Post-Tuberculosis Lung Disease: Clinical Review of an Under-Recognised Global Challenge

An estimated 58 million people have survived tuberculosis since 2000, yet many of them will suffer from post-tuberculosis lung disease (PTLD). PTLD results from a complex interplay between organism, host, and environmental factors and affects long-term respiratory health. PTLD is an overlapping spectrum of disorders that affects large and small airways (bronchiectasis and obstructive lung disease), lung parenchyma, pulmonary vasculature, and pleura and may be complicated by co-infection and haemoptysis. People affected by PTLD have shortened life expectancy and increased risk of recurrent tuberculosis, but predictors of long-term outcomes are not known. No data are available on PTLD in children and on impact throughout the life course. Risk-factors for PTLD include multiple episodes of tuberculosis, drug-resistant tuberculosis, delays in diagnosis, and possibly smoking. Due to a lack of controlled trials in this population, no evidence-based recommendations for the investigation and management of PTLD are currently available. Empirical expert opinion advocates pulmonary rehabilitation, smoking cessation, and vaccinations (pneumococcal and influenza). Exacerbations in PTLD remain both poorly understood and under-recognised. Among people with PTLD, the probability of tuberculosis recurrence must be balanced against other causes of symptom worsening. Unnecessary courses of repeated empiric anti-tuberculosis chemotherapy should be avoided. PTLD is an important contributor to the global burden of chronic lung disease. Advocacy is needed to increase recognition for PTLD and its associated economic, social, and psychological consequences and to better understand how PTLD sequelae could be mitigated. Research is urgently needed to inform policy to guide clinical decision-making and preventative strategies for PTLD.

Spirituality and Religiosity are Associated with Quality of Life in Patients with Lung Disease

Patients were separated into two groups: (1) non-waiting list (NWL) and (2) waiting list (WL) for the lung transplantation. We found greater levels of the faith and spirituality, in those awaiting transplantation. In the NWL group, higher 'meaning' was associated with higher 'vitality,' 'emotional well-being,' and 'mental health'; higher 'peace' was associated with higher 'mental health.' In the WL group, higher 'peace' was associated with and better 'mental health' and 'emotional well-being.' Regardless of whether patients are lung transplantation candidates or not, spirituality/religiosity may help those with lung diseases cope better with their disease and have better quality of life.

Acceptance of Illness Associates with Better Quality of Life in Patients with Nonmalignant Pulmonary Diseases

Chronic nonmalignant pulmonary diseases impose a heavy burden on patients, generate health-care costs, and contribute to poor health-related quality of life. It has been found that a wide range of factors negatively affects quality of life, but the role of acceptance of illness needs to be further investigated. The aim of the study was to evaluate the relationship between acceptance of illness and quality of life in patients with chronic nonmalignant pulmonary diseases. The study encompassed 200 patients of the mean age 58 ± 16 years who were mainly diagnosed with asthma (n = 72; 36%), COPD (n = 52; 26%), and obstructive sleep apnea (n = 38; 19%). The patients answered the Acceptance of Illness Scale (AIS) and the St. George's Respiratory Questionnaire (SGRQ). Sociodemographical and clinical data were collected. The level of acceptance of illness significantly associated with each of the SGRQ domains. The greater the acceptance of illness, the lowest was the SGRQ score. The mean total score of SGRQ was 44.6 ± 24.9 and that of AIS was 26.1 ± 8.2. Higher AIS scores significantly associated with lower SGRQ scores, i.e., with better quality of life (p < 0.001 for each domain). We conclude that in patients with chronic nonmalignant pulmonary diseases, acceptance of illness plays an important role and is closely related to the general level of quality of life. Interventions aimed at improving acceptance of illness may be considered to improve quality of life.

The Effect of Pulmonary Rehabilitation on Non-chronic Obstructive Pulmonary Disease Patients

BACKGROUND

Pulmonary rehabilitation has shown significant benefit for patients with chronic obstructive pulmonary disease (COPD). The effect on non-COPD pulmonary patients is less well established.

OBJECTIVES

To determine whether pulmonary rehabilitation is also beneficial for non-COPD pulmonary patients.

METHODS

Clinical and demographic data on non-COPD pulmonary patients who participated in our institutional pulmonary rehabilitation program between January 2009 and December 2016 were collected. Participants engaged in a 60-minute, twice-weekly, ambulatory hospital-based program lasting 12 to 24 sessions. Sessions included both endurance and muscle training as well as healthy lifestyle educational activities. The six-minute walk test (6MWT) and the St. George's Respiratory Questionnaire (SGRQ) were conducted before and after the rehabilitation program.

RESULTS

We recruited 214 non-COPD patients, of whom 153 completed at least 12 sessions. Of these, 59 presented with interstitial lung disease (ILD), 18 with non-ILD restrictive lung defects, 25 with asthma, 30 with lung cancer, and 21 with other conditions (e.g., pulmonary hypertension, bronchiectasis) The groups demonstrated significant improvement in 6MWT and in SGRQ scores. Non-COPD patients gained a 61.9 meter (19%) improvement in the 6MWT (P < 0.0001) and 8.3 point reduction in their SGRQ score (P < 0.0001).

CONCLUSIONS

Pulmonary rehabilitation is effective in non-COPD pulmonary patients. As such, it should be an integral part of the treatment armament provided to the vast majority of those suffering from chronic respiratory disease.

Effect of Long-term Nicotine Replacement Therapy vs Standard Smoking Cessation for Smokers With Chronic Lung Disease: A Randomized Clinical Trial

IMPORTANCE

Smokers with chronic obstructive pulmonary disease (COPD) have particular difficulty quitting. Long-term nicotine replacement therapy (LT-NRT) might offer a strategy for reducing harm from cigarettes and provide a pathway for later cessation.

OBJECTIVE

To compare the effect of LT-NRT vs standard smoking cessation (SSC) on exposure to cigarette smoke, harm related to smoking, and cessation among smokers with COPD.

DESIGN, SETTING, AND PARTICIPANTS

This unblinded, randomized clinical trial recruited smokers who self-reported a diagnosis of COPD at any level of readiness to quit from May 23, 2014, through November 30, 2015. The 12-month follow-up was completed December 6, 2016. Patients were recruited at a clinical research unit of an academic medical center. Analysis was based on intention to treat and performed from March 8 through November 30, 2017.

INTERVENTIONS

Standard smoking cessation treatment included 10 weeks of NRT and 4 follow-up counseling sessions for those willing to make a quit attempt. Long-term NRT included 12 months of NRT and 6 follow-up counseling sessions regardless of initial willingness to quit. Overall, 198 patients were randomized to SSC, and 197 were included in the primary analysis; 200 patients were randomized to LT-NRT, and 197 were included in the primary analysis.

MAIN OUTCOMES AND MEASURES

The primary outcome was 7-day abstinence verified by carbon monoxide (CO) levels at 12 months. Secondary outcomes included cigarettes smoked per day (CPD), exposure to CO, urinary excretion of 4-methylnitrosamino-1-3-pyridyl-1-butanol (NNAL) (a smoking-related carcinogen), and adverse events.

RESULTS

Among 398 patients who were randomized (59.8% female; mean [SD] age, 56.0 [9.3] years), the mean (SD) CPD was 23.1 (12.3). Twelve-month follow-up was completed by 373 participants (93.7%), and 394 (99.0%) were included in the primary analysis. At 12 months, CO-verified abstinence occurred in 23 of 197 participants (11.7%) in the SSC arm and 24 of 197 (12.2%) in the LT-NRT arm (risk difference, 0.5%; 95% CI, -5.9% to 6.9%). Continuing smokers in the SSC and LT-NRT arms had similar, significantly reduced harms caused by smoking, including cigarette consumption by 12.4 and 14.5 CPD, respectively, exhaled CO level by 5.5 and 7.8 ppm, respectively, and mean urinary NNAL excretion by 21.7% and 23.0%, respectively. In multivariate analyses, continuing smokers with greater adherence to NRT experienced less reduction in NNAL exposure. The frequency of major adverse cardiac events was similar in both groups.

