Children's Perceptions of the Ontario Student Nutrition Program (OSNP) in Southwestern Ontario, Canada

Purpose: This study aimed to explore children's lived experiences with the Ontario Student Nutrition Program (OSNP), a free, school-based snack program implemented in elementary schools in Southwestern, Ontario, Canada, to gain insights into future school food programs (SFP).Methods: Focus group discussions (n=17) were conducted with 105 children in Grades 5 to 8 in seven elementary schools. Focus groups were audio-recorded, transcribed, and coded for themes using inductive content analysis.Results: Overall, children appreciated the OSNP and felt that it filled a need in students. Children also reported a willingness to try novel food items. For future SFPs, participants recommended that input be sought from children to ensure food preferences were considered. Children also discussed wanting more appealing food offerings that may include some choice. Finally, children also mentioned wanting a fair and equitable distribution of food in classrooms.Conclusions: Children appreciated the OSNP and reported benefits to themselves and their peers. They also provided some valuable recommendations for future SFPs. If a nationally funded SFP is to be considered in Canada, children expressed the need to make the program equitable, while still allowing schools the flexibility to meet their unique needs and preferences.

Process evaluation of the Centrally Procured School Food Program (CPSFP) in Ontario, Canada: school-level perspectives

This study explored the implementation of the Centrally Procured School Food Program (CPSFP)-a free, universal, volunteer-led snack program for elementary school children. To assess participants' perceptions and experiences with the CPSFP, interviews were conducted in school-level participants (n = 33) using a semi-structured interview guide. Fifteen on-site visits also were conducted at each school to observe implementation practices. Quantitative data were obtained through a general information form where participants provided school characteristics and weekly logbooks where they described program operations and food quality. Most participants expressed positive perceptions of the CPSFP, identifying it as a valuable program for their students. Successful program implementation was associated with an appreciation for the CPSFP and the participation of the school community. Challenges to program implementation included concerns with the volume and types of food provided, issues with classroom food delivery and distribution and communication challenges. Suggestions for improvement included building capacities and enhancing student engagement in the program. Participants provided an in-depth assessment of the implementation of the CPSFP. The lessons learned and suggestions provided may help not only enhance the reach, feasibility and fidelity of the CPSFP, but inform the best practices for similar programs.

Sixty Percent of Foods Advertised in Grocery Store Flyers are Not In-line with Canada's Food Guide

Purpose: To evaluate foods advertised in discount and premium grocery flyers for their alignment with Canada's 2007 Food Guide (CFG) and assess if alignment differed by food category, season, page location, and price.Methods: Weekly flyers (n = 192) were collected from discount and premium grocery chains from each of 4 seasons. Health Canada's Surveillance Tool was used to assess food items as in-line or not in-line with CFG.Results: Of 35 576 food items, 39.7% were in-line with CFG. There were no differences in proportions of foods not in-line in discount versus premium flyers (60.9% and 60.0%, respectively). Other Foods and Meat & Alternatives were advertised most (28.0% and 26.3%, respectively; P < 0.001). Milk & Alternatives were the least advertised food group (10.3%). Vegetables & Fruit (19.6%), Grains (21.6%), Milk & Alternatives (20.6%), and Meat & Alternatives (20.2%) were promoted least in Fall (P < 0.001). A higher proportion of foods advertised on middle pages were not in-line (61.0%) compared with front (56.6%) and back (58.8%) pages (P < 0.001). Not in-line foods were more expensive ($3.49, IQR = $2.82) than in-line foods ($3.28, IQR = $2.81; P < 0.001).Conclusions: While there was no difference in healthfulness of foods advertised in discount versus premium flyers, grocers advertised more foods not in-line with CFG. Government policies to improve the food environment should consider grocery flyers.

