A brief bedside visual art intervention decreases anxiety and improves pain and mood in patients with haematologic malignancies.

Treatment of cancer-related symptoms represents a major challenge for physicians. The purpose of this pilot study was to determine whether a brief bedside visual art intervention (BVAI) facilitated by art educators improves mood, reduces pain and anxiety in patients with haematological malignancies. Thirty-one patients (21 women and 10 men) were invited to participate in a BVAI where the goal of the session was to teach art technique for ~30 min. Primary outcome measures included the change in visual analog scale, the State-Trait Anxiety Inventory and the Positive and Negative Affect Schedule scale, from baseline prior to and immediately post-BVAI. Total of 21 patients (19 women and two men) participated. A significant improvement in positive mood and pain scores (p = .003 and p = .017 respectively) as well as a decrease in negative mood and anxiety (p = .016 and p = .001 respectively) was observed. Patients perceived BVAI as overall positive (95%) and wished to participate in future art-based interventions (85%). This accessible experience, provided by artists within the community, may be considered as an adjunct to conventional treatments in patients with cancer-related mood symptoms and pain, and future studies with balanced gender participation may support the generalisability of these findings.

Bronchodilator response in the lung health study over 11 yrs.

Long-term changes in bronchodilator response in people with mild chronic obstructive pulmonary disease were assessed in this study. Changes in forced expiratory volume in one second (FEV1) in response to isoproterenol was measured in 4,194 participants in the Lung Health Study annually for 5 yrs, and again 11 yrs after study entry. Responses were quantitated in terms of mL (absolute), as per cent of the pre-bronchodilator value (relative), and as a per cent of the predicted normal value (% predicted). At baseline, the mean pre-bronchodilator FEV1 was 75.4% predicted, and responses were small. Relative and percentage predicted responses were similar in males and females; and correlated positively with methacholine reactivity, and negatively with smoking intensity and age. Baseline bronchodilator responses did not correlate with subsequent decline in FEV1. There was a substantial increase in response over the first year of the study, largely due to smoking cessation, with larger increases in those who stopped smoking. After the first year absolute responses changed little in those who maintained smoking cessation, but increased in those who did not. Mean relative and percentage predicted responses increased in all participants throughout the study. There was substantial annual variability of absolute response, and it was poorly reproducible in individual participants. In conclusion, smoking cessation increased bronchodilator response, and response did not predict the rate of decline of forced expiratory volume in one second.

The correlation of emphysema or airway obstruction with the risk of lung cancer: a matched case-controlled study.

A matched case-controlled study was conducted to determine if airway obstruction or emphysema were associated with an increased risk of lung cancer. Lung cancer cases (n=24) were identified through a low-dose spiral computed tomography (CT) screening trial from 1,520 participants. Four controls without lung cancer were selected for each case from the participants and matched by sex, age and smoking history. Emphysema was assessed by quantitative CT analysis. Conditional logistic regression was employed to assess results of spirometry and CT quantitative analysis as potential risk factors for lung cancer. The likelihood of lung cancer was found to be significantly increased for those with forced expiratory volume in one second (FEV1) < or = 40% of predicted. The results suggested that a lower percentage of predicted FEV1 was indicative of lung cancer. No compelling evidence was found to suggest that the percentage of emphysema was associated with lung cancer. These results suggest an increased risk of lung cancer associated with airway obstruction. However, percentage of emphysema as determined by computed tomography was not associated with an increased risk of lung cancer.

Obstructive lung diseases: COPD, asthma, and many imitators.

Chronic obstructive pulmonary disease (COPD) is a common respiratory disorder that occurs in 10% to 15% of people who smoke, an estimated 16 million Americans. Asthma is also common. Spirometry is generally used to detect early COPD in smokers and to evaluate patients with respiratory symptoms. Although COPD and asthma account for most obstructive lung diseases, a broad spectrum of other disorders, including bronchiectasis, upper airway lesions, bronchiolar diseases, and some interstitial lung diseases, are associated with airflow obstruction. These less common forms of obstructive lung diseases are often misdiagnosed because of their uncommon occurrence and poor recognition. We describe the heterogeneous spectrum of disorders that can present with evidence of airflow obstruction and outline a diagnostic approach to obstructive lung disease.

