General Practitioners Research Institute

Patients with Chronic Obstructive Pulmonary Disease (COPD) often experience limited health literacy, hampering health status assessment via standard questionnaires like the Clinical COPD Questionnaire (CCQ). We aimed to develop and validate a modified, literacy-sensitive version, the CCQgraphic (CCQg), for all patients with COPD co-designed with a large stakeholder group. CCQ items were rephrased and complemented with graphics, followed by optimization through semi-structured interviews with patients with limited health literacy. In adequate health literacy (n = 64) concordance of CCQg and CCQ was 0.88 (95% CI: 0.82-0.92). Correlation with the COPD Assessment Test (CAT) was 0.81 (95% CI: 0.70–0.88). Agreement showed a mean bias of 0.22 (95% CI: 0.10–0.34, P < 0.001) with higher scores on mental and functional domains compared to the original CCQ. Test-retest reliability in limited health literacy (n = 25) was high, CCC = 0.93 (95% CI: 0.86–0.97). The majority (88%) rated the CCQg as equal or better to the original. The CCQg offers a validated, literacy-sensitive tool, narrowing the gap in health status assessment for patients with COPD with varying literacy skills.

Post-intubation tracheal stenosis (PITS) is a potentially life-threatening but often underdiagnosed complication of prolonged mechanical ventilation. Its incidence is expected to increase with the global increase in intensive care unit admissions. We report two male patients, aged 60 and 18 years, in whom symptomatic tracheal restenosis developed after surgical repair for PITS. Both patients presented with dyspnea and stridor. Rigid bronchoscopy was performed with balloon dilation and silicone stent placement. In one case, granulation tissue developed as a complication of long-term stenting and was successfully treated with electrocautery. Both patients showed marked clinical improvement and maintained airway patency at 12-month follow-up. These cases highlight the importance of early recognition of PITS and indicate the value of bronchoscopic intervention as an effective salvage strategy when surgical repair is unsuccessful.

Background: Lithium is a cornerstone therapy for Bipolar I Disorder, yet its use necessitates vigilant monitoring for adverse drug reactions (ADRs). While lithium-induced hypothyroidism is a well-documented complication, the emergence of thyrotoxicosis secondary to destructive thyroiditis is a rare and diagnostically challenging event. This report presents a systematic analysis of a case of suspected lithium-induced thyroiditis notable for its paradoxical clinical presentation as a severe depressive episode. Case presentation: A 33-year-old female with a 10-year history of Bipolar I Disorder, stable on lithium for two years, was admitted with a severe depressive episode and active suicidal ideation. The onset of her psychiatric decompensation was temporally correlated with a diagnosis of thyrotoxicosis (suppressed TSH &lt;0.005 uIU/mL; elevated FT4 &gt;7.77 ng/dL). A formal causality assessment using the Naranjo Adverse Drug Reaction Probability Scale yielded a score of 6, indicating a "probable" relationship between lithium and the thyroiditis. Critically, the thyrotoxic state, which conventionally mimics mania, presented atypically as severe depression. Conclusion: This case of probable lithium-induced destructive thyroiditis, presenting paradoxically with severe depression, underscores the critical need for a high index of suspicion for iatrogenic endocrinopathies in patients on lithium who exhibit any mood destabilization. A systematic approach to ADR assessment is essential to guide appropriate clinical management in such complex presentations.

Breathlessness is common and often multifactorial. We are conducting the multi-country stepped-wedge cluster RCT “Yellow Box - Breathlessness Diagnostics in a Box (BiaB)” to evaluate its impact on time to diagnosis in routine primary care. The BiaB box includes an oscillometer/spirometer (ALDS), 4-patch 12-lead ECG, point-of-care NT-proBNP & D-dimer, pulse oximeter, and an iPad with BiaB app providing integrated interpretation (Fig1). The study is ongoing in NL, ES, and PT, with a usual care period followed by an intervention period using BiaB. We analysed inclusion reasons, demographics, and test results to date. 277 patients have been included (900 expected) (mean age 62.7±15.9 years, 50.4% male). Of these, 63.8% had new-onset breathlessness; 36.2% had worsening or unexplained symptoms in existing disease. Data from 65 intervention patients are shown in Fig2. Early findings show BiaB often detects relevant abnormalities, supporting its potential to expedite diagnosis. Diagnostic outcome and treatment changes are expected this summer. This study is financially supported by AstraZeneca. <fig><object-id>erj;66/suppl_69/OA2196/F1</object-id><object-id>F1</object-id><object-id>F1</object-id><graphic></graphic></fig> <fig><object-id>erj;66/suppl_69/OA2196/F2</object-id><object-id>F2</object-id><object-id>F2</object-id><graphic></graphic></fig>