CONCLUSIONS AND RELEVANCE

Similar rates of cessation and similar reductions in exposure to tobacco smoke resulted with LT-NRT and SSC. Among continuing smokers, ongoing use of NRT was not associated with reductions in smoke exposure.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02148445.

Improvement in patient-reported outcomes after lung transplantation is not impacted by the use of extracorporeal membrane oxygenation as a bridge to transplantation

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) is increasingly used as a bridge to lung transplantation. The impact of preoperative ECMO on health-related quality of life (HRQL) and depressive symptoms after lung transplantation remains unknown, however.

METHODS

In a single-center prospective cohort study, we assessed HRQL and depressive symptoms before and at 3, 6, and 12 months after lung transplantation using the Short Form 12 Physical and Mental Component Scores (SF12-PCS and SF12-MCS), Airway Questionnaire 20-Revised (AQ20R), EuroQol 5D (EQ5D), and Geriatric Depression Scale (GDS). Changes in HRQL were quantified by segmented linear mixed-effects models controlling for age, sex, diagnosis, preoperative forced expiratory volume in 1 second, 6-minute walk distance, and Lung Allocation Score. We compared changes in HRQL among subjects bridged with ECMO, subjects hospitalized but not on ECMO, and subjects called in for transplantation as outpatients.

RESULTS

Out of 189 subjects, 17 were bridged to transplantation with ECMO. In all groups, improvements in HRQL following lung transplantation exceeded the minimally clinically important difference using the SF12-PCS, AQ20R, EQ5D, and GDS. HRQL defined by SF12-MCS did not change after transplantation. Improvements were generally similar among the groups, except for EQ5D, which showed a trend toward less benefit in the outpatients, possibly due to their better HRQL before lung transplantation.

CONCLUSIONS

Subjects ill enough to require ECMO as a bridge to lung transplantation appear to achieve similar improvements in HRQL and depressive symptoms as those who do not. It is reassuring to both providers and patients that lung transplantation provides substantial improvements in HRQL, even for those patients who are critically ill in the run up to transplantation.

Advance care planning uptake among patients with severe lung disease: a randomised patient preference trial of a nurse-led, facilitated advance care planning intervention

OBJECTIVE

Advance care planning (ACP) clarifies goals for future care if a patient becomes unable to communicate their own preferences. However, ACP uptake is low, with discussions often occurring late. This study assessed whether a systematic nurse-led ACP intervention increases ACP in patients with advanced respiratory disease.

DESIGN

A multicentre open-label randomised controlled trial with preference arm.

SETTING

Metropolitan teaching hospital and a rural healthcare network.

PARTICIPANTS

149 participants with respiratory malignancy, chronic obstructive pulmonary disease or interstitial lung disease.

INTERVENTION

Nurse facilitators offered facilitated ACP discussions, prompted further discussions with doctors and loved ones, and assisted participants to appoint a substitute medical decision-maker (SDM) and complete an advance directive (AD).

OUTCOME MEASURES

The primary measure was formal (AD or SDM) or informal (discussion with doctor) ACP uptake assessed by self-report (6 months) and medical notes audit. Secondary measures were the factors predicting baseline readiness to undertake ACP, and factors predicting postintervention ACP uptake in the intervention arm.

RESULTS

At 6 months, formal ACP uptake was significantly higher (p<0.001) in the intervention arm (54/106, 51%), compared with usual care (6/43, 14%). ACP discussions with doctors were also significantly higher (p<0.005) in the intervention arm (76/106, 72%) compared with usual care (20/43, 47%). Those with a strong preference for the intervention were more likely to complete formal ACP documents than those randomly allocated. Increased symptom burden and preference for the intervention predicted later ACP uptake. Social support was positively associated with ACP discussion with loved ones, but negatively associated with discussion with doctors.

CONCLUSIONS

Nurse-led facilitated ACP is acceptable to patients with advanced respiratory disease and effective in increasing ACP discussions and completion of formal documents. Awareness of symptom burden, readiness to engage in ACP and relevant psychosocial factors may facilitate effective tailoring of ACP interventions and achieve greater uptake.

TRIAL REGISTRATION NUMBER

ACTRN12614000255684.

Control beliefs and risk for 4-year mortality in older adults: a prospective cohort study

BACKGROUND

Control beliefs are important psychological factors that likely contribute to heterogeneity in health outcomes for older adults. We evaluated whether control beliefs are associated with risk for 4-year mortality, after accounting for established "classic" biomedical risk factors. We also determined if an enhanced risk model with control beliefs improved identification of individuals with low vs. high mortality risk.

METHODS

We used nationally representative data from the Health and Retirement Study (2006-2012) for adults 50 years or older in 2006 (n = 7313) or 2008 (n = 6301). We assessed baseline perceived global control (measured as 2 dimensions-"constraints" and "mastery"), and health-specific control. We also obtained baseline data for 12 established biomedical risk factors of 4-year mortality: age, sex, 4 medical conditions (diabetes mellitus, cancer, lung disease and heart failure), body mass index less than 25 kg/m2, smoking, and 4 functional difficulties (with bathing, managing finances, walking several blocks and pushing or pulling heavy objects). Deaths within 4 years of follow-up were determined through interviews with respondents' family and the National Death Index.

RESULTS

After accounting for classic biomedical risk factors, perceived constraints were significantly associated with higher mortality risk (third quartile scores odds ratio [OR] 1.37, 95% CI 1.03-1.81; fourth quartile scores OR 1.45, 95% CI, 1.09-1.92), while health-specific control was significantly associated with lower risk (OR 0.69-0.78 for scores above first quartile). Higher perceived mastery scores were not consistently associated with decreased risk. The enhanced model with control beliefs found an additional 3.5% of participants (n = 222) with low predicted risk of 4-year mortality (i.e., 4% or less); observed mortality for these individuals was 1.8% during follow-up. Compared with participants predicted to have low mortality risk only by the classic biomedical model, individuals identified by only the enhanced model were older, had higher educational status, higher income, and higher prevalence of diabetes mellitus and cancer.

CONCLUSION

Control beliefs were significantly associated with risk for 4-year mortality; accounting for these factors improved identification of low-risk individuals. More work is needed to determine how assessment of control beliefs could enable targeting of clinical interventions to support at-risk older adults.

Co-calibrating quality-of-life scores from three pulmonary disorders: implications for comparative-effectiveness research

Background Efficient use of health resources requires accurate outcome assessment. Disease-specific patient-reported outcome (PRO) measures are designed to be highly relevant to patients with a specific disease. They have advantages over generic PROs that lack relevance to patient groups and miss crucial impacts of illness. It is thought that disease-specific measurement cannot be used in comparative effectiveness research (CER). The present study provides further evidence of the value of disease-specific measures in making valid comparisons across diseases. Methods The Asthma Life Impact Scale (ALIS, 22 items), Living with Chronic Obstructive Pulmonary Disease (LCOPD, 22 items) scale, and Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR, 25 items) were completed by 140, 162, and 91 patients, respectively. The three samples were analyzed for fit to the Rasch model, then combined into a scale consisting of 58 unique items and re-analyzed. Raw scores on the three measures were co-calibrated and a transformation table produced. Results The scales fit the Rasch model individually (ALIS Chi(2) probability value (p-Chi(2)) = 0.05; LCOPD p-Chi(2 )=( )0.38; CAMPHOR p-Chi(2 )=( )0.92). The combined data also fit the Rasch model (p-Chi(2 )=( )0.22). There was no differential item functioning related to age, gender, or disease. The co-calibrated scales successfully distinguished between perceived severity groups (p < 0.001). Limitations The samples were drawn from different sources. For scales to be co-calibrated using a common item design, they must be based on the same theoretical construct, be unidimensional, and have overlapping items. Conclusions The results showed that it is possible to co-calibrate scores from disease-specific PRO measures. This will permit more accurate and sensitive outcome measurement to be incorporated into CER. The co-calibration of needs-based disease-specific measures allows the calculation of γ scores that can be used to compare directly the impact of any type of interventions on any diseases included in the co-calibration.

