Brief Review of Coronavirus for Healthcare Professionals February 10, 2020

Richard A. Robbins, MD¹

Stephen A. Klotz, MD²

¹Phoenix Pulmonary and Critical Care Research and Education Foundation, Gilbert, AZ USA

²Division of Infectious Diseases, Department of Internal Medicine, University of Arizona, Tucson, AZ USA

The epidemic of coronavirus (2019-nCoV) near Wuhan City and the surrounding Hubei Province in China has received extensive news coverage. Some have predicted the virus will cause a worldwide pandemic (1). The CDC has an extensive website discussing over numerous pages whom to suspect, how to diagnose and how to treat 2019-nCoV. 2019-nCoV represents the most recent of the severe coronaviral infections. Severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) are also caused by coronaviruses that have jumped from animals to humans like 2019-nCoV. It should be remembered that there are only 12 confirmed cases of 2019-nCoV in the US and the mortality rate appears to be only about 3% which is lower than SARS or MERS (2,3). This could be offset by a greater infectiousness of 2019-nCoV resulting in more aggregate infectious, and hence, deaths.

Anyone with a fever who has recently visited the epidemic area in China or been exposed to someone with known 2019-nCoV should be quarantined (2). The only reliable symptom has been fever (98%) (4). Cough (76%), myalgia/fatigue (44%), sputum production (28%), headache (8%), hemoptysis (5%), and diarrhea (3%) were much less common. The clinical course was characterized by the development of dyspnea in 55% of patients and lymphopenia in 66%.

Persons suspected of 2019-nCoV should be quarantined and reported to their local state health departments. The incubation period appears about 2-14 days and is spread by person-to-person transmission based on the previous MERS epidemic (2). There is no need to wear masks in the US where the incidence is low and they are likely ineffective (2).

Diagnosis is made real-time reverse transcription polymerase chain reaction (rRT-PCR) assay. This was only available from the CDC but very recently the CDC has made kits available to state health departments (2).

At present the treatment for 2019-nCoV is supportive in appropriate respiratory isolation to protect healthcare workers. A randomized, controlled trial of Gilead’s antiviral drug remdesivir used to treat Ebola is currently underway in China in hopes that it will be an effective treatment for 2019-nCoV (5).

Please be aware that this information is current as of February 10, 2020. It is likely to change.

References

1. McNeil DG Jr. Wuhan coronavirus looks increasingly like a pandemic, experts say. New York Times. February 2, 2020. Available at: https://www.nytimes.com/2020/02/02/health/coronavirus-pandemic-china.html (accessed 2/10/20).
2. Centers for Disease Control. 2019 Novel Coronavirus (2019-nCoV) in the U.S. February 10, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html (accessed 2/10/20).
3. Worldometer. Novel coronavirus (2019-nCoV) mortality rate. Available at: https://www.worldometers.info/coronavirus/coronavirus-death-rate/ (accessed 2/10/20).
4. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Jan 24. pii: S0140-6736(20)30183-5. [Epub ahead of print] [CrossRef] [PubMed]
5. Wetsman N. An experimental antiviral medication might help fight the new coronavirus. The Verge. Feb 4, 2020. Available at: https://www.theverge.com/2020/2/4/21122327/coronavirus-experimental-medication-treatment-wuhan-china-gilead-hiv (accessed 2/10/20).

Cite as: Robbins RA, Klotz SA. Brief review of coronavirus for healthcare professionals February 10, 2020. Southwest J Pulm Crit Care. 2020;20(2):69-70. doi: https://doi.org/10.13175/swjpcc011-20 PDF 

December 2019 Pulmonary Case of the Month: A 56-Year-Old Woman with Pneumonia

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 56-year-old woman complained of 6 weeks of increasing cough and shortness of breath. She had been treated for pneumonia with antibiotics, but when she failed to improve, she was begun on prednisone. She was receiving oxygen at 4 L/min by nasal cannula at the time she was seen.

