GOLD in Practice: Chronic Obstructive Pulmonary Disease Treatment and Management in the Primary Care Setting.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Early detection and appropriate treatment and management of COPD can lower morbidity and perhaps mortality. Clinicians in the primary care setting provide the majority of COPD care and are pivotal in the diagnosis and management of COPD. In this review, we provide an overview of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 report, with a focus on the management of COPD in the primary care setting. We discuss the pathophysiology of COPD; describe COPD risk factors, signs, and symptoms that may facilitate earlier diagnosis of COPD; and reinforce the importance of spirometry use in establishing the diagnosis of COPD. Disease monitoring, as well as a review of the 2020 GOLD treatment recommendations, is also discussed. Patients and families are important partners in COPD management; therefore, we outline simple steps that may assist them in caring for those affected by COPD. Finally, we discuss nonpharmacological treatment options for COPD, COPD monitoring tools that may aid in the evaluation of disease progression and response to therapy, and the importance of developing a COPD action plan on an individualized basis.

Patients' and primary care physicians' beliefs about asthma control and risk.

Patients' and physicians' knowledge of asthma control and risks can affect long-term outcomes. The Asthma General Awareness and Perceptions II (Asthma GAP II) survey sought to assess the beliefs and behaviors of asthma patients and their physicians. In the United States, a telephone survey was conducted among 1885 adults with asthma (representative population sample [n = 1001] plus additional black [n = 436] and Hispanic samples [n = 448]) who took asthma medication in the previous year. An online survey included 300 primary care physicians. Most patients (66, 84, and 78% of national, black, and Hispanic samples, respectively) and physicians (80%) considered asthma a very or extremely serious condition. In contrast to current guidelines, most patients (69, 72, and 70%) believed that quick-relief medications could be taken daily. Many patients (42, 52, and 60%) and some physicians (22%) stated controller medications could be taken less regularly when symptoms decrease, although most patients (92, 92, and 89%) and physicians (95%) indicated that controller medications are most effective when taken daily. Of patients who discontinued controller medications (21%), 71% discontinued when symptoms abated. Most physicians (87%) believed that patients discontinued controller medications without their advice. After controller medication cessation, more black (22%) and Hispanic patients (22%) than patients in the national sample (15%) experienced serious health consequences after an asthma attack. Gaps exist between patients' understanding of asthma control and their use of controller and quick-relief medications. Many patients and physicians fail to recognize that, even with symptom abatement, serious asthma risks remain.

Survey of handheld computing among medical students.

The purpose of this study was to identify trends in the utilization and acceptance of handheld computers (personal digital assistants) among medical students during preclinical and clinical training. We surveyed 366 medical students and collected information on computer expertise, current handheld computer use, predicted future use, and user acceptance. Handheld computers were primarily used for personal applications by students during their preclinical training and as drug references and clinical calculators during their clinical training. In the future, all participants predicted they would use handheld computers at significantly higher rates and on a broader range of medical applications. The adoption of handheld computing was independent of user satisfaction. Those with more clinical experience were less satisfied with handheld computers, suggesting that the expectations of the more experienced users were not met. The lack of institutional support was seen as a key limitation.

Role of the Kidney in Type 2 Diabetes and Mechanism of Action of Sodium Glucose Cotransporter-2 Inhibitors.

The aim of this supplement is to discuss the important role of the kidney in glucose homeostasis. It produces glucose via gluconeogenesis, it filters glucose from the blood, and reabsorbs the filtered glucose in the proximal tubule, mainly via the sodium-glucose cotransporter-2 (SGLT-2). SGLT-2 is paradoxically upregulated in individuals with type 2 diabetes (T2D), which results in increased glucose reabsorption and hyperglycemia. This core defect in the pathophysiology of T2D provides the rationale for the use of SGLT-2 inhibitors to increase urinary glucose excretion and reduce hyperglycemia in an insulin-independent manner. Benefits of SGLT-2 inhibitor use in patients with T2D, in addition to improved glycemic control, include modest weight loss, decreased systolic blood pressure, reduced serum uric acid, and reduced risk of cardiovascular events. Common adverse events are urinary tract infection and genital mycotic infections. The risk of hypoglycemia is low with SGLT-2 inhibitors, particularly when they are given as monotherapy.

Saxagliptin versus glipizide as add-on therapy to metformin: assessment of hypoglycemia.

