Comparison of high-frequency chest wall oscillation with differing waveforms for airway clearance in cystic fibrosis

BACKGROUND: High-frequency chest wall oscillation (HFCWO) is commonly used by cystic fibrosis (CF) patients for airway clearance. The primary objective of this study was to determine whether the use of a newer HFCWO device that generates oscillations with a triangular waveform results in greater sputum production than a commonly used device that generates oscillations with a sine waveform. METHODS: This was a controlled, randomized, double-blind, crossover study. Fifteen clinically stable, adult CF patients participated. Patients performed airway clearance with each device once and at matched oscillation frequencies and pressures. All sputum produced during each session was collected. Patients completed pulmonary function tests before and after each session, and rated the comfort of the two devices. RESULTS: Mean sputum wet and dry weight produced during sine waveform and triangular waveform HFCWO sessions did not differ (p = 0.11 and p = 0.2, respectively). Mean changes in FEV(1) and FVC following HFCWO therapy were also comparable (p = 0.21 and p = 0.56, respectively). However, there was a significant reduction in air trapping by residual volume/total lung capacity ratio following triangular waveform HFCWO (p = 0.01). In addition, in vitro cough transportability was 10.6% greater following therapy with the triangular waveform device (p = 0.05). Patients perceived the two devices as equally comfortable (p = 0.8). CONCLUSIONS: Single-session sputum production is comparable with sine and triangular waveform HFCWO devices. Longer term comparisons are needed to determine whether sustained use of the devices results in clinically important differences in outcomes.     

Effect of high-frequency chest wall oscillation on the central and peripheral distribution of aerosolized diethylene triamine penta-acetic acid as compared to standard chest physiotherapy in cystic fibrosis

BACKGROUND AND OBJECTIVES: High-frequency chest wall oscillation (HFCWO) has been shown to be as effective as standard chest physiotherapy (SCPT) for removal of pulmonary secretions as well as increasing FEV(1) in cystic fibrosis (CF) patients. Patients using HFCWO often administer aerosolized medications simultaneously, reducing time required for daily care. While peripheral pulmonary distribution of tracer in normal subjects has been shown to be unaffected by HFCWO, this has not been studied in CF patients. We evaluated distribution of aerosolized (99m)Tc diethylene triamine penta-acetic acid (DTPA) administered simultaneously with HFCWO and compared this with DTPA aerosolized after SCPT. STUDY DESIGN: Ten CF patients, ages 22 to 38 years, with moderate-to-severe obstructive disease were studied in a crossover design after documentation of stable lung function. (133)Xe was administered to delineate total lung volume. DTPA was aerosolized (Pari LC Plus nebulizer and Pulmo-Aide compressor; Pari Respiratory Equipment Inc.; Richmond, VA) to delineate airway deposition. The central to peripheral deposition ratio (C/P ratio) of each lung was analyzed in each study group. Central regions were represented by the inner one third of the (133)Xe scan as demonstrated in previous research models. RESULTS: The mean C/P ratio (+/- SD) for both lungs was 1.45 +/- 0.31 with HFCWO and 1.46 +/- 0.28 following SCPT (p = not significant [NS]). Right lung mean C/P ratio was 1.74 +/- 0.43 with HFCWO and 1.85 +/- 0.63 after SCPT (p = NS). Left lung mean C/P ratio was 1.25 +/- 0.29 with HFCWO and 1.21 +/- 0.35 after SCPT (p = NS). There was no correlation between C/P ratio and FEV(1) or FVC. CONCLUSIONS: Use of HFCWO in combination with aerosolized DTPA did not result in increased central deposition as compared with aerosolized DTPA administered after SCPT. Further study is required to determine if combining HFCWO with aerosolized medications can be modified to improve peripheral deposition.     

Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs

STUDY OBJECTIVE: To evaluate the efficacy of a continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with unilateral multiple fractured ribs (MFR). DESIGN: Prospective nonrandomized case series. SETTING: Multidisciplinary tertiary hospital. PATIENTS: Fifteen patients with unilateral MFR. INTERVENTIONS: Insertion of a catheter into the thoracic paravertebral space. We administered an initial injection of 0.3 mL/kg (1.5 mg/kg) bupivacaine 0.5% with 1:200,000 epinephrine followed 30 min later by an infusion of bupivacaine 0.25% at 0.1 to 0.2 mL/kg/h for 4 days. Measurements and results: The following parameters were measured during the initial assessment before thoracic paravertebral block (TPVB), 30 min after the initial injection, and during follow-up on day 1 and day 4 after commencing the infusion of bupivacaine: visual analog pain score at rest and during coughing; respiratory rate; arterial oxygen saturation (SaO(2)); bedside spirometry (ie, FVC, FEV(1), FEV(1)/FVC ratio, and peak expiratory flow rate [PEFR]); arterial blood gas measurements; and O(2) index (ie, PaO(2)/fraction of inspired oxygen ratio). There were significant improvements in pain scores (at rest, p = 0.002; during coughing, p = 0.001), respiratory rate (p < 0.0001), FVC (p = 0.007), PEFR (p = 0.01), SaO(2) (p = 0.04), and O(2) index (p = 0.01) 30 min after the initial injection, which were sustained for the 4 days that the thoracic paravertebral infusion was in use (p < 0.05). PaCO(2) did not change significantly after the initial injection, but on day 4 it was significantly lower than the post-TPVB value (p = 0.04). One patient had an inadvertent epidural injection, and another developed transient ipsilateral Horner syndrome with sensory changes in the arm. No patient exhibited clinical signs of inadvertent intravascular injection or local anesthetic toxicity. CONCLUSION: Our results confirmed that continuous thoracic paravertebral infusion of bupivacaine is a simple and effective method of providing continuous pain relief in patients with unilateral MFR. It also produced a sustained improvement in respiratory parameters and oxygenation.     

Systemic sclerosis and interstitial lung disease: a pilot study using pulse intravenous methylprednisolone and cyclophosphamide to assess the effect on high resolution computed tomography scan and lung function

OBJECTIVE: To document the effectiveness, including the longterm effect, of a course of intravenous (IV) pulses of methylprednisolone (MP) and cyclophosphamide (CYC) in patients with scleroderma (SSc) who had evidence of lung inflammation on high resolution computer tomographic (HRCT) scan of the chest. METHODS: Fourteen consecutive patients with SSc and lung involvement were treated with 6 pulses of IV MP (10 mg/kg) and IV CYC (15 mg/kg) given at 3-4 weekly intervals. HRCT scans and lung function tests were performed at baseline and after the 6th pulse. Further lung function tests were repeated at 12 months and annually thereafter. RESULTS: Modified Rodnan skin scores improved significantly by 35% from a median baseline score of 17 (IQR 14-26.5) to a posttreatment score of 13 (IQR 10.5-18.5; p = 0.0058). HRCT scan scores improved significantly (p = 0.04). Twelve of 13 patients experienced either improvement or stabilization of the HRCT score. Median DLCO and lung volumes remained stable during the first 12 months. After a median followup of 26 months (IQR 19-43), 67% of patients experienced deterioration in DLCO. Median deterioration was 23% (IQR 44-0.6), with the median rate of deterioration of the predicted value of the DLCO/month being 0.87% (IQR 1.24-0.02). The treatment was safe and well tolerated. CONCLUSION: This IV regimen stabilized lung disease in patients with SSc. When treatment was stopped, or reduced in intensity, a deterioration in lung function occurred in the majority of patients. Rate of deterioration of DLCO may be a useful marker for determining the intensity of treatment. These findings have implications for treating lung disease and designing clinical trials in patients with SSc.     

Pleuropulmonary complications of esophageal variceal sclerotherapy with absolute alcohol

BACKGROUND: Esophageal variceal sclerotherapy (EVS) is an effective means of controlling variceal hemorrhage. However, it causes a wide variety of local and systemic complications. The present study was performed to document pleuropulmonary complications of EVS with absolute alcohol. METHODS: Twenty-six patients of portal hypertension of different etiologies were subjected to EVS with absolute alcohol. Baseline arterial blood gas analysis (PaO2, PaCO2, pH, HCO3, SaO2), chest X-ray and pulmonary function tests (forced expiratory volume at 1 s (FEV1), forced expiratory vital capacity (FVC), FEV1/FVC, maximum mid-expiratory flow rate (MMFR), and peak expiratory flow rate (PEFR)) were performed 4-6 h before the first session of EVS. These investigations were repeated within 24 h of EVS. Patients were asked to maintain a symptom diary and to record symptoms such as fever, chest pain, dysphagia and dyspnea during the study period. RESULTS: Ten patients (38.46%) had chest pain and four patients (15.68%) had fever after sclerotherapy. Eight patients (30.54%) complained of dyspnea and six patients (23.08%) developed pleural effusion. There was a significant decline in FVC and FEV1 after EVS as compared with baseline values. However, FEV1/FVC ratio, MMFR and PEFR did not have any significant change. CONCLUSIONS: Chest pain (38.46%), dyspnea (30.54%) and fever (15.68%) were the common symptoms after EVS while chest X-ray showed pleural effusion in 23.08%. Pulmonary function tests revealed a significant decline in FEV1 and FVC without change in FEV1/FVC ratio after EVS, suggesting a restrictive type of defect.     