PMH, SH, and FH

Her past medical history, social history and family were unremarkable other than a previous history of silicone breast implants. She was a nonsmoker.

Physical Examination

Her physical examination showed bibasilar crackles but was otherwise unremarkable.

Radiography

Her chest x-ray is shown in Figure 1.

Figure 1. Patient’s chest x-ray taken 6 weeks after the beginning of her illness.

Which of the following should be done at this time? (Click on the correct answer to be directed to the second of seven pages)

1. Coccidioidomycosis serology
2. Sputum gram stain and culture
3. Thoracic CT scan
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. December 2019 Pulmonary case of the month: a 56-year-old woman with pneumonia. Southwest J Pulm Crit Care. 2019;19(6):149-55. doi: https://doi.org/10.13175/swjpcc067-19 PDF

Severe Respiratory Disease Associated with Vaping: A Case Report

Evan Denis Schmitz MD

La Jolla, CA USA

Abstract

A case of severe respiratory disease associated with vaping cannabinoid oil is reported in a 38-year-old woman. She presented with shortness of breath and nonproductive cough. Chest x-ray and CT scan showed diffuse ground glass opacities and consolidation. Bronchoscopy showed diffuse bronchial erythema and bronchoalveolar lavage contained an increased percentage of eosinophils (59%). She was treated with high dose corticosteroids and rapidly improved.

Case Report

History of Present Illness

A 38-year-old woman complained of worsening shortness of breath and nonproductive cough for four weeks. She used to be able to climb three flights of stairs but now can barely walk ten feet. She had been treated with various forms of antibiotics, inhalers and steroids and was taking 20 mg of prednisone a day on the day of hospitalization. She also received opiates to help control her cough. She denied any hemoptysis, fever, chills, or sputum production. Because of her progressive symptoms she was hospitalized for further evaluation and management.

Past Medical History, Social History and Family History

She has a history of obesity and fibromyalgia. She has a prior history of smoking one to two packs a day for five years quitting approximately 15 years ago. Because of a family crisis she tried vaping cannabidiol (CBD) oil approximately one month prior to admission. She also resumed smoking tobacco one half a pack per day. Her family history was unremarkable.

Medications

She was taking prednisone 20 mg/day and cyclobenzaprine (Flexeril®) for her fibromyalgia. She was also taking codeine cough syrup.

Review of Symptoms

She did have some chest pain associated with her shortness of breath as well as chronic muscle aches and intermittent lower extremity edema. Her review of systems was otherwise unremarkable.

Physical Examination

Vital Signs: BP 137/72 mm Hg, Pulse 84 beats/min, temperature 98.8 °F, respirations 22 breaths/min, height 5’0, weight 231 lbs, SpO2 96%

General: She was morbidly obese and only able to speak in short sentences.

Mouth: Moist. Mallampati 3.

Pulmonary: Faint expiratory crackles. No wheezing.

Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard.

Abdominal: Soft, bowel sounds normal. No distension, mass or tenderness. No rebound or guarding. Centripetal obesity.

Extremities: Normal range of motion. No edema or tenderness.

Lymphatics: No cervical or supraclavicular adenopathy.

Neurological: Alert and oriented to person, place and time.

Skin: Warm and dry. No rash, erythema or pallor. Not diaphoretic. Capillary refill within normal limits. No skin tenting.

Psychiatric: Depressed mood.

Laboratory

Pertinent findings are on her laboratory evaluation include an elevated white blood cell count of 16,850 cells/µL with an increased number of neutrophils. Her electrolytes, liver enzymes, creatinine, blood urea nitrogen and urinalysis were within normal limits.

Radiology

Her admission chest x-ray is shown in Figure 1.

Figure 1. The admission portable chest x-ray showed bilateral patchy pulmonary infiltrates.

To better define the areas of consolidation, a thoracic CT scan was performed (Figure 2).

Figure 2. Representative images in lung windows from contrast enhanced thoracic CT scan showing nonspecific patchy areas of ground glass and alveolar opacities with septal thickening involving both lungs.