Pulmonary atresia with ventricular septal defect and persistent airway hyperresponsiveness.

OBJECTIVE: We and others have observed significant hyperinflation and airflow obstruction after the surgical repair of pulmonary atresia and ventricular septal defect. This study sought to objectively characterize this problem and determine the prevalence of airway hyperresponsiveness in these patients. METHODS: We performed a prospective study of children and young adults with pulmonary atresia and ventricular septal defect between June 1996 and December 1998. The participants were stratified into 2 distinct molecular genotypes on the basis of chromosome 22q11.2 microdeletion. A clinical diagnosis of asthma and an objective assessment of airway hyperresponsiveness were determined by means of an asthma inventory scale and methacholine challenge testing, respectively. Thirty-three patients were enrolled. Thirteen had velocardiofacial syndrome, each with chromosome 22q11.2 microdeletion. RESULTS: None of the nonsyndromic patients had evidence for haploinsufficiency. Overall, 66.7% (22/33) met criteria for a clinical diagnosis of airway hyperresponsiveness: 62% (8/13) from the microdeletion genotype and 70% (14/20) from the nonsyndromic group. CONCLUSIONS: We have identified an extremely strong association between pulmonary atresia and ventricular septal defect and persistent airway hyperresponsiveness. Haploinsufficiency at chromosome 22q11.2 did not contribute to this predilection for airway hyperresponsiveness. These results provide a basis to anticipate persistent respiratory difficulties after operations in patients with pulmonary atresia and ventricular septal defect. Moreover, this at-risk patient population may yield unique insights into fundamental mechanisms involved in the pathogenesis of airway hyperresponsiveness.

The effect of respiration on left ventricular diastolic filling as assessed by radionuclide ventriculography.

Left ventricular function is modified by respiration and pericardial constraint. The aim of this study was to compare left ventricular systolic and diastolic function during inspiration and expiration in four patient groups: patients (1) without cardiac disease, (2) with severe pulmonary disease, (3) with cardiac amyloid and (4) with pericardial constriction (before and after pericardiectomy). Using blood-pool left ventriculography with modified gating, we obtained time-activity curves at the onset of inspiration and expiration. On inspiration and expiration, patients with pericardial constriction and patients with cardiac amyloid were significantly different from those without cardiac disease and those with severe pulmonary disease, in that left ventricular ejection fraction (LVEF) was less, peak filling rate was greater, time to peak filling rate was shorter, and rapid filling fraction was increased. When inspiration and expiration were compared, time to left ventricular peak filling rate was shorter (P = 0.05) on inspiration (118 +/- 48 ms) than on expiration (168 +/- 35 ms) in patients with pericardial constriction. No other measures differed between inspiration and expiration in pericardial constriction, and left ventricular function was unaffected by respiration in the other groups. Time to left ventricular peak filling rate was 49 +/- 69 ms less on inspiration than on expiration in pericardial constriction and this difference was significantly different (P = 0.04) from that in patients with cardiac amyloid (34 +/- 58 ms greater), patients without cardiac disease (2 +/- 69 ms greater) and patients with severe pulmonary disease (19 +/- 63 ms less). In pericardial constriction, pericardial resection caused an increase in LVEF without a change in left ventricular diastolic filling but abolished the differences present between inspiration and expiration in time to left ventricular peak filling rate. This respiratory response in time to left ventricular peak filling rate may be valuable in the diagnosis of pericardial constriction.

Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease. The Lung Health Study.

