COPD care in Saudi Arabia: physicians' awareness and knowledge of guidelines and barriers to implementation.

OBJECTIVE: To assess Saudi physicians' awareness and knowledge about chronic obstructive pulmonary disease (COPD) guideline recommendations. METHODS: Cross-sectional study including physicians involved in COPD care in five hospitals in the Eastern Province of Saudi Arabia. The level of physicians' knowledge was considered as satisfactory (score > 80%), fair (score 50-80%) or poor (<50% of total score). RESULTS: Among the 44 physicians included in the study, the mean ± standard deviation knowledge score was 29.5 ± 4.2 out of 45 points (65.5%). Most physicians appeared to be unaware of any COPD guidelines (n = 27, 61.4%), and reported not adhering to guidelines (n = 28, 63.6%). CONCLUSION: Saudi physicians' knowledge about Global Initiative for Chronic Obstructive Lung Disease guidelines was assessed as fair. It is therefore highly recommended to increase physicians' awareness and knowledge about COPD-related guidelines.

Relationship between glycaemia and length of hospital stay during an acute exacerbation of chronic obstructive pulmonary disease.

We have assessed whether glucose concentration and patient outcome are related in hospitalised patients when glycaemia is quantified in detail. Continuous glucose monitoring was performed on 47 consecutive subjects with an acute exacerbation of chronic obstructive pulmonary disease. Length of hospital stay increased by 10% for each mmol/L increase in mean glucose (P = 0.01). In a multivariable analysis, mean glucose was independently associated with length of hospital stay (P = 0.02). These data add weight to evidence that hyperglycaemia may adversely affect patient outcomes in hospitalised patients.

Providing reviews of evidence to COPD patients: controlled prospective 12-month trial.

The aim of this study was to evaluate a novel patient-held manual designed to reduce the evidence-practice gap in chronic obstructive pulmonary disease (COPD). The intervention manual contained summaries of research evidence. It was developed using current best practice for patient information materials and designed to cause discussion of evidence between patient and doctor. A controlled before-and-after study was employed in two similar but geographically separate regions of metropolitan Adelaide, South Australia. Participants had moderate to severe COPD, with 249 included at baseline and 201 completing the study. Evidence-based COPD management was measured using an indicator with three components: rates of influenza vaccination, bone density testing, and pulmonary rehabilitation. A survey of behavioral steps leading to practice change was conducted with the trial. Analysis, by median split of socioeconomic disadvantage, showed significant difference between study arms for only one component of the indicator of evidence-based practice, enrollment in pulmonary rehabilitation and only for the most socioeconomically disadvantaged stratum. For both socioeconomic strata, more intervention participants than control participants reported remembering being given the information material, reading part or all, and finding it very or quite helpful. Other significant differences were restricted to the stratum of greatest socioeconomic disadvantage: reading all of the material, learning from it, referring back, and talking to a doctor about a topic from the material. Above 90% of all participants who received the manual reported reading from it, 42% reported discussing topics with a doctor, but only 10% reported treatment change attributable to the manual. We have found that people with COPD will read an evidence manual developed using current best practice. However, the study demonstrated improvement for only one of the three components of an indicator of evidence-based disease management for only the most socioeconomically disadvantaged stratum of participants. Future interventions should be designed to better translate reading uptake into evidence-based disease management.

Providing patients with reviews of evidence about COPD treatments: a controlled trial of outcomes.