Hospital Course

Echocardiography was unremarkable. Bronchoscopy with bronchoalveolar lavage was performed. She had diffuse upper and lower airway erythema and considerable coughing during the procedure. The cell differential revealed an increase in eosinophils (59%) and multiple foamy macrophages. Smears and cultures of the lavage fluid were negative for pathogens. She was treated with high dose corticosteroids (methylprednisolone 1000 mg/day). She rapidly improved over four days with her cough and shortness of breath resolving. A chest x-ray at discharge revealed improvement of the pulmonary infiltrates (Figure 3).

Figure 3. Chest x-ray on the morning of discharge showing near resolution of her pulmonary infiltrates.

Discussion

At the time of this writing (9/21/19) there have been 530 cases of lung injury associated with e-cigarette product use or vaping reported with seven deaths (1).  Nearly three fourths (72%) of cases have been male with two thirds (67%) 18 to 34 years old. Most patients have reported a history of using e-cigarette products containing tetrahydrocannabinol (THC). Many patients have reported using THC and nicotine. Some have reported the use of e-cigarette products containing only nicotine.

At present no specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance has been linked to all cases. It seems likely that there may be different mechanisms of lung injury from different substances. In support of this concept, the present case had high numbers of eosinophils in the bronchoalveolar lavage while other cases have shown an increase in neutrophils (2). Our patient was treated with high dose corticosteroids and did improve while on the corticosteroids. However, the time course does not establish a definite relationship between corticosteroid treatment and her improvement.

At present the CDC recommends refraining from using e-cigarette or vaping products (1). Anyone who uses an e-cigarette or vaping product should not buy these products (e.g., e-cigarette or vaping products with THC or CBD oils) off the street, and should not modify or add any substances to these products that are not intended by the manufacturer.

References

1. CDC. Outbreak of lung injury associated with e-cigarette use, or vaping. September 19, 2019. Available at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html (accessed 9/21/19).
2. Arizona Thoracic Society. September 2019 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2019;19(3):99-100. [CrossRef]

Cite as: Schmitz ED. Severe respiratory disease associated with vaping: a case report. Southwest J Pulm Crit Care. 2019;19(3):105-9. doi: https://doi.org/10.13175/swjpcc062-19 PDF 

September 2019 Pulmonary Case of the Month: An HIV Patient with a Fever

William P. Diehl IV, DO

Nicholas Villalobos, MD

Department of Internal Medicine

University of New Mexico

Albuquerque, NM USA

History of Present Illness

A 33-year old transgender male to female presented from human immunodeficiency virus (HIV) clinic for two months of fevers, intermittent shortness of breath, cough with blood streaked sputum, headache, and nausea. The clinic provider was concerned when labs showed up trending HIV viral load (3.3 million copies) and an absolute CD4 count of 57.

Past Medical History, Social History and Family History

The patient had a history of stage-III HIV diagnosed in 2014 on bictegravir, emtricitabine, tenofovir (Biktarvy) and latent tuberculosis (TB) diagnosed 2017 on isoniazid and B6. She is from Nicaragua and arrived in Albuquerque, NM in 2017. Social history is pertinent for sex trafficking and methamphetamine use.

Physical Examination

Upon admission, the patient’s vital signs were notable for a temperature of 39.2 degrees Celsius, blood pressure of 114/71 mmHg, oxygen saturation of 95% on room air with a respiratory rate of 18 breaths per minute. Physical exam was notable for an absence of rash, palpable lymphadenopathy or cachexia.

