End-of-life care for persons with advanced chronic obstructive pulmonary disease: report of a national interdisciplinary consensus meeting.

While systemic shortcomings in meeting the needs of individuals with progressive chronic illnesses at the end of life have been well documented, there is growing interest in improving both care and quality of life for persons with advanced chronic obstructive pulmonary disease (COPD). For instance, the American Thoracic Society has issued an official statement on palliative care for patients with respiratory diseases, affirming that the prevention, relief, reduction and soothing of symptoms "without affecting a cure" must become an integral component of standard care. A recent Medline search located 1015 articles related to palliative or end-of life care for people with COPD published between 2001 and 2008, compared with only 336 articles published before 2001. To address the needs of Canadian patients, an interdisciplinary consensus meeting, funded by the Canadian Institutes of Health Research and supported by the Canadian Thoracic Society, the Canadian Respiratory Health Professionals and the Canadian Lung Association was convened in Toronto, Ontario, on November 22, 2008, to begin examining the quality of end-of-life care for individuals with COPD in Canada. The present report summarizes the background to and outcomes of this consensus meeting.

A measurement process for evaluating clinical teachers in internal medicine.

With input from faculty members and residents in the internal medicine residency training program at McMaster University, Hamilton, Ont., the authors developed a form to evaluate attending physicians in clinical teaching units according to 14 domains of performance. Although brief, the form included all main areas of teacher performance, allowed specification of attending physician behaviour and differentiated areas of strengths and weaknesses between and within attending physicians. The authors describe the new evaluation process and the results for 41 attending physicians.

A three-year cohort study of the role of environmental factors in the respiratory health of children in Hamilton, Ontario. Epidemiologic survey design, methods, and description of cohort.

The relative importance of the effect of outdoor environmental factors (suspended particulates, sulphur dioxide) and indoor environmental factors (parental smoking, gas cooking), on the respiratory health of children is still unclear. To answer these questions, a 3-yr cohort analytic study has been conducted in Hamilton, Ontario between 1978 and 1981. The prevalence of respiratory symptoms and indoor environmental factors was determined by an interviewer-administered questionnaire. Pulmonary function measures included both the forced expiratory maneuver and the single- and multiple-breath nitrogen washouts. Outdoor air quality was measured by a comprehensive network of suspended particulate and sulphur dioxide monitors. There were 3,345 children 7 to 10 yr of age studied in the first year, a response rate of 95.4%, 3,727 in the second year, and 3,168 in the third year; 75.6% of the initial cohort were studied in both Year 2 and Year 3. Comprehensive quality control in the study included measurement of the repeatability of both the questionnaire and pulmonary function data. Repeatability was acceptable except for variables derived from the single-breath nitrogen washout (correlation between initial and repeat closing volume vital capacity was 0.14). Cigarette smoking in Year 3 was reported in 4.8% of the children. The distribution of other covariables was not uniform, and the prevalence of parental smoking and gas cooking was greatest in the industrial area with the highest particulate pollution. Future analysis of these data will require the effect of these covariables to be distinguished from that caused by outdoor air pollution.

Respiratory function of children in homes insulated with urea formaldehyde foam insulation.

A study was carried out to assess the respiratory function of children living in homes insulated with urea formaldehyde foam insulation (UFFI). A large data base on the effect of environmental variables on the respiratory function of 3500 children in the Hamilton, Ont., area had been collected from 1978 to 1980. From this data base 29 children who lived in UFFI-insulated homes were identified, and each was matched with 2 controls according to nine variables that had been shown to be strongly predictive of respiratory function. Reported respiratory symptoms and results of pulmonary function testing in the year immediately following installation of UFFI were examined. No significant differences in any variable were found between the subjects and controls. A power calculation indicated that the study had adequate power to detect clinically important changes. The authors conclude that there was no evidence of respiratory problems resulting from UFFI in the sample studied.

Exposure estimates in assessing helath effects of air pollution.

Air pollution has been associated with adverse health effects. Difficulties in interpreting studies of health effects of exposure to air pollution arise in estimating exposure. Until recently, studies of effects of air pollution have relied on pollution exposure measurements obtained from fixed location air pollution stations monitoring outside air (to evaluate compliance with air quality standards, rather than to examine population exposure). However, recent evidence suggests that there are substantial differences between air pollution levels measured at such sites and levels to which people are actually exposed, i.e. 'personal exposure'. The present study examines effects of ambient urban air pollution on persons suffering from asthma, healthy non-asthmatic subjects and school children (in 2 Canadian cities, Toronto and Hamilton). Air pollution exposure is being assessed by data obtained from: (1) conventional 'abatement' oriented fixed location air pollution monitoring stations, (2) an extensive 'population' oriented network, (3) inside and (4) outside structures (homes and schools) as well as (5) 'personal' air pollution samplers. The data indicate variability in these different estimates of exposure which have implications on health effects assessment.