Previous studies of lung function in relation to smoking cessation have not adequately quantified the long-term benefit of smoking cessation, nor established the predictive value of characteristics such as airway hyperresponsiveness. In a prospective randomized clinical trial at 10 North American medical centers, we studied 3, 926 smokers with mild-to-moderate airway obstruction (3,818 with analyzable results; mean age at entry, 48.5 yr; 36% women) randomized to one of two smoking cessation groups or to a nonintervention group. We measured lung function annually for 5 yr. Participants who stopped smoking experienced an improvement in FEV(1) in the year after quitting (an average of 47 ml or 2%). The subsequent rate of decline in FEV(1) among sustained quitters was half the rate among continuing smokers, 31 +/- 48 versus 62 +/- 55 ml (mean +/- SD), comparable to that of never-smokers. Predictors of change in lung function included responsiveness to beta-agonist, baseline FEV(1), methacholine reactivity, age, sex, race, and baseline smoking rate. Respiratory symptoms were not predictive of changes in lung function. Smokers with airflow obstruction benefit from quitting despite previous heavy smoking, advanced age, poor baseline lung function, or airway hyperresponsiveness.

Pulmonary function monitoring during adenosine myocardial perfusion scintigraphy in patients with chronic obstructive pulmonary disease.

OBJECTIVE: To determine whether adenosine could be safely administered to patients with chronic obstructive pulmonary disease (COPD) for coronary vasodilatation during perfusion scintigraphy without causing bronchospasm. MATERIAL AND METHODS: The study was divided into two phases. In the monitoring phase, patients with COPD were pretreated with an inhaled bronchodilator (albuterol) and had pulmonary function monitored during the infusion of a graduated dose of adenosine. Eligibility for entry into this phase of the study was determined on the basis of results of pulmonary function testing (PFT) during resting. Once we had shown that adenosine could be safely administered to patients with COPD, an implementation phase was begun. Entry did not require resting PFT, and patients were administered adenosine without monitoring of pulmonary function. Differences between patients with normal pulmonary function or mild COPD and those with more severe COPD were analyzed statistically. RESULTS: Of 94 patients entered into the monitoring phase, none had obvious bronchospasm. The dosage of adenosine was reduced in four patients because of a decrease in forced expiratory volume in 1 second (FEV1) of 20% in comparison with baseline (FEV1 before administration of albuterol). The mean FEV1 decreased slightly from 1.83 L after administration of albuterol to 1.78 L during the maximal adenosine dose. Patients with a remote history of asthma, positive result of a methacholine challenge test, or mild COPD (FEV1 60 to 80% of the maximal predicted value for age) did not differ significantly in their response to infusion of adenosine from those with moderate or severe COPD (FEV1 30 to 59% of the maximum predicted for age). Of 117 patients in the implementation phase, 2 had bronchospasm during infusion of adenosine that was quickly terminated by stopping the administration in one patient and reducing the dose of adenosine in the other. CONCLUSION: This study shows that adenosine can be safely administered intravenously to selected patients with known or suspected COPD to produce coronary vasodilatation for myocardial perfusion imaging. Patients who are within the guidelines established for this study should be considered for adenosine coronary vasodilatation with use of bronchodilator pretreatment, a graduated dose of adenosine, and regular chest auscultation during the infusion.

Evaluation of pulmonary resistance and maximal expiratory flow measurements during exercise in humans.

To evaluate methods used to document changes in airway function during and after exercise, we studied nine subjects with exercise-induced asthma and five subjects without asthma. Airway function was assessed from measurements of pulmonary resistance (RL) and forced expiratory vital capacity maneuvers. In the asthmatic subjects, forced expiratory volume in 1 s (FEV1) fell 24 +/- 14% and RL increased 176 +/- 153% after exercise, whereas normal subjects experienced no change in airway function (RL -3 +/- 8% and FEV1 -4 +/- 5%). During exercise, there was a tendency for FEV1 to increase in the asthmatic subjects but not in the normal subjects. RL, however, showed a slight increase during exercise in both groups. Changes in lung volumes encountered during exercise were small and had no consistent effect on RL. The small increases in RL during exercise could be explained by the nonlinearity of the pressure-flow relationship and the increased tidal breathing flows associated with exercise. In the asthmatic subjects, a deep inspiration (DI) caused a small, significant, transient decrease in RL 15 min after exercise. There was no change in RL in response to DI during exercise in either asthmatic or nonasthmatic subjects. When percent changes in RL and FEV1 during and after exercise were compared, there was close agreement between the two measurements of change in airway function. In the groups of normal and mildly asthmatic subjects, we conclude that changes in lung volume and DIs had no influence on RL during exercise. Increases in tidal breathing flows had only minor influence on measurements of RL during exercise. Furthermore, changes in RL and in FEV1 produce equivalent indexes of the variations in airway function during and after exercise.

