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Objectively measured severe physical inactivity (SPI) has been reported as the strongest independent predictor of mortality in patients with chronic obstructive pulmonary disease (COPD). Activity monitoring is not feasible in routine clinical practice; therefore, we set out to determine the utility of simple clinical measures for predicting SPI in patients with COPD. A total of 165 patients with COPD wore an activity monitor for 5 days to define the presence or absence of SPI. Logistic models were generated including the modified Medical Research Council (MMRC) dyspnea grade, spirometry and the age-dyspnea-airflow obstruction (ADO) index. Physical Activity Scale for the Elderly (PASE) and Stanford Brief Activity Scale (SBAS) were also tested for validity and reliability in a subgroup of 67 patients. The MMRC dyspnea grade, PASE score, ADO index and SBAS score were associated with SPI, but general self-efficacy and spirometry were not. An MMRC dyspnea grade !3 was the best independent predictor of SPI (AUC: 0.74; PPV: 0.83; NPV: 0.68) followed closely by a PASE score of <111. The combination of MMRC dyspnea grade and PASE score provided the most robust model (AUC: 0.83; Positive Predictive Value (PPV): 0.95; Negative Predictive Value (NPV): 0.63). The results were confirmed using 5000 bootstrapped models from the cohort of 165 patients. MMRC dyspnea grade !3 may be the best triage tool for SPI in patients with COPD. The combination of the MMRC and PASE score provided the most robust prediction. Our results may have significant practical applicability for clinicians caring for patients with COPD.

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Pulmonary aspergillosis presents with a variety of clinical forms including invasive pulmonary aspergillosis, chronic necrotising aspergillosis, aspergilloma, chronic cavitary pulmonary aspergillosis and allergic bronchopulmonary aspergillosis. Haemoptysis is a devastating complication of pulmonary aspergillosis and a common indication for surgery. We report a case of a 54-year-old man with a history of pulmonary tuberculosis and diabetes mellitus, who presented with productive cough and haemoptysis for 2 months. Chest CT revealed a 30 mm diameter soft tissue mass in the upper lobe of the right lung. Haemoptysis subsided with conservative measures, but 2 weeks later the patient developed a new episode of persistent haemoptysis, which was only partially controlled with bronchial arterial embolisation. He underwent right upper and middle lobectomy. Histology examination confirmed the presence of a fungal cavitary lesion. The patient was started on voriconazole, and recovered with no recurrence at 18 months follow-up.

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ObjectivesTo identify aspects of medication management that are associated with a greater risk of hospital readmission.Patients and MethodsWe conducted a prospective cohort study, with a thorough medication history and reconciliation performed at admission and discharge. Patients 18 years or older (N=258) were prospectively enrolled on admission to a cardiology service at a tertiary care hospital from September 1, 2011, through July 31, 2012. All patients received their hospital and outpatient care within our institution, which minimized loss to follow-up. Readmission rates within 30 days and 6 months after discharge were recorded and used to investigate associations with specific characteristics related to medication regimen and management. Nominal logistic fit tests were used to establish associations with risk factors.ResultsA higher risk of readmission within 30 days after discharge was seen with heart failure diagnosis (P=.003) and with increased severity of comorbid conditions based on Charlson score (P=.02). Patients whose family managed their medications entirely had a higher risk of readmission at 30 days (odds ratio, 2.92; 95% CI, 1.25-5.6; P=.01) and at 6 months (odds ratio, 3.54; 95% CI, 1.70-7.65; P<.001). These findings were independent of the presence of heart failure.ConclusionPatients requiring family member support with medication management should be considered at increased risk for readmission. Increased focus on these patients at discharge may help decrease readmissions.

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