Measuring respiratory symptoms of COPD: performance of the EXACT- Respiratory Symptoms Tool (E-RS) in three clinical trials

Background

Symptomatic relief is an important treatment goal for patients with COPD. To date, no diary for evaluating respiratory symptoms in clinical trials has been developed and scientifically-validated according to FDA and EMA guidelines. The EXACT – Respiratory Symptoms (E-RS) scale is a patient-reported outcome (PRO) measure designed to address this need. The E-RS utilizes 11 respiratory symptom items from the existing and validated 14-item EXACT, which measures symptoms of exacerbation. The E-RS total score quantifies respiratory symptom severity, and 3 domains assess breathlessness, cough and sputum, and chest symptoms.

Methods

This study examined the performance of the E-RS in each of 3 controlled trials with common and unique validation variables: one 6-month (N = 235, US) and two 3-month (N = 749; N = 597; international). Subjects completed the E-RS as part of a daily eDiary. Tests of reliability, validity, and responsiveness were conducted in each dataset.

Results

In each study, RS-Total score was internally consistent (Cronbach α) (0.88, 0.92, 0.92) and reproducible (intra-class correlation) in stable patients (2 days apart: 0.91; 7 days apart: 0.71, 0.74). RS-Total scores correlated significantly with the following criterion variables (Spearman’s rho; p < 0.01, all comparisons listed here): FEV₁% predicted (−0.19, −0.14, −0.15); St. George’s Respiratory Questionnaire (SGRQ) (0.65, 0.52, 0.51); Breathlessness, Cough, and Sputum Scale (BCSS) (0.89, 0.89); modified Medical Research Council dyspnoea scale (mMRC) (0.40); rescue medication use (0.43, 0.42); Functional Performance Inventory Short-Form (FPI-SF) (0.43); 6-minute walk distance (6-MWT) (−0.30, −0.14) and incremental shuttle walk (ISWT) (−0.18) tests. Correlations between these variables and RS-Breathlessness, RS-Cough and Sputum, RS-Chest Symptoms scores supported subscale validity. RS-Total, RS-Breathlessness, and RS-Chest Symptoms differentiated mMRC levels of breathlessness severity (p < 0.0001). RS-Total and domain scores differentiated subjects with no rescue medication use and 3 or more puffs (p < 0.0001). Sensitivity to changes in health status (SGRQ), symptoms (BCSS), and exercise capacity (6MWT, ISWT) were also shown and responder definitions using criterion- and distribution-based methods are proposed.

Conclusions

Results suggest the E-RS is a reliable, valid, and responsive measure of respiratory symptoms of COPD suitable for use in natural history studies and clinical trials.

Trial registration

MPEX: {"type":"clinical-trial","attrs":{"text":"NCT00739648","term_id":"NCT00739648"}}NCT00739648; AZ1: {"type":"clinical-trial","attrs":{"text":"NCT00949975","term_id":"NCT00949975"}}NCT00949975; AZ 2: {"type":"clinical-trial","attrs":{"text":"NCT01023516","term_id":"NCT01023516"}}NCT01023516

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-014-0124-z) contains supplementary material, which is available to authorized users.     

Sex determination from chest plate roentgenograms

Precise sexing--97% to 99% accuracy--of adult chest plates is possible when highly predictive costal cartilage ossification patterns are combined with four simple metric determinations. More than 1100 chest plate roentgenograms were evaluated for ossification pattern, fourth rib width, corpus width, sternal length and sternal area in an adult decedent population. An elementary, empirically obtained algorithm using the patternings and measurements, along with simple derivations (sternal length and area indices) was developed and then applied in chest plate sexing. This technique is not only easy, rapid and inexpensive, but it also results in a permanent and easily stored record.     

Maternal blood pressure and fetal ultrasonography in normal baboon pregnancies

Pregnancy in baboons is characterized by lower systolic, diastolic, and mean blood pressures than in the nonpregnant state. As pregnancy progresses, diastolic and mean pressures tend to increase whereas systolic pressure remains low. Sonographic measurements of fetal growth follow a sigmoid pattern, but their increase in relation to length of gestation approximates a straight line between 6 and 21 weeks of gestation (23 to 84% of term).     

