Subjective symptomatology of asthma in an outpatient population

Characteristics of subjective symptomatology of asthma were examined within a group of 132 adult asthma patients receiving medical care in a university-based, ambulatory clinic setting. Patients responded to 36 symptom descriptions or adjectives associated with asthma which were included in a modified version of the Asthma Symptoms Checklist (ASC). A principal components exploratory factor analysis was conducted and five factors were identified. The five factors measured 1) panic-fear, 2) airways obstruction, 3) hyperventilation, 4) fatigue, and 5) irritability. Psychometric properties of the factor scores were satisfactory. The reliabilities were high, standard deviations were large, and differences in factor mean scores conformed to clinical experience. Correlational analyses support the construct validity of the ASC, especially the panic-fear factor. An important outcome of this study was to verify the ASC factor structure in an outpatient setting. The ASC was confirmed as a valuable instrument for use in self-management programs for adults with asthma. The five ASC factors represent highly stable components of subjective symptomatology of asthma among diverse adult patient populations and geographical settings.

Patient characteristics relevant to effective self-management: scales for assessing attitudes of adults toward asthma

The Asthma Opinion Survey, a 33-item Likert-type instrument, was designed to measure attitudes relevant to self-management in adult outpatients. Items fall into eleven clusters; General Vulnerability, Specific Vulnerability, Attitudes Toward Patient Knowledge, Recognition of Airway Obstruction, Accessibility of Health Care, Panic-Fear, Belief in Treatment Efficacy, Staff-Patient Relationships, Sense of Control, Personal Impact, and Social Impact. Factor analysis of the clusters yielded three factors Vulnerability, Perceived Quality of Care, and Recognition and Control. The items, clusters, and factors all had adequate to good score spreads and internal consistencies. Asthma opinions covaried significantly with demographic characteristics, asthma severity, and intensity of health care utilization, and correlated with the Asthma Symptoms Checklist, an instrument developed at the National Jewish Hospital-National Asthma Center, in ways supporting construct validity. These results suggest the Asthma Opinion Survey is achieving its intended purpose.

Assessing the use of metered dose inhalers by adults with asthma

The development and analysis of an instrument to evaluate the use of metered dose inhalers by patients in the University of Alabama at Birmingham (UAB) Asthma Program is presented. A total of 238 adult asthma patients demonstrated use of the metered dose inhaler for this analysis. Patient skill in using the inhaler was recorded using the instrument, Inhaler-Use Checklist, developed at UAB. The study found that most patients use metered dose inhalers incorrectly, despite training received from their physicians on proper use of inhalers.

Detection of emphysema with computed tomography. Correlation with pulmonary function tests and chest radiography

We studied 60 male patients who had concurrent chest films (CXR), computed tomography scans (CT) and pulmonary function tests (PFT) to assess the sensitivity of CT and conventional films in detecting emphysema compared with PFT. We also sought to determine whether emphysema could be diagnosed by CT in patients with normal pulmonary function. Using a method similar to that proposed by Bergin, we scored the severity of emphysema depicted by CT, and using arterial deficiency and bullae as criteria, we estimated the degree of emphysema on CXR. There was a significant inverse correlation between CT scores for emphysema and percentage predicted values of DLco/VA (r = -0.650), FEV1 (r = -0.552), and FVC (r = -0.409), (P less than 0.001). A significant but smaller correlation also was noted with the CXR scores and percentage predicted: DLco/VA (r = -0.564), FEV1 (r = -0.454), and FVC (r = -0.355), (P less than 0.005). When decreased diffusion capacity and airway obstruction were used as functional criteria of emphysema, CT was as sensitive as PFT and more sensitive than CXR in detecting emphysema (96% vs. 68%). There was CT evidence of emphysema in 69% (24/35) of patients who did not have functional findings of emphysema. In 12 pathologic specimens available for review, 11 had emphysema by CT and pathologic examination; one patient had centrilobular emphysema undetected by CT. We conclude that CT is as sensitive as PFT in detecting emphysema and more sensitive than conventional radiography. CT may be more sensitive than PFT in detecting mild emphysema.(ABSTRACT TRUNCATED AT 250 WORDS)

Improvement in bronchial squamous metaplasia in smokers treated with folate and vitamin B12. Report of a preliminary randomized, double-blind intervention trial

To test whether changes in folate and vitamin B12 nutrition modify the severity of potentially premalignant lesions identified by cytology in sputum samples of smokers, we conducted a randomized, controlled prospective intervention trial in smokers with bronchial squamous metaplasia. Seventy-three men with a history of 20 or more pack-years of cigarette smoking who had metaplasia on one or more sputum samples were stratified according to smoking level and randomly assigned to four months' treatment with either placebo or 10 mg of folate plus 500 micrograms of hydroxocobalamin. Direct cytological comparison of the two groups after four months showed significantly greater reduction of atypia in the supplemented group. This provides preliminary evidence that atypical bronchial squamous metaplasia may be reduced by supplementation with folate and vitamin B12. However, the significance of these findings is tempered by substantial spontaneous variation in sputum cytologies, the small study population, the short duration of the trial, and the supraphysiological doses of folate and B12 used. The results should not be construed as pointing to a potential way of preventing lung cancer in individuals who continue to smoke or as supporting self-medication with large doses of folate or B12 by smokers.

