London Chest Hospital

<bold>Introduction:</bold> Chronic cough (CC; >8 weeks) affects around 10% of the population, and patients often undergo sequential investigations and therapies. Recent guidelines have evolved to targeted management based on traits; however, little is known about patient healthcare experience in CC. We aimed to investigate patient experience of the diagnostic pathway in CC. <bold>Methods:</bold> Consecutive patients were recruited from a specialist cough clinic (King’s College Hospital, UK). Semi-structured focus group interviews with open-to-closed questions were conducted, and followed by thematic analysis with open coding iteratively. <bold>Results:</bold> A total of 14 participants were recruited; mean (SD) age 65 (7) years, 10 (71%) female, and cough duration 14 (9) years. Five themes were identified: Patients reported concerns of serious underlying medical conditions for cough, <italic>“…you hear all these kind of horror stories about continuous cough could be… the beginning of a bigger thing…”</italic>. Patients often underwent multiple and repetitive investigations, <italic>“…you name it I think I’ve had it…”</italic>. Patients described inadequate clinician understanding of chronic cough as a disease, <italic>“I was told it was psychosomatic…”</italic>. Difficulty to access specialist care, which contributed to prolonged patient journey and themes above, <italic>“It's like delaying something that can be immediately narrowed down and sent in the right direction...”</italic>. Satisfaction with cough specialist care, <italic>“it just makes you realise you're not on your own…”</italic>. <bold>Conclusion:</bold> The study identified common themes in patient experience of the diagnostic pathway in CC. Addressing these themes in future guidelines will facilitate the delivery of a patient-focused cough service and optimise patient journey.

SUMMARYExercise-driven alterations of the immune system are a key mechanism in the prevention and treatment of various diseases. Here, we performed mass spectrometry-based proteomics analysis on peripheral blood mononuclear cells (PBMCs) at a depth of &gt;6000 proteins. Comparing time– and workload-matched high-intensity interval exercise (HIIE) and moderate-intensity continuous exercise (MICE) we discover versatile changes in the proteomic makeup of PBMCs and reveal profound alterations related to effector function and immune cell activation pathways within one hour after exercise. These changes were more pronounced after HIIE compared to MICE and occurred despite identical immune cell mobilization patterns between the two exercise conditions. We further identify an immunoproteomic signature that effectively predicts cardiorespiratory fitness. This study provides a reliable data resource that expands our knowledge on how exercise modulates the immune system, and delivers biological evidence supporting the WHO 2020 guidelines, which highlight exercise intensity as a relevant factor to maintain health.

Idiopathic pulmonary fibrosis (IPF) is a progressive, fatal disorder with a variable disease trajectory. The aim of this study was to assess the potential of neutrophil-to-lymphocyte ratio (NLR) to predict outcomes in IPF. We adopted a two-stage discovery (n=71) and validation (n=134) design using patients from the UCL partners (UCLp) cohort. We then combined discovery and validation cohorts and included an additional 794 people with IPF, using real-life data from 5 other UK centers, to give a combined cohort of 999 patients. Data were collected from patients presenting over a 13-year period (2006-2019) with mean follow up of 3.7 years (censoring: 2018-2020). In the discovery analysis, we showed that high values of NLR (>/=2.9 vs<2.9) were associated with increased risk of mortality in IPF (HR 2.04, 95% CI 1.09-3.81, n=71, p=0.025). This was confirmed in the validation (HR 1.91, 95% CI 1.15-3.18, n=134, p=0.0114) and combined cohorts (HR 1.65, n=999, 95% CI 1.39-1.95; p<0·0001). NLR correlated with GAP stage and GAP index (p<0.0001). Stratifying patients by NLR category (low/high) showed significant differences in survival for GAP stage 2 (p<0.0001), however not for GAP stage 1 or 3. In a multivariate analysis, a high NLR was an independent predictor of mortality/progression after adjustment for individual GAP components and steroid/anti-fibrotic use (p<0·03). Furthermore, incorporation of baseline NLR in a modified GAP-stage/index, GAP-index/stage-plus, refined prognostic ability as measured by concordance (C)-index. We have identified NLR as a widely available test that significantly correlates with lung function, can predict outcomes in IPF and refines cohort staging with GAP. NLR may allow timely prioritisation of at-risk patients, even in the absence of lung function. Breathing Matters, GSK, CF Trust, BLF-Asthma, MRC, NIHR Alpha-1 Foundation.

ObjectiveTo understand the burden of chronic obstructive pulmonary disease among people who use illicit opioids such as heroin, and evaluate inequalities in treatment.DesignCohort study.SettingPatients registered at primary care practices in England.Participants106 789 patients in the Clinical Practice Research Datalink with illicit opioid use recorded between 2001 and 2018, and a subcohort of 3903 patients with a diagnosis of chronic obstructive pulmonary disease. For both cohorts, the study sampled a comparison group with no history of illicit opioids that was matched by age, sex, and general practice.Main outcome measuresIn the base cohort: diagnosis of chronic obstructive pulmonary disease and death due to the disease. In the subcohort: five treatments (influenza vaccine, pneumococcal vaccine, pulmonary rehabilitation, bronchodilators or corticosteroids, and smoking cessation support) and exacerbations requiring hospital admission.Results680 of 106 789 participants died due to chronic obstructive pulmonary disease, representing 5.1% of all cause deaths. Illicit opioid use was associated with 14.59 times (95% confidence interval 12.28 to 17.33) the risk of death related to chronic obstructive pulmonary disease, and 5.89 times (5.62 to 6.18) the risk of a diagnosis of the disease. Among patients with a new diagnosis, comorbid illicit opioid use was associated with current smoking, underweight, worse lung function, and more severe breathlessness. After adjusting for these differences, illicit opioids were associated with 1.96 times (1.82 to 2.12) times the risk of exacerbations requiring hospital admission, but not associated with a substantially different probability of the five treatments.ConclusionsDeath due to chronic obstructive pulmonary disease is about 15 times more common among people who use illicit opioids than the general population. This inequality does not appear to be explained by differences in treatment, but late diagnosis of the disease among people who use illicit opioids might contribute.