), were screened for subjective hearing impairment (screening questions and whispered voice test) and by electrocardiogram for prolonged QTc (or JTc as appropriate). Other contraindications to LTDA were sought. 19/47 (40.4 %) had subjective hearing impairment. 8/43 (18.6 %) with electrocardiograms had prolonged manual QTc (or JTc in bundle branch block) intervals. 4/47 (8.51 %) had contraindicating co-morbidities. 26/47 (55.3 %) had one or more such risk factors/ contraindications. Those with risk factors/contraindications were more likely to be on LTOT (p = 0.001). In a hospital-based COPD population who would be candidates for LTDA therapy, more than half had either contraindications or risk
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 factors for toxicity from LTDA. LTDA may be appropriate for fewer COPD patients than previously thought, especially in those on LTOT. Reference: 1. Albert RK et al (2011) Azithromycin for prevention of exacerbations of COPD. N Engl J Med 365(8):689–698 No potential conflicts of interest apply
1.15. Review of Oxygen Clinic at Waterford Regional Hospital M. Mackey, F. Doody, M.P. Rogan, S.C. Foley Department of Respiratory Medicine, Waterford Regional Hospital, Waterford, Ireland The NICE Guideline on COPD (2010) states that oxygen assessment should be carried out on patients ‘‘whose COPD is stable’’. It also states ‘‘patients receiving long term oxygen therapy (LTOT) should be reviewed at least once a year by practitioners familiar with LTOT’’. This implies that review of oxygen prescriptions is indicated. A retrospective analysis was undertaken of Oxygen Clinic interventions over a 12 month period. All patients had a working or definitive diagnosis of chronic respiratory disease and were stable for 6 weeks when reviewed. Assessments for both portable and LTOT included pulse oximetry, Arterial Blood Gas (ABG) analysis and Six Minute Walk Test (6 MWT). Between June 2012 and June 2013, 170 patients were assessed. 44 (26 %) were new referrals. Oxygen therapy was commenced in 17 patients (10 %) and discontinued in 4 (2 %). 32 (19 %) required a change in prescription. 49 patients (29 %) did not meet the criteria for oxygen therapy. Given the above data, it is evident that this clinic optimises oxygen prescription and ensures best patient care. It is conducted by the Respiratory Physiotherapist and Clinical Nurse Specialist who operate in advanced practice roles and demonstrates effective use of the multidisciplinary specialist team. Reference: 1. NICE, 2010: National Clinical Guideline Centre (2010) Chronic Obstructive Pulmonary Disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: National Clinical Guideline Centre
1.16. How Useful is an Oxygen Assessment Clinic in Assessing Oxygen Requirements in Patients with Chronic Respiratory Disease? M. Ward, M.F. O’Driscoll & T.J. McDonnell Department of Nursing and Respiratory Medicine, St. Michael’s Hospital, Dun Laoghaire, Ireland Domiciliary oxygen (DO), given in the correct manner, significantly enhances survival and quality of life of patients with chronic respiratory conditions. Previous studies have demonstrated that oxygen is frequently inappropriately prescribed producing unnecessary expense and treatment. Oxygen assessment clinics may ensure patients are correctly prescribed supplementary oxygen, at rest, on exertion or nocturnally.1 The aim of this study was to assess whether patients referred to an oxygen assessment clinic, required new or changed prescription of oxygen following assessment.
S443 The study took place over a 3-month period with participants referred to the oxygen assessment clinic from the respiratory outpatient clinic, pulmonary rehabilitation programme or at 6 weeks post discharge from hospital. Out of 23 patients assessed, 35 % were already on DO. 100 % of these were using ambulatory oxygen with 75 % using oxygen at rest, with one person also using CPAP at night. 63 % of those with DO, following assessment, required changes in the amount of oxygen originally prescribed to them, 13 % required the same amount and 25 % did not require DO anymore. Nine per cent of the total assessed were newly commenced on DO. These results confirm the usefulness of an oxygen assessment clinic in ensuring the appropriate prescription of oxygen. References: 1. Lynes D, Kelly C (2009) Domiciliary oxygen therapy: assessment and management. Nursing Standard 23(20):50–56
1.17. Audit of Long Term Oxygen Prescribing Results in Cost Savings R. Cheng1, P. Davis1, S. Shelly1, R. Kennedy1, B. Korn1, N. Nyambe1, R. O’Donnell1 1 Respiratory Assessment Unit, CResT Directorate, St. James’s Hospital, Dublin, Ireland
Prescribing of oxygen is associated with significant costs, the average for long term oxygen therapy (LTOT) and portable oxygen being €1238 and €576 per annum respectively. Patients referred to the nurse and physiotherapy led oxygen assessment clinic in the Respiratory Assessment Unit (RAU) of St. James’s Hospital in the first 8 months of 2013 were evaluated for compliance with the oxygen prescribing recommendations outlined in the GOLD guidelines. Patients were segregated into two groups; Group 1; Chronic lung disease with the documented complications of pulmonary hypertension, congestive cardiac failure or polycythemia and Group 2; Chronic lung disease without documented evidence of these complications. This was determined by review of the patient’s records and assessments detailed on the hospital’s electronic patient records system. Patients were excluded if insufficient data or documentation was present. Of the 88 qualifying patients, 60 % of Group 1 patients and 81.1 % of Group 2 patients fulfilled the criteria for oxygen therapy. 12 patients were on oxygen without meeting the criteria, of which 5 had their therapies discontinued, resulting in a cost savings of €5528.16. The RAU oxygen assessment clinic effectively reduces the cost of inappropriate oxygen prescribing. No conflicts of interest to declare.
1.18. Evaluation of a pilot Physiotherapist and Nurse— Led Oxygen Clinic in Naas General Hospital (NGH) in 2013 S. Curtis, F. Kavanagh, C. Callan, S. Morrin, A.M. O’Connell, R. Ahmed, T. Quadri Naas General Hospital, Naas, Ireland The purpose of this study was to evaluate the effects of an oxygen clinic to manage users of Long term oxygen therapy (LTOT). Appropriate assessment, prescription and follow-up are recommended for users of LTOT to ensure effective therapy and monitor patients’ conditions and unnecessary side-effects.
S444 A list of patients prescribed LTOT from NGH in 2012 was obtained and a retrospective audit of initial prescriptions undertaken. Patients were then reassessed at the Oxygen Clinic. Descriptive statistics were used. There were 41 prescriptions of LTOT from NGH in 2012, 6 died, 7 palliative, 3 declined. Twenty-five postal appointments were sent. Attendance rate was 72 %. Oxygen was withdrawn from 2 patients. This withdrawal would save €2,255.04 per annum. (€46.98 per month per concentrator, €46.98 per month per portable). Nine patients no longer fit the criteria for LTOT. The cost of LTOT for these 9 patients was €7,892.64 per annum. Under-usage was identified in 7 patients at a total cost of €3,565.48 since prescription. Intervention was required in all patients (figure 1).
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 Oxygen prescriptions for the University Hospital were received and reviewed for the purpose of the audit. Mean age 60 years; 54 % female. 42 % had a diagnosis of COPD, 20 % Cancer, 10 % CCF, 4 % Pulmonary Fibrosis; 18 % had no diagnosis given. Consultant Physicians (both GIM and Respiratory) were the prescribers in 98 % of patients with GP’s accounting for the remainder. All patients were prescribed oxygen concentrators, with only 54 % provided with a back up cylinder. All patients had the concentration of oxygen prescribed, and the duration in 86 %. Only 66 % of patients were followed up in clinic, with only 56 % of them reviewed by a respiratory team. None of the patients had their LTOT discontinued subsequently. Conclusion: LTOT is not being prescribed properly, and there is a lack of appropriate follow-up for these patients.
1.20. Do Lengthy Waiting Lists for Pulmonary Rehabilitation (PR) Compromise Patient Care? M. O’Brien, T.J. McDonnell Department of Respiratory Medicine, St Michael’s Hospital, Dun Laoghaire, Co. Dublin, Ireland
This evaluation highlighted the issues surrounding LTOT. The high attendance rate would indicate a service need. An oxygen clinic has potential to improve both health care delivery and a cost saving initiative. References: 1. Chaney C. Jones J. et al (2002) Implementation of an oxygen therapy clinic to manage users of Long Term Oxygen Therapy. Chest 22:1661–1667 2. British Thoracic Society Working Group on Home Oxygen Services Clinical component for the home oxygen service in England and Wales 2006 London 3. BTS.Tinyurl.com/BTS-home-oxygen
1.19. Long Term Oxygen Therapy use at the University Hospital Limerick and Ennis C. McInerney, P. Ryan, M. Cullinan, R. Aziz, B. Casserly, A. O’Brien University Hospital Limerick and Ennis, Ireland Introduction: An audit of long term oxygen therapy (LTOT) in the University Hospital Limerick. Methods: Retrospective review of patients initiated on LTOT at the University Hospital Limerick and Ennis between Jan–July 2013. Research: 190 patients were initiated on LTOT in Clare and Limerick during this period, 50 of whom were included in the study.
PR is a multidisciplinary approach to improving the exercise capacity and symptoms of patients with chronic lung disease. Best practice guidelines recommend PR should be available from early diagnosis i ii but the average waiting time for PR in Ireland is currently 7 months. A detailed medical and oxygen assessment is performed on commencement of PR. This study investigated whether long waiting lists for PR are leading to delays in patients being assessed and whether the assessment changes their care plan. Of 118 patients assessed for PR in 2012 and 2013, 92 commenced the programme. 42 of these patients had oxygen therapy requirements. Nineteen of these patients were already on oxygen prior to PR. Of these; 15 required adjustments to their dosage whilst 4 had their oxygen stopped completely. No patients already on oxygen therapy continued on the same dosage once assessed. Of the 42 patients who had oxygen requirements, 23 were first prescribed oxygen following initial PR assessment. 12 patients commenced on oxygen therapy whilst 9 refused. 2 continued to smoke therefore oxygen therapy was contraindicated. It appears that patients awaiting PR may not be on appropriate therapy and/or may have deteriorated whilst on the waiting list. (196) References: 1. NICE Guideline. Idiopathic pulmonary fibrosis: the diagnosis and management of suspected pulmonary fibrosis [Internet]. NICE; 2013 [cited 2013 August 15th]. Available from: http://www. nice.org.uk/nicemedia/live/12955/62318/62318.pdf 2. National COPD Working Group. Pulmonary rehabilitation model of care [Internet]. National COPD Clinical Care Programme; 2010 [updated 2013 January; cited 2013 August 15th]. Available from: http://www.hse.ie/eng/health/hl/living/copd/Pulmonary_Reh abilitation_Model_of_Care_v_0_7.pdf
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Irish Thoracic Society Poster Review and Discussion Friday 15th November 2013
2. Lung Cancer, TB and Other Infections Chairs
N. Magee, Belfast City Hospital, Belfast R. Convery, Craigavon Area Hospital, Co Armagh
2.1. Development of Novel Lung Cancer Biomarkers for the Evaluation of Pulmonary Nodules M.E. O’Brien1, P. Dowling2, E. Keane1, M. Uzbeck1, M. Clynes2, R.K. Morgan1 1 Department of Respiratory Medicine, RCSI, Beaumont Hospital, Dublin, Ireland, 2National Institute for Cellular Biotechnology, Dublin City University, Dublin, Ireland
Lung cancer is the most common cause of cancer death in Ireland. Low dose CT screening for lung cancer can reduce mortality by 20 %. However, the false positive rate of 96.4 % for screening detected nodules is a major drawback. A lung cancer biomarker would lead to improved specificity, reduced costs and a reduction in unnecessary procedures for patients with CT-detected pulmonary nodules. We prospectively recruited 300 patients attending Beaumont Hospital between January 2011 and August 2013. All patients underwent bronchoscopic evaluation; paired BAL and serum samples were obtained. CT imaging was performed; nodule size & location, mediastinal lymphadenopathy and pulmonary parenchymal abnormalities were recorded. Patients were subsequently categorised into one of three groups; benign, surveillance, and cancer. An exploratory Principal Components Analysis (PCA) between control and cancer BAL was performed utilizing Orbitrap Mass Spectrometry (LC MS/MS). Bioinformatic statistical analysis on the data was performed; peptide number, max fold change in concentration, and confidence scores were recorded. Known protein:protein interactions were analysed using String v9.05 to examine for associations. A strong proteomic signal, differentiating cancer and control groups, was detected involving protease activity, glycolysis, and vascular haemostasis. PRTN3, AKR1C1 and HP, implicated in tumour metabolic activity and necrosis, were identified as central candidate biomarkers in BAL fluid. Validation of these and other biomarkers is currently underway in serum samples.
2.2. Follow-up of Pulmonary Nodules in a Tertiary Referral Centre D.B. Fitzgerald, O. O’Connell, C. Houlihan, D.M. Murphy, B.P. Plant, M.P. Kennedy, M.T. Henry Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland Recent studies have highlighted the importance of appropriate investigation of pulmonary nodules. We performed an audit of all incidentally-found new pulmonary nodules on CT Thorax between January and June 2010, with the aim of assessing compliance with follow up according to internationally recognised criteria1. Follow-up of new pulmonary nodules over a 2 year period was documented. Medical records were used for recording patient demographics and diagnoses. Statistical analysis was performed using the Chi Squared Test and Pearson’s coefficient.
S445 Of 873 scans, there were 230 nodules identified (26.35 %). 95 new nodules with malignant potential were identified. 46 % were followed up appropriately, 43 % had inadequate follow up and 10 % had excessive CT follow-up. Respiratory physicians were involved in 38 cases. Of these, 65 % were followed up appropriately. Of the nodules followed up by non-respiratory teams, 31 % were followed up appropriately according to Fleischner guidelines (p \ 0.0005). Patients are twice as likely to be followed appropriately by respiratory teams as other services (RR 2.01). Awareness of and adherence to Fleischner criteria in CUH is suboptimal and systems need to be implemented to ensure appropriate follow up pulmonary nodules, particularly amongst non-respiratory teams. References: 1. MacMahon H, Austin JHM, Gamsu G, et al (2005) Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology 237:395–400
2.3. Computerised Image Analysis of CT Thorax Images & Pulmonary Function Tests J. Naper, J. Dodd, D.G. Healy Departments of Thoracic Surgery & Radiology, St Vincent’s University Hospital, Dublin 4, Ireland
2.4. VATS Approaches in Adult Thoracic Surgery R. Kelly, D.G. Healy St Vincent’s & Mater Misericordiae University Hospitals, Dublin, Ireland
2.5. A Review of Rigid Bronchoscopy for Palliation of Endobronchial Tumours and Management of Benign Disease in an Integrated Thoracic Oncology Unit D. Ryan1, C. Deneshvar1, M. Da Costa2, D. Verasingham2, D.P. Breen1 1
Department of interventional Pulmonology, Galway University Hospital (GUH), Galway, Ireland, 2Department of Cardiothoracic Surgery, Galway University Hospital (GUH), Galway, Ireland Rigid Bronchoscopy is primarily used in palliation of central airway obstruction in malignant disease and rarely in the management of benign pathology. Here, we review the rigid bronchoscopy service in an Interventional Respiratory Unit over an 18-month period. 53 procedures were carried out since February 2012. 22 were for evaluation/treatment of endobronchial tumours. 7 were stented, 15 were unsuitable for stenting. Average survival post stenting was
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29 days (range 2–60 days), 3 remain alive (range 63–152 days). Average survival in those not stented was 101 days. 5 remain alive (range 53–311 days). Indication
Number of cases
Tumours (not stented)
Bronchopulmonary fistula (stented)
Bronchopulmonary fistula (valve insertion)
Haemoptysis Foreign object
References: 1. Ried M, Hofmann HS (2013) The treatment of pleural carcinosis with malignant pleural effusion. tsch Arztebl Int 110(18):313–318
2.7. A Review of Lung Cancer Detected at CT Cerebral Angiogram (CTA) I. Sulaiman, P. McElwaine, C. Fallon, M. Sheehy Midland Regional Hospital, Mullingar, Ireland
2.8. Video-conferenced Thoracic Surgical Clinics in a District General Hospital-A pilot study
Management of airway secretions
M. Doherty, M. Kelly, M. McCloskey, R.A. Sharkey, A. Graham
Respiratory Department, Altnagelvin Hospital, Derry, N Ireland, BT47 6SB, UK
This study demonstrates the role of interventional pulmonology in an integrated thoracic oncology service. NICE recommend that all lung cancer patients should have access to teams capable of providing endo-bronchial treatments (1) This service in GUH is developed to an International standard and provides important additional therapies in advanced malignancy. References: 1. NICE Lung Cancer clinical guidelines, CG121: April 2011
2.6. Medical Thoracoscopy in Ireland: An old technique with a new lease of life D. Ryan1, J. Scott1, C. Daneshvar1, B. Harte2, D. P. Breen1 1 Department of Interventional pulmonology, Galway University Hospital (GUH), Galway, Ireland, 2Department of Anesthesiology, Galway University Hospital (GUH), Galway, Ireland
Thoracoscopy is included in the algorithm of diagnosis and management of exudative pleural effusion. Diagnosis rates are consistently greater then 90 % and successful pleurodesis rates are quoted between 85–93 % (1). Compared to VATS, medical thoracoscopy is carried under conscious sedation in an ambulatory setting. A medical thoracoscopy service recently commenced at GUH. We report the first 8 cases performed. Procedures were performed under conscious sedation using alfentanil/midazolam. All were carried out for a diagnostic tissue sample. Seven patients had no diagnosis prior to procedure and one required tissue to confirm hormonal status in metastatic breast cancer. Mean age was 54 (32–73). Diagnoses included; three mesothelioma, one TB, one Adenocarcinoma, one triple negative breast cancer and two non-diagnostic pachypleuritis. The diagnostic rate was 75 %. Post procedure hospital stay was 1.6 days (1–4). The main side effect was failed re-inflation requiring prolonged drainage. Of four TALC procedures, three were successful with hospital discharge achieved within 4 days. One was a failed pleurodesis complicated by pain/poor lung expansion, extending hospitalization for 20 days. Medical thoracoscopy offers an important additional option in managing exudative pleural effusions. Diagnostic rates in GUH are currently 75 % but are expected to improve to International standards as expertise develops further.
Video-conferenced thoracic surgical clinics have been piloted between Altnagelvin Hospital and the regional thoracic surgical unit in the Royal Victoria Hospital in Belfast, 75 miles away. The logistics, activity, staff and patient experience of such clinics have been examined. A total of 17 patients (over 5 clinics) were offered appointments— 14 attended. One preferred to see the surgeon in person and 2 (elderly) couldn’t understand the concept. 2 patients had previous teleconference experience. 13 patients were meeting the surgeon for the first time. Excellent patient, nurse and surgeon satisfaction evaluation. ‘‘System is fantastic’’ ‘‘You couldn’t compare this service with a trip to and then a wait in Belfast.’’ Problems included increased workload for nurse in explanation and support to patients and setting up clinics and problems with technology. Improvements in administration and technology would enhance the application of the clinics but overall it is felt by all involved to be a satisfactory experience saving a 150 mile round-trip and gaining same results. Further evaluation of the service is required to confirm this initial finding but based on this pilot study, similar such clinics should be considered in hospitals located significant distances from their potential treatment centres.
2.9. A Comparison of Standard and Novel Bronchoscopic Endobronchial Biopsy Retrieval Methods K. Ali, C. Ryan, L. Burke, D.M. Murphy, B.J. Plant, M.T. Henry, T.M. O Connor, C. Curran, M.P. Kennedy Departments of Respiratory Medicine and Histopathology Cork and Mercy University Hospital, Cork, Ireland The targets of bronchoscopic biopsy now include not only adequate tissue for histological diagnosis but also tissue for further genetic analysis. We prospectively compared standard and novel bronchoscopic endobronchial biopsy (EBB) retrieval methods attempting to increase tissue yield. EBB samples were retrieved using techniques A, B and C (diagram 1) using a standard forceps. Per convention, at least 6 EBB were retrieved per patient. Results were compared to a gold standard composite of confirmatory pathological diagnosis or at least 6 months clinico-radiological follow up.
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 42/43 patients completed the required 6 biopsies for analysis. The final gold standard diagnosis was cancer (NSCLC, metastatic, carcinoid, carcinoma in situ) (24), benign disease (sarcoid, amyloid, hamartoma and chondroid tumor (4) and benign/nonspecific inflammation (14). EBB retrieved using method A were smaller than method B and C (P = 0.03). However, the percentage of cases where blood was the predominant component ([ 50 %) was less by method A (4/42) than B (16/42) and C (20/42) (p = 0.0001). There was no difference in mean viable tumor area (n = 23, sensitivity for EBB for cancer 96 %) between groups A compared to B and C (p = 0.27) and adequacy in benign cases by subepithelial depth ([ 0.3 mm) (p = 0.38). Standard retrieval of endobronchial biopsies through the bronchoscope and cap does not reduce the size of viable tissue and reduces contaminating blood and necrotic material.
S447 patients), non-persistent (\14 days) (50 %) and persistent ([14 days) (30 %). Persistent haemoptysis was significantly more frequent in patients diagnosed with lung cancer (p \ 0.05). There were no false negative CT scans for lung cancer. Approximately a quarter of patients presenting to RALC had haemoptysis. Approximately one sixth of those had lung cancer. Patients with lung cancer were more likely to have persistent haemoptysis. No patient identified with haemoptysis secondary to lung cancer had a normal CT. Table 1: Patients presenting to Rapid Access Lung Cancer clinic with haemoptysis (n = 155) over two year period Gold standard diagnosis
Number of cases N (%)
CT performed N (%)
Diagnostic CT* n (%)
Bronchoscopy Diagnostic Bronchoscopy* Performed N (%) N (%)
(16 %) Infection**
(100 %) 73
29 (100 %)
3 (2 %)
No cause identified
No gold standard
155 155 (100 %) (100 %)
4 (3 %) (16 %)
(66 %) 0
(52 %) 10
(100 %) 2
0 (100 %)
(0 %) 2
(0 %) 0
(17 %) 0
(95 %) 9
18 (79 %)
2 (1 %)
(0 %) 0
102 (66 %)
Figure legend: Endobronchial biopsy retrieval techniques. a The biopsy forceps (navy) is withdrawn through both the bronchoscope and biopsy valve (red) and sample (brown) is placed in specimen jar. b The biopsy forceps is left in position and the scope is removed with biopsy forceps distal to tip of scope- sample is placed in specimen jar and then biopsy forceps removed and scope repositioned for next biopsy. c The forceps is removed; however the biopsy valve is removed from the scope and slid back along forceps
*Any abnormal finding that contributed to the gold standard diagnosis **pneumonia, acute bronchitis, TB, non-mycobacterium TB, necrotising aspergillosis Q Eosinophilic bronchitis (1), intralobular sequestration (1), rib exostosis (1) telangiectasiaepiglottic fold (1)
2.10. The investigation of Haemoptysis through a National Cancer Control Program Rapid Access Lung Cancer Clinic
2.11. Diagnostic utility of Flexible Bronchoscopy Following Computed Tomography of Thorax in the Assessment of Haemoptysis
E. Bredin, M.T. Henry, D.M. Murphy, B.J. Plant, K. Ali, O. O’Connell, M.P. Kennedy
C. Murphy*, O.J. O’Connell*, Y. Gahan, D.S. O’Callaghan
Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland We performed a retrospective analysis of all cases referred to the RALC with haemoptysis between 2011 and 2012. The primary aim of the study was to establish the cause of haemoptysis and the diagnostic yields of investigations performed. A chart review was performed on all patients presenting to the RALC with haemoptysis in 2011–2012. The gold standard diagnosis for the cause of haemoptysis was a composite of confirmatory pathological or microbiological diagnosis with at least 6 months clinicoradiological follow up. Of the total number of patients presenting to the RALC (651), 155 (23.8 %) reported haemoptysis. Adequate follow up to ascertain a gold standard diagnosis was available in 86 % (Table 1). The duration of haemoptysis was categorised as a single episode (20 % of
Department of Respiratory Medicine, Mater Misericordiae Hospital, Eccles St, Dublin, Ireland *Joint first authors to study. Previous studies indicate approximately 5 % of endobronchial tumours are detected by bronchoscopy in patients with nonsuspicious computed tomography (CT) thorax findings. We examined the utility of bronchoscopy for detection of sinister causes of haemoptysis in patients without obvious attributable CT findings. Demographics, smoking status, anticoagulant/antiplatelet therapies, CT and bronchoscopy findings of patients referred with haemoptysis to the Mater Hospital Rapid Access Clinic from 05/2011–05/2013 were documented. CT findings were categorised into those with and without likely attributable cause of haemoptysis. Attributable causes included: cancer, bronchiectasis, infection and pulmonary vasculopathy. Adjudged non-attributable causes included: emphysema, sarcoidosis, pulmonary nodules and lymphadenopathy.
S448 Of 508 RALC referrals, 102 patients (41 F/81 M) reported haemoptysis and underwent CT scan and bronchoscopy. 59 patients were deemed to have an attributable cause identified on CT (lung cancer n = 40, bronchiectasis n = 13, pneumonitis n = 5). Bronchoscopy was normal in 31/43 patients without CT-attributable cause. Of the remaining 12 patients, three had benign laryngeal polyps and nine had benign mucosal changes. Modern CT thorax protocols appear more sensitive at detecting airway abnormalities attributable to sinister pathology such as lung cancer than previously reported.
2.12. Frequency of Unexpected Clinically Significant Findings on CTPA S.I. Shah, S. Galgey, M. Rourke, M. Sugawara, L.J. Cormican Department of Respiratory & Sleep Diagnostics, Connolly Hospital, Dublin, Ireland The aim of this study was to quantitatively analyse the frequency of incidental pulmonary nodules and other unexpected clinically significant findings picked up on consecutive CTPA performed to outrule pulmonary emboli. Data was collected retrospectively from 144 consecutive patients over a period of 4 months, who had standard 64 slice CTPA scans. Reports were examined for the presence of unexpected clinically significant findings (UCSF) The UCSFs were classified as follows: – Incidental pulmonary nodule:-single, multiple, unilateral, bilateral – Mediastinal lymphadenopathy – Other significant lung pathology Out of the 144 patients UCSFs were found on 51 %. Pulmonary nodules were seen in 35.4 % (n = 51), single nodule 22 % (n = 32) multiple 13 % (n = 19) bilateral 2.08 % (n = 3). Size of nodule was noted in15.2 % (n = 22) (10 \ 4 mm and 12 [ 5 mm). Lymphadenopathy was found in 13.1 % (n = 19). Lesions highly suspicious for malignancy seen in 2.08 % (n = 3) and other unexpected significant findings of clinical importance were seen in 15.97 % (n = 23). The study showed that irrespective of the result a significant number of patients had UCSFs on routine CTPA warranting follow up. Adherence to guidelines for follow up commits patients to additional radiation exposure. Diagnostic strategies involving V/Q scanning as first line imaging modality may need reconsideration
2.13. Outcome from CT-Guided Lung Biopsy over 2 years in Beaumont Hospital T. McEnery, S. Carolan, T. Cullen, M. Logan, S. Linnane, R. Morgan Department of Respiratory Medicine and Department of Radiology, Beaumont Hospital, Dublin, Ireland Percutaneous needle biopsy under CT guidance is a well-established method for the characterisation of peripheral lung lesions. We reviewed all patients who had CT-guided lung biopsies performed in our institution from January 2011 to December 2012 to assess complication rate and diagnostic yield. There were 215 patients with a mean age of 65 years (range 18 to 84 years). Mean lesion size was 37.6 mm (range 8 to 140 mm). 82 patients (38 %) had a core biopsy with an 18G needle; the remainder underwent Fine Needle Aspiration (FNA) with a 22G needle.
