Respiratory rehabilitation, exercise capacity and quality of life in chronic airways disease in old age

Respiratory rehabilitation improves exercise capacity and quality of life in younger patients but is untried in the aged. We aimed to: (a) assess repeatability of the 6-minute walk test, factors affecting it and its relation to quality of life in elderly patients with chronic obstructive airways disease (COAD); (b) assess compliance of such patients with an intensive respiratory rehabilitation protocol; (c) pilot the assessment of the effect of respiratory rehabilitation on the 6-minute walk test in these patients. Seventeen subjects with stable, symptomatic COAD were recruited, 15 (six men), 70-89 (mean 76) years, completed the study. Mean (standard deviation) 1-second forced expiratory volume (FEV1) = 49 (5)% predicted. Six-minute walk tests were repeated single-blind, 2-10 days apart. Quality of life was measured using Guyatt respiratory questionnaire. Patients underwent 12 weeks incremental respiratory rehabilitation (x4/day step-ups, unweighed arm raises, inflating balloons). Baseline 6-minute walk was repeatable and was correlated with the log Guyatt dyspnoea score (r = 0.65, p = 0.006). In multiple regression neither age nor FEV1 predicted walk distance: body mass index, maximal expiratory mouth pressure; calorie intake. Mean (SEM) 6-minute walk distance after-rehabilitation was greater than baseline (p = 0.003). Elderly patients with COAD tolerate intensive respiratory rehabilitation and a controlled, blinded study is needed.

Work hardening: evidence for success of a program

The effectiveness of a work hardening program in facilitating gains in physical strength and return to work in 40 chronic low back-pain clients was assessed. Statistically significant gains in physical strength were found. Also, 27 of the 32 clients reached by follow-up telephone calls returned to work full time.

In vivo study of indomethacin in bronchiectasis: effect on neutrophil function and lung secretion

Bronchiectasis is associated with sputum containing high levels of the proteolytic enzyme elastase, which is thought to be involved in the pathogenesis of the disease. Agents which inhibit neutrophil function and interfere with neutrophil elastase release may have a beneficial effect on the development and progression of such diseases. We have studied the effects of the nonsteroidal anti-inflammatory agent indomethacin on neutrophil function in nine patients with clinically stable bronchiectasis. All patients remained clinically stable during the study. We observed a significant reduction in peripheral neutrophil chemotaxis to 10 nmol.L-1 N-formyl-methionyl-leucyl-phenylalanine (FMLP) from a mean of 19.86 (SEM 1.35) to 8.46 (0.68) cells.field-1 after 4 weeks of therapy. There was also a significant reduction in fibronectin degradation both by resting and FMLP-stimulated neutrophils, from a mean of 1.90 (0.19) micrograms x 3 x 10(5) cells at the start of therapy to 0.87 (0.08) micrograms after 4 weeks, and from 3.17 (0.35) micrograms to 1.48 (0.05) micrograms, respectively. There was no effect on spontaneous or stimulated superoxide anion generation by neutrophils. Despite the marked changes in peripheral neutrophil function, no adverse effect was observed on viable bacterial load in the bronchial secretions. In addition, there was no difference in sputum albumin, elastase or myeloperoxidase levels, and only minor changes in the chemotactic activity of the sputum. These results suggest that nonsteroidal anti-inflammatory agents have a major effect on peripheral neutrophil function but do not appear to have an adverse effect on bacterial colonization of the airways.

In vivo study of indomethacin in bronchiectasis: effect on neutrophil function and lung secretion

