Process evaluation of the Centrally Procured School Food Program (CPSFP) in Ontario, Canada: school-level perspectives.

This study explored the implementation of the Centrally Procured School Food Program (CPSFP)-a free, universal, volunteer-led snack program for elementary school children. To assess participants' perceptions and experiences with the CPSFP, interviews were conducted in school-level participants (n = 33) using a semi-structured interview guide. Fifteen on-site visits also were conducted at each school to observe implementation practices. Quantitative data were obtained through a general information form where participants provided school characteristics and weekly logbooks where they described program operations and food quality. Most participants expressed positive perceptions of the CPSFP, identifying it as a valuable program for their students. Successful program implementation was associated with an appreciation for the CPSFP and the participation of the school community. Challenges to program implementation included concerns with the volume and types of food provided, issues with classroom food delivery and distribution and communication challenges. Suggestions for improvement included building capacities and enhancing student engagement in the program. Participants provided an in-depth assessment of the implementation of the CPSFP. The lessons learned and suggestions provided may help not only enhance the reach, feasibility and fidelity of the CPSFP, but inform the best practices for similar programs.

Exercise dysfunction in patients seropositive for the human immunodeficiency virus.

To confirm the presence of exercise dysfunction in patients seropositive for the human immunodeficiency virus (HIV), 32 such patients without AIDS were evaluated with cardiopulmonary exercise testing, pulmonary function testing, bronchoalveolar lavage, chest roentgenography, and gallium scanning. No evidence of pulmonary opportunistic infection was found. When compared to an otherwise similar group of HIV-seronegative controls, the patients exercised to a significantly lower workload (195 +/- 30 versus 227 +/- 31 W, p less than 0.001). The ventilatory anaerobic threshold (VAT) values were also significantly lower for the patients (49.2 +/- 13.0 versus 61.9 +/- 9.1% of maximum predicted VO2, p less than 0.001). Nine of the patients had VAT values less than the 95% confidence interval for the controls. This subgroup exercised to a significantly lower maximum VO2 (69.9 +/- 11.2 versus 95.9 +/- 17.5% of maximum predicted VO2, p less than 0.001) and workload (165 +/- 21 versus 227 +/- 31 W) when compared to the control group. These patients demonstrated a mild tachypnea throughout exercise relative to the controls and had a significant increase in the slope of the heart rate to VO2 relationship. These findings are most consistent with a limitation of oxygen delivery to exercising muscles, which may represent occult cardiac disease in this group.

Exercise responses during incremental and high intensity and low intensity steady state exercise in patients with obstructive lung disease and normal control subjects.

A study was undertaken to compare the cardiac and ventilatory responses to different types of exercise between 12 patients with COPD and ten normal age-matched control subjects. Both groups attained comparable heart rates and the percentage of their maximum predicted heart rate. Patients had a higher heart rate and VE with a lower O2P at every level of work load. Patients had a mean VT which approximated their FEV1 and increased their VE predominantly by increasing their respiratory frequency. During the low intensity test, despite the differences in work load, the patients had comparable heart rates and VE. No resting spirometric value accurately predicted work load, VE, or maximal VO2. We conclude that patients have a reduced work tolerance that is not adequately explained by their reduced lung function. Thus, cardiac factors, deconditioning, and the dyspneic sensation may be determinants of exercise limitation in some patients.

A comparison between a conventional and a fiberoptic flow-directed thermal dilution pulmonary artery catheter in critically ill patients.

Invasive hemodynamic monitoring is frequently required in the management of patients in intensive care units. A fiberoptic flow-directed thermal dilution pulmonary artery catheter capable of continuously monitoring the mixed venous saturation, while more expensive than a conventional pulmonary artery catheter, theoretically could result in better patient care, and might be cost-effective if it resulted either in fewer blood tests being ordered or in less time in the intensive care unit. To test this hypothesis, we designed a randomized trial in our Medical Intensive Care Unit to compare a standard pulmonary artery catheter with a fiberoptic catheter. Twenty-six patients received a standard catheter and 25 patients received the fiberoptic catheter. There were no statistical differences between the groups in age, time in the intensive care unit, number of tests ordered, hours of mechanical ventilator therapy, hours of vasoactive drug therapy, or mortality rate. The only statistically significant differences between the groups were that (1) the fiberoptic catheter required a longer insertion time and (2) there were more technical problems in consistently obtaining the wedge pressure in the patients with the fiberoptic catheters. We conclude that routine substitution of a fiberoptic catheter for the standard pulmonary artery catheter is not indicated.