Airway obstruction and perioperative complications in smokers undergoing abdominal surgery.

BACKGROUND: The goal of this study was to determine whether airway obstruction determined by preoperative spirometry predicts perioperative complications in smokers undergoing abdominal surgery whose treatment is managed according to current clinical practice. METHODS: A pulmonary function database identified patients undergoing abdominal surgery who met the following criteria for airway obstruction (n = 135): a forced expiratory volume less than 40% of predicted normal value, a forced expiratory volume:forced vital capacity ratio less than the lower limit of predicted normal, a smoking history of more than 20 pack-years, and an age older than 35 yr. A group of patients without airway obstruction (n = 135) was matched for gender, surgical site (upper vs. lower abdominal), smoking history, and age. Medical records were reviewed by an abstractor to identify perioperative complications that occurred within 30 days after surgery. RESULTS: The forced expiratory volume values were 0.9+/-0.21 (mean +/- SD) and 2.9+/-0.61 in patients with and without airway obstruction, respectively. When analyzed by conditional logistic regression using the 1:1 matched-pairs feature, including age, pack-year smoking history, site of incision, and current smoking status as covariates, in patients with airway obstruction bronchospasm was more likely to develop (odds ratio, 6.9 [95% confidence interval, 1.2 to 38.4]) but the patients were not more likely to need prolonged endotracheal intubation (odds ratio, 1.1 [95% confidence interval, 0.4 to 3.2]). They were also no more likely to need prolonged intensive care admission or readmission. The frequency of other complications was less than 5%. CONCLUSION: When other factors were considered, preoperative airway obstruction predicted the occurrence of bronchospasm, but not prolonged endotracheal intubation, in smokers undergoing abdominal surgery who are treated according to current clinical practices.

Lung volumes in 4,774 patients with obstructive lung disease.

STUDY OBJECTIVES: To determine the correlates of static lung volumes in patients with airways obstruction, and to determine if static lung volumes differ between asthma and COPD. PATIENTS AND METHODS: We examined the data from all of the adult patients (mean age of 69) who were referred to a pulmonary function laboratory from January 1990 through July 1994 with an FEV1/FVC ratio of < 0.70 and tested using a body plethysmograph. Correlates were determined using regression analysis. MEASUREMENTS AND RESULTS: Of the 4,774 patients observed with evidence of airways obstruction, 61% were men. Self-reported diagnoses included asthma, 19%; emphysema or COPD, 23%; chronic bronchitis, 1.5%; and alpha1-antiprotease deficiency, 0.6%. Fifty-six percent of the patients did not report a respiratory disease. The degree of hyperinflation, as determined by the residual volume (RV)/total lung capacity (TLC) ratio, or the RV % predicted (but not the TLC % predicted), was strongly associated with the degree of airways obstruction (the FEV1 % predicted). Patients with moderate to severe airways obstruction and high RV and TLC levels were more likely to have COPD than asthma. Of the 1,872 patients with a reduced vital capacity determined by spirometry testing, 87% had hyperinflation as defined by the RV/TLC, and 9.5% had a low TLC (with less severe airways obstruction). CONCLUSION: In patients found to have airways obstruction by spirometry, the additional measurement of static lung volumes added little to the clinical interpretation.

Colchicine versus prednisone as treatment of usual interstitial pneumonia.

