SESSION TITLE: COPD: Lessons for the Real-World Management of Disease SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 02:45 PM - 04:15 PM PURPOSE: GOLD recommendations suggest the use of long acting β2 agonist (LABA) and/or long acting muscarinic antagonist (LAMA) for most COPD patients, reserving regimens containing inhaled corticosteroids (ICS) for a more severe subset of patients. Data on implementation of GOLD recommendations into clinical practice are limited. The purpose of this study was to characterize real-world treatment patterns among a spirometry-confirmed COPD population by GOLD airflow limitation severity classifications. METHODS: Over a study period of 1/1/2011 to 11/30/2015, a cohort of newly diagnosed COPD patients was identified using administrative claims from a large US payer. Patients were required to have ≥1 inpatient, ED or office visit claim for COPD from 1/1/2012 to 11/30/2013 and continuous health plan enrollment for 1 year prior to and 2 years after the first COPD diagnosis date. Patients with ≥1 claim for spirometry were eligible for medical record abstraction to confirm COPD diagnosis (FEV1/FVC ratio <0.7) and to determine GOLD 1-4 classification (based on post-bronchodilator FEV1 % predicted). Following COPD diagnosis, treatment patterns including COPD maintenance therapy (LAMA, LABA, ICS) observed and medication persistence (using a 60 day permissible gap) were evaluated for each GOLD classification. The rate of moderate/severe COPD exacerbation post-diagnosis was calculated. RESULTS: 85,247 newly diagnosed COPD patients were identified and 14,293 (17%) had a claim for spirometry use. Medical records containing complete spirometry results were obtained for 4,130 patients, with 1,505 (36%) having a spirometry-confirmed diagnosis. Among the 1,505 confirmed COPD patients, 333 (22%) were GOLD 1, 823 (55%) were GOLD 2, 317 (21%) were GOLD 3 and 32 (2%) were GOLD 4. Following COPD diagnosis, maintenance therapy was observed in 43% of GOLD 1, 56% of GOLD 2, 73% of GOLD 3 and 75% of GOLD 4 patients. GOLD 1 and 2 patients on maintenance therapy most frequently used ICS-LABA (48% & 45%, respectively), followed by LAMA only (29% for each) and ICS only (16% & 9%), while approximately 5% of GOLD 1 and 9% of GOLD 2 patients used triple therapy (ICS-LABA+LAMA). Similarly, a majority of GOLD 3 and 4 patients on maintenance therapy used ICS-LABA (37% & 42%), followed by LAMA only (28% & 25%) and triple therapy (20% & 17%). Overall, the observed maintenance therapy after diagnosis was an ICS-containing regimen for 67% of patients. Assessing persistence, mean (±SD) days on maintenance therapy was 143 days (±130), 188 days (±142), 215 days (±143) and 282 days (±132) for GOLD 1-4 and 191 days (±142) overall. Rates of severe/moderate COPD exacerbation per 100 person-years for GOLD 1-4 patients were 40.4, 48.9, 83.6 and 89.1, respectively. CONCLUSIONS: Large numbers of patients did not use maintenance therapy and the majority of those who did, across all GOLD classifications, used ICS-containing regimens (especially ICS-LABA), which is inconsistent with GOLD recommendations. Medication persistence was poor overall, especially in GOLD 1 patients. CLINICAL IMPLICATIONS: The observed inconsistencies with GOLD recommendations for COPD medication in this study highlight a gap between guidelines and clinical practice and the need for improved diagnosis and treatment of COPD patients. DISCLOSURE: Anna Wallace: Employee: I am an employee of HealthCore, a wholly owned subsidiary of Anthem, a health insurance company. I own Anthem stock. HealthCore received funding to conduct the work that led to this abstract. Valentina Zubek: Employee: Dr. Zubek reports she is an Employee of Boehringer Ingelheim. Shuchita Kaila: Employee: Dr. Kaila reports she is an Employee of Boehringer Ingelheim. Asif Shaikh: Employee: Dr. SHAIKH reports he is an Employee of Boehringer Ingelheim.reports other from Boehringer-Ingelheim, during the conduct of the study. Mayura Shinde: Employee: Dr. Shinde was an employee of HealthCore during the conduct of this work. HealthCore received funds from Boehrniger Ingelheim to conduct this work. Vincent Willey: Employee: Dr. Willey reports his employer, HealthCore, received funding from Boehringer Ingelheim to perform the study. Joseph Singer: Employee: Dr. Singer reports he is an employee and shareholder of HealthCore/Anthem. HealthCore received funds from Boehringer Ingelheim to conduct this work. The following authors have nothing to disclose: Mark Napier No Product/Research Disclosure Information

Chronic lymphocytic leukaemia (CLL), even when severe, is not directly associated with opportunistic infections. Opportunistic infections that occur with CLL are almost exclusively related to immunosuppression caused by chemotherapeutic drugs used to treat CLL. We report a case of Pneumocystis jirovecii (PJ) pneumonia that occurred in a patient with untreated CLL with pulmonary involvement. We suspect that PJ pneumonia resulted from an inadequate immune response in the lung parenchyma resulting from excessive local accumulation of CLL cells.

Granulomatosis with polyangiitis (GPA) is a distinct systemic disorder of obscure etiology characterized by necrotizing granulomatous inflammation and pauci-immune small-vessel vasculitis. Anti-neutrophil cytoplasmic antibodies (ANCA) appear to play an important role in the pathogenesis of GPA. Herein, we report a rare case of GPA presenting with ANCA-associated pauci-immune necrotizing and crescentic glomerulonephritis accompanied by a mediastinal mass and mediastinal lymphadenopathy in the absence of pulmonary parenchymal involvement. Furthermore, we describe the effects of plasmapheresis and concomitant immunosuppression on renal and mediastinal disease.

A 74-year-old man was found to have an incidental right-sided pleural effusion during a renal ultrasound. Five months previous, he had an acute respiratory illness, including fever, chills, and cough productive of green sputum for several weeks. His cough resolved, but persistent dyspnea on exertion remained. A review of systems also revealed early satiety and vague abdominal pain. His medical history included urolithiasis and gastroesophageal reflux. Medications included esomeprazole, aspirin, zolpidem, and melatonin. He had a history of 30 pack-years of tobacco use.

INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a powerful tool for the assessment of mediastinal lymphadenopathy. We present a patient who was initially diagnosed with metastatic carcinoid tumor. On the basis of immunohistochemical staining of mediastinal lymph node biopsy obtained via EBUS-TBNS, the correct diagnosis was made.

INTRODUCTION: Central cord syndrome (CCS), an injury often seen in the elderly, is caused by hyperextension of the cervical spine resulting in weakness and sensory changes with the upper extremities more affected than the lower. Recovery is variable and residual deficits are common. Three reports of CCS as a result of endotracheal intubation exist in the literature.[1Yan K, Diggan MF. A case of central cord syndrome caused by intubation. J Spine Cord Med 1997; 20 : 230–232Google Scholar, 2Buchowski JM, et al. Central cord syndrome after total hip arthroplasty. Spine 2005; 30 : E103–E105Google Scholar, 3Clinchot DM, et al. An unusual case of traumatic spinal cord injury. Spinal Cord 1997; 35 : 181–2Google Scholar] We present a fourth case that occurred when a patient was emergently re-intubated.