Transbronchial biopsy without fluoroscopy. A seven-year perspective.

The use of fluoroscopic guidance for transbronchial biopsy (TBB) during flexible fiberoptic bronchoscopic examination has been controversial. Patient records and bronchoscopy reports for 112 transbronchial biopsies performed with fluoroscopy over a seven-year period were reviewed and compared with those of 135 transbronchial biopsies performed without fluoroscopy over the same interval. Complication rates with regard to pneumothorax, fever, and hemorrhage were compared, as were yield data for neoplasm, sarcoidosis, and other miscellaneous pulmonary diagnoses. Complication rates were low in both groups and not statistically different; yield data were likewise comparable, particularly in diffuse neoplasm and sarcoidosis. This report suggests that TBB without fluoroscopy (in the basilar segments) is safe and that diagnostic yield, particularly in sarcoidosis and diffuse neoplasm, is good.

Improving house staff ordering of three common laboratory tests. Reductions in test ordering need not result in underutilization.

Most studies of modifying test ordering have focused on costs. Questions not addressed are whether programs to reduce testing lead to a higher proportion of clinically indicated tests and is underutilization an adverse outcome of such programs? To investigate this, we studied the house staff's ordering of three common laboratory tests at baseline and after educational and administrative interventions. Over a 2-year period, 3,603 urine cultures, sputum cultures, and admission urinalyses were reviewed. A lecture emphasizing the indications for these tests followed by chart audit and weekly feedback increased the proportion of clinically indicated tests. Subsequently, an administrative intervention requiring the intern to list the reason for ordering the test on the laboratory request form further improved test ordering. Underutilization, defined as a failure to order a potentially indicated test, was assessed during two representative periods. The "underutilization rate" (omitted tests per 100 patients) was no worse during maximal intervention than it was 9 months after the last intervention (7.7 vs. 11.1, NS). No immediate adverse consequences resulted from tests not ordered. Our findings indicate that it may be possible to selectively reduce the ordering of unnecessary tests without sacrificing quality of care.

Microprocessor exercise physiology systems vs a nonautomated system. A comparison of data output.

Several microprocessor exercise physiology systems have been introduced recently. Comparison of the data output between these systems and more traditional nonautomated systems has not been reported extensively. Twelve normal adult men were exercised in random sequence on different days on a Sensormedics MMC Horizon system, the Medical Graphics Corporation System 2000, and a nonautomated system. heart rate, minute ventilation, tidal volume, respiratory frequency, oxygen consumption, and carbon dioxide production were compared at each level of work during a maximal incremental test and during a constant work load test. The overall data output between the three systems was comparable. However, minute ventilation was consistently higher on the Medical Graphics system, oxygen consumption was consistently lower on the Horizon system, and a technical error was discovered in the Medical Graphics system which resulted in a systematic overestimation of carbon dioxide production. Different methods of analyzing the data from the same test (60-s average, 15-s average, breath-by-breath, and 8-breath average) resulted in differences of up to 20 percent in the maximal values. This was greater than the differences between the three systems. Despite the comparability of the data output, important differences did exist which can be potentially significant when data output from one system are compared to predicted normal values obtained under different conditions.

Diagnosis of parenchymal Hodgkin's disease using bronchoalveolar lavage.

The usefulness of bronchoalveolar lavage in the diagnosis of parenchymal Hodgkin's disease is illustrated in this case report. Recovery of characteristic Reed-Sternberg cells from the lavage fluid may serve as both a diagnostic and staging procedure and potentially may obviate more invasive steps such as thoracotomy.

Thoracic computed tomography in the preoperative evaluation of primary bronchogenic carcinoma.

One hundred seventy-four patients with bronchogenic carcinoma underwent computed tomography (CT) as part of their preoperative evaluation. Overall, CT had a sensitivity of 86%, a specificity of 78%, and an accuracy of 81% in identifying mediastinal lymph node metastases. In patients with a central tumor, the sensitivity was 93%, the specificity 74%, and the accuracy 83%. In patients with a peripheral tumor, the respective percentages were 55%, 82%, and 77%. Only 11 of 66 patients with a peripheral tumor had mediastinal metastases, and five of these patients had a normal CT scan. Conversely, 43 of 64 patients with a central tumor and mediastinal lymph node enlargement on the CT scan had unresectable disease, compared with only one of 44 patients without such enlargement. We conclude that CT is not useful in the evaluation of patients with a peripheral tumor; however, it is useful in determining which patients with a central tumor do not require a surgical staging procedure prior to thoracotomy.