<bold>Introduction:</bold> Despite normal spirometry, tobacco-exposed persons may experience symptoms, exacerbations and activity limitation. <bold>Aim:</bold> To evaluate the impact of inhaled triple therapy on small airway disease in tobacco-exposed persons with preserved FEV1/FVC ratio. <bold>Methods:</bold> In this investigator-initiated, interventional trial, symptomatic tobacco-exposed individuals with ≥10pack-year smoking history and FEV1/FVC>0.7 (intervention group) underwent evaluation, including quality-of-life assessments, lung function, computed tomography, and exercise capacity measurements at baseline and after 12 weeks of therapy with ICS(Fluticasone furoate 92mcg), LABA(Vilanterol 22mcg) and LAMA(Umeclidinium 55mcg). Baseline characteristics were compared to age- and gender-matched cohort with no smoking history (control group). The primary outcome was change in small airway function (Sacin and/or R5-19) from baseline to 12 weeks post-treatment. <bold>Results:</bold> 147 participants were included: 73 in intervention and 74 in control groups. Tobacco-exposed individuals had lower baseline FEV1 Z-score than controls (0.04±0.82 vs 0.34±0.86, p=0.0234) and higher N2-multiple breath washout Sacin Z-score (3.14±4.65 vs 0.86±3.01, p=0.0048). After 12 weeks of treatment, Sacin improved significantly (3.097 to 1.885, p=0.0296), as did FEV1 Z-score (0.04 to 0.22, p=0.0004). No change was observed in airway oscillometry. Symptom burden decreased, with improvement in CAT (9.18 vs 6.44, p<0.0001) and SGRQ scores (11.66 vs 7.35, p<0.0001). <bold>Conclusions:</bold> Inhaled triple therapy significantly reduces the burden of small airway disease and alleviates symptoms in symptomatic tobacco-exposed individuals with preserved FEV1/FVC ratio.

Background: Duplex renal is a rare congenital anomaly of the urinary system, occurring in only 0.3–0.8% of the population. It is characterized by a duplicated collecting system within a single kidney. Most individuals remain asymptomatic, and the condition is often discovered incidentally during evaluation for unrelated urinary complaints such as urolithiasis. Anatomical variations in duplex systems can complicate diagnosis and management, particularly in cases involving kidney stones. This case report aims to highlight the diagnostic challenges and surgical approach in managing a large obstructive stone in an incomplete duplex renal system. Case Presentation: A 45-year-old woman presented with persistent left flank pain for one month. The physical examination showed tenderness at the left renal angle, while the laboratory findings were unremarkable. Abdominal ultrasound revealed severe hydronephrosis with a large nail-shaped stone in the left kidney. Ureteroscopy showed proximal bifurcation of the left ureter, and a double J stent was placed. Contrast-enhanced CT confirmed a bipelvic and biureteral system merging at S2, with a dilated upper collecting system and a 6.8 × 1.3 cm obstructive stone extending from the renal pelvis to the proximal ureter. Due to limited availability of minimally invasive tools, an open heminephroureterectomy was performed, removing the non-functioning upper moiety filled with pus and the stone. Postoperative recovery was uneventful. Conclusion: The management of nephrolithiasis in duplex renal systems requires tailored strategies based on anatomical variations, available resources, and stone characteristics. In this case, open surgery provided a definitive solution for both stone removal and excision of the non-functional renal segment.

IntroductionNeutrophilic asthma has been suggested to be a clinically distinct phenotype characterised by more severe airflow obstruction and higher exacerbation risk. However, this has only been assessed in few and smaller studies, using different cut-offs to define neutrophilia, and with conflicting results. We used data from ATLANTIS, an observational longitudinal study including a large number of patients with asthma and healthy controls. The aim of the present study was to examine whether neutrophilic inflammation, either in sputum or blood, is more prevalent in asthma and whether it correlates with disease severity.MethodsATLANTIS included 773 asthma patients, with blood collected from 767 (99%) and sputum from 228 patients (30%). Data were available from 244 healthy controls, all providing blood and 126 (52%) providing sputum. Asthma patients were characterised, including parameters of large and small airways disease at baseline and after 6 and 12 months of follow-up. Sputum and blood neutrophilia were defined as values exceeding the upper quartile in asthma patients.ResultsThe prevalence of sputum neutrophilia did not differ between asthma patients and healthy controls. Asthma patients with sputum neutrophilia did not display more severe symptoms, large or small airways disease or more frequent exacerbations. Blood neutrophilia was more common in asthma and was associated with higher body mass index, female sex, current smoking and systemic corticosteroid use. Patients with blood neutrophilia had a statistically significant, but small, increase in residual volume/total lung capacity. Blood neutrophilia was not associated with large or small airways disease or exacerbation risk.ConclusionSputum and blood neutrophilia do not define a distinct clinical phenotype in asthma.

