Comparison of the SF-36 health survey questionnaire with the Nottingham Health Profile in long-term survivors of a myocardial infarction.
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BACKGROUND: Health-related quality of life, an important outcome measure in health interventions, can readily be assessed by questionnaire. Two widely evaluated examples are the Short Form 36 (SF-36) and Nottingham Health Profile (NHP) questionnaires, but as yet the discriminatory power of these tools has not been compared in a large population of patients with coronary heart disease. METHODS: All 4-year survivors of a myocardial infarction, identified from the Nottingham heart attack register, were sent the SF-36, NHP and additionally the Rose angina and dyspnoea questionnaires. Mean scores on the SF-36 and NHP were compared with age- and sex-adjusted norms in patients under and over 65 years. Sensitivity of the respective tools was assessed in distinguishing patients with differing degrees of cardiovascular symptomatology. RESULTS: In patients under 65 years the SF-36 and NHP differed to the same extent from normative data--scores were lower in the comparable domains physical functioning/mobility, bodily pain/pain and energy/vitality, but not in mental health/emotional reaction scores. In social functioning/social isolation results were disparate--SF-36 scores were lower and the NHP similar to normative data. In patients over 65 years mean scores in all five domains were not significantly different from normative data for either tool. The SF-36 was more sensitive than the NHP at detecting the impact of breathlessness, particularly in patients with mild symptoms. Similarly, the SF-36, but not the NHP, could distinguish the effect of differing degrees of angina severity and frequency on social functioning. CONCLUSION: At least in myocardial infarction survivors, the SF-36 appears a more sensitive tool and may have benefits for assessing health-related quality of life in this patient group. (+info)
Airway obstruction and chronic exertional dyspnoea in patients with persistent bronchial asthma.
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In patients with COPD, flow limitation (FL) predicts chronic exertional dyspnoea (CED) better than routine spirometry. Whether, and to what extent, FL and CED are overlapping quantities in chronic asthma has not yet been defined. Forty consecutive clinically stable asthmatic patients without smoking history or cardiopulmonary disorders, were studied. In each subject respiratory function, including static and dynamic pulmonary volumes, was evaluated; maximal (MEFV) and partial (PEFV) expiratory V'-V curves and isovolumic partial to maximal flow ratio (M/P). FL was assessed in a seated patient by comparing tidal and PEFV curves; FL was detected when tidal flows were superimposed or exceeded those obtained during PEFV curves, and was expressed as a percentage of the expired control tidal volume (V(T)) affected by flow limitation (FL% VT). Dyspnoea was assessed by both MRC scale and Baseline Dyspnoea Index (BDI) focal score. Half of the patients were found to have FL. They were older, more dyspnoeic and more obstructed (P<0.03 - P<0.000005) than the non-FL group. FEV1, vital capacity (VC), age, body mass index, FL and M/P ratio were all related to dyspnoea scores. FL was significantly related to FEV1 (r = - 0.59). Multiple regression analysis showed that FEV1 (P=0.003, r2= 15-3% and P = 0.004, r2= 20.3%) and age (P = 0.0006, r2 = 26.8% and P = 0.016, r2 = 11%) independently predicted a part of the variance of MRC (P = 0.0001, r2 = 42.1%) and BDI (P = 0.0008, r2 = 31.3%), respectively. With dyspnoea scale being the gold standard, diagnostic accuracy (sensitivity and specificity) by ROC (receiver operating characteristics) analysis was similar for FEV1 and FL. The results indicate that FL may be present in this subset of asthmatics. CED may not be easily explained by abnormalities of routine spirometry or FL, the largest part of the CED variance remained unexplained. Thus, routine spirometry, FL and CED in patients with bronchial asthma are only partially overlapping quantities which need to be assessed separately. (+info)
Bronchiolitis obliterans-organizing pneumonia: an Italian experience.
