Confirmatory Spirometry for Adults Hospitalized with a Diagnosis of Asthma or Chronic Obstructive Pulmonary Disease Exacerbation

Background: Objective measurement of airflow obstruction by spirometry is an essential part of the diagnosis of asthma or COPD. During exacerbations, the feasibility and utility of spirometry to confirm the diagnosis of asthma or chronic obstructive pulmonary disease (COPD) are unclear. Addressing these gaps in knowledge may help define the need for confirmatory testing in clinical care and quality improvement efforts. This study was designed to determine the feasibility of spirometry and to determine its utility to confirm the diagnosis in patients hospitalized with a physician diagnosis of asthma or COPD exacerbation. Methods: Multi-center study of four academic healthcare institutions. Spirometry was performed in 113 adults admitted to general medicine wards with a physician diagnosis of asthma or COPD exacerbation. Two board-certified pulmonologists evaluated the spirometry tracings to determine the proportion of patients able to produce adequate quality spirometry data. Findings were interpreted to evaluate the utility of spirometry to confirm the presence of obstructive lung disease, according to the 2005 European Respiratory Society/American Thoracic Society recommendations. Results: There was an almost perfect agreement for acceptability (κ = 0.92) and reproducibility (κ =0.93) of spirometry tracings. Three-quarters (73%) of the tests were interpreted by both pulmonologists as being of adequate quality. Of these adequate quality tests, 22% did not present objective evidence of obstructive lung disease. Obese patients (BMI ≥30 kg/m2) were more likely to produce spirometry tracings with no evidence of obstructive lung disease, compared to non-obese patients (33% vs. 8%, p = 0.007). Conclusions: Adequate quality spirometry can be obtained in most hospitalized adults with a physician diagnosis of asthma or COPD exacerbation. Confirmatory spirometry could be a useful tool to help reduce overdiagnosis of obstructive lung disease, especially among obese patients

Multicenter Study Comparing Case Definitions Used to Identify Patients with Chronic Obstructive Pulmonary Disease

Rationale: Clinical trials in chronic obstructive pulmonary disease (COPD) usually require evidence of airflow obstruction and clinical risk factors. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes or patient-reported physician diagnoses are often used for epidemiologic studies and performance improvement programs

Physical Activity after COPD Exacerbations

Background: Although pulmonary rehabilitation after hospital discharge improves outcomes in Chronic Obstructive Pulmonary Disease (COPD) patients, its impact is limited due to poor reach and adoption. The study’s objectives were to evaluate the feasibility of conducting a physical activity promotion program for recently hospitalized patients with COPD and to evaluate time-related changes in functional capacity, objectively measured physical activity parameters, and patient-generated outcomes in these patient population. Methods: This 12-week prospective cohort study involved recently discharged (≤4 weeks) patients with COPD exacerbations. Additional eligibility criteria include airflow obstruction by spirometry, inability to attend pulmonary rehabilitation (PR) and no medical contraindications to participation, as determined by the patient’s physician. Patients are enrolled while hospitalized or during outpatient clinic follow-up appointments, attend 5 in-person outpatient study visits (eligibility/baseline visit, and visits on week 1, 2, 4 and 12) and are asked to carry pedometers for physical activity monitoring. Daily physical activity (step counts) was analyzed as mean daily step counts over 7 days. At each visit participants also completed standardized questionnaires regarding their mental, physical and social health (Patient-Reported Outcomes Measurement Information System, PROMIS). To reduce participant burden, visits are scheduled around the time of clinical appointments and participants receive monetary compensation. Results: Fifty participants were enrolled in the study, however only twenty-two patients discharged a mean (standard deviation, SD) of 21(19) days prior to enrollment participated in the study past the enrollment visit. Several study modifications were implemented to improve recruitment and retention, including implementing a more flexible eligibility criteria and decreasing the burden of study procedures. Participants were predominantly younger (mean age [SD] 63.8[7.1] years), women (68%), African American (90%), and had high school education or less (72%). Comorbidities were common, with 45% of patients reporting at least one comorbidity associated with chronic pain (e.g., osteoarthritis) and 68% had a body mass index ≥30 kg/m2. Participants also had limited functional capacity, with a median (interquartile range, IQR) incremental shuttle walk test of 110 (30 – 210), and PROMIS physical function, ability to participate in social roles and activities, and satisfaction with participation roles and activities T-scores at least one standard deviation lower than the national mean. The median daily step count (IQR) on enrollment was 3,101 (1,144 - 5,330) steps. There was a high within-person correlation in week-to-week daily physical activity over the course of the study (R>0.8). There was no significant change in mean PROMIS T-scores at week 12 compared to enrollment (p>0.05). Discussion: There are multiple challenges to enrolling participants in practice-based research involving physical activity promotion following a hospitalization for COPD. There is a wide range of daily physical activity between patients with COPD recently discharged from the hospital. However, we found limited within-person time-related change in daily physical activity and patient-reported outcomes during the observation period. Future real-world studies of interventions for COPD patients will require more tailored recruitment strategies, a more flexible enrollment criteria and minimization of study burden on participants

