Long-term decline in lung function, utilisation of care and quality of life in modified GOLD stage 1 COPD

BACKGROUND

Little is known about the long-term outcomes of individuals with mild chronic obstructive pulmonary disease (COPD) as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

METHODS

A population cohort of 6671 randomly selected adults without asthma was stratified into categories of modified GOLD-defined COPD (prebronchodilator spirometry). Further stratification was based on the presence or absence of respiratory symptoms. After 11 years, associations between baseline categories of COPD and decline in forced expiratory volume in 1 s (FEV(1)), respiratory care utilisation and quality of life as measured by the SF-36 questionnaire were examined after controlling for age, sex, smoking and educational status.

RESULTS

At baseline, modified GOLD criteria were met by 610 (9.1%) participants, 519 (85.1%) of whom had stage 1 COPD. At follow-up, individuals with symptomatic stage 1 COPD (n = 224) had a faster decline in FEV(1) (-9 ml/year (95% CI -13 to -5)), increased respiratory care utilisation (OR 1.6 (95% CI 1.0 to 2.6)) and a lower quality of life than asymptomatic subjects with normal lung function (n = 3627, reference group). In contrast, individuals with asymptomatic stage 1 COPD (n = 295) had no significant differences in FEV(1) decline (-3 ml/year (95% CI -7 to +1)), respiratory care utilisation (OR 1.05 (95% CI 0.63 to 1.73)) or quality of life scores compared with the reference group.

CONCLUSIONS

In population-based studies, respiratory symptoms are of major importance for predicting long-term clinical outcomes in subjects with COPD with mild obstruction. Population studies based on spirometry only may misestimate the prevalence of clinically relevant COPD.

[Antibiotic-associated diarrheas in phthisiatric care: standardization of their diagnosis, treatment, prevention, examination of health care quality]

The authors propose a phthisiological care-adjusted standard of the diagnosis, treatment, prevention of antibiotic-associated diarrhea. They have developed a standard-driven algorithm of expert assessment of the quality of medical aid to this group of patients.

The prevalence of tobacco smoking and attitudes of Polish pulmonologists towards smoking

INTRODUCTION

Pulmonologists can play an important role in smoking prevention and control. The aim of this study was to assess smoking prevalence among Polish pulmonologists and physicians' behaviour towards smoking patients.

MATERIAL AND METHODS

The study was performed in 2006 during national congress of Polish Respiratory Society. The survey was performed using a questionnaire including questions regarding age, sex, professional activities, specialty, academic degree and respondents' nicotine status, attitude and activity towards smoking patients.

RESULTS

Questionnaires were filled in by 498 physicians: 160 (32.1%) men and 338 (67.9%) women, out of 852 participating physicians (58.5%) who received the questionnaire. There were 11.3% smokers (13.8% men and 10% women), 25.1% of surveyed physicians were ex-smokers, and 63.6% never smokers. 91.4% of respondents always ask patients if they smoke. 87.4% physicians always advise smoking cessation to their patients, but smoking cessation support is offered only by 48% of respondents. Almost half respondents use drugs in nicotine dependence treatment. Majority of respondents (81.1%) think that physician's attitude influences patient's behaviour. More than a half (55.7%) think that smoking by physicians is not in accordance with physician's ethics. 91.4% support smoking ban in public places.

CONCLUSIONS

This study found a lower prevalence of smoking among Polish pulmonologists compared with the general population, and with the previous surveys and demonstrated the impact of personal smoking on physicians' attitudes towards smoking.

[Smoking habits among Polish pulmonary physicians]

INTRODUCTION

Chronic obstructive pulmonary disease is the most common pulmonary disease, mostly caused by smoking. Reduction of this habit in the society, should be one of the most important tasks for physicians. They should set a good example. The aim of the study was to assess smoking habits among Polish pulmonary physicians.

MATERIAL AND METHODS

During a congress of the Polish Respiratory Society in 2006 participants were asked to fill out an anonymous questionnaires including questions regarding age, sex, and smoking status.

RESULTS

Questionnaires were filled in by 406 physicians (43% of congress participants): 272 women (67%) and 134 men (33%). There were 10.1% current smokers (9% in women, 13% in men), 19.5% were ex-smokers (18% were women, 23% were men), and 70.2% never smokers (73% were women, 64% were men).