Erythrityl tetranitrate: sustained effects on systolic time intervals. changes consistent with sustained preload reduction.

The effects of sustained preload reduction have been demonstrated for several nitrates but not for erythrityl titranitrate. In seven patients with coronary heart disease, a randomized double-blind crossover clinical trial showed that chewable erthrityl tetranitrate, 10 mg, produced significant changes in systolic time intervals consistent with preload reduction and lasting for at least four hours. As compared with placebo, ejection time index (ETI) fell and remained significantly low between 6 and 90 minutes after administration, and pre-ejection period (PEP), isovolumic contraction time IVCT), and pre-ejection period/left ventricular ejection time (PEP/LVET) rose and remained significantly increased between 22 minutes and the four-hour endpoint. We conclude that erythrityl tetranitrate is a physiologically effective long-acting agents in patients with coronary heart disease.

Subsittution of inhaled beclomethasone dipropionate for ingested prednisone in steroid-dependent asthmatics.

The effect of inhaled beclomethasone dipropionate (dose, 400 mug daily) was investigated in 31 prednisone-dependent asthmatics. In a double-blind noncrossover study of 25 patients dependent on a daily prednisone dose of 17.5 mg or less, the dose of ingested prednisone was significantly diminished through the use of beclomethasone as compared with placebo (P < 0.001). In a subsequent single-blind study of the 12 patients who had received placebo, a similar decrease in prednisone dose was possible when these patients received beclomethasone. In all 25 patients the effect of beclomethasone was maintained for 2 years; 9 came to require less beclomethasone and 1 required more. In an additional single-blind study of six patients with severe asthma, dependent on prednisone in a dose of 20 to 25 mg/d, the response to beclomethasone was more variable and less significant (P < 0.01). However, at 2 years there was no significant benefit (P > 0.05) and there were two treatment failures.In patients in whom reduction of dose or discontinuation of prednisone was possible plasma cortisol values before and after corticotropin administration increased significantly (P < 0.001). Prednisone reduction was associated with the appearance of mild musculoskeletal steroid-withdrawal symptoms of short duration in 15 patients, and recurrence of symptoms of rhinitis in 15 patients. Side effects of beclomethasone included episodes of hoarseness in 6 and easily treated oropharyngeal Candida albicans infection in 14.

Clavicular Auscultation. Preferential clavicular transmission and amplification of aortic valve murmurs.

Clavicular transmission of aortic valve murmurs was investigated in 15 consecutive patients. In all patients, transmission to the clavicle of aortic systolic murmurs was detected both by auscultation and by phonocardiographic studies. Of seven patients with aortic diastolic murmurs, auscultation revealed clavicular transmission in six, but only four were recordable. There was increased murmur amplitude over the clavicle in 13 out of 15 cases. In contrast, murmurs were attenuated over the subclavian artery in eight out of nine and over the carotid artery in nine out of 11 patients. We conclude that clavicular auscultation regularly discloses aortic valve murmurs. The aortic systolic murmurs are consistently propagated to the clavicle, where they are usually conspicuously amplified. Aortic systolic murmurs are less frequently transmitted to the carotid and subclavian arteries, where they are usually considerably attenuated. Clavicular auscultation appears to be more rewarding than the traditional search for transmission of aortic murmurs to the carotid artery.

Symposium on allergic lung disease. II. The late asthmatic responses.

Immediate asthmatic responses have been regarded as the characteristic type of asthmatic response to follow exposure to inhaled allergens in patients with extrinsic asthma. They begin within minutes, clear within one to three hours and are inhibited by disodium cromoglycate but not by corticosteroids. They involve the reaction of antigen with antibodies usually of the IgE class. In recent years allergen inhalation tests have demonstrated the frequent occurrence of late asthmatic responses, either following immediate responses (dual responses) or occurring in isolation. The late asthmatic responses begin two to six hours after the allergen challenge, are prolonged and often severe, and are inhibited by both disodium cromoglycate and corticosteroids. The mechanisms involved in their provocation are not clearly understood but from the allergic viewpoint they may involve the participation of IgG +/- IgM antibodies and/or IgE antibodies. Late asthmatic responses explain the frequent occurrence of allergen-induced prolonged asthma. Their features suggest that they are more important than immediate responses in the pathophysiology of asthma.