Electronic inhalers provide information about patterns of routine inhaler use. During a 12-week study, 360 asthma patients using albuterol Digihaler generated 53,083 inhaler events that were retrospectively analyzed. A total of 41,528 (78%) of the recorded inhalation events were suitable for flow analysis (having a PIF ≥ 18 L/min and <120 L/min). Median PIF, inhalation volume, inhalation duration, and time to PIF for these events steadily decreased between the first and last 10 days of the study, by 5.1%, 12.6%, 15.9%, and 6.4%, respectively. Continuous short-acting beta2-agonist (SABA) overuse, defined as ≥2 SABA inhalations/week throughout the study period, was seen in 29% (n = 104) of patients. Of 260 patients with ≥1 instance of acute short-term SABA overuse, 55 (21%) had a confirmed exacerbation. Electronic recording of real-life inhaler use can capture valuable, objective information that could inform disease management and clinical decision-making.

The need for and adoption of eHealth programs are growing worldwide. However, access can be limited among patients with low socioeconomic backgrounds, often resulting in a so-called "digital divide" due to a mismatch between eHealth and target populations that can gain benefit. This digital divide can result in unsuccessful eHealth implementations, which is of critical importance to health care. This study evaluated the opinions of elderly patients with asthma and chronic obstructive pulmonary disease (COPD) about an existing pharmacy-based personalized patient web portal that provides medication overview and information on associated diagnoses. The aim was to obtain insights on the common barriers of elderly people when using health-related websites, which can help to improve accessibility. This was a cross-sectional qualitative study of a patient panel of the Groningen Research Institute for Asthma and COPD in primary care. Participants were required to be older than 55 years, be Dutch speaking, have no prior experience with the study website, and be diagnosed with a chronic respiratory illness. Two focus groups were created, and they completed a 45-minute session for testing the website and a 120-minute session for semistructured interviews. The focus group sessions were recorded, transcribed verbatim, and analyzed by content analysis. We enrolled 11 patients (9 women) with a mean age of 66 (SD 9) years. Of these, 5 had asthma, 3 had COPD, 2 had asthma-COPD overlap syndrome, and 1 had bronchiectasis. Participants were generally positive about the website, especially the areas providing disease-related information and the medication overview. They appreciated that the website would enable them to share this information with other health care providers. However, some difficulties were reported with navigation, such as opening a new tab, and others reported that the layout of the website was difficult either because of visual impairments or problems with navigation. It was also felt that monitoring would only be relevant if it is also checked by health care professionals as part of a treatment plan. Participants mentioned few privacy or safety concerns. It is feasible to develop websites for elderly patients; however, developers must take the specific needs and limitations of elderly people into account (eg, navigation problems, poor vision, or poor hand-eye coordination). The provision of information appears to be the most important aspect of the website, and as such, we should endeavor to ensure that the layout and navigation remain basic and accessible. Patients are only motivated to use self-management applications if they are an integrated part of their treatment. The usability of the website can be improved by including older people during development and by implementing design features that can improve accessibility in this group.

<b>Introduction:</b> Small airways dysfunction (SAD) is an increasingly recognized aspect of asthma pathophysiology. Quantitative computed tomography (qCT) imaging of the lungs may provide additional insight into SAD in addition to physiological measurements. However, the relationship between qCT biomarkers, small airway physiology and clinical patient reported outcomes (PROs) is still poorly understood. <b>Objectives:</b> To determine whether a particular set of qCT imaging biomarkers are associated with physiological SAD markers and asthma PROs over 1 year. <b>Methods:</b> Data from the Assessment of Small Airways Involvement in Asthma (ATLANTIS) study, including 47 healthy and 278 asthmatic participants, were used. qCT markers capturing lung tissue deformation gradients, imaging lung volume and mean lung density were extracted. Leading variables of five radiomic signatures derived from factor analysis were evaluated as predictors of physiological SAD (R5-R20, Sacin, RV/TLC, FEF25-75) and PROs (ACQ, AQLQ, SAD questionnaire score, EuroQoL-5D-5L and asthma exacerbations) using mixed models. <b>Results:</b> The lung density gradient along the anterior-posterior axis was significantly associated with all four SAD markers of interest over the 1-year prospective follow-up, where reduced posterior ventilation suggests increased SAD. None of the qCT markers were significantly associated with clinically important changes in the PROs of interest. <b>Conclusions:</b> The selected qCT imaging biomarkers were associated with prospective SAD. The results underscore qCT as a potential screening tool for early, pre-symptomatic asthma. However, this would need to be tested in prospective studies.