The Attitudes of Pulmonologists Regarding Smoking Behavior of Their Patients with Advanced COPD: A Qualitative Research.

Background: Patients with diseases linked with smoking, such as COPD, report a health-related stigma on their smoking behavior, which is related to a poorer quality of life and psychological distress. According to patients with COPD, health-care professionals sometimes reinforce the sense of stigma. However, little is known about the physicians' attitudes on this topic towards the patient with COPD. Purpose: To explore attitudes of pulmonologists regarding the smoking behavior of their patients with COPD and if (and to what extent) a stigma is present in their attitudes towards their smoking patients. Patients and methods: Eighteen pulmonologists were interviewed using a semi-structured guide with prespecified topics. The interview transcripts were coded using Atlas.ti. Analysis of data from these interviews was performed using conventional content analysis. Results: We identified three themes: attitudes towards smoking in general, the interaction between patient and physician, and smoking cessation. All participants said patients are not fully responsible for their smoking behavior. Contrarily, smoking was also seen as a free choice by most physicians. Moreover, smoking cessation was mostly seen as the responsibility of the patient. Feelings of powerlessness, frustration and compassion were reported in the guidance of patients with COPD. Conclusion: The results of this study show an ambivalent attitude of pulmonologists regarding the smoking behavior of their patients with COPD. The outcomes of this study can form a base for further research and can be used as insights for interventions that aim to raise awareness of physicians' own attitudes and increase the quality of physician-patient communication.

Traumatic pseudoaneurysm following ankle trauma.

False aneurysms following inversion trauma of the ankle are very uncommon. We present a case of a 40-year-old male referred to our radiology department with persisting and painful swelling of the ankle following an inversion trauma. An MRI scan was performed that showed a false aneurysm originating from a distal anterior tibial artery side branch; the lateral malleolar artery. The false aneurysm was confirmed with ultrasound and successfully treated with ultrasoundguided thrombin injection. The patient made an uneventful recovery.

The value of pre-operative computed tomography scanning for the assessment of lymph node status in patients with colon cancer.

AIM: Our aim was to determine the value of a pre-operative computed tomography (CT) scan for the assessment of lymph node status in patients diagnosed with colon cancer by comparing radiological N-stage to histopathological N-stage. PATIENTS AND METHODS: We performed a retrospective cohort study at the Sint Lucas Andreas Hospital in Amsterdam, the Netherlands. Between 2008 and 2010, two radiologists independently reviewed all pre-operative CT scans of patients diagnosed with colon cancer. The scans were examined for signs of regional lymphatic spread (N+), defined as lymph nodes exceeding 1 cm, clusters of ≥ 3 lymph nodes or a combination of the two. The results were compared with the histopathological N-stage. Inter-observer agreement, positive predictive value (PVV), negative predictive value (NPV), sensitivity, specificity, and accuracy were calculated. RESULTS: We included 106 patients in our study. PVV, NPV, sensitivity, specificity, and accuracy of detecting regional lymph nodes metastases were 47%, 66%, 71%, 41% and 54%, respectively. Inter-observer agreement was 74.5% (к = 0.48). CONCLUSION: Although our study group was relatively large and newer techniques were used in comparison to previous studies, our results demonstrated that the value of a pre-operative CT scan for the assessment of regional lymph nodes remained poor and unreliable. Therefore we question if a radiologist should assess regional lymph nodes on a pre-operative CT scan in colon cancer. Before treatment decisions are made on the appearance of lymph nodes in colon cancer patients, its diagnostic accuracy needs strong improvement.

Bisferiens peaks in the radial artery pressure wave during patent ductus arteriosus in newborn infants: relationship with ascending aortic flow.

Previously, we found evidence that bisferiens peaks in the radial artery pressure wave in the newborn infant may suggest the presence of a left-to-right shunt through a patent ductus arteriosus (PDA). The purpose of the present study was to analyze the origin of this pulsus bisferiens. Starting from the assumption that the radial artery pressure wave form is similar to the aortic pressure wave form, as described previously, we attempted to explain the bisferiens peaks on the basis of echocardiographically obtained ascending aortic flow. We studied 11 preterm mechanically ventilated infants with a left-to-right shunt through a PDA and 7 without. Aortic volume flow was established echocardiographically, and radial artery blood pressure measurement was performed with a high fidelity cathetermanometer system. Ascending aortic peak flow during PDA was significantly higher in the case of PDA, compared with the case without PDA. An augmented peak flow with an abrupt decline after the high peak in PDA, resulting in a sharp pressure peak with a steep decline after the peak, was thought to explain the first sharp peak of pulsus bisferiens. An abrupt decline of flow after peak flow is thought to be due to the fast runoff of blood through the ductus. According to the pulsatile pressure dynamics theories, which state that pressure wave forms consist of forward and backward wave forms, the second peak of the pulsus bisferiens can be explained by the return of the reflected (backward) wave form when the forward wave form has already considerably decreased. We conclude that the bisferiens peaks found in PDA result from a combination of large stroke volume (augmented first peak) and large runoff (quick decline of the forward wave) before the return of the reflected wave.