Key stakeholders' perspectives on a Web-based advance care planning tool for advanced lung disease

PURPOSE

There is a paucity of scalable advance care planning strategies that achieve the diverse goals of patients, families, and clinicians. We convened key stakeholders to gain their perspectives on developing a Web-based advance care planning tool for lung disease.

MATERIALS AND METHODS

We conducted semistructured interviews with 50 stakeholders: 21 patients with lung disease, 18 surrogates, and 11 clinicians. Interviews explored stakeholders' desired content and design features of a Web-based advance care planning tool. Participants also rated the tool's acceptability and potential usefulness. We analyzed the interviews with modified grounded theory and validated themes through member checking.

RESULTS

Stakeholders highly rated the acceptability (median, 5; interquartile range, 5-5) and potential usefulness (median, 5; interquartile range, 4-5) of a Web-based tool. Interviewees offered several suggestions: (1) use videos of medical scenarios and patient narratives rather than text, (2) include interactive content, and (3) allow the user control over how much they complete in 1 sitting. Participants identified challenges and potential solutions, such as how to manage the emotional difficulty of thinking about death and accommodate low computer literacy users.

CONCLUSIONS

There is strong stakeholder support for the development of a Web-based advance care planning tool for lung disease.

Development and psychometric properties of the Pulmonary-specific Quality-of-Life Scale in lung transplant patients

BACKGROUND

The Pulmonary-specific Quality-of-Life Scale (PQLS) was developed to measure quality of life (QoL) among patients awaiting lung transplant. The objective of this study was to determine the psychometric properties of the PQLS, identify empirically derived sub-scales, and examine ability to detect changes in pulmonary-specific QoL scores after lung transplantation.

METHODS

Data were derived from the INSPIRE trial, a dual-site randomized controlled trial of coping skills training in 389 lung transplant candidates (obstructive [48.3%], restrictive [24.2%], cystic fibrosis [13.6%], and other [13.9%]). Cronbach alpha was calculated to assess the internal reliability of the PQLS (n = 388). Test-retest reliability was assessed with correlation coefficients between baseline and 12-week post-baseline scores for the usual care control condition (n = 140). Convergent validity was assessed with correlation coefficients between the PQLS and established measures of QoL and emotional distress, 6-minute walk test distance, forced expiratory volume in 1 second, and use of supplemental oxygen at rest (n = 388). Change from baseline to 6 months post-transplantation was assessed with repeated measures analysis of variance (n = 133).

RESULTS

The PQLS was internally reliable and stable across 12 weeks. The PQLS correlated strongly with QoL measures (e.g., Shortness of Breath Questionnaire, r = 0.78, p < 0.0001), moderately with mood and anxiety (e.g., Beck Depression Inventory-II, r = 0.59, p < 0.0001), and modestly with lung disease severity (e.g., 6-minute walk test, r = -0.41, p < 0.0001). PQLS scores improved by nearly 2 SDs after transplant.

CONCLUSIONS

These results demonstrated the reliability, validity, and sensitivity to change of the PQLS for measuring pulmonary QoL among patients with advanced lung disease and the responsiveness of the PQLS to changes in QoL after lung transplantation.

[Going forward--five years experience in pulmonary rehabilitation]

INTRODUCTION

Pulmonary rehabilitation is regarded as a crucial component of the therapeutic armamentarium in chronic lung disease. Ten years ago the Pulmonary Rehabilitation Service at the Shaare Zedek Medical Center (SZMC) was established as part of the Cardiac Rehabilitation Center. Over the last six years this service operates independently within the physiotherapy center under the supervision of the Pulmonary Institute, in collaboration with the social and nutritional services.

AIMS

To evaluate the efficacy of pulmonary rehabilitation in improving the patients' quality of life and functional capacity.

METHODS

Prospective follow-up of patients referred for pulmonary rehabilitation at the SZMC between the years 2009-2013. The participants were required to complete a pulmonary function test, a 6 minute walk test (6MWT) and a quality of life questionnaire, the Saint George Respiratory Questionnaire (SGRQ). The SGRQ and the 6MWT were readministered after completion of the program.

RESULTS

During the follow-up period 415 patients underwent pulmonary rehabilitation at SZMC, of them 330 completed a series of at least 12 sessions. Complete data pertaining to the 6MWTwas obtained for 276 subjects. Participation in the program led to an improvement of 57.5 meters (p < 0.001) in the walking distance. Complete data regarding the SGRQ were available for 94 patients. Completion of the pulmonary rehabilitation program led to a decrease of 8.9 points in the SGRQ (p < 0.001).

CONCLUSIONS

Our results indicate that pulmonary rehabilitation was clinically useful as well as statistically significant in improving the functional capacity and quality of life among patients with chronic lung diseases.

Psychological intervention - a critical element of rehabilitation in chronic pulmonary diseases

Chronic pulmonary diseases represent a segment of pathology with an increasing prevalence worldwide, this requiring joint efforts from specialists in this field to (a) identify those factors insufficiently explored so far, but critical for their evolution and (b) address them via new therapies. This study aims to explore the existing data regarding the psychological factors involved in the dynamics of chronic pulmonary diseases and the main possibilities of psychological intervention, as a distinct part of pulmonary rehabilitation (PR). 49 articles published on this topic in peer-reviewed journals between 1979 and 2010, indexed in PubMed, ProQuest and EBSCO databases, were examined for evidence. Among psychological factors considered important by study authors were the following: 1) the deficient instruction of the patient, 2) decreased treatment motivation, 3) a marginal social role, 4) a disadaptive cognitive style and 5) psychiatric comorbidity (especially anxiety and depression). Efficient interventions were, for physicians, 1) patient education and 2) designing a personalized self-management plan, and for the clinical psychologists, 1) cognitive-behavioral therapy, 2) biofeedback, 3) family therapy, 4) relaxation and 5) hypnosis. Despite the undeniable effect of these methods in selected cases, the high heterogeneity of designs and personal affiliations of researchers do not allow new generalizations about their efficacy or their routine implementation into PR. Further research including larger samples, more uniform designs, construction of consensual international standards regarding the objectives of PR, and assessments done by experts from multiple study domains could contribute to a better understanding of the role psychological interventions could play in PR.

Frequency-modulated orocutaneous stimulation promotes non-nutritive suck development in preterm infants with respiratory distress syndrome or chronic lung disease

OBJECTIVE

For the premature infant, extrauterine life is a pathological condition, which greatly amplifies the challenges to the brain in establishing functional oromotor behaviors. The extent to which suck can be entrained using a synthetically patterned orocutaneous input to promote its development in preterm infants who manifest chronic lung disease (CLD) is unknown. The objective of this study was to evaluate the effects of a frequency-modulated (FM) orocutaneous pulse train delivered through a pneumatically charged pacifier capable of enhancing non-nutritive suck (NNS) activity in tube-fed premature infants.

STUDY DESIGN

A randomized trial to evaluate the efficacy of pneumatic orocutaneous stimulation 3 × per day on NNS development and length of stay (LOS) in the neonatal intensive care unit among 160 newborn infants distributed among three sub-populations, including healthy preterm infants, respiratory distress syndrome (RDS) and CLD. Study infants received a regimen of orocutaneous pulse trains through a PULSED pressurized silicone pacifier or a SHAM control (blind pacifier) during gavage feeds for up to 10 days.