Which of the following should be done? (Click on the correct answer to be directed to the second of six pages)

1. Blood cultures
2. Lumbar puncture
3. Sputum for AFB and tuberculosis
4. 1 & 3
5. All of the above

Cite as: Diehl WP IV, Villalobos N. September 2019 pulmonary case of the month: an HIV patient with a fever. Southwest J Pulm Crit Care. 2019;19(3):87-94. doi: https://doi.org/10.13175/swjpcc056-19 PDF 

Adherence to Prescribed Medication and Its Association with Quality of Life Among COPD Patients Treated at a Tertiary Care Hospital in Puducherry – A Cross Sectional Study

S Keerti kumar S

B Maharani, MD

R Venkateswara Babu, MD

M Prakash, MD 

Departments of Pharmacology, Respiratory Medicine and Community Medicine

Indira Gandhi Medical College and Research Institute

Puducherry, India

Abstract

Introduction: Medication adherence is a major determinant for the success of therapy among chronic obstructive pulmonary disease (COPD) patients. The research objectives of the present study were to assess the adherence to prescribed medications and its association with quality of life among COPD patients, to determine the major factors that influence the medication adherence and to assess patient’s knowledge on COPD and its relation to medication adherence.

Methods: It was a hospital based cross-sectional study. Patient demographic characteristics, smoking and alcoholic status, severity grading of COPD, concomitant disease, affordability of patients to medication, patient knowledge on COPD (Knowledge Questionnaire), adherence to medication and inhaler, major factors influencing adherence, disease control and quality of life (COPD Assessment Test) were recorded.

Results: Most of the patients were non-smokers and patients exposed to occupational air pollutants was high. Complete adherence to prescribed medication was found among 47% (MAS Score 6) of the participants and 81% of the participants were partially adherent (MAS score, range of 1-6). Highly adherent group was found to have high CAT score which was statistically significant. (P=0.020). Major factors for medication non-adherence were forgetfulness (82.5%) and symptomatic relief of illness (12.5%). There was no statistically significant association between individual knowledge questions and medication adherence except the question “COPD medicines prevent the disease from getting worse” (P=0.021).

Conclusion: There was a statistically significant association between medication adherence and quality of life. Appropriate health education should be implemented for improving patient awareness and medication adherence.

Introduction

Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases (1). In industrialized and developed countries, it is one of the leading causes of morbidity and mortality (2). The World Health Organization predicts that COPD will become the third leading cause of death by 2030 (3). Currently, various drugs like β2 agonist (long and short acting), inhalational anticholinergics, inhalational corticosteroids and methyl xanthines are utilized to prevent, control the symptoms and also to minimize the occurrence of COPD exacerbations (4,5).

The main factor that determines the success of therapy appears to be medication adherence. The medication adherence rates among COPD patients in clinical trials has been found to be 70 to 90% but in clinical practice it was very low accounting for only 10 to 40% (6-11). Non-adherence to therapy may lead to poor health and increased morbidity and health care cost, which in turn alters the quality of life (12). There appear to be few studies in India on medication adherence among COPD patients. This study is novel in assessing the adherence to drug therapy and its relation to quality of life, patients’ knowledge on COPD and its relationship to medication adherence and major factors influencing the medication adherence among COPD patients attending the tertiary care Institute in one of the Union Territory in India. 

Methods

Study design and setting: A cross-sectional study was conducted in a tertiary care hospital. The study center was a referral hospital for nearby primary and secondary care hospitals and a separate COPD clinic was run every week for treating COPD patients. The study was conducted for a period of 6 months after obtaining Institutional Ethics Committee clearance.

Study Population: Eligible patients were those referred and diagnosed with COPD by FEV1 and categorized according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging and were receiving medications (with no alterations in treatment regimen during the past 3 months). Since the study was on medication adherence, all the COPD patients attending the outpatient department during the study period were considered. Patients with a history of asthma, allergic rhinitis, hospitalization for COPD exacerbation in last 3 months, heart failure or serious liver disease or renal failure or acute coronary syndrome patients and mental illness patients were excluded.

Data Collection: The patients satisfying the inclusion criteria were interviewed after obtaining their written informed consent. Patient demographic details, smoking and alcoholic status, occupational exposure to air pollutants, age at diagnosis of COPD, duration of COPD, concomitant disease, affordability of patients to medication were recorded. Post-bronchodilator FEV1 was measured with spirometry and grading of COPD was done following Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging (13).  