Thoracic splenosis: History is the key

Splenosis is an acquired ectopic autotransplantation of splenic tissue; that occurs after traumatic splenic rupture and splenectomy [1]. Splenosis is a rare but benign disease, and the diagnosis can be challenging as the multiple incidentally found nodules could mimic malignancy [2]. Abdominopelvic Splenosis is thought to occur in as many as 65% of cases of splenic rupture [1]. However, Thoracic Splenosis is rare and usually involve the left parietal and visceral pleura [1,2]. Intraparenchymal lesions are less common but have been reported in cases of parenchymal and diaphragm laceration [1,2]. Taking a thorough history is of utmost importance, as these patients usually present more than two decades after the splenic traumatic rupture. The use of commonly available nuclear studies will further confirm the diagnosis [3]. This will help to avoid unnecessary procedures, like biopsies; and prevent the potential complications. We present a case of Thoracic Splenosis that highlights the importance of taking a detailed history; and the importance of using nuclear studies for the diagnosis. Further adding to its uniqueness, this case showed with multiple intraparenchymal nodules which is a less common presentation of Splenosis

Confirmatory spirometry for adults hospitalized with a diagnosis of asthma or chronic obstructive pulmonary disease exacerbation

Abstract Background Objective measurement of airflow obstruction by spirometry is an essential part of the diagnosis of asthma or COPD. During exacerbations, the feasibility and utility of spirometry to confirm the diagnosis of asthma or chronic obstructive pulmonary disease (COPD) are unclear. Addressing these gaps in knowledge may help define the need for confirmatory testing in clinical care and quality improvement efforts. This study was designed to determine the feasibility of spirometry and to determine its utility to confirm the diagnosis in patients hospitalized with a physician diagnosis of asthma or COPD exacerbation. Methods Multi-center study of four academic healthcare institutions. Spirometry was performed in 113 adults admitted to general medicine wards with a physician diagnosis of asthma or COPD exacerbation. Two board-certified pulmonologists evaluated the spirometry tracings to determine the proportion of patients able to produce adequate quality spirometry data. Findings were interpreted to evaluate the utility of spirometry to confirm the presence of obstructive lung disease, according to the 2005 European Respiratory Society/American Thoracic Society recommendations. Results There was an almost perfect agreement for acceptability (κ = 0.92) and reproducibility (κ =0.93) of spirometry tracings. Three-quarters (73%) of the tests were interpreted by both pulmonologists as being of adequate quality. Of these adequate quality tests, 22% did not present objective evidence of obstructive lung disease. Obese patients (BMI ≥30 kg/m2) were more likely to produce spirometry tracings with no evidence of obstructive lung disease, compared to non-obese patients (33% vs. 8%, p = 0.007). Conclusions Adequate quality spirometry can be obtained in most hospitalized adults with a physician diagnosis of asthma or COPD exacerbation. Confirmatory spirometry could be a useful tool to help reduce overdiagnosis of obstructive lung disease, especially among obese patients.</p

Multicenter Study Comparing Case Definitions Used to Identify Patients with Chronic Obstructive Pulmonary Disease

Rationale: Clinical trials in chronic obstructive pulmonary disease (COPD) usually require evidence of airflow obstruction and clinical risk factors. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes or patient-reported physician diagnoses are often used for epidemiologic studies and performance improvement programs. Objectives: To evaluate agreement between these case definitions for COPD and to assess the comparability of study populations identified as having COPD not using the clinical trial reference standard. Methods: We recruited patients from the COPD Outcomes-based Network for Clinical Effectiveness and Research Translation multicenter clinical registry in a cross-sectional study. Demographics, clinical, and post-bronchodilator spirometry data were collected at an in-person study visit. The kappa statistic (κ) was used to evaluate agreement. A multivariable logistic regression model was used to identify patient characteristics associated with meeting the trial reference standard. Measurements and Main Results: A total of 998 (82.8%) of 1,206 study participants met at least one case definition for COPD (of the 998: 91% using ICD-9 codes, 73% using patient-reported physician diagnosis, 56% using trial reference standard); agreement between case definitions was poor (κ = 0.20–0.26). Lack of airflow obstruction was the principal (89%) reason patients identified as having COPD did not meet the trial reference standard. Patients who were black (vs. white), obese (vs. normal weight), or had depression (vs. not) were less likely to meet the trial reference standard (odds ratio [95% CI], 0.37 [0.26–0.53], 0.51 [0.34–0.75], 0.53 [0.40–0.71], respectively). Conclusions: Findings highlight concerns about the applicability of findings in clinical trials to patients meeting other case definitions for COPD