Studies in many countries have identified gaps between what is known from research evidence and what is done in clinical practice. Merely making research evidence available to practitioners does not cause much change in their behaviour, and researchers are now looking for more effective ways to improve the implementation of evidence. We report outcomes at three months of a parallel group trial of an evidence based patient manual designed to improve implementation of evidence by the patient's doctors. The patient manual was produced with extensive patient and professional input. It contained summaries of the evidence for treatments used in COPD (chronic obstructive pulmonary disease) and prompted discussion of evidence with doctors. Participants in the intervention arm of the trial (n = 125) were supplied with the manual and participants in the control arm (n = 124) were supplied with a pamphlet about COPD produced by the Australian Lung Foundation. The primary outcome measure (rates of current influenza vaccination and bone density testing) was an indicator of evidence based management of COPD. Secondary outcomes were quality of life (mastery component), satisfaction with information, communication with usual doctor, and anxiety. At three months no pattern of benefit in outcome measures was found for either group. Process measures showed high levels of personal use of the manual but progression to conversations with doctors for fewer than half of participants, and little treatment change. The findings highlight the difficulties of promoting changes in health behaviour and show that even when all stakeholders are consulted success is not guaranteed. Further research is required to identify those patients most likely to use manuals such as the one reported here, and how to make patient mediated interventions more effective for a greater proportion of the target population.

Barriers to success for an evidence-based guideline for chronic obstructive pulmonary disease.

OBJECTIVES: To evaluate 1) barriers to clinical guideline use and 2) the relationship between guideline use and inpatient outcomes in chronic obstructive pulmonary disease (COPD). METHODS: 1) Four focus groups of specific health professions (n = 30), from three metropolitan hospitals, and interview of 99 medical officers (MOs), linked to 349 admissions, both guided by behavioural modelling theory; 2) association between guideline use and patient outcomes (length of hospital stay > or = 14 days, and readmission within 28 or 90 days) was evaluated in a cohort of 405 COPD patients. RESULTS: 1) In focus groups, nurses and allied health professionals emphasized facilitation issues including paperwork duplication and time limitations as barriers, but considered improved patient care outcomes as the major guideline use determinant. There were similar findings in junior MOs (nonconsultants) by both focus group and interview, with the addition of a need for a sense of ownership. Senior MOs (consultants) greatly emphasized sense of ownership. Barriers to guideline use varied between types of units. Behavioural modelling explained 49% of the variation in intention to use the guideline for MOs. For nonconsultants, habit and intention were significantly associated with extent of guideline use. 2) Patient outcomes: guideline use was not associated with length of stay or readmission. CONCLUSIONS: 1) Guideline implementation should address issues relevant to different health professions, units and seniority of profession. 2) Guideline use was not associated with reductions in readmission or length of stay.

Impact on readmission rates and mortality of a chronic obstructive pulmonary disease inpatient management guideline.

AIMS: Chronic obstructive pulmonary disease (COPD) is a common condition associated with considerable morbidity, mortality and hospital admissions. However, published COPD management guidelines have major limitations and lack practical summaries. We aimed to optimally develop, implement, and evaluate a multidisciplinary COPD inpatient management 'ACCORD' guideline, including prompts for comprehensive day one assessments through to a discharge criteria checklist. METHOD: Two intervention and two control public teaching hospitals in Adelaide, South Australia, took part, with pre-intervention (721 COPD admissions over 7 months) and intervention phases (509 COPD admissions over 7 months). During the intervention stage the ACCORD guideline was placed in the case notes on the day of admission or soon after. Readmissions were categorized as either emergency or elective and compared between the study arms, as were mortality and potential confounders (age, gender, number of comorbidities), with Poisson regression analysis. RESULTS: Of case notes of eligible COPD patients, 60% had the ACCORD guideline placed, of which 76% had evidence of use as judged by completion of guideline entry and tick boxes. The ACCORD guideline was associated with an increase in elective admissions and a reduction in emergency admissions in the intervention group in relation to the control group (P < 0.01), with no difference in overall admissions or death rates. CONCLUSIONS: The ACCORD guideline was associated with a shift from emergency admissions to more planned elective care, suggesting more proactive care of health problems, but without overall reduction in admissions.

Acute retinal necrosis in children caused by herpes simplex virus.