OBJECTIVE: To assess the results with colchicine and prednisone as initial single-drug therapy in patients with usual interstitial pneumonia (UIP). MATERIAL AND METHODS: We reviewed the serial pulmonary function test results in 22 patients with typical clinical and high-resolution computed tomographic features of UIP who were treated with colchicine as initial single-agent therapy and compared them with a group of 22 historical patients with UIP of similar severity diagnosed by open-lung biopsy who were given prednisone as initial single-drug therapy. RESULTS: No significant difference was detected in the rate of decline of pulmonary function or in the time to "failure" between the two study groups. A trend was suggested for more rapid decline of pulmonary function in the prednisone-treated than in the colchicine-treated group. The design of this study does not allow distinction between a possible beneficial effect of colchicine and a possible adverse effect related to weaning from high-dose prednisone. Colchicine was well tolerated; few side effects other than mild diarrhea were noted in those patients able to take the drug long enough to return for pulmonary function testing at 3 months. In comparison, the side effects of prednisone were more serious and were not always reversible with cessation of therapy. CONCLUSION: This study lends further support to the assumption that colchicine may be a satisfactory and less hazardous substitute for prednisone in the treatment of patients with UIP.

Lung resection in patients with compromised pulmonary function.

BACKGROUND: Some patients are denied curative pulmonary resection for lung carcinoma because of pulmonary insufficiency. To identify factors that affect postoperative morbidity and mortality, we reviewed 85 consecutive patients (53 men and 32 women) with a preoperative forced expiratory volume in 1 second of less than 1.2 L who underwent pulmonary resection for lung cancer between January 1986 and December 1990. METHODS: Median age was 70 years (range, 49 to 82 years). Sixty patients (71%) had been previously denied operation because of pulmonary insufficiency. Preoperative pulmonary function demonstrated a median preoperative forced expiratory volume in 1 second of 1.0 L (44% of predicted normal; range, 0.5 to 1.2 L) and a diffusing capacity of the lung for carbon monoxide of 60% of predicted normal (range, 22% to 104%). RESULTS: Pneumonectomy was done in 6 patients (7.1%), bilobectomy in 6 (7.1%), lobectomy in 38 (44.7%), segmentectomy in 12 (14.1%), and wedge excision in 29 (27.1%). The median predicted postoperative forced expiratory volume in 1 second was 0.83 L (34% of predicted normal; range, 0.45 to 1.14 L), and the median predicted postoperative diffusing capacity of the lung for carbon monoxide was 48% of predicted normal (range, 19% to 87%). Seventy-two patients (85%) received postoperative epidural analgesia. Median hospitalization was 15 days (range, 5 to 66 days). Operative mortality was 2.4%, and complications occurred in 49%. We did not identify any factors that predicted postoperative morbidity and mortality. Median follow-up was 3.2 years (range, 0.2 to 9 years). Seven patients (8%) required supplemental home oxygen. A predicted postoperative percent forced expiratory volume in 1 second less than 43% correlated with the need for home oxygen (p < 0.05). Overall 5-year survival was 44.0%. Survival for stage I cancer was 54.2%; stage II, 33.1%; and stage IIIa, 21.3%. CONCLUSIONS: We conclude that some patients with lung cancer and compromised pulmonary function can safely undergo pulmonary resection if selected appropriately.

Regulation of ventilatory capacity during exercise in asthmatics.

In asthmatic and control subjects, we examined the changes in ventilatory capacity (VECap), end-expiratory lung volume (EELV), and degree of flow limitation during three types of exercise: 1) incremental, 2) constant load (50% of maximal exercise capacity; 36 min), and 3) interval (alternating between 60 and 40% of maximal exercise capacity; 6-min workloads for 36 min). The VECap and degree of flow limitation at rest and during the various stages of exercise were estimated by aligning the tidal breathing flow-volume (F-V) loops within the maximal expiratory F-V (MEFV) envelope using the measured EELV. In contrast to more usual estimates of VECap (i.e., maximal voluntary ventilation and forced expiratory volume in 1 s x 40), the calculated VECap depended on the existing bronchomotor tone, the lung volume at which the subjects breathed (i.e., EELV), and the tidal volume. During interval and constant-load exercise, asthmatic subjects experienced reduced ventilatory reserve, higher degrees of flow limitation, and had higher EELVs compared with nonasthmatic subjects. During interval exercise, the VECap of the asthmatic subjects increased and decreased with variations in minute ventilation, due in part to alterations in their MEFV curve as exercise intensity varied between 60 and 49% of maximal capacity. In conclusion, asthmatic subjects have a more variable VECap and reduced ventilatory reserve during exercise compared with nonasthmatic subjects. The variations in VECap are due in part to a more labile MEFV curve secondary to changes in bronchomotor tone. Asthmatics defend VECap and minimize flow limitation by increasing EELV.

