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Lee HW, Lee JK, Hwang YI, Seo H, Ahn JH, Kim SR, Kim HJ, Jung KS, Yoo KH, Kim DK. Spirometric Interpretation and Clinical Relevance According to Different Reference Equations. J Korean Med Sci 2024; 39:e20. [PMID: 38288534 PMCID: PMC10825457 DOI: 10.3346/jkms.2024.39.e20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/21/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Global Lung Function Initiative (GLI)-2012 reference equation is currently suggested for interpretation of spirometry results and a new local reference equation has been developed in South Korea. However, lung function profiles according to the different reference equations and their clinical relevance have not been identified in chronic obstructive pulmonary disease (COPD) patients. METHODS Our cross-sectional study evaluated Choi's, Korean National Health and National Examination Survey (KNHANES)-VI, and GLI-2012 reference equations. We estimated the percentages of predictive forced expiratory volume in one second (FEV1) and airflow limitation severity according to reference equations and analyzed their associations with patient reported outcomes (PROs): COPD assessment test (CAT) score, St. George's Respiratory Questionnaire for COPD patients (SGRQ-C) score, and six minute walk distance (6MWD). RESULTS In the eligible 2,180 COPD patients, lower predicted values of FEV1 and forced vital capacity (FVC) were found in GLI-2012 compared to Choi's and KNHANES-VI equations. GLI-2012 equation resulted in a lower proportion of patients being classified as FEV1 < 80% or FVC < 80% compared to the other equations. However, the Z-scores of FEV1 and FVC were similar between the KNHANES-VI and GLI-2012 equations. Three reference equations exhibited significant associations between FEV1 (%) and patient-reported outcomes (CAT score, SGRQ-C score, and 6MWD). CONCLUSION GLI-2012 reference equation may not accurately reflect FEV1 (%) in the Korean population, but the Z-score using GLI-2012 equation can be a viable option for assessing FEV1 and airflow limitation in COPD patients. Similar to the other two equations, the GLI-2012 equation demonstrated significant associations with PROs.
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Affiliation(s)
- Hyun Woo Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Kyu Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Il Hwang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyewon Seo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - June Hong Ahn
- Department of Internal Medicine, Yeungnam University Medical Center, College of Medicine, Yeungnam University, Daegu, Korea
| | - Sung-Ryeol Kim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Hyun Jung Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Ki-Suck Jung
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kwang Ha Yoo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Deog Kyeom Kim
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea.
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2
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Kerr M, Tarabichi Y, Evans A, Mapel D, Pace W, Carter V, Couper A, Drummond MB, Feigler N, Federman A, Gandhi H, Hanania NA, Kaplan A, Kostikas K, Kruszyk M, van Melle M, Müllerová H, Murray R, Ohar J, Pollack M, Pullen R, Williams D, Wisnivesky J, Han MK, Meldrum C, Price D. Patterns of care in the management of high-risk COPD in the US (2011-2019): an observational study for the CONQUEST quality improvement program. LANCET REGIONAL HEALTH. AMERICAS 2023; 24:100546. [PMID: 37545746 PMCID: PMC10400879 DOI: 10.1016/j.lana.2023.100546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 08/08/2023]
Abstract
Background In this study, we compare management of patients with high-risk chronic obstructive pulmonary disease (COPD) in the United States to national and international guidelines and quality standards, including the COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST). Methods Patients were identified from the DARTNet Practice Performance Registry and categorized into three high-risk cohorts in each year from 2011 to 2019: newly diagnosed (≤12 months after diagnosis), already diagnosed, and patients with potential undiagnosed COPD. Patients were considered high-risk if they had a history of exacerbations or likely exacerbations (respiratory consult with prescribed medication). Descriptive statistics for 2019 are reported, along with annual trends. Findings In 2019, 10% (n = 16,610/167,197) of patients met high-risk criteria. Evidence of spirometry for diagnosis was low; in 2019, 81% (n = 1228/1523) of patients newly diagnosed at high-risk had no record of spirometry/peak expiratory flow in the 12 months pre- or post-diagnosis and 43% (n = 651/1523) had no record of COPD symptom review. Among those newly and already diagnosed at high-risk, 52% (n = 4830/9350) had no evidence of COPD medication. Interpretation Findings suggest inconsistent adherence to evidence-based guidelines, and opportunities to improve identification, documentation of services, assessment, therapeutic intervention, and follow-up of patients with COPD. Funding This study was conducted by the Observational and Pragmatic Research Institute (OPRI) Pte Ltd and was partially funded by Optimum Patient Care Global and AstraZeneca Ltd. No funding was received by the Observational & Pragmatic Research Institute Pte Ltd (OPRI) for its contribution.
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Affiliation(s)
- Margee Kerr
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
| | - Yasir Tarabichi
- Center for Clinical Informatics Research and Education, MetroHealth, Cleveland, OH, USA
| | | | - Douglas Mapel
- University of New Mexico College of Pharmacy, Albuquerque, NM, USA
| | - Wilson Pace
- DARTNet Institute, Aurora, USA
- University of Colorado, Denver, CO, USA
| | | | - Amy Couper
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - M. Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Norbert Feigler
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | - Alex Federman
- General Internal Medicine, Mount Sinai, New York, NY, USA
| | - Hitesh Gandhi
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | - Nicola A. Hanania
- Section of Pulmonary and Critical Care Medicine, and Director of the Airways Clinical Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Alan Kaplan
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Family Physician Airways Group of Canada, Stouffville, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Maja Kruszyk
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Queensland, Australia
| | - Marije van Melle
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Connecting Medical Dots BV, Utrecht, the Netherlands
- ORTEC, Zoetermeer, the Netherlands
| | | | | | - Jill Ohar
- Department of Internal Medicine, WakeForest University, Winston-Salem, NC, USA
| | - Michael Pollack
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | - Rachel Pullen
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Dennis Williams
- UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
- Allergy and Asthma Network, Vienna, VA, USA
| | | | | | - Catherine Meldrum
- Division of Pulmonary & Critical Care at University of Michigan Hospital, Ann Arbor, MI, USA
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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3
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Tsai ML, Li CL, Chang HC, Tsai YC, Tseng CW, Liu SF. The Relationship between Exertional Desaturation and Pulmonary Function, Exercise Capacity, or Medical Costs in Chronic Obstructive Pulmonary Disease Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020391. [PMID: 36837592 PMCID: PMC9963049 DOI: 10.3390/medicina59020391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/06/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023]
Abstract
Background and Objectives: Exertional desaturation (ED) is common and is associated with poorer clinical outcomes in chronic obstructive pulmonary disease (COPD). The age, dyspnea, airflow obstruction (ADO) and body mass index, airflow obstruction, dyspnea, and exercise (BODE) indexes are used to predict the prognosis of COPD patients. This study aimed to investigate the relationship between these indexes, pulmonary function, medical costs, and ED in COPD patients. Materials and Methods: Data were collected from the electronic database of the Kaohsiung Chang Gung Memorial Hospital. This retrospective study included 396 patients categorized as either ED (n = 231) or non-ED (n = 165). Variables (including age, smoking history, body mass index (BMI), pulmonary function test, maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP), six minutes walking test distance (6MWD), SpO2, COPD Assessment Test (CAT) score, ADO index, BODE index, Charlson comorbidity index (CCI), and medical costs) were compared between the two groups, and their correlations were assessed. ED was defined as SpO2 less than 90% or SpO2 decrease of more than 4% compared to baseline levels during 6MWT. Results: A significant statistical difference was found regarding a lower score of the ADO index and the BODE index (both p < 0.001), better pulmonary function (forced expiratory volume in the first second (FEV1), p < 0.001; FEV1/ forced vital capacity (FVC), p < 0.001; diffusion capacity of the lung for carbon monoxide (DLCO), p < 0.001), and higher minimal oxygen saturation (p < 0.001) in non-ED COPD patients. No difference was found in the distance of the 6MWT (p = 0.825) and respiratory muscle strength (MIP; MEP, p = 0.86; 0.751). However, the adjusted multivariate logistic regression analysis showed that only SpO2 (minimal) had a significant difference between of the ED and non-ED group (p < 0.001). There was either no difference in the medical expenses between ED and non-ED COPD patients. Conclusions: SpO2 (minimal) during the 6MWT is the independent factor for ED. ED is related to BODE and ADO indices, but is not related to medical expense.