"My Roommates Would Laugh at me": Young Males Reveal Embarrassment over Lack of Food Skills

Purpose: This descriptive qualitative study explored young males' perceptions of food skills in 3 domains: food selection and planning, food preparation, and food safety and storage.Methods: Semi-structured interviews were audio-recorded and transcribed verbatim. Data were analyzed using the constant comparative method.Results: Forty-four young men (aged 17-35) reported varying levels of food skills, from little/no confidence to very confident and skilled. Most participants learned food skills from their mothers. Greater involvement in food selection and planning at a young age appeared to be related to parental influence and encouragement, exposure to food skills at school, and interest in food-related activities, which, in turn, provided a solid foundation for being confident cooks as young adults. Most notable was the lack of knowledge about, or confidence in, food safety and storage. Young men with low self-perceived food skills were deeply embarrassed about this deficiency in front of peers who had higher levels of confidence and skills.Conclusions: Future interventions or curricula should emphasize food safety and storage. This research also illustrates the importance of the home environment in teaching food skills to youth and ensuring that food skills are taught well before young adults begin living independently.

Using the Food Skills Questionnaire (FSQ) to Evaluate a Cooking Intervention for University Students: A Pilot Study

Purpose: To pilot test the Food Skills Questionnaire (FSQ) to evaluate a cooking intervention.Methods: Students attending Western University were invited to participate in 3 cooking classes over a 3-month period. All participants were asked to complete the FSQ pre- and post-intervention. The FSQ evaluated food skills in 3 domains-Food Selection and Planning, Food Preparation, and Food Safety and Storage-with a maximum score of 100 per domain. Domain scores were then computed as a weighted average for the Total Food Skills Score out of 100. Open-ended questions assessed participants' perceptions of the classes.Results: Forty-four students participated. There was a significant increase in food planning (70.6 ± 13.5-77.6 ± 14.3, P < 0.01), food preparation (67.5 ± 14.0-74.9 ± 12.9, P < 0.01), food safety (78.0 ± 9.9-80.8 ± 13.0, P = 0.04), and total food skills (71.9 ± 8.9-77.8 ± 10.6, P < 0.01) post-intervention. Content analysis of open-ended questions indicated that participants enjoyed healthy recipes, supportive Peer Educators, discussions, the cooking experience, socializing, and the safe environment.Conclusions: The FSQ shows strong potential for evaluating basic (e.g., peeling, chopping, slicing) to intermediate (e.g., meal planning) food skills in an effective and feasible manner. It can also capture changes in specific domains, allowing the development of more focused nutrition education and skills-based interventions.

Participating in Faculty-Supervised Extracurricular Experiential Learning Activities Contributes to Dietetic Competency Development

Purpose: To examine the relationship between Food and Nutrition graduates' involvement in faculty-supervised extracurricular experiential learning activities (FEEs) and the development of dietetic competencies. Methods: An original web-based survey, assessing involvement in FEEs and self-perceived level of Canadian dietetic competencies, was administered to Brescia University College Food and Nutrition graduates for graduation years 2011-2017. Competency scores were calculated for each respondent in 4 practice areas (Professional Practice, Communication and Collaboration, Population and Public Health, and Management), and summed for a Total Competency Score. Multiple linear regressions were used to assess predictors of competency scores. Results: The final sample consisted of 233 respondents who participated in 1.9 ± 1.1 FEEs. The highest average competency score (out of 100) was Communication and Collaboration (59.7 ± 31.7); the lowest was Management (40.3 ± 30.9). Total hours spent and breadth of experiences in FEEs were significant predictors of all scores (P < 0.05). Depth of experiences was a significant predictor of all competency scores (P < 0.05) except for Management (P = 0.27). Conclusions: Participation in FEEs contributes to Food and Nutrition students' development of entry-level dietetic competencies; therefore, counting some FEEs as curricular credits may be warranted. Given the prominence of competency-based learning assessments, these results also have implications for faculty resources, budgets, and collective agreements.

Validity and Reliability of a Food Skills Questionnaire

OBJECTIVE

Develop, validate, and assess reliability of a food skills questionnaire.

DESIGN

Phase 1: Questionnaire development categorized questions into domains (Food Selection and Planning, Food Preparation, and Food Safety and Storage). Phase 2: Content validity included expert panel quantitative and qualitative feedback. Phase 3: Face validity involved pilot testing. Phase 4: Reliability assessed test-retest and inter-item reliability.