PURPOSE: To report the diagnosis, management, and outcome of acute retinal necrosis syndrome in children. METHOD: Case series of three consecutive children aged 11 years and younger who were diagnosed with acute retinal necrosis. In addition to full ocular and systemic examinations, the children underwent vitreous biopsy (Patients 1 and 2) or aqueous tap (Patient 3) for polymerase chain reaction analysis. RESULTS: All patients had unilateral retinitis that was associated with preexisting chorioretinal scars, and two patients (Patients 1 and 3) had concurrent extraocular central nervous system abnormalities. Intraocular herpes simplex virus was detected in all three children: Type 1 in Patient 1 and Type 2 in Patients 2 and 3. In addition, all three children had a history of extraocular herpes simplex virus infection. CONCLUSIONS: Retinitis associated with preexisting chorioretinal scars and detectable intraocular herpes simplex virus on polymerase chain reaction was common to all three children with acute retinal necrosis.

Fluvoxamine-methadone interaction.

OBJECTIVE: The aim of this paper is to report a case of symptomatic methadone toxicity associated with fluvoxamine treatment. CLINICAL PICTURE: A 28-year-old woman was admitted to hospital with severe hypoxaemia and hypercapnia indicating hypoventilation. Medication prior to admission had been stable and included methadone 70 mg daily and diazepam 2 mg twice daily. Three weeks before admission she had commenced treatment with fluvoxamine. TREATMENT: Methadone was decreased to 50 mg daily and diazepam was tapered to zero. OUTCOME: The serum methadone concentration decreased and oxygenation improved considerably. CONCLUSIONS: Clinicians should be aware of the potential for a significant drug interaction between fluvoxamine and methadone.

Posterior sub-Tenon's triamcinolone injections in the treatment of uveitis.

PURPOSE: This is the first study reported in the United Kingdom to investigate the efficacy and safety of posterior, sub-Tenon's triamcinolone acetonide injections in the treatment of posterior and intermediate uveitis. METHODS: Twenty-eight posterior sub-Tenon's triamcinolone injections (40 mg) were given and the results analysed with a 6 month prospective follow-up in 13 cases. RESULTS: At 6 weeks follow-up, objective improvement in visual acuity occurred in 25 eyes (p < 0.05). Vitreous cellular activity was diminished in 21 eyes (p < 0.05). In most cases improvement was observed within 2 weeks of injection. No patient required repeat triamcinolone injection within 3 months and all patients previously treated with systemic immunosuppression were able to decrease or discontinue this treatment. Complications included transient elevation of intraocular pressure in 4 patients and persistent mild ptosis in 2 patients. CONCLUSIONS: We have demonstrated that posterior sub-Tenon's triamcinolone injection significantly decreases cystoid macular oedema, with a corresponding increase in visual acuity, in patients with posterior uveitis. Systemic immunosuppression may be reduced or discontinued with the avoidance of associated systemic side effects, and the technique has a high level of patient acceptability.

A comparison of two long-acting vasoselective calcium antagonists in pulmonary hypertension secondary to COPD.

UNLABELLED: STUDY OBJECTIVES AND PATIENTS: Pulmonary hypertension (PH) is common in COPD and may predict mortality in this disorder. We have compared the pulmonary vasodilator effects, dose-response characteristics, and tolerability of two calcium channel blockers, amlodipine and extended-release (ER) felodipine, in 10 patients (seven men, age 68+/-4.8 [SD] years) with clinically stable COPD and PH. DESIGN: Drugs were given in equal single daily oral doses (2.5, 5, and 10 mg), increasing weekly for 3 weeks, in a randomized investigator-blinded crossover manner with a 1-week wash-out period between the two treatments. MEASUREMENTS: Doppler measurements of pulmonary hemodynamics were made on the seventh day of treatment at each drug dose. Lung function, arterial blood gases, and adverse events were also monitored weekly. RESULTS: A dose-dependent decline of pulmonary artery pressure (PAP) was observed with each drug. A dose of 2.5 mg produced a significant decrease in PAP compared with baseline (20% amlodipine, 17% felodipine ER). Additional decreases in PAP were observed at 5 mg and 10 mg that were similar for both drugs, but did not reach statistical significance compared with 2.5 mg. There was a dose-related decrease in pulmonary vascular resistance and increase in oxygen delivery with amlodipine and felodipine ER. Lung function and blood gas values were stable throughout. Side effects (headache and ankle edema) were less frequent during amlodipine treatment (p<0.05). CONCLUSIONS: Both amlodipine and felodipine ER, given as a single daily oral dose of > or = 2.5 mg, are effective pulmonary vasodilators in COPD patients with PH. Their dose-response characteristics are similar, but amlodipine treatment was associated with fewer side effects.