Questionnaires used: Patient knowledge on COPD was assessed using COPD Knowledge Questionnaire (COPD-Q) (14). It is a valid, reliable and low-literacy tool to assess COPD related knowledge in patients. Adherence to medication and inhaler was evaluated by using Medication Adherence Scale (MAS) and Medication adherence report scale (MARS) (15,16). Reasons for non-adherence (missing or discontinuing the dose) were also obtained from the patients.  Disease control and quality of life was assessed by using COPD assessment Test (CAT) (17). CAT score varies with changes in treatment and exacerbations of disease due to poor adherence. CAT scoring ranges between 0 and 40. Score of

> 30                - very high impact of COPD on patients

>20                 - high impact of COPD on patients

10 to 20         - medium impact of COPD on patients

<10                - low impact of COPD on patients

5                   - very low impact of COPD on patients

Statistical Analysis: Data entry was done in MS Excel 2010.  Data was analyzed using professional statistics package EPI Info 7.0 version for windows. Descriptive data was represented as mean ± SD, median and interquartile range for numeric variables, percentages and proportions for categorical variables. Appropriate tests of significance were used depending on nature & distribution of variables like Chi square test, student’s t test for categorical variables. Values of p<0.05 were considered statistically significant. Spearman’s correlation test was used to find out the relationship between medication adherence and quality of life.

Results

During the six months study period, 157 COPD patients were contacted. Out of the 157 patients, 19 patients refused to participate in the study, 5 patients were not able to answer appropriately and 42 patients had not satisfied the inclusion criteria. A total of 91 patients completed the study and gave complete responses to the questionnaire. 

Sociodemographic characteristics of the patients were summarized in Table 1.

Table 1. Sociodemographic characteristics of the study participants.

Most of the patients were non-smokers and patients exposed to occupational air pollutants was high. Based on GOLD staging of severity of COPD, 14% were graded as mild, 63% were graded as moderate, 20% were graded as severe and 3% of patients had very severe form of COPD. Concomitant diseases like diabetes, hypertension and hyperthyroidism was found in 74.7% of the participants. Nearly 50% of the participants belong to very low socioeconomic status as per Modified Prasad Classification and medication cost was affordable only by 24.2%.  

Patient responses to COPD – Knowledge Questionnaire (COPD-Q) and its relation to medication adherence were summarized in Table 2.

Table 2. COPD Knowledge Questionnaire responses and its relation to medication adherence among study participants.

*p<0.05 - statistically significant.

There was no statistically significant association between individual knowledge questions and medication adherence except the question “COPD medicines prevent the disease from getting worse” (P=0.021). Average COPD-knowledge score was 6.23 ± 1.57.

Responses to medication adherence scale were summarized in Table 3.

Table 3. Responses to COPD medication adherence.

The adherent sum score ranged between 1-6, 43 (47%) participants who had a sum score of 6 were fully adherent to prescribed medications, 27 (30%) participants had a sum score of 5 and others had a sum score of 1-4 were partially adherent to prescribed medications. The overall medication adherence (range 1-6) among the participants was 81%.

Inhalational medications were used only by 43 (47.3%) patients. Responses to adherence to inhaled medications were summarized in Table 4.

Table 4. Responses to inhalational medication adherence.

MARS sum score was 23.55±3.95. Higher score indicates higher self-reported adherence. MARS sum score ranged between 5-25. Out of 43 patients, 39 (91%) had the sum score in the range of 21-25.

The common reasons for medication non-adherence were forgetfulness (82.5%), symptomatic relief of illness (12.5%), 10% responded that medicines got exhausted and 2.5% reported that it was socially inconvenient to take the medications.

CAT score of the patients and grading were summarized in Tables 5 and 6.

Table 5. COPD Assessment Test (CAT) – Individual item responses.

Table 6. Categorization of study participants based on CAT Score.

There was a statistically significant difference between adherent and partially adherent groups with respect to CAT score of the participants (Student’s t test; p value=0.020).