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 43 patients (19 %) overall had a pneumothorax apparent on imaging post-procedure. Most pneumothoraces were not clinically evident. Significant pneumothorax requiring drainage occurred in 19 patients (88 %), of which 9 (47 %) were in the core biopsy group. 12 % of patients were noted to have haemorrhage on CT imaging post procedure but this was clinically apparent in only 1 in 5 of these, who reported small volume haemoptysis. The overall diagnostic yield for core biopsy and FNA were 90 % and 77 % respectively. For malignant disease the sensitivity was 88 % and 77 %. Percutaneous biopsy is a safe and well-tolerated procedure. CT guided core biopsy is associated with higher diagnostic yield in malignant disease.
2.14. The role of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in Mediastinal and Hilar Lymph Node Evaluation of Patients with Extrapulmonary Malignancy J. Scott1, D. Ryan1, R. Casey1, M. Gorecka1, D. Breen1 1
Respiratory Department, Department of Medicine, Galway University Hospital, Galway, Ireland Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a modern minimally invasive technique for investigating hilar and mediastinal lymphadenopathy. This study describes its role in patients with confirmed or suspicious extrapulmonary malignancy, presenting with lymphadenopathy. A retrospective review of all patients (N = 183) who underwent EBUS-TBNA, between August 2012 and July 2013, was performed. Only those patients with extrapulmonary malignancy without prior histological confirmation of nodal disease were included. EBUS-TBNA identified extrapulmonary malignancy in eight patients. There were 7 males (87.5 %) and 1 female, with a median age of 71 years. Histology revealed 2 cases of squamous cell cancer of the head and neck (25 %), 2 cases of renal cell carcinoma (25 %). There were single cases of bladder TCC, merkel cell carcinoma, follicular lymphoma and GIST identified. There were no adverse events reported. Given that the differential of hilar and mediastinal lymphadenopathy in patients with extrapulmonary malignancy is broad, histopathologic confirmation is essential. EBUS-TBNA is a relatively safe, minimally invasive and fast technique, largely replacing the need for invasive mediastinoscopy. It is an effective diagnostic tool for nodal sampling and can help differentiate between synchronous or recurrent disease.
2.15. The Role of Ultrasound-guided Fine Needle Aspiration in Lymph Node Evaluation of Patients with Suspected Tuberculosis J. Scott1, D. Ryan1, R. Casey1, M. Gorecka1, D. Breen1 1 Respiratory Department, Department of Medicine, Galway University Hospital, Galway, Ireland
Ultrasound-guided fine needle aspiration (U-GFNA) is a minimally invasive technique for investigating lymphadenopathy in patients with suspected tuberculosis and prior negative investigations. A retrospective review of all patients (N = 183) who underwent ultrasound-guided FNA, between August 2012 and July 2013, was performed. Patients with confirmed or suspicious histopathological evidence of tuberculosis were selected.
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Four patients were identified and tuberculosis was confirmed in three; two by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and one by supraclavicular node U-GFNA. A fourth patient with granulomatous lymphadenitis on EBUS-TBNA is highly suspicious—prolonged cultures are awaited. Mycobacterium TB DNA was detected, using the GeneXpert System, in 3 cases, despite only one being positive for acid fast bacilli (AFB) and one culture positive. Prior investigations were negative, including sputum for AFB in all cases and negative bronchoalveolar lavage in one case. Tuberculosis remains an important Public Health issue that is often challenging to diagnose. U-GFNA is a safe, minimally invasive and rapid technique that allows definitive diagnosis in patients with prior negative investigations but high clinical suspicion. GeneXpert analysis allows early diagnosis despite low mycobacterium load. However, this requires sufficient tissue and we have demonstrated that this can be provided by U-GFNA.
33.3 % inpatients with COPD/Asthma did not receive vaccination. 41 % of other medical and surgical patients with other indications for influenza vaccination were not vaccinated. 38 % inpatients aged less then 65, where indicated received vaccination. Increasing age correlates with compliance. Hospitalization is the key reason for non compliance because patients miss their community vaccination programs. Inpatients during the influenza season [October to April] should have their vaccination status documented to achieve higher rates of influenza vaccination. Admissions necessitate either in hospital vaccination or a discharge letter reinforcing the need for vaccination.
2.18. Antimicrobial Stewardship Programs—are we doing the Right Thing? I. Moore1, E. Hayes1
2.16. An Analysis of Non-Tuberculous Mycobacterium (NTM), excluding Mycobacterium Avium Complex (MAC), in an Urban Dublin Hospital from 2003–2013 1
A. Mc Cann , M. Fitzgibbon , L. Montgomery , C. McDonald , J. Keane1, A.M. McLaughlin AM1 1 Department of Respiratory Medicine, St James Hospital, Dublin 8, Ireland, 2National Mycobacterial Laboratory, St James Hospital, Dublin 8, Ireland, 3Pharmacy Department, St James Hospital, Dublin 8, Ireland NTM are environmental organisms with relatively low virulence, that are potential pulmonary pathogens increasingly affecting patients with chronic lung disease. The presence of NTM in the sputum of patients poses a significant diagnostic dilemma, as it may represent contamination, colonisation or infection. Not all patients will benefit from treatment of NTM. The most recent American Thoracic Society (ATS) consensus provides useful guidance in evaluating NTM. Herein we present cases of NTM which have been treated in St. James Hospital. Two cases of M. malmoense, one of M. chelonae, one with both M. fortuitum and M. chelonae, and one with M. Kansasii.
2.17. Influenza Vaccination among Inpatients at the End of the Influenza Season in an Irish Hospital A. Sahadevan, A. Deegan, T. McDonnell
1 Department of Respiratory Medicine, Daisy Hill Hospital, Southern Health and Social Care Trust, Portadown, Northern Ireland
Antimicrobial stewardship programs (ASPs) can effectively reduce resistance. There has nevertheless been growing concerns of patient safety due to the impact of restrictive antibiotic guidelines with no systemic reviews to date. Observational data however indicates an association between ASP and increases in pneumonia mortality (1). Data from patients admitted with a diagnosis of community acquired pneumonia was collected prospectively. CURB score as per trust guidelines determined antibiotic choice. Patients were followed until either discharge or mortality. Seventy patients were identified. Mean age was 75.5 years with an average stay of 11.3 days. 11 % required HDU/ICU admission and all-cause mortality was 19 %. 58.5 % were adherent to guidelines. In this group 35.5 % required antibiotic escalation. Mortality was 22.6 % (100 % CURB C 3). In addition 57.1 % of patients who died in the adherent group were from nursing home accommodation. In the non-adherent group (41.5 %) 50 % were prescribed inferior antibiotics with 63.3 % requiring escalation and a mortality of 9.1 %. Community acquired pneumonia (CAP) is associated with a mortality of 8–14 %. Our study would support recent concerns suggesting an association between ASP and increases in pneumonia mortality. Moreover these results would suggest a review is needed of the current antibiotic regime for CURB C 3 with particular reference to patients admitted from nursing homes. References: 1. Price DB, Honeybourne D, Little P et al (2004) Communityacquired pneumonia mortality: a potential link to antibiotic prescribing trends in general practice. Respir Med 98: 17–24
Respiratory Department, St Michaels Hospital, Dun Laoghaire, Ireland Improved influenza vaccination reduces community pneumonias. Medicinal compliance requires understanding the reason of a specific therapeutic intervention; in this case the influenza vaccine. Hospital admissions should improve compliance. A research tool was designed using SphinxSurveyPlus software. Medical and surgical inpatients were then interviewed during the end of the influenza season [March/April]. 42 inpatients were randomly selected from respiratory, other medical and surgical teams. Data was analysed with Sphinx software. 85 % of inpatients acknowledged influenza is an infectious respiratory disease. 71.4 % knew there was an effective vaccine. 62 % were aware the influenza season is October to April. 34 % inpatients failed to identify correct months [September/October] to be vaccinated.
2.19. GeneXpert MTB/RIF for Rapid Diagnosis of Tuberculous Lymphadenitis on Endobronchial Ultrasound Fine-Needle Aspirate (EBUS-FNA) Specimens: A Preliminary Report P. Nadarajan1, M. Fitzgibbon2, F. O’Connell1, J. Keane1, A. McLaughlin1 1
Department of Respiratory Medicine, St James’ Hospital, Dublin, Ireland, 2Irish Mycobacterial Reference Laboratory, St James’ Hospital, Dublin, Ireland GeneXpert MTB/RIF is a rapid nucleic acid amplification test that detects DNA sequences specific for Mycobacterium Tuberculosis
S450 (MTB) and rifampicin resistance by polymerase chain reaction. Conventional drug susceptibility testing in culture can take as long as 6 weeks, making the GeneXpert particularly relevant to detect cases of multi-drug resistant tuberculosis (MDR-TB). We describe our initial experience on performance of GeneXpert on tuberculous mediastinal lymphadenitis. Patients referred to the TB service with a high index of suspicion of tuberculous lymphadenitis underwent EBUS-FNA. A single GeneXpert MTB/RIF assay was performed on EBUS-FNA samples in addition to cytological and microbiological analysis. This was evaluated against culture-confirmed TB. Seven patients underwent EBUS-FNA for suspected tuberculous lymphadenitis. 1/7 was smear positive and 3/7 were GeneXpert
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 positive. There were no cases of MDR-TB. Final culture was negative in all 3 patients. The 3 patients were commenced on standard TB treatment and had good clinical and radiological response. The remaining 4 patients were diagnosed with sarcoidosis and were followed up appropriately. While there is discrepancy between the assay and final culture, our preliminary evaluation shows GeneXpert to be a valuable test to exclude MTB (negative predictive value 100 %) and to identify drug resistant disease. This study is on-going. References: 1. Hassan T, McLaughlin A, O’Connell F et al (2011) EBUS-TBNA performs well in the diagnosis of isolated thoracic tuberculous lymphadenopathy. AJRCCM 183:136–137
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Irish Thoracic Society Poster Review and Discussion Friday 15th November 2013 3. Asthma, Sleep and Pulmonary Hypertension Chairs
T. McManus, South West Acute Hospital, Enniskillen L. Doherty, Bons Secours Hospital, Cork
3.1. Results of Quality Improvement Program to Improve Inhaler use by Patients in Hospital D. Long, C. Geraghty, J. Seheult, E. Dunican, A.M. Tuohy, C. Geoghegan, T. Byrne, E. Hayes, M. Murray, S. Chotirmall, E. O’Brien, T. Bophal, R. Reilly, S. D’Arcy, I. Sulaiman, R.W. Costello Beaumont Hospital, Dublin, Ireland Most respiratory patients are prescribed inhaled medication, which are often left with the patient at their bedside for self-administration. Therefore, we have no idea of how many doses the patient has taken, or even if the medication was taken properly. A novel acoustic inhaler tracking device was used to assess when and how an individual took their inhaler. Fifty-one in-patients were randomly selected that were on a Seretide Diskus inhaler, verbal consent was obtained and patients Errors were divided into timing and technique errors. Errors in timing were noted in 37 % of patients, with 16 % having significant overdosing and technique errors in 40 % of patients. A quality improvement program was undertaken which involved inhalers being stored in individually patient labelled bags in the drug trolley and administered as prescribed and supervised. Post Policy timing errors = 8 %, technique error = 14 %. Overall timing and technique error pre-policy = 43 % compared to 25 % post policy change (table 1) A change of inhaler policy, recorded by a novel inhaler tracker device showed a satisfactory improvement in patient timing and technique errors. Table 1: comparing pre and post policy change Pre policy
No of patients
51 doses (16 %)
2 doses (1 %)
70 doses (21 %)
21 doses (7 %)
Error in timing
Error in technique Blew into inhaler
75 doses (15 %)
Inadequately inhaled or 81 doses (25 %) failed to hold breath
5 doses (3 %) 28 doses (11 %)
Overall error in timing 204 doses (43 %) 56 doses (25 %) or technique
3.2. Inhaler Compliance Assessment (INCA) S. D’Arcy, I. Sulaiman, M. Holmes, J. Seheult, E. MacHale, R.B. Reilly, R.W. Costello Beaumont Hospital, Dublin, Ireland A crucial treatment for obstructive lung disease includes inhaled medication. Adherence to such medications is therefore vital in managing these patients. With a novel device, used to record acoustic recordings from inhaler devices (INCA), we hope to show the importance of adherence on clinical health. A cohort of 65 patients had an INCA device attached to their inhalers. Both groups were followed over 3 months, kept daily Peak Flow Diaries and had 4 visits over the 3 months. Patients in the active group were given feedback downloaded from the INCA device at every visit, letting them know what levels of compliance and technique errors they had. Patients in the control arm continued with their current management. The overall proportion of errors observed over time significantly reduced from month 1 to month 3 (p = 0.035). Patients in the active arm showed a drop in technique errors from 10 to 5 % (p \ 0.05). The dataset was also divided into AQLQ and PEFR improvers and non-improvers. The combined temporal and technique adherence rates were correlated with the changes in the AQLQ and PEFR. This study has demonstrated that providing feedback on adherence to patients improves their clinical outcomes.
3.3. Inhaler Proficiency after the Implementation of a new Inhaler Management Policy for Hospitalised Patients D. Long, A.M. Lyons, T. Byrne, I. Sulaiman, R.W. Costello Beaumont Hospital, Dublin, Ireland Inhaled medications are crucial treatments in many respiratory conditions. However inhaler technique and adherence is poorly studied, particularly in the hospitalised patient. This audit follows the implementation of an Inhaler Management Policy. It was hypothesized that following the implementation of the policy poor inhaler technique would be identified and corrected prior to discharge All patients on inhalers admitted from the Emergency Department were included in the audit over a 4 month period. Verbal consent was obtained. 126 patients were observed, 100 (n = 100) female = 58 and male = 42 completed, 26 uncompleted = discharge early or infection control. Mean age = 68 (-49/+ 19). Diagnosis = COPD (55 %), asthma = (24 %) and other = (21 %). A ten point Inhaler Proficiency Score (IPS) was used to assess inhaler technique. On admission, 54 patients had good inhaler technique, IPS C 9, 19 were too ill to be assessed properly, on discharge, 21 % of the patients with a low initial score improved the IPS to C 9 and 25 % had no improvement, all had an initial IPS \ 5 on admission. Overall, 20 % required intervention, 16 had further inhaler education and 4 were deemed not suited for inhalers. Poor inhaler technique on admission improved with appropriate intervention as part of the new Inhaler Management Policy. A group of patients have been highlighted that are unable to use inhalers following instructions and this needs further audit.
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3.4. Changing Inhaler Management for Hospitalised Patients D.A. Long, C. McGeoghegan, A.M. Lyons, T. Byrne, R.W. Costello Beaumont Hospital, Dublin, Ireland An audit using an adherence monitor of Hospitalised patients identified that 16 % of patients overused their inhalers that 21 % of doses were not administered and 40 % of doses were taken incorrectly. We undertook a practice change, including a new Inhaler Management Policy which included staff inhaler education, storage change, improved nursing documentation. A prospective, observational study was carried out following the implementation of this practice change. Four key components of the policy were monitored; inhaler prescription/storage, patient knowledge, nursing knowledge, and nursing documentation. An audit tool based on the Metrix Scale was devised to monitor the impact of the new policy. Inhaler Ward Audit 20 15 90-100% No.of Wards 10
5 0 Storage
P. Knowledge N.Knowledge
Seventeen wards were included in the study. Monthly audits were performed and results relayed back to the wards. Six months after the practice change there was a 90–100 % improvement in inhaler prescription/storage on 17 wards as well as a 90–100 % improvement in patients and nurse’s knowledge regarding inhaler technique and 7 wards demonstrated a 90–100 % improvement in nursing documentation. In conclusion, the introduction of the new inhaler management policy has improved the safety of inhaler administration and knowledge of inhaler technique for both patients and staff.
3.5. Can Dietary Supplementation Minimise Symptoms Or Improve Pulmonary Function in Asthmatic Patients? M. Delaney Student General Nurse, Dublin City University, Dublin 9, Ireland The objectives of this project were to evaluate whether the supplementation of vitamins and/or minerals will help reduce the symptoms of asthma and improve lung function of asthma patients. Dietary supplementation of antioxidants, probiotics, fatty acids, and magnesium were analysed and the results correlated. A systematic review of current literature was conducted using inclusion criteria resulting in 10 included studies. They contained both adult and child participants diagnosed with asthma. A thorough search of reputable databases using specific search words identified research trials for this review. While 40 % of the trials resulted in quite negative results, showing minimal or no improvement in asthma symptomatology or pulmonary function, there were some positive outcomes. Interventions using magnesium, probiotics and Vitamin C supplemented individually were shown to improve asthma control and quality of life. However using supplements in combination appeared to have the most impact on asthma control.
It is encouraging to see positive results emerging from studies relating to supplementation and its effects on asthma. However as yet, the research is unclear. Further studies with large participant numbers over longer periods of time are necessary to accomplish reliable findings that can be used clinically and referred to asthmatic patients and healthcare providers.
3.6. Asthma—the untold story M. Dunne, I. Kelly Asthma Society of Ireland, 42-43, Amiens Street, Dublin 1 Most of the Irish population have heard of asthma, or knows someone—a relation or friend, who suffers from the condition, but what of the little known facts and figures of asthma, should we not know about them too? A study of Irish data regarding morbidity and mortality, hospitalisations, days lost to school or work because of the condition, and prevalence of asthma in the general population was undertaken. Death rates: From 2007–2010 (4 years) a total of 210 people died from asthma (35 % male). Hospital admissions: From 2008–2011 (4 years) 20,236 were admitted to hospital with a principal diagnosis of asthma, with 13,128 (64 %) being emergency admissions. Use of Intensive Care beds: From 2009–2011, there was an annual mean of 99 discharges, affecting a mean of 88 patients (31 % under 15 years of age) and a mean of 296 ICU bed days utilised. Children loose 10 school days per year. Adults loose 12 work days per year. Current prevalence of asthma: Estimates suggest that there are 461,535 people with asthma in Ireland. The National Asthma Programme needs to be adopted and implemented immediately, so that patients can take control of their asthma, and better understand their management, reducing cost to the health service and giving them better quality of life.
3.7. Exhaling into a DiskusTM Inhaler Before Inhalation has a Detrimental Effect on Subsequent Drug Delivery M.S. Holmes1, J. Seheult2, P. O’Connell3, S. D’Arcy1, C. Ehrhardt3, A.M. Healy3, R. Costello2, R. Reilly1 1
Trinity Centre for Bioengineering, Trinity College Dublin, Dublin, Ireland, 2The Department of Medicine Respiratory Research Division, RCSI, Dublin, Ireland, 3School of Pharmacy, Trinity College Dublin, Dublin, Ireland Exhaling into a dry powder inhaler (DPI) before the inhalation manoeuvre is a critical error and can lead to decreased medication efficacy. This study aims to investigate the effect of exhaling into the mouthpiece of a common DPI, the DiskusTM. The effect of four factors (exhalation flow rate, distance from mouthpiece, exhalation duration, and air condition) on subsequent drug delivery was investigated in a controlled experiment. A flow meter controlled the flow rate of the simulated exhalations (30–120 L/ min), while distance from the mouthpiece was varied between 0–10 cm. A flow controller was used to set the duration of the exhalations (2–6 s) and air condition was classed as either dry or humid. Drug was subsequently extracted from the DiskusTM DPI using a Dosage Unit Sampling Apparatus (DUSA) and analysed using a High Performance Liquid Chromatography (HPLC) technique.
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Multivariate regression analysis revealed that all four factors had a statistically significant effect on drug dispersal from the DiskusTM DPI (p \ 0.05). Results demonstrated that the DiskusTM inhaler is very sensitive to exhalations and that they can cause a reduction in the quantity of drug available for inhalation (Figure 1). This study has quantified the detrimental effect of exhaling into a DPI for the first time.
related morbidities would provide additional evidence for Omalizumab use. References: 1. Oba Y, Salzman GA (2004) Cost-effectiveness analysis of omalizumab in adults and adolescents with moderate to severe allergic asthma. J Allergy Clin Immunol 114(2):265–269 2. Campbell JD, Spackman DE, Sullivan SD (2010) The cost and consequences of omalizumab in uncontrolled asthma from a USA payer perspective. Allergy 65(9):1141–1148
3.9. Asthma Education for Older Adults: A Literature Review T. McDonagh Department of Nursing Midwifery and Health Studies, Dundalk Institute of Technology, Dundalk, Ireland
Figure 1: Percentage of drug recovered (%) from the Diskus DPI after air was exhaled at various flow rates (L/Min) and distances (cm) directly towards the inhaler mouthpiece using humid air
3.8. The Impact of Omalizumab on Health Care Utilisation and Subjective Assessment in Severe Allergic Asthmatics S. Shelley, O. Dempsey, R. Kennedy, P. Davis, B. Korn, C. McDonald, A. M. Brady, R. Fahy, R. O’Donnell Respiratory Assessment Unit, Department of Respiratory Medicine, St. James’s Hospital, D.8 and Centre for Practice and Healthcare Innovation, Trinity College Dublin, Ireland Omalizumab is a humanised monoclonal antibody shown to be effective in the treatment of moderate to severe uncontrolled asthma1,2. Omalizumab is costly; therefore treatment is provided if there is evidence to suggest a positive outcome for the patient after a 16-week trial. The aim of this audit is to establish the effectiveness of Omalizumab for treating these patients in the Irish setting. A retrospective audit of eight patients treated with Omalizumab in a Dublin hospital was undertaken. The main outcomes measured one year before and after commencing Omalizumab were Quality of Life (QOL), asthma control, GP visits, Emergency Department (ED) attendances and hospital admissions, and antibiotic and steroid use. Wilcoxon Signed Rank Tests revealed statistically significant increases in QOL (p = 0.018) and Asthma Control (p = 0.018) one year after commencing Omalizumab. Five patients (71 %) showed an increase in QOL scores one year after commencing Omalizumab. ED attendances, hospital admissions, and antibiotic and steroid use were reduced by 79 %, 82 % and 21 % respectively. Omalizumab is effective in improving quality of life while reducing unscheduled hospital visits in the Irish setting. A cost benefit analysis and further research into the reduction of steroid
Adult-onset asthma is underdiagnosed and undertreated worldwide. Although the effectiveness of asthma education for children is widely accepted less is known about the effect of asthma education for older adults (C65 years). This is unfortunate since the World Health Organisation (1) has identified a global phenomenon of population ageing which has profound implications for future healthcare provision. Based on a literature review conducted using electronic databases and the Cochrane Review, predominantly from 2008–2013, this paper synthesises the published literature regarding asthma education for older adults. The selection of studies was non-systematic and the studies were not graded by criteria determined a priori. The review identifies gaps in knowledge to inform future research. Searches included other web-based resources including those of government bodies. Further studies were identified by manual search of the reference lists of articles sourced in the database search. This article emphasises asthma education considerations specific to older adults. Challenges in providing appropriate, accessible, acceptable and individually tailored asthma education to this cohort of asthma patients are identified within the scope of the review. The review concludes with a basis for the development of educational resources for late onset asthma potentially making a significant contribution to health outcomes. References: 1. World Health Organisation. April 2012. 10 facts on ageing and the life course. Available; http://www.who.int/features/factfiles/ageing/ ageing_facts/en/index.html [Accessed 15 July, 2013].
3.10. Experiences with Omalizumab in a Specialist Asthma Clinic G. Giblin, E. Jennings, H. Song, P. Ryan, B. Casserly, A. O’Brien Department of Respiratory Medicine, University Hospital Limerick, Limerick, Ireland Omalizumab is an anti-IgE monoclonal antibody recommended by the Global Initiative of Asthma guidelines as add-on treatment for severe persistent allergic asthma.
S454 This was a retrospective study examining the effect of omalizumab treatment on antibiotic and corticosteroid use, hospitalisation rates and inpatient bed days over 6 months before and after commencing therapy in a cohort of 19 patients attending a specialist asthma clinic. Descriptive statistics were used and the means compared with 2-tailed paired student t tests. All patients fulfilled criteria for commencing therapy. There was a 47 % reduction in hospitalisations (1 ± 1.25 to 0.53 ± 0.93), 67 % % reduction in hospital days (7.26 ± 11.65 to 2.42 ± 6.68), 55 % reduction in antibiotic use (p = \0.01) and a 66 % reduction in the use of rescue corticosteroids (p = \0.01). 2/7 patients on maintenance oral corticosteroids prior to initiation of omalizumab were able to discontinue steroid therapy within 6 months. With regard to pulmonary function testing, mean FEV1/FVC improved from 68 ± 7 % to 73 ± 7 % % (p = \0.01) while mean FEV1 improved from 1.86 ± 0.85 to 2.01 ± 1.01. To date, 10 % of patients have been able to discontinue treatment due to excellent asthma control. This study highlights the significant clinical and healthcare cost benefits of omalizumab therapy in carefully selected severe asthma patients after 6 months of treatment.