Near-fatal asthma in South Australia: descriptive features and medication use.

BACKGROUND: Self-reported prior morbidity levels and medication use among survivors of a near-fatal asthma attack (NFA) were studied. AIMS: To identify deficiencies in asthma management and opportunities for intervention. METHODS: A hundred and twenty-seven consecutive patients aged 15 years or more presenting with a NFA to accident and emergency departments of teaching hospitals were interviewed. RESULTS: High levels of morbidity due to asthma were reported. Most cases (79%) reported symptoms occurring at least weekly in the three months before their NFA. A mean of 20.8 days was reportedly lost from work, school or other usual daily activity in the 12 months before these events. Regular use of beta agonist as nebuliser solution was reported by 27% of cases, increasing to 34.5% in response to increased symptoms, while 41% reported use of nebulised beta agonist in response to the NFA event. Less than half of all cases (46%) reported using an inhaled corticosteroid on a regular basis. Oral corticosteroids were used by 33% of cases at times of increased symptoms in the preceding 12 months. However, only 7% of cases reported initiating or increasing oral corticosteroids at the time of the NFA. CONCLUSIONS: Despite high levels of prior asthma morbidity, regular preventive inhaled corticosteroid use was not widespread in this series of NFA asthmatics. By comparison, over-reliance on regular beta agonist medication was common. Oral corticosteroids were rarely commenced in response to the NFA.

Characteristics of near-fatal asthma in childhood.

As part of the South Australian asthma mortality survey, we examined 30 cases of near-fatal asthma attacks in children under 15 years of age who were seen over a 3-year period from May 1988 to June 1991. Subjects presented with asthma and either respiratory arrest, PaCO2 above 50 mm Hg, and/or an altered state of consciousness or inability to speak on presentation at a metropolitan Adelaide teaching hospital. A standardized interview and questionnaire was completed with subjects/parents and medical practitioners. Data were reviewed by the assessment panel which made collective judgments based on predetermined criteria. Seventeen patients (57%) were male, 20% were less than 7 years of age, and the majority (53%) were aged between 12 and 15 years. The majority (83%) had severe asthma and only one case (3.3%) had mild asthma. Half of the subjects were waking every night due to asthma and 79% had significant exercise limitation. A quarter of the subjects had a previous ICU admission and 70% had a hospital admission in the last 12 months. Primary care was carried out by a general practitioner in 57% of cases, and 70% of subjects had a crisis plan. Only 46% of those older than 7 years of age had ever used a peak-flow meter. Eighty percent of subjects or their families had high denial scores, and in 73% of cases psychosocial factors were considered to be significant. Eighty percent of cases experienced acute progressive respiratory distress, and 63% of cases delayed seeking medical care.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychiatric and medical features of near fatal asthma.

BACKGROUND: The associations between psychiatric caseness, denial, and self reported measures of handicap and morbidity due to asthma in patients suffering a near fatal attack of asthma have not been fully explored. METHODS: Seventy seven consecutive subjects who presented to Adelaide teaching hospitals with a near fatal attack of asthma were assessed with a validated semi-structured interview following discharge from hospital. RESULTS: 43% of the patients scored > or = 5 on the GHQ-28 questionnaire. There was a positive correlation between GHQ-28 score and limitation to daily activities due to asthma, and between GHQ-28 score and days lost from work, school or usual daily activities, both of which were retained after adjusting for age and sex. Asthma severity did not show a clear association with GHQ-28 score. The asthmatic patients reported high levels of denial, 57% scoring more than 3 out of 5 on the denial scale of the Illness Behaviour Questionnaire. Presentation with a history of progressive respiratory distress was negatively associated with denial score. This persisted after adjustment for age and sex--that is, those with high denial scores were more likely to report presentation as sudden collapse than progressive respiratory distress. CONCLUSIONS: Psychiatric caseness (GHQ score > or = 5) is associated with high levels of morbidity in asthmatic patients who survive a near fatal attack of asthma. High levels of denial in asthmatic subjects may be life threatening. The link between morbidity associated with asthma and psychiatric features, along with other psychosocial issues, warrants further investigation. A broader paradigm than the traditional medical model should be considered when assessing patients with asthma.