Highly adherent group was found to have high CAT score. (Table 7).

Table 7. Association between medication adherence score and CAT score.

Student’s t test; p value=0.020.

There was a statistically significant weak positive correlation (r=0.246) between medication adherence sum and CAT score.

Discussion

The patients in the present study had adherence to the medication at 47%. The percentage of adherence was less than the studies conducted in Hungary (58.2%) and Nepal (65%) (18,19). Although complete adherence was less than 50%, majority of the participants were partially adherent to the medications which was at 81% (Table-3). The most common cause for non-adherence was forgetfulness (82.5%). The percentage was very high when compared to other studies in which forgetfulness accounted for about 50% (15,19). 

There was a statistically significant association between medication adherence score and the CAT score similar to the study done by Kocakaya et.al. (20). The study had revealed better the adherence, better the quality of life. Though there is weak positive spearman’s correlation which was statistically significant, it may not be clinically significant. This can be overcome by increasing the sample size. Only 43 participants used inhalational medications and there was higher self-reported adherence to inhalational medications. That data is similar to a study done by Tommelein et al. (16).

In the tertiary care Institute where the study was conducted, patients with moderate and severe symptoms alone were advised to purchase inhaler and during inhaler introduction they were properly trained on how to use the inhaler. Further, compliance to the inhalational medications were checked during each follow-up. Since moderate to severe symptomatic patients were comfortable with inhalational medications, there was high degree of adherence to inhalational medications.

The patient’s COPD knowledge score was 6.23 ± 1.57. It was less when compared to the study done by Ray SM., et al. (7.6 ± 2.1) (14). Awareness of the patients on smoking and its association with COPD, reversal of COPD with quitting of smoking was only around 50% but comparable to prior studies (14). The percentage of COPD patients with smoking was only 22%. The results were similar to the study done by Mahmood T et.al., in which the percentage of nonsmokers with COPD was higher when compared to smokers with COPD (21). It was interesting to note that 100% of the participants were not aware about the importance of flu and pneumonia vaccination. It may be because of poor literacy rate and lack of awareness among the participants.

The results of our study are not surprising and consistent with prior studies. However, sociodemographic factors affect compliance. To our knowledge this is the first study to show the association between adherence and quality of life in COPD in a unique Indian population.

Conclusion

The study showed a statistically significant association between medication adherence and quality of life. Further studies evaluating the impact of education on medication adherence and quality of life are needed.  

References

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6. Rand CS, Nides M, Cowles MK, Wise RA, Connett J. Long-term metered-dose inhaler adherence in a clinical trial. The Lung Health Study Research Group. Am J Respir Crit Care Med. 1995;152:580–8. [CrossRef] [PubMed]
7. Kesten S, Flanders J, Serby CW, Witek TJ. Compliance with tiotropium, a once daily dry powder inhaled bronchodilator, in one-year COPD trials. Chest. 2000;118:191s– 192s.
8. Van Grunsven PM, Van Schayck CP, Van Deuveren M, Van Herwaarden CL, Akkermans RP, Van Weel C. Compliance during long-term treatment with fluticasone propionate in subjects with early signs of asthma or chronic obstructive pulmonary disease (COPD): results of the Detection, Intervention and Monitoring Program of COPD and Asthma (DIMCA) Study. J Asthma. 2000;37:225–34. [PubMed]
9. Krigsman K, Nilsson JL, Ring L. Refill adherence for patients with asthma and COPD: comparison of a pharmacy record database with manually collected repeat prescriptions. Pharmacoepidemiol Drug Saf. 2007;16:441–8. [CrossRef] [PubMed]
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Cite as: kumar S KS, Maharni B, Babu RV, Prakash M. Adherence to prescribed medication and its association with quality of life among COPD patients treated at a tertiary care hospital in Puducherry – a cross sectional study. Southwest J Pulm Crit Care. 2019;18(6):157-66. doi: https://doi.org/10.13175/swjpcc021-19 PDF