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 Table 1 Percentage of respondents agreeing/strongly agreeing with Beliefs about Medicines Questionnaire statements
Percentage agreeing or strongly agreeing Harm scale Most medicines are addictive
Natural remedies are safer than medicines
Medicines do more harm than good
All medicines are poisons Overuse scale
Doctors use too many medicines
People who take medicines should stop their treatment for a while every now and again
Doctors place too much trust on medicines 10 (40%) If doctors had more time with patients they would prescribe fewer medicines
3.11 Beliefs about medications and inhalers adherence in asthma patients during pregnancy O. Mikulich1, J. Carney1, C. Mc Donnell1, A. Cotter2, A. O’Brien1 University Hospital Limerick; 2Maternity Hospital Limerick
Background: Asthma is the most common chronic disease in pregnant women, complicating up to 12.4 % of pregnancies. Nonadherence to controller medication increases this risk, and average compliance with medication during pregnancy is poor. Aim of the study: To assess compliance with prescribed asthma medications in pregnant women and its relationship with women’s attitudes and beliefs. Methods: Prospective study of asthmatic women on the delivery ward in Limerick Maternity Hospital. All (n=25) completed 3 Questionnaires: Asthma Control Questionnaire (ACQ), Beliefs About Medications Questionnaire (BMQ), and Medications Adherence Report Scale (MARS). Patients’ pharmacies were contacted about asthma medications collection during pregnancy and 6 months prior to that. Results: Mean age 28.9 years. Smoking History: current 28 %, previous 20 %. 10 (40 %) subjectively had a deterioration in their asthma, with poor asthma control in 9 (36 %) (ACQ). 3 (12 %) had pregnancy-related complications. Ten (40 %) had asthma-related GP visits during pregnancy. Only 3 (12 %) were compliant with their medication during pregnancy (MARS). Majority of patients (72 %) appreciated the value of medications in asthma management, reflected by positive necessitiesto- concerns ratio in BMQ. Scores on Harm/Overuse scale in BMQ were also high suggesting unmet women’s concerns about medications safety during pregnancy. Conclusion: Adherence to inhaled asthma medications during pregnancy is low, in spite of asthma control deterioration in significant proportion of patients. In spite of their concerns, most women realised the necessity of medications for asthma control.
3.12. A Novel Human In Vitro Model for the Study of Nociceptive Responses in Sensory Nerves C. Rebecca, M. Kevin, A. Curtis Tim, S. Cosby Louise, T. Lundy Fionnuala, L. McGarvey School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, UK The transient receptor potential (TRP) channel family are specialised ion channels expressed on airway sensory nerves. Activation by physical and/or chemical stimuli induces nociceptive reflex responses. TRP channels merit investigation as possible therapeutic targets for cough. Study of neuronal TRP channel expression and regulation in human disease is limited by the fact that peripheral neurons lack cell bodies. To overcome this we have differentiated stem cells from redundant human dental pulp towards a neuronal phenotype, termed peripheral neuronal equivalents (PNEs). PNEs are a novel source of human neurons containing cell bodies for in vitro study. PNEs were grown on substrate-coated coverslips and the expression of neuronal markers and TRP channels (TRPV1, TRPV4, TRPA1, TRPM8) determined using immunofluorescence. TRP channel functionality was investigated using whole cell patch clamping and calcium microfluorimetry. Dental pulp stem cells undergo phenotypic switching during the differentiation with PNEs expressing specific neuronal markers (PGP9.5) but not fibroblast markers (FSP). Preliminary data acquired using microfluorimetry showed increased [Ca2?]i in PNEs stimulated with the TRPA1 agonist cinnamaldehyde suggesting TRPA1 functionality which was confirmed by patch clamping. These findings indicate the differentiation of dental pulp stem cells into functional PNEs that are suitable for in vitro studies of human neuronal function. This work was funded by NC3Rs.
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3.13. Biometrics and the Severity of Obstructive Sleep Apnoea Syndrome (OSAS) S. Apetroaei2, A. McGowan1, A. O’Brien1, K. Fennell1, J. Faul1, L. Cormican1, P. Goodman2, C. Burke1
Inventory (BDI), a neuropsychological assessment (trail making) and wore an ambulatory BP monitor for 24-h. Subjects were randomized to either 140 ml beetroot juice (BRJ) (14 mmol nitrate) nightly or 140 ml water (\ 0.5 mmol nitrate) nightly for 2 weeks followed by the crossover condition. Assessments were repeated at 2- and 4-weeks.
Respiratory & Sleep Diagnostics, Connolly Hospital, Blanchardstown, Dublin 15, Ireland, 2Department of Physics, DIT Kevin Street, Dublin 2, Ireland
Differences between water and BRJ: Baseline
Specific physical measurements might predict the presence and/or severity of OSAS. The aim of this study was to investigate whether physical parameters combined with historical detail (via a sleep questionnaire) might predict the severity of OSAS in patients referred for polysomnography. One hundred and seventy two patients (118 men) underwent diagnostic polysomnogram and completed a questionnaire and several physical measures were recorded. 143 (84 %) of patients were diagnosed with OSAS (AHI of [ 5). In our patient population no significant asociation was found between the presence of OSAS and nasal obstruction or ESS score. The following table represents gender specific attributes that indicate the presence of OSAS.
BMI, neck circumference, waist and hip circumference are associated with increasing severity of OSAS. A raised waist/hip ratio ([ 0.94) was associated with the presence of OSAS but not related to severity. BMI, neck, waist and hip circumference were significantly associated with the presence of OSAS in both genders.
Trail making A (s)
Trail making B (s)
Nocturnal SBP (mmHg)
Nocturnal DBP (mmHg) % dipping SBP
Nocturnal dietary nitrate may improve NO bioavailability in OSAS, resulting in BP benefits. References: 1. Urbano F, Roux F, Schindler J, Mohsenin V (2008) Impaired cerebral autoregulation in obstructive sleep apnea. J Appl Physiol.105:1852–1857 2. Franco CM, Lima AM, Ataı´de L Jr, Lins OG, Castro CM, Bezerra AA, de Oliveira MF, Oliveira JR (2012) Obstructive sleep apnea severity correlates with cellular and plasma oxidative stress parameters and affective symptoms. J Mol Neurosci 47(2):300–310
3.15. Can you Die from Obstructive Sleep Apnoea Syndrome (OSAS)? E. Doody, L.S. Doherty
3.14. Nocturnal Dietary Nitrate OSAS: A randomized, Crossover 2 week Trial C.P. Kerley1,2, E. Dolan3, J. Bramham4, J.L. Faul1, L.J. Cormican1 1 Respiratory & Sleep Diagnostics Department, Connolly Hospital, Dublin 15, Ireland, 2School of Medicine, University College Dublin, Dublin, Ireland, 3Department of Geriatrics, Connolly Hospital, Dublin 15, Ireland, 4 School of Psychology, University College Dublin, Dublin, Ireland
Obstructive sleep apnoea syndrome (OSAS) is associated with high blood-pressure (BP), and decreased cerebral blood-flow1. The bioavailability of nitric oxide (NO), a vasodilator, is indicated by serum nitrate/nitrite, which are typically decreased in OSAS2. Dietary nitrate may increase serum nitrate/nitrite, lower BP, and increase cerebral blood-flow. 3 CPAP naı¨ve males (mean age 53.3 y; mean BMI 38.1 kg/m2) with severe OSAS (mean AHI 34) completed the Fatigue Severity Scale (FSS), Epworth Sleepiness Scale (ESS), Beck Depression
Department of Medicine, Bon Secours Hospital, Cork, Ireland Conservative estimates suggest 2–4 % of the population suffer from Obstructive Sleep Apnoea Syndrome (OSAS). Several recent studies have suggested an independent association between OSAS and cardiovascular death. In our experience this is not reflected in current death certification. We aim to highlight the lack of documentation of OSAS-related deaths in national certification despite adequate awareness of this association by doctors. We contacted the Central Statistics Office (CSO) and obtained all relevant mention of OSAS on death certificates. We surveyed 127 doctors on their view of OSAS-related deaths. CSO data from 2008–2010, revealed one death caused by OSAS, but 52 deaths with OSAS as a contributory cause. 89 of 127 doctors responded to an email survey. Of the 89 respondents, 42 % believed OSAS can be a direct cause of death. 100 % believed OSAS could be an indirect cause of death. Of those who had signed death certificates, no one had put down OSAS as a cause of death.
S456 OSAS is seldom recorded on death certificates. This is at odds with expected epidemiological forecasts and contrary to an onion poll from a random selection of doctors. This in turn minimises the importance of a very serious public health concern.
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 This is an audit carried out in the Sleep Department of Peamount Healthcare. The data of 250 patients were recorded in 2012.
3.16. The Use of Mapping Technology to Characterise Patient Distribution & Guide Service Rationalisation: Pilot in Obstructive Sleep Apnoea (OSA) M. Mc Menamin1, H. Phelan1, C. Meehan1, M. Mc Closkey1, R. Sharkey1, T. Mc Manus2, A. Aziz1, A. Boyce3, M.G. Kelly1 1
Respiratory Medicine, Altnagelvin Hospital, Derry BT47 6SB, Respiratory Medicine, Southwest Acute Hospital, Enniskillen BT74 6DN, 3Account Development Manager, Land & Property Services, Colby Houst, Belfast BT9 5BJ
OSA is still under-diagnosed and linked to long-term adverse health consequences such as hypertension, metabolic dysfunction, cardiovascular disease, neurocognitive deficits and motor vehicle accidents1. There has been rapid expansion in diagnosis of OSA & demand for services. The Western Health and Social Care Trust (WHSCT) approached Land & Property Services Geographic Information Consultancy Team for assistance. They created maps of the WHSCT area & superimposed patient location information. The patient locations were mapped by joining postcode to a mapped dataset of postcode centroids i.e. the centre point of a postcode area. This ensures patient confidentiality by generalising their location whilst providing sufficient spatial accuracy. WHSCT wanted to clarify location of their OSA patient population to aid targeting current and future resources in a more coherent, systematic and strategic manner. If informative, such methodology may be used for other diseases. OSA database contained 1116 patients. Upon mapping, 21 (1.9 %) fell outside the Trust area. Mean age 54 y, with range of 31–88 years. 722 (64.7 %) were male. The maps identified patients by age, sex, equipment usage & deprivation index. Use of such mapping has allowed better distribution of resources and development of an outreach OSA clinic in Enniskillen. More developments will follow. References: 1. Mc Nicholas WT (2008) Diagnosis of obstructive sleep apnoea in adults. Proc Am Thorac Soc 5:154–160
3.17. The Prevalence of Periodic Limb Movement Disorder Referred to a Specialist Sleep Unit in Ireland M. Kooblall, E. Moloney, S. Lane Respiratory Department, Tallaght Hospital, Dublin, Ireland Periodic limb movements Disorder (PLMD) are repetitive leg movements occurring in sleep. PLMD often are asymptomatic, with only the bed partner reporting their presence PLMD can associated with sleep disorders, such as in restless leg syndrome (RLS) and Obstructive sleep apnea (OSA). The Objective of this audit is to determine the prevalence of PLMD in patients referred to the sleep clinic in Peamount Healthcare.
10 % of the patients were diagnosed with PLMD only. Furthermore we recorded and compared the gender, age group, BMI, Epworth Sleep Score, clinical symptoms and co morbidities of this group. PLMD can cause poor sleep and subsequent daytime somnolence. PLMD is a diagnosis of exclusion to be made after other associated disorders have been ruled out. Polysomnography (PSG) must be done to document the presence of limb movements. Because the etiology is not clear, a combination of clinical assessment and polysomnography is needed to help determine the precise diagnosis.
3.18. Home detection of Obstructive Sleep Apnoea using the SleepMinderTM—a Novel Bio-motion Sensor S.J. Crinion1, B.D. Kent1, P. Boyle1, M. Traynor1, A. Zaffaroni2, E. O’Hare2, E. Doheny2, D. Flanagan2, C. Heneghan2, W.T. McNicholas1 1
The Respiratory Sleep Disorders Unit, St. Vincents Hospital Healthcare Group, Dublin 4, Ireland, 2Resmed Sensor Technologies, NexusUCD, Bellfield Office Park, Dublin 4, Ireland Obstructive Sleep Apnoea (OSA) is a common disorder causing near or complete obstruction of the upper airway during sleep. This can cause interruption of the normal sleep pattern that leads to daytime sleepiness and decreased concentration. Overnight inpatient polysomnography (PSG) is the gold standard diagnostic test, but is resource heavy and inconvenient to the patient. The SleepMinderTM device is a non-contact bio motion sensor that estimates AHI based on the analysis of detected movements. In this on-going study, patients are recruited to use the SleepMinderTM device for seven consecutive nights at home followed by inpatient PSG. Mean at-home SleepMinderTM derived AHI is compared to the AHI determined from the inpatient PSG. PSG and SleepMinderTM analysers are blinded to the other’s result. Interim analysis is presented of the first thirty-five patients who completed the study protocol. Good correlation was seen between inpatient PSG AHI and mean domiciliary SleepMinderTM AHI (r = 0.72, p \ 0.01). SleepMinderTM showed a sensitivity of 100 % at detecting an AHI of C 5, and specificity of 96 % at detecting an AHI C 30.
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 The SleepMinderTM device is a promising screening tool for detecting OSA in an unselected patient group.
3.19. Improving the Detection of Pulmonary Hypertension Connective Tissue Disease Patients R.P. Cusack, C. Kennedy, D. Fitzgerald, R. Ryan Department of Rheumatology, Cork University Hospital, Cork, Ireland A leading cause of morbidity and mortality in patients with connective tissue diseases including systemic sclerosis is respiratory complications. The investigation of choice for diagnosing and evaluating pulmonary hypertension is right heart catheterization (RHC). Patient selection for this test is important given its invasive nature. We gathered data on all patients who underwent RHC with connective tissue disease in the previous 5 years. Using this data we validated a published formula for estimating pulmonary pressures non-invasively. mPAP = 136 – SpO2 – 0.25 9 DLCO % predicted 20 patients with connective tissue disease with clinical suspicion of pulmonary hypertension underwent RHC in the preceding 5 years. 16 patients had systemic sclerosis. Using RHC, 12 patients were diagnosed with pulmonary hypertension while 8 had normal pulmonary pressures. When we applied the published formula for noninvasively detecting pulmonary hypertension was applied, those with a predicted mPAP of [ 30 mmHg (n = 9) were at high risk of having RHC confirmed pulmonary hypertension. We validated an easily applied formula that identifies a subgroup with a high prevalence of pulmonary hypertension that could improve and simplify the selection of patients for RHC. References: 1. Schreiber BE, Valerio CJ, Keir GJ, Handler C, Wells AU, Denton CP John G (2011) Coghlan improving the detection of pulmonary
S457 hypertension in systemic sclerosis using pulmonary function tests. Arthr Rheum 63(11):3531–3539
3.20. National Pulmonary Hypertension Unit: the Evolving Role of Clinical Nurse Specialists in Ireland C. Minnock, D. Moran National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland The National Pulmonary Hypertension Unit (NPHU), established in 2003 at the Mater Misericordiae University Hospital, Dublin, ensures that patients with pulmonary arterial hypertension (PAH) receive appropriate inpatient and outpatient care. Two Clinical Nurse Specialists (CNS) manage the NPHU and provide clinical expertise to clients, families and healthcare providers. The CNS role is varied and includes running specialist nurse-led clinics, acting as advocates for patients, providing education to patients, co-ordinating clinical trials, facilitating vasoreactivity testing and supporting patients receiving complex medical therapies. In 2012, 128 patients attended the PH CNS outpatient clinic (85 in 2011). Admissions: the average length of stay has been reduced from 15 days in 2011 to 10.5 days in 2012. In-patient episodes: these have increased from 42 in 2011 to 49 in 2012. Reasons for admission: management of PAH worsening (51.1 %), PAH diagnosis (25.5 %), diagnosis/stratification of chronic thromboembolic pulmonary hypertension (12.7 %), initiation of prostacyclin therapy (10.6 %). Confirmation of PAH diagnosis by right heart catheterisation was conducted in 42 patients (as outpatients) in 2012 (35 in 2011). The pivotal role played by the CNS in delivering specialised patient care and expert advice at the NPHU could provide a good model for other specialist pulmonary hypertension services.
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4. Irish Thoracic Society Oral Presentations I Friday 15th November 2013 Chairs
C. O’Kane, Queens University Belfast A. O’Brien, Mid Western Regional Hospital, Limerick
4.1. Adherence to Inhalers After Discharge from Hospital Following an Exacerbation of COPD
85 % of all rare mutations detected. In addition, 2 novel null mutations were identified, Q0dublin and Q0cork. Rare mutations were detected in 1.5 % of individuals screened. Our findings underline the need for a comprehensive diagnostic work up of all patients with low AAT levels including phenotyping, genotyping and if necessary, DNA sequencing.
4.3. Alpha-1 Antitrypsin Inhibits Leukotriene B4 Mediated Respiratory Inflammation
B. Deering, N. MacCormack, K. Kerrigan, S. D’Arcy, R.W. Costello Beaumont Hospital, Dublin, Ireland Non-adherence to inhaler medication is a major problem in managing COPD. We used a novel audio recording device (INCA) attached to an inhaler, to assess both temporal and technique adherence. A cohort of 24 patients with COPD were recruited on discharge from Hospital to take part in this study. Each patient was given an INCA enabled inhaler to use over the course of a month, at the end of which the recordings of inhaler use were downloaded from the devices and analysed. A total of 912 inhaler events were recorded from the INCA devices. Overall, 40 % had less than 50 % adherence. The results indicated three types of patterns of inhaler use; adequate adherence was seen in 9. Six of 20 had [ 50 % errors in inhaler technique, and 5 omitted [ 40 % of doses. The overall rate of adherence was 0.41 ± 12. The use of an inhaler requires several steps to be performed in a co-ordinated manner, this relies on functional frontalstriatal regions of the brain, termed executive function. In this study, the median Montreal Cognition (MOCA) score for this cohort was 24 (9–30), with a strong inverse relationship of MOCA and adherence. In this pilot study on adherence in COPD patients there were low levels of adherence.
4.2. Rare Alpha-1 Antitrypsin Mutations in the Irish Population T.P. Carroll1, L. Fee1, C. O’Connor1, P. O’Brien2, I. Ferrarotti3, S. Ottaviani3, M. Luisetti3, N.G. McElvaney1 1 Alpha One Foundation, RCSI Education & Research Centre, Beaumont Hospital, Dublin 9, Ireland, 2Department of Biochemistry, Beaumont Hospital, Dublin 9, Ireland, 3Department of Biochemistry and Clinical Genetics, University of Pavia, Pavia, Italy
AAT deficiency (AATD) results from mutations in the AAT gene, classically presenting with COPD and liver disease. The most common mutation is the Z mutation (Glu342Lys), with S (Glu264Val) weakly associated with lung disease. AATD is under-diagnosed and prolonged delays in diagnosis are common. ATS/ERS guidelines advocate screening all COPD, poorly-controlled asthma, and cryptogenic liver disease patients, as well as relatives of known AATD individuals. Over 10,000 individuals have been screened following ATS/ERS guidelines as part of a national AATD targeted detection programme. AAT quantification is by immune turbidimetry and AAT phenotyping is by isoelectric focusing. Suspected rare and novel mutations are identified by DNA sequencing. A large number of rare AAT mutations including I, F, null (Q0), Mmalton, and Zbristol were identified. The I mutation (Arg39Cys) was the most common, with 96 cases identified, while the F mutation (Arg223Cys) was found in 32 cases. These two mutations account for
C.A. O’ Dwyer, N. Banville, N.G. McElvaney, E.P. Reeves Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland Neutrophil driven airway inflammation is a major factor in the pathology of chronic obstructive pulmonary disease (COPD) associated with alpha-1 antitrypsin (AAT) deficiency (AATD). Leukotriene B4 (LTB4) is a pro-inflammatory agent that contributes to the neutrophil burden in the airways. The aim of our study was to determine the ability of exogenous AAT to act as a novel LTB4 antagonist. Peripheral blood neutrophils were isolated from healthy control (n = 15) and AATD individuals (n = 15). IP3, Ca2+ levels and adhesion were assessed fluorometrically by stimulating cells with LTB4 (100 nM) in the presence or absence of AAT (27.5 lM). The impact of AAT on LTB4 induced neutrophil degranulation was analysed by Western blot analysis. The interaction between LTB4 and AAT was assessed spectrophotometrically. Our in vitro data indicates that AAT prevents LTB4 neutrophil signalling, as indicated by a lack of IP3 production, cytosolic Ca2+ flux, reduced cell adhesion and decreased levels of neutrophil degranulated myeloperoxidase, hCAP-18 and matrix metalloprotease 9 (markers of 1o, 2o and 3o granule release, respectively). The mechanism of inhibition involved direct binding of AAT to LTB4. The results of this study indicate that AAT can inhibit LTB4 neutrophil signalling and proposes AAT augmentation therapy as an effective treatment not only for AATD, but also for other LTB4 associated pulmonary diseases including cystic fibrosis and severe asthma.
4.4. Reducing Iatrogenic CO2 Narcosis in COPD Admissions: An Enhanced Early Warning Patient Safety Initiative E. Mulligan, R. Dickson, N. Chapman, R. Convery Respiratory Medicine, Craigavon Hospital SHSCT, Portadown, UK Background: The BTS & NPSA have published guidelines re Emergency oxygen use & specifically a target saturation range1,2. As part of a ‘Patient Safety Initiative’ in our department we aimed to reduce iatrogenic CO2 Narcosis in ambulance transfers and during the 1st hour Emergency Department treatment by 50 % & specifically minimise the use of high-flow O2 for COPD admissions. Methods: We prospectively surveyed patients over a 7 month period. Sequential NIAS & ED sheets reviewed for evidence of inappropriate levels of O2 ([ 4 litres/min) in patients eventually requiring NIV. 110 cases reviewed Aug’12–Mar’13. Results: Up to 50 % of all patients requiring NIV in our department have been given inappropriately high oxygen concentrations in ED or
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 in transit. The percentage of patients with high-flow fell from peak of 60 % to 30 % with improved education of ED staff. Outcomes: Phase 1. More visible warning bracelets are being provided to patients at risk of recurrent narcosis from Sep 2013. 2. Ongoing paramedic & ‘interface’ medical staff education programs are being developed locally as part of a patient & staff education care bundle. References: 1. BTS Emergency Oxygen use in Adult Patients (Thorax 2008) 2. National Patient Safety Agency 2009 Rapid Response Report
4.5. The Potential Role for Suppressor of Cytokine Signalling 1 in the Attenuation of Persistent Airway Inflammation in Asthma Subtypes E. Doran1, D.F. Choy2, A. Shikotra3, C.A. Butler1, J.A. Johnston1, P. Bradding3, J.R. Arron2, L.G. Heaney1 1
The Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK, 2ITGR Biomarker Group, Genentech Inc., South San Francisco, CA, USA, 3Glenfield Hospital, Leicester, UK Approximately 10 % of adult asthmatics suffer from severe disease and do not respond adequately to current therapies. The precise underlying mechanism associated with severe asthma remains unknown. Association of Th2 cytokines in propagating airway inflammation led us to investigate the expression of suppressors of cytokine signalling (SOCS) in the airways of asthmatics. Healthy controls (n = 17), mild/moderate asthmatics (n = 29) and well characterised severe asthmatics (n = 18) were recruited from 2 UK Specialist Centres (City Hospital, Belfast and Glenfield, Leicester). Bronchial mucosal biopsy specimens were collected from each recruit and the tissue was analysed by gene microarray analysis, qPCR and immunohistochemistry. SOCS1 mRNA was significantly lower in the airways of severe asthmatics compared to mild/moderate asthmatics (P = 0.024). There was no difference in SOCS2 or SOCS3 mRNA expression. Stratifying patients based on the presence of airway tissue eosinophilia demonstrated significantly reduced SOCS1 expression in this group (P = 0.0026). The level of Th2 inflammation in the airways negatively correlated with SOCS1 gene expression (rs = -0.37, P = 0.0023). SOCS1 mRNA expression in bronchial biopsies is significantly decreased in patients with severe asthma compared to those with mild/moderate disease. Persistent eosinophilia despite steroid treatment is associated with significantly reduced levels of SOCS1 expression in the bronchial biopsies of severe asthmatics.
4.6. An Audit of Nationwide Nurse—Led Asthma Clinics by the Asthma Society of Ireland F. Guiney, M. Llewellyn, D. Donaghy, C. Carrick, O. Behan Asthma Society of Ireland, 42-43, Amiens Street Dublin 1, Ireland Self management plans are currently advocated in international guidelines for the management of patients suffering from asthma. In our study we looked to investigate:
S459 • • • • •
the use of Asthma Management Plans the patient’s understanding of asthma medication assessment of inhaler technique referral to GP services number of patients with acute exacerbations in the last 12 months
A retrospective study of 520 patients attending nurse-led asthma clinics between January and June 2013 was carried out. The clinics were held in pharmacies, mobile units and regional clinics throughout Ireland. The ASI issued each asthma nurse with an ‘‘Asthma Patient Pre-Consultation Evaluation Form’’ to be completed by those attending the clinic. The data were extrapolated from completed forms. Quantitative analysis was undertaken • • • • • •
7 % had a management plan 60 % were referred to a GP 36 % had poor inhaler technique 28 % had poor understanding of ‘‘Role of both Reliever and Controller’’ 42 % had an asthma attack in the past 12 months 90 % did not have a good understanding of their asthma
The audit recognised that asthma management plans are not being used There is a high referral rate to GPs to review asthma control The results were reinforced by the high number of patients who had an asthma attack, poor inhaler technique and poor understanding of their condition.
4.7. Bronchial Thermoplasty for Severe Persistent Asthma P. Riddell1, I. Lawrie1, S. Zaidi1, S. Lane2, J.J. Egan1 1 Advanced lung disease and transplant programme, Mater Misericordiae University Hospital, Dublin, Ireland, 2Department of Respiratory Medicine, Adelaide and Meath Hospital, Dublin, Ireland
Bronchial thermoplasty (BT) is a minimally invasive bronchoscopic technique which reduces bronchial smooth muscle mass, leading to reduced airway hyper-responsiveness and improved symptom control. We sought to describe our early experience with this technique. An audit of all asthmatics that have undergone BT at our centre was performed. Detailed demographic, clinical and therapeutic data was collected for each patient. Asthma quality of life questionnaires (AQLQ) and pulmonary function tests were completed prior to each treatment and follow up appointment. Two-tailed student’s t-tests with last observation carried forward analysis were used for statistical evaluation. Unless stated, data is expressed as mean ± standard deviation. Six patients completed BT. Age 54.4 ± 15.4 years. Mean FEV1 prior to BT was 64 % predicted. No significant difference in FEV1 was seen following BT. Over the course of three sessions, 96 ± 25.7 thermal activations were performed per patient. Significant improvements in AQLQ scores were seen 3 months after the completion of BT (p = 0.074). AQLQ improvements were maintained at 12 months. There was a trend towards a reduction in exacerbation frequency, as well as lower prednisolone requirements. Although a small sample, our data supports the use of BT in the management of severe persistent asthma.
