Psychopathology and illness beliefs influence COPD self-management

OBJECTIVE: To explore the influence of psychological characteristics in Chronic Obstructive Pulmonary Disease (COPD) self-management. METHODS: Patients admitted with an exacerbation of COPD were interviewed for psychiatric symptoms, illness beliefs and self-management behaviour using a new COPD Self-Management Interview (COPD-SMI). This comprised three scenarios to mimic a future evolving exacerbation. Responses were scored for knowledge and actions (adherence) for each scenario. RESULTS: Of 47 people approached, 39 participated; 41% had panic attacks, 33% general anxiety, 35% a depression history, 31% an anxiety history and 21% an alcohol dependence history. Twenty-six (67%) had a self-management plan. When hypothetically "well" lower (poorer) COPD-SMI Knowledge Scores were associated with an alcohol dependence history (P=.025), no panic (P=.021) and males (P=.028). Those perceiving less influence over COPD had lower Action Scores during this scenario (P=.01) and the "early exacerbation" scenario (P=.05). Lower Knowledge Scores for the "early exacerbation" were associated with no panic (P=.01) and no self-management plans (P=.03). For the "severe exacerbation", lower Action Scores were associated with depression history (P=.004), panic (P=.002), higher FEV(1)% and no self-management plans (P=.005). Higher PaCO(2) was associated with lower confidence in symptom recognition, self-management ability and medical care influencing COPD. CONCLUSION: Anxiety, depression, alcohol use and illness beliefs may differentially influence self-management. Depression, previous alcohol dependence and perceived less influence over COPD inhibited self-management. Those with panic demonstrated more self-management knowledge when "well" but performed poorly on actions during the "severe exacerbation". Those with self-management plans had better knowledge and actions.     

On-road exposure to highway aerosols. 2. Exposures of aged, compromised rats

Ambient particulate pollution is associated with adverse health effects in epidemiological studies of the elderly with cardiopulmonary diseases. We hypothesize that ultrafine particles (UFP) contribute to these effects, especially when they are freshly generated and occur at high number concentrations. Studies to determine adverse effects have been performed using laboratory-generated surrogates, diluted exhaust from stationary engines, or concentrated ambient UFPs. Methodological difficulties exist with such experiments, and questions remain about how well these particles model those found in ambient air. Freshly generated UFPs are present at high concentrations on highways and vehicle passengers are directly exposed to them. We wished to expose rats to these UFPs to test their potential to cause effects. Since such exposures have not been done before, one objective of our study was to demonstrate the feasibility of an on-road exposure study. Secondly, we wished to determine if there are significant exposure-related effects in aged, compromised rats. Old rats (21-mo F-344) were exposed directly on highways to either the aerosol (<1 microm)/gas phase, gas phase only, or filtered air using an on-road exposure system. Some rats were pretreated with a low dose of inhaled endotoxin or with instilled influenza virus to induce lung inflammation. The exposures in compartmentalized whole-body chambers consisted of 6-h driving periods on I-90 between Rochester and Buffalo once or 3 days in a row. Endpoints related to lung inflammation, inflammatory cell activation, and acute-phase responses were measured after exposure. The on-road exposure system did not affect measured endpoints in filtered air-exposed rats, indicating that it was well tolerated by them. We observed the expected increases in response (inflammation, inflammatory cell activation) to the priming agents. We also found a significant particle-associated increase in plasma endothelin-2, suggesting alterations in vascular endothelial cell activation. In addition, we observed main effects of particles related to the acute-phase response and inflammatory-cell activation. Interactions between on-road particles and the priming agents were also found. These results suggest that exposures to on-road particle mixtures have effects on the pulmonary and cardiovascular system in compromised, old rats. Furthermore, they demonstrate that on-road exposures are feasible and could be performed in future studies with more continuous particle exposures.     

Assessing performance in final year medical students. Can a postgraduate measure be used in an undergraduate setting?