Forty month follow-up of persistent and difficultly controlled acromegalic patients treated with depot long acting somatostatin analog octreotide

The objective of the present study was to investigate the effects of octreotide long acting release (S-LAR) preparation on GH and IGF-1 serum concentrations and pituitary tumor size in patients with persistent and difficultly controlled acromegaly even after adjuvant irradiation and/or dopamine agonists. Thirty-three patients with active acromegaly (26 female and 7 male, mean age; 43.94 +/- 14.01 SD years) were included in this study. Patients were evaluated at baseline and at 6, 12, 30 and 40 months for GH, IGF-1, and GH response to OGTT and biliary ultrasonography. Sella MRI was performed at initial and at 40 months. All patients received 20 mg S-LAR. Afterwards, the dosage was titrated to improve individual GH response and reduction of IGF-1 into normal ranges. Basal serum IGF-1 levels decreased from median: 530 microg/l [IQR: 420-600] to 340 microg/l [IQR: 230-460] at 6 months (p = 0.01), to 400 microg/l [IQR: 222.4-600] at 12 months (p = 0.48), to 396 microg/l [IQR: 318-468] at 30 months (p = 0.49), to 482 microg/l [308-580] at 40 months (p = 0.47). Nadir GH levels in OGTT fell from 2.70 ng/ml [IQR: 1.35-6.90] to 1.60 ng/ml [IQR: 0.36-4.10] at 6 months (p = 0.03), to 0.31 ng/ml [IQR: 0.18-0.65] at 12 months (p<0.0001), to 1.50 ng/ml [IQR: 0.83-4.00] at 30 months (p = 0.398) and to 0.89 ng/ml [IQR: 0.58-1.35] at 40 months (p<0.0001). Initially, pituitary adenoma volume was median: 1.18 ml [IQR: 0.08-3.50] and it shrank to 0.21 ml [IQR: 0-2.1] at 40 months (p = 0.08). Gallstones were detected in 12 patients and six of them underwent cholecystectomy. S-LAR is an effective treatment regimen in reducing GH and IGF-1 concentrations and as well as in shrinking tumor volume in persistent and difficultly controlled acromegalic patients.     

Oral forms of tetracycline and doxycycline are effective in producing pleurodesis

PURPOSES: We investigated whether oral tetracyclines could produce an efficient and safe pleurodesis as does parenteral doxycycline, which is currently unavailable in many countries. METHODS: Parenteral doxycycline (10 mg/kg), oral tetracycline (35 mg/kg), or doxycycline (10 mg/kg) was injected intrapleurally through a right chest tube in rabbits. The oral forms were dissolved in saline solution and passed through a sterile membrane filter. When daily aspirated pleural fluid was < 5 mL/24 h, the chest tube was removed. Fluid WBC, lactate dehydrogenase (LDH), and protein levels were measured 24 h after the injection. After the death of the animals on day 14, pleurodesis was graded from 1 (none) to 8 (> 50% symphysis) by two observers blinded to treatment groups. RESULTS: The right pleurodesis score of the combined oral groups (median, 7.0; interquartile range [IQR], 4.0; n = 26) did not differ significantly (p = 0.349) from that of the parenteral group (median, 7.5; IQR, 6.0; n = 10). Oral tetracycline (capsule or tablet, n = 6 in each group) and doxycycline (capsule or tablet, n = 7 in each group) were as effective as parenteral doxycycline in producing pleurodesis: tetracycline capsule (median, 7.50; IQR, 6.00); tetracycline tablet (median, 6.50; IQR, 6.00); doxycycline capsule (median, 4.00; IQR, 1.00); doxycycline tablet (median, 8.00; IQR, 5.00), and parenteral doxycycline (median, 7.50; IQR, 6.00) [p = 0.235]. The left pleurodesis scores were 1.00 in all 36 rabbits. Fluid total volume, WBC, LDH, and protein levels were comparable between each oral and parenteral group, excluding WBCs in the tetracycline tablet group (p = 0.047). The complications were nonfatal (right hemothorax: tetracycline capsule [n = 3]/tetracycline tablet [n = 2], doxycycline tablet [n = 2], parenteral doxycycline [n = 2]; left hemothorax: tetracycline capsule [n = 1]; ascites: parenteral doxycycline [n = 1]). There was no growth on all filtrate cultures. Oral forms cost less than parenteral doxycycline (<1 US dollar vs 4.72 US dollars per rabbit). Filtering costs were 1.12 US dollars per rabbit. CONCLUSION: Oral tetracycline or doxycycline is as effective and safe as parenteral doxycycline in producing pleurodesis in rabbits; thus, they may also be used in humans.     