4.8. Human Rhinovirus Up-regulates Transient Receptor Potential Channels in a Human Neuronal Cell Line: Implications for Virus Induced Cough Reflex Sensitivity H. Abdullah, L. Heaney, S.L. Cosby, L. McGarvey Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7AE, UK
4.9. Is Emphysema a Fibrotic Lung Disease? A. Fabre1, M.J. Narski2, D. Healy2,3, I. Lawrie3, M. Keane4, J. Egan3, M. Butler4 1
Department of Histopathology, St Vincent’s University Hospital, Dublin 4, Ireland, 2Department of Thoracic surgery, St Vincent’s University Hospital, Dublin 4, Ireland, 3National Lung Transplant Programme, Mater Misericordiae Hospital, Dublin 7, Ireland, 4 Department of Respiratory Medicine, St Vincent’s University Hospital, Dublin 4, Ireland Fibrosis with emphysema occur in either combined pulmonary fibrosis (UIP type) with emphysema or in localised fibrosis as part of emphysema or related to respiratory bronchiolitis (smoking related interstitial fibrosis -SRIF). We undertook a clinico-pathological analysis of non-cancerous lung tissue extensively sampled on surgical specimens for lung cancer (n = 20) and emphysema explanted lungs (n = 10, COPD = 5, a1anti-trypsin deficiency = 5), to assess the occurrence of SRIF, emphysema, smoking related small airway disease.
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 All 20 cases of lung cancer were prospectively included, 90 % were stage 1A/B disease, all were smokers/ex-smokers with various degree of obstructive disease. A SRIF histological pattern of fibrosis was observed in 40 % of cases, at distance from peripheral pulmonary adenocarcinomas and associated with emphysema, respiratory bronchiolitis and smoker’s macrophagic alveolitis. Similar gender and age distribution was seen in both SRIF and non-SRIF groups. SRIF was observed in 87.5 % of the cases in the right lung, and in 62.5 % in the right upper lobe. Transplant cases for emphysema (either a1anti-trypsin deficiency or COPD) were used as controls and SRIF was seen in 3/5 COPD cases and 0/5 a1AT deficiency. In summary, interstitial fibrosis associated with emphysema and small airway disease is a common feature in lungs of current/exsmokers.
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5. Irish Thoracic Society Paediatric Forum Friday 15th November 2013 Oral Presentations Chairs
B Linnane, Mid Western Regional Hospital, Limerick D. Cox, Our Lady’s Children’s Hospital, Crumlin, Dublin, Ireland
5.1. Congenital Thoracic Malformations—The Northern Ireland Experience from 1994 to 2011 E.A. Gorman1, S Thavagnanam2, J.P. Houghton1, A Dick2, A Patterson2, M.D. Shields1,2 1 School of Medicine, Queen’s University Belfast, Belfast, UK, 2Royal Belfast Hospital for Sick Children, Belfast, UK
5.2. Is a Single Overnight Pulse Oximetry Recording at Home Adequate for Hypoxaemia Screening? C. Hunter1,2, R. Verma1, B. Maxwell 1, D. O’Donoghue1,2, M.D. Shields1,2
S461 obstructive sleep apnoea (OSA) affects approximately 3 % of children with a considerably higher prevalence in certain groups such as children with Down Syndrome. In line with the increased recognition of SRBD there has been a marked increase in demand for sleep services internationally. We determined the current awareness of SRDB amongst Irish paediatricians via a questionnaire and examined the provision of sleep services to children throughout the country between 2007 and 2011. In addition we audited diagnostic sleep services in a single tertiary centre during 2011. There was a poor response rate to the questionnaire (18 %) likely reflecting discomfort with the subject matter among some respondents. Among respondents there was a reasonable awareness of SRDB but a poor understanding of diagnostic evaluation. There has been a very sharp increase in both diagnostic sleep tests (414 %) and the use of non-invasive ventilation (NIV) for treatment of SRBD between 2007 and 2011 in Ireland. There has been no corresponding increase in resource allocation to this area. Appropriate use of abbreviated testing modalities such as domiciliary overnight oximetry reduced by 70 % the requirement for more formal polysomnography in a tertiary setting. A clearly structured national paediatric sleep service is required in order to optimise the diagnosis and management of paediatric SRBD in Ireland.
1 Royal Belfast Hospital for Sick Children, Belfast, UK, 2Queen’s University Belfast, Belfast, UK
Little research has been performed regarding the need for routine screening oximetry monitoring on a single night or whether several nights are required when testing for hypoxaemia. A single night’s screening would be less burdensome especially for annual assessments of children with Down’s syndrome (DS) and neuromuscular disorders. We retrospectively studied overnight oximetry traces from 145 children who had 3 consecutive nights recorded. We compared the concordance and agreement of the first nights basal oxygen saturation, percentage time with O2 saturation less than 90 %, and the adjusted ‘dips’ per hour with the subsequent night traces. The overall intraclass correlation was 0.5 for basal oxygen saturation, 0.87 for adjusted dips, 0.62 for time oxygen saturation below 90 % and 0.51 for duration of technically satisfactory monitoring. Down syndrome did not appear to be associated with poorer absolute agreement compared with other groupings (neuromuscular, cerebral palsy, craniofacial abnormalities and normal children with large tonsils/adenoids). Only moderate concordance was detected between the 1st trace and subsequent nocturnal traces for the important basal oxygen saturation, and time saturation below 90 %. This suggests that some results were discrepant and potentially wrong decisions could have been made if only the first trace had been obtained.
5.3. The Diagnosis and Treatment of Sleep Related Breathing Disorders in Children in Ireland 2007–2011: Recognition of an Unmet Healthcare Need A. Walsh, F. Phelan, M. Phelan, M. Ryan, F. Healy, D. Slattery, B. ElNazir, P. Greally, B. Linnane, M. Ni Chroinin, D. Mullane, M. Herzig, D. Cox, S. Javadpour, P. McNally Our Lady’s Children’s Hospital Crumlin, Temple Street Children’s University Hospital, The Adelaide and Meath Hospital Incorporating the National Children’s Hospital, Mid-Western Regional Hospital Limerick, Cork University Hospital, Galway University Hospital, Galway, Ireland Sleep related breathing disorders (SRBD) are very common in children and are increasingly recognised in recent years. Paediatric
5.4. Accommodating Interruptions: A Grounded Theory of Adolescent Asthma M. Hughes Doctoral Candidate, Lecturer Practitioner, School of Nursing and Midwifery University College Cork, Cork, Ireland Background: The incidence of asthma among adolescents in Ireland is increasing according to the Irish ISAAC data, 18.9 % of 13–15 years olds have asthma with 10 missed school days per year on average (Kabir, Manning et al. 2011). Inadequate management of asthma symptoms is the cause of unnecessary morbidity for adolescents and places an unnecessary burden on the health service It is also known that adolescents are less likely to seek medical assistance in an emergency (Rhee Hyekyun 2009). This suggests poor understanding and management of symptoms, or poor adaptation to living with the symptoms of asthma. Aim: Gaining an insight into the impact of asthma on their daily lives could play a significant role in developing treatment guidelines and management plans that are relevant to adolescents. Methods: Classical Grounded Theory approach was used. It is an advanced methodology with the ultimate goal of developing theoretical explanation of behaviours. In-depth interviews were conducted in participants own homes and optional completion of 2 week asthma diary. The theory emerged by using constant comparative analysis and theoretical coding. Results: Adolescents accommodate multiple interruptions caused by asthma into their lives. They assimilate behaviours to reduce the impact of the disease, associated symptoms and treatment burden in order to be accepted and included in daily life. Conclusion: This theory will allow HCPs to develop ways of meeting distinct needs of adolescents, potentially improve their symptom control and reduce associated morbidity and mortality rates. It is currently being used to develop an adolescent educational package for the Asthma Society of Ireland. References: 1. Kabir Z, Manning P et al (2011) Prevalence of symptoms of severe asthma and allergies in Irish school children: an ISAAC
S462 protocol study, 1995–2007. Int J Environ Res Public Health 8(8):3192 2. Rhee Hyekyun MJBSCJB (2009) Barriers to asthma selfmanagement in adolescents: relationships to psychosocial factors. Pediatric Pulmonol 44(2):183–191
5.5. Evaluation of the Effectiveness of a Pilot Transition Year Asthma e-learning Programme M. Hughes (2013) Research and Education Consultant Asthma Society of Ireland, 42-43, Amiens Street, Dublin 1, Ireland The aim of our research was to create an on-line programme to increase awareness of asthma and symptom management among transition year students. On-line learning is an accepted medium for teaching today’s adolescents. Providing the programme as part of transition year facilitates access to health information that is reliable, safe, convenient, and evidence-based,—this makes it an attractive option for adolescents (Franck 2008). Improving awareness about asthma facilitates an openness to allow students with asthma manage their symptoms more effectively. Based on data from the ISAAC study it is highly probable that a large percentage of students in each class in school have asthma and are required to manage symptoms while away from home. A pilot study is currently under way in the Kinsale Community School covering 120 students, due to finish on September 3rd. A pretest/post-test design (Kitner 1996) will be used to evaluate the effectiveness of the programme aimed at improving students’ knowledge. The effectiveness of the educational intervention will be presented. Any revisions for the National Transition Year Asthma E-learning Programme will be suggested. References: 1. Franck LS (2008) Young people’s views on a health website. Paediatric Nursing 20(1):10–10 2. Kintner EK (1996) Testing of the school-aged child and adolescent acceptance of asthma model. Doctoral Dissertation, The University of Arizona, Tucson, AZ
5.6. A Prospective, Randomised, Open Labelled Trial to Examine the Clinical Efficacy of an Oral Nutritional Supplement (ONS) with Regards to Improving the Nutritional Status of Undernourished Children (2–10 years) over 6 weeks M. O’ Reilly1, S. Boland1, D. Slattery2, F. Ward1 1 Department of Nutrition & Dietetics, Children’s University Hospital Temple Street, Dublin 1, Ireland, 2Respiratory Department, Children’s University Hospital Temple Street, Dublin 1, Ireland
Currently 9 % of hospitalised children are underweight1. While ONS are commonly prescribed with good effect in adults there is a lack of studies examining their efficacy and compliance in children. Randomised controlled trial undertaken to investigate the effect of ONS with dietetic counselling (treatment group) versus dietetic
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 counselling alone (control). The study also examined compliance rates with ONS. At baseline there were a total of 67 children with comparable age, body weight, calorie, protein or fluid. They were assessed again at 2 further visits. The control and treatment groups calorie and protein intake and weight were compared at baseline, visit 2 and 3, in both groups there was a trend for an increase between visits. Calorie intake was significantly greater at visit 2 and 3 than baseline (p \ 0.001 and p = 0.001) in both groups. All groups across the visits fluid intake was below the recommended daily amount. Mean compliance with the prescribed 2 9 200 ml/d ONS was 45 %. Mean number of supplements taken was 14 equivalent to \ 50 % of the prescribed volume of supplement taken daily. This study reinforces that dietary counselling should remain first line treatment. Further studies are required reviewing factors affecting compliance in children (e.g. prescribed volume, palatability). References: 1. A report by the University of Ulster, Nutrition screening week survey and audit, UK and Ireland, (2011)
5.7. Outpatient Parenteral Anti-Microbial Therapy (O.P.A.T) a Report of Three years Experience in an Irish Paediatric Respiratory Unit A. Murphy, S. Connor, O. Ameerheen, F. Healy, D.M. Slattery Respiratory Unit, Children’s University Hospital Temple Street, Dublin 1, Rep of Ireland Paediatric O.P.A.T is being practiced more widely, internationally in recent years. However, there is a paucity of data regarding its outcomes. A retrospective analysis over 3 years (January 2010–2013) was performed in a tertiary paediatric respiratory unit which runs an OPAT programme. Retrospective study data collected from hospital records and both pharmaceutical companies who supplied all the antimicrobials. Patient population: Children well known to the Respiratory/C.F team with cystic fibrosis or immune deficiency. 362 courses were administered to 32 children, 30 of whom had cystic fibrosis and 2 had recurrent pneumonia. A total of 3,688 days of antibiotics were administered. The median age was 8.8 years (range 2.75–17.8 years). Sixteen (50 %) were male. Each child received an average of 11 courses. Median duration of O.P.A.T. was 10 days (range 2–21 days). Tobramycin was the commonest antimicrobial prescribed, with ceftazidime second. There was one readmission (0.3 %) and 3 (2 %) portacath infections. All patients attended for weekly clinical review by the respiratory/CF team and for weekly laboratory monitoring. Our results compare favourably to international colleagues1. Our study demonstrates that O.P.A.T. in paediatrics, if conducted in accordance with national2 and international standards appears safe, effective and reduces the need for inpatient beds. References: 1. Htin AK, Friedman ND, Hughes A et al (2013) Outpatient parenteral antimicrobial therapy is safe and effective for the treatment of infective endocarditis : a retrospective cohort study. Intern Med J. [doi:10111 epub ahead of print 2. Gallagher D, O’Reilly A, Fitzpatrick F, Slattery DM et al Outpatient Parenteral antimicrobial therapy in Ireland: practice standards.
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5.8. Prevalence and Treatment of Pseudomonas aeruginosa in children with Cystic Fibrosis attending Cork University Hospital
5.10. Pulmonary Aspiration of Gastric Contents in Preschool Children with Cystic Fibrosis (CF) I. Gorman1,2, D. Clarke2,5, F. Ringholz2,5, B. Linnane2,3,4, P. McNally1,2,5
E. Barry, D. Mullane Dept of Paediatrics and Child Health, University College Cork Paediatric Department, Cork University Hospital (CUH), Cork, Ireland
1 Trinity College Dublin, Dublin 12, Ireland, 2National Children’s Research Centre, Crumlin, Dublin 12, Ireland, 3University Hospital Limerick, Limerick, Ireland, 4University of Limerick, Limerick, Ireland, 5Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland
5.11. Annual Modified Shuttle Walk Test in Clinically Stable Children with Cystic Fibrosis 5.9. A 4 year Review of Bronchoalveolar Lavage (BAL) Surveillance Carried out in Preschool Aged Children with Cystic Fibrosis B. Treston1, D. Clarke1,2, R. Millar1,2, F. Ringholz1,2, D. Cox1,2, A. Zaid1, B. Elnazir3, P. Greally3, B. Linnnane2,4, P. McNally1,2 1
Department of pediatric respiratory medicine, Our Lady’s Children’s Hospital, Crumlin (OLCHC), Dublin 12, Ireland. 2National Children’s Research Centre, Our Lady’s Children’s Hospital Crumlin, Dublin 12, Ireland, 3The Adelaide and Meath Hospital Dublin, Incorporating The National Children’s Hospital, Dublin 24, Ireland, 4University Hospital Limerick, Co Limerick, Ireland BAL surveillance with concurrent oropharyngeal swabs (OPS) occurs annually at OLCHC in CF preschool children. Studies have shown that OPS can predict BAL cultures, however their accuracy is questionable (1). Free neutrophil elastase (fNE) in BAL early in life is a risk factor for bronchiectasis at an earlier age (2). The primary aim was to investigate the correlation between BAL and OPS cultures in an Irish CF paediatric population. The secondary aim was to determine whether routine indices (e.g.: percent neutrophil counts (%NC)) could predict the presence of fNE in BAL. BAL and OPS cultures were analysed as per standard local practice. Inflammatory and cellular analyses were performed through the SHIELD-CF study as previously described. 107 BAL and OPS pairs were analysed. The positive predictive value, negative predictive value, specificity, sensitivity and prevalence were: P. aeruginosa 0.5, 0.98, 97 %, 60 %, 4.6 %; S. aureus 0.77, 0.887, 95 %, 58 %, 22 %; H. influenza 0.70, 0.688, 92 %, 30 % 37 %; S. pneumonia 0.4, 0.91, 95.8 %, 18 %, 10 %; Normal Flora 0 0.676, 0.333, 2 %, 97 %, 68 %. Increased fNE was associated with a higher %NC on cytology; however %NC did not predict the presence of fNE in BAL. OPS cultures are incompletely representative of BAL cultures. %NC alone cannot predict fNE in BAL. References: 1. Rosenfeld M, Emerson J, Accurso F, Armstrong D, Castile R, Grimwood K, Hiatt P, McCoy K, McNamara S, Ramsey B, Wagener J (1999) Diagnostic accuracy of oropharyngeal cultures in infants and young children with cystic fibrosis. Pediatr Pulmonol 28(5):321–328 2. Sly PD, Gangell CL, Chen L, Ware RS, Ranganathan S, Mott LS, Murray CP, Stick SM; AREST CF Investigators (2013) Risk factors for bronchiectasis in children with cystic fibrosis. N Engl J Med 368(21):1963–1970
M. Gilbourne, K. Ingoldsby, P. McNally Cystic Fibrosis Centre, Department of Respiratory Medicine, Our Lady’s Children’s Hospital Crumlin, Dublin, Ireland Cystic Fibrosis (CF) is a chronic genetic disease characterised by progressive respiratory failure. Forced Expiratory Volume in the 1st second (FEV1), is the most commonly used outcome measure for pulmonary disease. The Modified Shuttle Walk Test (MSWT) is a validated test used to assess exercise capacity. Currently there is no normative data for MSWT distance in children. The aim of this audit was to determine mean MSWT distance in clinically stable children with CF and measure correlation between MSWT distance and age, height, weight, BMI and pulmonary function parameters. MSWT data (distance, oxyhaemoglobin saturations, heart rate, Borg score) collected at CF annual assessments August 2008–March 2013 were analysed. Lung function data were collected from the patients’ files. Data were stored on Microsoft Excel. Data were analysed using Graph Pad Prism Software. 336 MSWTs were carried out at annual assessments (4–18 yr olds). Mean MSWT distance was 854 metres and generally increased with age until teenage years. Statistically significant correlations were seen between MSWT distance and FEV1 (%), FEV1 (L) (Fig. 1), age, height, weight, and body mass index. MSWT distance is strongly correlated with FEV1. We have gathered mean values for all age groups which will enable us to benchmark and track pulmonary exercise capacity in future years. Normative data is required to enable us to use MSWT distance as a reliable measure of clinical pulmonary status. We are planning a school based study of MSWT distance in healthy children.
S464 References: 1. Bradley J, Howard J, Wallace E, Elborn S (1999) Validity of the modified shuttle test in adult cystic fibrosis. Thorax 54:437–439 2. Rogers D, Smith P, John N, Oliver W, Doull IJM (2002) Validity of a modified shuttle walk test as a measure of exercise tolerance in paediatric CF patients. J Cyst Fibros. 1(Suppl. 1):22 (abstract)
5.12. Resolvin D1 Restores Airway Surface Liquid Hydration and Attenuates IL8 Secretion in Cystic Fibrosis (CF) Bronchial Epithelial Cells F.C. Ringholz1, A. Moukachar2, G. Higgins1, P. McNally1,3, V. Urbach1,4 1
Respiratory Research, National Children’s Research Centre, Crumlin, Dublin, Ireland, 2Universite´ Pierreet MarieCurie, Paris VI, France 3Respiratory Medicine, Our Lady’sChildren’sHospital, Crumlin, Dublin, Ireland, 4INSERM, U845, Faculte´de Me´decine Paris Descartes, Paris, France CF is caused by a mutation in the Cystic Fibrosis Transmembrane Conductance Regulator which results in airway surface liquid (ASL) dehydration, impaired muco-ciliary clearance and chronic pulmonary infection and inflammation leading to progressive lung destruction. Resolvin D1 (RvD1) is a Docosahexaenoic acid derived lipid mediator which effects the resolution of inflammation (1) and attenuates LPS induced lung inflammation by suppressing NFjB activation (2). NuLi-1 (normal genotype) and CuFi-1airway epithelial cells (D508/D508) were grown as polarised, differentiated bronchial epithelia. Cells were treated with vehicle control or RvD1 1 nM or 100 nM (30 min for ASL/overnight for IL8 experiments). The ASL was stained with Texas red-dextran and imaged by live-cell confocal fluorescence microscopy. IL8 secretion was induced by TNFa or heat inactivated P. aeruginosa. Apical IL8 concentration was measured by ELISA. ASL height measured 7.2 lm in NuLi-1 cells. CuFi-1 cells demonstrated reduced ASL height at 5.8 lm and disrupted architecture. RvD1 1 nM and 100 nM restored ASL height in CuFi-1 cells to 7.1 lm* and 8.1 lm** respectively (*P \ 0.05/**P \ 0.01, Student t test). RvD1 100 nM attenuated TNFa induced IL8 secretion by CuFi1 cells. Resolvin D1 restores airway surface liquid architecture and attenuates pro-inflammatory IL8 secretion by CF bronchial epithelial cells, suggesting therapeutic potential in CF lung disease. The authors acknowledge grant support from the National Children’s Research Centre, Health Research Board of Ireland and the French National Institute of Health (INSERM). References: 1. Serhan CN, Hong S, Gronert K, Colgan SP, Devchand PR, Mirick G et al (2002) Resolvins: a family of bioactive products of omega-3 fatty acid transformation circuits initiated by aspirin treatment that counter proinflammation signals. J Exp Med 196(8):1025–1037. Epub 2002/10/23 2. Liao Z, Dong J, Wu W, Yang T, Wang T, Guo L et al (2012) Resolvin D1 attenuates inflammation in lipopolysaccharideinduced acute lung injury through a process involving the PPARgamma/NF-kappaB pathway. Respir Res 13:110. Epub 2012/12/04
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5.13. Prospective Audit Examining the Resting Energy Expenditure (REE) of Children with Cystic Fibrosis (CF) M. O’Reilly, C. Dempsey, A. Murphy, F. Healy, D. M. Slattery Department of Respiratory Medicine, Children’s University Hospital, Temple St, Dublin, Ireland REE represents the calories required over a 24-h period by the body during an inactive period. REE is 10–20 % greater in CF patients than in healthy controls. The objective of this study was to evaluate parameters that may influence REE. REE was measured with indirect calorimetry in 35 patients (females = 12) at respiratory baseline (9.5–15.2 years). Mean REE was 107 % predicted. The increase was greater in females (110 %) than males (102 %). There was no significant difference in REE in the pubertal group. A small positive association was found between age and REE and between FEV1 and REE. Increased weight was associated with higher REE. There was no association between height and REE. Those with PEG tubes (12/35) had a lower FEV1 (60 % V 91 %), and a lower REE than those without (105 v 115). Our study concurs with others internationally in that REE appears elevated in CF, particularly in females. In contrast with our international colleagues, our overall REE results are lower than those in other studies. Potentially those with PEG have lower REE due to reduced physical effort secondary to poor lung function. REE may be useful to help guide calorie requirements in individual CF patients. References: 1. Vaisman N et al (1987) J Pediatr 111:496–500 2. Buchdahl RM et al (1988) J App Phys 64:1810–1816
5.14. Sweat Tests in Ireland 2011 V. Tsang1, A. Roman1, R. Ghori1, S. Whelan1, P. Mayne3, G Boran2, O. Blake1. B. Linnane1 1
Paediatric Cystic Fibrosis Unit and Department of Biochemistry, Mid-Western Regional Hospital (MWRH), Limerick, Ireland, 2 Department of Clinical Chemistry, Tallaght Hospital, Dublin 3, Ireland, Department of Biochemistry, Children’s University Hospital, Temple St, Dublin, Ireland Background: Sweat testing is the gold standard diagnostic test for cystic fibrosis (CF). The current pattern of sweat testing in Ireland is not known. Methods: Hospitals contained in the HSE hospital directory, along with private hospitals, were contacted directly to ascertain if sweat tests were performed in that centre during the calendar year 2011. A detailed questionnaire was completed by the head of biochemistry, and de-identified sweat test data was collated. Results: In 2011 15 centres performed sweat tests; 13 public hospital, and 2 private hospitals. Between January and December 2011 2,555 sweat tests were performed. Data was missing on 13 studies, leaving 2,542 with sweat chloride and/or conductivity data for analysis. Sweat chloride and conductivity were both reported in 813 tests, with 143 tests, from two centres, reporting conductivity alone. In 445 tests it was not possible to ascertain if the test was a repeat. In the remaining 2,110 tests, 213 (10.1 %) were repeats. Of these, 182 represented a second test, 25 were a third test, 5 were a fifth test, and 1 child had 5 attempts. Overall QNS was reported in 234 (9.2 %) tests. There was wide variability in reporting QNS, resulting in a QNS rate ranging from 0 % to 28.3 %. Sweat test data detected 2057 sweat Chloride \ 40 mmol/l, 43 were 40–60 mmol/l, 65 were[ 60 mmol/l, 234 were QNS.
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6. Oral Presentations II Friday 15th November 2013 Chairs
M. Henry, Cork University Hospital J. Rendall, Belfast City Hospital, Belfast
6.1. Detection of High Sensitivity Troponin in Outpatients with Stable Pulmonary Hypertension Identifies a Subgroup at Higher Risk of Adverse Outcomes A.K. Roy1,2, B.N. McCullagh1,2, C. Mc Gorrian1,2, E. Keane3, J. Keaney1,2, M. Fitzgibbon1, N.G. Mahon1,2, P.T. Murray1,2 S.P. Gaine 1,2 1
Mater Misericordiae University Hospital, Dublin 7, Ireland, University College Dublin, Dublin 4, Ireland, 3 Beaumont Hospital, Dublin, Ireland
The detection of elevations in cardiac biomarkers, such as troponins and brain natriuretic peptides, are associated with poor outcomes in patients hospitalized with acute heart failure. Less is known about the association of these markers with adverse events in chronic right ventricular dysfunction due to pulmonary hypertension, and whether their measurement may improve risk assessment in the outpatient setting. We performed a cohort study of 108 patients attending the National Pulmonary Hypertension Unit in Dublin, Ireland, from 2007–2009. Cox proportional hazards analysis and receiver operating characteristic curves were used to determine predictors of mortality and hospitalization. Death or hospitalization occurred in 50 patients (46.3 %) during the median study period of 4.1 years. Independent predictors of mortality were- (i) decreasing 6-min walk test (6 MWT) (hazard ratio [HR] 12.8; p \ 0.001), (ii) Brain Natriuretic Peptide (BNP) (HR: 6.68; p \ 0.001), and (iii) highly sensitive troponin (HsTNT) (HR: 5.48; p \ 0.001). Adjusted hazard analyses remained significant when highly sensitive troponin was added to a model with BNP and 6 MWT (HR 9.26; 95 % CI, 3.61, 23.79), as did the predictive ability of the model for death and rehospitalization (AUC 0.81; 95 % CI, 0.73, 0.90). Detection of troponin using a highly sensitive assay identifies a pulmonary hypertension subgroup with a poorer prognosis. HsTNT may also be used in a risk prediction model to identify patients at higher risk who may require escalation of targeted pulmonary vasodilator therapies and closer clinical surveillance.