CONCLUSIONS

Prevalence of smoking among Polish pulmonologist is decreasing. However, it is still higher than in countries with low smoking prevalence in the general population.

High prevalence of skin test positivity in severe or difficult-to-treat asthma

BACKGROUND

Skin tests are considered the gold standard for detecting allergen-specific immunoglobulin E (IgE) in the clinical setting and are an important tool for diagnosing and managing allergic asthma.

OBJECTIVE

To assess the prevalence of skin testing in patients > or = 12 years enrolled in The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study.

METHODS

Patients were asked whether they had ever been skin tested and, if so, they were asked to provide the test results. Clinical characteristics were used to compare positive (ST+), negative (ST-), and skin test not done (STND) patients.

RESULTS

Of 2,985 patients eligible, 85.8% recalled being skin tested. Of those tested, 93.5% were positive (allergist 95.7%, pulmonologist 87.3%). A high proportion of Whites (93.5%) and non-Whites (94.0%) were ST+; however, more non-Whites had never been skin tested (21.7% vs. 12.3%, respectively; p < 0.0001). Total serum IgE was 104.6 IU/mL for ST+ patients, 87.1 IU/mL for STND patients, and 32.4 IU/mL for ST- patients. Age at asthma onset, duration of asthma, and the prevalence of atopic disorders and asthma triggers differentiated the ST+ from the ST- group. Disease severity appeared similar between the two groups. In general, values for STND patients were closer to the ST+ group, suggesting that those not tested would have been ST+ if administered a test.

CONCLUSIONS

The prevalence of ST+ patients was high in allergy and pulmonology practices, and in White and non-White patients. These data support the utility of a more complete allergic evaluation in severe asthmatics. Skin testing appears associated with disease pathophysiologies in asthma.

Early detection of pneumology inpatients at risk of extended hospital stay and need for psychosocial treatment

BACKGROUND

In a context of increasing concern for complex care needs in medical patients, this study is intended to document the utility in pneumology patients of INTERMED, a reliable and valid instrument to assess case complexity at the time of hospital admission.

METHODS

Three hundred and fifteen consecutive patients were assessed at hospital admission with INTERMED by a trained nurse. At discharge, independent research workers, blind to the previous results, reviewed the medical database and a subsample (n = 144) was assessed for psychopathological outcome. Severity of the pulmonary disease was assessed with the Cumulative Illness Rating Scale (CIRS), and psychopathology with the Hospital Anxiety and Depression Scale, Mini-Mental Status Examination (MMSE) (cognitive disturbances), and CAGE Scale (alcohol abuse). Operational definitions were used for measures of care complexity.

RESULTS

Most patients were in geriatric age, and 78 patients (24.7%) were classified as "complex" by means of INTERMED (IM+). In support of the working hypotheses, IM+ patients scored significantly higher in measures of care complexity (Cumulative Illness Rating Scale, "number of consultations during admission" and "diagnostic count") and on both anxiety and depression. INTERMED was also associated with length of hospital stay (LOS) and with both anxiety and depression after controlling for significant predictors and socio-demographic data.

CONCLUSIONS

This is the first report about the ability of INTERMED to predict complexity of care in pneumology patients, and the first to predict a negative psychopathological outcome in any type of medical patients.

[Characterization of the leadership subject areas in the respiratory field in Spain]

OBJECTIVE

The aim of this study was to characterize the leading topics in respiratory system in Spain through a bibliometric analysis.

MATERIAL AND METHOD

For identify and characterize the performance of the different research topics in respiratory system in Spain, we compile the production using a journal that turn out representative of a broad group of researcher. In this sense the journal Archivos de Bronconeumología is the most important publication in Spanish language of this field.