Proton pump inhibitors for patients with coronary artery disease associated with reduced chest pain, emergency department visits, and hospitalizations

BACKGROUND: Patients with coronary artery disease (CAD) presenting to an emergency department (ED) with chest pain are likely to undergo hospitalization as clinicians attempt to elucidate the etiology. HYPOTHESIS: We hypothesized that proton pump inhibitor (PPI) therapy is associated with reduced chest pain events and evaluations in patients with CAD. METHODS: A patient population from a veterans medical center with documented CAD was identified retrospectively, and chest pain episodes, ED visits, and hospitalizations for chest pain were prospectively followed over 2 years. Comparison of patient outcomes between PPI (+PPI) and nonuse of PPI therapy (-PPI) was determined. RESULTS: Of 415 male patients, average age 73.4 years, 23% utilized a PPI and 77% did not. Proton pump inhibitor therapy was associated with reduced chest pain episodes (11.8 vs. 26.2%, p = 0.002), ED visits (12.3 vs. 24.3%, p = 0.044), and hospitalizations (12.8 vs. 23.9%, p = 0.086). Relative reductions were 55, 49, and 46%, respectively, after 2 years. Numbers of adverse events were also decreased in the +PPI group of patients: 70% fewer occurrences of chest pain (p = 0.002, relative risk [RR] = 3.3), 55% fewer ED visits (p = 0.049, RR = 2.2), and 53% fewer hospitalizations (p = 0.064, RR = 2.1). By multivariate analysis, PPI therapy independently predicted reduced prevalence of patients experiencing chest pain, ED visits, or hospitalizations (odds ratio [OR] = 0.09 [0.04-0.21]; 0.15 [0.06-0.40]; 0.14 [0.05-0.40]; all p < 0.001). CONCLUSIONS: Proton pump inhibitor therapy for male patients with CAD from a veterans medical center was associated with reduced prevalence of chest pain, ED visits, and hospitalizations for chest pain and reduced incidence of these events.     

Prevalence and correlates of nonadherence to antiretroviral therapy in a population of HIV patients using Medication Event Monitoring System

Nonadherence to antiretroviral therapy (ART) jeopardizes good clinical outcome in people living with HIV. In a single-center prospective study, prevalence and correlates of nonadherence were investigated in 43 patients on ART. Nonadherence was assessed using Medication Event Monitoring System (MEMS), self-report and collateral report of treating physicians. Based on MEMS data, median taking adherence, dosing adherence, and timing adherence was 98% (interquartile range [IQR] = 5.3), 91.5% (IQR = 18), and 86% (IQR = 31.5), respectively. The median number of drug holidays per 100 days was 0.8 (IQR = 4.8). The prevalence of nonadherence measured by MEMS was 40%. Self-reported nonadherence and collateral report of nonadherence by physicians varied from 5% to 41% and 24% to 28%, respectively. Patients were categorized as adherent or nonadherent based on a clinically validated algorithm derived from MEMS parameters. Nonadherent patients used significantly more escaping coping strategies (p = 0.003) and planned problem solving strategies (p = 0.049), were prescribed significantly more antiretroviral medications (p = 0.02) and were significantly longer on ART (p = 0.04) than adherent patients. Identified correlates of nonadherence may help clinicians in detecting patients with HIV at risk for nonadherence and can support the development of adherence enhancing interventions.     