6.2. Lung Function Abnormalities and Structural Lung Disease in Adult Survivors of Bronchopulmonary Dysplasia S. Caskey1, S. Gillespie2, J. Clarke2, H. Halliday3, M. Shields1, L. McGarvey1 1
Centre for Infection and Immunity, Queen’s University Belfast, Belfast, N. Ireland, 2Imaging Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK, 3Regional Neonatal Unit, Royal Maternity Hospital, Belfast Health and Social care Trust, Belfast, UK Bronchopulmonary dysplasia (BPD) in neonatal life may predispose to chronic lung disease in adulthood. We aimed to
S465 characterise the nature and extent of lung function and structural lung abnormalities on high resolution computed tomography (HRCT) of chest in adult survivors of BPD compared with adults born preterm without BPD. 21 BPD adults and 23 preterm non BPD subjects underwent full lung function and HRCT scanning of chest. A validated scoring tool was used to assess HRCT1 scans. 25 full term controls also underwent full lung function. For all spirometric end points, BPD adults had significantly lower values than full term peers (p \ 0.05). A greater proportion of BPD adults had obstructive spirometry compared with both control groups. Transfer factor and KCO values were significantly lower in BPD adults. Mean HRCT scores were more severe in BPD adults. This was significant when corrected for birthweight and gestational age. All adult survivors of BPDs had abnormalities present on HRCT. Subpleural opacities were present in 95 %, airtrapping in 70 %, bullous disease in 25 % and mosaic perfusion in 20 %. Lung function and parenchymal abnormalities persist in adult survivors of BPD. Respiratory physicians should be aware of neonatal insults impacting on long term respiratory outcomes. References: 1. Aukland SM et al (2009) Neonatal bronchopulmonary dysplasia predicts abnormal pulmonary HRCT scans in long-term survivors of extreme preterm birth. Thorax 64:405–410
6.3. CXCR3 is Required for the IL-13 Mediated Upregulation of IL-13Ra2 in Pulmonary Fibroblasts J.C. Barnes1, R.V. Lumsden1, S.M. Walsh1, J.C. Worrell1, J.A. Belperio4, A. Fabre3, D. Boylan1, R. Kane1, M.P. Keane1,2 1 UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland, 2Department of Respiratory Medicine, St. Vincent’s University Hospital and School of Medicine and Medical Science, Elm Park, Dublin 4, Ireland, 3Department of Pathology, St. Vincent’s University Hospital and School of Medicine and Medical Science, Elm Park, Dublin 4, Ireland, 4Division of Pulmonary and Critical Care Medicine, Dept of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease characterized by fibrosis. IL-13, a profibrotic cytokine that plays a role in IPF, induces the expression of, and binds to, one of its receptors, IL-13Ra2, which is thought to function as decoy receptor. CXCR3 has also been implicated in the development of IPF. CXCR3 knockout mice display increased fibrosis, compared to wildtype mice, in the bleomycin model of fibrosis. We have previously shown significant rises in the expression of CXCR3 that corresponded to early IL-13Ra2 expression following lung injury. This study used pulmonary fibroblasts isolated from wild type and CXCR3-/- mice. These fibroblasts were characterised and stimulated with IL-13. RNA and protein were isolated. Quantitative PCR and western blotting were performed. Functional assays; migration, proliferation and collagen production were performed. CXCR3 expression was demonstrated in cultured fibroblasts from wild-type mice, and was found to be necessary for IL-13 mediated upregulation of IL-13Ra2. CXCR3-/- fibroblasts attenuate upregulation of IL-13Ra2 in response to IL-13. Stimulation of fibroblasts with IL-13 resulted in increased collagen production and this effect was augmented in CXCR3-/- fibroblasts. This study is the first to demonstrate the expression of CXCR3 in fibroblasts and its relationship with the expression of IL-13Ra2.
6.4. The CXCR3 Ligands CXCL9, CXCL10 and CXCL11 Up-regulate IL-13Ra2 in NIH-3T3 Fibroblasts
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 The Algorithm (Which will be presented) has shown in the reaudit that judicious use of IHC does not adversely affect tumour subtyping, helps to preserve tissue whilst also being cost effective.
J.C. Worrell1, R.V. Lumsden1, J.C. Barnes1, S.M. Walsh2, D.A. Boylan1, R. Kane1, M.P. Keane2 1
UCD Conway Institute of Biomolecular and Biomedical research, University College Dublin, Belfield, Dublin 4, Ireland, 2Department of Respiratory Medicine, St Vincent’s University Hospital and School of Medicine and Medical Science, UCD Conway Institute, University College Dublin, Belfield, Dublin 4, Ireland Idiopathic pulmonary fibrosis (IPF) is a chronic progressive form of idiopathic interstitial pneumonia, characterized by fibrosis. The chemokine ligands CXCL9, CXCL10 and CXCL11 have been implicated in vascular remodelling and fibroblast motility during the development of pulmonary fibrosis and their receptor CXCR3 (7 trans-membrane domain GPCR) has been shown to have a nonredundant role in limiting fibrosis following lung injury. IL-13 is a pro-inflammatory cytokine that mediates the development of fibrosis and it can induce expression of and bind to its own receptor IL13Ra2. IL-13Ra2 is proposed to act as a non-signalling decoy receptor. In this study, NIH-3T3 fibroblasts were treated with various cytokines, and the expression of IL-13Ra2 and CXCR3 were measured. The functional impact of overexpressing CXCR3 by transfection in these fibroblasts was also examined. We have shown that NIH-3T3 fibroblasts express CXCR3.The ligands CXCL9, CXCL10 and CXCL11 up-regulate the expression of IL-13Ra2 in NIH-3T3 fibroblasts and IL-13 has been shown to negatively regulate CXCR3 expression. The up-regulation of IL13Ra2 has no effect on soluble collagen synthesis. Elucidating the link between the regulation of both CXCR3 and IL-13Ra2 by IL-13 and further investigation of the signalling mechanisms involved may reveal new therapeutic targets in acute lung injury.
6.5. Judicious use of Immunohistochemistry for Lung Cancer Diagnosis
6.6. Unexpected Findings on PET/CT in the Investigation of Suspected Lung Cancer C. McKinney, M. Doherty, M. Kelly, T. Mc Manus, A. Aziz, R.A. Sharkey, M. McCloskey Respiratory Department, Altnagelvin Hospital, Derry, BT 47 6SB, N Ireland NICE and BTS guidelines recommend PET/CT (positron emission tomography) imaging for the staging of operable lung cancers, assessment of solitary pulmonary nodules and for patients who are to undergo radical radiotherapy (NICE 2011, BTS 2010). We performed a retrospective audit of all those patients referred by the Respiratory Department WHSCT for PET/CT imaging between 1/1/2013 and 31/5/13. 42 patients (19 male, 23 female) were referred—Mean age 62 years, range 23–86 years. Of the total of 42 patients, 18 (42.86 %) had unexpected findings on their PET scan, 17 (94.44 %) of which required further investigation, ultrasound/biopsy neck nodes 6 (14.29 %), barium small bowel series 2 (4.76 %). Other further investigations included colonoscopy, ultrasound testes, skin biopsy, MRI. 10 (23.8 %) out of the 42 were diagnosed with a disease other than primary lung cancer- these included 3 (7.14 %) Gastro-intestinal malignancies, 2 (4.76 %) Carcinoid tumours, I (2.3 %) Tuberculosis I (2.3 %) Metastatic breast cancer and 3 (7.14 %) other benign conditions. This audit confirms that PET imaging, in the investigation of potential lung cancer, results in additional investigations and the discovery of other pathology in a significant number of patients. References: 1. NICE (2011) Lung Cancer, The Diagnosis and Treatment of Lung Cancer. CG121. NHS. 2. BTS (2010) Guidelines on the Radical Management of Patients with Lung Cancer. http://www.thoraxjnl.com
C. Fives1, J. McCarthy1, N. Mayer1, M. Kennedy2, M.T. Henry2, T.M. O’Connor3, D. Curran3, L. Burke1 1
Department of Histopathology, Cork University Hospital, Cork, Ireland, 2Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland, 3Department of Respiratory Medicine, Mercy University Hospital, Cork, Ireland In the era of targeted therapy, judicious use of immunohistochemistry (IHC) on small lung biopsy/cytology specimens is necessary to ensure accurate tumour sub-typing whilst conserving tissue for molecular analysis where required. The aim of our study was to define an evidence based algorithm for directing IHC use on these specimens to achieve these two goals. International guidelines where applicable were also consulted. Based on the data from an audit in 2012 of 318 patients who underwent lung biopsy, cytological evaluation and/or resection in 2011, an algorithm was proposed. A repeat audit was performed, spanning again a years data, to review the impact on our service. Following the implementation of the Algorithm we noted a 19 % reduction in our use of IHC. Despite using less IHC, 100 % concordance rates between biopsy/cytology and resection specimens remained, and our Non-Small Cell Carcinoma, Not Otherwise Specified (NOS) category remained low at 2.9 %.
6.7. Minimally Invasive (VATS) Lobectomy: 80 Consecutive Cases R. Motyer, D.G. Healy St Vincent’s & Mater Misericordiae University Hospitals, Dublin, Ireland
6.8. Developing a Training Programme for Pleural Ultrasound in a Territory Referral Centre: when a High Workload Could Equal High Reward D. Ryan1, J. Scott1, C. Deneshvar1, D.P. Breen1 1 Department of Interventional Pulmonology, Galway University Hospital (GUH), Galway, Ireland
Thoracic Ultrasound (TUS) is an essential diagnostic tool in pleural disease. Assessment by non-Radiologists is acceptable and allows
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 rapid evaluation. According to Royal College of Radiologists guidelines, Clinicians should obtain Level1 (L1) training prior to performing TUS unsupervised. Training should be observed by clinicians with level 2/2 years L1 training. Competency is obtained by observing 20 TUS, performing 20 normal/10 abnormal TUS and 5 thoracocentesis/drain placements. In January 2012 the Interventional Respiratory Unit commenced in GUH. After agreement with Radiology, all TUS is carried out by this service. We reviewed the numbers of TUS carried out over 6 months from Jan to June 2013. Using these figures we hypothesise the number of clinicians that could be trained to L1 competence. 364 TUS were carried out on 182 patients. Both pleural spaces were scanned in each case. 174 TUS demonstrated effusions, 132 were normal. 60 involved thoracocentesis/drain insertion. This workload would allow 6 clinicians achieve L1 training within 6 months. TUS is a mainstay investigation for pleural disease. Respiratory trainees are recommended to obtain LI Competence. Furthermore a recent RCPI guideline for general medicine higher specialist trainees emphasizes level 1 Competence on an ultrasound-based technique. These results demonstrate the potential to train 12 clinicians a year in a dedicated unit with a high workload.
6.10. Resolvin D1 Restores Airway Surface Liquid Hydration and Attenuates IL8 Secretion In Cystic Fibrosis (CF) Bronchial Epithelial Cells F.C. Ringholz1, A. Moukachar2, G. Higgins1, P. McNally1,3, V. Urbach1,4 1
6.9. Outcomes from Lung Cancer at Beaumont Hospital 2012 T. McEnery, E. Keane, C. Higgins, J.M. Clince, R.K. Morgan, S.J. Linnane Beaumont Hospital, Beaumont Rd, Beaumont, Co. Dublin, Ireland Sustainable lung cancer data collection requires infrastructure and resources to produce meaningful results. A lung cancer dataset was commenced in 2011 based on a UK model. This was extensively modified over 6 months and 11 iterations. Interim activity analyses were reviewed by the lung cancer team. A lung cancer data coordinator was appointed. Survival was calculated using a Kaplan–Meier analysis. All patients presenting to the service in 2012 are reported. There were 236 patients diagnosed with lung cancer, 123 (52 %) via the rapid access clinic. 439 new patients attended the rapid access clinic and 99 % were seen within 10 working days. The average age at diagnosis was 69 years. 70 % had an ECOG performance score of 2 or less. 96 % of patients had a pathological diagnosis. 63 % of non-small cell patients had stage IIIa disease or above. The average time from referral to diagnosis and treatment was 13 and 19 working days respectively. 58 % of all patients had active anti-cancer treatment. 23 % had radical surgery. 64 % of all patients were alive at 6 months. We will continue to monitor survival as the gold standard for quality of care. We are developing improved database management using proprietary software.
Respiratory Research, National Children’s Research Centre, Crumlin, Dublin, Ireland, 2Universite´ Pierreet MarieCurie, Paris VI, France 3Respiratory Medicine, Our Lady’sChildren’sHospital, Crumlin, Dublin, Ireland, 4INSERM, U845, Faculte´de Me´decine Paris Descartes, Paris, France CF is caused by a mutation in the Cystic Fibrosis Transmembrane Conductance Regulator which results in airway surface liquid (ASL) dehydration, impaired muco-ciliary clearance and chronic pulmonary infection and inflammation leading to progressive lung destruction. Resolvin D1 (RvD1) is a Docosahexaenoic acid derived lipid mediator which effects the resolution of inflammation (1) and attenuates LPS induced lung inflammation by suppressing NFjB activation (2). NuLi-1 (normal genotype) and CuFi-1airway epithelial cells (D508/ D508) were grown as polarised, differentiated bronchial epithelia. Cells were treated with vehicle control or RvD1 1 nM or 100 nM (30 min for ASL/overnight for IL8 experiments). The ASL was stained with Texas red-dextran and imaged by live-cell confocal fluorescence microscopy. IL8 secretion was induced by TNFa or heat inactivated P. aeruginosa. Apical IL8 concentration was measured by ELISA. ASL height measured 7.2 lm in NuLi-1 cells. CuFi-1 cells demonstrated reduced ASL height at 5.8 lm and disrupted architecture. RvD1 1 nM and 100 nM restored ASL height in CuFi-1 cells to 7.1 lm* and 8.1 lm** respectively (*P \ 0.05/**P \ 0.01, Student t test). RvD1 100 nM attenuated TNFa induced IL8 secretion by CuFi-1 cells. Resolvin D1 restores airway surface liquid architecture and attenuates pro-inflammatory IL8 secretion by CF bronchial epithelial cells, suggesting therapeutic potential in CF lung disease. The authors acknowledge grant support from the National Children’s Research Centre, Health Research Board of Ireland and the French National Institute of Health (INSERM).
S468 References: 1. Serhan CN, Hong S, Gronert K, Colgan SP, Devchand PR, Mirick G, et al (2002) Resolvins: a family of bioactive products of omega-3 fatty acid transformation circuits initiated by aspirin treatment that counter proinflammation signals. J Exp Med 196(8):1025–37. Epub 2002/10/23 2. Liao Z, Dong J, Wu W, Yang T, Wang T, Guo L et al (2012) Resolvin D1 attenuates inflammation in lipopolysaccharideinduced acute lung injury through a process involving the PPARgamma/NF-kappaB pathway. Resp Res 13:110. Epub 2012/12/04
6.11. The CF-able Score: a 2-year Evaluation of a 4-year Prognostic Tool I.J. Meurling, C. McCarthy, C. Gunaratnam, N.G. McElvaney, S.J. O’Neill Department of Respiratory Medicine, Beaumont Hospital, Dublin 9, Ireland The CF-ABLE score was developed over 2 years ago in Beaumont Hospital as a prognostic tool for cystic fibrosis (CF). The score ranges from 0 to 7, based on age, body mass index (BMI), lung function and number of exacerbations in the last 3 months. Patients with a score of [ 5 points have a 26 % risk of poor outcome within 4 years1. Now after incorporating the score clinically for 2 years we can start evaluating its clinical application. 103 charts were reviewed in the Beaumont Hospital CF unit. 25 were excluded due to incomplete data. 78 patients were evaluated for lung transplant referral, transplantation and death in subcategories of ABLE scores above or below 5. 25 patients had an ABLE score [ 5 in 2011. Five died over the following 2 years, four were referred for lung transplant, and three more received transplants. Out of 53 patients with an ABLE score \ 5, only two patients with scores of 4.5 were also referred for transplant. At a two-year evaluation point, the CF-ABLE score proves to be a useful tool based on everyday clinical parameters, to concisely predict a patient’s prognosis to an endpoint of death or transplant over a 4 year period. References:
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 1. McCarthy C, Dimitrov BD, Meurling IJ, Gunaratnam C, McElvaney NG (2013) The CF-ABLE score: a novel clinical prediction rule for prognosis in patients with cystic fibrosis; Chest. 143(5): 1358–1364
6.12. A Prospective Study of the CF Gut: Prevalence, Ribotyping and Toxigenic Capability of Clostridium difficile in Adult CF M.J. Harrison1,2, D. Burke4, C. Fleming1, M. McCarthy1, C. Shortt1, G. O’Callaghan1,2, D.M. Murphy1,2, F. Shanahan3, C. Hill3, P. Ross3,4, C. Stanton3,4, J.A. Eustace2, M.C. Rea4, B.J. Plant1,2 1 Cork Adult CF Centre, Dept of Respiratory Medicine, Cork University Hospital, Cork, Ireland, 2Health Research Board, Clinical Research Facility, Cork, Ireland, 3Alimentary Pharmabiotic Centre, Cork, Ireland, 4Teagasc Food Research Centre, University College Cork, Moorepark, Fermoy, Cork, Ireland
Little is known about Clostridium difficile (CD) in CF. We examined prevalence, ribotype and toxigenicity of CD in the gut of CF patients attending our centre and correlated results with clinical parameters and healthy controls. 72 stool samples were collected. 62 % male, 82 % pancreatic insufficient, 78 % class 1-3 mutation, median age 28 years (IQR 24–37) and median FEV1 69 % predicted (IQR 46–83). 70 % were receiving macrolide therapy and 51 % taking a proton pump inhibitor (PPI). CD was detected in 49 % (n = 35) of the CF group and 2 % (n = 2) of healthy controls. CD-toxin was detected (ELISA) in 24 samples, all of which contained isolates that were PCR-positive for the toxin genes tcd-A and tcd-B. No significant associations were seen between the presence of CD and number of inpatient days, total duration of antibiotic therapy over the previous 3 years, gender, genotype, FEV1, PPI or macrolide use. While ribotype analysis of CF stool detected ribotypes previously associated with CD infection (001,002,005,014,015,046 and 078), all patients were asymptomatic. No disease-causing ribotypes were seen in controls. This is the largest study of CD in CF and reports the highest prevalence to date. This is the first study to report ribotypes. Despite toxin-positivity and ribotypes associated with CD infection all patients were asymptomatic.
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Irish Thoracic Society Poster Review and Discussion Saturday 16th November 2013
7. COPD Clinical Chairs
K. Cullen, Royal Victoria Hospital, Belfast D. Breen, Galway University Hospital, Galway
7.1. COPD Outreach Service—A Revolving Door? J. O’Herlihy, P. O’Toole, T.J. Mc Donnell COPD Outreach Service and Department of Respiratory Medicine, St. Michael’s Hospital, Dun Laoghaire, Co. Dublin, Ireland Average length of stay (ALOS) and bed days used (BDU) are key performance indicators for the COPD National Clinical Programme. Pressure to reduce ALOS and BDU risks the development of a revolving door. Nationally, almost half of all patients admitted with COPD are either dead (8 %) or re-admitted to hospital (41 %) within 90 days1. This study evaluates if COPD Outreach influenced the readmission rate (ReR) in St Michaels Hosptial. HIPE data for COPD discharges and readmissions for J40-47 [ 35 years and the COPD Outreach data were compared for 2012 and Jan–May 2013. In St Michaels Hospital there were 26 more discharges in 2012 than 2011. The ALOS decreased by 2.37 days generating an overall saving of 82 BDU. More admissions were managed with fewer BDU. St Michaels Hospital had a 90 day ReR of 15–20 % for COPD patients in 2012/2013, which was similar to the COPD outreach ReR for the same time period. Few factors highlighted those at increased risk of readmission; however, 33–44 % of COPD outreach patients on oxygen accounted for 70–87 % of readmissions. COPD outreach was associated with a reduced ALOS but does not appear to have a revolving door effect with ReR being maintained. European Respiratory Society (2012) International comparison of COPD care in Europe: results of the first European COPD audit, Lausanne (online) Available at: http://www.ciberes.org/audipoc/ docs/CD%20ERS%20COPD%20Audit/ERS%20COPD%20Audit% 20Report%20National.pdf (Accessed 22 August 2013).
7.2. COPD Satellite Clinic J. O’Herlihy1, P. O’Toole1, J. Gallagher2, T.J. Mc Donnell1 1 COPD Outreach Service and Dept. of Respiratory Medicine, St. Michael’s Hospital, Dun Laoghaire, Co. Dublin, Ireland, 2The Palms Surgery, Gorey, Co Wexford, Ireland
It is known that COPD is under-diagnosed and lack of access to community diagnostic resources is a contributing factor1. This study evaluated the performance of a COPD satellite clinic providing specialist testing and education for patients who would normally have to travel to a respiratory clinic. COPD outreach team members attended a primary care centre in Co. Wexford each month obtaining spirometry with reversibility, 6 min walk test and clinical history from respiratory patients referred by the practice. Results were reviewed by the respiratory consultant, diagnosis and/or treatment plan formulated and a report
S469 sent to the GP. During assessment, patients with inhalers or chronic sputum production had their technique reviewed and airway clearance taught. Of the patients reviewed 50 % had COPD and 25 % had asthma diagnoses confirmed; the remainder had no significant respiratory problem. Cost savings were generated through avoidance of multiple outpatient clinic attendances and optimisation of medication prescription and delivery. Patients benefitted through early integrated diagnosis and treatment recommendations in a single visit to a clinic based in their locality. This suggests that satellite clinics can provide a time saving and cost saving alternative to the traditional hospital based outpatient clinic model for those thought to have COPD. References: 1. Jithoo A, Enright P, Burnet P, Buist AS, Bateman ED, Tan WC et al (2013) Case-finding options for COPD: results from the BOLD Study. Eur Res J 41(3): 548–555
7.3. An Overview of the Impact of a COPD Outreach Service in an Acute Hospital Setting, Comparing two 4 month Periods Pre and Post Introduction of Service U. Lehane, C. Hanrahan, S. Turvey, T. O’Connor, D. Curran COPD Outreach, Respiratory Department, Physiotherapy Department Mercy University Hospital Cork, Cork, Ireland
7.4. The Impact of a New Chronic Obstructive Pulmonary Disease (COPD) Outreach Programme on Reducing the Average Length of Stay (ALOS) of Patients with Acute Exacerbations of COPD (AECOPD) in a Large Dublin Teaching Hospital C. Baily1, L. Cullen1, M. Kooblall2, A. Sahadevan2, S. Lane2, E. Moloney2 1
COPD Outreach Department, Tallaght Hospital, Dublin 24, Ireland, Respiratory Department, Tallaght Hospital, Dublin 24, Ireland
COPD is characterised by airflow obstruction and the clinical course is intermittently interrupted by exacerbations and hospital admissions. The COPD Outreach Programme was initiated in Tallaght Hospital in July 2012, as part of the National COPD Clinical Care Programme. It provides care at home for patients with AECOPD that would otherwise require hospitalisation. The aim of this study is to determine the impact of the programme on reducing ALOS for AECOPD patients. Forty-two out of 153 patients presenting to Tallaght Hospital with AECOPD from July 2012–December 2012 were suitable candidates for the Outreach Programme. They were discharged home within 72 h on either the Admission Avoidance or Early Supported Discharge Programme. Hospital In-patient Enquiry Scheme (HIPE) data from July–December 2011 was compared to that of 2012. This is a prospective study, with data analysed using Microsoft Excel. The ALOS for all patients with AECOPD for July–December 2012 was 7.32, compared to 8.21 for the same time period of 2011. The ALOS for patients accepted onto the Outreach Programme was 2. The COPD Outreach Programme in Tallaght Hospital has had a positive influence in its first 6 months of implementation on reducing the ALOS of patients with exacerbations from 8.21 to 7.32 days. It is an effective alternative to acute hospital care for selected patients.
7.5. COPD Outreach—the St. Vincent’s University Hospital Experience to Date C. Wynne, A. Lanigan, J. Alam, P. Hawkins, E. Kelly Respiratory Department, St Vincent’s University Hospital, Dublin, Ireland Chronic Obstructive Pulmonary Disease (COPD) Outreach is a service to deliver increased care at home to patients with acute exacerbations (AE) of COPD to safely facilitate earlier discharge from hospital. This programme commenced in SVUH in February 2012. This is a prospective audit of the experience to date. We collected information on demographic information, COPD severity, length of stay, readmission rate, quality of life and smoking cessation. Ninety two patients have been taken on the early discharge programmes with an average age of 73 years (46–90). Fifty six (60.8 %) were female. Severity of COPD varied; 7.2 % GOLD 1, 35 % GOLD 2, 37.3 % GOLD 3, 16.8 % GOLD 4. Average length of stay (ALOS) for those admitted with COPD AE in 2012 was 11.75 days, compared to 12.9 in 2011. ALOS of patients on the early discharge in 2012 was 1.7 days, to date for 2013 was 2.97. Twelve patients were readmitted within 90 days, 5 with COPD AE, 6 with hospital acquired pneumonia, 1 with a leaking AAA. Both breathless and Quality of Life scores have improved in 80 % of patients. 13.7 % quit smoking. These results suggest that the COPD Outreach service is improving care for these patients in our institution.
7.6. Pulmonary Rehabilitation Study T. Mc Manus1, M. Kelly2, M. Mc Menamin2, H. Phelan2, B. Leonard1 1
Respiratory Department, WHSCT, South West Acute Hospital, Fermanagh, UK, 2Respiratory Department, WHSCT, Altnagelvin Hospital, Derry, UK Background: Pulmonary rehabilitation, consisting of exercise training combined with education and instruction in self-management, is a cornerstone of care for patients with stable chronic obstructive pulmonary disease (COPD). There is strong evidence that pulmonary rehabilitation reduces dyspnoea, increases functional exercise capacity and improves quality of life (Waatz et al., 2008; Eaton et al., 2009, Troosters et al., 2010). Purpose of the Study: The purpose of this audit is to improve the provision Pulmonary Rehabilitation Programmes across the WHSCT (region) and enable harmonisation of future services by enforcing the standards set out within the Respiratory Framework. Methodology: This clinical audit is criterion based patient survey employing standards within the Respiratory Framework. The criteria identified appropriate referral to Pulmonary Rehabilitation, Record of MRC, CATS, BODE, 6 min walk, Initiation of Programme, Smoking Cessation Referral rates, a tailored programme addressing individual needs. A prospective audit was conducted of all patients attending Pulmonary Rehabilitation Programmes in the WHSCT during a 1 year period from 1st March 2011 to 1st March 2012. Results: There were a total of n = 223 participants had undertaken Pulmonary Rehab during the period of this audit. Conclusion: Pulmonary rehabilitation is a highly effective intervention that is a cornerstone of care for people with COPD. Higher physical activity levels are associated with better clinical outcomes. References: 1. DHSSPS (2006) A Healthier Future: a Strategic Framework for Respiratory Conditions from Northern Ireland Department of
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 Health, Social Services and Public Safety. Belfast: Northern Ireland 2. Eaton T, Young P, Fergusson W, Moodie L, Zeng I, O’Kane F et al (2009) Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study. Respirology 14:230–238 3. Troosters T, Sciurba F, Battaglia S, Langer D, Valluri SR, Martino L et al (2010) Physical inactivity in patients with COPD: a controlled multi-centre pilot study. Resp Med 104:1005–1011 4. Waatz H, Waschki B, Hoehme C, Claussen M, Meyer T, Magnussen H (2008) Extra pulmonary effects of chronic obstructive pulmonary disease on physical activity: a cross sectional study. Am J Respir Crit Care Med 177:743–751 No conflict of interest to be disclosed.