RESULTS

A total of 2198 articles published in Archivos Bronconeumología from 1970 to 2000 were analyzed. In each three decades, we did not found differences except in the productivity index in oncology in the eighty decade and in respiratory failure and sleep disturbance (RFSD) and oncology areas in the ninetieth decade and in the Price index (consumption indicators) in the diagnostic and therapeutic techniques area in seventy decade. When we compare the productivity index of each subject areas between decades, we found a significant production increase in the ninetieth decade in asthma, RFSD, tuberculosis, non tuberculosis infection, circulation, oncology, pleural disease and interstitial areas versus the same in seventy decade, and also, we found significant differences between ninetieth and eighty decades in the asthma, RFSD, non tuberculosis infection, circulation and pleural disease areas. Tuberculosis area maintains an insularity index higher than the other areas. We also found a progressive increase in the insularity index of RFSD, non tuberculosis infection, oncology and interstitial disease areas.

CONCLUSIONS

In general all the indicators maintains stable although the more productivity topics were respiratory failure and sleep disturbances, and oncology. The productivity has increased in asthma, respiratory failure and sleep disturbances, tuberculosis, non - tuberculosis respiratory infections, oncology, pulmonary circulation, pleura and interstitial disease.

[Changes in patient profiles at a regional respiratory medicine clinic over a 10-year period]

OBJECTIVE

To analyze the quantitative and qualitative changes in demand for health care services at a regional respiratory medicine clinic over the last 10 years.

PATIENTS AND METHODS

During the years 1992-1993 (group A) and 2002-2003 (Group B), the following information was recorded for all new patients: referring physician s initial diagnosis, pneumologist's definitive diagnosis, age, sex, and source of referral (primary care clinic, emergency department, hospital admission, other specialist services, and other sources). The recorded data was then compared between groups.

RESULTS

Group A comprised 616 patients and group B 424. Most subjects were men (60%) aged 40 to 80 years (71.9% of group A; 75.7% of group B). In both groups, most referrals came from primary care. The number of patients in group B who were referred by primary care and by emergency departments decreased in comparison with group A, while referrals from all other sources increased (P< .001). Initial diagnosis of airway disorders and associated symptoms produced most of the demand for health care services (group A, 58%; group B, 62.2%). When the 2 groups were compared, the following changes were observed in group B: a) an increase in hospital-referred cases with right heart disease (P< .001; relative risk [RR]=7.3) and in cases of obstructive sleep apnea syndrome (OSAS) (P< .001; RR=24.3)--the most common diagnosis in group B--referred from primary care and other specialist services and b) an overall decrease in cases of tuberculosis (P< .001; RR=0.3) and in referrals made without a recorded initial diagnosis by primary care physicians. When definitive diagnoses were analyzed, the initial diagnosis was confirmed in a high percentage of patients with airway disorders (group A, 47.2%; group B, 53.1%). An increase in cases with a definitive diagnosis of OSAS was observed in group B (P< .001; RR=18.3) compared to group A. In addition, a 2-fold increase was recorded for right heart disease and consultations for radiographic abnormalities. The number of patients diagnosed with tuberculosis decreased.

CONCLUSIONS

The changes observed over the 10-year period analyzed were as follows: a) a decrease in referrals made by primary care centers and emergency departments and an increase in referrals from other sources; b) a significant increase in referrals for OSAS, which became the most common reason for consultation; c) an increase in referrals for right heart disease; and d) a decrease in tuberculosis cases.

Profile of research published in the annals of the Brazilian Pulmonology and Phthisiology Conferences held over the last twenty years

OBJECTIVE

To increase the knowledge base regarding pulmonology research in Brazil.

METHODS

A retrospective, observational study of the abstracts published in the Annals of the Brazilian Pulmonology and Phthisiology Conferences held from 1986 to 2004, quantifying the institutions of origin by geographic distribution and type, as well as categorizing the abstracts by study design and topic.

RESULTS

A total of 6467 abstracts were published. The institutions of origin were located, variously, in the Southeast (3870 abstracts), South (1309), Northeast (783), Central-West (267) and North (84). There were 94 abstracts originating from foreign institutions, especially from institutions in Portugal (56.3%) and the United States (13.8%). Most of the studies (5825) were conducted in public Brazilian institutions. There were 4234 clinical studies, 1994 case reports and 239 original research articles. A marked, progressive increase was observed in the number of clinical studies and case reports during the period evaluated. Overall, the most common themes were tuberculosis and other infections diseases (25.2%), following by oncology (11.6%), interstitial lung diseases (8.8%) and thoracic surgery (8.5%). Nevertheless, the number of abstracts on each topic varied widely from year to year.