Concomitant functional dyspepsia and irritable bowel syndrome decrease health-related quality of life in gastroesophageal reflux disease

OBJECTIVE: Previous studies have reported an overlap between gastroesophageal reflux symptoms, functional dyspepsia (FD) and irritable bowel syndrome (IBS). The aim of this study was to investigate the prevalence of FD and IBS in gastroesophageal reflux disease (GERD) and the effect on health-related quality of life (HRQoL). MATERIAL AND METHODS: FD and IBS prevalence and HRQoL were assessed by means of questionnaires in 215 referred and 48 non-referred (non-care-seeking) GERD patients, proven with 24-h pH-metry. HRQoL in 131 matched controls was used for comparison. RESULTS: In this group of GERD patients 25% had FD (Dutch general population 13-14%), 35% had IBS (Dutch general population 0.6-6%) and 5% had both FD and IBS. Only 35% had neither FD nor IBS. Among referred GERD patients, the prevalence of FD and IBS was higher (p=0.002 versus non-referred). Compared with controls, GERD patients without FD/IBS had lower HRQoL scores on only one of the nine SF-36 subscales (p相似文献   

Secreted modular calcium-binding protein 2 haplotypes are associated with pulmonary function

RATIONALE: Previously reported linkage to FEV(1) (LOD score = 5.0) on 6q27 in the Framingham Heart Study (FHS) led us to explore a candidate gene, SMOC2, at 168.6 Mb. OBJECTIVES: We tested association between SMOC2 polymorphisms and FEV(1) and FVC in unrelated FHS participants. METHODS: Twenty single-nucleotide polymorphisms (SNPs) around SMOC2 were genotyped in 1,734 subjects. MEASUREMENTS AND MAIN RESULTS: SNP data were analyzed using multiple linear regression models incorporating sex, age, body mass index, height, and smoking history as covariates, and analyses were repeated within strata of ever- and never-smokers. The minor allele of SNP rs1402 was associated with higher mean FEV(1) (p = 0.003) and FVC (p = 0.02) measures. In never-smoking subjects, association with higher measures was observed with the minor allele of rs747995 (FEV(1), p = 0.0006; FVC, p = 0.0008). These two SNPs lie in different haplotype blocks and reside in intron 4 of SMOC2. Haplotype analysis revealed a common G-T haplotype (rs747995-rs1402) with 77% frequency in never-smoking FHS subjects. The G-T haplotype was associated with reduction of 126 ml for FEV(1) (p = 0.0002) and 157 ml for FVC (p = 0.0002). The G-T haplotype was similarly associated in a set of never-smoking subjects from the Family Heart Study (FEV(1), p = 0.03; FVC, p = 0.03). CONCLUSIONS: The replication of the association in two populations supports the possibility that SMOC2 might play an important role in the determination of FEV(1) and FVC.     

Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease

Although exacerbations of chronic obstructive pulmonary disease (COPD) are associated with symptomatic and physiological deterioration, little is known of the time course and duration of these changes. We have studied symptoms and lung function changes associated with COPD exacerbations to determine factors affecting recovery from exacerbation. A cohort of 101 patients with moderate to severe COPD (mean FEV(1) 41.9% predicted) were studied over a period of 2.5 yr and regularly followed when stable and during 504 exacerbations. Patients recorded daily morning peak expiratory flow rate (PEFR) and changes in respiratory symptoms on diary cards. A subgroup of 34 patients also recorded daily spirometry. Exacerbations were defined by major symptoms (increased dyspnea, increased sputum purulence, increased sputum volume) and minor symptoms. Before onset of exacerbation there was deterioration in the symptoms of dyspnea, sore throat, cough, and symptoms of a common cold (all p < 0.05), but not lung function. Larger falls in PEFR were associated with symptoms of increased dyspnea (p = 0.014), colds (p = 0.047), or increased wheeze (p = 0.009) at exacerbation. Median recovery times were 6 (interquartile range [IQR] 1 to 14) d for PEFR and 7 (IQR 4 to 14) d for daily total symptom score. Recovery of PEFR to baseline values was complete in only 75.2% of exacerbations at 35 d, whereas in 7.1% of exacerbations at 91 d PEFR recovery had not occurred. In the 404 exacerbations where recovery of PEFR to baseline values was complete at 91 d, increased dyspnea and colds at onset of exacerbation were associated with prolonged recovery times (p < 0.001 in both cases). Symptom changes during exacerbation do not closely reflect those of lung function, but their increase may predict exacerbation, with dyspnea or colds characterizing the more severe. Recovery is incomplete in a significant proportion of COPD exacerbations.     