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The purpose of this study was to describe the clinical features at onset and outcome and the diagnostic approach in subjects with bronchiolitis obliterans-organizing pneumonia (BOOP). Over a 7-year period we observed 78 cases of biopsy-proven bronchiolitis obliterans-organizing pneumonia, in which well documented clinical and radiographic data were available. The final diagnosis of BOOP was validated when patients presented: (i) negative microbiological analysis on BAL fluid; (ii) a well documented improvement either spontaneous, or after steroid treatment or (iii) cases with progressive respiratory failure and increasing radiographic shadows, an open lung biopsy or autopsy that excluded other entities. There were 42 males and 36 females; the mean age was 61+/-12 years (range 12-85 years). Forty-two (54%) patients were current smokers, 25 (32%) had never smoked and 11 (14%) were ex-smokers. The clinical pattern at presentation of BOOP was more frequently similar to classical acute or sub-acute infectious pneumonia. Fever (63%), dyspnoea (58%) and dry cough (53%) were the typical symptoms on admission. A flu-like syndrome preceeding BOOP was observed in 21 cases (27%). Inspiratory crackles (78%) were the most typical finding at physical examination. However, 13% of the patients were asymptomatic and an abnormal chest X-ray film was the reason for seeking medical attention. Radiographically the most frequent pattern of BOOP was a unilateral consolidation (44%) with lower field predominance. A migratory behaviour was present in 22% of the cases. High-resolution computed tomographic (HR-CT) scan when performed, was more sensitive in detecting ground glass infiltrates, sub-pleural or peri-bronchovascular distribution or the presence of nodules or cavitation. Most patients (68%) were classified as having idiopathic BOOP. However, the same clinical-roentgenological pattern was observed in patients after radiotherapy for ductal breast carcinoma (6%), in collagen-vascular diseases (6%), related to drugs (9%), to infections serologically documented (4%), and to graft vs. host disease (4%). Four patients (all of whom had idiopathic BOOP) presented a rapid progressive respiratory failure needing mechanical ventilation. In another two cases respiratory failure appeared after a long period during which patients experienced exertional dyspnoea and low grade fever. BAL profile was characterized by lymphocytosis with a reduction of the CD4/CD8 ratio, associated with a slight increase of neutrophils and eosinophils and scattered mast cells. However in two cases we had an increased CD4/CD8 ratio and in one case the presence of a significant 12% of polyclonal B cells. In a few cases atypical (cytokeratin-positive cells) epithelial cells were detected: these cells were constantly present in the BAL fluid of patients with rapidly progressive respiratory failure. From the diagnostic point of view this series documents that transbronchial lung biopsy (coupled with BAL) can be the first diagnostic step. However, therapy can be started on the basis of BAL data (when a characteristic morphological and phenotypical profile is evident) in cases in which the clinical presentation is suggestive and a biopsy cannot be made. Most patients showed a rapid and good response to steroid therapy. However, three patients died (4%) in spite of steroid therapy (two cases) and steroid and cyclophosphamide therapy (one case). In conclusion, although clinical findings, chest X-ray film and CT Scan findings usually suggest the diagnosis a definite confirmation requires transbronchial lung biopsy and BAL and, less frequently, open lung biopsy. (+info)
Exercise hemodynamic findings in patients with exertional dyspnea.