7.7. Nutritional Assessment in Pulmonary Rehabilitation (PR) L. Maher, M. O’Brien, T.J. McDonnell St.Micheal’s Hospital, Dun Laoghaire, Dublin, Ireland Weight loss and low BMI are independent predictors of increased morbidity and mortality. The prevalence of malnutrition in COPD is 10–45 %, increasing significantly with disease severity1. Nutrition support leads to improvements in nutritional intake, body weight, muscle mass, fat mass and in peripheral muscle strength1. We evaluated the implementation of a nutrition support care pathway for patients on PR. All patients enrolled in PR over 18 months were audited. The PR co-ordinator screened patients using the Malnutrition Universal Screening Tool (MUST), a five-step scoring system developed by the British Association of Parenteral and Enteral Nutrition, which can detect over-nutrition (overweight and obesity) and undernutrition, and is linked to a flexible care plan. The patients were screened on initial assessment, and repeated on subsequent assessments. In this study over 60 % of patients in PRP are overweight, with almost one-third in the obese category. Less than 10 % were considered to be at risk of malnutrition, according to the MUST. PRP did not alter either BMI or MUST scores at 8 weeks. While nutritional input may not change BMI over the short time frame of a PR programme, PR offers a good opportunity to develop a dietary care plan for patients with COPD. References: 1. Collins PF, Stratton RJ, Elia M (2012) Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Am J Clin Nutr 95:1385–1395
7.8. Pulmonary Rehabilitation with Psychological Input Further Improves Clinically Relevant Anxiety and Depression in Patients with Stable COPD? B.R. Bowen1, M.J. Harrison1, T.P. Morgan2, B.J. Plant1, M.P. Kennedy1, D.M. Murphy1, M.T. Henry1 1
Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland, 2Department of Physiotherapy, PCCC, St. Finbarr’s Hospital, Cork, Ireland A comparison study between 81 patients (2008–2011) who attended an 8 week community based pulmonary rehabilitation programme
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(PR) without psychology input and 57 patients (2011–2013) who attended the same programme with psychology input. Patients completed the Hospital Anxiety and Depression Scale (HADS) (Score 0–21) pre and post PR. Lower scores indicate reduced anxiety and depression. No. of patients
PR (without psychology)
PR (with psychology)
p Pre value
Mean anxiety score of clinically relevant scores (HADS C 8)
11.57 ± 2.81
9.67 ± 1.67 0.04
Mean depression score of clinically relevant scores (HADS C 8)
10 ± 2.57 7.46 ± 3.33
An audit of medical records in two academic teaching hospitals was conducted covering October–December 2012. Criteria for PR, based on HSE model of care, were used to determine eligibility.
10.59 ± 9.19 ± 0.03 2.39 3.28 9.69 ± 1.7
7.46 ± 0.028 3.04
Significant improvements were seen in both anxiety and depression after completing the 8 week programme. This study of 57 patients also showed similar improvements but there was no significant difference in the mean improvement in anxiety or depression scores between those who participated in PR vs. PR with psychology (p = 0.702). No correlation existed between likelihood of improvement in anxiety/depression, and age, BMI, gender, FEV1, LTOT or smoking status in either group. The addition of a clinical psychologist for one education session per programme does not further improve outcome.
7.9. What Percentage of Patients with COPD Commence Pulmonary Rehabilitation? C. Condon1, E. Moloney3, S. Lane1,2, R. O’Donnell3, E.K. Stokes1 1 Physiotherapy Trinity College, Dublin, Ireland, 2Tallaght Hospital, Dublin, Ireland, 3St James’s Hospital, Dublin, Ireland
Pulmonary rehabilitation (PR) is a proven intervention in maintaining quality of life and function in people with COPD (1). It is one of the main evidence based interventions that physiotherapists offer and is a key feature of the HSE model of care (2). The purpose of this audit was to examine the percentage of patients with COPD who were eligible and referred for PR and started within a 6-month period of referral.
Figure 1: Audit flowchart Of 183 people with COPD, 99 people (54 %) met the criteria for PR. 66 people were referred directly for PR (n = 33) or to another service (Outreach/Respiratory Assessment Unit) that assess for or offers PR (n = 50). 16 declined referral. Only 42 % (14/33) of individuals referred directly to PR commenced within 6 months of referral. Where GOLD stage was recorded in people considered suitable for PR, 51/53 were C Stage 2. Although referral to PR assessment is relatively high, commencing within 6 months of hospital consultation is low, and furthermore, the PR completion rate is also low (7/14). References: 1. Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J (2011) Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011 (10):CD005305. PubMed PMID: 21975749. Epub 2011/10/07. eng. 2. HSE 2. Pulmonary rehabilitation–model of care. National COPD Clinical Programme, 2010
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7.10. Evaluation of the Effects of an Outpatient Pulmonary Rehabilitation (PR) on the hospitalisation of patients in Naas General Hospital from 2006–2012 S. Curtis, F. Kavanagh, C. Callan, S. Morrin, A.M. O’Connell, T. Quadri, J. Power Naas General Hospital, Naas, Ireland The purpose of this study was to evaluate the effects of PR on admissions and bed days for 1 year pre and post PR. PR is an effective program for increasing exercise capacity and quality of life. There are few studies on its effects on healthcare utilisation in Ireland. From 2006–2012, 74 patients attended at least 60 % of their classes and completed post assessments. Hospital admissions and bed days in the 12 months before and after PR were recorded for these 74 patients. Data was collected from hospital databases (HIPE). Descriptive statistics were used. Results: 28 males and 46 females, mean age of 68 were included. The total number of admissions reduced by 17.88 %, bed days reduced by 16.31 %, with a reduction in average length of stay of 4.19 days.
respiratory disease. This development evolved from COPD Early Discharge and now includes shared care with specialist palliative care (SPC). This reflection aims to demonstrate the impact of a respiratory palliative care pathway on patient care. A reflective analysis, using Gibbs cycle (1), of a patient pre (patient A) and post (patient B) introduction of a respiratory palliative care pathway was undertaken. This involved reviewing all interventions from RAU and SPC. Patient A received 52 interventions from RAU. Her anxiety and breathlessness were difficult to manage, family continually struggled to cope. Despite a wish to die at home, patient A died in hospital. Patient B and family received 231 interventions, 158 of which were SPC. He died in hospice 1 years after initial referral to SPC. His wife and son received a high level of support. Introducing a respiratory palliative care pathway had a positive impact on patient experience at end of life. The symbiotic relationship between RAU and SPC empowered patient B and his family to be confident managing his illness at home. Early intervention from SPC allowed for improved advanced care planning. References: 1. GIBBS G (1988) Learning by Doing: A guide to teaching and learning methods. Oxford: Further Education Unit, Oxford Brookes University
7.12. Palliative Care in COPD: Nurses’ Knowledge and Attitudes
Pre PR (12 months)
PostPR (12 months)
Patients admitted (no.) Total admissions
A.M. Cronin, M. Landers, Bons Secours Hospital Cork, University College Cork
Total bed days
The aim was to explore nurses’ knowledge of and attitudes towards palliative care in COPD. International health policy has highlighted the benefits of timely initiation of palliative care in COPD disease management1. However, only 65.4 % of inpatients with COPD in Ireland use palliative care services2. A qualitative descriptive approach using semi-structured interviews was adopted. A purposive sample of nurses (n = 10) in the acute setting was recruited. Data were organised according to predetermined categories and then sorted into themes according to Morse and Field (1996). The benefits of palliative care in terms of patient support and symptom management in COPD were highlighted. There was uncertainty regarding when to initiate palliative care in COPD. Nurses had mixed opinions re disease staging versus individualised care to guide the initiation of palliative care in COPD. Nurses reported emotional stress related to palliation in COPD. The findings highlight the need for emotional support and specialised education for nurses in the acute setting. Multidisciplinary team co-operation amongst those providing palliative care in the acute setting is recommended. Further research is needed to explore the best time to initiate palliative care in COPD. Nevertheless, the findings will aid the development of a holistic care delivery system for patients. References: 1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013. Available from: http://www.goldcopd.org/ 2. Irish Thoracic Society (2008). National Respiratory (COPD) Framework (Draft). Dublin: Irish Thoracic Society. Available at: http://www.irishthoracicsociety.com/documents/Draft_Resp Framework_Oct_000.pdf
Average LOS per admission
*Total hospital cost
*Cost based on average day cost for COPD overnight stay €660 (HSE 2012)
This evaluation shows that PR has a positive effect on admissions and bed days resulting in cost savings. References: 1. Griffiths et al (2001) Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation program. Thorax 56:779–784
7.11. Impact of a Respiratory Palliative Care Pathway on patient care P. Davis1, S. Shelly1, K. Kealy2, R. Kennedy1, N. Nyambe1, B. Korn1, G. Tracey2, J. Brady1, P. Nolan1, R. O’Donnell1 1 Respiratory services, CResT Directorate, St. James’s Hospital, Dublin, Ireland, 2Our Lady’s Hospice & Care Services, Harold’s Cross, Dublin 6, Ireland
The Respiratory Assessment Unit (RAU) developed a Respiratory Home Support Programme to support patients with advanced
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7.13. Profile of COPD Admissions to a Tertiary Referral Centre—An observational study
S473 mEWS scores were 0 and 0 respectively. One patient (EWS = 6) was re-admitted to hospital during our episode of care. Seven patients (Median EWS = 4) were re-admitted within 1 month.
H. Forde, K. Harkin, A.M. Egan, S. Farrell, M. Burns, R.M. Rutherford, A. O’Regan
Median EWS and mEWS for COPD early discharge patients in St James's Hospital
Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland
Chronic Obstructive pulmonary disease (COPD) accounts for approximately 12,000 admissions to Irish hospitals each year. In an observational study undertaken at Galway University Hospital, we analysed the profiles, outcomes and follow up of 48 patients who were admitted with exacerbations of COPD. The average age of patients was 74.79 years. Of the 48 patients, 31.2 % required long term oxygen therapy and 8.3 % required non-invasive ventilation pre-admission. The mean number of reported General Practitioner visits per year was 7.1. The mean number of hospitalisations was 1.77 per year. Patients demonstrated poor insight into their steroid use with 27 % underreporting and another 27 % over-reporting the number of steroid courses they received in the previous 12 months. This suggests that patients may not be reliable in the subjective assessment of exacerbation rates which may lead to inappropriate treatments as per new GOLD guidelines. The mean length of stay was 8.6 days. 2 patients died during their admission. 25 % of patients were readmitted within 3 months of discharge. 3 patients died within this group. This demonstrates a reduction in readmission rates compared to figures published in the European COPD audit which may be explained by the introduction and implementation of the COPD outreach program.
mEWS Day 1
mEWS Day 7-14
EWS Day 1
EWS Day 7-14
Early warning scores are low for COPD early discharge patients. One patient re-admitted to hospital had a significantly higher EWS. The EWS for patients that required an escalation of care could be assessed in future and could alert staff that the patient requires further medical input. References: 1. Lawlor M, Kealy S, Agnew M, Korn B, Quinn J, Cassidy C, Silke B, O’Connell F, O’Donnell R (2009) Early discharge care with ongoing follow-up support may reduce hospital readmissions in COPD. Int J Chron Obstruct Pulmon Dis 4: 55–60 2. National Early Warning Score, National Clinical Guideline No. 1 http://www.hse.ie/eng/about/Who/clinical/natclinprog/acutemedicine programme/EWSguide.pdf
7.15. Use of a COPD Acute Care bundle in St. Vincent’s University Hospital
7.14. An analysis of the Early Warning Scores of Early Discharge Patients with COPD in St James’s Hospital
P. Hawkins, A. Lanigan, C. Wynne, J. Alam, E. Kelly
M. Scanlan1, C. Gleeson1, P. Davis1, M. Kane1, R. Kennedy1, B. Korn1, S. Shelly1, R. O’Donnell1
Background: Care pathways and care bundles are pivotal to the National COPD Programme’s plan for acute management of COPD. This is a collection of evidence based, best practice interventions for patients with COPD exacerbations presenting to the acute hospital. Methods: A COPD acute management bundle (ACMB) was implemented in St. Vincent’s University Hospital in 2012. We audited adherence to this bundle, through a chart review of consecutive patients admitted with COPD exacerbation over an initial 4 week period in July 2013. Results: Ten patients were admitted with COPD exacerbations at this first interval audit. Only one of these patients was commenced on the ACMB. The patient who was put on the ACMB received treatment as per its recommendations. Of those patients not on the ACMB, prescription of steroids and antibiotics was inconsistent. One patient did not receive nebulised bronchodilators or systemic steroid treatment. All patients were reviewed by the COPD outreach service. Conclusions: This study shows that the use of the acute COPD care bundle in SVUH is sub optimal. Education sessions on the benefits of applying this bundle should aid its more widespread use and improve delivery of care to these patients.
Respiratory Assessment Unit, CResT Directorate, St James’s Hospital, Dublin, Ireland Nurse/physiotherapist led early discharge care for COPD patients has been in place in St James’s Hospital since 2002 (1). The current system for escalating care (i.e. medical review) relies solely on clinical judgement. Recently the Hospital implemented the early warning score (EWS) system (2) for inpatients. Modified EWS’s (mEWS) based on typical parameter changes for COPD patients are also used by medical staff for inpatients. The aim of this project was to determine the efficacy of using the EWS and/or the mEWS and to determine normal values in this population. Fifty COPD early discharge patients’ charts were retrieved at random. Retrospective EWS and mEWS for each patient were calculated based on the physiological observations recorded. The median EWS for patients was 2.5 (range 0–9) and 1.5 (range 0–7) on Day 1 and Day 7–14 post discharge respectively. Median
St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
7.16. Use of a Chronic Obstructive Pulmonary Disease (COPD) Prescription Checklist Improves Quality Indicators in the Acute Management of COPD in the Emergency Department P. O’Toole, J. O’Herlihy, T.J. Mc Donnell COPD Outreach Service and Dept. of Respiratory Medicine, St. Michael’s Hospital, Dun Laoghaire, Co. Dublin, Ireland Variations in the management of COPD may contribute to poor patient outcomes i Implementation of checklists has been suggested to improve outcomes such as mortality, admission rates and length of stay ii. A key intervention in the COPD checklist is the use of oral rather than intravenous steroids and antibiotics. This follows the recommendations of the GOLD guidelines. The COPD management checklist was introduced in 2012, but has a completion rate of 22 %. We developed a COPD prescription checklist to incentive emergency staff to use it and therefore improve compliance with components. A cross sectional audit demonstrated that the prescription checklist was used for 67 % of COPD exacerbations. Adherence to oral medication on the checklist was analysed (see results below). Compared to a previous audit in 2012 there was a significant improvement in the adherence to checklist instructions. Prescription checklists may incentive staff to use them resulting in improved standardisation of care. References: 1. Koehler BE (2009) Reduction of 30-day post discharge hospital readmission or emergency department visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hospital Med 4(4): 211–218 2. Matthews H (2013) Care bundles reduce readmissions for COPD. Nursing Times. 109 (7):18–20
7.17. Remote Telehealth Monitoring: Hope on the horizon for Hospital admission prevention? F. Campbell, N. Armstrong, D. Morgan, E. Hayes Department of Respiratory Medicine, Daisy Hill Hospital, Southern Health and Social Care Trust, Portadown, Northern Ireland Chronic Obstructive Pulmonary Disease (COPD) is the second commonest cause of emergency admissions. Prevention of admission has been shown to be beneficial. Innovative technologies such as Remote Telehealth Monitoring (RTM) are now being developed to help achieve this. RTM uses technology to transfer physiological data thus
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 allowing for early detection of deterioration and appropriate timely intervention. However there has been controversy over its benefits. We looked at the 64 patients with COPD using RTM over a year to assess whether it led to prevention of admissions. RTM alerts are triggered by a number of parameters. Alerts prompt a phone call and/ or a home visit. Any admission prevention was recorded. RTM led to a prevention of 60 hospital admissions. 17 % of these preventions were triggered by a change in sputum, 47 % by oxygen saturations, 23 % by dyspnoea and 13 % by patient concern. Interventions included commencement of antibiotics and/or steroids, oxygen, physiotherapy and reinforcement of medication regime. As patients are living longer with chronic conditions and resources are finite current models of care in the management of COPD are unsustainable and alternative approaches must be sought. RTM is a safe and cost effective method of preventing hospital admissions with a high level of patient satisfaction.
7.18 Domicilary non-invasive ventilation in Galway— Roscommon over 10 years: J. Chua, T. Cahill, D. Langan, A. O’Regan Department of Respiratory Medicine, Galway University Hospital For two decades domiciliary non-invasive ventilation (NIV) has emerged as a feasible and effective method of managing hypercapnic respiratory failure. Little is known about trends in its’ use, indications or outcomes. We carried out retrospective study of all home-based NIV in Galway—Roscommon from 2003-2013. Cases were identified from hospitals, PCCC, and home providers. Data was collected from database, chart, clinic, discharge letter reviews, and computerized data. 259 patients were identified. 158 (61 %) alive and 51 (19 %) excluded due to inadequate data. New initiations increase by 30 % each year until 2008 then plateau at 35 per year. Indications for treatment were: Chronic Obstructive Pulmonary Disease (COPD) (42 %); Obesity Hypoventilation Syndrome (OHS) (25 %); Neuromuscular disease NMD (12 %); Chest wall deformity CWD (9 %); other (9 %). COPD and OHS prescriptions increased while CWD and NMD remained static. 1 year case fatality rates: COPD 27 %; OHS 2 %; CWD 8 %; NMD 34 %. The use of domiciliary NIV has significantly increased. This is predominantly due to an increase in COPD and OHS patients. Survival data had a strikingly high mortality for COPD and NMD NIV users, in contrast to CWD and OHS. A study of the indications and outcomes of COPD patients using NIV is required. Research was HRB funded.
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Irish Thoracic Society Poster Review and Discussion Saturday 16th November 2013
8. ILD, CF and Rarer Respiratory Disorders Chairs
A. O’Regan, Galway University Hospital, Galway E. McGrath, St Vincent’s University Hospital, Dublin
8.1. The Th2-mediated Lymphocyte Response in Sarcoidosis B. Cushen, A. Talbot, A. O’Regan Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland Sarcoidosis is a multisystem granulomatous disease characterised by a predominant Th1 lymphocyte response to an unknown antigen. The Th2 immune response is thought to be suppressed in this population. Some studies have proposed that those with higher levels of atopy at disease onset have a shorter course of disease. We assessed the degree of atopy in a cohort of patients with sarcoidosis. Data was initially collected on 36 patients between April 2009 and March 2011. Serum IgE was measured as was serum radioallergosorbent test (RAST) to common antigens including house dust mite, tree pollen and timothy grass. Parameters were re-checked following an interval of 2–3 years. Of the original cohort 21 % were atopic, based on positive serum RAST test, similar to quoted prevalence in the general population. 11 patients presented for follow-up of whom 45 % were RAST positive at the time of diagnosis. 60 % of the RAST positive patients were in remission at follow-up compared with 16 % of the non-atopic group, p = 0.24. We did not identify lower levels of atopy amongst this patient population. While there was a trend toward persistent disease in the non-atopic population the sample size was too small to demonstrate any statistical significance.
8.2. Sarcoidosis & Geography: does Location Matter in the Western Trust? M. Kinsella1, M. Mc Closkey2, T. Mc Manus3, R. Sharkey2, M. Mc Menamin2, J.G. Daly2, J.P.L. Davis4, A. Boyce5, M.G. Kelly2 1
Medical student, Dundee University, DD2 4BF, Dundee, UK, Respiratory Medicine, Altnagelvin Hospital, Derry BT47 6SB, UK, 3 Respiratory Medicine, Erne Hospital, Enniskillen, BT74 6AY, UK, 4 Lecturer (Teaching & Scholarship), Centre for Biomedical Sciences & Public Health, Dundee University DD2 4BF, Dundee, UK, 5 Account Development Manager, Land & Property Services, Colby House, Belfast, Ireland 2
A previous Western Trust audit indicated a high prevalence population for sarcoidosis1. Epidemiology may shed some light on sarcoidosis aetiology. Worldwide, there are geographic variations, with higher incidence in Northern Europe & amongst African Americans2. An increased prevalence as one travels west within Europe is posited & even suggested within countries. Is there an association with proximity to the Atlantic seaboard?
S475 A descriptive cross-sectional study design was used, with all patients with sarcoidosis living in the Western Trust in May 2011 being eligible for the study. Data collected from patient records. Patient location was plotted on a map of the Trust, based on postcodes, and adjusted for population density of the area. This study indicated a prevalence of 61/100000 population. Though numbers are relatively small, there are some intriguing patterns visualised on viewing the plots. There is some western clustering, not necessarily associated with higher population density. For example, within the city of Derry, more cases lie within lower population density areas. Some rural clustering is suggested. No obvious association with topographical features, except possible proximity to rivers (west Derry, west Tyrone, Limavady & Enniskillen). This methodology is worth further development. What lies across the border in Donegal? References: 1. Kinsella M, Mc Closkey M, Mc Manus T, Sharkey R, Daly JG, Kelly MG (2011) Sarcoidosis attending chest physicians in Western Trust: preliminary audit data offers insights into prevalence. In: ITS Annual scientific conference 2. Iannuzzi MC, Rybicki BA, Teirstein AS (2007) Medical progress: sarcoidosis. N Eng J Med 357:2153–2165
8.3. An Update on Sarcoidosis in A Captive Population: in-depth Assessment of Western Trust Patients Attending Chest Physicians M. Kinsella1, M. Mc Closkey2, T. Mc Manus3, R. Sharkey2, J.G. Daly2, J.P.L. Davis4, M.G. Kelly2 1
Medical student, Dundee University, DD2 4BF, Dundee, UK, Respiratory Medicine, Altnagelvin Hospital, Derry, BT47 6SB, UK, 3 Respiratory Medicine, Erne Hospital, Enniskillen, BT74 6AY, UK, 4 Lecturer (Teaching & Scholarship), Centre for Biomedical Sciences & Public Health, Dundee University DD2 4BF, Dundee, UK 2
Previous calculated prevalence of sarcoidosis in the Western Trust was 64.9/100,0001. This study attempted to describe the epidemiology in a well-defined population with a high estimated prevalence. A descriptive cross-sectional study design was used. All patients with sarcoidosis living in the Western Trust in May 2011 were eligible for the study. Data was collected from patient records & stored on an Excel document. The prevalence of sarcoidosis in the Western Trust in May 2011 was found to be 61 per 100,000; 61.88 % of cases were male. Peak decade of diagnosis was 30–39 years. 2.8 % of cases (n = 5) had a positive family history. 57.8 % of cases were reported as being lifelong non-smokers. More cases were diagnosed in spring & summer (58.9 %). 53.3 % of cases had histological proof of a diagnosis of sarcoidosis. Numerous occupational types were reported more commonly amongst cases than the general population in the 2001 census of Northern Ireland, including occupations in skilled construction and building trades, skilled agricultural trades, skilled metal and electrical trades, elementary trades, plants and storage related occupations or health professionals. This confirms a high prevalence population, an atypical sex distribution compared with the literature2 and associations with various occupations akin to that described2. References: 1. Kinsella M, Mc Closkey M, Mc Manus T, Sharkey R, Daly JG, Kelly MG (2011) Sarcoidosis attending chest physicians in
S476 Western Trust: preliminary audit data offers insights into prevalence. In: ITS Annual scientific conference, 2. Iannuzzi MC, Rybicki BA, Teirstein AS (2007) Medical progress: sarcoidosis. N Eng J Med 357:2153–2165
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8.5. Patient Reported Experience of Pirfenidone use at a Specialist ILD Clinic in Ireland O.J. O’Connell, B. Bowen, D.M. Murphy, B.J. Plant, M.P. Kennedy, M.T. Henry Interstitial Lung Disease clinic, Department of Respiratory Medicine, Cork University Hospital, University College Cork, Cork Ireland
8.4. Experience Using Rituximab in the Management of Pulmonary Complications of Connective Tissue Disease in a Tertiary Centre D.B. Fitzgerald, S.M. Harney, M.T. Henry Respiratory Department and Connective Tissue Disease Clinic, Cork University Hospital, Cork, Ireland Pulmonary complications of connective tissue disease (CTD) are common. Recent studies have shown benefit with rituximab (RTX) in the treatment of CTD related interstitial lung disease1,2. We reviewed 5 cases of CTD-ILD receiving RTX. Pre- and post-treatment pulmonary function, exercise physiology, echocardiograph and HRCT thorax data were analysed. Four patients were treated for systemic sclerosis related ILD (SScILD) and one patient had rheumatoid arthritis ILD (RA-ILD). Three patients received RTX after failure of alternate immunosuppression. All 5 patients demonstrated either radiological and/or physiological improvement in response to RTX. No patient had a significant side effect of treatment. RTX is a chimeric monoclonal antibody with activity against CD20 expressed by B-cells. Evidence has shown benefit from rituximab used either alone or in conjunction with other immunosuppressive agents. Our patients represent a cohort in whom RTX therapy has been beneficial. These results indicate that consideration should be given to RTX therapy in patients with connective tissue disease related pulmonary complications. References: 1. Keir GJ, Maher TM et al (2012) Severe interstitial lung disease in connective tissue disease: rituximab as rescue therapy. Eur Respir J 40:641–648 2. Daoussis D, Liossis SC et al (2012) Effect of long-term treatment with rituximab on pulmonary function and skin fibrosis in patients with diffuse systemic sclerosis. Clin Exp Rheumatol 30(2 Suppl 71):S17–S22
The National Centre for Pharmacoeconomics (NCPE) has agreed to reimburse Pirfenidone, for patients with mild/moderate IPF in Ireland from August 2013. This study reports the patient reported experience of Pirfenidone at a specialist interstitial lung disease (ILD) clinic in Cork. Consecutive patients with mild/moderate IPF (FEV1 [ 50 % predicted, DLCO [ 35 % predicted) prescribed Pirfenidone at the ILD clinic in the Cork University Hospital completed a questionnaire of the tolerability, side-effect profile, dosing and subjective improvements in symptomatology to Pirfenidone. Patient demographics were recorded from medical records. 24 patients with IPF were recruited. Mean age 73.5 years (SD6.0); mean FVC 81.5 L (SD17.3) and mean DLCO 45.9 ml/min/mmHg (SD 13.6). All patients at the time of study enrolment were prescribed a proton-pump inhibitor and 92 % were prescribed N-acetylcysteine. 44 % of patients reported no side-effects to Pirfenidone; 19 % of patients reported rash, 32 % reported nausea and 5 % reported diarrhoea. 1 patient stopped due to gastrointestinal side-effects. 7/9 (78 %) patients reported a subjective improvement in cough and 9/18 (50 %) reported improvements in dyspnoea since commencement of Pirfenidone. 66 % of patients tolerated the maximal dose of Pirfenidone, whilst 33 % were on reduced doses due to side-effects. To date, patients with IPF attending a specialist ILD clinic have reported an excellent response to Pirfenidone, with good tolerability.
