Sociodemographic Characteristics and Physical Activity in Patients with COPD: A 3-Month Cohort Study.

Decreased physical activity (PA) is associated with morbidity and mortality in COPD patients. In this secondary analysis of data from a 12-week longitudinal study, we describe factors associated with PA in COPD. Participants completed the Physical Activity Checklist (PAC) daily for a 7- to 8-day period. PA was measured monthly using the Physical Activity Scale for the Elderly (PASE). At three different time points, daily step count was measured for one week with an Omron HJ-720ITC pedometer. The 35 participants were primarily male (94%) and White (91%), with an average age of 66.5 years and FEV1 44.9% predicted. Common activities reported on the PAC were walking (93%), preparing a meal (89%), and traveling by vehicle (96%). PA measured by both PASE score (p = 0.01) and average daily step count (p = 0.04) decreased during follow-up. In repeated measures multivariable modeling, participants living with others had a higher daily step count (ß = 942 steps, p = 0.01) and better PASE scores (ß = 46.4, p < 0.001). Older age was associated with decreased step count (ß = -77 steps, p < 0.001) whereas White race was associated with lower PASE scores (ß = -55.4, p < 0.001) compared to non-White race. Other demographic factors, quality of life, and medications were not associated with PA. A better understanding of the role of social networks and social support may help develop interventions to improve PA in COPD.

Differences in Syphilis Incidence Using a Laboratory Algorithm in People With and Without HIV in an 11-Year Nationwide Cohort Study.

BACKGROUND: To measure the incidence of syphilis diagnoses among people with HIV vs those without HIV in a national multiyear retrospective cohort. METHODS: Treponemal and nontreponemal tests, HIV status, and demographic data were identified among all individuals receiving Veterans Health Administration (VHA) care between January 1, 2009, and December 31, 2019. Syphilis testing rates and incident syphilis diagnoses as defined by a laboratory algorithm were stratified by HIV status. RESULTS: Syphilis was diagnosed in 1.2% (n = 2283) of 194 322 tested individuals in VHA care in 2019. Among individuals with HIV tested for syphilis, 6.1% met criteria for syphilis compared with 0.7% without HIV. Syphilis incidence in 2019 was 35/100 000, a 17% increase from 2009 (30/100 000). In 2019, syphilis incidence was 3381 per 100 000 persons among individuals with HIV and 19 per 100 000 in those without HIV. CONCLUSIONS: Using a laboratory-based diagnostic algorithm, a 178-fold difference in syphilis incidence was observed between individuals with and without HIV in 2019. US syphilis incidence data that incorporate HIV status are needed. Interventions to monitor and prevent sexually transmitted infections should address the role of HIV status.

Alanine Aminotransferase Results Differ by Analyzer Manufacturer in a National Integrated Health Setting, 2012-2017.

CONTEXT.­: Disease guidelines specify universal alanine aminotransferase (ALT) thresholds for clinical decision-making, yet the effect of variability among ALT analyzers remains unclear. OBJECTIVE.­: To compare ALT results from different analyzers from 2012-2017. DESIGN.­: Veterans Health Administration (VHA) laboratories perform external ALT proficiency testing using standardized College of American Pathologists (CAP) samples in analyzers by 5 manufacturers. In this operational analysis, we evaluated 22 950 ALT values from 80 independent CAP samples tested at 223 laboratories. Using mixed effects modeling, we estimated the association between analyzer manufacturer and CAP outcome, adjusting for manufacturer, facility, and calendar year. We performed subgroup analyses on CAP samples with overall means near clinical guideline-specified thresholds, including less than 50 U/L (n = 10) and less than 35 U/L (n = 5). RESULTS.­: The VHA used Abbott Laboratories (n = 3175; 14%), Beckman Coulter Diagnostics (n = 8723; 38%), Roche Diagnostics (n = 2595; 11%), Siemens Healthineers USA (n = 5713; 25%), and Vitros/Ortho Clinical Diagnostics (n = 2744; 12%) analyzers. The CAP samples (n = 80 samples, n = 22 950 tests) covered a wide range of mean ALT values (21-268 U/L). The average difference in mean ALT value per sample between the highest-reading and lowest-reading manufacturers was 15.4 U/L (SD = 1.8) for the 10 samples with mean ALT less than 50 U/L, and it was 10.4 U/L (SD = 3.6) overall (n = 80). In linear mixed effects modeling, we found statistically significant differences in ALT values between the different manufacturers in each year. CONCLUSIONS.­: We found statistically and clinically meaningful differences between analyzers across the ALT spectrum in each year, including at ALT levels lower than 50 U/L and lower than 35 U/L. Universal ALT thresholds should be avoided as a trigger for clinical action until differences between analyzers can be resolved.