BACKGROUND: The transition between medical school and graduate performance should be a continuum. This study aimed to evaluate an assessment tool developed for practising doctors when applied to undergraduates. METHODS: A 12-item rating form was developed from that used for practising doctors by the Royal Australasian College of Physicians. Over a 2-year period, senior doctors, junior doctors and nurses completed the rating form on final year medical students. Some students completed self-assessments. We performed factor analysis and correlated scores between raters and attachments. Correlating ratings with concurrent traditional assessment results across the year tested construct validity. RESULTS: Ten forms per student were distributed for all 123 students and 856 were returned (70%). Internal consistency was very high. In all, 71.1% of the variance was accounted for by two factors (clinical skills and humanistic). This factor structure is unchanged when restricted to different raters and is the same as that noted previously when rating practising doctors. There were good correlations between raters (including self) and between attachments. Nurse ratings were reliable but nurses rated students significantly lower on humanistic qualities. Correlations with traditional assessments were high when all traditional assessments were combined. Women scored more favourably than men on humanistic qualities. CONCLUSION: A rating instrument for doctors in practice retains the same factor structure and a high degree of reliability and validity for senior medical students. Reliable ratings by nurses have implications for measures of collegiality and teamwork. We believe the instrument could be a useful outcome measure for medical programmes and employers.     

High diversity of non-human leukocyte antigens in transplant-associated coronary artery disease

BACKGROUND: Antibodies to endothelial derived non-human leukocyte antigens (HLA) have been associated with transplant (Tx)-associated coronary artery disease (CAD) after cardiac transplantation; however, few have been identified. The aim of this study was to screen a human coronary artery endothelial cell cDNA library with patient sera to establish the diversity and nature of the target antigens. METHODS: A human coronary artery endothelial cell cDNA library was screened with sera from seven long-term cardiac transplant patients with angiographically diagnosed TxCAD and sera from five healthy volunteers. RESULTS: Of the seven patients' sera, five showed reactivity, as did sera from two of the five normal subjects. Eighteen positive cDNA clones were isolated by TxCAD sera; DNA sequence analysis and DNA database searching identified all but one clone; 16 were nuclear or cytoplasmic proteins and 1 of them was the cell surface protein neuropilin 2. Five clones were targeted by normal sera. A different spectrum of reactive clones was identified by the sera of each patient where reactive clones were evident. CONCLUSIONS: A high diversity of non-HLA antigens, probably autoantigens, are involved in the pathogenesis of TxCAD.     

Tracheo-esophageal puncture (TEP) for voice rehabilitation in laryngectomised patients blom-singer® Vs Provox® Prosthesis: Our experience

Background: Stage III and IV cancers of larynx and hypopharynx often require total laryngectomy which leaves the patient with severe communication handicap. In such laryngectomised patients tracheo-esophageal puncture is the best way for voice rehabilitation using either Blom-Singer® prosthesis or Provox® indwelling valve.     

Gallstone prevalence in Christchurch: risk factors and clinical significance

AIMS: To determine the frequency, risk factors and clinical significance of gallstones in a New Zealand population. METHODS: One thousand names were randomly selected from the Christchurch electoral rolls to recruit controls for a study on the prevalence of gallstones in diabetics. Three hundred and eighteen subjects (169 females, 149 males) were recruited and in this study we analyse this control group for gallstone disease. All subjects completed a questionnaire, provided a fasting blood sample and underwent an ultrasound examination of their gallbladder unless they had previously undergone a cholecystectomy. RESULTS: Overall gallstone disease, defined as previous cholecystectomy or a positive scan for gallstones was seen in 20.75% of the 318 subjects recruited. Gallstone disease was more frequent in females (23.1%) compared to males (18.1%) but this difference was not statistically significant. For both genders there was a significant increase in gallstones with age. On univariate analysis, risk factors for gallstone disease included age, increased body mass index, family history of gallstones and decreased alcohol intake in females. However, only age and family history were significant on multiple logistic regression. There was no difference in the frequency of dyspeptic symptoms or abdominal pain between those with or without gallstones confirmed on scanning. The ratio of cholecystectomy to silent gallstones was higher in females (46.2%) than in males (22.2%). CONCLUSION: Gallstones are prevalent in the New Zealand Community (20.8% overall). Risk factors are increasing age and family history. Gallstones detected on scanning were not associated with an increased incidence of dyspeptic symptoms or abdominal pain.     