The admission urinalysis: impact on patient care.

Although urinalysis is one of the most frequently ordered tests in primary care, its usefulness in screening has not been demonstrated. A retrospective review of 1,607 admission urinalyses for inpatients in a referral/community hospital identified 861 as clinically indicated and 746 as routine. Routine urinalyses were abnormal less frequently than clinically indicated urinalyses (18.1% vs 39.6%) and when abnormal, were responded to less often (33.3% vs 75.4%). Forty-five (6.0%) of the routine urinalyses yielded an abnormality that led to diagnostic action. Of these, 18 were normal on repeat testing and 17 were considered unlikely to represent significant disease. Therefore, only ten (1.3%) of the routine urinalyses affected patient therapy. In eight of these cases, the abnormality was pyuria, of which six proved to be asymptomatic bacteriuria. The admission urinalysis as a routine test had little impact on patient care in the authors' institution.

Rounded atelectasis: a new criterion for benignancy.

A malignancy must be considered whenever a mass lesion is encountered on a chest roentgenogram. Unless an unequivocal diagnosis of a benign lesion is made, thoracotomy is usually indicated. Rounded atelectasis, while only having been recently described, is being encountered with increasing frequency. As illustrated by our three cases, radiologic diagnosis of this entity is a major criterion for judging the benignity of a mass and obviates the need for a thoracotomy.

Zinc chloride (smoke bomb) inhalational lung injury.

Physicians, military and civilian alike, may be called upon to recognize, treat, and provide long-term care to patients who have suffered a zinc chloride (smoke bomb) inhalational injury. Pathologic changes described in the literature include laryngeal, tracheal, and bronchial mucosal edema and ulceration; interstitial edema; interstitial fibrosis; alveolar obliteration; and bronchiolitis obliterans. Acute injury is associated with a high mortality. Following is a report of a patient with a zinc chloride smoke injury which resulted in subpleural emphysematous blebs complicated by pneumothorax and abnormal exercise physiology. Gradual recovery occurred over several months. However, the chest roentgenogram remains abnormal with emphysematous blebs.

Lung cancer. An update.

Lung cancer is the leading cause of cancer mortality in the United States in 1985. Early diagnosis and an aggressive surgical approach offer the best chance for a cure. Unfortunately, the majority of patients will be diagnosed after the disease has metastasized. Radiation therapy and chemotherapy, despite recent advances, are still basically palliative modalities. The most efficacious approach to the control of lung cancer is an effective anti-smoking campaign.

Nifedipine does not alter methacholine-induced bronchial reactivity.

Calcium ions have been shown to be involved in smooth muscle contraction and various secretory processes. Nifedipine, a calcium channel blocking drug, does not have any intrinsic bronchodilatory effect, but it has been suggested to possibly inhibit bronchial reactivity. Eight patients, with normal baseline pulmonary function studies and methacholine-induced bronchial reactivity, had a repeat metacholine challenge after nifedipine. Spirometry was obtained at baseline and three minutes after successive inhalations of normal saline and five, 15, 30, 50, 100 and 200 inhalation units of 0.5% methacholine. Plethysmographic lung volumes and airways resistance were measured at the start of the test and after the last inhalation of methacholine. The FEV1, FVC, MMEF and PEFR were reduced by an average of 35.6%, 20.6%, 54.4% and 30.6%, respectively, on the initial study, and by 35.4%, 20.5%, 54.8% and 34.5% after nifedipine. Airways resistance was increased by 249.3% in the initial study and by 265.7% after nifedipine. There was no statistical difference in baseline spirometry, spirometry obtained at any level of methacholine inhalation, or in airways resistance between the two studies. Despite comparable decreases in lung function, all patients were less symptomatic after receiving nifedipine. Nifedipine does not alter methacholine-induced bronchial reactivity. Until the role of nifedipine in asthma is better defined, caution should be used in prescribing nifedipine to asthmatic patients with heart disease, because their perception of airways resistance may be altered.

Endobronchial tuberculosis simulating lung cancer.