A comparison of asthma deaths and near-fatal asthma attacks in South Australia.

Studies seeking to identify factors predictive of asthma mortality have relied on information obtained from relatives, other close acquaintances, and doctors who cared for the deceased. We wanted to determine whether asthmatics who have suffered a near-fatal asthma attack (NFA) are similar to asthmatics who have died of asthma with respect to important features, because studies of NFA asthmatics may provide a better insight into causes of asthma death. Such studies would avoid the difficulties associated with seeking information secondhand from proxy informants. Two groups were studied: asthmatics who had suffered a near-fatal asthma attack resulting in a visit to the accident and emergency departments of teaching hospitals (n = 154), and asthmatics certified as dying of asthma who, following panel review, were confirmed to have died from this disease (n = 80). For each case in the two groups, an interview questionnaire was administered to a close acquaintance (household or family member) and to the general practitioner. Both groups shared many important characteristics. Similarities related to: frequency of symptoms; frequency of hospital and intensive care unit admissions for asthma; use of asthma crisis plans; compliance with prescribed medications; quality of personal asthma management; and asthma severity. The two groups also showed similar psychiatric profiles, and similar use of asthma medications on a regular basis and with increased symptoms. However, NFA cases tended to be younger, were more likely to be male, and less likely to have concurrent medical conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Glomerular basement membrane thinning in a patient with hematuria and hemoptysis mimicking Goodpasture's syndrome.

Ultrastructural morphometric studies of glomerular basement membrane (GBM) thickness are described in two renal biopsy specimens from a patient who presented with hemoptysis and hematuria mimicking Goodpasture's syndrome. Significant GBM abnormality, with attenuation as the main lesion, identified in a biopsy specimen taken during active clinical disease appeared to have resolved in a second biopsy specimen taken during the recovery phase. There was no evidence of glomerulonephritis. Concurrent lung biopsy studies showed focal alveolar-capillary wall basal lamina changes of uncertain diagnostic significance. These observations suggest the alternative possibilities that GBM attenuation may be either an acquired consequence of systemic disease or may be part of an hitherto unrecognized primary multisystem abnormality of basal lamina affecting, in this case, glomerular and pulmonary laminae, resulting in hematuria and hemoptysis. The morphometric studies in this case indicate that simple-mean measurements of GBM thickness are inadequate alone for the quantitative study of this lamina because significant inter- and intraglomerular membrane variation, if irregularly distributed, can remain undetected.

Near fatal asthma attacks: the reliability of descriptive information collected from close acquaintances.