Bronchiectasis is associated with sputum containing high levels of the proteolytic enzyme elastase, which is thought to be involved in the pathogenesis of the disease. Agents which inhibit neutrophil function and interfere with neutrophil elastase release may have a beneficial effect on the development and progression of such diseases. We have studied the effects of the nonsteroidal anti-inflammatory agent indomethacin on neutrophil function in nine patients with clinically stable bronchiectasis. All patients remained clinically stable during the study. We observed a significant reduction in peripheral neutrophil chemotaxis to 10 nmol.L-1 N-formyl-methionyl-leucyl-phenylalanine (FMLP) from a mean of 19.86 (SEM 1.35) to 8.46 (0.68) cells.field-1 after 4 weeks of therapy. There was also a significant reduction in fibronectin degradation both by resting and FMLP-stimulated neutrophils, from a mean of 1.90 (0.19) micrograms x 3 x 10(5) cells at the start of therapy to 0.87 (0.08) micrograms after 4 weeks, and from 3.17 (0.35) micrograms to 1.48 (0.05) micrograms, respectively. There was no effect on spontaneous or stimulated superoxide anion generation by neutrophils. Despite the marked changes in peripheral neutrophil function, no adverse effect was observed on viable bacterial load in the bronchial secretions. In addition, there was no difference in sputum albumin, elastase or myeloperoxidase levels, and only minor changes in the chemotactic activity of the sputum. These results suggest that nonsteroidal anti-inflammatory agents have a major effect on peripheral neutrophil function but do not appear to have an adverse effect on bacterial colonization of the airways.

The isolation and characterization of non-typeable Haemophilus influenzae from the sputum of adult cystic fibrosis patients

The role of non-typeable Haemophilus influenzae in cystic fibrosis (CF) remains unclear. We wanted, therefore, to determine the presence and characteristics of non-typeable H. influenzae in sputum samples from patients with CF. In order to do this, we have assessed sputum samples from 55 consecutive clinically stable patients seen routinely at an adult CF out-patient clinic. Quantitative bacterial culture was performed using a selective media containing cefsoludin, and isolates were characterized by biotyping and outer membrane protein profile analysis. In 17 (30%) of these samples, non-typeable H. influenzae was isolated and was present in similar viable numbers (mean 7.7 x 10(8) colony-forming units (cfu).mL-1; SEM 3.1) to Pseudomonas aeruginosa (mean 8 x 10(8) cfu.mL-1: SEM 2.4). All non-typeable H. influenzae isolates recovered were beta-lactamase negative and sensitive to a range of antibiotics. Several biotypes and outer membrane protein profiles were observed, with no apparent association between these two phenotypic characteristics. The study showed that large numbers of non-typeable H. influenzae are often present in sputum from adult patients with CF. Further longitudinal studies of outer-membrane protein profile analysis are required to determine the dynamics of non-typeable H. influenzae colonization in individual patients and the clinical significance.

The isolation and characterization of non-typeable Haemophilus influenzae from the sputum of adult cystic fibrosis patients

The role of non-typeable Haemophilus influenzae in cystic fibrosis (CF) remains unclear. We wanted, therefore, to determine the presence and characteristics of non-typeable H. influenzae in sputum samples from patients with CF. In order to do this, we have assessed sputum samples from 55 consecutive clinically stable patients seen routinely at an adult CF out-patient clinic. Quantitative bacterial culture was performed using a selective media containing cefsoludin, and isolates were characterized by biotyping and outer membrane protein profile analysis. In 17 (30%) of these samples, non-typeable H. influenzae was isolated and was present in similar viable numbers (mean 7.7 x 10(8) colony-forming units (cfu).mL-1; SEM 3.1) to Pseudomonas aeruginosa (mean 8 x 10(8) cfu.mL-1: SEM 2.4). All non-typeable H. influenzae isolates recovered were beta-lactamase negative and sensitive to a range of antibiotics. Several biotypes and outer membrane protein profiles were observed, with no apparent association between these two phenotypic characteristics. The study showed that large numbers of non-typeable H. influenzae are often present in sputum from adult patients with CF. Further longitudinal studies of outer-membrane protein profile analysis are required to determine the dynamics of non-typeable H. influenzae colonization in individual patients and the clinical significance.

Age and gender differences in students' preadmission qualifications and medical school performances

PURPOSE

To investigate the age- and gender-related differences in matriculants' preadmission performances and in their subsequent medical school performances.

METHOD

A longitudinal database was used to provide information on the 557 students in six entering classes (1984-1989) at the University of Kentucky College of Medicine. The preadmission variables were undergraduate science and cumulative grade-point averages (GPAs), Medical College Admission Test (MCAT) scores, and interview ratings. The medical school variables were GPAs for the four years of school and scores on the National Board of Medical Examiners Part I and Part II examinations. Age- and gender-related differences were analyzed by analyses of variance. To examine age differences, the students were grouped by age at matriculation: less than 23 years old, between 23 and 27, and 28 or older.