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Affiliation(s)
- Meng-Lin Tsai
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
| | - Chin-Ling Li
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
| | - Hui-Chuan Chang
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
| | - Yuh-Chyn Tsai
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
| | - Ching-Wan Tseng
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
| | - Shih-Feng Liu
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Correspondence: ; Tel.: +886-7-731-7123 (ext. 8199)
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Martinez FJ, Han MK, Lopez C, Murray S, Mannino D, Anderson S, Brown R, Dolor R, Elder N, Joo M, Khan I, Knox LM, Meldrum C, Peters E, Spino C, Tapp H, Thomashow B, Zittleman L, Make B, Yawn BP. Discriminative Accuracy of the CAPTURE Tool for Identifying Chronic Obstructive Pulmonary Disease in US Primary Care Settings. JAMA 2023; 329:490-501. [PMID: 36786790 PMCID: PMC9929696 DOI: 10.1001/jama.2023.0128] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 01/04/2023] [Indexed: 02/15/2023]
Abstract
Importance Chronic obstructive pulmonary disease (COPD) is underdiagnosed in primary care. Objective To evaluate the operating characteristics of the CAPTURE (COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk) screening tool for identifying US primary care patients with undiagnosed, clinically significant COPD. Design, Setting, and Participants In this cross-sectional study, 4679 primary care patients aged 45 years to 80 years without a prior COPD diagnosis were enrolled by 7 primary care practice-based research networks across the US between October 12, 2018, and April 1, 2022. The CAPTURE questionnaire responses, peak expiratory flow rate, COPD Assessment Test scores, history of acute respiratory illnesses, demographics, and spirometry results were collected. Exposure Undiagnosed COPD. Main Outcomes and Measures The primary outcome was the CAPTURE tool's sensitivity and specificity for identifying patients with undiagnosed, clinically significant COPD. The secondary outcomes included the analyses of varying thresholds for defining a positive screening result for clinically significant COPD. A positive screening result was defined as (1) a CAPTURE questionnaire score of 5 or 6 or (2) a questionnaire score of 2, 3, or 4 together with a peak expiratory flow rate of less than 250 L/min for females or less than 350 L/min for males. Clinically significant COPD was defined as spirometry-defined COPD (postbronchodilator ratio of forced expiratory volume in the first second of expiration [FEV1] to forced vital capacity [FEV1:FVC] <0.70 or prebronchodilator FEV1:FVC <0.65 if postbronchodilator spirometry was not completed) combined with either an FEV1 less than 60% of the predicted value or a self-reported history of an acute respiratory illness within the past 12 months. Results Of the 4325 patients who had adequate data for analysis (63.0% were women; the mean age was 61.6 years [SD, 9.1 years]), 44.6% had ever smoked cigarettes, 18.3% reported a prior asthma diagnosis or use of inhaled respiratory medications, 13.2% currently smoked cigarettes, and 10.0% reported at least 1 cardiovascular comorbidity. Among the 110 patients (2.5% of 4325) with undiagnosed, clinically significant COPD, 53 had a positive screening result with a sensitivity of 48.2% (95% CI, 38.6%-57.9%) and a specificity of 88.6% (95% CI, 87.6%-89.6%). The area under the receiver operating curve for varying positive screening thresholds was 0.81 (95% CI, 0.77-0.85). Conclusions and Relevance Within this US primary care population, the CAPTURE screening tool had a low sensitivity but a high specificity for identifying clinically significant COPD defined by presence of airflow obstruction that is of moderate severity or accompanied by a history of acute respiratory illness. Further research is needed to optimize performance of the screening tool and to understand whether its use affects clinical outcomes.
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Affiliation(s)
| | - MeiLan K. Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor
| | - Camden Lopez
- School of Public Health, University of Michigan, Ann Arbor
| | - Susan Murray
- School of Public Health, University of Michigan, Ann Arbor
| | - David Mannino
- Division of Pulmonary and Critical Care Medicine, University of Kentucky, Lexington
| | | | - Randall Brown
- School of Public Health, University of Michigan, Ann Arbor
| | - Rowena Dolor
- Division of General Internal Medicine, Duke University, Durham, North Carolina
| | - Nancy Elder
- Oregon Health & Science University, Portland
| | - Min Joo
- Division of Pulmonary and Critical Care Medicine, University of Illinois, Chicago
| | - Irfan Khan
- Circuit Clinical, Clarence Center, New York
| | - Lyndee M. Knox
- LA Net Community Health Resource Network Collaboratory, Long Beach, California
| | - Catherine Meldrum
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor
| | - Elizabeth Peters
- Weill Cornell Medicine/NY Presbyterian Hospital, New York, New York
| | - Cathie Spino
- School of Public Health, University of Michigan, Ann Arbor
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health, Charlotte, North Carolina
| | - Byron Thomashow
- Division of Pulmonary and Critical Care Medicine, Columbia University, New York, New York
| | - Linda Zittleman
- Department of Family Medicine, High Plains Research Network, University of Colorado, Aurora
| | - Barry Make
- Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - Barbara P. Yawn
- Department of Family and Community Health, University of Minnesota, Minneapolis
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5
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Fox C, Pace W, Brandt E, Carter V, Chang KL, Edwards C, Evans A, Gaona G, Han MK, Kaplan A, Kent R, Kocks JWH, Kruszyk M, Chantal LL, LiVoti T, Mahle C, Make B, Ratigan A, Shaikh A, Skolnik N, Stanley B, Yawn BP, Price DB. Variation in Demographic and Clinical Characteristics of Patients with COPD Receiving Care in US Primary Care: Data from the Advancing the Patient EXperience (APEX) in COPD Registry. Pragmat Obs Res 2022; 13:17-31. [PMID: 35516162 PMCID: PMC9064065 DOI: 10.2147/por.s342736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 04/15/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Little is known about the variability in chronic obstructive pulmonary disease (COPD) management and how it may be affected by patient characteristics across different healthcare systems in the US. This study aims to describe demographic and clinical characteristics of people with COPD and compare management across five primary care medical groups in the US. Methods This is a retrospective observational registry study utilizing electronic health records stored in the Advancing the Patient Experience (APEX) COPD registry. The APEX registry contains data from five US healthcare organizations located in Texas, Ohio, Colorado, New York, and North Carolina. Data on demographic and clinical characteristics of primary care patients with COPD between December 2019 and January 2020 were extracted and compared. Results A total of 17,192 patients with COPD were included in analysis: Texas (n = 811), Ohio (n = 8722), Colorado (n = 472), New York (n = 1149) and North Carolina (n = 6038). The majority of patients at each location were female (>54%) and overweight/obese (>60%). Inter-location variabilities were noted in terms of age, race/ethnicity, exacerbation frequency, treatment pattern, and prevalence of comorbid conditions. Patients from the Colorado site experienced the lowest number of exacerbations per year while those from the New York site reported the highest number. Hypertension was the most common co-morbidity at 4 of 5 sites with the highest prevalence in New York. Depression was the most common co-morbidity in Ohio. Treatment patterns also varied by site; Colorado had the highest proportion of patients not on any treatment. ICS/LABA was the most commonly prescribed treatment except in Ohio, where ICS/LABA/LAMA was most common. Conclusions and Relevance Our data show heterogeneity in demographic, clinical, and treatment characteristics of patients diagnosed with COPD who are managed in primary care across different healthcare organizations in the US.
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Affiliation(s)
- Chester Fox
- DARTNet Institute, Aurora, CO, USA
- University at Buffalo, Buffalo, NY, USA
| | - Wilson Pace
- DARTNet Institute, Aurora, CO, USA
- University of Colorado, Denver, CO, USA
| | | | - Victoria Carter
- Optimum Patient Care, Cambridge, UK
- Observational and Pragmatic Research Institute, Singapore
| | - Ku-Lang Chang
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | | | | | | | - Alan Kaplan
- Observational and Pragmatic Research Institute, Singapore
- Family Physician Airways Group of Canada, Stouffville, Ontario, Canada
- University of Toronto, Toronto, Canada
| | | | - Janwillem W H Kocks
- Observational and Pragmatic Research Institute, Singapore
- General Practitioners Research Institute, Groningen, the Netherlands
- Groningen Research Institute Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maja Kruszyk
- Observational and Pragmatic Research Institute, Singapore
- Optimum Patient Care, Brisbane, Queensland, Australia
| | - Le Lievre Chantal
- Observational and Pragmatic Research Institute, Singapore
- Optimum Patient Care, Brisbane, Queensland, Australia
| | - Tessa LiVoti
- Optimum Patient Care, Cambridge, UK
- Observational and Pragmatic Research Institute, Singapore
| | | | - Barry Make
- Department of Medicine, NJH, Denver, CO, USA
| | | | | | - Neil Skolnik
- Abington Jefferson Health, Jenkintown, PA, USA
- University of Minnesota, Minneapolis, MN, USA
| | | | | | - David B Price
- Optimum Patient Care, Cambridge, UK
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Correspondence: David B Price, Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK, Tel +65 3105 1489, Email
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6
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Iwasaki K, Matsuzawa Y, Wakabayashi H, Kumano K. Diffuse alveolar haemorrhage with suspected idiopathic pulmonary hemosiderosis and decrease in lung diffusing capacity and chronic respiratory failure. BMJ Case Rep 2021; 14:e242901. [PMID: 34215641 PMCID: PMC8256727 DOI: 10.1136/bcr-2021-242901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/30/2022] Open
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown aetiology that causes recurrent episodes of diffuse alveolar haemorrhage (DAH). A male patient in his 50s had repeatedly experienced hemoptysis for the past 6 years, along with a decrease in the pulmonary diffusing capacity and chronic respiratory failure. After a 6-year follow-up, the patient experienced sudden exacerbation of hemoptysis and respiratory failure, and he was hospitalised. A CT of the chest revealed diffuse pulmonary infiltrates, whereas the bronchoalveolar lavage revealed hemosiderin-laden macrophages. Thus, the patient was diagnosed with DAH. As all diseases that cause DAH other than IPH were negative, the patient was suspected of IPH. He was treated with a combination of glucocorticoids and azathioprine, and his hemoptysis and chronic respiratory failure improved; however, the decrease in the pulmonary diffusing capacity did not improve. Treating adult-onset IPH with glucocorticoids and azathioprine might not improve pulmonary diffusing capacity.