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To determine whether upright bicycle exercise could provide useful information about disabling exertional dyspnea in the absence of severe abnormalities (as shown by traditional testing methods), we evaluated 13 such patients. There were 3 men and 10 women with a mean age of 49+/-15 (SD) years. We used pulmonary artery catheterization at rest and during upright bicycle exercise to evaluate these patients. All patients had normal left ventricular function except for 1, who had an ejection fraction of 45%. The mean duration to peak exercise was 9+/-6 minutes. Normal systolic pulmonary artery pressure was defined as 25+/-5 mmHg. Four patients had normal systolic pulmonary pressure, and 9 exhibited pulmonary hypertension with exercise. In those 9, the mean mixed pulmonary venous oxygen saturation at rest was 61%+/-9% and fell to 32%+/-9% at peak exercise. Six of the 9 patients also had some degree of resting pulmonary hypertension that worsened with exercise: their mean pulmonary artery systolic pressure at rest was 47+/-14 mmHg and rose to 75+/-25 mmHg at peak exertion (P = 0.01). The other 3 patients showed no pulmonary hypertension at rest; their mean pulmonary artery systolic pressure was 27+/-6 mmHg. However, this level rose to 53+/-4 mmHg at peak exertion (P = 0.04). In this pilot study of patients with dyspnea, 9 of 13 (69%) displayed marked pulmonary hypertension with exercise. The resting hemodynamic levels were normal in 3 (33%) of those with exercise pulmonary hypertension. We conclude that hemodynamic data from bicycle exercise tests can provide additional information regarding the mechanisms of exertional dyspnea. (+info)
Investigation of an acute chemical incident: exposure to fluorinated hydrocarbons.
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OBJECTIVES: To assess whether attendance at the site after an incident in a sewer was associated with symptoms in emergency personnel and whether the prevalence of symptoms was associated with estimated levels of exposure to any chemical hazard. METHODS: Symptoms experienced by people attending an incident involving two dead sewer workers suggested the presence of a chemical hazard, before environmental sampling confirmed any toxic agent. Self reported symptoms, estimated exposures, and biomarkers of exposure for likely agents from all 254 people who attended the incident and a referent occupational group matching the 83 emergency personnel who went to the Accident and Emergency department (A and E) in the first 48 hours were recorded. The prevalence of symptoms and concentrations of creatine phosphokinase in serum of the 83 early patients at A and E were compared with their referent occupational group. In all workers who attended the incident, the trends in symptom prevalences and concentrations of creatine phosphokinase in serum were examined by distance from the site and predefined exposure category. RESULTS: Among all workers who attended the incident, symptoms of shortness of breath and sore throat were significantly associated with indirect estimates of exposure but not associated with concentrations of creatine phosphokinase. Freon was detected in two blood samples. The early patients at A and E reported more symptoms than their matched reference group and their median concentrations of creatine phosphokinase were higher. CONCLUSIONS: The association between symptoms and concentrations of creatine phosphokinase with attendance at the site indicated the presence of a continuing hazard at the site and led to extra precautions being taken. Comparison values from the referent occupational group prevented unnecessary medical follow up. (+info)
Ten year follow up of pulmonary function in patients with primary Sjogren's syndrome.
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OBJECTIVES: To follow up a previous report on the lung function of patients with primary Sjogren's syndrome (SS), and describe the findings having followed up this cohort for a median duration of 10 years (range 8-12 years). METHODS: 30 patients fulfilling Fox's criteria for definite or probable primary SS were assessed within six months of diagnosis and after a median duration of four and then 10 years by a clinical examination, chest radiograph, and lung function studies (FEV(1), FVC, TLCO, and KCO). RESULTS: At baseline, symptomatic dyspnoea was a common finding, reported by 13/30 patients, of whom two had evidence of fibrosing alveolitis on plain chest radiograph. Five patients had a carbon monoxide transfer factor (TLCO) more than two standardised residuals below the predicted value. After four years' follow up two further patients developed radiological fibrotic changes and there were significant reductions in TLCO (p<0.02) and transfer coefficient (KCO) (p<0.02) compared with the baseline measurements. At 10 years' follow up four patients had died and four were lost to follow up. One patient with fibrosing alveolitis had died from chest disease. There were no further cases of pulmonary fibrosis identified on plain chest radiograph. The lung function studies showed no further deterioration from the results found at year four with significant improvements in both TLCO (p<0.001) and KCO (p<0.001). Those patients who were anti-Ro antibody positive had significantly lower transfer factors than patients with primary SS without this serological marker (p<0.02). CONCLUSION: This long term follow up of lung disease in primary SS is reassuring, and suggests that most patients do not develop progressive lung disease. Pulmonary disease occurs predominantly in anti-Ro antibody positive patients and presents early in the course of the disease. (+info)
Effects of short-term pulmonary rehabilitation on exercise capacity and quality of life in patients with chronic obstructive pulmonary disease.