Outcomes of interferon alpha and ribavirin treatment for chronic hepatitis C in patients with normal serum aminotransaminases

INTRODUCTION: Information on treatment outcomes with interferon plus ribavirin combination therapy in chronic hepatitis C patients with normal alanine aminotransaminase (ALT) levels is limited. AIM: The aims of this study were to assess outcomes of treatment with interferon plus ribavirin in patients with normal ALT levels (normal ALT group, n=52) compared with those with elevated ALT levels (raised ALT group, n=53), and to document the rate at which patients with normal ALT levels have an apparent worsening of disease, as shown by increases in ALT levels. RESULTS: At the end of treatment (week 48), 31 patients (59.6%) in the normal ALT group and 30 patients (56.6%) in the raised ALT group had undetectable hepatitis C virus (HCV) RNA (p=0.75). A sustained virological response (SVR) was achieved in 20 patients (38.5%) in the normal ALT group and in 21 patients (39.6%) in the raised ALT group (p=0.90). Patients were subsequently followed up for a median of 29.8 (interquartile range 25th-75th percentile (IQR) 20.8-36.2) months in the normal ALT group and for a median of 26.1 (IQR 17.7-36.3) months in the raised group (p=0.20) after week 72 of treatment. Among patients without SVR in the normal ALT group, only three patients (9.4%) developed persistently raised ALT levels following therapy. CONCLUSIONS: Combination therapy with interferon plus ribavirin is associated with a similar SVR in patients with normal ALT levels compared with those with elevated ALT levels. In patients with normal ALT levels, virological non-response to therapy results in new elevations in serum ALT levels in a small minority only.     

Effect of adherence to newly initiated antiretroviral therapy on plasma viral load.

OBJECTIVE: To determine whether differences in adherence to newly initiated antiretroviral therapy exist between subjects who do and do not achieve undetectable plasma viral loads. DESIGN: Observational cohort study monitoring adherence and virological and immunological parameters over the initial 4 months of therapy with nelfinavir. Adherence was measured using the microelectronic monitoring system (MEMS; APREX Corporation, Menlo Park, California, USA). SETTING: General Clinical Research Center at a tertiary care center. PARTICIPANTS: Forty-one protease inhibitor-naive subjects with viral loads > 10 000 copies/ml newly starting a regimen including nelfinavir, referred from HIV clinics in Philadelphia. MAIN OUTCOME MEASURES: The primary outcome was undetectable viral load (< 50 copies/ml) after 4 months. Secondary measures included changes in viral load and CD4 cell counts. We hypothesized that adherence would be greater in subjects who achieved undetectable viral loads. RESULTS: Adherence was greater in undetectable subjects, who took a median of 93% of prescribed doses [interquartile range (IQR) 84-96%], whereas detectable subjects took a median of 70% (IQR 46-93%). Adherence correlated with viral load decrease (Spearman's rho = 0.38, P < 0.01) and CD4 cell count increase (Spearman's rho = 0.25, P = 0.06). Despite differences between the groups over 4 months of therapy, there were no adherence differences over the first month [undetectables, 95% (IQR 88-98%) versus detectables, 94% (IQR 87-98%), P > 0.50]. CONCLUSIONS: Adherence is important in determining whether or not individuals achieve suppression with a newly initiated antiretroviral regimen. Adherence begins to wane after the first month of therapy. Therefore, closer assessment of adherence particularly after this first month is important.     

Effect and duration of lung volume reduction surgery: mid-term results of the Brompton trial