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Affiliation(s)
- Kotaro Iwasaki
- Department of Internal Medicine, Toho University Medical Center Sakura Hospital, Sakura, Japan
| | - Yasuo Matsuzawa
- Department of Internal Medicine, Toho University Medical Center Sakura Hospital, Sakura, Japan
| | - Hiroki Wakabayashi
- Department of Internal Medicine, Toho University Medical Center Sakura Hospital, Sakura, Japan
| | - Kotaro Kumano
- Department of Internal Medicine, Toho University Medical Center Sakura Hospital, Sakura, Japan
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7
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Edwards CL, Kaplan AG, Yawn BP, Kocks JWH, Bulathsinhala L, Carter VA, Chang KL, Fox C, Gopalan G, Han MK, Kruszyk M, Le Lievre CE, Mahle C, Make B, Pace WD, Price C, Shaikh A, Skolnik N, Price DB. Development of the Advancing the Patient Experience in COPD Registry: A Modified Delphi Study. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2020; 8. [PMID: 33238085 DOI: 10.15326/jcopdf.2020.0154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Chronic obstructive pulmonary disease (COPD) is commonly managed by family physicians, but little is known about specifics of management and how this may be improved. The Advancing the Patient Experience in COPD (APEX COPD) registry will be the first U.S. primary care, health system-based registry following patients diagnosed with COPD longitudinally, using a standardized set of variables to investigate how patients are managed in real life and assess outcomes of various management strategies. Objective Gaining expert consensus on a standardized list of variables to capture in the APEX COPD registry. Methods A modified, Delphi process was used to reach consensus on which data to collect in the registry from electronic health records (EHRs), patient-reported information (PRI) and patient-reported outcomes (PRO), and by physicians during subsequent office visits. The Delphi panel comprised 14 primary care and specialty COPD experts from the United States and internationally. The process consisted of 3 iterative rounds. Responses were collected electronically. Results Of the initial 195 variables considered, consensus was reached to include up to 115 EHR variables, 34 PRI/PRO variables and 5 office-visit variables in the APEX COPD registry. These should include information on symptom burden, diagnosis, COPD exacerbations, lung function, quality of life, comorbidities, smoking status/history, treatment specifics (including side effects), inhaler management, and patient education/self-management. Conclusion COPD experts agreed upon the core variables to collect from EHR data and from patients to populate the APEX COPD registry. Data will eventually be integrated, standardized and stored in the APEX COPD database and used for approved COPD-related research.
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Affiliation(s)
| | - Alan G Kaplan
- Observational and Pragmatic Research Institute, Singapore.,Family Physician Airways Group of Canada, Stouffville, Ontario.,University of Toronto, Toronto, Canada
| | - Barbara P Yawn
- University of Minnesota, Minneapolis, Minnesota, United States.,COPD Foundation, Washington, DC, United States
| | - Janwillem W H Kocks
- Optimum Patient Care, Cambridge, United Kingdom.,Observational Pragmatic Research Institute, Singapore.,General Practitioners Research Institute, Groningen, Netherlands
| | | | | | - Ku-Lang Chang
- College of Medicine, University of Florida, Gainesville, FL, United States
| | - Chester Fox
- DARTNet Institute, Aurora, Colorado, United States.,University at Buffalo, Buffalo, New York, United States
| | - Gokul Gopalan
- Boehringer Ingelheim, Ridgefield, Connecticut, United States
| | - MeiLan K Han
- University of Michigan, Ann Arbor, Michigan, United States
| | | | | | - Cathy Mahle
- Boehringer Ingelheim, Ridgefield, Connecticut, United States
| | - Barry Make
- Department of Medicine, National Jewish Health, Denver, Colorado, United States
| | - Wilson D Pace
- DARTNet Institute, Aurora, Colorado, United States.,University of Colorado, Denver, Colorado, United States
| | - Chris Price
- Optimum Patient Care, Cambridge, United Kingdom
| | - Asif Shaikh
- Boehringer Ingelheim, Ridgefield, Connecticut, United States
| | - Neil Skolnik
- Thomas Jefferson University, Pennsylvania, United States.,Abington Jefferson Health, Jenkintown, Pennsylvania, United States
| | - David B Price
- Optimum Patient Care, Cambridge, United Kingdom.,Observational Pragmatic Research Institute, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
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8
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Chin KL, Sarmiento ME, Alvarez-Cabrera N, Norazmi MN, Acosta A. Pulmonary non-tuberculous mycobacterial infections: current state and future management. Eur J Clin Microbiol Infect Dis 2020; 39:799-826. [PMID: 31853742 PMCID: PMC7222044 DOI: 10.1007/s10096-019-03771-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 11/18/2019] [Indexed: 12/11/2022]
Abstract
Currently, there is a trend of increasing incidence in pulmonary non-tuberculous mycobacterial infections (PNTM) together with a decrease in tuberculosis (TB) incidence, particularly in developed countries. The prevalence of PNTM in underdeveloped and developing countries remains unclear as there is still a lack of detection methods that could clearly diagnose PNTM applicable in these low-resource settings. Since non-tuberculous mycobacteria (NTM) are environmental pathogens, the vicinity favouring host-pathogen interactions is known as important predisposing factor for PNTM. The ongoing changes in world population, as well as socio-political and economic factors, are linked to the rise in the incidence of PNTM. Development is an important factor for the improvement of population well-being, but it has also been linked, in general, to detrimental environmental consequences, including the rise of emergent (usually neglected) infectious diseases, such as PNTM. The rise of neglected PNTM infections requires the expansion of the current efforts on the development of diagnostics, therapies and vaccines for mycobacterial diseases, which at present, are mainly focused on TB. This review discuss the current situation of PNTM and its predisposing factors, as well as the efforts and challenges for their control.
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Affiliation(s)
- Kai Ling Chin
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah (UMS), Kota Kinabalu, Sabah, Malaysia.
| | - Maria E Sarmiento
- School of Health Sciences, Universiti Sains Malaysia (USM), Kubang Kerian, Kelantan, Malaysia
| | - Nadine Alvarez-Cabrera
- Center for Discovery and Innovation (CDI), Hackensack Meridian School of Medicine at Seton Hall University, Nutley, NJ, USA
| | - Mohd Nor Norazmi
- School of Health Sciences, Universiti Sains Malaysia (USM), Kubang Kerian, Kelantan, Malaysia
| | - Armando Acosta
- School of Health Sciences, Universiti Sains Malaysia (USM), Kubang Kerian, Kelantan, Malaysia.
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9
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Moore P, Atkins GT, Cramb S, Croft JB, Davis L, Dolor RJ, Doyle D, Elehwany M, James C, Knudson A, Linnell J, Mannino D, Rommes JM, Sood A, Stockton E, Weissman DN, Witte M, Wyatt E, Yarbrough WC, Yawn BP, Johnson L, Morris T, Kiley JP, Ammary-Risch NJ, Punturieri A. COPD and Rural Health: A Dialogue on the National Action Plan. J Rural Health 2019; 35:424-428. [PMID: 30677167 PMCID: PMC6790602 DOI: 10.1111/jrh.12346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Paul Moore
- Federal Office of Rural Health Policy, Health Resources and Services Administration, Rockville, Maryland
| | - Graham T Atkins
- Dartmouth-Hitchcock Medical Center and the Geisel School of Medicine, Lebanon, New Hampshire
| | | | - Janet B Croft
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa Davis
- Pennsylvania Office of Rural Health, University Park, Pennsylvania
| | - Rowena J Dolor
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Daniel Doyle
- Department of Family Medicine, West Virginia University, Morgantown, West Virginia
| | | | - Cara James
- Office of Minority Health, Centers for Medicare and Medicaid Services, Baltimore, Maryland
| | - Alana Knudson
- Walsh Center for Rural Health Analysis, University of Chicago, Chicago, Illinois
| | - John Linnell
- US COPD Coalition/Board of Directors, Washington, DC
| | | | | | - Akshay Sood
- Division of Pulmonary Critical Care and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - David N Weissman
- National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia
| | - Mike Witte
- California Primary Care Association, Sacramento, California
| | | | | | | | - Lenora Johnson
- Office of Science Policy Engagement Education and Communications, National Heart, Lung, and Blood Institute/National Institutes of Health, Bethesda, Maryland
| | - Tom Morris
- Federal Office of Rural Health Policy, Health Resources and Services Administration, Rockville, Maryland
| | - James P Kiley
- Division of Lung Diseases, National Heart, Lung, and Blood Institute/National Institutes of Health, Bethesda, Maryland
| | - Neyal J Ammary-Risch
- Office of Science Policy Engagement Education and Communications, National Heart, Lung, and Blood Institute/National Institutes of Health, Bethesda, Maryland
| | - Antonello Punturieri
- Division of Lung Diseases, National Heart, Lung, and Blood Institute/National Institutes of Health, Bethesda, Maryland
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Martinez FJ, Abrahams RA, Ferguson GT, Bjermer L, Grönke L, Voß F, Singh D. Effects of baseline symptom burden on treatment response in COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:181-194. [PMID: 30655665 PMCID: PMC6324615 DOI: 10.2147/copd.s179912] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
RATIONALE In symptomatic patients with COPD, the decision whether to initiate maintenance treatment with a single agent or a combination of long-acting bronchodilators remains unclear. OBJECTIVE To investigate whether baseline symptomatic status influences response to tiotropium/olodaterol treatment. MATERIALS AND METHODS Post hoc analysis of the randomized OTEMTO® studies (NCT01964352; NCT02006732), in which patients with moderate-to-severe COPD received placebo, tiotropium 5 µg, tiotropium/olodaterol 2.5/5 µg, or tiotropium/olodaterol 5/5 µg once daily for 12 weeks via the Respimat® inhaler (Boehringer Ingelheim, Ingelheim am Rhein, Germany). Impact of baseline symptomatic status (modified Medical Research Council [mMRC] score) on response to treatment with tiotropium/olodaterol 5/5 µg, tiotropium 5 µg, or placebo at Week 12 was assessed by St George's Respiratory Questionnaire (SGRQ) total score and response rate, transition dyspnea index (TDI) focal score and response rate, and trough forced expiratory volume in 1 second response. RESULTS Tiotropium/olodaterol improved SGRQ total scores and response rates compared with placebo and tiotropium for patients with baseline mMRC scores 0-1 and ≥2. For tiotropium/olodaterol vs tiotropium, greater improvements were observed for patients with mMRC ≥2 (SGRQ score adjusted mean treatment difference -3.44 [95% CI: -5.43, -1.46]; P=0.0007; SGRQ response rate ORs 2.09 [95% CI: 1.41, 3.10]; P=0.0002). Dyspnea, measured by TDI score, was consistently improved with tiotropium/olodaterol vs placebo for patients with mMRC scores 0-1 and ≥2 (adjusted mean treatment difference 1.63 [95% CI: 1.06, 2.20]; P<0.0001 and 1.60 [95% CI: 1.09, 2.10]; P<0.0001, respectively). In patients with mMRC scores 0-1 and ≥2, tiotropium/olodaterol consistently improved TDI response rate and lung function vs placebo and tiotropium. CONCLUSIONS Patients with COPD with more severe baseline dyspnea appear to derive greater health status benefit with tiotropium/olodaterol compared with tiotropium alone.