Bisferiens peaks in the radial artery pressure wave in newborn infants: a sign of patent ductus arteriosus.

Previously, we found evidence that radial artery pressure wave forms in newborns represent central aortic wave forms, provided that pressure is measured with adequate accuracy. Therefore, we postulated that the neonatal radial artery wave form, like the adult aortic wave form, may contribute to cardiovascular diagnosis. We investigated whether radial artery wave forms in infants suffering from patent ductus arteriosus (PDA) are different from the wave forms as seen without the presence of PDA. We studied 34 newborn infants with a radial artery line and with the possible clinical diagnosis of PDA with left-to-right shunt. On the basis of echocardiographic examination to assess PDA, these infants were divided in two groups: infants with PDA (n = 24) and without PDA (n = 10). In 15 out of 24 infants with PDA, recordings were repeated after ductal closure. Blood pressure measurement was performed with a high fidelity cathetermanometer system using a tip-transducer (natural frequency 95 Hz, damping coefficient 0.15). Contour analysis was performed by describing morphology of the waves during PDA and without PDA. In 23 out of 24 infants with PDA, a pulsus bisferiens was present: two peaks separated by a deep cleft. The average pressure difference between the first pressure peak and the cleft [delta Ppeak1] was 0.35 +/- 0.19 kPa, and the average difference between the cleft and the second pressure peak [delta Ppeak2] was 0.44 +/- 0.23 kPa. the ratio of mean magnitude of delta Ppeak1 and delta Ppeak2 was 0.81 +/- 0.26. None of the 10 infants without PDA showed pulsus bisferiens.(ABSTRACT TRUNCATED AT 250 WORDS)

Fetal atrioventricular and outflow tract flow velocity waveforms during conducted and blocked supraventricular extrasystoles.

Maximum flow velocity waveforms at atrioventricular and outflow tract level were studied cross-sectionally in 19 human fetuses with conducted and/or blocked supraventricular extrasystoles ranging from 25 to 38 weeks of gestation. At outflow tract level, peak systolic velocity and acceleration time for extrasystolic and post-extrasystolic beats were compared with those for the immediately preceding normal beat. Regression lines were calculated for peak systolic velocities with filling time. At atrioventricular level, peak-E wave and peak-A wave velocities and E/A ratio for the extrasystolic and post-extrasystolic beats were compared with those for the normal beat. At all levels, time-averaged velocities were compared with reference charts standardized for gestational age.Peak systolic velocity and acceleration time during the post-extrasystolic beat were higher than during the normal beat; the Frank-Starling mechanism, post-extrasystolic potentiation as well as reduced ventricular afterload may all play a role in this. At all measuring levels, time-averaged velocity during the extrasystolic beat was strikingly lower than the reference velocities. It is postulated that the increased blood volume and contraction force during the post-extrasystolic beat cause the valve area to become larger, resulting in a relative decrease in velocities measured by Doppler ultrasound.

Reproducibility of fetal cardiac flow velocity waveforms at atrioventricular level.

Reproducibility of flow velocity waveform recording and analysis was studied at fetal atrioventricular level (mitral and tricuspid valve) in 25 normal pregnancies. The flow velocity parameters studied were peak-E wave velocity, peak-A wave velocity and time-averaged velocity. In each patient, two consecutive measurements were performed (time delay, 15 min) and of each measurement two hardcopies were analyzed. A high reproducibility was achieved for all parameters studied; the coefficients of variation between readings of hardcopies were < or = 2% and the coefficients of variation between tests within patients were < or = 4%.

Flow velocity wave forms in the human fetal ductus arteriosus during the normal second half of pregnancy.

Maximum flow velocity wave forms in the ductus arteriosus were studied longitudinally in 40 fetuses from 18 to 38 wk of gestation at 3- to 4-wk intervals. Median maternal age was 29 y (range 18-41 y), median parity was 1 (range 0-6). All flow velocity wave forms were obtained using a mechanical sector scanner with a continuous Doppler system (carrier frequency 3.5 MHz). The flow velocity parameters studied were peak-systolic, peak-diastolic, and time-averaged velocity and acceleration time. There was considerable variability in measurements between fetuses at any particular gestational age. An increase of ductal flow parameters with advancing gestational age was found. They showed no correlation with heart rate. These results suggest that the normal second half of pregnancy is characterized by a reduction in right ventricular afterload. This may be a result of decreased placental vascular resistance or increased pulmonary vascular flow. Acceleration time in ductal flow velocity wave forms was significantly higher than that observed in the pulmonary artery and ascending aorta, suggesting a lower afterload in the ductus arteriosus compared with the other two outflow tract vessels.

Fetal atrioventricular and outflow tract flow velocity waveforms during normal second half of pregnancy.