RESULTS

The younger matriculants had significantly higher undergraduate GPAs than did their older peers; however, their performances on the MCAT were nearly identical. The men had higher MCAT scores than the women in all age groups, but the older women had higher undergraduate GPAs than the older men. The younger students tended to have slightly higher medical school GPAs than the older students. No age differences were found for the NBME I and II, and no gender difference was found for the NBME II; however, a modest gender difference was found for the NBME I, with the men performing better than the women.

CONCLUSION

Dramatic age and gender differences were evident in the preadmission performances, while the differences in the medical school performances were much smaller.

A description of a new DR allele, DRB1*1113

We have discovered a previously unpublished HLA-DRB1 allele, observed in a patient (SB), his mother, and one sibling. The undefined allele gave sporadic positive reactions with sera in the DR52-associated group. SSOPH analysis utilizing both generic and group specific primers and probes also gave ambiguous results. SB typed clearly as a DRB1*0301 (paternal allele) but the DNA from SB also bound probes specific for DRB1*14 and DRB1*11. Sequencing revealed that the undefined allele was similar to a DRB1*14 allele with a segment of sequence found in DRB1*11 alleles. The patient was MLC reactive with donors who express DRB1*0301, *1401 and *0301, *11 and was nonreactive solely to DRB1*0301 (Dw3) homozygous typing cells.

Domestic violence in a primary care setting. Patterns and prevalence

OBJECTIVES

To determine the prevalence of domestic violence among women patients in a primary care setting, the types of violence experienced by each woman, and the reasons for their visit to the family physician.

DESIGN AND SAMPLE

Structured interviews with all consecutive, consenting women patients scheduled for morning appointments between July 26 and August 13, 1993.

SETTING

A community-based family practice residency outpatient clinic in a midwestern city with a population of 85,000.

RESULTS

Of the 42 women interviewed, 45% reported experiencing physical, social, and/or emotional violence in their relationships. Thirty-six percent reported being physically battered during their lifetimes; 12% reported being currently involved in a battering relationship. Relationships and patterns between various types of violence were evident. Sixty-two percent of the women who had experienced slapping and hitting (moderate abuse) also experienced punching and kicking (severe violence), some of which included sexual violence and weapon use. Women who were sexually abused were also likely to be emotionally abused (r = .66; P < .001), and women who were socially abused were also likely to be severely battered (r = .60; P < .005). None of the currently battered women was being seen for routine health maintenance reasons, but presented instead with specific complaints such as neck stiffness and migraine headache.

CONCLUSIONS

Domestic violence is very prevalent among women patients in primary care settings and involves predictable patterns of injury. Physicians should routinely assess for violence at all types of visits, educate patients about violence, and work to prevent the violence that occurs in abusive relationships.

Effects of family disruption on Southeast Asian refugee women

Identifying refugee women at a high risk of depression, anxiety and post-traumatic stress is an important role of the nurse, so that appropriate interventions--including family and community support--can be implemented. Below, an assessment of Southeast Asian refugee women experiencing emotional distress from the disruption of family ties that occurred during war, escape and resettlement.

Detection of hepatocellular carcinoma-specific alpha-fetoprotein by isoelectric focusing

BACKGROUND

Serum alpha-fetoprotein (AFP) is elevated in up to 80% of patients with hepatocellular carcinoma (HCC). Modestly raised AFP levels (10-400 ng/ml) are also found in patients with nonmalignant liver diseases. In the present study, isoelectric focusing of AFP was used to differentiate the AFP found in patients with HCC.

METHODS

To establish the assay conditions, isoelectric focusing was performed on sera from 14 patients with HCC and 13 with nonmalignant liver diseases. Sera was also analyzed under coded conditions from 16 patients with HCC, 14 with chronic active hepatitis (CAH), and 6 with cirrhosis to determine the specificity and sensitivity of the assay in the diagnosis of HCC.