CONCLUSION

Public Brazilian institutions are the principal sources of pulmonology research in Brazil. Such research activity is concentrated in the southeastern part of the country. Case reports account for one-third of this activity. Although there was great variability in the subjects addressed, diseases that are highly prevalent in Brazil, such as tuberculosis and other infections diseases, were the most common topics.

[Evaluation of quality of life and knowledge about tobacco smoking toxicity among patients hospitalized in Department of Pneumonology]

The aim of the study was to evaluate knowledge about tobacco toxicity among patients hospitalized in Department of Internal Diseases, Pneumonology and Allergology in Warsaw and to examine their quality of life. The study comprised 51 people at age between 18-80 years, from Warsaw and its environs. They were hospitalized because of many reasons like: COPD or asthma exacerbation, cough and focal pulmonary lesions diagnostics, follow-up examinations because of sarcoidosis or pulmonary fibrosis. Data for analysis were achieved from anonymous questionnaire prepared by authors and filled by patients. Quality of life was assessed with EQ-5D Questionnaire. The tobacco addiction rate was assessed with the Fagerström questionnaire, and the motivation to quit smoking with the Schneider test. It was found that only 14% of hospitalized patients have never smoked cigarettes, 86% smoked in the past, and 29% declare regularly smoking in present. The most common pointed tobacco-related diseases were lung cancer and hearth diseases. People hospitalized because of COPD exacerbation (CHPOChP) had significantly lower level of quality of life than patients hospitalized because of asthma exacerbation (CHA) (p = 0.03), and this both groups had significantly lower level of quality of life than persons without obstructive pulmonary diseases (NCH) (NCH - CHPOChP p = 0.0004; NCH - CHA p = 0.04). The motivation to quit smoking in COPD smokers group was significantly lower than in group treated in the hospital because of other reasons (p = 0.004).

Current practice of exercise stress testing among pediatric cardiology and pulmonology centers in the United States

The objective of this study was to characterize current practice patterns for clinical exercise stress testing (EST) in children in the United States. We conducted a survey of 109 pediatric cardiology programs and 91 pediatric pulmonology programs at children's hospitals or university hospitals in the United States. A total of 115 programs from 88 hospitals responded (response rate, 58%). A higher percentage of cardiology programs (98.7%) have exercise laboratories compared with pulmonology programs (77.5%). Sixty-three percent of respondents have both a treadmill and a cycle ergometer. A larger proportion of respondents (76%) rely primarily or exclusively on treadmill, whereas a smaller number use cycle ergometer (24%). Sixty-seven percent of respondents reported that they include metabolic measurements in EST protocols. Respondents have varying minimum age criteria for EST, with 9% reporting < or = 4 years, 25% reporting 5 years, 31% reporting 6 years, 16% reporting 7 years, and 20% reporting > or =8 years. Programs using cycle ergometers tend to test children at a younger age and to measure metabolic parameters. Seventy-nine percent of respondents use Bruce and modified Bruce protocols. Institutional protocols are used by 14%. Ninety percent of respondents use technicians to perform EST and 8% use nurses, but 76% require physician presence during testing. The majority of respondents (57%) perform < 100 pediatric tests per year. There are wide variations in the current practice of EST among pediatric subspecialty programs in the United States. Treadmills are used more frequently than cycle ergometers, and Bruce and modified Bruce protocols are commonly used. Most survey respondents measure metabolic parameters during EST.

The impact of allergy and pulmonary specialist care on emergency asthma utilization in a large managed care organization

OBJECTIVE

To evaluate the longitudinal impact of asthma specialist care on the risk of emergency department (ED) visits and hospitalization for asthma.

DATA SOURCES/STUDY SETTING

A prospective cohort study using both telephone survey and computerized utilization data.

STUDY DESIGN

We recruited a prospective cohort of 4,742 adult members of a closed panel managed care organization who were hospitalized for asthma (the "baseline hospitalization").

DATA COLLECTION/EXTRACTION METHODS

Visits to asthma specialists were ascertained from computerized utilization databases. Specialist visits after baseline hospitalization were defined as time-dependent covariates. An alternative analysis defined specialist visits during the year preceding baseline hospitalization. A subcohort of 596 subjects completed telephone interviews.