OBJECTIVE: To compare characteristics of hypoglycemic episodes in patients with type 2 diabetes receiving saxagliptin or glipizide add-on therapy to metformin. PATIENTS AND METHODS: This was a post hoc analysis of an international, randomized, parallel-group, double-blind, active-controlled, phase 3 trial. The 52-week trial and 52-week extension were conducted from December 2007 to August 2010. Patients aged ≥18 years with glycated hemoglobin (HbA1c) >6.5% to 10.0% receiving stable metformin doses (≥1500 mg/d) were randomized 1:1 to add-on therapy with saxagliptin 5 mg/d or glipizide 5 to 20 mg/d (titrated to optimal effect or highest tolerable dose during the initial 18 weeks). Hypoglycemic episodes were recorded in patient diaries. Confirmed hypoglycemic events were defined as fingerstick glucose ≤50 mg/dL (≤2.8 mmol/L) with associated symptoms. RESULTS: Of 858 patients randomized, 428 received saxagliptin + metformin, and 430 received glipizide + metformin. Saxagliptin was noninferior to glipizide in lowering HbA1c. Hypoglycemia with saxagliptin + metformin and glipizide + metformin was reported by 15 (24 events) and 165 (896 events) patients, respectively, through week 104. The mean (SD) number of hypoglycemic events per patient reporting hypoglycemia was lower with saxagliptin + metformin versus glipizide + metformin through weeks 52 (1.5 [SD 0.88] vs 4.8 [SD 4.9], respectively) and 104 (1.6 [SD 0.99] vs 5.4 [SD 5.8]). Most patients receiving glipizide + metformin with hypoglycemia had multiple events (124/165 patients [75%]). Confirmed hypoglycemia, major events, and severe events occurred only with glipizide + metformin. Time to first hypoglycemic event was shorter with glipizide versus saxagliptin. Limitations of this analysis include its post hoc nature, a high rate of study discontinuation, and exclusion of patients with serious comorbidities and complications. CONCLUSION: Saxagliptin + metformin was associated with fewer patients reporting hypoglycemia and fewer and less severe hypoglycemic events in those experiencing hypoglycemia compared with glipizide + metformin. ClinicalTrials.gov registration number: NCT00575588.

Evaluating oral case presentations using a checklist: how do senior student-evaluators compare with faculty?

PURPOSE: Previous studies have shown student-evaluators to be reliable assessors of some clinical skills, but this model has not been studied for oral case presentations (OCPs). The purpose of this study was to examine the validity of student-evaluators in assessing OCP by comparing them with faculty. METHOD: In 2010, the authors developed a dichotomous checklist. They trained 30 fourth-year medical students (student-evaluators) to use it to assess 170 second-year medical students' OCPs in real time during a year-end objective structured clinical examination. Ten faculty physicians then scored videos of a random sample of these OCPs. After discarding items with poor faculty reliability, the authors assessed agreement between faculty and student-evaluators on 18 individual items, total scores, and pass/fail decisions. RESULTS: The total score correlation between student-evaluators and faculty was 0.84 (P < .001) and was somewhat better than the faculty-faculty intraclass correlation (r = 0.71). Using a 70% pass/fail cutoff, faculty and student-evaluator agreement was 74% (Kappa = 0.46; 95% CI, 0.20-0.72). Overall, student-evaluator scores were more lenient than faculty scores (72% versus 56% pass rates; P = .03). CONCLUSIONS: Senior student-evaluators were able to reliably assess second-year medical students' OCP skills. The results support the use of student-evaluators for peer assessment of OCPs in low-stakes settings, but evidence of leniency compared with faculty assessment suggests caution in using student-evaluators in high-stakes settings. Extending peer assessment to OCPs provides a practical approach for low-resource evaluation of this essential skill.

Prevalence of airway obstruction assessed by lung function questionnaire.

OBJECTIVE: To estimate the prevalence of unidentified chronic obstructive pulmonary disease (COPD) and determine the screening accuracy of the Lung Function Questionnaire (LFQ). PATIENTS AND METHODS: Cigarette smokers who had a smoking history of 10 or more pack-years and were aged 30 years or older were recruited from 36 centers from February 18, 2009, to May 29, 2009. A total of 1575 patients completed a Web-based survey including the 5-item LFQ. Spirometry was performed on patients with an LFQ total score of 18 or less and on a subset scoring more than 18. The primary outcome was the proportion of patients at risk of airflow obstruction as measured by the LFQ (score, ≤ 18) in whom an airflow obstruction was confirmed by spirometry. RESULTS: Of the patients who completed the LFQ, 849 (54%) had standardized spirometry data available. On the basis of LFQ and spirometry results, the estimated prevalence of possible COPD was 17.9% (95% confidence interval, 15.3%-20.6%). At a cut point of 18 or less, sensitivity, specificity, positive predictive value, and negative predictive value of the LFQ were 88%, 25%, 21%, and 90%, respectively. Approximately 1 in 5 patients (21%) aged 30 years or older and 1 in 4 (26%) aged 50 years or older scored 18 or less on the LFQ and had a ratio of forced expiratory volume in the first second of expiration to forced vital capacity less than 0.70. CONCLUSION: On the basis of postbronchodilator spirometry results using weighted estimates, approximately 1 in 5 patients (21%) aged 30 years or older with a smoking history of 10 or more pack-years seen in a primary care setting is likely to have COPD. The LFQ could be a helpful COPD case-finding tool for clinicians to identify patients who need further evaluation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01013948.

Trends in handheld computing among medical students.

The purpose of this study was to identify trends in the utilization and acceptance of handheld computers (personal digital assistants) among medical students during preclinical and clinical training. These results can be used to identify differences between preclinical and clinical users, differences between current use and idealized use, and perceived limitations of these devices.