RESULTS

Isoelectric focusing of sera from patients with HCC and various non malignant liver diseases identified AFP variants (AFP I-IV). All 14 patients with HCC had AFP variants I and III, and 7 of the 14 also had variant IV. When analyzed in the coded study 13 of the 16 cases of HCC were predicted correctly by the presence of AFP variants III or III and IV. AFP bands III and IV were not discernible in 12 of the 14 patients with CAH and 4 of the 6 with cirrhosis.

CONCLUSION

Isoelectric focusing of sera from patients with HCC and nonmalignant liver disease identified two AFP variants apparently specific for HCC. In the setting of borderline elevation of AFP, this technique has a sensitivity of 81% and specificity of 85% for detecting the presence of bands III or IV and may prove suitable for use in a routine laboratory as a screening assay.

Studies on the platelet surface-associated von Willebrand factor

The contribution of platelets to the prevention and control of bleeding depends not only on the plasma and vessel wall von Willebrand (vW) factor, but also on the vW factor originating from platelets. Although platelet vW factor is mainly stored in the alpha-granules, small amounts of vW factor have been detected on the platelet surface under conditions without direct stimulation. This communication focuses on the small amount of vW factor associated with the surface of platelets. EDTA-washed platelets in a calcium-free medium containing prostaglandin E1 (PGE1) were exposed to anti-vW factor F(ab')2 fragments. The platelet-associated anti-vW factor antibodies were separated from the free fragments by gel chromatography. Normal platelets were compared to platelets from patients with Bernard Soulier syndrome, Glanzmann's thrombasthenia, and Hermansky-Pudlak syndrome. These experiments showed that, in the absence of extracellular calcium, vW factor can be detected on the surface of washed platelets independent of glycoproteins Ib and IIb-IIIa, and despite markedly reduced intracellular calcium content. This particular platelet surface expression of vW factor is probably the result of disturbing the platelet during the in vitro manipulation. von Willebrand factor is an extremely important element in the multiple molecular interactions required to stop and anchor the platelet in areas of high flow rates. Mechanical perturbation of platelets leading to surface expression of the vW factor helps increase its availability for such critical interactions.

Sputum and serum pharmacokinetics of loracarbef (LY163892) in patients with chronic bronchial sepsis

Sputum and serum pharmacokinetics of loracarbef (LY163892) were performed in 19 patients with purulent bronchiectasis. Nine of the patients received 200 mg twice daily and ten patients, 400 mg twice daily, for a total of 14 days. beta-Lactamase activity was measurable in the lung secretions of all 19 patients at the start of therapy. Mean peak serum concentrations of 11.7 mg/L (S.E.M. 1.7) were recorded at 1 h after administration of 200 mg doses on day 2 of therapy and were 18.5 mg/L (S.E.M. 1.9) at 1.5 h in the 400 mg group. Loracarbef was shown to penetrate lung secretions even in the presence of beta-lactamase activity. Mean peak sputum concentrations were achieved between 2 and 4 h following dosing and were 0.2 mg/L (S.E.M. 0.05) in the 200 mg group and 0.4 mg/L (S.E.M. 0.08) in the 400 mg group. On days 7 and 14 of therapy, sputum loracarbef concentrations were similar 4 h after the morning dose (0.23 mg/L following 200 mg; 0.35 mg/L after 400 mg). These concentrations were approximately 2% of the peak serum concentration and penetration into lung secretions is similar to other beta-lactams.

Thinking about strategies during, before, and after making a decision

Two studies examined the impact of think-aloud and self-report instructions on the decision-making performance of young and older adults. Findings from Study 1 indicated that think-aloud instructions increased total time to decision for young and older adults but did not otherwise affect decision-making processes. Counter to predictions, the only significant interaction effect indicated that young adults in the think-aloud condition more frequently rechecked information than older adults. Findings from Study 2 confirmed the nonreactive nature of self-report methods. Despite potential age-related decrements in cognitive function, differences in functioning are not compounded and cannot be explained by the think-aloud or self-report instructions used by cognitive aging researchers.