Health Care Facility Characteristics are Associated with Variation in Human Immunodeficiency Virus Pre-exposure Prophylaxis Initiation in Veteran's Health Administration.

To quantify health care facility-level variation in pre-exposure prophylaxis (PrEP) use in the Veteran's Health Administration (VHA); to identify facility characteristics associated with PrEP use. Retrospective analysis of the health care facility-level rate of PrEP initiation in VHA through June 30, 2017. Standardized PrEP initiation rates were used to rank facilities. Characteristics of facilities, prescribers, and PrEP recipients were examined within quartiles. Multiple linear regression was used to identify associations between facility characteristics and PrEP use. We identified 1600 PrEP recipients. Mean PrEP initiation rate was 20.0/100,000 (SD 22.8), ranging from 3.0/100,000 (SD 2.0) in the lowest quartile to 48.1/100,000 (SD 29.1) in the highest. PrEP prescribing was positively associated with proportions of urban dwellers and individuals < 45, tertiary care status, and location. Variability in PrEP uptake across a national health care system highlights opportunities to expand access in non-tertiary care facilities and underserved areas.

Use of a Remote Inhaler Monitoring Device to Measure Change in Inhaler Use with Chronic Obstructive Pulmonary Disease Exacerbations.

BACKGROUND: Remote inhaler monitoring is an emerging technology that enables the healthcare team to monitor the time and location of a patient's inhaler use. We assessed the feasibility of remote inhaler monitoring for chronic obstructive pulmonary disease (COPD) patients and the pattern of albuterol inhaler use associated with COPD exacerbations. METHODS: Thirty-five participants with COPD used an electronic inhaler sensor for 12 weeks which recorded the date and time of each albuterol actuation. Self-reported COPD exacerbations and healthcare utilization were assessed monthly. We used generalized estimating equations with a logit link to compare the odds of an exacerbation day to a nonexacerbation day by the frequency of daily albuterol use. RESULTS: Average daily albuterol use on nonexacerbation days varied greatly between patients, ranging from 1.5 to 17.5 puffs. There were 48 exacerbation events observed in 29 participants during the study period, of which 16 were moderate-to-severe exacerbations. During the moderate-to-severe exacerbation days, the median value in average daily albuterol use increased by 14.1% (interquartile range: 2.7%-56.9%) compared to average nonexacerbation days. A 100% increase in inhaler use was associated with increased odds of a moderate-to severe exacerbation (odds ratio 1.54; 95% CI: 1.21-1.97). Approximately 74% of participants reported satisfaction with the sensor. CONCLUSIONS: The electronic inhaler sensor was well received in older patients with COPD over a 12-week period. Increased albuterol use captured by the device was associated with self-reported episodes of moderate-to-severe exacerbations.

Overuse of short-acting beta-agonist bronchodilators in COPD during periods of clinical stability.

BACKGROUND: Overuse of short-acting beta-agonists (SABA) is described in asthma, but little is known about overuse of SABA in chronic obstructive pulmonary disease (COPD). METHODS: Prospective 3-month cohort study of patients with moderate-to-severe COPD who were provided a portable electronic inhaler sensor to monitor daily SABA use. Subjects wore a pedometer for 3 seven-day periods and were asked to complete a daily diary of symptoms and inhaler use. Overuse was defined as >8 actuations of their SABA per day while clinically stable. RESULTS: Among 32 participants, 15 overused their SABA inhaler at least once (mean 8.6 ± 5.0 puffs/day), and 6 overused their inhaler more than 50% of monitored days. Compared to those with no overuse, overusers had greater dyspnea (modified Medical Research Council Dyspnea Scale: 2.7 vs. 1.9, p = 0.02), were more likely to use home oxygen (67% vs. 29%, p = 0.04), and were more likely to be on maximal inhaled therapy (long-acting beta-agonist, long-acting antimuscarinic agent, and an inhaled steroid: 40% vs. 6%, p = 0.03), and most had completed pulmonary rehabilitation (67% vs. 0%, p < 0.001). However, 27% of overusers of SABA were not on guideline-concordant COPD therapy. CONCLUSIONS: Overuse of SABA was common and associated with increased disease severity and symptoms, even though overusers were on more COPD-related inhalers and more had completed pulmonary rehabilitation. More research is needed to understand factors associated with inhaler overuse and how to improve correct inhaler use.

Assessment and Management of Symptoms for Outpatients Newly Diagnosed With Lung Cancer.