PRINCIPAL FINDINGS

Compared with subjects who received no specialist visits after baseline hospitalization, treatment by allergists (hazard ratio (HR) 1.04; 95 percent confidence interval (CI) 0.87-1.26) or pulmonologists (HR 0.92; 95 percent CI 0.71-1.19) was not associated with a reduction in the risk of future ED visits for asthma in the entire cohort, controlling for age, sex, race, recent asthma medication dispensing, and pharmacy benefits status. There was also no association between allergist visits and the risk of subsequent hospitalizations for asthma (HR 0.93; 95 percent CI 0.75-1.14). In contrast, visits to pulmonologists (HR 0.74; 95 percent CI 0.55-0.99) were related to a reduced risk of rehospitalization.

CONCLUSIONS

Pulmonary specialist visits appeared to reduce the risk of hospitalization for asthma, whereas asthma specialist visits did not reduce the risk of ED visits. In the context of comprehensive prepaid health care, the benefit of specialist care was modest.

Contraindications and safety of transbronchial lung biopsy via flexible bronchoscopy. A survey of pulmonologists and review of the literature

BACKGROUND

Transbronchial lung biopsy (TBLB) via flexible bronchoscopy is a common procedure performed by pulmonologists. Limited scientific data exist concerning the risk of this procedure in patients with conditions that may adversely affect the rate of procedural complications.

OBJECTIVES

To evaluate the current practice pattern and attitude of pulmonologists toward the performance of TBLB in the presence of high-risk conditions.

METHODS

A survey was constructed and distributed at the American College of Chest Physicians annual meeting, held in Philadelphia, USA, in November of 2001.

RESULTS

A total of 227 surveys were distributed with a return of 158 (69.6%). Anticoagulation medications are temporarily held prior to TBLB by the majority of our survey respondents (98.7% for intravenous heparin, 90.5% for warfarin, and 87.3% for low-molecular-weight heparin). Medications with effect on platelet function are held by fewer pulmonologists. There is a wide variation in the pulmonologists' perception of the risk of performing TBLB when certain medical conditions coexist: pulmonary hypertension [absolute contraindication (AC), 28.7%; relative contraindication (RC) 58.6%], superior vena cava syndrome (AC 19.6%, RC 51%), mechanical ventilation (AC 17.8%, RC 58.6%) and lung cavity/abscess (AC 7%, RC 44.9%). A significant percentage of pulmonologists (55%) do not regard an elevated serum creatinine at any level as AC to TBLB. Thirty-eight percent of the survey participants administer desmopressin prior to TBLB in uremic patients to prevent excessive bleeding.

CONCLUSIONS

Prior to performing bronchoscopic TBLB, the majority of pulmonologists temporarily holds anticoagulation medications. However, there is a lack of agreement in relation to perceived contraindications and safety of TBLB.

[The use and safety of butamirate containing drops, syrup and depot tablets in Hungary]

INTRODUCTION

Butamirate citrate containing medicines are marketed in Hungary since 1991. Every year several hundred thousands of children and adults are treated with these pharmaceutical products. Aim of the study was to compare the prescription habits with the directions provided in the Summary of Product Characteristics and to get an overview on the safety and efficacy of these products.

METHODS

The study results are based on the evaluation of 3215 questionnaires provided by 276 general practitioners and pulmonologists having medical practice in many regions and the capital of Hungary. Responses were included into the evaluation only if the name of the physician, the address and type of the practice, the therapeutic indication could be precisely identified and if the patient returned for at least one control visit.

RESULTS

The main therapeutic indication of butamirate was cough due to acute lower respiratory tract infections (tracheitis, laryngitis, bronchitis). The treatment interval was usually 1-2 weeks. Depot tablets were prescribed according to the Summary of Product Characteristics. The doses of syrup and drops were frequently and notoriously below the one proposed in the Summary of Product Characteristics. In 14% of the cases the syrup was prescribed for the treatment of children below 3 years of age. All three products were regarded as effective. Adverse events (nausea, vomiting, diarrhoea, skin exanthemas) were reported at 0.5-1% of the patients.