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Affiliation(s)
- Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA,
| | - Roger A Abrahams
- Morgantown Pulmonary Clinical Research, Morgantown, WV, USA
- Department of Pulmonary & Critical Care, Mon Health Care, Morgantown, WV, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Lars Grönke
- Biotechnology, CSL Behring, Wiesbaden, Germany
| | - Florian Voß
- Biostatistics + Data Sciences Corp., Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester, UK
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11
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Thomashow B, Crapo JD, Drummond MB, Han MK, Kalhan R, Malanga E, Malanga V, Mannino DM, Rennard S, Sciurba FC, Willard KS, Wise R, Yawn B. Introducing the New COPD Pocket Consultant Guide App: Can A Digital Approach Improve Care? A Statement of the COPD Foundation. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2019; 6:210-220. [PMID: 31075813 DOI: 10.15326/jcopdf.6.3.2018.0167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The COPD Foundation has tried to address gaps in chronic obstructive pulmonary disease (COPD) care by providing COPD Pocket Consultant Guide cards to U.S. health care providers. Since launching the card in 2007, there have been numerous updates and more than 800,000 of these cards have been distributed at no charge to health care professionals. The most recent versions have concentrated on presenting an algorithm for COPD management based on 7 severity domains: spirometry, symptoms, exacerbations, oxygen requirements, the presence of chronic bronchitis or emphysema and comorbidities. To increase the usability and reach of this tool, the COPD Pocket Consultant Guide is now available as an app for iOS and Android. This updated version of the app includes new COPD and asthma/COPD overlap flow charts; an interactive therapy chart that takes into account modified Medical Research Council (mMRC), COPD Assessment Test (CAT), and spirometry scores; anxiety and depression screeners; up-to-date medication charts in both brand and generic formats; a checklist to aid in determining when a patient should be referred to a pulmonologist and more. Potential use of the COPD Pocket Consultant Guide app in clinical care is discussed.
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Affiliation(s)
- Byron Thomashow
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York
| | - James D Crapo
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Medicine, Department of Medicine, University of North Carolina, Chapel Hill
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
| | - Ravi Kalhan
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - David M Mannino
- GlaxoSmithKline, Philadelphia, Pennsylvania and Department of Preventative Medicine and Environmental Health University of Kentucky, College of Public Health, Lexington
| | - Stephen Rennard
- Early Clinical Development, IMED Biotech Unit, AstraZeneca, Cambridge, United Kingdom and Department of Medicine, University of Nebraska Medical Center, Omaha
| | - Frank C Sciurba
- Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Robert Wise
- Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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12
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Leidy NK, Martinez FJ, Malley KG, Mannino DM, Han MK, Bacci ED, Brown RW, Houfek JF, Labaki WW, Make BJ, Meldrum CA, Quezada W, Rennard S, Thomashow B, Yawn BP. Can CAPTURE be used to identify undiagnosed patients with mild-to-moderate COPD likely to benefit from treatment? Int J Chron Obstruct Pulmon Dis 2018; 13:1901-1912. [PMID: 29942123 PMCID: PMC6005334 DOI: 10.2147/copd.s152226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE™) uses five questions and peak expiratory flow (PEF) thresholds (males ≤350 L/min; females ≤250 L/min) to identify patients with a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) <0.70 and FEV1 <60% predicted or exacerbation risk requiring further evaluation for COPD. This study tested CAPTURE's ability to identify symptomatic patients with mild-to-moderate COPD (FEV1 60%-80% predicted) who may also benefit from diagnosis and treatment. Methods Data from the CAPTURE development study were used to test its sensitivity (SN) and specificity (SP) differentiating mild-to-moderate COPD (n=73) from no COPD (n=87). SN and SP for differentiating all COPD cases (mild to severe; n=259) from those without COPD (n=87) were also estimated. The modified Medical Research Council (mMRC) dyspnea scale and COPD Assessment Test (CAT™) were used to evaluate symptoms and health status. Clinical Trial Registration: NCT01880177, https://ClinicalTrials.gov/ct2/show/NCT01880177?term=NCT01880177&rank=1. Results Mean age (+SD): 61 (+10.5) years; 41% male. COPD: FEV1/FVC=0.60 (+0.1), FEV1% predicted=74% (+12.4). SN and SP for differentiating mild-to-moderate and non-COPD patients (n=160): Questionnaire: 83.6%, 67.8%; PEF (≤450 L/min; ≤350 L/min): 83.6%, 66.7%; CAPTURE (Questionnaire+PEF): 71.2%, 83.9%. COPD patients whose CAPTURE results suggested that diagnostic evaluation was warranted (n=52) were more likely to be symptomatic than patients whose results did not (n=21) (mMRC >2: 37% vs 5%, p<0.01; CAT>10: 86% vs 57%, p<0.01). CAPTURE differentiated COPD from no COPD (n=346): SN: 88.0%, SP: 83.9%. Conclusion CAPTURE (450/350) may be useful for identifying symptomatic patients with mild-to-moderate airflow obstruction in need of diagnostic evaluation for COPD.
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Affiliation(s)
- Nancy K Leidy
- Evidera, Patient-Centered Research, Bethesda, MD, USA
| | - Fernando J Martinez
- Weill Cornell Medicine, Joan & Sanford Weill Department of Medicine, New York, NY, USA
| | | | - David M Mannino
- University of Kentucky, Preventive Medicine & Environmental Health, Lexington, KY, USA
| | - MeiLan K Han
- University of Michigan, Division of Pulmonary & Critical Care Medicine, Ann Arbor, MI, USA
| | | | - Randall W Brown
- University of Michigan, Department of Health Behavior & Health Education, School of Public Health, Ann Arbor, MI, USA
| | - Julia F Houfek
- University of Nebraska Medical Center College of Nursing, Omaha, NE, USA
| | - Wassim W Labaki
- University of Michigan, Division of Pulmonary & Critical Care Medicine, Ann Arbor, MI, USA
| | - Barry J Make
- National Jewish Health, Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, Denver, CO, USA
| | - Catherine A Meldrum
- University of Michigan, Division of Pulmonary & Critical Care Medicine, Ann Arbor, MI, USA
| | - Wilson Quezada
- Columbia University Medical Center, Division of Pulmonary, Allergy, & Critical Care, New York, NY, USA
| | - Stephen Rennard
- AstraZeneca, IMED Biotech Unit, Cambridge, UK & University of Nebraska Medical Center, Department of Medicine, Omaha, NE, USA
| | - Byron Thomashow
- Columbia University Medical Center, Division of Pulmonary, Allergy, & Critical Care, New York, NY, USA
| | - Barbara P Yawn
- University of Minnesota, Department of Family & Community Health, Minneapolis, MN & COPD Foundation, Miami, FL, USA
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13
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Anzueto A, Miravitlles M. The Role of Fixed-Dose Dual Bronchodilator Therapy in Treating COPD. Am J Med 2018; 131:608-622. [PMID: 29305841 DOI: 10.1016/j.amjmed.2017.12.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 12/23/2022]
Abstract
The incidence of chronic obstructive pulmonary disease (COPD) is rising in the United States, and the disease represents a significant source of morbidity and mortality. Primary care providers face many challenges in COPD diagnosis and treatment, as different clinical phenotypes require personalized treatment approaches. Patient adherence and inhaler technique also contribute to treatment outcomes. Around 48% of primary care providers are unaware of guidelines and recommendations for COPD diagnosis and treatment, which may lead to misdiagnosis or undertreatment of COPD symptoms. Inadequately treated COPD can impair patients' quality of life and ability to perform everyday activities. Long-acting bronchodilator therapy is the cornerstone treatment for patients with COPD; combinations of bronchodilators of different pharmacological classes have shown improved efficacy vs monotherapy. We review the rationale behind fixed-dose dual bronchodilator therapy, evidence for the 4 currently Food and Drug Administration-approved long-acting anticholinergic bronchodilators/long-acting β2-agonists fixed combinations, patient suitability for the available inhaler devices, and practical guidance to optimize personalized care for patients with COPD.