Reappraising the early evidence of durophagy and drilling predation in the fossil record: implications for escalation and the Cambrian Explosion

The Cambrian Explosion is arguably the most extreme example of a biological radiation preserved in the fossil record, and studies of Cambrian Lagerstätten have facilitated the exploration of many facets of this key evolutionary event. As predation was a major ecological driver behind the Explosion – particularly the radiation of biomineralising metazoans – the evidence for shell crushing (durophagy), drilling and puncturing predation in the Cambrian (and possibly the Ediacaran) is considered. Examples of durophagous predation on biomineralised taxa other than trilobites are apparently rare, reflecting predator preference, taphonomic and sampling biases, or simply lack of documentation. The oldest known example of durophagy is shell damage on the problematic taxon Mobergella holsti from the early Cambrian (possibly Terreneuvian) of Sweden. Using functional morphology to identify (or perhaps misidentify) durophagous predators is discussed, with emphasis on the toolkit used by Cambrian arthropods, specifically the radiodontan oral cone and the frontal and gnathobasic appendages of various taxa. Records of drill holes and possible puncture holes in Cambrian shells are mostly on brachiopods, but the lack of prey diversity may represent either a true biological signal or a result of various biases. The oldest drilled Cambrian shells occur in a variety of Terreneuvian‐aged taxa, but specimens of the ubiquitous Ediacaran shelly fossil Cloudina also show putative drilling traces. Knowledge on Cambrian shell drillers is sorely lacking and there is little evidence or consensus concerning the taxonomic groups that made the holes, which often leads to the suggestion of an unknown ‘soft bodied driller’. Useful methodologies for deciphering the identities and capabilities of shell drillers are outlined. Evidence for puncture holes in Cambrian shelly taxa is rare. Such holes are more jagged than drill holes and possibly made by a Cambrian ‘puncher’. The Cambrian arthropod Yohoia may have used its frontal appendages in a jack‐knifing manner, similar to Recent stomatopod crustaceans, to strike and puncture shells rapidly. Finally, Cambrian durophagous and shell‐drilling predation is considered in the context of escalation – an evolutionary process that, amongst other scenarios, involves predators (and other ‘enemies’) as the predominant agents of natural selection. The rapid increase in diversity and abundance of biomineralised shells during the early Cambrian is often attributed to escalation: enemies placed selective pressure on prey, forcing phenotypic responses in prey and, by extension, in predator groups over time. Unfortunately, few case studies illustrate long‐term patterns in shelly fossil morphologies that may reflect the influence of predation throughout the Cambrian. More studies on phenotypic change in hard‐shelled lineages are needed to convincingly illustrate escalation and the responses of prey during the Cambrian.     

Daily,weekly and annual patterns in children’s accidental sport injuries*

Details of serious injuries to children ≤16 yrs. of age that necessitated urgent surgical intervention by the Department of Pediatric Surgery of the University Hospital of Lausanne, Switzerland were recorded into a database registry. Some 15 110 entries listed the precise time of injury, and 3114 (20.6%) of these resulted from participating in sport-associated activities. Time-of-day, day-of-week and month-of-year differences in the total number of children’s accidental sport injuries (CASI) were validated. Time-of-day patterns were substantiated for “All Sports”, for both boys and girls 5–16 yrs. of age, with more boys than girls experiencing incidents at almost every clock hour. Moreover, they were substantiated for this age group for each of the six different considered individual and team CASI categories – Physical Exercises at School; Bicycle Riding; Roller Skating and Skateboarding; Snow Skiing, Sledding, and Tobogganing; Soccer; and Basketball – for which sample sizes were sufficiently large (n > 230) to perform statistical assessment by ANOVA, t-test and/or cosinor analyses. CASI happened primarily between 06:00 and 17:00 h and rarely evening or overnight. Features – specific clock-time and number of peaks and troughs – of the CASI daily curve pattern of the individual six sport categories differed somewhat; nonetheless, excess or greatest number of CASI typically happened between 12:00 and 14:00 h, even when summertime and other scheduled school and family vacation periods were taken into account. Time-of-day and day-of-week patterns in the boy/girl sex ratio were also validated, with midday and Friday/Saturday peaks, respectively. We hypothesize the prominent 24 h patterns of CASI of 5–16 yr. olds, in particular, are representative of a combination of several determinants. These include exogenous periodic and cyclic environmental and sociocultural phenomena, genetic sex-related traits, plus endogenous circadian cognitive and physiologic rhythms, with the common midday injury excess of many sport categories, at least in part, the consequence of the well-documented midday dip in attention and vigilance of children.     