IDEAL PAIN RELIEF FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY

In a previous report the effectiveness of intraperitoneal bupivacaine in reducing pain following laparoscopic cholecystectomy was demonstrated. Other methods of pain relief are commonly used but none has been compared following laparoscopic cholecystectomy. In two further studies we have compared the analgesic effect of intraperitoneal bupivacaine against wound infiltration with bupivacaine, and against intraperitoneal bupivacaine with the addition of a non-steroidal anti-inflammatory drug (NSAID) in patients undergoing laparoscopic cholecystectomy. Two consecutive studies were performed. In the first, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine injected into the trocar wounds. In the second study, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity and a diclofenac suppository (100 mg) one hour before surgery. Postoperative pain was assessed with a visual analogue pain scale. There was no difference in pain scores in the two groups in either study. Intraperitoneal bupivacaine is as effective as wound infiltration. The addition of an NSAID makes no difference in the reduction of postoperative pain following laparoscopic cholecystectomy.     

Effects of L-5HTP with and without carbidopa on plasma ß-endorphin and pain perception

L-Tryptophan (L-TP) has been used in migraine and other pain conditions. The mechanism underlying the analgesic effect is still partly undefined. In this study the effects of subchronic administration of L-5-hydroxy-tryptophan (L-5HTP) (with and without carbidopa) on plasma beta-endorphin (beta-EP) levels and subjective pain threshold and tolerance were investigated in seven healthy volunteers. To measure also an objective indicator for pain, the nociceptive flexion reflex threshold was studied. L-5HTP treatment with and without carbidopa administration increased beta-EP levels significantly (p less than 0.05). L-5HTP plus carbidopa induced an increase in beta-EP significantly (p less than 0.05) higher than that after L-5HTP alone. Neither subjective pain threshold and tolerance nor RIII threshold was modified by either treatment. Our data seem to point to the existence of a complex linkage between plasma opioid levels and pain perception.     

Childhood neglect and abuse as predictors of antidepressant response in adult depression

Background: Childhood neglect and abuse are recognized as risk factors for depression, but are not often studied as predictors of treatment response in depression. Methods: Clinically depressed outpatients (n=195) were asked about childhood experiences before beginning a randomized antidepressant trial with either fluoxetine or nortriptyline. Three treatment outcomes were measured: Adequate trial, six‐week response and two months sustained recovery. Results: Patients reporting low paternal care (paternal neglect), as measured by the Parental Bonding Instrument (PBI), were less likely to complete an adequate six‐week trial of medication. Patients who reported high maternal protection (maternal overprotection) on the PBI had poorer treatment response in the short‐term at six weeks, and longer term, for two months of sustained recovery. However, abuse, whether sexual, physical, or psychological in nature, did not predict treatment response. Conclusions: The experience of having a neglectful father or an overprotective mother was more predictive of response to treatment for depression than abuse, suggesting that the quality of ongoing intra‐familial relationships has a greater impact on treatment outcomes for depression than experiences of discrete abuse in childhood. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Peptic ulcer and gastric carcinoma: diagnosis with biphasic radiography compared with fiberoptic endoscopy

The diagnostic value of biphasic radiographic examination of the stomach and duodenum was compared with that of fiberoptic endoscopy in a prospective, blinded study of 385 patients with dyspepsia. This investigation was directed at gastric malignancies and peptic ulcers. Methodologically there is no absolute standard for a study of this kind because histologic examination is useful for detection of cancer but inadequate for ulcers. As an alternative, kappa indexes and the sensitivity and specificity, as derived by Hui and Walter, were calculated and compared. For the detection of gastric carcinoma, radiographic and endoscopic findings had almost perfect agreement beyond chance. For gastric ulcers, radiography and endoscopy had substantial agreement, which became perfect if small ulcers (less than 5 mm) were excluded. For duodenal ulcers, radiography had a lower sensitivity than endoscopy; this disagreement disappeared if small ulcers were excluded. Both methods have equal merit; choice of the initial diagnostic procedure will therefore depend on cost, discomfort to the patient, and risk of complications.