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Affiliation(s)
- Antonio Anzueto
- South Texas Veterans Health Care System, and University of Texas Health Science Center, San Antonio, Texas.
| | - Marc Miravitlles
- Department of Pneumology, Vall d'Hebron University Hospital, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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14
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Patel M, Steinberg K, Suarez-Barcelo M, Saffel D, Foley R, Worz C. Chronic Obstructive Pulmonary Disease in Post-acute/Long-term Care Settings: Seizing Opportunities to Individualize Treatment and Device Selection. J Am Med Dir Assoc 2018; 18:553.e17-553.e22. [PMID: 28549708 DOI: 10.1016/j.jamda.2017.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/28/2017] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The burden of chronic obstructive pulmonary disease (COPD) in post-acute/long-term care (PA/LTC) settings is high, and many patients do not receive guideline-recommended care. METHODS An interprofessional expert panel of PA/LTC professionals convened to discuss the unmet medical needs in patients with COPD in PA/LTC settings, and to make recommendations for the assessment of COPD patients to individualize the selection of maintenance treatment. RESULTS Unmet needs observed in patients with COPD are described in addition to new tools for assessing individual patient abilities and appropriate device selection for maintenance treatment. CONCLUSION COPD management in PA/LTC settings needs to be reevaluated and updated to help reduce exacerbations, hospitalizations, and readmissions.
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Affiliation(s)
- Meenakshi Patel
- Wright State University, Boonshoft School of Medicine, Dayton, OH
| | - Karl Steinberg
- California State University Institute for Palliative Care, San Marcos, CA.
| | | | - Dana Saffel
- PharmaCare Strategies, Inc., Santa Rosa Beach, FL
| | | | - Chad Worz
- University of Cincinnati, College of Pharmacy, Cincinnati, OH
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15
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DePietro M, Gilbert I, Millette LA, Riebe M. Inhalation device options for the management of chronic obstructive pulmonary disease. Postgrad Med 2017; 130:83-97. [PMID: 29210318 DOI: 10.1080/00325481.2018.1399042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by chronic respiratory symptoms and airflow limitation, resulting from abnormalities in the airway and/or damage to the alveoli. Primary care physicians manage the healthcare of a large proportion of patients with COPD. In addition to determining the most appropriate medication regimen, which usually includes inhaled bronchodilators with or without inhaled corticosteroids, physicians are charged with optimizing inhalation device selection to facilitate effective drug delivery and patient adherence. The large variety of inhalation devices currently available present numerous challenges for physicians that include: (1) gaining knowledge of and proficiency with operating different device classes; (2) identifying the most appropriate inhalation device for the patient; and (3) providing the necessary education and training for patients on device use. This review provides an overview of the inhalation device types currently available in the United States for delivery of COPD medications, including information on their successful operation and respective advantages and disadvantages, factors to consider in matching a device to an individual patient, the need for device training for patients and physicians, and guidance for improving treatment adherence. Finally, the review will discuss established and novel tools and technology that may aid physicians in improving education and promoting better adherence to therapy.
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Affiliation(s)
| | - Ileen Gilbert
- a Medical Affairs , AstraZeneca LP , Wilmington , DE , USA
| | | | - Michael Riebe
- b Inhalation Product Development , AstraZeneca LP , Durham , NC , USA
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16
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Baseline Symptom Score Impact on Benefits of Glycopyrrolate/Formoterol Metered Dose Inhaler in COPD. Chest 2017; 152:1169-1178. [DOI: 10.1016/j.chest.2017.07.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/26/2017] [Accepted: 07/03/2017] [Indexed: 11/17/2022] Open
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17
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Naseer BA, Al-Shenqiti AM, Ali AH, Al-Jeraisi TM, Gunjan GG, Awaidallah MF. Effect of a short term pulmonary rehabilitation programme on exercise capacity, pulmonary function and health related quality of life in patients with COPD. J Taibah Univ Med Sci 2017; 12:471-476. [PMID: 31435281 PMCID: PMC6694923 DOI: 10.1016/j.jtumed.2017.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 07/20/2017] [Accepted: 07/27/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Patients with chronic obstructive pulmonary disease (COPD) have been shown to benefit from pulmonary rehabilitation programmes. The purpose of this study was to ascertain the effects of a short-term pulmonary rehabilitation programme (PRP) on exercise capacity, pulmonary function and quality of life in patients with COPD. METHODS A pre-test and post-test experimental design was conducted on patients from the outpatient physical therapy department. Thirty stable COPD patients with mild to severe airflow obstruction, (mean age 54.1 ± 5.22, FEV1, between 0.80 and 0.30 predicted; FEV1/FVC < 0.70) were recruited for a 6-week comprehensive pulmonary rehabilitation programme (PRP) that included education and exercise training. Exclusion criteria included the following: cardiovascular conditions likely to be aggravated by exercise, locomotor impairment, haemoptysis, cognitive impairment, severe pulmonary hypertension, and metastatic cancer. The patients were randomly divided into experimental and control groups. RESULTS Six-minute walk distance (6MWD), pulmonary function (FEV1, FVC, FEV1/FVC), and St. George's Respiratory Questionnaire (SGRQ) scores were measured at baseline, at the end of the 3rd week and at the end of the 6th week. The results showed significant improvements in 6MWD and SGRQ (p < 0.05). CONCLUSION A 6-week outpatient-based PRP significantly improves exercise capacity and quality of life, irrespective of the degree of airflow obstruction.
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Affiliation(s)
- Bangi A. Naseer
- Faculty of Medical Rehabilitation Sciences, Taibah University, KSA
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18
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Martinez FJ, Mannino D, Leidy NK, Malley KG, Bacci ED, Barr RG, Bowler RP, Han MK, Houfek JF, Make B, Meldrum CA, Rennard S, Thomashow B, Walsh J, Yawn BP. A New Approach for Identifying Patients with Undiagnosed Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2017; 195:748-756. [PMID: 27783539 DOI: 10.1164/rccm.201603-0622oc] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
RATIONALE Chronic obstructive pulmonary disease (COPD) is often unrecognized and untreated. OBJECTIVES To develop a method for identifying undiagnosed COPD requiring treatment with currently available therapies (FEV1 <60% predicted and/or exacerbation risk). METHODS We conducted a multisite, cross-sectional, case-control study in U.S. pulmonary and primary care clinics that recruited subjects from primary care settings. Cases were patients with COPD and at least one exacerbation in the past year or FEV1 less than 60% of predicted without exacerbation in the past year. Control subjects were persons with no COPD or with mild COPD (FEV1 ≥60% predicted, no exacerbation in the past year). In random forests analyses, we identified the smallest set of questions plus peak expiratory flow (PEF) with optimal sensitivity (SN) and specificity (SP). MEASUREMENTS AND MAIN RESULTS PEF and spirometry were recorded in 186 cases and 160 control subjects. The mean (SD) age of the sample population was 62.7 (10.1) years; 55% were female; 86% were white; and 16% had never smoked. The mean FEV1 percent predicted for cases was 42.5% (14.2%); for control subjects, it was 82.5% (15.7%). A five-item questionnaire, CAPTURE (COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk), was used to assess exposure, breathing problems, tiring easily, and acute respiratory illnesses. CAPTURE exhibited an SN of 95.7% and an SP of 44.4% for differentiating cases from all control subjects, and an SN of 95.7% and an SP of 67.8% for differentiating cases from no-COPD control subjects. The PEF (males, <350 L/min; females, <250 L/min) SN and SP were 88.0% and 77.5%, respectively, for differentiating cases from all control subjects, and they were 88.0% and 90.8%, respectively, for distinguishing cases from no-COPD control subjects. The CAPTURE plus PEF exhibited improved SN and SP for all cases versus all control subjects (89.7% and 78.1%, respectively) and for all cases versus no-COPD control subjects (89.7% and 93.1%, respectively). CONCLUSIONS CAPTURE with PEF can identify patients with COPD who would benefit from currently available therapy and require further diagnostic evaluation. Clinical trial registered with clinicaltrials.gov (NCT01880177).
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Affiliation(s)
- Fernando J Martinez
- 1 Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York, New York
| | - David Mannino
- 2 Department of Preventive Medicine and Environmental Health, University of Kentucky, Lexington, Kentucky
| | | | | | | | - R Graham Barr
- 5 Department of Medicine and.,6 Department of Epidemiology, Columbia University Medical Center, New York, New York
| | - Russ P Bowler
- 7 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - MeiLan K Han
- 8 Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, Michigan
| | | | - Barry Make
- 7 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Catherine A Meldrum
- 8 Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Stephen Rennard
- 10 Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska.,11 Clinical Discovery Unit, Early Clinical Discovery, AstraZeneca, Cambridge, United Kingdom
| | - Byron Thomashow
- 12 Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, New York
| | - John Walsh
- 13 COPD Foundation, Washington, District of Columbia; and
| | - Barbara P Yawn
- 14 Department of Family and Community Health, University of Minnesota, Minneapolis, Minnesota
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19
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Carlin BW, Schuldheisz SK, Noth I, Criner GJ. Individualizing the selection of long-acting bronchodilator therapy for patients with COPD: considerations in primary care. Postgrad Med 2017; 129:725-733. [PMID: 28707495 DOI: 10.1080/00325481.2017.1353885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common condition encountered in primary care settings. COPD remains the third leading cause of death in the United States and carries a significant burden to both patients and the healthcare system. COPD is a chronic, progressive, irreversible lung disease associated with high morbidity and mortality. Proper assessment and diagnosis requires spirometry which is currently underutilized in primary care. Management is focused on adequate symptom control, improving quality of breathing and quality of life, and preventing exacerbations and hospitalizations. However, many patients are not receiving long-acting bronchodilator maintenance therapy as recommended in current clinical guidelines. Even when patients receive appropriate therapy, real-world issues such as a patient's health literacy, physical and cognitive limitations, and therapy nonadherence limit the effectiveness of prescribed inhaled medications. Primary care providers are well situated to ensure that prescribed therapies and long-term management goals are matched to the individual needs of patients with COPD.