8.6. The Survival Benefit of Lung Transplantation in Idiopathic Pulmonary Fibrosis P. Riddell, I. Lawrie, S. Winward, D. Healy, H. Javadpour, J. McCarthy, L. Nolke, K. Redmond, J.J. Egan National Heart and Lung Transplant Programme, Mater Misericordiae University Hospital, Dublin, Ireland Idiopathic pulmonary fibrosis (IPF) is a devastating disease that results in progressive respiratory failure and death. The median survival from time of diagnosis, without transplantation, is 2–3 years. We sought to describe the survival benefit which may be achieved by lung transplantation in IPF. All IPF patients who have received lung transplantation at our centre, since the inception of the transplant programme, were included in the study (n = 30). Survival data was compared with IPF patients who had died on the transplant waiting list over the past 3 years (n = 20). We analysed survival outcomes using Kaplan–Meier curves. The overall survival following transplantation was 96.6 % at 1 year, 90.1 % at 2 years and 78.9 % at 5 years. Subgroup analysis showed that those transplanted over the age of 65 had similar outcomes to younger patients (5 year survival being 88.9 % (n = 9)). Waiting list mortality was unfortunately very high (25 % at 6 months; 70 % at 12 months; 85 % at 18 months), indicating the need for early referrals and increased organ availability. Lung transplantation remains the only available therapy for IPF with proven prognostic benefit. It confers a significant survival benefit to these patients. Age should not be seen as a contraindication to transplant referral.
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8.7. The Effect of TGF-b & TNF-a on Collagen 1A1 Gene Expression & Collagen Production in Human Fibrocytes S.M. Walsh, D.A. Boylan, R. Lumsden, J.C. Worrell, R. Kane, A. Fabre, M.P. Keane School of Medicine & Medical Science, Conway Institute, University College Dublin, Dublin, Ireland Fibrocytes are bone marrow-derived circulating progenitor cells expressing collagen and the leucocyte common antigen CD45. They traffic to sites of injury, differentiate into myofibroblasts and contribute to fibrosis. Transforming growth factor-beta (TGF-b), the profibrotic cytokine, promotes fibrocyte differentiation and activation, while tumour necrosis factor-alpha (TNF-a) has a negative influence. The aim of this study was to determine the effect of both agents in combination. Peripheral blood mononuclear cells (PBMC’s) were isolated from human buffy coats. Fibrocytes were cultured from PBMC’s according to established protocols (1). Confirmation of the resulting cell population was performed by immunohistochemistry and flow cytometry. Fibrocytes were treated with TGF-b and TNF-a. Real time PCR and a soluble collagen assay were performed. Fibrocyte population was confirmed by positivity for CD45, collagen I, CXCR4 and a-SMA. TGF-b (2.5 ng/ml) increased collagen 1A1 gene expression (p 0.0189). TNF-a (2.5 ng/ml) had minimal effects alone, but when given in combination with TGF-b, had an additive effect (p 0.0347). A soluble collagen assay demonstrated a 1 lg/ml quantitative increase in collagen when fibrocytes were treated with both agents. This study demonstrates that the combination of TGF-b and TNFa promotes a more pro-fibrotic fibrocyte population. Targets blocking both agents may contribute to fibrosis treatment. References: 1. Phillips RJ, Burdick MD, Hong K, Lutz MA, Murray LA, Xue YY et al (2004) Circulating fibrocytes traffic to the lungs in response to CXCL12 and mediate fibrosis. J Clin Investig 114(3):438–446
8.8. Dexamethasone Increases Lysyl Oxidase Release from Primary IPF Fibroblasts with Possible Therapeutic Implications M.G. Jones1,2, C. Calderwood1, L. Hoile2, D.E. Davies1,2, K.M.A. O’Reilly1,3 1
The Brooke Laboratory, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK, 2NIHR Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK, 3Mater Misericordiae University Hospital, Dublin, Ireland
8.9. The Introduction of Pirfenidone use in Ireland; Audit of a University Hospital Service P. Ryan, M. Cullinan, C. McInerney, G. Giblin, B. Casserly, A. O’Brien Introduction: An audit on the use of Pirfenidone therapy at an Irish University Hospital. Methods: Retrospective review of patients who were initiated on Pirfenidone at the University Hospital Limerick in 2012 and 2013.
S477 Results: Data from the 11 patients who initiated on Pirfenidone during this time period was reviewed. Mean age was 73 years; 54 % male. All had a diagnosis of mild to moderate Usual Interstitial Pneumonia (UIP), (consistent CT, restrictive pattern on PFT’s with FVC C 50 %, DLCO C 35 %, and[150 m walking distance). 27 % suffered a photosensitivity reaction or rash, with 18 % having to stop Pirfenidone completely, with one patient who had a mild photosensitivity reaction continuing on therapy successfully under close supervision. One death occurred; this event was unrelated to his Pirfenidone use. All patients had normal baseline LFT’s apart from one with mild abnormality that remained unchanged while on therapy. 36 % of patients had mild abnormalities on baseline U&E’s, with no change while on therapy. Gastrointestinal side effects occurred in 36 % of patients (anorexia and nausea); resolving with reduction in Pirfenidone dose. Conclusion: We describe the successful introduction of a Pirfenidone programme at our institution. Commonest side effects experienced were gastrointestinal and photosensitivity reactions.
8.10. Impact of Cystic Fibrosis on Pregnancy-Maternal and Fetal Outcomes at a Specialist Centre, Belfast S. Bhaskar1, S. McNeill2, D. Downey2, J.S. Elborn2, A. Hunter1, J. Rendall2 1
Royal Jubilee Maternity Service, Belfast, Ireland, 2Northern Ireland Regional Adult Cystic Fibrosis Centre, Belfast, Ireland
Quality of life and survival continues to improve in women with cystic fibrosis. Our aim was to review the consequence of pregnancy and the impact on maternal and neonatal health. A retrospective case note review of 30 pregnant women with cystic fibrosis, 1990–2012. Main outcomes measured were; maternal FEV1 and BMI, hospital admissions, gestational weeks at delivery, and birth weight. 30 pregnancies in 25 women were reviewed. 23 % had a history of miscarriage. 87 % had a normal BMI at booking. Of the 20 with full booking PFTs, 65 % had an FEV1 greater than 60 %. 29 % demonstrated a 10 % reduction in FEV1 during the third trimester. All babies were live born and there were no maternal deaths. 27 babies were born after 36 weeks of gestation and 43 % weighed less than 3000 g. Outcome for the infant is generally good, but is variable for the mother depending on disease severity. Planned pregnancy, with prior counselling and multidisciplinary care improve outcomes.
8.11. Should we be Treating Low Z-scores in Cystic Fibrosis? A. Carolan, M.A. Abel, T. McEnery, I.J. Meurling, C. McCarthy, N.G. McElvaney, C. Gunaratnam Department of Respiratory Medicine, Beaumont Hospital, Dublin 9, Ireland Low bone-mineral-density (BMD) is a well reported complication of cystic fibrosis (CF), however the aetiology is poorly understood. The aim of this study was to explore the significance of BMD in CF and correlate this with pulmonary outcomes and fractures. Data was collected for all patients attending over a 10-year-period. Clinical parameters including FEV1, BMI, Z-scores, exacerbations, corticosteroid and bisphosphonate were recorded. Patients were surveyed regarding fracture history. 109 living patients had Z-scores available. 16 % had a Z-score \ -2.5 and 45 % had between -1 and -2.5. 83 patients were surveyed and had a similar distribution of Z-scores, with 33 % reporting a fracture. There was no significant difference in mean Z-score of the fracture
S478 group: -1.15, and those without fractures: -1.21 (p = 0.77). In those with fractures 18.5 % had Z-scores \ -2.5. 36 % of all surveyed with Z-scores \ -2.5 had fractures and 31 % with normal Z-scores had fractures. No association was found between low Z-score and fracture incidence. Corticosteroid use did not correlate with an increased fracture frequency, however, in the corticosteroid sub-group; a higher cumulative dose conferred an increased risk. Low Z-scores in CF do not appear to confer an increased risk of fractures. This may have implications for whether bisphosphonates should be prescribed in CF.
8.12. Altered Lipid Raft Structure and Membrane Cholesterol Content as a Potential Cause for Dysregulated Neutrophil Activity in Cystic Fibrosis M. White1, S. Cox1, E. Hayes1, D. Bergin1, J. Keenan2, P. Meleady2, M. Henry2, M. Clynes2, N.G. McElvaney1, E.P. Reeves1 1 Respiratory Research Division, Royal College of Surgeons in Ireland, Dublin 2, Ireland, 2National Institute for Cellular Biotechnology, Dublin City University, Dublin 9, Ireland
A hallmark of cystic fibrosis (CF) lung disease is sustained neutrophil recruitment and neutrophil dominated inflammation. Considerable debate exists as to the underlying cause of dysregulated neutrophil activity in CF. The aim of this study was to resolve this incongruity and to enlighten us on whether an intrinsic CF-related defect modifies neutrophil function. Specifically, the aim of this study was to investigate a link between neutrophil cholesterol content and disruption of membrane lipid-rafts. Neutrophils were isolated from stable patients with CF homozygous for the DF508 mutation or during an exacerbation (n = 13), healthy controls (HC) (n = 13) and stable non-CF bronchiectasis patients (NCFB; inflammatory control, n = 6). Lipid raft and membrane fractions were isolated by subcellular fractionation and density gradient ultra-centrifugation. Altered raft protein expression was assessed by western blot analysis. Cholesterol was quantified by a fluorometric assay and membrane fluidity was measured using a lipophilic probe. Results revealed lower cholesterol content and expression levels of the structural protein flotillin-1 in neutrophil membranes and isolated raft domains of individuals with CF. Increased membrane fluidity in CF neutrophil membranes was also demonstrated. Our data has identified major changes to membrane lipid raft structure intrinsic to the CF neutrophil. Results suggest that therapeutics targeting cellular cholesterol content may positively impact on neutrophil activity in CF.
8.13. The Effect of PA401 on Interleukin-8 (IL-8) Levels in Bronchoalveolar Lavage Fluid (BALF) of Patients with Cystic Fibrosis (CF) N. O’Reilly1, H. Kerr1, O.J. McElvaney1, D.A. Bergin1, T. Adage2, J.H. Slingsby2, A.J. Kungl2, M.R. Bartley2, E.P. Reeves1, N.G. McElvaney1 1
Respiratory Research Division, Royal College of Surgeons Ireland, ERC Beaumont Hospital, Dublin 9, Ireland, 2ProtAffin Biotechnologie AG, Impulszentrum Graz-West, Reininghausstraße 13a, 8020 Graz, Austria
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8.14. Importance of CFTR Expression for Neutrophil Function in Patients with Cystic Fibrosis B. Jundi, K. Pohl, N.G. McElvaney, E.P. Reeves Department of Medicine, Respiratory Research, Beaumont Hospital, RCSI, Dublin 9, Ireland Neutrophils in cystic fibrosis (CF) fail to eradicate pathogens causing lung infections. However it remains unknown whether neutrophil dysfunction in CF is due to chronic inflammation or the defect of the CF transmembrane conductance regulator (CFTR). Therefore, the aim of this project was to provide support for additional intrinsic alterations by investigating the expression and function of CFTR in healthy control and CF neutrophils. Cellular proteins were isolated from purified neutrophils from healthy control and CF patients and the CFTR protein expression was investigated by using Western blot analysis. The CFTR protein in healthy controls neutrophils was inhibited by treatment with the CFTR-172 (10 lM) to examine CFTR function. Our novel results clearly confirm the expression of CFTR channel in neutrophils with levels of the mature, membrane CFTR being reduced in CF cells. Inhibition of CFTR function using the CFTR-172 inhibitor resulted in accumulation of cytosolic chloride in healthy neutrophils. This indicates that CFTR plays an important role in neutrophil function and dysfunctional CFTR may directly cause the impaired neutrophil killing ability observed in CF patients. Additionally, the presence of the CFTR protein makes it possible to treat neutrophil dysfunction directly using new drugs that correct the CFTR defect.
8.15. The use of Azithromycin in Patients with Bronchiectasis in a District General Hospital D. Todd, C. Kennedy, R. Sharkey, A. Aziz, M.G. Kelly, M. Mc Closkey Respiratory Department, Altnagelvin Area Hospital, Derry, UK Macrolides, particularly azithromycin, have been increasingly used over recent years to treat non Cystic Fibrosis Bronchiectasis. The aim of this study was to look at the use of azithromycin in patients with bronchiectasis attending Altnagelvin Area Hospital (AAH). This was a retrospective study looking at all the patients with bronchiectasis who attend AAH. All patients who have received azithromycin were identified. The number of antibiotic prescriptions received by patients per year before commencing azithromycin and per year after starting azithromycin was recorded. The number of positive sputum cultures before and after commencing azithromycin was noted. Macrolide resistance was also recorded. There are 759 patients attending AAH with a diagnosis of bronchiectasis, 162 have been prescribed azithromycin, given at a dose of 250–500 mg 3 days per week over winter. Data on antibiotic prescriptions was available on 29 of these patients. The number of antibiotics prescribed per year was decreased (mean 5.2) whilst on azithromycin compared to the number of antibiotics prescribed per year before commencing azithromycin (mean 6.5) p value \ 0.005. The number of patients with positive sputum cultures was decreased with the use of azithromycin, p value \ 0.001. This study supports recent data on the beneficial effects of azithromycin in patients with bronchiectasis but also identifies that some patients are still receiving more antibiotics than clinically indicated.
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8.16. Prevalence of Hiatus Hernia in Non-cystic Fibrosis Bronchiectasis and Associations with Disease Severity
8.18. Exercise Capacity in Adult Survivors of Bronchopulmonary Dysplasia
M.J. McDonnell1, M. Ahmed1, D. Wall2, J. Bruzzi3, M. O’Mahoney1, D. Breen1, A. O’Regan1 R.M. Rutherford1
S. Caskey1, J. Megarry2, P. Nicholls, M. Riley2, M. Shields1, H. Halliday3, L. McGarvey1
Respiratory Medicine, Galway University Hospitals, Galway, Ireland, 2School of Mathematics, Statistics and Applied Maths, NUI Galway, Galway, Ireland, 3Radiology, Galway University Hospitals, Galway, Ireland An increased prevalence of hiatus hernia (HH) has been reported in several respiratory diseases. We aimed to evaluate the prevalence of HH among a well-defined cohort of stable non-cystic fibrosis bronchiectasis patients and to determine correlation with markers of disease severity. A retrospective observational cohort study over an 18-month period was performed. Data was collected on baseline variables, microbiology, lung function and radiology. Imaging was independently assessed by a thoracic radiologist to determine presence of HH and extent of bronchiectatic disease. 81 patients had confirmed bronchiectasis on HRCT. 29 (35.8 %) were confirmed to have HH on CT (mean age 64.4 years, 72.4 % females, BMI 29.4). Of the remaining 52 patients, mean age was 61.6 years, 65.4 % females, BMI 26.1. A higher proportion of HHpositive patients had high BMI (p = 0.05). HH-positive patients had an increased frequency of cystic bronchiectasis (31.0 % versus 11.5 %, p = 0.03) and an increased number of bronchiectatic lobes affected (2.62 versus 2.17, p = 0.033) compared with HH-negative patients. There was no predilection for any particular lobe. A trend in reduced FEV1 % in HH-positive patients was noted (78.6 % versus 90.3 %, p = 0.091). In this cohort, HH correlated with increased extent and severity of radiological disease with a trend towards reduced lung function.
8.17. Paradoxical Vocal Cord Dysfunction: A Case Series
Centre for Infection and Immunity, Queen’s University Belfast, Belfast, N. Ireland, 2Pulmonary function laboratory, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK, 3 Regional Neonatal Unit, Royal Maternity Hospital, Belfast Health and Social care Trust, Belfast, UK Children and adolescents who survived bronchopulmonary dysplasia (BPD) have impaired exercise tolerance but little is known regarding those surviving to adulthood. Exercise capacity was measured in 22 adult survivors of BPD, 23 born preterm without BPD and 24 term controls. Subjects underwent symptom limited, maximum cardiopulmonary treadmill exercise testing using a Modified Bruce Protocol. General levels of physical activity were determined from subject responses to European Community Respiratory Health Survey. At peak exercise, adult survivors of BPD attained lower peak oxygen consumption (VO2 ml/kg/min% predicted) and travelled less distance on the treadmill, compared to controls (p \ 0.05). Adult BPD survivors also had significantly lower VE/VO2 and higher VE/ VCO2 levels at anaerobic threshold (p \ 0.05). Adult BPD survivors had lower exercise capacity than preterm non BPD and term control groups. Significantly they had lower oxygen consumption at peak exercise and walked a shorter distance on the treadmill than either control group. They also attained lower peak heart rates and lower respiratory exchange ratio values than term controls (p \ 0.05). There were no statistically significant differences in perceived symptoms (Modified Borg Score) between groups. There were no statistically significant differences in weekly activity levels, smoking status or BMI between each group.
8.19. Acute Toxicity from Accidental Industrial Chlorine Gas Exposure H. A. O’Neill, A. O’Brien
R.P. Cusack, S.A. Landers, D.R. Curran, T.M. O’Connor Respiratory Department, Mercy University Hospital, (MUH), Cork, Ireland To evaluate demographic and diagnostic methods used in a series of 10 patients with paradoxical vocal cord dysfunction (PVCD). Case series from retrospective medical chart review in a tertiary referral centre using 10 patients diagnosed as having PVCD aged 15 or older. Main outcomes recorded were age at referral and diagnosis, background history, symptoms and investigation results. Five patients were female and 5 male. The mean age of referral was 34.3 years, with mean age of 35.2 years at diagnosis. There were 21 hospital admissions including 3 ICU admissions. 4 patients had a history of Gastro-oesophageal reflux, 9 had a history of asthma and 6 had a history of sinusitis. 4 patients had a history of anxiety/ depression with 3 reporting chronic pain and 1 having a history of pseudo-seizures. 8 patients reported dyspnoea, with 5 patients reporting stridor. 2 patients reported hoarseness. 4 patients had flattened inspiratory curves on the PFT’s and 6 had a normal chest xray. All 10 patients underwent bronchoscopy which was diagnostic for PVCD. To our knowledge this is the first series of PVCD in Ireland. The authors plan to expand this cohort by reporting on cases from other centres in Ireland in the future.
Respiratory Department, University Hospital Limerick, Dooradoyle, Limerick, Ireland Chlorine gas is a pulmonary irritant that affects the mucous membranes in both the upper and lower respiratory tract and may induce severe disturbances in pulmonary gas exchange. Eight patients, aged 45 ± 5, were hospitalised following an acute industrial chlorine exposure and subsequent decontamination in the Emergency Department. Exposure time ranged from 30 s to 3 min. Symptoms reported included shortness of breath, airway irritation, ocular irritation and one report of palpitations. Four patients had abnormal respiratory examination and three patients had tachycardia. Five patients were in type 1 respiratory failure and one was in type 2 respiratory failure. Chest X-ray (CXR) on admission was normal for six patients; one demonstrated focal infiltrates; two pneumonitis. A further patient developed pneumonitis the following day. One patient required non-invasive ventilation and had further complications. All patients were treated with steroids and nebulisers, three were also treated with co-amoxiclav. Chest X-ray changes were resolved up to 3 months later. Two patients remained symptomatic at follow-up 6 months later. Follow-up pulmonary function tests are still being conducted. This study reports the range and impact of complications associated with accidental industrial chlorine gas exposure. It also highlights the resulting longer-term morbidity, despite best treatment.
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Irish Thoracic Society Poster Review and Discussion Saturday 16th November 2013
9. Treatment, management and policy—challenges and novel approaches Chairs:
D. Downey, Belfast City Hospital, Belfast P. Branagan, Beaumont Hospital, Dublin
9.1. To assess the Relationship of Acoustics and Physiological Measures of Lung Function K.C. Tee1, J.N. Seheult1, M.S. Holmes2, T. Bholah1, S. D’Arcy2, I Sulaiman1, R.B. Reilly2, R.W. Costello1 1 The Department of Medicine Respiratory Research Division, The Royal College of Surgeons in Ireland, Dublin 2, Ireland, 2Trinity Centre for Bioengineering, Trinity College, Dublin, Ireland
Lung function has an important role in a clinical setting. For example COPD exacerbations tend to be accompanied with dynamic changes in lung function and volume. For this study, with a novel device (INCA) that records patient inhalations and exhalations, we hope to use these acoustic measurements to predict Peak Inspiratory Flow Rate (PIFR) and Inspiratory Capacity (IC). A polyethylene terephthalate container, ‘lunchbox,’ was used as an airtight medium between a DiskusTM Inhaler, INCA device and a hot-wire anemometer spirometer. 120 patients with asthma, COPD, obesity, cystic fibrosis, restrictive lung disease and miscellaneous diseases were recruited. Both baseline spirometry (best of 3) and lunchbox recordings (best of 5) were obtained from each patient. Valid data was collected from 93 patients (27 patients excluded due to device failure). Audio files recorded from INCA were analysed using audacity and Matlab. PIFR was calculated from Mean Absolute Deviation (MAD) using equations derived from a previously published paper1. Using the calculated PIFR and duration, IC was then calculated using a Generalized Linear Model1. To compare measured and calculated values we used Ordinary Least Squares (OLS) regression. PIF measured versus PIF calculated showed a R2 = 0.882 (figure 1). IC measured versus IC calculated showed a R2 = 0.893. Measured acoustics can be used accurately in predicting PIFR and IC using a novel device, INCA, in a variety of clinical conditions. Conflicts of Interest: The patented acoustic device [INCA device] used in this study is manufactured by Vitalograph, Ireland. The first authors of this abstract have no affiliation to Vitalograph and is not listed as a holder of the relevant patents. References: 1. Holmes M, Seheult J, Geraghty C, D’Arcy S, O’Brien U, O’Connell GC, Costello RW, Reilly RB A method of predicting inspiratory flow rate and volume from an inhaler using acoustic
Figure 1: Plot of measured PIFR against calculated PIFR (right) with 95 % prediction interval of ± 15L/Min and measured IC against calculated IC (left) with 95 % prediction interval of ±0.4 L/Min
9.2. Connolly Hospital the first Respiratory & Sleep diagnostics department in Ireland to join the National Integrated Medical Imaging System (NIMIS) for Pulmonary Function (PFT) and Sleep (PSG/NIV) Results and Reports A. McGowan, A. O’Brien, K. Fennell, J. Faul, L. Cormican, C.Burke Respiratory & Sleep Diagnostics, Connolly Hospital, Blanchardstown, Dublin 15, Ireland As with many other Respiratory & Sleep Diagnostic departments in Ireland PFT, PSG, NIV reports are only available within the individual department local network or as a paper copy in the patient medical record. Aims were to achieve a paperless workflow environment, to improve efficiency, patient safety, communication and data archiving,
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to introduce electronic ordering, multimedia reporting, provide outside hospitals and GPs electronic access to reports at a national level. Respiratory & Sleep Diagnostic staff worked with the NIMIS team on the test catalogue, patient appointment letters, ordering prompts, testing and implementation of the system. Connolly Hospital was fully integrated with the NIMIS project in October 2012. One year on the system is fully operational, has not been without its issues but has achieved its goals.
9.3. A Survey of Multidisciplinary use of Manometry whilst carrying out Manual Hyperinflation Manual hyperinflation (MHI) is a frequently used technique for the management of intubated and ventilated patients in the intensive care unit (ICU). MHI is a form of positive pressure therefore it is important to consider pressures delivered (Hila et al., 2002). The aim of this survey was to determine the use of pressure manometers amongst members of the multidisciplinary team (MDT) in Beaumont Hospital ICUs, to establish MDT awareness of pressure parameters for MHI and to determine if members of the MDT would use disposable manometers if they were available to them. Thirty four members of the MDT who had used MHI took part in the survey. Data was collected regarding previous manometry use, awareness of pressure manometers and potential use of disposable manometers.
There was male predominance in both groups with a larger proportion of non-smokers in the younger group. Strikingly there was more number of trans-bronchial biopsies performed in older people mostly for diagnostic evaluation of lung cancers. As one may expect sedation was cautiously used in the elderly. Although few elderly patients required reversal of sedation, there is no significant difference noted in patient comfort levels. The complication rates of bronchoscopy in elderly are not a consequence of their age, but factors like co-morbidities, sedation, pre-procedure state etc. should be considered. The anticipation of risk shouldn’t preclude older people from getting these interventions. References: 1. Rokach A, Fridlender ZG, Arish N, Berkman N (2008) Institute of Pulmonology, Hadassah-Hebrew University Medical Center; Age Ageing. 37(6):710–713 2. Chotirmall SH, Watts M, Moore A, Kearney F, Brewer L, McElvaney NG, Donegan CF (2009) Age Ageing 38(6):764–765
9.5. Readability and Content of Patient Information Leaflets for Endoscopic Procedures F.S. Gargoum1, M. Mokoka1, S.T. O’Keeffe2 1
Department of Respiratory, Galway University Hospitals, Galway, Ireland, 2Department of Geriatric Medicine, Galway University Hospitals, Galway, Ireland
Results of survey Yes No Yes % No % Have you previously used manometry?
12 65 %
Would you find the new Manometer useful? 34
100 % 0 %
Would you use the new manometer if available?
100 % 0 %
Are you aware of pressure limits?