Thinking about strategies during, before, and after making a decision

Two studies examined the impact of think-aloud and self-report instructions on the decision-making performance of young and older adults. Findings from Study 1 indicated that think-aloud instructions increased total time to decision for young and older adults but did not otherwise affect decision-making processes. Counter to predictions, the only significant interaction effect indicated that young adults in the think-aloud condition more frequently rechecked information than older adults. Findings from Study 2 confirmed the nonreactive nature of self-report methods. Despite potential age-related decrements in cognitive function, differences in functioning are not compounded and cannot be explained by the think-aloud or self-report instructions used by cognitive aging researchers.

Ongoing ischemic pain as a workload indexed by P3 amplitude and latency in real-versus feigned-pain conditions

We tested four independent groups: real pain, real pain/tracking, feigned pain, and feigned pain/tracking. After baseline (auditory oddball task only, .8/.2), the real pain groups had an ischemia cuff applied, which generated intense pain after 14 min. The pain feigners were instructed to simulate pain. The oddball task was repeated during low pain (6 min following cuff application) and during high pain (7-15 min following application). Real pain ratings were affected by low versus high pain and by tracking (reporting pain regularly), which elevated ratings. Nontracking feigned- and real-pain subjects differed in oddball-evoked P3 amplitude and latency during high pain. Oddball P3 amplitude decreased and latency increased from real low pain to high pain. Tracked but not untracked real low pain affected oddball P3 amplitude. Real and feigned pain-tracking subjects did not differ in P3 amplitude. P3 latency differed between real-pain and feigning subjects during low-pain tracking. A 91% individual hit rate (real vs. feign) obtained.

Technical note: an improved method to quantify nonesterified fatty acids in bovine plasma

Nonesterified fatty acids (NEFA) are measured routinely in the study of nutrition and growth physiology. To improve the efficiency with which this variable is measured, a two-reaction, enzymatic-based assay was adapted and validated to quantify NEFA in bovine blood plasma using 96-well microtiter plates. The effects of incubation time, temperature, and of sample volume were examined in addition to possible interfering substances, recovery, reagent stability, and range of linearity. Incubation for 30 min at 21 degrees C for each of the two reactions resulted in maximal slope and r2 values (1.94 and .999, respectively). Percentage of recovery was 107% when using 5 microL and 100% when using 10 microL of heparinized bovine plasma in the assay. Uniform linear standard curves (r2 > .99) were obtained using reagents stored at 4 degrees C for 9 d. An equal volume of 1 mM acetate, propionate, valerate, and butyrate added to plasma did not affect results. The assay was linear from 125 to > 1,000 microEq/L. Intra- and interassay CV for the 5-microL sample volume were 3.6 and 3.7%, respectively. This modified assay provides results comparable to the standard assay yet reduces reagent and labor requirements and increases sample capacity.

Oddball-evoked P300-based method of deception detection in the laboratory. II: Utilization of non-selective activation of relevant knowledge

We used a deception paradigm modeled on the type used for pre-employment screening procedures. Our novel dependent measure was P300 amplitude. Event-related potentials (ERPs) were recorded while subjects were presented with a list of eight antisocial acts one at a time, and one target-response phrase to which a 'yes' button press was required. Subjects were instructed to try to escape detection during the ERP test if they were guilty of any of the acts. After the ERP test, ground truth was established by the completion of an innocent/guilty check list of antisocial acts under perceived anonymous conditions tending to favor honest responding. Subjects were classified as innocent (n = 14) or guilty (n = 17) based on their check list response to the relevant act 'Used Falsified ID'. When comparing the P300 amplitudes in response to the relevant and to another act, we found that most group analyses revealed significant differences between guilty and innocent subjects. The subjects were also individually classified by a 3-step algorithm which involved: (1) a bootstrap amplitude test that compared the bootstrapped amplitudes of the P300s to the relevant and to another act; (2) relevant-to-target item P300 amplitude ratios; and (3) relevant act P300 amplitudes. Overall, the algorithm yielded 87% accuracy. The present study was intended to be an advance over our previous study (Rosenfeld, et al., 1991), in which we correctly classified 89% of the subjects using a similar P300-based deception detection paradigm. However, the possible confounding limitation of that study was that subjects had to complete an innocent/guilty check list of their antisocial acts prior to the ERP test. The present study investigated the accuracy of the P300-based test when subjects did not admit or selectively rehearse their guilt of the relevant act prior to the ERP test.