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Affiliation(s)
- Brian W Carlin
- a Sleep Medicine and Lung Health Consultants , LLC , Pittsburgh , PA , USA
| | | | - Imre Noth
- c Interstitial Lung Disease Program , The University of Chicago Medicine , Chicago , IL , USA
| | - Gerard J Criner
- d Thoracic Medicine and Surgery, Lewis Katz School of Medicine , Temple University , Philadelphia , PA , USA
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Yawn BP, Thomashaw B, Mannino DM, Han MK, Kalhan R, Rennard S, Cerrata S, Crapo JD, Wise R. The 2017 Update to the COPD Foundation COPD Pocket Consultant Guide. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2017; 4:177-185. [PMID: 28848929 PMCID: PMC5556909 DOI: 10.15326/jcopdf.4.3.2017.0136] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/23/2017] [Indexed: 02/06/2023]
Abstract
The COPD Foundation Pocket Consultant Guide (PCG) was first released in 2007 as a practice tool for use at point of service for clinicians, especially primary care clinicians diagnosing and treating patients with chronic obstructive pulmonary disease (COPD). Over the years, the PCG has been supplemented with a mobile app that presents the tool in an online smart phone accessible version that also allows the clinician to enter patient specific data for guidance to next steps of diagnosis or management. In November 2016, a new update of the PCG was released that incorporates a flow diagram for stepped care that includes the newest recommendation for diagnosis, assessment and treatment; including the broad use of dual bronchodilator therapy and consideration of asthma COPD overlap syndrome (ACOS). The current controversy regarding when to add inhaled corticosteroids (ICSs) is addressed to support clinical decision making. The PCG comes in 2 versions, one with generic names for COPD drugs available in the United States and one with trade names for those drugs. The update continues to recommend spirometry for those at highest risk, also emphasizing the need to assess symptoms, exacerbation risks and comorbidity before selecting appropriate non-pharmacological as well as pharmacological therapy. The tool is designed to facilitate COPD management in daily practice.
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Affiliation(s)
- Barbara P. Yawn
- Department of Family and Community Health, University of Minnesota School of Medicine, Minneapolis
| | - Byron Thomashaw
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - David M. Mannino
- Department of Preventive Medicine and Environmental Health, University of Kentucky, College of Public Health, Lexington
| | - MeiLan K. Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
| | - Ravi Kalhan
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen Rennard
- Clinical Discovery Unit, Early Clinical Development, AstraZeneca, Cambridge, United Kingdom and Department of Medicine, University of Nebraska Medical Center, Omaha
| | | | - James D. Crapo
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - Robert Wise
- Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Foda HD, Brehm A, Goldsteen K, Edelman NH. Inverse relationship between nonadherence to original GOLD treatment guidelines and exacerbations of COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:209-214. [PMID: 28123293 PMCID: PMC5230726 DOI: 10.2147/copd.s119507] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Prescriber disagreement is among the reasons for poor adherence to COPD treatment guidelines; it is yet not clear whether this leads to adverse outcomes. We tested whether undertreatment according to the original Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines led to increased exacerbations. Methods Records of 878 patients with spirometrically confirmed COPD who were followed from 2005 to 2010 at one Veterans Administration (VA) Medical Center were analyzed. Analysis of variance was performed to assess differences in exacerbation rates between severity groups. Logistic regression analysis was performed to assess the relationship between noncompliance with guidelines and exacerbation rates. Findings About 19% were appropriately treated by guidelines; 14% overtreated, 44% under-treated, and in 23% treatment did not follow any guideline. Logistic regression revealed a strong inverse relationship between undertreatment and exacerbation rate when severity of obstruction was held constant. Exacerbations per year by GOLD stage were significantly different from each other: mild 0.15, moderate 0.27, severe 0.38, very severe 0.72, and substantially fewer than previously reported. Interpretation The guidelines were largely not followed. Undertreatment predominated but, contrary to expectations, was associated with fewer exacerbations. Thus, clinicians were likely advancing therapy primarily based upon exacerbation rates as was subsequently recommended in revised GOLD and other more recent guidelines. In retrospect, a substantial lack of prescriber adherence to treatment guidelines may have been a signal that they required re-evaluation. This is likely to be a general principle regarding therapeutic guidelines. The identification of fewer exacerbations in this cohort than has been generally reported probably reflects the comprehensive nature of the VA system, which is more likely to identify relatively asymptomatic (ie, nonexacerbating) COPD patients. Accordingly, these rates may better reflect those in the general population. In addition, the lower rates may reflect the more complete preventive care provided by the VA.
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Affiliation(s)
- Hussein D Foda
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Veterans Affairs Medical Center, Northport; Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY
| | - Anthony Brehm
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Veterans Affairs Medical Center, Northport; Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY
| | - Karen Goldsteen
- MPH Program, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | - Norman H Edelman
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY; Department of Preventative Medicine and Program in Public Health, Stony Brook University Medical Center, Stony Brook, NY, USA
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Jones PW, Rennard S, Tabberer M, Riley JH, Vahdati-Bolouri M, Barnes NC. Interpreting patient-reported outcomes from clinical trials in COPD: a discussion. Int J Chron Obstruct Pulmon Dis 2016; 11:3069-3078. [PMID: 27994447 PMCID: PMC5153282 DOI: 10.2147/copd.s117378] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
One of the challenges faced by the practising physician is the interpretation of patient-reported outcomes (PROs) in clinical trials and the relevance of such data to their patients. This is especially true when caring for patients with progressive diseases such as COPD. In an attempt to incorporate the patient perspective, many clinical trials now include assessments of PROs. These are formalized methods of capturing patient-centered information. Given the importance of PROs in evaluating the potential utility of an intervention for a patient with COPD, it is important that physicians are able to critically interpret (and critique) the results derived from them. Therefore, in this paper, a series of questions is posed for the practising physician to consider when reviewing the treatment effectiveness as assessed by PROs. The focus is on the St George's Respiratory Questionnaire for worked examples, but the principles apply equally to other symptom-based questionnaires. A number of different ways of presenting PRO data are discussed, including the concept of the minimum clinically important difference, whether there is a ceiling effect to PRO results, and the strengths and weaknesses of responder analyses. Using a worked example, the value of including a placebo arm in a study is illustrated, and the influence of the study on PRO results is considered, in terms of the design, patient withdrawal, and the selection of the study population. For the practising clinician, the most important consideration is the importance of individualization of treatment (and of treatment goals). To inform such treatment, clinicians need to critically review PRO data. The hope is that the questions posed here will help to build a framework for this critical review.
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Affiliation(s)
- Paul W Jones
- Institute for Infection and Immunity, University of London, London
- Global Respiratory Franchise, GlaxoSmithKline, Uxbridge, UK
| | - Stephen Rennard
- Division of Pulmonary, Critical Care, Sleep and Allergy, Nebraska Medical Center, Omaha, NE, USA
- Clinical Discovery Unit, AstraZeneca, Cambridge
| | | | - John H Riley
- Global Respiratory Franchise, GlaxoSmithKline, Uxbridge, UK
| | | | - Neil C Barnes
- Global Respiratory Franchise, GlaxoSmithKline, Uxbridge, UK
- William Harvey Institute, Bart’s and the London School of Medicine and Dentistry, London, UK
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Kubota Y, London SJ, Cushman M, Chamberlain AM, Rosamond WD, Heckbert SR, Zakai N, Folsom AR. Lung function, respiratory symptoms and venous thromboembolism risk: the Atherosclerosis Risk in Communities Study. J Thromb Haemost 2016; 14:2394-2401. [PMID: 27696765 PMCID: PMC5378065 DOI: 10.1111/jth.13525] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Indexed: 02/02/2023]
Abstract
Essentials The association of lung function with venous thromboembolism (VTE) is unclear. Chronic obstructive pulmonary disease (COPD) patterns were associated with a higher risk of VTE. Symptoms were also associated with a higher risk of VTE, but a restrictive pattern was not. COPD may increase the risk of VTE and respiratory symptoms may be a novel risk marker for VTE. SUMMARY Background The evidence for the association between chronic obstructive pulmonary disease (COPD) and venous thromboembolism (VTE) is limited. There is no study investigating the association between restrictive lung disease (RLD) and respiratory symptoms with VTE. Objectives To investigate prospectively the association of lung function and respiratory symptoms with VTE. Patients/Methods In 1987-1989, we assessed lung function by using spirometry, and obtained information on respiratory symptoms (cough, phlegm, and dyspnea) in 14 654 participants aged 45-64 years, without a history of VTE or anticoagulant use, and followed them through 2011. Participants were classified into four mutually exclusive groups: 'COPD' (forced expiratory volume in 1 s [FEV1 ]/forced vital capacity [FVC] below the lower limit of normal [LLN]), 'RLD' (FEV1 /FVC ≥ LLN and FVC < LLN), 'respiratory symptoms with normal spirometic results' (without RLD or COPD), and 'normal' (without respiratory symptoms, RLD, or COPD). Results We documented 639 VTEs (238 unprovoked and 401 provoked VTEs). After adjustment for VTE risk factors, VTE risk was increased for individuals with either respiratory symptoms with normal spirometric results (hazard ratio [HR] 1.40, 95% confidence interval [CI] 1.12-1.73) or COPD (HR 1.33, 95% CI 1.07-1.67) but not for those with RLD (HR 1.15, 95% CI 0.82-1.60). These elevated risks of VTE were derived from both unprovoked and provoked VTE. Moreover, FEV1 and FEV1 /FVC showed dose-response relationships with VTE. COPD was more strongly associated with pulmonary embolism than with deep vein thrombosis. Conclusions Obstructive spirometric patterns were associated with an increased risk of VTE, suggesting that COPD may increase the risk of VTE. Respiratory symptoms may represent a novel risk marker for VTE.