RESULT

Mixed modeling, adjusted for the infant's gender, gestational age, postmenstrual age and birth weight, was used to handle interdependency among repeated measures within subjects. A significant main effect for stimulation mode (SHAM pacifier vs PULSED orosensory) was found among preterm infants for NNS bursts per min (P=0.003), NNS events per min (P=0.033) and for total oral compressions per min (NNS+nonNNS) (P=0.016). Pairwise comparison of adjusted means using Bonferroni adjustment indicated RDS and CLD infants showed the most significant gains on these NNS performance indices. CLD infants in the treatment group showed significantly shorter LOS by an average of 2.5 days.

CONCLUSION

FM PULSED orocutaneous pulse train stimuli delivered through a silicone pacifier are effective in facilitating NNS burst development in tube-fed RDS and CLD preterm infants, with an added benefit of reduced LOS for CLD infants.

Update in pulmonary medicine

Pulmonary disorders are common and important causes of morbidity and even mortality in adolescents. Conditions that are considered in this article include asthma, cystic fibrosis, and vocal cord dysfunction. Chronic and recurrent exacerbations may occur in youth with such disorders; therefore, they must adhere to potentially many pharmacologic agents and therapeutic procedures on a regular basis for maximum medical and psychosocial outcomes. It is important that physicians use au courant evidence-based guidelines in the management of adolescents. It is also critical that physicians educate adolescents about these regimens to help them maximize management outcomes. If disease control is inadequate, referral to a pulmonary specialist can be helpful to verify the correct diagnosis(es) and ensure that the most appropriate therapies are used.

What do you mean, a spot?: A qualitative analysis of patients' reactions to discussions with their physicians about pulmonary nodules

BACKGROUND

More than 150,000 Americans each year are found to have a pulmonary nodule. Even more will be affected following the publication of the National Lung Screening Trial. Patient-doctor communication about pulmonary nodules can be challenging. Although most nodules are benign, it may take 2 to 3 years to rule out cancer. We sought to characterize patients’ perceptions of communication with their providers about pulmonary nodules.

METHODS

We conducted four focus groups at two sites with 22 adults with an indeterminate pulmonary nodule. Transcripts were analyzed using principles of grounded theory.

RESULTS

Patients described conversations with 53 different providers about the pulmonary nodule. Almost all patients immediately assumed that they had cancer when first told about the nodule. Some whose providers did not discuss the actual cancer risk or explain the evaluation plan experienced confusion and distress that sometimes lasted for months. Patients were frustrated when their providers did not address their concerns about cancer or potential adverse effects of surveillance (eg, prolonged uncertainty, radiation exposure), which in some cases led to poor adherence to evaluation plans. Patients found it helpful when physicians used lay terms, showed the CT image, and quantified cancer risk. By contrast, patients resented medical jargon and dismissive language.

CONCLUSIONS

Patients commonly assume that a pulmonary nodule means cancer. What providers tell (or do not tell) patients about their cancer risk and the evaluation plan can strongly influence patients’ perceptions of the nodule and related distress. We describe simple communication strategies that may help patients to come to terms with an indeterminate pulmonary nodule.

[Benefits of oxygen on exercise performance in patients with chronic lung diseases]

Chronic respiratory diseases limit exercise capacity, due to breathlessness and hypoxemia. A decrease in daily activity results in impairment of quality of life and higher mortality. Oxygen therapy improves exercise capacity. The main mechanism of this improvement in COPD patients is a reduction in dynamic hyperinflation. The benefits of oxygen therapy is present not only in patients with severe hypoxemia at rest (PaO2 < 60 mm Hg) requiring long-term oxygen therapy, but also in mild hypoxemic patients who develop desaturation during exercise. An improvement in exercise tolerance is proportional to the administered oxygen flow. Provision of oxygen flow from ambulatory source may be continuous or intermittent only during inspiration. Both methods seem to be comparable in terms of improving exercise tolerance and reducing hypoxemia. Ambulatory oxygen should be prescribed to all patients on long-term oxygen therapy who report outdoor activity. Moreover, normoxemic patients with severe exertional desaturation and low exercise tolerance should also be prescribed ambulatory oxygen. The flow of oxygen should be titrated to prevent desaturation during activities. The long-term effects of ambulatory oxygen such as improvement of quality of life and increasing daily activity have not been confirmed and require further investigation.

[Type D personality in chronic lung diseases: prevalence, psychological features]

AIM

To estimate the prevalence and impact of Type D personality on the psychological status and quality of life (QL) of patients with chronic lung diseases.

SUBJECTS AND METHODS

117 patients (105 men and 12 women; mean age 59.6 +/- 0.9 years) with chronic lung diseases were examined. The DS14 questionnaire was used to identify Type D personality. According to the test results, the patients were divided into 2 groups: 1) 39 Type D patients; 2) 78 non-Type D patients. The levels of depression and anxiety and QL were additionally determined using the SF-36 questionnaire. Clinical and laboratory parameters, spirometric data, and 6-minute walk test (6'WT) distance were estimated.

RESULTS

The Type D versus non-Type D patients had higher levels of situational (46.6 +/- 1.7 and 41.2 +/- 1.2 scores; p = 0.01) and personality (47.6 +/- 1.5 and 43.7 +/- 0.9 scores; p = 0.02) anxiety and depression (42.9 +/- 1.6 and 35.9 +/- 0.8 scores; p = 0.00004), as well as lower QL levels in the vitality (42.2 +/- 2.2 and 52.2 +/- 1.9 scores; p = 0.002), emotional function (20.5 +/- 4.0 and 36.8 +/- 4.4 scores; p = 0.02), and mental health (56.2 +/- 1.9 and 63.4 +/- 1.9 scores; p = 0.006) scales. The 6'WT distance was less in the Type D patients (463.3 +/- 17.2 m)than in non-Type D patients (504.1 +/- 8.7 m); p = 0.02.

CONCLUSION

Type D personality is encountered in 33% of patients with chronic lung diseases associated with the higher level of psychological distress in the patients, with the worsening of a mental component of QL, and with the reduction in exercise tolerance.

Health behavior change following chronic illness in middle and later life

OBJECTIVES

Understanding lifestyle improvements among individuals with chronic illness is vital for targeting interventions that can increase longevity and improve quality of life.

METHODS

Data from the U.S. Health and Retirement Study were used to examine changes in smoking, alcohol use, and exercise 2-14 years after a diagnosis of heart disease, diabetes, cancer, stroke, or lung disease.

RESULTS

Patterns of behavior change following diagnosis indicated that the vast majority of individuals diagnosed with a new chronic condition did not adopt healthier behaviors. Smoking cessation among those with heart disease was the largest observed change, but only 40% of smokers quit. There were no significant increases in exercise for any health condition. Changes in alcohol consumption were small, with significant declines in excessive drinking and increases in abstention for a few health conditions. Over the long term, individuals who made changes appeared to maintain those changes. Latent growth curve analyses up to 14 years after diagnosis showed no average long-term improvement in health behaviors.

DISCUSSION

Results provide important new information on health behavior changes among those with chronic disease and suggest that intensive efforts are required to help initiate and maintain lifestyle improvements among this population.

[Smoking cessation in patients with cardiopulmonary diseases]

OBJECTIVE

To determine the smoking cessation rates of outpatients with cardiopulmonary disease and the differences between non-cardiopulmonary diseases.