Some simple scales for use in asthma research

Several reviewers have recently identified a need for systematic efforts to improve the quality of questionnaires and other measures used in asthma research. This article applies standard psychometric techniques to scales developed to help meet this need. These scales assess asthma symptoms, respiratory diseases, the extent to which asthma inconveniences patients, medication regimens, and medication side effects. Scale quality was assessed by using data from 262 adult asthma patients. The results in general support the usefulness of these scales. The reliabilities indicate an acceptable to good level of internal consistency; the spread of scores is good; and correlations with external variables support validity.

Promoting self-management in adults with asthma: an overview of the UAB program

Most asthma self-management programs have focused on children, but the prevalence and impact, both personal and economic, of adult asthma is substantial. Moreover, failure to adhere to treatment regimens appears to be a significant problem in adult asthma. It appears important, therefore, to develop asthma self-management programs for adults. The UAB program is based on the Health Belief Model for health behavior and on the PRECEDE Model for patient education. A needs assessment and a review of existing educational materials were used to specify the content of a self-care workbook. This workbook seeks to increase cognitive skills, encourage daily self-assessment of asthma, demonstrate success in asthma self-management, and promote effective social support. The overall intervention integrates this workbook with systematic reinforcement of self-monitoring and self-management. A prospective controlled study is comparing patients receiving this "special intervention" with "usual care" patients who receive only routinely available pamphlets providing information about asthma. Patients are randomly assigned to treatments by the closed envelope technique. Sample sizes were determined on the basis of statistical power. Outcomes in five areas are assessed: (1) health care utilization, (2) functional status, (3) knowledge, (4) adherence, and (5) psychological reactions.

Occult coin perforation of the esophagus

Only a small number of ingested foreign bodies perforate the esophagus and even a smaller fraction migrate extraluminally with no symptoms. Both of these events are even rarer after coin ingestion. Between 1972 and 1984, three children (16 months to 5 years), who had unabating upper respiratory symptoms, were found to have ingested coins. In only one child could the time interval between ingestion and appearance of symptoms (3 years) be established, and in this child the diagnosis was delayed because of failure to x-ray the chest after an ingestion episode. Surgical evaluation included chest/neck films: tracheal and esophageal shadows were separated by the object and a soft tissue mass; esphagogram: deviation of the esophagus, irregularity of the lumen, and no leak or tracheoesophageal fistula (TEF) and esophagoscopy: mucosa was intact with no direct visualization of the coin. Treatment consisted of exploration: cervical, one; thoracic, two; localization: coin in extraluminal granulomatous soft tissue; removal: without resection of the soft tissue mass or esophagus, and drainage: penrose, one; chest tube, two. There was no morbidity or mortality from 1 to 13 years later. Though generally harmless, ingested coins are capable of penetrating the esophagus. Sporadic literature reports confirm that the clinical findings and operative results are typical of this seemingly intermediate stage between perforation with mediastinitis and perforation with TEF.

Rhabdomyosarcoma of pterygoid fossa. Resection for cure utilizing an innervated facial flap and craniofacial reconstruction

Tumors of the pterygoid fossa are often regarded as unresectable because of their anatomic inaccessibility. The rapidly developing techniques of craniofacial surgery have advanced sufficiently to now allow safe ablative surgery in this area and yet preserve the functional status and cosmetic appearance of the patient. A technique utilizing a bicoronal incision that is extended to the angle of the mandible on the involved side is described. This allows wide exposure of the bony structures at the lateral base of the skull while maintaining the integrity of the facial nerve within the cutaneous flap. Temporary removal of the zygomatic arch achieves direct access to and visualization of the contents of the temporal and pterygoid fossae. Skull, mandibular, and maxillary bone adjacent to tumor can easily and safely be resected to obtain complete tumor-free margins. Craniectomy bone is harvested and split into inner and outer tables to reconstruct the bony defects. This approach was successfully utilized in a 5-year-old boy with a Group III rhabdomyosarcoma with residual tumor following combined chemo- and radiotherapy. He remains tumor-free at 15 months, postoperation. The technique can be adapted for a variety of mass lesions located at the anterior base of the skull, both intra- and extracranially. Morbidity and mortality should be minimal with an experienced craniofacial team.