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Affiliation(s)
- Yasuhiko Kubota
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Stephanie J. London
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC, USA
| | - Mary Cushman
- Departments of Medicine and Pathology, University of Vermont College of Medicine, Burlington, VT, USA
| | | | - Wayne D. Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Susan R. Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Neil Zakai
- Departments of Medicine and Pathology, University of Vermont College of Medicine, Burlington, VT, USA
| | - Aaron R. Folsom
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Wise RA, Acevedo RA, Anzueto AR, Hanania NA, Martinez FJ, Ohar JA, Tashkin DP. Guiding Principles for the Use of Nebulized Long-Acting Beta2-Agonists in Patients with COPD: An Expert Panel Consensus. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 4:7-20. [PMID: 28848907 DOI: 10.15326/jcopdf.4.1.2016.0141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Determining which patients with COPD may benefit from a nebulized long-acting beta2-agonist (LABA) is a challenge in current practice. In the absence of strong clinical guidelines addressing this issue, an expert panel convened to develop guiding principles for the use of nebulized LABA therapy in patients with COPD. This article summarizes these guiding principles and other practical issues discussed during a roundtable meeting.
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Affiliation(s)
- Robert A Wise
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Antonio R Anzueto
- University of Texas Health Science Center, and South Texas Veterans Health Care System, San Antonio, Texas
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Jill A Ohar
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Donald P Tashkin
- David Geffen School of Medicine at the University of California, Los Angeles
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25
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Wong CK, Yu WC. Correlates of disease-specific knowledge in Chinese patients with COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:2221-2227. [PMID: 27695309 PMCID: PMC5028094 DOI: 10.2147/copd.s112176] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This study aimed to determine the associations of various sociodemographic factors with the level of disease-specific knowledge among Hong Kong Chinese patients with COPD. Methods A cross-sectional survey of 100 Chinese adults with COPD recruited from outpatient clinics was conducted from September 2009 to September 2010. Data on the knowledge specific to COPD and patients’ sociodemographics were collected from face-to-face interviews. Primary outcome of disease-specific knowledge was measured using 65-item Bristol COPD Knowledge Questionnaire (BCKQ), summing up the 65 items as the BCKQ overall score. Associations of sociodemographic factors with the BCKQ overall score were evaluated using the linear regression model. Results The mean BCKQ overall score of our patients was 41.01 (SD: 10.64). The knowledge in topics of “Smoking” and “Phlegm” achieved the first (3.97, SD: 0.82) and second (3.91, SD: 1.17) highest mean scores, respectively, while the topic of “Oral steroids” returned the lowest mean score of 1.89 (SD: 1.64). The BCKQ overall score progressively declined (P<0.001) with increase in education level, with the highest BCKQ overall score of 46.71 at no formal education among all subgroups. Compared to nondrinkers, current drinkers were associated with lower total BCKQ score. Conclusion We found that among COPD patients in outpatient clinics, impairments in the level of COPD knowledge were evident in patients who were current drinkers or had higher level of education.
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Affiliation(s)
- Carlos Kh Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong
| | - W C Yu
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Special Administrative Region
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Rennard SI, Martinez FJ, Rabe KF, Sethi S, Pizzichini E, McIvor A, Siddiqui S, Anzueto A, Zhu H. Effects of roflumilast in COPD patients receiving inhaled corticosteroid/long-acting β2-agonist fixed-dose combination: RE(2)SPOND rationale and study design. Int J Chron Obstruct Pulmon Dis 2016; 11:1921-8. [PMID: 27574416 PMCID: PMC4994799 DOI: 10.2147/copd.s109661] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Roflumilast, a once-daily, selective phosphodiesterase-4 inhibitor, reduces the risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations. The RE2SPOND study is examining whether roflumilast, when added to an inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) fixed-dose combination (FDC), further reduces exacerbations. The methodology is described herein. Methods In this Phase IV, multicenter, double-blind, placebo-controlled, parallel-group trial, participants were randomized 1:1 (stratified by long-acting muscarinic antagonist use) to receive roflumilast or placebo, plus ICS/LABA FDC, for 52 weeks. Eligible participants had severe COPD associated with chronic bronchitis, had two or more moderate–severe exacerbations within 12 months, and were receiving ICS/LABA FDC for ≥3 months. The primary efficacy measure is the rate of moderate or severe COPD exacerbations per participant per year. The secondary efficacy outcomes include mean change in prebronchodilator forced expiratory volume in 1 second (FEV1) over 52 weeks, rate of severe exacerbations, and rate of moderate, severe, or antibiotic-treated exacerbations. Additional assessments include spirometry, rescue medication use, the COPD assessment test, daily symptoms using the EXACT-Respiratory symptoms (E-RS) questionnaire, all-cause and COPD-related hospitalizations, and safety and pharmacokinetic measures. Results Across 17 countries, 2,354 participants were randomized from September 2011 to October 2014. Enrollment goal was met in October 2014, and study completion occurred in June 2016. Conclusion This study will further characterize the effects of roflumilast added to ICS/LABA on exacerbation rates, lung function, and health of severe–very severe COPD participants at risk of further exacerbations. The results will determine the clinical benefits of roflumilast combined with standard-of-care inhaled COPD treatment.
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Affiliation(s)
- Stephen I Rennard
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA; AstraZeneca, Cambridge, UK
| | - Fernando J Martinez
- Joan and Sanford I Weill Department of Medicine, Weill Cornell University, New York, NY; Department of Internal Medicine, Michigan Health System, Ann Arbor, MI, USA
| | - Klaus F Rabe
- LungenClinic Grosshansdorf, Großhansdorf; Department of Medicine, University Kiel, Kiel; Airway Research Center North, German Center for Lung Research, Großhansdorf, Germany
| | - Sanjay Sethi
- Department of Medicine, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Emilio Pizzichini
- Department of Medicine, Universidade Federal de Santa Catarina, Santa Catarina, Brazil
| | - Andrew McIvor
- Firestone Institute of Respiratory Health, St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | | | - Antonio Anzueto
- South Texas Veterans Health Care System at San Antonio, University of Texas Health Science Center, San Antonio, TX
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27
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Han MK, Martinez CH, Au DH, Bourbeau J, Boyd CM, Branson R, Criner GJ, Kalhan R, Kallstrom TJ, King A, Krishnan JA, Lareau SC, Lee TA, Lindell K, Mannino DM, Martinez FJ, Meldrum C, Press VG, Thomashow B, Tycon L, Sullivan JL, Walsh J, Wilson KC, Wright J, Yawn B, Zueger PM, Bhatt SP, Dransfield MT. Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective. THE LANCET RESPIRATORY MEDICINE 2016; 4:473-526. [PMID: 27185520 DOI: 10.1016/s2213-2600(16)00094-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 12/21/2022]
Abstract
The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.
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Affiliation(s)
- MeiLan K Han
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA.
| | - Carlos H Martinez
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - David H Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, and VA Puget Sound Health Care System, US Department of Veteran Affairs, Seattle, WA, USA; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Jean Bourbeau
- McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard Branson
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Ravi Kalhan
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Jerry A Krishnan
- University of Illinois Hospital & Health Sciences System, University of Illinois, Chicago, IL, USA
| | - Suzanne C Lareau
- University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL, USA
| | | | - David M Mannino
- Department of Preventive Medicine and Environmental Health, University of Kentucky, Lexington, KY, USA
| | - Fernando J Martinez
- Department of Internal Medicine, Weill Cornell School of Medicine, New York, NY, USA
| | - Catherine Meldrum
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - Valerie G Press
- Section of Hospital Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Byron Thomashow
- Division of Pulmonary, Critical Care and Sleep Medicine, Columbia University Medical Center, New York, NY, USA
| | - Laura Tycon
- Palliative and Supportive Institute, Pittsburgh, PA, USA
| | | | | | - Kevin C Wilson
- Boston University School of Medicine, Boston, MA, USA; American Thoracic Society, New York, NY, USA
| | - Jean Wright
- Carolinas HealthCare System, Charlotte, NC, USA
| | - Barbara Yawn
- Family and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Patrick M Zueger
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, and UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, and UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
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28
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The Relationship between Dietary Fiber Intake and Lung Function in the National Health and Nutrition Examination Surveys. Ann Am Thorac Soc 2016; 13:643-50. [DOI: 10.1513/annalsats.201509-609oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Cerceo E, Deitelzweig SB, Sherman BM, Amin AN. Multidrug-Resistant Gram-Negative Bacterial Infections in the Hospital Setting: Overview, Implications for Clinical Practice, and Emerging Treatment Options. Microb Drug Resist 2016; 22:412-31. [PMID: 26866778 DOI: 10.1089/mdr.2015.0220] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The increasing prevalence of infections due to multidrug-resistant (MDR) gram-negative bacteria constitutes a serious threat to global public health due to the limited treatment options available and the historically slow pace of development of new antimicrobial agents. Infections due to MDR strains are associated with increased morbidity and mortality and prolonged hospitalization, which translates to a significant burden on healthcare systems. In particular, MDR strains of Enterobacteriaceae (especially Klebsiella pneumoniae and Escherichia coli), Pseudomonas aeruginosa, and Acinetobacter baumannii have emerged as particularly serious concerns. In the United States, MDR strains of these organisms have been reported from hospitals throughout the country and are not limited to a small subset of hospitals. Factors that have contributed to the persistence and spread of MDR gram-negative bacteria include the following: overuse of existing antimicrobial agents, which has led to the development of adaptive resistance mechanisms by bacteria; a lack of good antimicrobial stewardship such that use of multiple broad-spectrum agents has helped perpetuate the cycle of increasing resistance; and a lack of good infection control practices. The rising prevalence of infections due to MDR gram-negative bacteria presents a significant dilemma in selecting empiric antimicrobial therapy in seriously ill hospitalized patients. A prudent initial strategy is to initiate treatment with a broad-spectrum regimen pending the availability of microbiological results allowing for targeted or narrowing of therapy. Empiric therapy with newer agents that exhibit good activity against MDR gram-negative bacterial strains such as tigecycline, ceftolozane-tazobactam, ceftazidime-avibactam, and others in the development pipeline offer promising alternatives to existing agents.
