The 2011 revision of the GOLD global strategy on COPD is a major paradigm shift in diagnosis and management of the disease. In particular, detailed assessment of current symptom control and future risk in terms of airflow limitation and exacerbation history, now allows more accurate categorisation of individual COPD patients. Pharmacological interventions are now directly linked to these categories. The recommendations for drug therapy in each of the 4 new categorical groups of COPD phenotypes reflect the accumulated knowledge base from literature. Bronchodilatation and anti-inflammatory drug therapy continue to be the main basis of drug choice and regimens.

Cognition ; Diagnostic Errors ; psychology ; Humans ; Physicians ; psychology ; Thinking

INTRODUCTIONOverlap syndrome between obstructive sleep apnoea (OSA) and chronic obstructive pulmonary disease (COPD) is important but under-recognised. We aimed to determine the prevalence of overlap syndrome and the predictors of OSA in patients with COPD.

METHODSPatients aged ≥ 40 years were recruited from a dedicated COPD clinic and underwent overnight polysomnography. A diagnosis of OSA was made when apnoea-hypopnoea index (AHI) was ≥ 5.

RESULTSIn all, 22 patients (aged 71 ± 9 years), predominantly men, were recruited. Mean values recorded were: predicted forced expiratory volume in the first second percentage 55 ± 15; body mass index 23.7 ± 6.5 kg/m2; Epworth Sleepiness Scale score 5.6 ± 5.8; and AHI 15.8 ± 18.6. Among the 14 patients with OSA (prevalence of overlap syndrome at 63.6%), the mean number of hospital visits for COPD exacerbations in the preceding one year was 0.5 ± 0.7. Patients with overlap syndrome had worse modified Medical Research Council dyspnoea scale scores and a lower percentage of rapid eye movement (REM) sleep than patients without. There were no other statistical differences in lung function or sleep study indices between the two patient groups.

CONCLUSIONThe majority of our patients had overlap syndrome and minimal exacerbations, and were not obese or sleepy. Significant differences between patients with and without overlap syndrome were seen in two aspects - the former was more dyspnoeic and had less REM sleep. Our findings suggest that standard clinical predictors cannot be used for patients with overlap syndrome, and therefore, a high index of suspicion is needed.

Adult ; Aged ; Body Mass Index ; Cohort Studies ; Comorbidity ; Female ; Forced Expiratory Volume ; Hospitals, Teaching ; Humans ; Male ; Middle Aged ; Polysomnography ; Prevalence ; Pulmonary Disease, Chronic Obstructive ; complications ; diagnosis ; Respiratory Function Tests ; Singapore ; Sleep Apnea, Obstructive ; complications ; diagnosis ; Sleep, REM

Heart Failure ; diagnostic imaging ; Humans ; Male ; Middle Aged ; Pleural Effusion ; diagnostic imaging ; Tomography, X-Ray Computed ; Ventricular Dysfunction, Left ; diagnostic imaging

Knowledge of chronic obstructive pulmonary disease (COPD) as a common, preventable and treatable condition has advanced in the last two decades, as evidenced by the increase in scientific literature. Tobacco smoking still remains a predominant risk factor for COPD. Thus smoking cessation management should be obligatory in every case. Although spirometry is integral to the diagnosis of COPD, one should also be aware of its limitations. COPD is a chronic disease associated with comorbidities that define its extrapulmonary manifestations. Systemic inflammation provides the biological link, while exacerbations play a prominent role in the current approach to disease evaluation. This paper reviews the latest Global Initiative for Chronic Obstructive Pulmonary Disease revision, focusing on the paradigm shift in assessment that would directly influence therapeutic decisions. Also discussed are the newer drugs and combinations of existing inhaler therapies that now present clinicians with more options, as well as bronchoscopic interventions that may perhaps offer a lower-morbidity alternative than surgical lung volume reduction. Finally, this review highlights how integrated care models can bridge the gap between components and complete a comprehensive sphere of COPD care.
Comorbidity ; Humans ; Inflammation ; Pulmonary Disease, Chronic Obstructive ; diagnosis ; physiopathology ; therapy ; Pulmonary Medicine ; methods ; standards ; trends ; Risk Factors ; Smoking ; adverse effects ; Spirometry ; Treatment Outcome

INTRODUCTIONThere are limited data on the use of endosonography-guided fine-needle aspiration (EUS-FNA) to determine the nature of left adrenal lesions. We described our experience in performing EUS-FNA of left adrenal lesions.

CLINICAL PICTUREDuring a 20-week period, data on consecutive patients who underwent EUS with or without EUS-FNA were prospectively captured. Patients with a left adrenal mass and who underwent EUS-FNA formed our study population.

TREATMENTEUS-FNA.