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Although the rehabilitation of patients with chronic obstructive pulmonary disease (COPD) improves both exercise capacity and quality of life, a standard protocol for COPD patients has not been established. To clarify whether physiologic and quality-of-life improvements can be achieved by an inpatient pulmonary rehabilitation program 5 days per week for 3 weeks, 18 patients with COPD were enrolled in a rehabilitation program. The physical exercise training regimen consisted of respiratory muscle stretch gymnastics and cycle ergometer exercise training. Pulmonary function tests, an incremental ergometer exercise test, a 6-min walking test, and a quality of life assessment by the Chronic Respiratory Questionnaire were administered before and after the program. The peak VO2, an indicator of maximal exercise capacity, did not increase, although the 6-min walking distance, an indicator of functional exercise capacity, increased significantly after rehabilitation. There was a significant improvement in the quality of life in terms of dyspnea, fatigue, and emotional state. These findings suggest that even a 3-week program may be beneficial for COPD patients. Increases in functional exercise capacity, even without an increase in maximal exercise capacity, are helpful for reducing dyspnea and improving quality of life parameters in patients with COPD. (+info)
Stages of disease severity and factors that affect the health status of patients with chronic obstructive pulmonary disease.
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BACKGROUND: We hypothesized that the factors which may influence health status would differ in patients at different disease stages of chronic obstructive pulmonary disease (COPD). The present study investigated how impairments in health status were distributed in male patients at each disease stage according to the British Thoracic Society (BTS) guidelines, and analysed the contribution of the clinical indices, the dyspnoea rating and the psychological status to the health status of patients at the three disease stages of COPD. METHODS: A total of 218 consecutive male patients with stable COPD were recruited from our outpatient clinic. All eligible patients completed pulmonary function testing, progressive cycle ergometry, a dyspnoea rating [Medical Research Council (MRC) dyspnoea scale], an assessment of their anxiety and depression [Hospital Anxiety and Depression Scale (HADS)], and an assessment of their health status [the St. George's Respiratory Questionnaire (SGRQ)]. The patients were categorized into three groups: mild COPD with a FEV1 at 60-79% of the predicted value, moderate COPD at 40-59% of the predicted value, and severe COPD at below 40% of the predicted value. RESULTS: Twenty-five patients (11%) had mild COPD, 72 patients (33%) had moderate COPD, and 121 patients (56%) had severe COPD. Significant differences were observed for the total score and for three components on the SGRQ among patients at the three stages (one-way ANOVA, P<0.05). The scores for the total SGRQ and for the activity component were significantly higher for patients with severe COPD than for patients with moderate COPD [Fisher's least-significant-difference (LSD) method, P<0.05], and also significantly higher for moderate COPD patients than for mild COPD patients. The maximal oxygen uptake (VO2 max) correlated significantly with the total SGRQ score in the mild patients [Pearson's correlation coefficient (r) = -0.67], but not in the moderate or severe patients. The MRC dyspnoea scale had strong correlations with the SGRQ in all patient groups (r = 0.53 to approximately 0.70). Anxiety and depression on the HADS showed moderate correlations with the SGRQ score in the mild and severe patients (r = 0.51 to approximately 0.57). Multiple regression analysis showed that in patients with mild COPD, the MRC and VO2 max accounted for the total score on the SGRQ. Anxiety on the HADS plus the MRC scale accounted for the total score on the SGRQ in patients with moderate COPD, and anxiety on the HADS, the MRC scale and the FEV1 significantly influenced the SGRQ severe COPD patients. CONCLUSIONS: The disease staging proposed by the BTS guidelines can separate patients with COPD according to impairments in their health status. Furthermore, the factors that influence health status differed in patients at the three disease stages. Our findings support the boundaries used in disease staging and some recommendations from the BTS guidelines. (+info)