RATIONALE: Little is known about symptom assessment around the time of lung cancer diagnosis. The purpose of this pilot study was to assess symptoms within 2 months of diagnosis and the frequency with which clinicians addressed symptoms among a cohort of veterans (n = 20) newly diagnosed with lung cancer. We administered questionnaires and then reviewed medical records to identify symptom assessment and management provided by subspecialty clinics for 6 months following diagnosis. RESULTS: Half (50%) of the patients were diagnosed with early-stage non-small-cell lung cancer (NSCLC), stage I or II. At baseline, 45% patients rated their overall symptoms as severe. There were no significant differences in symptoms among patients with early- or late-stage NSCLC or small-cell lung cancer. Of the 212 clinic visits over 6 months, 70.2% occurred in oncology. Clinicians most frequently addressed pain although assessment differed by clinic. CONCLUSIONS: Veterans with newly diagnosed lung cancer report significant symptom burden. Despite ample opportunities to address patients' symptoms, variations in assessment exist among subspecialty services. Coordinated approaches to symptom assessment are likely needed among patients newly diagnosed with lung cancer.

Association between hyperglycemia at admission during hospitalization for acute myocardial infarction and subsequent diabetes: insights from the veterans administration cardiac care follow-up clinical study.

OBJECTIVE: Among patients with acute myocardial infarction (AMI) without known diabetes, hyperglycemia at admission is common and associated with worse outcomes. It may represent developing diabetes, but this association is unclear. Therefore, we examined the association between hyperglycemia (≥140 mg/dL) at admission and evidence of diabetes among patients with AMI without known diabetes within 6 months of their hospitalization. RESEARCH DESIGN AND METHODS: We studied a national cohort of consecutive patients with AMI without known diabetes presenting at 127 Veterans Affairs hospitals between October 2005 and March 2011. Evidence of diabetes either at discharge or in the following 6 months was ascertained using diagnostic codes, medication prescriptions, and/or elevated hemoglobin A1c. Association between hyperglycemia at admission and evidence of diabetes was evaluated using regression modeling. RESULTS: Among 10,499 patients with AMI without known diabetes, 98% were men and 1,761 (16.8%) had hyperglycemia at admission. Within 6 months following their index hospitalization, 208 patients (11.8%) with hyperglycemia at admission had evidence of diabetes compared with 443 patients (5.1%) without hyperglycemia at admission (P < 0.001). After multivariable adjustment, hyperglycemia at admission was significantly associated with subsequent diabetes odds ratio 2.56 (95% CI 2.15-3.06). Among those with new evidence of diabetes, 41% patients (267 of 651) had a hemoglobin A1c ≥6.5% without accompanying diagnostic codes or medication prescriptions, suggesting they had unrecognized diabetes. CONCLUSIONS: Hyperglycemia at admission occurred in one of six patients with AMI without known diabetes and was significantly associated with new evidence of diabetes in the 6 months following hospitalization. In addition, two of five patients with evidence of diabetes were potentially unrecognized. Accordingly, diabetes-screening programs for hyperglycemic patients with AMI may be an important component of optimal care.

Diminished quality of life and physical function in community-dwelling elderly with anemia.

The occurrence of anemia in older adults has been associated with adverse outcomes including functional decline, disability, morbidity, and mortality. It is not clear to what extent these outcomes are the result of the anemia or concurrent illness. We performed a cross-sectional, observational study to determine whether lower hemoglobin concentrations in older adults are associated with reduced health-related quality of life, functional status, depression, disability, and physical strength, independent of chronic disease. Three sites participated in this research: an academic geriatric practice, a hospital-based geriatric outpatient unit, and a community-based multispecialty internal medicine group. Health-related quality of life and functional status were measured using the Short Form-36 Health Survey (SF-36) and the Functional Assessment of Chronic Illness Therapy-Anemia (FACIT-An). Disability and depression were assessed using the Instrumental Activities of Daily Living (IADL) and the Geriatric Depression Scale (GDS) questionnaires, respectively. Handgrip strength was used as a physical performance measure. Anemia was defined as hemoglobin <13 g/dL for men or <12 g/dL for women. The mean SF-36 physical health component summary scores were 38.9 (with anemia) and 44.1 (without anemia) (p<0.001). Anemia was associated with greater fatigue (p < 0.001), lower handgrip strength (p = 0.014), increased number of disabilities (p=0.005), and more depressive symptoms (p = 0.002). Multivariate regression analysis, adjusted for demographic and clinical characteristics, demonstrated strong associations for reduced hemoglobin, even within the "normal" range, and poorer health-related quality of life across multiple domains. Thus, anemia was independently associated with clinically significant impairments in multiple domains of health-related quality of life, especially in measures of functional limitation. Mildly low hemoglobin levels, even when above the World Health Organization (WHO) anemia threshold, were associated with significant declines in quality of life among the elderly.