OUTCOMEA total of 119 consecutive patients underwent diagnostic EUS +/- FNA, during which the left adrenal gland was routinely examined. Twelve of these patients underwent EUS as part of lung cancer staging and among these 12 lung cancer patients, 2 had left adrenal masses detected by computed tomography (CT). EUS detected left adrenal nodules in 2 other patients which were not visualised by CT. The overall prevalence of a left adrenal mass was 3.4%; in the subgroup with confirmed lung cancer, the prevalence was 33.3%. All 4 patients were male, with a mean age of 76.3 years (range, 67 to 87). The mean size of the left adrenal lesion was 30.4 mm (range, 9 to 84.8). EUS-FNA of the left adrenal lesions was performed under Doppler guidance. The mean number of needle passes was 2 (range, 1 to 4). A cellular aspirate was obtained in all patients. No procedural complications occurred. Metastatic non-small cell lung cancer was diagnosed in 2 patients, including a lesion missed on CT. For the other 2 cases, EUS-FNA revealed benign adrenal cells.

CONCLUSIONSEUS-FNA appears safe and useful for the evaluation of left adrenal masses.

Adrenal Gland Neoplasms ; diagnostic imaging ; pathology ; Aged ; Aged, 80 and over ; Biopsy, Fine-Needle ; adverse effects ; methods ; Endosonography ; adverse effects ; Humans ; Prospective Studies ; Singapore

INTRODUCTIONUnderstanding the burden of uncontrolled severe asthma is essential for disease-targeted healthcare planning. There is a scarcity of data regarding the proportion, healthcare utilisation and costs of patients with uncontrolled severe asthma in Asia. This study aimed to plug the knowledge gap in this area.

MATERIALS AND METHODSConsecutive patients with asthma managed in our respiratory specialist clinic were evaluated prospectively. Healthcare utilisation comprising unscheduled asthma-related primary care visits, emergency department (ED) visits and hospital admissions were obtained from the national health records system. We defined uncontrolled severe asthma as poor symptom control (Asthma Control Test score <20); 2 or more asthma exacerbations requiring ≥3 days of systemic corticosteroids in the previous year; 1 or more serious asthma exacerbation requiring hospitalisation in the previous year; or airflow limitation with pre-bronchodilator forced expiratory volume in 1 second (FEV) <80% predicted despite high dose inhaled corticosteroids and another controller medication.

RESULTSOf the 423 study participants, 49 (11.6%) had uncontrolled severe asthma. Compared to non-severe asthma, patients with uncontrolled severe asthma were older and more likely to be female and obese. They had a median of 2 (interquartile range: 0 to 3) exacerbations a year, with 51% having ≥2 exacerbations in the past 12 months. They were responsible for 43.9% of the hospital admissions experienced by the whole study cohort. Mean annual direct asthma costs per patient was S$2952 ± S$4225 in uncontrolled severe asthma vs S$841 ± S$815 in non-severe asthma.

CONCLUSIONApproximately 12% of patients with asthma managed in a hospital-based respiratory specialist clinic in Singapore have uncontrolled severe asthma. They account for a disproportionate amount of healthcare utilisation and costs. Healthcare strategies targeting these patients are urgently needed.

Chronic obstructive pulmonary disease (COPD) is a condition commonly encountered by primary care practitioners. The disease should be detected in its early stages to prevent disease progression and to reduce the burden of symptoms. Early treatment also results in improved mortality and reduced morbidity. COPD should be differentiated from other similar conditions such as asthma, as the basis of treatment differs in these conditions, and misdiagnosis can lead to poorer patient outcomes. Non-pharmacological treatment such as smoking cessation and vaccinations are important in the management of COPD, while pharmacotherapy such as bronchodilators and antimuscarinics are the mainstay of therapy in COPD. Referral to a specialist is recommended when there is progression of the disease or uncertainty regarding the diagnosis.
Diagnosis, Differential ; Disease Progression ; Humans ; Pulmonary Disease, Chronic Obstructive ; diagnosis ; Referral and Consultation

INTRODUCTIONIn light of the growing evidence base for better clinical results with the use of the dual bronchodilator indacaterol/glycopyrronium (IND/GLY) over inhaled corticosteroid-containing salmeterol/fluticasone combination (SFC), this study aimed to evaluate the cost-effectiveness of IND/GLY over SFC in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) who are at low risk of exacerbations, in the Singapore healthcare setting.

METHODSA previously published patient-level simulation model was adapted for use in Singapore by applying local unit costs. The model was populated with clinical data from the LANTERN and ECLIPSE studies. Both costs and health outcomes were predicted for the lifetime horizon from a payer's perspective and were discounted at 3% per annum. Costs were expressed in 2015 USD exchange rates. Uncertainty was assessed through probabilistic sensitivity analysis.

RESULTSCompared to SFC, use of IND/GLY increased mean life expectancy by 0.316 years and mean quality-adjusted life years (QALYs) by 0.246 years, and decreased mean total treatment costs (drug costs and management of associated events) by USD 1,474 over the entire lifetime horizon. IND/GLY was considered to be 100% cost-effective at a threshold of 1 × gross domestic product per capita. The cost-effectiveness acceptability curve showed that IND/GLY was 100% cost-effective at a willingness-to-pay threshold of USD 0 (additional cost) when compared to SFC.

CONCLUSIONIND/GLY was estimated to be highly cost-effective compared to SFC in patients with moderate-to-severe COPD who are not at high risk of exacerbations in the Singapore healthcare setting.