Maximum flow velocity waveforms at atrioventricular and outflow tract level were studied longitudinally in 40 fetuses from 18 to 38 weeks' gestation at 3- to 4-week intervals. Flow velocity parameters studied were peak systolic and time-averaged velocity and acceleration time at outflow tract level and time-averaged velocity, peak E-wave and peak A-wave velocities, and E/A ratio at atrioventricular level. An increase of all flow parameters with advancing gestational age was found. Aortic parameters were higher than pulmonary ones. Time-averaged, peak E-wave, and peak A-wave velocities were higher at tricuspid level than at mitral level, whereas E/A ratios were higher at mitral level. Outflow tract parameters showed no correlation with period time. A positive correlation for peak E-wave velocity and E/A ratio, and a negative correlation for time-averaged and peak A-wave velocity was found with period time. These results suggest that the normal second half of pregnancy is characterized by rising ventricular stroke volume and output and reduction in ventricular afterload. The left ventricular afterload seems to be lower than the right ventricular afterload. Atrioventricular flow velocities are heart rate dependent.

[Effect of fetal behavioral reactions and respiratory movements on the blood flow in the ductus arteriosus]. / Vliianie povedencheskikh reaktsii i dykhatel'nykh dvizhenii ploda na krovotok v arterial'nom protoke.

Relationship between blood flow velocity waveform and fetal behavioral states was studied in 16 normal pregnancies at 37 to 38 weeks' gestation. The peak flow velocity has demonstrated a statistically significant reduction during active sleep, as against that in quite sleep. These data reflect reduced ductal flow and suggest a redistribution in the left-ventricular and right-ventricular output in favor of the left side of the heart during active sleep. In a prospective cross-sectional study of 49 pregnancies (50 fetuses) between 25th and 38th weeks an exponential increase in breathing-related ductal blood flow velocity modulation was observed with advancing gestational age, reflecting the developing pulmonary vascular bed. Fetal ductal flow velocity waveforms were also recorded in 13 cases of prolonged severe oligohydramnios after membrane rupture before 28 weeks' gestation. Normal ductal blood flow velocity modulation values were associated with normal neonatal lung performance, whereas reduced blood flow velocity modulation values were associated with pulmonary hypoplasia. Fetal breathing-related ductal flow velocity modulation appears to be a promising predictor of neonatal lung performance.

Effect of fetal breathing movements on fetal cardiac hemodynamics.

Maximum flow velocity waveforms were studied at atrioventricular and outflow tract level in 12 cases during fetal breathing activity and in 12 cases during fetal apnea matched for maternal and gestational age and maternal parity. Gestational age ranged between 27 and 40 weeks (median 30 weeks). All flow velocity waveforms were obtained using a mechanical sector scanner with a pulsed Doppler system (carrier frequency 3.5 MHz). Time-averaged flow velocities were clearly different between inspiration and expiration at all four recording levels, reflecting changes in venous return as a result of fluctuations in intrathoracic pressure during fetal breathing activity. Percentage change between inspiration and expiration at outflow tract level was positively correlated with gestational age. Time-averaged flow velocity at mitral level and ascending aorta level was significantly higher during fetal breathing activity than during apnea, suggesting increased shunting of blood flow through the foramen ovale. Acceleration time at outflow tract level demonstrated very little change relative to inspiration and expiration.

Ductus arteriosus flow velocity modulation by fetal breathing movements as a measure of fetal lung development.

A test is needed that would accurately predict favorable neonatal lung performance in the presence of prolonged severe oligohydramnios caused by ruptured membranes so that optimal obstetric care can be provided. We propose such a test that is based on the degree of modulation of fetal ductal blood flow velocity by fetal breathing movements after maternal glucose loading. In a prospective cross-sectional study of 49 normal pregnancies (50 fetuses) between 25 and 38 weeks an exponential increase in breathing-related ductal blood flow velocity modulation was observed with advancing gestational age, reflecting the developing pulmonary vascular bed. Fetal ductal flow velocity waveforms were also recorded in 13 cases of prolonged severe oligohydramnios after ruptured membranes before 28 weeks' gestation. Normal ductal blood flow velocity modulation values were associated with normal neonatal lung performance, whereas reduced ductal blood flow velocity modulation values were associated with pulmonary hypoplasia. Fetal breathing-related ductal flow velocity modulation appears to be a promising predictor of neonatal lung performance.

Human fetal ductal flow velocity waveforms relative to behavioral states in normal term pregnancy.

In 16 normal pregnancies the relationship between the blood flow velocity waveform and fetal behavioral states at 37 to 38 weeks' gestation was studied. Whereas behavioral state independency was established for the acceleration time, peak flow velocity demonstrated a statistically significant reduction during active sleep, compared with quiet sleep. These data reflect reduced ductal flow and suggest a redistribution in the left-ventricular and right-ventricular output in favor of the left side of the heart during active sleep. Peak flow velocities in the fetal ductus arteriosus were independent of fetal heart rate.