CONCLUSIONS

The prescribed average daily doses of drops between the ages 1 month-12 years and the syrup between the ages 6-12 years were 20-30% below the recommended amounts. In Hungary the butamirate citrate containing medicines are regarded to be effective. The adverse events were rare and non-serious.

Research outputs in respiratory medicine

BACKGROUND

There is currently little information regarding how much the distribution of research activity in respiratory medicine reflects the interests of its clinicians and scientists, the disease burden in any country, or the availability of funding.

METHODS

A total of 81,419 respiratory medicine publications identified in the Science Citation Index for the years 1996-2001 were assigned to 14 subject areas (mainly based on title words) and to 15 OECD countries. Outputs were compared with a nation's disease burdens and, for the UK, the sources of research funding were investigated.

RESULTS AND CONCLUSIONS

Overall, Finland, Canada, Spain and the UK had the greatest relative commitment to respiratory medicine research expressed as a ratio of their share of world biomedical research. The largest subject areas were asthma, lung cancer, and paediatric lung disease, each with over 1400 papers published per year. Australia and Canada led in relative commitment to sleep research and Sweden and Finland led in research on asthma. Australia and the UK produced significant numbers of publications on cystic fibrosis (CF) but Finland produced few. The Netherlands has a strong output on chronic obstructive pulmonary disease (COPD), France and the UK on diffuse parenchymal lung disease (DPLD), and Finland dominated occupational lung disease research but had few publications on HIV/AIDS where Spain proportionately produced most. Finland and Australia had strong outputs in paediatric lung disease research. For most subject areas the research output of a country correlated poorly with disease burden. In the UK, lung cancer research appeared unduly low in relation to the number of deaths and COPD outputs were low compared with those for asthma. However, correlations were positive for the burden of CF and pulmonary complications of HIV/AIDS which explains, for example, the low outputs in these subject areas from Finland. The strong performance in CF research in the UK is likely to reflect significant charitable funding, while sleep research, pulmonary circulatory disease, and DPLD had little stated external funding or sponsorship.

[Change of patients profile hospitalized because of pulmonary sarcoidosis in Department of Pneumonology in Zabrze (Poland) in 1976-80 and in 1996-2000]

The comparision of two groups of patients with pulmonary sarcoidosis hospitalized in Department of Pneumonology Silesian Medical School of Medicine in Zabrze in 1976-1980 (n=120) and 20 years later i.e. in 1986-2000 (n=190) was done. We have noticed, that in comparision with period of 1976-80 the mean age of patients hospitalized in 1986-2000 has significantly increased (41.6 vs. 37.0 p < 0.05) and percentage of females has significantly diminished (50.0% vs. 63.3% p < 0.05). No change in age structure of patients in both groups was observed. Sarcoidosis was observed most frequently (about in 34% of patients) among subjects aged 30-39 years. In group hospitalized in 1996-2000 percent of patients aged above 60 has rised (6.8% vs. 2.5%) and percent of patients without clinical complaints has significantly decreased (30.5% vs. 50.0% p < 0.05), also percent of subjects in II radiological stage has significantly diminished (32.1% vs. 52.5% p < 0.05). We conclude that during 20 years the profile of hospitalized patients with pulmonary sarcoidosis has changed.

Detection of lung cancer on radiographs: receiver operating characteristic analyses of radiologists', pulmonologists', and anesthesiologists' performance

PURPOSE

To compare and quantify, by means of receiver operating characteristic (ROC) and localization ROC analyses, the performance of radiologists, pulmonologists, and anesthesiologists (residents and staff) in the detection of missed lung cancer.

MATERIALS AND METHODS

The study was approved by the institutional review board, and informed consent was not required or obtained for review of radiographs. A set of 60 posteroanterior chest radiographs was presented to 36 observers: 12 radiologists, 12 pulmonologists, and 12 anesthesiologists. Each of these three observer categories included six residents and six staff. Thirty of the radiographs each depicted one lung cancer that was overlooked at prospective image interpretation; the other 30 were normal radiographs matched for age and smoking history. Observers were asked to rate their degree of suspicion concerning the presence of lung cancer by using a visual analog scale and to point out the zone of suspicion on a schematic of the lung. These data were used to generate combined ROC-localization ROC curves and to assess performance. Intraobserver consistency was evaluated by using intraclass correlation coefficients and weighted kappa statistics.