Exposure Assessment of Tractor-Related Tasks Presenting Potential Overturn Hazards on Catfish Farms in Mississippi,USA

Tractors are used in pond culture of catfish for a variety of mobile tasks, including placing aerators into ponds, mowing, spreading feed into ponds, and transporting equipment (e.g., seining reels), as well as for the stationary task of using the tractor's power-take-offs to operate aerators in the ponds. The mobile tasks place the tractor operator at risk of injury in the event of an overturn, and rollover protective structures (ROPS) are a proven intervention to mitigate injury in a tractor overturn. A 2008 survey was conducted among 96 participants in Mississippi (USA) to determine the hours of tractor use for these tasks. This article reports on exposures to tractor-related tasks conducted on catfish farms as identified in this survey. Annual exposure to potential tractor overturns was calculated based on the hours of mobile operation. The overall annual exposure to potential tractor overturns on the catfish farms participating in the survey was 7322 h per farm and 837 h per tractor on these farms. Findings show a prevalence of 88.2% of ROPS-equipped tractors on farms surveyed and a seasonal variation in exposure to each of the tasks, culminating in an annual estimate of exposure by task.     

The preventive and therapeutic effects of molecular hydrogen in ocular diseases and injuries where oxidative stress is involved

Oxidative stress initiates, accompanies and contributes to the development of several human diseases and injuries, including ocular diseases. Reactive oxygen species (ROS) can generate oxidative stress via excessive ROS production and/or decreased physiologically occurring antioxidants. To replace these weakened antioxidants, substances with effective antioxidant properties are needed in order to suppress oxidative stress and enable healing. Molecular hydrogen (H₂) is very suitable for this purpose due to its unique properties. H₂ is the only antioxidant that crosses the blood–brain and blood-ocular barriers. It quickly penetrates through tissue due to its small molecular size and effectively removes ROS, mainly hydroxyl radicals and peroxynitrite. Apart from its antioxidant effects, H₂ also displays anti-inflammatory, antiapoptotic, cytoprotective and mitohormetic properties. A significant advantage of H₂ is its nontoxicity, even when applied at high concentrations. In this review, we present the results of studies utilising H₂ in the treatment of ocular diseases involving oxidative stress. These results, obtained in experimental animals as well as in human clinical studies, show that the suppression of oxidative stress by H₂ treatment leads to the prevention or improvement of ocular diseases. In severe degenerative diseases, H₂ slows disease progression.     

Plasma nociceptin/orphanin FQ levels rise after spontaneous episodes of angina, but not during induced myocardial ischemia

The aim of our study was to evaluate the effects of repeated episodes of angina and induced myocardial ischemia on plasma nociceptin/orphanin FQ (N/OFQ) levels. Patients with unstable angina (23 with new onset severe angina or accelerated angina and 18 with subacute angina at rest) who had had repeated spontaneous episodes of chest pain in the last week before the study underwent myocardial perfusion single-photon emission computed tomography using adenosine infusion. Twenty subjects without clinical symptoms of angina matched for age, sex and cardiac risk factors served as a control group. N/OFQ levels were significantly (P < 0.01) higher in the patients (15.2 ± 2.1 pg/ml) than in the control group (8.5 ± 2.6 pg/ml). Blood pressure and heart rate did not significantly differ. All patients showed transient adenosine infusion myocardial ischemia that did not induce chest pain or significantly modify plasma N/OFQ levels or hemodynamic parameters. Our findings show that unstable angina is associated with a significant increase in circulating N/OFQ levels unrelated to intervening transient myocardial ischemia or hemodynamic changes. This increase is probably related to the chest pain repeatedly occurring in the course of coronary artery disease, but absent during transient adenosine-induced myocardial ischemia.     

干湿纺聚乳酸／壳聚糖纤维交织织物作为细胞体外培养载体的实验观察

在体外培养的条件下观察干湿纺聚乳酸/壳聚糖纤维交织织物与成骨细胞的相容性,探讨其作为人工胸壁支架材料和人工骨支架材料的可行性。将hFOB1.19人SV40转染的成骨细胞与干湿纺聚乳酸/壳聚糖纤维交织织物体外联合培养。用扫描电镜对体外联合培养早期细胞的形态学进行观察。结果表明,成骨细胞与干湿纺聚乳酸/壳聚糖交织织物间黏附良好,具有良好的相容性,干湿纺聚乳酸/壳聚糖纤维交织织物有可能成为一种理想的可用于修复胸壁缺损和骨缺损的成骨细胞载体。