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Improving adherence with inhaler therapy in COPD. (Open Access Full Text Article)

Chronic obstructive pulmonary disease (COPD) is a major public health problem, associated with considerable morbidity and health care costs. The global burden of COPD morbidity is predicted to rise substantially in the coming decade, but could be moderated by better use of existing management strategies.

Smoking cessation, medication therapy, and pulmonary rehabilitation have all been shown to diminish morbidity and improve patient outcomes. But each of these strategies requires adherence. Adherence is crucial for optimizing clinical outcomes in COPD, with nonadherence resulting in a significant health and economic burden. Suboptimal medication adherence is common among COPD patients, due to a number of factors that involve the medication, the delivery device, the patient, and the health professionals caring for the patient. Lack of medication adherence needs to be identified and addressed by using simplified treatment regimens, increasing patient knowledge about self-management, and enhancing provider skills in patient education, communication, and adherence counseling.

This article reports some of the challenges of medication nonadherence faced by the clinician in the management of COPD, and suggests ways to evaluate and improve adherence effectively in primary care.

Association between lung function and exacerbation frequency in patients with COPD. (Open Access Full Text Article)

To quantify the relationship between severity of chronic obstructive pulmonary disease (COPD) as expressed by Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage and the annual exacerbation frequency in patients with COPD.

Body CT During Pregnancy: Utilization Trends, Examination Indications, and Fetal Radiation Doses

The objective of our study was to analyze body CT utilization trends, indications, fetal radiation doses, and scanning parameters associated with high fetal radiation doses (defined as > 30 mGy).

MATERIALS AND METHODS. A retrospective review of all chest and abdominopelvic CT examinations performed between 1998 and 2005 of patients known to be pregnant was conducted. Demographics, gestational age, examination indication, and scan parameters were recorded. Fetal radiation dose was calculated for those abdominopelvic examinations with direct fetal irradiation.

RESULTS. From a database of more than 170,000 chest and more than 180,000 abdominopelvic CT examinations, 74 chest and 86 abdominopelvic examinations of pregnant patients were identified. Chest CT use increased on average 75%/y/1,000 deliveries in pregnancy versus 19%/y increase in all patients (p = 0.2700). Abdominopelvic CT utilization increase was on average 22%/y/1,000 deliveries in pregnant patients versus 13%/y increase in all patients (p = 0.1865). The most common indication for chest CT during pregnancy was suspected pulmonary embolism (85%, 63/74) and for abdominopelvic CT, suspected appendicitis (58%, 50/86). The average fetal dose from abdominopelvic CT was 24.8 mGy (range, 6.7–56 mGy); one examination exceeded the 50-mGy threshold for increased risk of childhood cancer. Scanning parameters associated with a dose of more than 30 mGy were a pitch of less than 1 (p = 0.0080) and more than one series acquisition (p = 0.0136).

CONCLUSION. Growth of CT during pregnancy reflects the trend of increased CT utilization in the general population. Avoiding use of CT in pregnant patients with suspected appendicitis would significantly decrease fetal radiation exposure. Abdominopelvic CT during pregnancy should be carefully planned and monitored so as not to exceed the fetal radiation dose for negligible risk.

Diagnostic Yield of Electromagnetic Navigation Bronchoscopy Is Highly Dependent on the Presence of a Bronchus Sign on CT Imaging: Results From a Prospective Study

Electromagnetic navigation bronchoscopy (ENB) has been developed as a novel ancillary tool for the bronchoscopic diagnosis of pulmonary nodules. Despite successful navigation in 90% of patients, ENB diagnostic yield does not generally exceed 70%. We sought to determine whether the presence of a bronchus sign on CT imaging conditions diagnostic yield of ENB and might account for the discrepancy between successful navigation and diagnostic yield.

The diagnostic yield of ENB was 67% (34/51). The sensitivity and specificity of ENB for malignancy in this study were 71% and 100%, respectively. ENB was diagnostic in 79% (30/38) patients with a bronchus sign on CT imaging but only in 4/13 (31%) with no discernible bronchus sign. Univariate analysis identified the bronchus sign (P = .005) and nodule size (P = .04) as statistically significant variables conditioning yield, but on multivariate analysis, only the bronchus sign remained significant (OR, 7.6; 95% CI, 1.8-31.7). No procedure-related complications were observed.

We conducted a prospective, single-center study of ENB in 51 consecutive patients with pulmonary nodules. ENB was chosen as the least invasive diagnostic technique in patients with a high surgical risk, suspected metastatic disease, or advanced-stage disease, or in those who demanded a preoperative diagnosis prior to undergoing curative resection. We studied patient and technical variables that might condition diagnostic yield, including size, cause, location, distance to the pleural surface, and fluorodeoxyglucose uptake of a given nodule; the presence of a bronchus sign on CT imaging; registration point divergence; and the minimum distance from the tip of the locatable guide to the nodule measured during the procedure.

ENB diagnostic yield is highly dependent on the presence of a bronchus sign on CT imaging.

Antiendothelial Cell Antibodies in Patients With COPD

Circulating antiendothelial cell antibodies (AECA) bind to endothelial antigens and induce endothelial cell damage. These antibodies have been detected in patients with collagen vascular diseases and systemic vasculitis. Recently, autoimmune mechanisms and vascular involvement have attracted attention in COPD. This study aimed to investigate the expression of AECA in patients with COPD.

A total of 116 patients with COPD, whose condition was established based on the Global Initiative for Chronic Obstructive Lung Disease criteria, were evaluated. Serum samples were examined for AECA by a cellular enzyme-linked immunosorbent assay using human umbilical vein endothelial cells. In addition, 157 subjects without any clinical or radiologic evidence of COPD or pulmonary disease served as a reference population.

The patients with COPD exhibited significantly higher serum AECA concentrations than subjects in the reference population. The expression of AECA was significantly elevated in the patients with COPD, even when compared with that in smokers among the reference population who had similar smoking habits to the patients with COPD but normal spirometry.

These findings suggest that an autoimmune component associated with endothelial cell damage is possibly involved in COPD.

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