Radiographic bronchiectasis in COPD patients is associated with increased respiratory infection and hospitalisation, independent of coexisting emphysema and BWT. COPD-related bronchiectasis is therefore an important diagnosis with potential implications for treatment.
Background People who use illicit opioids are more likely to be admitted to hospital than people of the same age in the general population. Many admissions end in discharge against medical advice, which is associated with readmission and all-cause mortality. Opioid withdrawal contributes to premature discharge. We sought to understand the barriers to timely provision of opioid substitution therapy (OST), which helps to prevent opioid withdrawal, in acute hospitals in England. Methods We requested policies on substance dependence management from 135 National Health Service trusts, which manage acute hospitals in England, and conducted a document content analysis. Additionally, we reviewed an Omitted and Delayed Medicines Tool (ODMT), one resource used to inform critical medicine categorisation in England. We worked closely with people with lived experience of OST and/or illicit opioid use, informed by principles of community-based participatory research. Results Eighty-six (64%) trusts provided 101 relevant policies. An additional 44 (33%) responded but could not provide relevant policies, and five (4%) did not send a definitive response. Policies illustrate procedural barriers to OST provision, including inconsistent application of national guidelines across trusts. Continuing community OST prescriptions for people admitted in the evening, night-time, or weekend was often precluded by requirements to confirm doses with organisations that were closed during these hours. 42/101 trusts (42%) required or recommended a urine drug test positive for OST medications or opioids prior to OST prescription. The language used in many policies was stigmatising and characterised people who use drugs as untrustworthy. OST was not specifically mentioned in the reviewed ODMT, with ‘drugs used in substance dependence’ collectively categorised as posing low risk if delayed and moderate risk if omitted. Conclusions Many hospitals in England have policies that likely prevent timely and effective OST. This was underpinned by the ‘low-risk’ categorisation of OST delay in the ODMT. Delays to continuity of OST between community and hospital settings may contribute to inpatient opioid withdrawal and increase the risk of discharge against medical advice. Acute hospitals in England require standardised best practice policies that account for the needs of this patient group.
Poster sessionsThorax 2012;67(Suppl 2):A1-A204 A139importantly a significant number of first PA isolations over a short follow-up period. Furthermore, a large percentage of patients had no microbe isolated (including at exacerbation) suggesting a possible use of future molecular microbe techniques. . Radiographic evidence of 'damaged and dilated bronchi' can be seen on CT Thorax in up to 50% of COPD patients. However the contribution of radiographic bronchiectasis to the clinical course of COPD is not fully understood. We aimed to determine the impact of bronchiectasis on lung function, sputum microbiology and outcomes in COPD patients, independent of coexisting emphysema and bronchial wall thickening (BWT). COPD-RELATED BRONCHIECTASISMethods COPD patients admitted with first exacerbation 1998-2008 were identified retrospectively using ICD10 codes J44.0,1,8,9. Patients with high resolution CT images within 2 years of admission were included. CT scans were graded by consensus of 2 senior thoracic radiologists for severity of bronchiectasis, emphysema and BWT on a 5 point scale (0-absent, 1-minor, 2-mild, 3-moderate, 4-severe). Operational definitions were set prior to scan review and radiologists were blinded to clinical parameters. Results 406 patients (71±11years, 56% male, FEV 1 52±23% predicted) were included. 278 (69%) patients had bronchiectasis: minor, 112 (40%); mild, 81 (29%); moderate, 62 (22%); severe 23 (8%). There was considerable overlap between bronchiectasis and other pathologies (figure). Bronchiectasis severity correlated with severity of BWT (r=0.276, p<0.001) and emphysema (r=0.120, p=0.015). After adjustment for severity of emphysema and BWT, increasing severity bronchiectasis was not an independent predictor of lung function parameters, but independently determined isolation of Pseudomonas aeruginosa (Odds ratio (OR) 1.39 (95% CI 1.07-1.80), p=0.013) and atypical mycobacteria from sputum cultures (OR 2.44 (95% CI 1.04-5.69), p=0.040). After correction for increasing severity emphysema, BWT, age, gender and comorbidities, increasing severity bronchiectasis determined annual admissions (regression coefficient B=0.14 (95% CI 0.00-0.28), p=0.044) and inpatient days (B=2.1 (95% CI 0.8-3.4), p=0.001) for respiratory causes, but did not influence survival from first hospital admission (p=0.257). Conclusions Radiographic bronchiectasis in COPD patients is associated with increased respiratory infection and hospitalisation, independent of coexisting emphysema and BWT. COPD-related bronchiectasis is therefore a diagnosis with important clinical implications. Further research should determine whether treatment strategies for non-CF bronchiectasis can improve the clinical course of COPD-related bronchiectasis.
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