RESULTS

Areas under the ROC curves indicated better performance for radiologists and pulmonologists compared with anesthesiologists (P < .002) and for staff compared with residents (P < .022). Performance was lower for all categories of observers when localization ROC curves were used. Radiologists and staff pulmonologists showed a higher degree of confidence in the assessment of normality than did other categories of physicians. Intraobserver consistency was poor.

CONCLUSION

Experienced readers showed better ability to distinguish normality from abnormality. Combined ROC and localization ROC analyses gave a more reliable quantification of observer performance than did ROC analysis alone.

Urban air pollution and children's asthma: what do parents and health professionals think?

Our objective was to explore and compare, in the context of other exposures, lay and professional perceptions of the links between urban air pollution and children's asthma. We used a triangulated survey approach, using quantitative questionnaire surveys enriched by qualitative interviews. Derivation of indicators of actual local air quality used modelled air pollution and a geographical information system. Our setting involved families and community health professionals in the London borough of Ealing, and pediatric respiratory specialists across the United Kingdom. Participants included 863 parents of children aged 3-11 years, 151 reporting currently asthmatic children, of whom 20 were extensively interviewed; 98 local general practitioners and 50 practice nurses; and 75 paediatric respiratory consultants and 55 specialist nurses. Main outcome measures involved views about the links between urban air pollution and children's asthma, relative to other triggers. Comparison of assessments of local air quality, with actual pollution levels, was made by parents with and without asthmatic children. Many parents were unsure as to what factors initiate asthma, but the most frequently cited was traffic pollution; it was also considered important in the exacerbation of asthma. Health professionals' assessments were inconsistent: specialists conformed to the dominant literature dismissing strong links between air pollution and asthma, while local clinicians reflected the views of parents in their community. Surrounding parents' views were difficulties defining exposures to urban air pollution, underlying concerns about risks to general health, perceived lack of control, unclear expert opinion, and widely accepted informal "messages" which assumed strong links. Parents with experience of asthma were found to have significantly less accurate (negatively biased) perceptions of local air quality. In conclusion, reactions to uncertainty surrounding associations between asthma and urban air pollution varied: parents' concerns were heightened (and propagated by other influences), specialist clinicians were dismissive, and community clinicians fell between these extremes.

Perspectives of patients with cystic fibrosis on preventive counseling and transition to adult care

The purpose of this study was to investigate how adolescents and adults with cystic fibrosis (CF) view preventive counseling and their transition to adult-centered care within a children's hospital. Thirty-two patients >/=16 years old diagnosed with CF were recruited from a pediatric tertiary care setting. During face-to-face interviews, patients were asked 27 structured questions and completed a 30-item self-administered questionnaire on preventive counseling by healthcare providers and on transition issues. The median age of patients was 25.5 years (range, 16-43 years); 69% of patients identified a pulmonologist as their "main doctor," even though 78% had a primary care provider. Participants felt that 13-16 years of age was the best time for them to begin spending time alone with their main doctor. Less than half of the participants recalled receiving preventive counseling during the previous 12 months, and more patients wanted to discuss issues than actually did. Qualitative data emphasized the importance of independence in making decisions in healthcare and establishing relationships with providers, and many patients did not desire to transfer care to an adult hospital. Participants identified adult-focused services such as inpatient rooms, discussion groups, work options, and social service support that would enhance care. In conclusion, the majority of adolescent/young adult patients with CF receiving care in a pediatric institution reported satisfaction with their healthcare. However, patients identified preventive issues that they desired to be more regularly addressed, starting in early adolescence, and changes in the delivery of services to enhance transition to adult-oriented care. This study underscored the understanding of the integration of transition planning into the facilitation of healthcare decision-making by the adolescent in issues of self-care, sexuality, education, and finances. Future initiatives to enhance the care of patients with CF should provide training of pulmonologists in preventive care and increased attention to helping patients utilize appropriate primary-care services during the adult years. In addition, prospective studies are needed to compare outcomes of CF patients who have transitioned and transferred to adult hospitals and those transitioning to adult-oriented services in a pediatric institution.