BACKGROUND: The reliability of information collected from close acquaintances of the deceased in studies on mortality from asthma has not been assessed. As part of a South Australian asthma mortality study, levels of agreement for information obtained directly from cases--that is, cases who had experienced near fatal asthma attacks--were compared with corresponding information concerning these cases obtained independently from close acquaintances. METHODS: The first 51 subjects presenting from the outset of the main study to hospital accident and emergency departments with near fatal asthma attacks were included to gain an early assessment of the reliability of responses. The level of agreement between self reported information and that obtained from close acquaintances was compared by means of a kappa statistic or intraclass correlation coefficient, depending on the measurement scale. Both score one for complete agreement and zero when there is no agreement. RESULTS: High levels of agreement were found for questions relating to use of hospital services, with agreement levels ranging from 0.92 for visits in the past month to accident and emergency departments, to 0.86 for prior hospital admissions and 0.78 for prior need for assisted ventilation. Levels of agreement for drug treatment ranged from 1.00 for use of beta agonists to 0.64 for corticosteroid use, and to a low 0.24 for use of sodium cromoglycate. There was moderate agreement for histories of regular use of over the counter medications without a medical consultation (0.57). Psychiatric characteristics showed moderate levels of agreement, with values of 0.44 for personal history of psychiatric consultations and 0.50 for denial score. Agreement scores were 0.66 for doctor visits in the past month, 0.66 for limitations in daily activities, 0.76 for loss of work days in the past month, 0.59 for severity of asthma, and 0.55 for frequency of asthma attacks in the past month. Poorer agreement scores were found for trends in asthma symptoms (0.21) and frequency of symptoms during the past three years (0.12). Sleep disturbance was also associated with a low agreement score (0.25). CONCLUSIONS: The more visible the asthma manifestation, and the more recent the period to which it applies, the more reliable is the information provided by close acquaintances. These factors need to be taken into account when using information from close acquaintances in asthma mortality studies.

Felodipine improves pulmonary hemodynamics in chronic obstructive pulmonary disease.

Pulmonary hypertension in chronic obstructive pulmonary disease (COPD) is associated with a poor prognosis. Reduction of pulmonary artery pressure in COPD by prolonged oxygen treatment has been shown to be associated with increased survival. In an attempt to find a suitable pharmacologic method of reducing pulmonary artery pressure and pulmonary vascular resistance in COPD, we enrolled 13 stable pulmonary-hypertensive, hypoxemic COPD patients in a study to test the effects of felodipine, a relatively new, vascular-selective calcium antagonist. Doppler echocardiography was used to estimate pulmonary artery pressure and cardiac output before treatment, 2, 7, and 12 weeks during felodipine treatment (10 to 20 mg/d), and after a 1-week placebo washout period. Measurements of lung function, arterial blood gases, and exercise capacity during an incremental bicycle ergometer test were also performed at intervals during the study period. Three patients withdrew from the study and of the remaining 10, 8 had some side effects of medication (peripheral edema or headache) that improved either spontaneously or following a reduction in drug dose. In the 10 patients who completed the study (8 male; mean age, 67 years), felodipine resulted in significant reductions in mean pulmonary artery pressure (22 percent) and total pulmonary (vascular) resistance (30 percent) and increases in cardiac output (15 percent) and stroke volume (13 percent) compared with baseline measurements and those taken after placebo washout. These effects were sustained over the 12 weeks of felodipine treatment. There was no adverse effect of felodipine treatment on pulmonary gas exchange at rest or during exercise and no change in lung function or exercise capacity. We conclude that in pulmonary hypertensive, hypoxemic COPD patients, felodipine substantially improves pulmonary hemodynamics.

Accuracy of asthma statistics from death certificates in South Australia.

OBJECTIVE: To assess the accuracy of asthma statistics from death certificates in South Australia. DESIGN: Comparison of death certificate coding with expert panel assessments of causes of death after interviews with certifying doctors, regular medical practitioners and close acquaintances of the deceased. SUBJECTS: 261 subjects for whom the term "asthma", "asthmatic" or "asthmaticus" was recorded in Part I or Part II of death certificates lodged in the 24-month period from May 1988. MAIN OUTCOME MEASURES: Sensitivity, specificity and predictive value of death certificate coding, with expert panel assessments as the reference standard. RESULTS: About 95% of deaths assessed as definitely due to asthma were so coded from death certificates, but only 69% of deaths assessed by the panel as not due to asthma were coded to a "non-asthmatic" cause. Of the 129 deaths coded to asthma, the percentage assessed as definitely or likely to be due to asthma was 56%. For ages under 65 years, this figure was 84% compared with only 38% for older subjects. CONCLUSION: The accuracy of death certificate data on asthma for the age group 65 years and over would be too low at present for most epidemiological purposes.