This survey suggests that the introduction of disposable pressure manometers in ICU could result in improved compliance and accuracy of pressure monitoring amongst members of the MDT and thus prove to be an important safety initiative. References: 1. Hila et al. (2002) Feedback withdrawal and changing compliance during manual hyperinflation. Physiother Res Int 7(2):53–64
9.4. Bronchoscopy in Octogenarians Myth versus Reality C. Varghese, S.H. Chotirmall, J. Lyons, F. O’Connell Department of Respiratory medicine, St. James’s Hospital, Dublin, Ireland Bronchoscopy remains an important tool in the evaluation of various respiratory conditions. As there is an increasing prevalence of respiratory diseases in older people, including lung cancer the role of various diagnostic techniques is becoming more valuable. We did a retrospective analysis of bronchoscopic outcomes in patients over 80 years over a period of 6 months. We have considered factors which might potentially affect the outcome of the intervention, including procedure type, amount of sedation, comfort levels and risk of bleeding. Similar factors have been evaluated in equal number of patients below 80 years of age.
Patient information leaflets (PILs) are used as part of informed consent for treatment. The information provided must be in a form that most people can understand. One in four Irish adults have literacy difficulties. Studies show that PILs are too hard to read. We wrote seeking copies of PILs related to consent for endoscopic procedures in 24 hospitals. All PILs were scanned, and converted to Microsoft Word 2010 digital format using optical character recognition software. Readability was measured using Flesch-Kincaid grade level scores. We received 61 PILs: 47 from 17 GI units, and 7 bronchoscopy PILs from 7 respiratory units. The response rate was 60 %. The mean (standard deviation, range) Flesch readability score for the PILs was 61.2 (4.9, 46.2–73.2). Overall, 38 (62 %) PILs met a minimum standard of a reading ease score of 60 or more. Results for the FleschKincaid grade level were 7.9 (1.1, 5.9–9.2). One-third of PILs in Irish endoscopy units didn’t meet a minimum standard for readability. Few met the recommended reading level for medical information. Current PILs fail to inform their target audience. We suggest a standardised approach to developing PILs for common procedures.
9.6. Respiratory Case Load in Acute Medical Assessment Unit/Acute Medical Unit in St. Vincent’s University Hospital (SVUH) J. Alam, P. Hawkins, E.E. McGrath, E. Kelly Respiratory Department and Acute Medical Assessment Unit/Acute Medical Unit, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland Respiratory disease (RD) is a common reason for admission through the Acute Medical Unit (AMU). Reviewing the volume and specifics of the respiratory cases should help future service provision.
S482 This was a retrospective review of consecutive patients attending the AMU in July 2013. In total, 168 patients were admitted and discharged from AMAU/AMU in July under both AMU (87 %) and non-AMU consultants (13 %). Data was obtained from electronic discharge letters and AMU admission register. SPSS 17 was used for statistical analysis. Six patients were excluded as information on diagnosis could not be readily obtained. The median age was 66 (range 20–95) years, 60 % were female. RD was the most common cause of admission (33, 20 %); 13 pneumonia, 8 COPD, 3 pulmonary embolism, 3 asthma, 3 sinusitis, 2 pleural effusion, 1 with dyspnoea unclear cause. Mean length of stay (LOS) of patients with RD is 2.61 days VS 2.19 with non-RD patients. The median LOS in days was also high in pts with genitourinary diagnoses (3.2), poor mobility/falls (2.8) and cardiovascular disease (2.7). The high proportion of respiratory cases demonstrated here suggests the need for on-going collaboration between the AMU and Respiratory Department in delivering optimal care to these patients.
9.7. Nursing student assessment and objective setting on the respiratory ward J. Brady1, P. Nolan1, O. Nugent2, B. Korn1 1 John Houston Ward, Department of Respiratory Medicine, St. James’s Hospital, Dublin 8, Ireland, 2Nursing Practice Development Unit, St. James’s Hospital, Dublin 8, Ireland
Staff nurses mentor between approximately 40 nursing students annually on our 31-bedded in-patient respiratory unit in a large academic teaching hospital. Assessment of student learning is directly correlated to academic objectives. However learning is influenced by the environment and the individual nurses in the mentoring role. We identified inconsistencies in nursing student’s assessments and objective setting dependent upon the nurses involved. We therefore developed a template for student nurse assessment and objective setting specific to the respiratory ward environment. We aimed to evaluate staff nurse’s perception on the effectiveness of the assessment and objective setting template. A brief questionnaire was distributed to all respiratory ward based staff nurses. 15 of 25 staff nurses completed the questionnaire (60 %). Of those 94 % felt that objectives accurately facilitated student assessment during their initial interview. 94 % stated that it supported assessment of student’s level of performance at intermediate and final interview. According to 94 % it gave clear focus when devising an action plan for underperforming students. Respondents recommended the template as a positive development. The assessment and objectives setting template gave nurses on the respiratory ward clarity and guidance when assessing nursing students and resulted in a more direct and focused learning environment.
9.8 Demonstration skills and knowledge for inhalers use are lacking among Health Care Professionals O. Mikulich, L. Abdul, C. Mc Donnell, P. Ryan, B. Casserly, A. O’Brien University Hospital Limerick Rationale: Limited information is available on healthcare professionals knowledge of inhaled medications and devices for their administration.1
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 Methods: Prospective audit of Hospital Doctors (Consultants, NCHDs, Medical Students) and nurses. 110 subjects (20 nurses, 50 NCHD, 12 non-Respiratory Medical Consultants, 28 medical students) completed questionnaires about the most commonly prescribed inhalers (Spiriva, Seretide, Symbicort, Beclasone, Ventolin) and underwent evaluation of their demonstration skills for: meter-dose inhaler (MDI), Easibreathe, Turbohaler, Diskus, Handihaler, Respimat. Resuls: Ventolin was the most familiar inhaler: 94 % NCHDs and 85 % nurses knew its generic name, 86 % doctors and 60 % nurses knew its drug class and 75 % of both knew frequency of use. Only 12 % of doctors (vs 55 % nurses) knew its correct dosage. Least familiarity was shown for Symbicort generic name (22 % doctors vs 10 % nurses), its drug class (34 % doctors vs 25 % nurses) and frequency of usage (42 % doctors vs 70 % nurses). Interestingly, familiarity with Symbicort remained lowest among Consultants also: 16.7 % knew its generic name and dose, 42 % identified correctly drug class and 58 % named rightly its frequency of use. In relation to Beclasone and Ventolin – Consultants and medical students demonstrated similar level of knowledge: 75 % Consultants (vs 71 % students) knew Ventolin generic name, 75 % (vs 85 % among students) knew its drug class and 83 % (vs 53 % of students) named correctly its frequency of use. For Beclasone correct answers were given about its generic name by 66 % of Consultants and 75 % students, while 83 % Consultants (vs 86 % students) knew its drug class, and 58 % Consultants (vs 28 % students) gave its correct frequency of use. Nurses were more familiar with devices: 60 % named correct device for Seretide, 50 % for Ventolin and 40 %remainder. For doctors: 24 % Seretide, 18 % Ventolin, 16% Beclasone, 14 % Symbicort and 8 % Spiriva. 80 % doctors and 60% nurses demonstrated correct use of MDI. Demonstration skills were least successful for Respimat (16 % doctors; 25 % nurses). Conclusion: Inhalers knowledge among healthcare professionals is lacking. Doctors demonstrate better knowledge about inhalers generic names and drug class than nurses. Nurses’ knowledge is better for doses, frequency of use and devices. Education of healthcare professionals about inhaled respiratory medication is extremely important. Reference: 1. Self T et al. Inadequate skill of healthcare professionals in using asthma inhalation devices.J Asthma. 2007 Oct;44(8):593–8
9.9. Can Karnofsky Score (KS) & ECOG Performance Status (PS) Better Characterise Severity of Illness for Inpatients on a Respiratory Ward? M.G. Kelly Consultant Respiratory Physician, Department of Respiratory Medicine, Altnagelvin Area Hospital, Derry, UK Both PS & the lesser known KS were developed to allow clinicians to evaluate patients’ ability to survive chemotherapy. Palliative care physicians advocate their use to assess survivability on a non-cancer ward. We were interested to assess severity of illness for our patients, particularly as we felt that patients on a respiratory ward were more ill than elsewhere in the hospital, and this was not recognised by managers. Over a 22 month period, the author intermittently recorded the KS & PS score on his own patients (representative of the ward complement) at the weekly multidisciplinary meeting. Additionally, on 16 occasions, the age profile of this 29 bedded ward was recorded. Both scores are linear categorical variables from 0 % (death) to 100 % (normal, no signs of disease) & 0 (asymptomatic, fully able) to 5 (death) respectively.
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 Median KS of 40 (disabled, requires special care & help) and PS of 3 (symptomatic, [ 50 % in bed, capable of only limited self-care) represents quite an ill cohort of patients. 71.6 % had KS B 40. Median of 10 (34.5 %) C 75, 6 (20.7 %) C 80 & 2 (6.9 %) C85 y. Illness severity scores can be useful & should be used to better characterise inpatients. References: 1. Karnofsky DA, Burchenal JH (1949) The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM (ed) Evaluation of Chemotherapeutic Agents. Columbia Univ Press, Columbia, p 196 2. Oken MM, Creech RH, Tormey DC et al (1982) Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 5(6): 649–655
9.10. The Moratorium on Recruitment and Promotions—its effects on the Pulmonary Function Services in Ireland O. Farrelly Chairperson, Faculty of Respiratory IICMS-MRH, Mullingar, Ireland The Government declared a moratorium on Recruitment and Promotions in the Public Service including the health sector with effect from the 27th of March 2009 until the end of 2010. It is still in place today, 4 years later. The conditions of this moratorium, is to allow for the continued development of integrated healthcare, including cancer services and the development of clinical programmes aimed at streamlining care and reducing waiting lists, particularly primary and community care. Pulmonary Function departments provide key diagnostic services in healthcare. Before the moratorium many departments were already understaffed. In addition Pulmonary Function departments were neither included nor consulted for staffing requirements prior to the development of the National Cancer Control Programme (NCCP) (2006) or Acute Medicine Programme (2009). These programmes have a direct impact on our provision to deliver services yet have resulted in no new recruitment. While we did have a representative on the Asthma & COPD Clinical Programmes (2009) this has not resulted in any new recruitment either despite the huge need to provide spirometry in the community. The majority of Pulmonary Function departments do not have clerical support. Higher paid skilled respiratory scientists carry out grade 3 clerical duties representing poor value for money and inappropriate use of respiratory scientist time. This needs to be acknowledged and addressed. Direct contact by phone and email with all head of departments (HOD) took place to discuss the issues raised and the shortage of staff before & after the moratorium. Conclusion, to seek a moratorium exemption for clinical measurement science.
9.11. Seachange in Pleural Procedures & Chest Drain Insertion: 2008 vs 2012 Audit Figures C. King, A. Green, N. Chapman, R. Convery Respiratory Medicine, Craigavon Area Hospital, County Armagh, UK We previously audited our Chest Drain data against BTS guidelines in 2008 highlighting the widespread use of large bore drains and poor
S483 documentation of consent/procedure used. A similar audit took place in 2010 resulting in a written policy document for Chest Drain Insertion in 2011 and widespread availability of pleural ultrasound (and training in its use). Elective Pleurocentesis Clinic slots and a written logbook of all pleural procedures outside the ED allowed us to demonstrate change of practice. A 2008 chart search found 48 drains (including the ED) with 2012 showing only 20 elective drains (excluding ED) inserted on the Respiratory ward logbook. Elective drain insertion on the Respiratory ward was for effusion/empyema in 95 %—almost all emergency drains reserved for Pneumothorax in the ED. Ultrasound guidance was used in 90 % of the elective drains and not recorded in the remaining two. In 2008, only 4 had areas marked under ultrasound in the radiology department and 44 drains were inserted without ultrasound guidance. Consent was recorded in 18 of the 20 cases, compared with 20 out of 48 in 2008. We are still not logging all procedures especially those performed in the ED. Enhanced use of seldinger drains is also probably responsible for the perceived reduction in drain complications. The audit demonstrated how; 1. Ultrasound and effective training has become an essential tool for safe chest drain insertion, leading to fewer complications. 2. In the interests of patient safety all chest drains are cared for on a Respiratory ward by appropriately trained staff. 3. A written log of all procedures is vital with a computerized database being developed. 4. Our written policy on Chest drain insertion was updated in Jan 2013 following an 18 month trial. 5. Elective clinic pleurocentesis slots allow a safer centralized service.
9.12. Social Care Needs of a Respiratory Ward Population in a DGH K. Reilly, L. Reilly, M. Mc Closkey, M. Kelly, A. Aziz, D. Carlin, E. Buchanan, V. Gray, B. Crossan, B. Donaghy, R.A. Sharkey Department of Respiratory Medicine, Altnagelvin Hospital, Derry, N. Ireland With the planned introduction of ‘Transforming Your Care’ (TYC) in N Ireland, care of patients will move more into the community. We wished to determine the non-medical requirements of patients admitted to our respiratory ward and so help determine the impact in relation to TYC. Review of notes of the multidisciplinary discharge planning meeting of 94 inpatients on our respiratory ward during 2012. 94 patients (51 F/43 M) with mean age of 68 years (37–93 years) were included. Diagnosis—COPD 42 (45 %), pneumonia 26 (28 %), Bronchiectasis 6, pulmonary fibrosis 4, Asthma 4, PE 3, TB 2, metastatic cancer 2, other diagnosis 5. 60 (64 %) patients lived with family, 18 (20 %) lived alone, 6 (7 %) in Nursing home, 1 in residential home, 1 in sheltered accommodation and 8 unknown. 40 patients (44 %) required social worker and occupational therapy assessment. 5 patients (5 %) had a delayed discharge as a result of a nonmedical reason. This review has highlighted the significant non-medical needs of the patient population of a respiratory ward in a DGH. This factor has to be factored into TYC planning as this will have a significant influence on the ability to discharge patients in a timely manner.
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9.13. Prognostic Significance of the ‘Surprise Question’ in an Respiratory Inpatient Population in a DGH
9.15. Smoking and Tobacco Control Survey of Healthcare Professionals (HCP) in Ireland
L. Reilly, K. Reilly, M. Mc Closkey, M. Kelly, A. Aziz, D. Carlin, E. Buchanan, V. Gray, R.A. Sharkey
S. Keogan, V. Clarke, M. Ward, L. Clancy
Department of Respiratory Medicine, Altnagelvin Hospital, Derry, N. Ireland The ‘surprise question’—‘‘Would you be surprised if this patient died in the next year?’’—is a simple and effective tool to identify cancer patients with a greatly increased risk of 1-year mortality (GSF). We looked to determine the efficacy of the surprise question in a respiratory inpatient population. Review of notes of 85 non-cancer inpatients on our respiratory ward during 2012. 85 patients’ (49 F/36 M) with mean age was 68 years (27–88 years) were randomly selected. Diagnosis-COPD (48 %), Pneumonia (28 %), Bronchiectasis (10 %), pulmonary fibrosis (5 %), Asthma (4 %), muscular dystrophy (2 %) and others (2 %). Of the total 85 patients, 28 (33 %) were dead at 1 year. Respiratory consultants classified 67 (78 %) patients into the ‘‘No’’ group and 18 (22 %) into the ‘‘Yes’’ group. Of the 67 in the ‘‘No’’ group, 28 (42 %) were dead at 1 year. Of the 18 in the ‘‘Yes’’ group, all were alive at 1 year. This review has highlighted the poor prognosis of a significant % of the inpatient non-cancer population in a DGH respiratory ward. Use of the ‘surprise question’ alone, in this population, is insufficient in predicting those patients at increased risk of death at one year. Gold Standards Framework. http://www.goldstandardsframework. nhs.uk
9.14. How High is the Level of Illicit Tobacco Trade in Ireland? L. Clancy, L. Currie, S. Keogan, V. Clarke For PPACTE Consortium TobaccoFree Research Institute Ireland, Dublin, Ireland Measuring illicit trade reliably is difficult. The Tobacco Industry (TI) claims it is particularly high in Ireland. This is in their interest as it deters the Government from raising tobacco taxes. This is important to the TI because high prices discourage smoking, especially among the young and the poor. Also it allows the TI to increase their prices and increase their profits. As part of the PPACTE (Pricing Policy and Tobacco Control in Europe) FP7 EU project MRBI surveyed 16 European countries including Ireland. We asked about use of illicit tobacco through a number of validated questions including where purchased and price paid. Also each smoker was asked to ‘show their pack’ which was examined for language, health warnings and tax stamps to identify status of packs. This was compared with official figures available from KPMG report where much of the methodology was redacted. 4.6 % of packs were identified as illicit and 10.3 % of packs as non-domestic duty paid. The KPMG figure was nearly 20 % Measurement of illicit trade is inherently imprecise. Methodology needs to be open to full scrutiny and applied consistently. Illicit tobacco trade should be regularly estimated and be completely independent of the TI.
TobaccoFree Research Institute Ireland, Dublin, Ireland The need to control tobacco is probably the most important health intervention. Tobacco dependence is a recognized lifedestroying disease. It is therefore very important that all health care professionals are educated and feel competent as role models to enable the treatment of tobacco dependence which is highly cost effective, to be a successful medical intervention. Thus the attitudes, knowledge and preparedness of health professionals in Ireland are highly relevant and must embrace all health professionals. The objectives of this study were to estimate: the prevalence of smoking the knowledge as well as attitudes and training concerning treatment of tobacco dependence (TTD) among Healthcare Professionals (HCP): A previously validated electronic questionnaire using ‘Survey Monkey’ was circulated to the INMO, IMO and IDA members. The prevalence of current smokers was 19.6 % of Nurses, 20.3 % of Doctors and 23.4 % of Dentists.
Figure 1: HCPs perception of their knowledge and training needs in treatment of smoking cessation The data suggests that prevalence of smoking among HCP is similar to the general population of the same socio-economic group. None of the groups feel adequately trained, nurses of which 97.4 % are female have the lowest prevalence. This study will have implications with regard to training and availability of resource with regard to treatment of smokers wishing to quit.
9.16. Tobacco Free Playground-Millennium Park, Dublin 15 Initiative V. Clarke1, C, Hayden2, M. Gunning3, C. Wilde3, M. Ward1, K. Halpenny4, S. Keogan1, L. Clancy1 1
TobaccoFree Research Institute, Dublin, Ireland, 2Dublin Institute of Technology, Dublin 1, Ireland, 3Health Service Executive, Dublin, Ireland, 4Fingal County Council, Parks Division, Dublin, Ireland Second hand smoke (SHS) is a significant cause of death and disease with pregnant women and children being particularly vulnerable. Smokefree policies are important in protecting people from SHS and also in denormalising smoking.
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The Tobacco Free Playground Initiative Group was established in early 2010 with representatives from the HSE, Fingal County Council Parks Division and the TobaccoFree Research Institute, Ireland. The Group proposed making Millennium Park, Dublin 15 a Smokefree playground thus denormalising tobacco use and reducing litter from cigarette butts. A survey of 105 people, conducted in August 2010, prior to the initiative, showed strong support for reducing SHS in the playground. Following this and linking with World No Tobacco Day, on 27th May 2011, the Millennium Park Playground went smoke free. The survey was repeated in August 2011. The results showed good compliance with the initiative, with 80 % of smokers not smoking in the playground. Particle levels were low and decreased after the initiative. Only 3 butts were found after the initiative. A summary of the results of both surveys is provided below. Table 1: Results of surveys prior to and post the introduction of the smokefree playground initiative Prior to playground Post playground going Smokefree going Smokefree Support for reducing SHS 87 % in the playground
Highest recorded level of 5 micrograms PM2.5 Highest recorded level of 26 micrograms PM 10
Highest recorded number 27 of butts at a park bench
6 micrograms 3
Given the success of this initiative Fingal County Council adopted a policy of smokefree playgrounds on a county wide basis.
9.17. BiPAP Education from Student to Registrar Level—a Case for Formalised Training? S. Fitzgerald, O. McElvaney, P. Doyle, F. McEneaney, J. Meurling, K. Bolger, R. Morgan Respiratory Division, Department of Medicine, Beaumont Hospital, Dublin 9, Ireland The purpose of this study was to assess the degree of competence felt by trainee physicians, who trained in Beaumont Hospital Dublin, with regard to the theory and practical elements of bi-level positive airway pressure (BiPAP). Despite the fact that 50 % of events necessitating BiPAP occur out of hours, anecdotal evidence suggests that junior staff are not comfortable initiating and managing noninvasive ventilation. A series of 27 multiple choice questions were employed to assess NCHDs’ experiences with BiPAP training to date, as well as their subjective opinion of their ability to deal with common clinical scenarios relating to BiPAP. 25 Interns, 25 SHOs and 5 registrars were interviewed. The vast majority of respondees felt that training at undergraduate level was not adequate. Most respondees did not feel competent responding to changes in clinical parameters (pO2, pCO2, pH, GCS) of a patient on BiPAP. Most did not feel competent in managing individual elements of patient care. The results of this study suggest that a formalised NIV training programme, administered by a training body, may be a welcome step. Structured training courses, tailored to the appropriate level, would appear to be most effective.
9.18. A Neuromuscular Respiratory Outpatient Clinic: Patient Profile (Beaumont Hospital) K. Carty, C. Egan, M. Guidon Beaumont Hospital, Dublin, Ireland Due to advancements in respiratory interventions patients with neuromuscular disorders are progressing into an adulthood healthcare setting and there is a need for intervention in this phase of transition . Currently children with NMD transition to adult services without a designated medical consultant. In January 2012 a multidisciplinary Neuromuscular Respiratory Clinic was established in Beaumont Hospital. This is the first of its kind in an adult setting in Ireland. The patient profile was completed using a retrospective review of patient charts that attended the clinic from January 2012. Forty-one patient records were reviewed. The majority of the patients (56 %) presented with a form of Muscular Dystrophy. 51 % of patients were under 35 years. 78 % of patients reported a Peak Cough Flow below 270 L/min. 7 out of the 13 patients who had pulmonary function tests carried out recorded an FEV1 less than 50 % of the predicted value. Interventions provided included breath stacking, deep breathing exercises and the use of a cough assist device. The young age profile justifies the need for this clinic. There is currently no clinic in Ireland accommodating this patient group and access to this care-team is vital for optimal management of their condition. References: 1. Passamno L, Gagila A, Palladina A, Iggiano E, et al (2012) Improvement of survival in Duchenne Muscular Dystrophy: Retrospective analysis of 835 patients Acta Myologica. 31(2):121–125 2. Bach JR, Zhitnikov S (1998) The management of neuromuscular ventilatory failure. Semin Pediatric Neurol 5(2)92–105
9.19. In vitro Correlation of Inhalation with Drug Deposition Using the Next Generation Impactor J.N. Seheult1, P. O’ Connell2, T. Bholah1, K.C. Tee1, M.S. Holmes2, S. D’Arcy3, F. Keane4, E. Kelly4, R.B. Reilly3, R.W. Costello1 1 The Department of Medicine Respiratory Research Division, The Royal College of Surgeons in Ireland, Dublin 2, Ireland, 2School Of Pharmacy, Trinity College, Dublin, Ireland, 3Trinity Centre for Bioengineering, Trinity College, Dublin, Ireland, 4Vitalograph, Ennis, Co Clare, Ireland
When used correctly, dry powder inhalers (DPI) can improve patients’ clinical outcomes in obstructive airways disease. However, some patients are unable to reach the peak inspiratory flow rate (PIFR) necessary to de-agglomerate these drug particles which then impacts on drug deposition. Using a Next Generation Impactor we aim to see what relationship PIFR has on drug deposition and Fine Particle Dose (FPD). The Next Generation Cascade Impactor was set up according to the United States Pharmacopoeia guidelines. Seretide (Salmeterol 50 mcg, Fluticasone 250 mcg) inhaler, was attached to the induction port. High Performance Liquid Chromatography was used to quantify the drug product in each cup and in the Preseparator and Throat of the Impactor. FPD (\5 lm) and Total Emitted Dose was measured at 30, 60 and 90 L/min each for 2, 4 and 6 s duration. Multivariate regression of FPD vs PIFR and duration was performed. Figure 1 shows that FPD increases as both PIFR and duration increase. The relationship of FPD vs flow rate and duration has an
S486 adjusted R-squared value of 94 %. Both flow rate and duration were statistically significant predictors of FPD (p \ 0.05). Flow rate and duration of inhalation as measured can be used to accurately predict FPD delivery in vitro.
Ir J Med Sci (2013) 182 (Suppl 10):S427–S486 may be classified as: Hypoxemic (Type I), characterized by a Pa O2 lower than 60 mm Hg with a normal or low arterial Pa CO2 and Hypercapnic (Type II): characterized by a PaCO2 higher than 50 mm Hg. Objective: To document the clinical practice in patients of RF admitted to our unit from 1st January 2011 to 31st January 2011. Methodology: Medical records of all the patients were analysed and screened for RF & data was gathered on a structured proforma made according to BTS Guidelines. Results: 1: 51 patients were in RF, Males 23 (45.10 %) & Females were 28 (54.9 %). Type 1 RF 22.22 % (10) & Type 2 RF 77.78 % (35).
Figure 1: Graph of Fine Particle Dose vs PIF, stratified by duration of inhalation References: 1. Sumby B, Cooper S, Smith I (1992) A comparison of the inspiratory effort required to operate the Diskhaler inhaler and Turbohaler inhaler in the administration of powder drug formulations. Br J Clin Res 3:117–23 2. Marple VA, Roberts DL, Romay FJ, Miller NC, Truman KG, Van Oort M, Olsson B, Holroyd MJ, Mitchell JP, Hochrainer D (2003) Next generation pharmaceutical impactor (a new impactor for pharmaceutical inhaler testing). Part I: Design. J Aerosol Med 16(3):283–299
9.20 Clinical practice in patients with Respiratory Failure – an audit. H. Ullah Department of Respiratory Medicine, Khyber Teaching Hospital, Peshawar, Pakistan Introduction: Failure of respiratory system in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. It
2: ABG’s showed Acidosis in 35.55 % (16). 90 % (9) in Type 1 RF were treated by increasing FiO2 via nasal canula. In Type 2 RF, 42.86 % (15) were put on NIPPV & 51.43 % (18) on Venturi mask. 40 % (6) had no documentation of the duration of weaning but 77.78 % (7) improved. 3: Patients on NIPPV, 66.66 % (10) improved, no documentation in 26.66 % (4), 6.68% (1) refused NIPPV. 27.45 % (14) were discharged on LTOT. Conclusion: Oxygen delivery via nasal canula was found to be effective in Type 1 RF. NIPPV was found to be safe and effective in treating Type 2 RF with acidosis and in cases of normal PH, controlled oxygen therapy via venture mask was effective.