METHODS

Two hundred and two active smokers with comorbid diseases were prospectively evaluated between September 2004 and January 2008 in this observational study. All of the patients answered Fagerstrom test for nicotine dependence with a regular questionnaire of general characteristics. Behavioral counseling therapies were administered to all of the subjects. Nicotine replacement therapy, bupropion or combination therapies were the pharmacological therapies after running the baseline spirometry and carbon monoxide oximetry tests. Subjects were classified as patients with cardiopulmonary disease (124) and non-cardiopulmonary diseases (78), based on medical history. Student t and Chi-square tests were used for statistical analyses.

RESULTS

The age of smoking was similar but total amount of smoked tobacco was higher (p<0.05) in the cardiopulmonary diseases group. In this group, the main smoking cessation reason was the existing disease (51%) (p<0.05). There was no other significant difference between two groups including treatment protocols. The smoking cessation rates were less (40%) with high relapses (12%) in cardiopulmonary diseases group (p<0.01 and p=0.01 respectively). In the subgroup analysis, treatment procedures were equivalent (p>0.05).

CONCLUSION

Results of this analysis confirm that, tobacco dependence is still a severe but necessary condition for the patients with cardiopulmonary diseases. Additionally neither of the treatment protocols was superior to the others.

Relationship among differentiation of self, relationship satisfaction, partner support, and depression in patients with chronic lung disease and their partners

The purpose of the present study is to test the relationships among differentiation of self, relationship satisfaction, perceived partner support, and depression in a sample of patients with chronic lung disease (CLD) and their partners. The sample consisted of 52 patients with CLD and their partners. Hierarchical multiple regression was used for data analysis. The results indicate that (a) patients' differentiation of self is significantly lower than partners' differentiation of self, (b) patients' relationship satisfaction is positively correlated with partners' relationship satisfaction, (c) patients' relationship satisfaction predicts perceived partner supportive behavior, (d) perceived partner unsupportive behavior predicts patients' depression, (e) partners' differentiation of self predicts partners' relationship satisfaction, (f) partners' relationship satisfaction predicts partner supportive behavior, and (g) partners' differentiation of self and relationship satisfaction predicts partners' depression. The study serves to highlight the fact that the patient is part of a system, and that taking the system into account is relevant to the well-being of both the patient and the partner, in particular for patients with CLD, a heretofore unstudied population. The results of such studies have significant implications for couple and family therapists.

Depression while on the lung transplantation waiting list

BACKGROUND

Patients inflicted with severe illnesses are prone to depression, which tends to intensify the burden of the disease. Those awaiting organ transplantation cannot help but feel that they may not be fortunate enough to breathe through a new lung. Such sense of doom along with constraints imposed by the illness increases the likelihood of depression. We sought to investigate the presence of depression in a group of patients on the lung transplantation waiting list in Iran.<br />

MATERIAL/METHODS

This cross-sectional study, conducted between August and September 2007, recruited 64 candidates from a single lung transplantation clinic. The Beck Depression Inventory was employed to identify the presence and severity of depression. This 21-item questionnaire has a total score ranging from 0 to 63, with higher scores denoting more severe depressive symptoms. In an Iranian population, scores from 0 to 15 signify no problem, while scores from 16 to 30 indicate mild, 31 to 46 moderate, and 47 to 63 severe depression.<br />

RESULTS

The patient population was composed of 70.3% men and 29.7% women at a mean age of 36.6+/-13.6 years. 40.6% were single and 59.4% were married. Whereas 43.8% had no abnormal depressive symptoms, 37.5% had mild and 18.7% had moderate symptoms.<br />

CONCLUSIONS

More than half of the patients on the lung transplantation waiting list had a degree of depression. Given the risk of non-compliance with treatment in depressives, it is advisable that lung transplantation candidates be screened for depression and diagnosed cases be referred for the treatment of depression.<br /> <br />

Are they really that happy? Exploring scale recalibration in estimates of well-being

OBJECTIVE

The authors addressed a lingering concern in research on hedonic adaptation to adverse circumstances. This research typically relies on self-report measures of well-being, which are subjective and depend on the standards that people use in making judgments. The authors employed a novel method to test for, and rule out, such scale recalibration in self-reports of well-being.

DESIGN

The authors asked patients with chronic illness (either lung disease or diabetes) and nonpatients to evaluate quality of life (QoL) for the patients' disease. In addition, the authors also asked them to rank and rate the aversiveness of a diverse set of adverse circumstances, allowing examination of both the numerical ratings and ordering among items.

MAIN OUTCOME MEASURES

The authors compared patients' and nonpatients' ratings and rankings for the patients' disease and other conditions.

RESULTS AND CONCLUSION

The authors found that patients not only assigned higher numerical QoL ratings to their own disease than did nonpatients but also ranked it higher among the broad set of conditions. These results suggest that scale recalibration cannot account for discrepant QoL ratings between patients and nonpatients. More generally, this study presents a new approach for measuring well-being that is not subject to the problem of scale recalibration.

[The problems of premature senescence in occupational lung diseases]

The article presents the results of researches aimed at estimation of the rate of biological aging at dust diseases of lungs. It is proved that influence of fibrogenic aerosols leads to the increase in biological age of patients with the dust diseases of lungs. It is proved that definition of biological age as a criterion of diagnostics is possible at dust diseases of lungs.

Psychological effects of chronic lung disease

Carol Kelly and Dave Lynes outline the potential psychological consequences of living with a chronic respiratory disease and how nurses can assess problems and implement strategies to help patients to adjust and cope.

Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

BACKGROUND

Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation.

METHODS

The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline updates the previous recommendations and also examines new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline grading system.

RESULTS

The new evidence strengthens the previous recommendations supporting the benefits of lower and upper extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD.

CONCLUSIONS

There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases. Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need.

Impact of oral cyclophosphamide on health-related quality of life in patients with active scleroderma lung disease: results from the scleroderma lung study

OBJECTIVE

To assess the impact of cyclophosphamide (CYC) on the health-related quality of life (HRQOL) of patients with scleroderma after 12 months of treatment.

METHODS

One hundred fifty-eight subjects participated in the Scleroderma Lung Study, with 79 each randomized to CYC and placebo arms. The study evaluated the results of 3 measures of health status: the Short Form 36 (SF-36), the Health Assessment Questionnaire (HAQ) disability index (DI), and Mahler's dyspnea index, and the results of 1 preference-based measure, the SF-6D. The differences in the HRQOL between the 2 groups at 12 months were calculated using a linear mixed model. Responsiveness was evaluated using the effect size. The proportion of subjects in each treatment group whose scores improved at least as much as or more than the minimum clinically important difference (MCID) in HRQOL measures was assessed.

RESULTS

After adjustment for baseline scores, differences in the HAQ DI, SF-36 role physical, general health, vitality, role emotional, mental health scales, and SF-36 mental component summary (MCS) score were statistically significant for CYC versus placebo (P < 0.05). Effect sizes were negligible (<0.20) for all of the scales of the SF-36, HAQ DI, and SF-6D at 12 months. In contrast, a higher proportion of patients who received CYC achieved the MCID compared with placebo in the HAQ DI score (30.9% versus 14.8%), transitional dyspnea index score (46.4% versus 12.7%), SF-36 MCS score (33.3% versus 18.5%), and SF-6D score (21.3% versus 3.8%).

CONCLUSION

One year of treatment with CYC leads to an improvement in HRQOL in patients with scleroderma lung disease.

The challenge of patients' unmet palliative care needs in the final stages of chronic illness

BACKGROUND

There is consensus in the literature that the end of life care for patients with chronic illness is suboptimal, but research on the specific needs of this population is limited.

AIM

This study aimed to use a mixed methodology and case study approach to explore the palliative care needs of patients with a non-cancer diagnosis from the perspectives of the patient, their significant other and the clinical team responsible for their care. Patients (n = 18) had a diagnosis of either end-stage heart failure, renal failure or respiratory disease.

