Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone?

BACKGROUND: The value of the history and physical examination in diagnosing chronic obstructive pulmonary disease (COPD) is uncertain. This study was undertaken to determine the best clinical predictors of COPD and to define the incremental changes in the ability to diagnose COPD that occur when the physical examination findings and then the peak flowmeter results are added to the pulmonary history. SUBJECTS AND METHODS: Ninety-two outpatients with a self-reported history of cigarette smoking or COPD completed a pulmonary history questionnaire and received peak flow and spirometric testing. The subjects were independently examined for 12 physical signs by 4 internists blinded to all other results. Multivariate analyses identified independent predictors of clinically significant, moderate COPD, defined as a forced expiratory volume in 1 second (FEV1) less than 60% of the predicted value or a FEV1/FVC (forced vital capacity) less than 60%. RESULTS: Fifteen subjects (16%) had moderate COPD. Two historical variables from the questionnaire--previous diagnosis of COPD and smoking (70 or more pack-years)--significantly entered a logistic regression model that diagnosed COPD with a sensitivity of 40% and a specificity of 100%. Only the physical sign of diminished breath sounds significantly added to the historical model to yield a mean sensitivity of 67% and a mean specificity of 98%. The peak flow result (best cutoff value was less than 200 L/min) significantly added to the models of only one of the four physicians for a mean final sensitivity of 77% and a specificity of 95%. Subjects with none of the three historical and physical variables had a 3% prevalence of COPD; this prevalence was unchanged by adding the peak flow results. CONCLUSIONS: Diminished breath sounds were the best predictor of moderate COPD. A sequential increase in sensitivity and a minimal decrease in specificity occurred when the quality of breath sounds was added first to the medical history, followed by the peak flow result. The chance of COPD was very unlikely with a normal history and physical examination.

The clinical evaluation for diagnosing obstructive airways disease in high-risk patients.

OBJECTIVE: We measured the ability of the medical history, physical examination, and peak flowmeter in diagnosing any degree of obstructive airways disease (OAD). DESIGN: Prospective comparison of historical and physical findings with independently measured spirometry. SETTING: University outpatient clinic. PATIENTS: Ninety-two adult consecutive outpatient volunteers with a self-reported history of smoking, asthma, chronic bronchitis, or emphysema. MEASUREMENTS: All subjects completed a pulmonary history questionnaire and received peak flow (PF) and spirometric testing. The subjects were independently examined for 12 pulmonary physical signs by four internists blinded to all other results. Multivariable analysis was used to create a diagnostic model to predict OAD as diagnosed by spirometry (FEV1 < 80 percent of predicted not secondary to restrictive disease, or FEV1/FVC less than 0.7). RESULTS: The best model diagnosed OAD when any of three variables were present--a history of smoking more than 30 pack-years, diminished breath sounds, or peak flow less than 350 L/min. This model had a sensitivity of 98 percent and specificity of 46 percent. In addition, the model detected all subjects with probable restrictive lung disease. Thirty-one percent of subjects had none of these variables and were at very low (3 percent) risk of OAD. Fifty percent of subjects with one or more abnormal variables had OAD. CONCLUSIONS: The history, physical examination, and peak flowmeter can be used to screen high-risk patients for OAD. Using this diagnostic model, 31 percent of subjects could be classified at very low risk of OAD while half of those referred for spirometry would have abnormal results.

Outcomes from use of an evidence-based practice guideline.

The aim of evidence-based guidelines is primarily to improve patient outcomes without adding to the existing cost of care because both payers and policymakers want to identify health care costs that do not result in benefit to the patient. The purpose of the reported project was to generate a practice guideline for the treatment of uncomplicated acute cystitis in a female population, to determine the extent to which the guideline would be used by providers and to measure the cost and quality of outcomes from its use. A retrospective chart review was used to gather pre-guideline practice and cost data. Measurements included the type, frequency, and duration of antibiotic therapy and the use of urine cultures and both complications and routine followup visits. The implementation of an outpatient practice guideline resulted in a significant change in antibiotic prescribing and a trend toward a change in ordering cultures and clinic followup. There was also a significant decrease in treatment costs.

Electrophoretic deposition of thermites onto micro-engineered electrodes prepared by direct-ink writing.

This work combines electrophoretic deposition (EPD) with direct-ink writing (DIW) to prepare thin films of Al/CuO thermites onto patterned two- and three-dimensional silver electrodes. DIW was used to write the electrodes using a silver nanoparticle ink, and EPD was performed in a subsequent step to deposit the thermite onto the conductive electrodes. Unlike conventional lithographic techniques, DIW is a low-cost and versatile alternative to print fine-featured electrodes, and adds the benefit of printing self-supported three-dimensional structures. EPD provides a method for depositing the composite thermite only onto the conductive electrodes, and with controlled thicknesses, which provides fine spatial and mass control, respectively. EPD has previously been shown to produce well-mixed thermite composites which can pack to reasonably high densities without the need for any postprocessing. Homogeneous mixing is particularly important in reactive composities, where good mixing can enhance the reaction kinetics by decreasing the transport distance between the components. Several two- and three-dimensional designs were investigated to highlight the versatility of using DIW and EPD together. In addition to energetic applications, we anticipate that this combination of techniques will have a variety of other applications, which would benefit from the controlled placement of a thin film of one material onto a conductive architecture of a second material.

Is screening for chronic obstructive pulmonary disease justified?

BACKGROUND: Many experts recommend spirometry to screen for chronic obstructive pulmonary disease (COPD) in asymptomatic patients; however, evidence for this recommendation has not been systematically reviewed. METHODS: We examined whether screening spirometry meets standard criteria for effective screening. We performed structured searches of MEDLINE, followed by a selective search of the CITATION index, to locate randomized trials of interventions for asymptomatic patients with COPD. In regard to smoking cessation, we included all controlled trials of smoking cessation programs that used spirometry. We also included all studies that assessed the ability of spirometry to predict successful smoking cessation by comparing baseline lung function in smokers who subsequently quit versus those who did not. RESULTS: With the exception of smoking cessation, all interventions for COPD have only been proven effective in symptomatic patients. Two studies found that multifaceted smoking cessation programs that included spirometry were efficacious. There was no effect in a third study that isolated the role of spirometry. Smokers with abnormal spirometric results are less likely than other smokers to quit over the ensuing year. CONCLUSIONS: There is no evidence that spirometry, as an isolated intervention, aids smoking cessation.