Although many studies have reported improvement in lung function following LVRS, the magnitude of improvement and subsequent decline has not been evaluated against medical therapy after the second year. METHODS: Existing pulmonary function records were collapsed for ech participant since randomisation from Brompton LVRS trial cohort. Longitudinal data analysis was used to profile th history of medically treated patients and the effect of LVRS. RESULTS: Pulmonary function results were collated from survivors over a median of 25 (17 to 39) months. The estimated immediate increase in mean FEV1, following surgery was +0.2591 (0.179, 0.339), with a rate of change of -0.0051 (-0.009, -0.001) per month compared to medical therapy (p < 0.001). The changes in the secondary outcome measures (LVRS compared to medical therapy) were an increase in FVC (p = 0.004), decrease in RV (p < 0.001) and TLC (p < 0.001), with differences that were maintained over time. The initial reduction in RV/TLC ration was sustained (p < 0.001), but the estimated initial increase in peak flow was accompanied by a gradual decline that was not statistically significant (p = 0.062). KCOc showed no immediate change, but there was a gradual sustained increase with time (p = 0.009). Mean oxygen saturations improved and continued to do so compared to patients on medical therapy (p = 0.001). CONCLUSIONS: The immediate increase in FEV1 is not sustained, although the mechanical improvements of LVRS on increasing FVC, reducing both the RV and RV/TLC ratio, appear to be maintained. The important benefits of LVRS may be the gradual and sustained increase in transfer factor accompanied by improved oxygen saturations.     

Use of Sniff nasal-inspiratory force to predict survival in amyotrophic lateral sclerosis

Respiratory muscle weakness is the usual cause of death in amyotrophic lateral sclerosis. The prognostic value of the forced vital capacity (FVC), mouth-inspiratory force, and sniff nasal-inspiratory force were established in a group of 98 patients with amyotrophic lateral sclerosis who were followed trimonthly for 3 years. Sniff nasal-inspiratory force correlated with the transdiaphragmatic pressure (r = 0.9, p < 0.01). Sniff nasal-inspiratory force was most likely to be recorded at the last visit (96% of cases), compared with either the FVC or mouth-inspiratory force (86% and 81%, respectively, p < 0.01). A sniff nasal-inspiratory force less than 40 cm H(2)O was significantly related with nocturnal hypoxemia. When sniff nasal-inspiratory force was less than 40 cm H(2)O, the hazard ratio for death was 9.1 (p = 0.001), and the median survival was 6 +/- 0.3 months. The sensitivity of FVC < 50% for predicting 6-month mortality was 58% with a specificity of 96%, whereas sniff nasal-inspiratory force less than 40 H(2)O had a sensitivity of 97% and a specificity of 79% for death within 6 months. Thus the sniff nasal-inspiratory force test is a good measure of respiratory muscle strength in amyotrophic lateral sclerosis, it can be performed by patients with advanced disease, and it gives prognostic information.     

Prognostic value of bronchoalveolar lavage lymphocyte count in recently diagnosed pulmonary sarcoidosis.

We prospectively looked at the prognostic value of bronchoalveolar lavage (BAL) lymphocyte count in 98 patients with recently diagnosed (less than 4 months) untreated sarcoidosis. These 50 men and 48 women (mean age, 37.4) were followed up for a period of 6 to 60 months (mean, 25.6), and were clinically evaluated every three to six months with repeated chest roentgenograms and pulmonary function tests. Twenty-four patients required steroid treatment during the study period. The proportion of treated patients was not significantly higher in the group presenting a BAL lymphocyte count less than or equal to 30 percent at diagnosis than in the group with fewer lymphocytes (31.9 and 17.7 percent of total group respectively, p = 0.10). No significant change in TLC, FRC, FVC, FEV1 or DLCO was found at follow-up between the groups with or without an initial high lymphocyte count. In the treated group, BAL lymphocyte percent weakly correlated with the improvement of FEV1 and FVC while on steroid treatment (mean duration: 3.5 months): r = 0.41, p = 0.031 and r = 0.36, p = 0.05 respectively; no correlation was found with lung volumes and DCO. We conclude that BAL lymphocyte count at the time of diagnosis is not a helpful predictor of lung function deterioration in recently diagnosed sarcoidosis and is not very useful in predicting response to treatment.     

Airway and systemic inflammation and decline in lung function in patients with COPD