METHODS

The Short Form 36 and Hospital and Anxiety and Depression Questionnaire were completed by all patients. Unstructured interviews were (n = 35) were conducted separately with each patient and then their significant other. These were followed by a focus group discussion (n = 18) with the multiprofessional clinical team. Quantitative data were analysed using simple descriptive statistics and simple descriptive statistics. All qualitative data were taped, transcribed and analysed using Colaizzi's approach to qualitative analysis.

FINDINGS

Deteriorating health status was the central theme derived from this analysis. It led to decreased independence, social isolation and family burden. These problems were mitigated by the limited resources at the individual's disposal and the availability of support from hospital and community services. Generally resources and support were perceived as lacking. All participants in this study expressed concerns regarding the patients' future and some patients described feelings of depression or acceptance of the inevitability of imminent death.

CONCLUSION

Patients dying from chronic illness in this study had many concerns and unmet clinical needs. Care teams were frustrated by the lack of resources available to them and admitted they were ill-equipped to provide for the individual's holistic needs. Some clinicians described difficulty in talking openly with the patient and family regarding the palliative nature of their treatment. An earlier and more effective implementation of the palliative care approach is necessary if the needs of patients in the final stages of chronic illness are to be adequately addressed.

Long-term outcomes after allogeneic stem cell transplantation for children with hematological malignancies

We analyzed long-term outcomes and psycho-social aspects in 112 children with malignancies surviving 1 year after hematopoietic stem cell transplantation. At 10 years, overall survival was 75+/-5%, TRM 18+/-4% and relapse 14+/-3%; 10-year cumulative incidence of infections was 31+/-4%, cataract 44+/-4%, pulmonary dysfunction 20+/-4%, bone and joint complications 29+/-5%, hypothyroidism 36+/-4%, cardiac complications 11+/-3% and secondary malignancies 7+/-3%. Total body irradiation (TBI) was the most significant risk factor associated with cataract, pulmonary impairment, osteoarticular complications and hypothyroidism. Chronic graft-versus-host disease was associated with higher incidence of pulmonary dysfunction. The number of complications per patient increased with time. Half of the patients had psychological disturbance, 13 signs of depression and 16 a history of eating behavior disorders; 54% of patients with one or more long-term complications had psychological problems. Sixty-nine patients had learning difficulties and 36 achieved normal scholarship. With increased follow-up, development of late effects and of psycho-social disturbance are of major concern. While the use of single-dose TBI has now been abandoned, other risk factors are still of concern in the early 2000s.

[Anxiety and Depression Short Scale: norms for its use in rehabilitation]

In the rehabilitation setting it is important to identify clinically significant conditions of distress so as to be able to provide, in addition to the conventional multidisciplinary rehabilitation treatment, specific psychotherapeutic interventions targeted to the individual's problems. This paper presents the findings from a psychometric test for the measurement of anxiety and depression (AD-R Scale) administered at the start and end of a rehabilitation program in patients with cardiopulmonary disease. The study population consisted of 765 patients affected by cardiac and pulmonary disease undergoing an in-hospital course of intensive rehabilitation. We observed that AD-R scores are related to sex, age and diseases. Among anxiety and depression scores there are statistically significant differences regarding sex: women achieved higher AD-R scores compared with men. Depression scores are influenced by age: younger subjects reached lower scores compared with the older ones. Among patients with respiratory disease, the subjects affected by chronic respiratory failure showed statistically significant higher depression scores compared to subjects affected by chronic obstructive pulmonary disease and bronchial asthma. Anxiety and depression scores among subjects affected by cardiac diseases did not show important differences. At the end of the multidisciplinary rehabilitation program, a significant reduction in both anxiety and depression scores was observed, compared to values at the start, particularly for those that, at the beginning of the rehabilitation program, reached clinically remarkable AD-R scores and in general for the youngest subjects. The paper also presents the means, standard deviations and percentile range of scores for anxiety and depression in the population studied, according to age, sex, underlying pathology or hospital division. The Scale AD-R appears to be a valid instrument for the screening of patients undergoing cardio-pulmonary rehabilitation and as an outcome index.

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.

Major depression and physical illness trajectories in heart failure and pulmonary disease

The purpose of this study was to examine conjoint trajectories of depression-physical illness in elderly medical inpatients with heart failure and/or chronic pulmonary disease and major depression (MDD), and to identify baseline predictors of trajectory. Consecutive medically hospitalized patients over age 50 with heart failure and/or chronic pulmonary disease were screened for MDD using the Structured Clinical Interview for Depression. Patients were re-evaluated at 6, 12, 18, and 24 weeks. Four depression-physical illness conjoint trajectories were examined: depression better, illness better; depression better, illness same; depression same, illness better; and depression same, illness same. Baseline predictors of trajectory were examined. MDD was identified in 413 patients; 352 had at least one follow-up. By 6 weeks, 22.3% improved on both depression and illness and 38.1% improved on neither. By 24 weeks, 45.0% had improved on both and 24.8% on neither. Short-term baseline predictors of trajectory (6 weeks) differed from long-term (12-24 weeks); past psychiatric history, overall medical illness severity, and education were short-term predictors, whereas past psychiatric history, depression treatments, and physical functioning were long-term. Improvements in MDD and physical illness track closely together. Characteristics during baseline hospitalization predict outcome trajectory after discharge, and may be useful in understanding etiology and directing treatment.

Telephone-based coping skills training for patients awaiting lung transplantation

Impaired quality of life is associated with increased mortality in patients with advanced lung disease. Using a randomized controlled trial with allocation concealment and blinded outcome assessment at 2 tertiary care teaching hospitals, the authors randomly assigned 328 patients with end-stage lung disease awaiting lung transplantation to 12 weeks of telephone-based coping skills training (CST) or to usual medical care (UMC). Patients completed a battery of quality of life instruments and were followed for up to 3.4 years to assess all-cause mortality. Compared with UMC, CST produced lower scores on perceived stress, anxiety, depressive symptoms, and negative affect and improved scores on mental health functioning, optimism, vitality, and perceived social support. There were 29 deaths (9%) over a mean follow-up period of 1.1 year. Survival analyses revealed that there was no difference in survival between the 2 groups. The authors conclude that a telephone-based CST intervention can be effectively delivered to patients awaiting lung transplantation. Despite the severity of pulmonary disease in this patient population, significant improvements in quality of life, but not somatic measures or survival to transplant, were achieved.

Angry breathing: A prospective study of hostility and lung function in the Normative Aging Study

BACKGROUND

Hostility and anger are risk factors for, or co-occur with, many health problems of older adults such as cardiovascular diseases, all-cause mortality, and asthma. Evidence that negative emotions are associated with chronic airways obstruction suggests a possible role for hostility in the maintenance and decline of pulmonary function. This study tests the hypothesis that hostility contributes to a faster rate of decline in lung function in older adults.

METHODS

A prospective examination was undertaken of the effect of hostility on change in lung function over time. Data are from the VA Normative Aging Study, an ongoing cohort of older men. Hostility was measured in 1986 in 670 men who also had an average of three pulmonary function examinations obtained over an average of 8.2 years of follow up. Hostility was ascertained using the 50-item MMPI based Cook-Medley Hostility Scale. Pulmonary function was assessed using spirometric tests to obtain measures of forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC).

RESULTS

Baseline pulmonary function differed between high and medium/low hostility groups (mean (SE) percent predicted FEV(1) 88.9 (18.5) v 95.3 (16.9) and FVC 92.5 (16.5) v 98.9 (15.9), respectively; p < 0.01 for both). This overall association between higher hostility and reduced lung function remained significant after adjusting for smoking and education, although the effect size was attenuated for both FEV1 and FVC. Higher hostility was associated with a more rapid decline in lung function, and this effect was unchanged and remained significant for FEV1)in multivariate models but was attenuated for FVC. Each standard deviation increase in hostility was associated with a loss in FEV1 of approximately 9 ml/year.

