A.G. Mathioudakis comments: Chronic bronchitis: an objective diagnosis of exclusion

The authors of the above article published would like to thank A.G. Mathioudakis and co-workers for their interest and comments regarding our recently published article in the July issue of the European Respiratory Journal [1].

A.G. Mathioudakis and co-workers raise a concern regarding the term of “chronic bronchitis phenotype” and the actual diagnosis. They also comment that the phenotype could include patients with tuberculosis, lung cancer, asthma, bronchiectasis and heart failure, and that these diagnoses were not sufficiently investigated in our study. We agree with the position that the phenotype includes patients with other conditions and, in this way, the term was addressed in our study [1]. The self-reported comorbidity (asthma, tuberculosis and lung cancer) of the subjects with spirometric diagnosis of chronic obstructive pulmonary disease (COPD) is clearly shown in table 3 of our article (description of subjects with COPD, by chronic bronchitis) [1]. However, we think that the problem is that A.G. Mathioudakis and co-workers did not understand the type of study PLATINO (Proyecto Latinoamericano de Investigación en Obstrucción Pulmonar) is. This study is a well-known population-based study on COPD and not a study of a selected COPD population, so it is not possible to conduct additional analyses to rule out, for example, congestive heart failure in this type of study. In addition, we think that it is important to highlight the existing proposal for defining COPD phenotypes as “a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes (symptoms, exacerbations, response to therapy, rate of disease progression, or death).” This more focused definition allows classification of patients into distinct prognostic and therapeutic subgroups for both clinical and research purposes [2]. This definition is not restricted exclusively to selected COPD samples (there is no limit for its use in unselected populations), so it can also be used to study COPD phenotypes in a population-based sample and this is the case of our study. We presented the association of chronic bronchitis symptoms (a single attribute of the disease) in the PLATINO COPD population with the severity of airway obstruction, subjects’ perceptions of their general health status, physical activity limitation and exacerbations (relation to clinically meaningful outcomes).

A.G. Mathioudakis and co-workers also made a comment regarding the low prevalence of the chronic bronchitis phenotype and suggest that this could be associated with the use of post-bronchodilator forced expiratory volume in 1 s/forced vital capacity ratio <0.70 to define COPD and the possible over-diagnosis of stage I COPD patients with low symptom prevalence. Unfortunately, it seems that A.G. Mathioudakis and co-workers have not reviewed the supplementary material of our study, which shows all analyses performed using the lower limit of normal (LLN) to define COPD [1]. Interestingly, supplemental tables 1 and 2 showed the parallel analysis using the LLN to define COPD, and the proportion of persons in both groups was quite similar to that found with the use of the fixed ratio [1]. Supplemental table 3 (description of subjects with COPD), and supplemental figures 1 and 2 (Global Initiative for Chronic Obstructive Lung Disease severity distribution of COPD subjects by chronic bronchitis and general health status assessed in COPD and non-COPD subjects, respectively) also showed the analyses using the LLN definition with similar findings [1].

Finally, we think that the data presented in our article helps to better understand the prevalence of the chronic bronchitis phenotype in an unselected COPD population using different criteria for defining COPD, and the association of this phenotype with some important outcomes (reduced pulmonary function, more respiratory symptoms and exacerbations, worse health status, and more physical activity limitation).

see link


Singhal R.; Dheerendra S.K.; Charalambous C.P.; Waseem, M; Medical Ultrasonography; June 2012

This article published in Medical Ultrasonography was co-authored by
Dr Dheerendra and Mr Waseem from East Cheshire NHS Trust.

Ultrasound examination of the shoulder conducted by orthopaedic surgeons in the diagnosis and treatment of shoulder conditions is increasingly reported. Shoulder ultrasound is not a mandatory component of postgraduate  orthopaedic training in the United Kingdom. The aim of this study was to assess the effectiveness of the shoulder ultrasound teaching workshop administered to postgraduate orthopaedic surgical trainees.

Citation: Medical Ultrasonography, June 2012, vol./is. 14/2(120-124), 1844-4172;2066-8643 (June 2012) 

Available via Proquest


Lucas, A; BJM, Dec 2012; Interpreting cardiotocographs using soft systems methodology

Another article from Amanda Lucas, Deputy Head of Midwifery and Women’s Services/Supervisor of Midwives, Macclesfield Hospital.

This article in the BJM will outline and contexualise the problem of poor
cardiotocograph (CTG) interpretation within maternity services. By
applying creative thinking or a soft systems methodology to this ‘wicked’
problem, reference to other approaches will be provided and the reasons
for rejection considered. Finally, through reflection, the appropriateness
of the creative thinking approach will be critiqued and future action

Introduction:  Within the health service it is widely acknowledged that practitioners take responsibility for the care they provide and are answerable to their own judgements and actions (Manley et al, 2011). In midwifery, the practitioner is responsible for the health and safety of both the mother and baby. During labour, women with identified potential risks to either themselves or their baby will receive continuous fetal monitoring by cardiotocograph (CTG) (National Institute for Health and Clinical Excellence (NICE), 2007).

Amanda Lucas
British Journal of Midwifery,  Vol. 20, Iss. 12, 05 Dec 2012, pp 866 – 870

Doctors to work across 7 days a week

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8601 (Published 18 December 2012)

docsdiaryDoctors working in the NHS in England
will be required to work across seven days a week, under new plans tabled by the NHS Commissioning Board.

Hospital consultants and GPs face having their hours reorganised to give patients the same level of service at weekends as they receive during the week, to bring the health service in line with other sectors.

The proposals, included in the board’s first planning guidance for 2013-14,1 will initially focus on improving access to diagnostics and urgent and emergency care but could extend to surgery in the future. General practices will be expected to extend their opening hours to weekends as part of the drive.

New Year opportunity – 3 Learning events

Eastern Cheshire Clinical Commissioning Group and East Cheshire NHS Trust have specified a number of Ambulatory Care Sensitive Condition Pathways which will be developed and implemented during 2012/13. These pathways contribute to the national and local healthcare agenda which supports the seamless delivery of integrated care to our patients, avoiding hospital admission where it is safe and effective to do so.

East Cheshire NHS Trust are hosting 3 learning events in 2012 to support the implementation of six pathways underpinned by best practice and NICE Guidance, and to facilitate the partnership working required to deliver interventions and treatment closer to home.  This redesign is an opportunity for colleagues from all partner organisations to work collaboratively to improve the patient experience.

Please see timetable below for dates, localities and pathways.






Congleton War Memorial Hospital     Room 9

12.30 –
1.30 pm

First Seizure



Knutsford Community Hospital     Room 3

12.30 –
1.30 pm

Pulmonary Embolism



Waters Green MC Macclesfield
Training Room 2

12.30 –
1.30 pm



If you are interested in attending one or all of the events, please indicate which by return email to ecn-tr.BusinessSupportUnit@nhs.net as this will help us to plan effectively for the events.

Please do not hesitate to contact Karen.shawhan@nhs.net or Elizabeth.muskett@nhs.net if you require any further information.

George urges people to ‘get involved’.

KNUTSFORD’S MP, George Osbourne has backed our hospital trust’s bid to become a ‘public membership’ body.

East Cheshire NHS Trust began a programme of public consultation for its plans to become an NHS Foundation Trust in November. The consultation process began at the beginning of November with three public meetings on the plans being held in Winsford, Congleton and Crewe. Guardian readers reported low turnouts for one of the events – in Winsford – and now George Osborne, MP for Tatton, is urging residents from across the area to get involved in the process.

Read the full story in the Knutsford Guardian