Surgical treatment of atypical mycobacterial lymphadenitis in children

A retrospective study was done on 38 patients with atypical mycobacterial lymphadenitis who underwent surgical intervention at The Children's Hospital, Denver, between the years 1953 and 1983. One group consisting of 18 patients had incision and drainage of the abscess or biopsy only. Sixteen of these patients developed a draining sinus or recurrent disease within a few months despite the use of antituberculous drugs or antibiotics. The other group, consisting of 20 patients, were treated initially by total excision of the inflammatory mass with no persistence or recurrence. The groups were found to be comparable with respect to age, sex, race, duration of disease and size and site of the lymph node involved. We recommend total excision of the lesion without antituberculous medications as the first choice of treatment.

Nephroblastomatosis and Wilms' tumor. Clinical experience and management of seven patients

Nephroblastomatosis is an uncommon abnormality believed to represent the persistence of embryonal renal tissue. Its association with simultaneous or eventual Wilms' tumor has led to the speculation that it is a premalignant lesion. The accumulated clinical experience with this process and its progression to Wilms' tumor in three of seven individuals is discussed. It is concluded that conservative tissue sparing surgery, chemotherapy, and ultrasonographic follow-up are the approaches most appropriate for the management of these difficult patients.

Surgical complications in Henoch-Schönlein Purpura

Intestinal intussusception, perforation, and infarction constitute the major surgical complications in Henoch-Schönlein Purpura (HSP). This report reviews the surgical experience in 13 patients of the 58 treated for HSP at our institution in the past 10 years. In addition, the reported surgical cases of anaphylactoid purpura in the pediatric age are analyzed. Attention is focused on observations not previously emphasized in regard to the timing of the surgical event in relation to the cutaneous manifestation of HSP.

Epizootiology of Posthodiplostomum minimum (MacCallum) and Proteocephalus ambloplitis (Leidy) in bluegill (Lepomis macrochirus Rafinesque)

A total of 529 bluegills (Lepomis macrochirus) from two Iowa ponds was examined for infections of parasitic white grubs (Posthodiplostomum minimum) and bass tapeworms (Proteocephalus ambloplitis). Fish from pond 1 harbored significantly greater levels of both parasites than did fish from pond 2. Female pond 1 bluegills generally supported greater intensities of P. minimum and P. ambloplitis than did males. A correlation coefficient (r) was determined as a measure of the relationship between metacercariae and plerocercoid populations in sexually mature pond 1 bluegills. A significant positive correlation was found, indicating that, as one parasite population increased or decreased, the other population did likewise. Fibrotic liver cysts were found in 25% of all age class IV pond 1 bluegills. Female fish exhibited a greater percent of lesions (30%) than did males (17%). The infection intensity of P. ambloplitis plerocercoids was significantly greater in hosts with fibrotic livers than in those without the fibrotic cysts.

Computed tomography of invasive pleural mesothelioma

The computed tomography (CT) findings in three patients with invasive pleural mesothelioma are presented, and the invasive route and metastatic extension of the disease in the abdomen and retroperitoneum are discussed. These findings indicate the value of CT in detecting the extrathoracic extension of mesothelioma. Abdominal CT studies should be obtained in evaluating mesothelioma patients for extrathoracic extension of the disease.

Treatment of atypical mycobacterial disease

The most common disease patterns produced by atypical mycobacteria are pulmonary disease, cervical lymphadenitis, and infection of soft tissue, bones, and joints. The treatment of disease due to atypical mycobacteria can be confusing unless one clearly differentiates the organisms according to clinical characteristics and response to various chemotherapeutic agents. For this reason, we have attempted to simplify the task by proposing a new classification system. The organisms that might be isolated from human material are divided into the following three classes: nonpathogens; those that are easy to treat with standard mycobacterial therapy; and finally, those that are difficult to treat with standard mycobacterial therapy and require other approaches. This new system of classification should help the clinician in dealing with these organisms. Because even the pathogens may sometimes appear as a contaminant in human material, including sputum, one must document that these organisms are associated with disease prior to instituting therapy.

The deterrent effect of capital punishment during the 1950s

This investigation examines the deterrence hypothesis of an inverse relationship between state execution rates and homicides. Although this question has received some attention in recent studies, the findings of these investigations are mixed. Cross-sectional analyses of states have typically shown execution and homicide rates to be positively associated, while at least two national time-series studies report support for the deterrence hypothesis. To test whether these divergent findings are result of the two different methodologies employed (cross-sectional vs. time-series), a methodology that combines the strengths of each is used in the present study. For the period 1950 to 1960, we examine cross-sectionally for states the relationship between changes in execution rates and changes in murder rates. This analysis does not find support for the deterrence argument for the certainty of the death penalty when a number of models of the execution rate--murder rate relationship are considered, and when a variety of imprisonment and socio-demographic factors are considered as control variables.