CONCLUSIONS

This study is one of the first to show prospectively that hostility is associated with poorer pulmonary function and more rapid rates of decline among older men.

Impact of pain in health related quality of life of patients with systemic sclerosis

OBJECTIVES

Systemic sclerosis (SSc) has an heterogenous clinical pattern, with variable organ involvement and degrees of severity. Like in other rheumatic diseases, the self-questionnaires have been used to evaluate SSc globally. The aim of the study is as to evaluate the quality of life (QoL) in patients with either diffuse or limited SSc, and to examine the impact of pain on the QoL scores.

METHODS

Patients with SSc, either diffuse or limited SSc, were included in a cross-sectional study. The QoL was evaluated with the short-form 36 (SF-36) and the functional repercussion with the SSc-modified Health Assessment Questionnaire (S-HAQ).

RESULTS

A total of 89 patients (67 with diffuse and 22 with limited SSc) were included. The SF-36 score values were lower in SSc patients than those reported in the general population. The physical component scores (PCS) of the SF-36 was significantly worse in diffuse compared with limited SSc (P < 0.05). The PCS was significantly negatively related to the number of clinical manifestations (ANOVA, P < 0.0001). The mental component score (MCS) was not influenced by the type of SSc or the number of clinical manifestations presented by the patient. The QoL of SSc patients was highly correlated with pain (R = 0.69) and disability (R = 0.70). Interestingly, the QoL of SSc patients was only slightly correlated with cutaneous (R = 0.42) and pulmonary involvement (R = 0.57).

CONCLUSION

The QoL of patients with SSc is strongly influenced by the type of SSc, the burden of clinical manifestations, the functional disability and by the pain, whatever its cause. The treatment of pain should be considered as priority to improve the QoL of SSc patients.

Comparison of older depressed hospitalized patients with and without heart failure/pulmonary disease

Test the hypothesis that depressed hospitalized patients with congestive heart failure (CHF) and/or chronic pulmonary disease (CPD) are no different from depressed patients with other medical disorders, and so can be treated similarly. Consenting patients aged 50 or over consecutively admitted to the medical services at Duke University Medical Center and three community hospitals were screened for depressive disorder using the Structured Clinical Interview for Depression (SCID-IV). Characteristics of patients reflecting vulnerability, stressors, and coping resources were assessed. CHF/CPD patients with major (n = 413) and minor (n = 587) depression were compared to depressed patients with other medical disorders (n = 63). Among those with major depression, patients with CHF/CPD differed from those with other medical disorders in having less severe depression and less severe cognitive impairment, but greater physical illness severity. Among those with minor depression, CHF/CPD patients tended to be older and, as with major depression, had less severe depression and more severe medical illness. These findings were largely confirmed when CHF and CPD patients were examined separately. Depressive disorders in CHF/CPD patients are similar to those in patients with other medical disorders. However, they may be associated with less severe depressive symptoms and more severe physical illness than depressed patients with other medical disorders. These findings help to identify the unique ways in which depressive disorder manifests itself in hospitalized patients with chronic heart and lung disease that may impact their management.

Minor depression and physical outcome trajectories in heart failure and pulmonary disease

We examined conjoint trajectories of depression-physical illness outcomes in elderly inpatients with minor depression and heart failure or pulmonary disease, and identified demographic, psychosocial, physical, and treatment predictors of trajectory. Consecutively admitted patients over age 50 with heart failure and/or chronic pulmonary disease were screened for minor depression using the Structured Clinical Interview for Depression. Follow-up evaluations were performed at 6 and 12 weeks using the Longitudinal Interview Follow-Up Evaluation, Hamilton Depression Scale, and Chronic Heart Failure-Chronic Respiratory Disease Questionnaire. Patients were placed into four depression-physical illness outcome trajectories: (T#1) depression better, illness better; (T#2) depression better, illness same; (T#3) depression same, illness better; and (T#4) depression same, illness same. Bivariate and multivariate predictors were examined. Minor depression was identified in 587 patients. Of these, 487 were evaluated at 6 weeks and 444 at 12 weeks. By 6 weeks, 39.4% of patients improved both on depression and physical illness (T#1), and 27.3% improved on neither (T#4). By 12 weeks, 49.6% had improved on both and 20.5% on neither. Race, admitting hospital, past psychiatric history, family psychiatric history, comorbid physical illnesses, and antidepressant drug treatment independently predicted outcome trajectory. Improvements in depression and physical illness track closely together in elderly inpatients with heart failure or pulmonary disease. Baseline patient characteristics predict which outcome trajectory they are likely to follow after hospital discharge, and may be useful in diagnosis and management.

[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).

Baseline pulmonary function and quality of life 9 years later in a middle-aged Chinese population

STUDY OBJECTIVE

This research examined the association of baseline pulmonary function with future quality of life (QOL).

METHODS

We collected baseline pulmonary function data in 1993 and 1994, and assessed QOL using the Chinese 35-Item Quality of Life Instrument in 2002 in a cohort of 1,356 participants. We used Pearson correlation analysis, multivariate analysis of variance, and multivariate linear regression analysis to assess the relationship between pulmonary function and QOL.

RESULTS

The baseline percentage of age- and height-predicted FEV1 (FEV1%) was significantly correlated with the resurvey total QOL score (r = 0.126, p < 0.001) and with QOL scores for the general (r = 0.074, p = 0.006), physical (r = 0.085, p = 0.002), independence (r = 0.178, p < 0.001), and psychological (r = 0.064, p = 0.018) domains but not with the social and environmental domains after adjusting for age and sex. These associations were weaker for the percentage of age- and height-predicted FVC. Multiple linear regression showed that the above associations were independent of baseline and resurvey smoking status. Inclusion of respiratory symptoms in the model reduced the regression coefficients from 0.82 to 0.41 for the total QOL score and from 1.43 to 0.94 for the independence domain score, for a 10% change in FEV1%. The age- and sex-adjusted mean total QOL scores were 78, 76, 76, and 69, respectively (p < 0.001), for the groups of normal, symptomatic only, impaired pulmonary function only, and both symptomatic and impaired pulmonary function. This trend was also significant for the general, physical, independence, and psychological domain scores.

CONCLUSION

Impaired baseline pulmonary function has a significant negative impact on QOL in later life that is independent of age, sex, height, and smoking status and is largely mediated through the development of chronic respiratory symptoms.

INTIMACY NEEDS AND CHRONIC ILLNESS: Strategies for Sexual Counseling and Self-Management

Individuals experiencing a chronic illness have many needs and concerns. One area frequently overlooked is that of intimacy. Those experiencing cardiovascular illnesses have concerns about the strain of sexual activity on their heart. Individuals with lung diseases may perceive that sexual activity is no longer possible because of breathing difficulties. Accurate information and strategies for self-management are needed to address the intimacy needs and concerns of these individuals. The purpose of this article is to identify intimacy needs and strategies for sexual counseling for individuals with cardiovascular illnesses such as myocardial infarction, heart failure, implantable defibrillators, hypertension, and for chronic lung problems.

Gas exchange and exercise capacity affect neurocognitive performance in patients with lung disease

OBJECTIVE

This study examined the relationship between cognitive functioning and the severity of underlying lung disease in patients awaiting lung transplantation.

METHODS

Ninety-four patients with end-stage lung disease completed a test battery to assess cognitive performance in two domains: executive functioning/attention (Trails A and B, COWA, Animal Naming, Stroop Color-Word Test, Digit Symbol, and the 2 & 7 Test) and verbal memory (Digit Span-Backward and Forward, WMS-R Logical Memory and Paired Verbal Associates).