Endobronchial tuberculosis, while relatively common before the advent of effective antituberculosis chemotherapy, is seldom recognized now. Four patients with what appeared to be primary tuberculosis complicated by endobronchial spread were recently seen by us. Three of the four patients presented with anterior segment upper lobe disease with partial segmental collapse. Clinically and roentgenographically, all four patients were felt to have primary bronchogenic carcinoma. Definitive diagnosis was established via the fiberoptic bronchoscope. The declining incidence of tuberculosis in the United States has altered the clinical and roentgenographic presentation. The diagnosis of tuberculosis should be considered even when the clinical features are atypical.

Methacholine challenge test.

Methacholine challenge has been proposed as a diagnostic test in situations where clinical asthma is suspected but reversible airway obstruction cannot be demonstrated spirometrically. Methacholine challenge was used in 14 patients with suspected asthma and five normal controls. Eight individuals (six patients and two controls) had a reduction in the forced expiratory volume at 1 s (FEV1) of 20% or more with 100 inhalation units (IUs) of methacholine; seven additional individuals (six patients and one control) met one or more of the American Thoracic Society's criteria for a positive bronchoprovocation test; and four individuals (two patients and two controls) were not sensitive to methacholine by any criteria. The diagnosis of asthma can be excluded if methacholine does not induce reversible obstruction. However, provocation of reversible obstruction with methacholine is not specific for asthma. More stringent criteria, such as reduction of FEV1 by 20% by 20 IUs of methacholine, would be less sensitive but more specific for asthma.

Thoracic CT scanning in the staging of bronchogenic carcinoma.

The use of thoracic CT scans in the staging of bronchogenic carcinoma has been controversial. Previous studies have resulted in conflicting conclusions concerning the incidence of false positive and false negative scans. We attempted to determine if thoracic CT scans were of value in staging bronchogenic carcinoma using objective criteria and in a clinical situation applicable to most modern medical centers. Forty-eight patients who had a staging mediastinoscopy and/or thoracotomy and a CT scan prior to surgery were studied. Twenty-eight had evidence of mediastinal node enlargement on CT scan, and 19 of those patients had metastatic disease confirmed. One of 20 patients without evidence of mediastinal lymph node enlargement on CT scan had lymph node metastases at surgery. The CT scan was 68.0 percent specific, 95.0 percent sensitive, and 79.2 percent accurate in predicting mediastinal neoplastic involvement. No difference was noted between left upper lobe tumors and tumors arising in other areas of the lung. We conclude that the third generation chest CT scan is extremely sensitive in identifying enlarged mediastinal lymph nodes, but this is not specific for metastatic disease. Patients with a positive chest CT scan should have pathologic confirmation of metastatic disease with a surgical staging procedure. Patients with a negative chest CT scan, however, can be taken directly to thoracotomy.

Sarcoidosis. Reversal of respiratory failure 21 years after onset of disease.

Patients with sarcoidosis who have roentgenographic evidence of interstitial lung disease for several years are assumed to have irreversible disease. Respiratory failure in this setting is usually ascribed to end-stage pulmonary fibrosis. We describe a 62-year-old man with this condition. Treatment with prednisone resulted in a dramatic improvement in both symptoms and respiratory values.

Exercise testing in pulmonary sarcoidosis.

The variable natural history of sarcoidosis and the toxicity of corticosteroids result in many clinical situations where there is controversy concerning the need for treatment. Progressive incremental testing is an excellent method to identify physiologic mechanisms responsible for exercise limitation. It is therefore ideal to determine if subjective symptoms such as dyspnea are due to cardiac abnormalities, pulmonary abnormalities, or poor physical conditioning. Thirty-one patients with sarcoidosis underwent progressive incremental exercise testing. Four of 14 asymptomatic patients and eight of 17 symptomatic patients demonstrated pulmonary abnormalities which potentially limited exercise tolerance. These consisted of an abnormal respiratory pattern or gas exchange abnormalities, or both. Patients with completely normal routine pulmonary function studies almost always performed normally with exercise. Symptomatic patients with multiple abnormalities on routine pulmonary function studies invariably demonstrated a pulmonary limitation on exercise testing. Patients with one or two abnormalities on routine pulmonary function studies, regardless of the presence or absence of parenchymal infiltrates, required exercise testing to determine if symptoms were due to physiologically significant abnormalities of the respiratory system. The important variables necessary to be measured, arterial desaturation and an abnormal respiratory pattern, can be measured noninvasively with a minimum of equipment.