Fatty acid kinetic responses to running above or below lactate threshold.

During running exercise above the lactate threshold (LT), it is unknown whether free fatty acid (FFA) mobilization can meet the energy demands for fatty acid oxidation. This study was performed to determine whether FFA availability is reduced during running exercise above compared with below the LT and to assess whether the level of endurance training influences FFA mobilization. Twelve marathon runners and 12 moderately trained runners ran at a workload that was either above or below their individual LT. Fatty acid oxidation (indirect calorimetry) and FFA release ([1-14C]palmitate) were measured at baseline, throughout exercise, and at recovery. The plasma FFA rate of appearance increased during exercise in both groups; running above or below the LT, but the total FFA availability for 30 min of exercise was greater (P < 0.01) in the below LT group (marathon, 23 +/- 2 mmol; moderate, 21 +/- 2 mmol) than in the above LT group (18 +/- 3 and 13 +/- 3 mmol, respectively). Total fatty acid oxidation (indirect calorimetry) greatly exceeded circulating FFA availability, regardless of training or exercise group (P < 0.01). No statistically significant exercise intensity or training differences in fatty acid oxidation were found (above LT: marathon, 71 +/- 12, moderate, 64 +/- 17 mmol/30 min; below LT: marathon 91 +/- 12, moderate, 60 +/- 5 mmol/30 min). In conclusion, during exercise above or below LT, circulating FFA cannot meet the oxidative needs and intramuscular triglyceride stores must be utilized. Further marathon training does not enhance effective adipose tissue lipolysis during exercise compared with moderate endurance training.

Role of chest physicians in detection and treatment of occupational and environmental respiratory disease. A practice survey.

A survey of American College of Chest Physicians (ACCP) members was conducted to determine their degree of involvement in the diagnosis and prevention of occupational and environmental respiratory disease (OERD). Although the response rate was relatively low, the results are likely to be representative. Calculations based on the data estimate that in the prior year, chest physicians on the average saw 15 patients with OERD caused by work, 13 worsened by work, and 28 affected by the home environment. Asthma appears to be a more common occupational or environmental concern than pulmonary fibrosis. Chest physicians clearly perceived a need for more education in OERD. The survey also demonstrated that although many chest physicians perform routine industrial surveillance testing, it is often done without using standardized methods. Furthermore, chest physicians are actively involved with medical/legal aspects of OERD. Overall, the survey documents the role of chest physicians in the area of OERD and emphasizes significant educational needs.

Cessation of long-term nicotine gum use--a prospective, randomized trial.

Nicotine gum is an important adjunct for smoking cessation for many smokers, and long-term use of nicotine gum will occur in a small percentage of patients. To date, no method of cessation in long-term users has been studied in a randomized trial. We enrolled 26 subjects at the Mayo Clinic site of the Lung Health Study who had used nicotine gum for more than 6 months to participate in a trial where subjects were randomly assigned to: (1) abrupt cessation, (2) taper with placebo gum, or (3) taper with active gum. At the end of the 6-week trial, the percentage of subjects abstinent from gum use and not smoking was not different among the three groups: 66.7% for the abrupt cessation group, 71.4% for the taper with placebo gum group and 60% for the taper with active gum group. One subject in the taper with placebo gum group relapsed to smoking during the trial but was abstinent from smoking again at long-term follow-up. Long-term follow-up (median 284 days) showed 65% of subjects were abstinent from all nicotine products. Motivated subjects can stop long-term nicotine gum use without relapse to gum use or smoking by either abrupt cessation or brief tapering.