RESULTS

Thirty-seven percent of the patients demonstrated moderate to severe cognitive impairment data on two or more tests. Adjusting for age and education, there were no statistically significant differences on executive functioning or verbal memory as a function of specific lung disease diagnosis. Lower PCO2 values were associated with better cognitive performance on latent measures of executive functioning and attention (p = .006) and verbal memory (p = .009), whereas higher PO2 values tended to be associated with better performance on the executive functioning/attention measure (p = .064). Distance walked in 6 minutes was positively related to verbal memory (p < .023).

CONCLUSIONS

Impaired neurocognitive functioning may be relatively common in patients awaiting lung transplantation and is associated with ineffective pulmonary gas exchange and reduced exercise tolerance.

Quality of life and coping strategies among lung transplant candidates and their family caregivers

Although numerous studies have examined coping strategies and quality of life (QOL) among patients with chronic diseases and their family caregivers, no studies have examined the reciprocal effects of patient and caregiver coping strategies on their dyad partner's QOL. Because most people who cope with stressful health experiences do so within the context of interpersonal relationships, it is important to understand the ways in which the two partners' coping strategies may reciprocally affect each other's QOL. Adult lung transplant candidates and their caregivers (N=114 pairs) participated in semi-structured interviews that included measures of QOL and coping with patients' health-related problems. Multivariate, canonical correlation analyses were performed to examine unique patterns of associations between coping and QOL in patient-caregiver dyads. Better patient QOL, across multiple domains, was associated with better caregiver QOL. Multiple elements of patients' coping, including greater use of active coping and emotionally oriented coping were related to generally poorer patient QOL in psychosocial and physical domains. Similarly, caregivers who used more emotionally oriented coping had poorer QOL. There was no statistically reliable relationship between either (a) patient and caregiver use of coping strategies, or (b) caregiver coping and patient QOL. However, patients' coping strategies were important correlates of caregivers' QOL. These findings belie common clinical beliefs that family members' coping responses to patients' health are likely to affect patient well-being. Instead, patients' coping and QOL may be critical for understanding caregiver well-being, especially in the current era in which caregivers are assuming increased responsibility for providing patient care.

Identification of children who may benefit from self-hypnosis at a pediatric pulmonary center

BACKGROUND

Emotional difficulties can trigger respiratory symptoms. Thus, children presenting with respiratory complaints may benefit from a psychological intervention. The purpose of this study was to define the proportion of patients referred to a Pediatric Pulmonary Center who may benefit from instruction in self-hypnosis, as a psychological intervention.

METHODS

A retrospective chart review was conducted for all newly referred patients to the SUNY Upstate Medical University Pediatric Pulmonary Center during an 18 month period beginning January 1, 2000. Patients were offered hypnosis if they presented with symptoms or signs suggestive of psychological difficulties. Hypnosis was taught in one or two 15-45 minute sessions by a pediatric pulmonologist.

RESULTS

Of 725 new referrals, 424 were 0-5 years old, 193 were 6-11 years old, and 108 were 12-18 years old. Diagnoses of anxiety, habit cough, or vocal cord dysfunction accounted for 1% of the 0-5 year olds, 20% of the 6-11 year olds, and 31% of the 12-18 year olds. Hypnotherapy was offered to 1% of 0-5 year olds, 36% of 6-11 year olds, and 55% of 12-18 year olds. Of 81 patients who received instruction in self-hypnosis for anxiety, cough, chest pain, dyspnea, or inspiratory difficulties, 75% returned for follow-up, and among the returning patients 95% reported improvement or resolution of their symptoms.

CONCLUSION

A large number of patients referred to a Pediatric Pulmonary Center appeared to benefit from instruction in self-hypnosis, which can be taught easily as a psychological intervention.

An assessment of the feasibility of telephone and email consultation in a chest clinic

One hundred and sixty-four consecutive patients attending a busy respiratory outpatient service were asked how acceptable was the concept of alternating face to face consultation with consultation by either telephone or email. The patients were then assessed as to their suitability for such non-traditional methods of consultation. Thirty patients (18.3%) were not agreeable to other forms of consultation and five could not speak English. One hundred and thirty-three (84%) had a suitable daytime telephone number for consultation purposes, but only 34 (21%) had email access, with this being commoner in the younger ages. One hundred and five patients were not thought to be suitable for alternative methods of consultation because of: the severity of their condition, the difficulty of assessing it over the telephone, or because they needed to attend the hospital for investigations. However, even in a clinic where the policy was already to return as many patients as possible to the care of their primary care physicians, and in a clinic where much work was already shared with respiratory nurse specialists, over one-third of patients were thought to be suitable for alternating face to face with telephone consultation. The diagnoses in those cases included asthma, suspected obstructive sleep apnoea, chronic obstructive pulmonary disease (COPD), unexplained cough, and some patients with respiratory malignancy being visited at home by the palliative medicine services. However, for those with asthma and for those awaiting results of investigations especially, use of telephone consultation appears to be an acceptable and convenient way of reducing the pressure upon time available for face to face consultations.

Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research

BACKGROUND

The literature on patient adherence to treatment includes hundreds of empirical studies. A comprehensive examination of the findings requires the organization and quantification that is possible with meta-analysis.

OBJECTIVES

The goals of this research are retrieval, compilation, and averaging of adherence rates in all published empirical studies from 1948 to 1998; assessment of variation according to sample characteristics, time period of publication, measurement method, disease, and regimen; and examination of the effects on adherence of patient demographic characteristics.

METHODS

We calculated a meta-analysis of 569 studies reporting adherence to medical treatment prescribed by a nonpsychiatrist physician, and 164 studies providing correlations between adherence and patients' age, gender, education, and income/socioeconomic status; group comparison and multiple regression analysis of moderators.

RESULTS

The average nonadherence rate is 24.8%. Controlling for intercorrelations among moderator variables, adherence is significantly higher in more recent and smaller studies and in those involving medication regimens and adult samples. The use of physical tests and self-report have respectively significant and borderline negative effects on the level of adherence, and disease severity and use of the medical record have no significant effects. Adherence is highest in HIV disease, arthritis, gastrointestinal disorders, and cancer, and lowest in pulmonary disease, diabetes, and sleep. Demographic effects on adherence are small and moderated by sample, regimen, and measurement variables.

CONCLUSIONS

This review offers insights into the literature on patient adherence, providing direction for future research. A focus on reliability and validity of adherence measurement and systematic study of substantive and methodologic moderators are recommended for future research on patient adherence.

The longitudinal relation between chronic diseases and depression in older persons in the community: the Longitudinal Aging Study Amsterdam

OBJECTIVE

The purposes of this study were to examine the differences in influence of various chronic diseases on depressive symptomatology over time and to determine whether there were differences in such influence depending on physical limitations and time of onset of disease.

STUDY DESIGN AND SETTING

Data for this study were obtained from the Longitudinal Aging Study Amsterdam. Two thousand two hundred eighty-eight respondents (age 55-85) were included and followed for a maximum of 6 years. Depressive symptoms (using the CES-D scale), the presence of seven frequently occurring chronic diseases, physical limitations, and sociodemographic variables were assessed by structured interviews. Generalized estimating equation models were estimated for each disease and compared with each other.

RESULTS

Lung disease, arthritis, cardiac disease, and cancer were all positively associated with increased depressive symptoms over time. Stroke was associated with depressive symptoms, but these associations were not found when adjusted for physical limitations. For atherosclerosis and diabetes mellitus only weak or no associations with depressive symptoms were found. Recent onset of disease resulted in less strong associations for in cancer, lung disease, and arthritis.

CONCLUSION

The results demonstrate that the level of depressive symptoms varies across type of chronic disease. In cardiac disease, arthritis, cancer, and lung disease increased depressive symptoms could not be attributed to physical limitations, but in stroke the association found with depressive symptoms was to a large extent attributable to physical limitations.