STUDY OBJECTIVES: Patients with COPD experience lower airway and systemic inflammation, and an accelerated decline in FEV1. There is no evidence on whether this inflammation changes over time, or if it is associated with a faster decline in FEV1. PATIENTS AND DESIGN: A cohort of 148 COPD patients (100 men) was monitored daily for a median of 2.91 years (interquartile range [IQR], 2.1 to 4.8). At recruitment, median age was 68.5 years (IQR, 62.5 to 73.6) and FEV1 as percentage of predicted (FEV1%Pred) was 38.5% (IQR, 27.7 to 50.3). RESULTS: During the study, the patients experienced 1,389 exacerbations, a median of 2.52/yr (IQR, 1.48 to 3.96) and FEV1 declined by 40.2 mL/yr or as FEV1%Pred by 1.5%/yr. Concerning inflammatory markers, sputum interleukin (IL)-6 rose by 9 pg/mL/yr, sputum neutrophil count rose by 1.64 x 10(6) cells per gram sputum per year, an plasma fibrinogen rose by 0.10 g/L/yr (all p < 0.05). Patients with frequent exacerbations (> or = 2.52/yr) had a faster rise over time in plasma fibrinogen and sputum IL-6 of 0.063 g/L/yr (p = 0.046, n = 130) and 29.5 pg/mL/yr (p < 0.001, n = 98), respectively, compared to patients with infrequent exacerbations (< 2.52/yr). Using the earliest stable (nonexacerbation) measured marker, patients whose IL-6 exceeded the group median had a faster FEV1%Pred decline of 0.42%/yr (p = 0.018). Similarly, a high neutrophil count or fibrinogen were associated with a faster FEV1%Pred decline of 0.97%/yr (p = 0.001) and 0.40%/yr (p = 0.014), respectively. CONCLUSIONS: In COPD, airway and systemic inflammatory markers increase over time; high levels of these markers are associated with a faster decline in lung function.     

Influence of carvedilol on hospitalizations in heart failure: incidence, resource utilization and costs. U.S. Carvedilol Heart Failure Study Group

BACKGROUND: Carvedilol reduces disease progression in heart failure, but to our knowledge, its effects on hospitalizations and costs have not been evaluated. OBJECTIVES: We examined the effects on hospitalization frequency and costs in the U.S. Carvedilol Heart Failure Trials Program. This program consisted of four concurrent, multicenter, double-blind, placebo-controlled studies involving 1,094 patients with New York Heart Association class II to IV heart failure, which treated patients with placebo or carvedilol for up to 15 months (median, 6.5 months). METHODS: Detailed resource utilization data were collected for all hospitalizations occurring between randomization and the end of follow-up. In-patient care costs were estimated based on observed levels of resource use. RESULTS: Compared with placebo, carvedilol reduced the risk of hospitalization for any reason by 29% (p = 0.009), cardiovascular hospitalizations by 28% (p = 0.034) and heart failure hospitalizations by 38% (p = 0.041). Carvedilol also decreased the mean number of hospitalizations per patient (for cardiovascular reasons 30% [p = 0.02], for heart failure 53% [p = 0.03]). Among hospitalized patients, carvedilol reduced severity of illness during hospital admission, as reflected by shorter length of stay and less frequent use of intensive care. For heart failure hospital admissions, carvedilol decreased mean length of stay by 37% (p = 0.03) and mean number of intensive care unit/coronary care unit days by 83% (p = 0.001), with similar effects on cardiovascular admissions. As a result, estimated inpatient care costs with carvedilol were 57% lower for cardiovascular admissions (p = 0.016) and 81% lower for heart failure admissions (p = 0.022). CONCLUSIONS: Carvedilol added to angiotensin-converting enzyme inhibition reduces hospitalization risk as well as severity of illness and resource utilization during admission in patients with chronic heart failure.     

School attendance in children with Type 1 diabetes.

AIMS: To determine whether children with Type 1 diabetes mellitus (DM) miss more school than their non-DM siblings and peers and to identify factors associated with school absenteeism in children with DM. METHODS: School absenteeism data for the 2000-01 school year were obtained for 78 children with DM, 38 non-DM siblings and 118,269 age-matched peers in Toronto, Ontario. Questionnaires and hospital records were utilized to evaluate child-, family- and diabetes-related factors associated with school absenteeism in children with DM. RESULTS: Children with DM missed only slightly, albeit significantly more school than both their non-DM siblings (mean +/-sd: 10.9 +/- 8.9 vs. 8.1 +/- 8.1 days, P < 0.001) and peers (median: 8.8 vs. 5.5 days, P = 0.0005). A multiple regression analysis indicated that school absenteeism in children with DM was associated with their parents' attitudes towards school attendance (P = 0.002), poorer metabolic control (P = 0.006), shorter disease duration (P = 0.006) and a lack of aggressive behaviour (P = 0.02). CONCLUSIONS: With current management strategies, near normal school attendance is a reasonable goal for all children with DM and should be strongly encouraged by parents, educators and health care professionals.