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Affiliation(s)
- Elizabeth Cerceo
- 1 Division of Hospital Medicine, Cooper Medical School of Rowan University , Camden, New Jersey
| | - Steven B Deitelzweig
- 2 Department of Hospital Medicine, Ochsner Clinical School, Ochsner Health Center , New Orleans, Louisiana
| | | | - Alpesh N Amin
- 4 Department of Medicine, University of California , Irvine, California
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30
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Bhatt SP, Han MK. Developing and Implementing Biomarkers and Novel Imaging in COPD. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 3:485-490. [PMID: 28848871 DOI: 10.15326/jcopdf.3.1.2015.0170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article serves as a CME available, enduring material summary of the following COPD9USA presentations: "Computed Tomography and COPD" Presenter: George R. Washko, MD "CT Imaging in Routine Clinical Practice: Are We Ready for Prime Time?" Presenter: Meilan K. Han, MD "Beyond CT: What MRI can Tell Us about COPD" Presenter: R. Graham Barr, MD.
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Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, and Lung Health Center, University of Alabama, Birmingham
| | - Meilan K Han
- Division of Pulmonary and Critical Care, University of Michigan Hospital and Health Systems, Ann Arbor
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31
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The Alpha-1 Constellation of Voluntary Health Organizations as a Paradigm for Confronting Rare Diseases. ALPHA-1 ANTITRYPSIN 2016. [DOI: 10.1007/978-3-319-23449-6_9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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32
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Parreira VF, Kirkwood RN, Towns M, Aganon I, Barrett L, Darling C, Lee M, Hill K, Goldstein RS, Brooks D. Is there an association between symptoms of anxiety and depression and quality of life in patients with chronic obstructive pulmonary disease? Can Respir J 2015; 22:37-41. [PMID: 25379656 PMCID: PMC4324523 DOI: 10.1155/2015/478528] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In addition to symptoms, such as dyspnea and fatigue, patients with chronic obstructive pulmonary disease (COPD) also experience mood disturbances. OBJECTIVE To explore the relationships between health-related quality of life measures collected from patients with stable COPD and a commonly used measure of depression and anxiety. METHODS The present analysis was a retrospective study of patients with COPD enrolled in a pulmonary rehabilitation program. Hospital Anxiety and Depression Scale (HADS), Chronic Respiratory Disease Questionnaire (CRQ), Medical Research Council dyspnea scale and 6 min walk test data were collected. Statistical analyses were performed using Spearman's correlations, and categorical regression and categorical principal component analysis were interpreted using the biplot methodology. RESULTS HADS anxiety scores retrieved from 80 patients were grouped as 'no anxiety' (n=43 [54%]), 'probable anxiety' (n=21 [26%]) and 'presence of anxiety' (n=16 [20%]). HADS depression scores were similarly grouped. There was a moderate relationship between the anxiety subscale of the HADS and both the emotional function (r=-0.519; P<0.01) and mastery (r=-0.553; P<0.01) domains of the CRQ. Categorical regression showed that the CRQ-mastery domain explained 40% of the total variation in anxiety. A principal component analysis biplot showed that the highest distance between the groups was along the mastery domain, which separated patients without feelings of anxiety from those with anxiety. However, none of the CRQ domains were able to discriminate the three depression groups. CONCLUSIONS The CRQ-mastery domain may identify symptoms of anxiety in patients with COPD; however, the relationship is not strong enough to use the CRQ-mastery domain as a surrogate measure. None of the CRQ domains were able to discriminate the three depression groups (no depression, probable and presence); therefore, specific, validated tools to identify symptoms of depression should be used.
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Affiliation(s)
- Verônica F Parreira
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil and Fellow (CAPES – Brazil)
- Department of Physical Therapy, University of Toronto
- Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario
| | - Renata N Kirkwood
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Megan Towns
- Department of Physical Therapy, University of Toronto
| | - Isabel Aganon
- Department of Physical Therapy, University of Toronto
| | | | | | - Michelle Lee
- Department of Physical Therapy, University of Toronto
| | - Kylie Hill
- Department of Physical Therapy, University of Toronto
- School of Physiotherapy and Curtin Health Innovation Research Institute, Curtin University
- Lung Institute of Western Australia and Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Perth, Australia
| | | | - Dina Brooks
- Department of Physical Therapy, University of Toronto
- Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario
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Abstract
Clinical practice guidelines are usually developed by a group of experts coming together to review the evidence in a field to make evidence-based recommendations on how to integrate new evidence into practice. The development process often draws on strict methodological rules to assess and assign quality grades to the evidence used to underpin the recommendations. Yet the goal of clinical practice guidelines--to help guide clinicians to understand, translate, and apply new evidence into everyday practice--can be thwarted by a lack of diversity and plurality of committee members, by limitations in the published evidence base, and by the design of the randomized controlled trials (RCTs) that largely underpin their pronouncements. Asthma and chronic obstructive pulmonary disease (COPD) RCTs often represent only a minority (5 to 10%) of the routine care population in whom licensed interventions will be applied. Thus, the implications of extrapolating RCT efficacy (based on idealized patients and management settings) to real-life treatment effectiveness (achieved in broad patient populations being managed in routine care) is unclear. Although RCTs can adequately demonstrate efficacy of a specific treatment, pragmatic trials and postmarketing observational studies are usually required to evaluate the long-term safety of therapeutic interventions. The practical usefulness of clinical practice guidelines may be enhanced by ensuring representation of a broad stakeholder group within guideline committees (e.g., patients, primary and secondary care clinicians, policy makers, and health insurers) and by integrating effectiveness as well as efficacy data. Only in this way can clinical practice guidelines achieve their goal of guiding the meaningful implementation of new research into practice, for the benefit of all stakeholders.
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Thomashow B, Crapo J, Yawn B, McIvor A, Cerreta S, Walsh J, Mannino D, Rennard S. The COPD Foundation Pocket Consultant Guide. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2014; 1:83-87. [PMID: 28848814 DOI: 10.15326/jcopdf.1.1.2014.0124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The COPD Foundation Guide to COPD Diagnosis and Treatment is designed to provide practical advice for the health care provider. Available as a hard copy, online and as a mobile device application (app), the Guide serves as an accessible tool for clinicians. To date, over 400,000 cards have been distributed to health care providers nationwide at no charge. The Guide is updated as necessary and suggestions from the COPD physician and health care provider community are integrated into updates.
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Affiliation(s)
- Byron Thomashow
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - James Crapo
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Barbara Yawn
- Olmsted Medical Center, Department of Research, Rochester, Minnesota
| | - Andrew McIvor
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | | | | | - David Mannino
- Departments of Preventive Medicine and Environmental Health, University of Kentucky, College of Public Health, Lexington
| | - Stephen Rennard
- Pulmonary, Critical Care, Sleep and Allergy Division, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
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Thomashow BM, Walsh JW, Malanga ED. The COPD Foundation: Celebrating a Decade of Progress and Looking Ahead to a Cure. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2014; 1:4-16. [PMID: 28848806 PMCID: PMC5559136 DOI: 10.15326/jcopdf.1.1.2014.0122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/10/2014] [Indexed: 11/21/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) affects 15-25 million Americans and over 300 million people around the world. The COPD Foundation is a global organization whose mission is to prevent and cure COPD and to improve the lives of all people affected by it. The year 2014 marks the 10th anniversary of the COPD Foundation. The Foundation works to accomplish its mission through a unique partnership between patients, patient families, health care providers, investigators, academic institutions, government agencies and industry. This partnership has led to real progress in awareness, advocacy, education, and research, but much more needs to be done.
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Affiliation(s)
- Byron M. Thomashow
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
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Martinez FJ. Long-acting bronchodilators in COPD: an evolving story. THE LANCET RESPIRATORY MEDICINE 2013; 1:499-501. [PMID: 24461600 DOI: 10.1016/s2213-2600(13)70177-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Fernando J Martinez
- Internal Medicine and Pulmonary & Critical Care Medicine, University of Michigan, 1500 East Medical Center Drive, TC 3916 Ann Arbor, MI 48109, USA.
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