SETTING

Phase 1: The authors developed a draft questionnaire in London, Ontario, Canada.

PARTICIPANTS

Phase 2: Dietitians, home economists, academics, and chefs completed content validity (n = 17; 57% response rate). Phase 3: A convenience sample of students completed face validity (n = 20; 17% response rate). Phase 4: Randomly selected students completed test-retest reliability (time 1: n = 189, time 2: n = 165; 9% response rate).

MAIN OUTCOME MEASURES

Lawshe content validity ratio, Lawshe content validity index, intraclass correlation coefficients (ICCs), and Cronbach α.

ANALYSIS

Test-retest reliability was evaluated using ICC, and inter-item reliability by Cronbach α coefficient.

RESULTS

In phase 2, Lawshe content validity index was 0.80 (90% expert panel consensus). In phase 3, 85% of respondents identified the main construct. In phase 4, Cronbach α coefficients were .67-.88 for domains and .90 for the questionnaire overall, and ICC scores ranged from 0.67-0.92 for questions, 0.86-0.93 for domains, and 0.92 for the questionnaire overall.

CONCLUSIONS AND IMPLICATIONS

This questionnaire demonstrated strong content validity, face validity, test-retest reliability, and good inter-item reliability. It is appropriate for evaluating food skills in a population with basic to intermediate skills (eg, young adults).

Predictors of Food Skills in University Students

Purpose: To determine predictors of food skills in university students, specifically, the relative effects of a food and nutrition (FN) course; sex, age, and body mass index; food-related behaviours in the parental home; and food-related behaviours in university. Methods: Undergraduate students (n = 30 310) at Western University were invited to complete an online cross-sectional survey that assessed 7 components of food skills, from mechanical (e.g., peeling/chopping) to conceptual (e.g., weekly meal planning). The primary outcome measure was Total Food Skills Score (TFSS). All variables that were statistically associated with TFSS (P < 0.05) were analyzed hierarchically in 4 regression models. Results: The sample was comprised of 3354 students living independently for 2.6 ± 1.1 years. Students who had taken an FN course had higher food skills than those who had not (B = 30.72; P < 0.001), and this relationship remained significant through all subsequent models. The strongest predictor of food skills was meal preparation as a teen (B = 25.66; P < 0.001). Frequency of using a grocery list, packing a lunch, and time spent preparing meals on weekends were positively associated with food skills (P < 0.001), whereas frequency of buying pre-prepared meals was negatively associated with food skills (P < 0.001). Conclusions: Food skill development should occur well before young adults begin living independently.

Point-of-Purchase Labels and Reward Cards Improve Sales of Healthy Foods in University Dining Halls

Purpose: To compare sales of Food Resources and Education for Student Health (FRESH) Approved versus non-FRESH Approved menu cycle items pre- and postimplementation of the FRESH program.

Methods: Sales data from 2011–2015 of FRESH Approved versus non-FRESH Approved menu items were analyzed. Fruit and milk items sold, net sales, and the cost of free fruit and milk redeemed through the FRESH Reward Card (FRC) program, were also analyzed.

Results: FRESH Approved items sold more often than non-FRESH Approved items in the latter 2 years (P = 0.01). Prices of FRESH Approved menu items were significantly lower than non-FRESH Approved items for all years (e.g., $1.52 ± $0.94 vs $2.21 ± $1.02 per serving in 2014–2015; P < 0.001). Across all FRESH implementation years, FRESH Approved menu items were found more often on the 6-week menu (P < 0.05). The number of fruit items sold increased from a baseline of 143 052 to 170 954, and net sales increased from $135 450 to $154 248 after 3 years of the FRC implementation.

Conclusions: FRESH Approved items were less expensive, available more often, and had higher sales. The FRC increased net fruit sales despite the cost of free fruit. Highlighting and reducing the cost of healthy foods are promising practices to improve campus food environments.

Factors that influence excessive gestational weight gain: moving beyond assessment and counselling

One in four Canadian adults is obese, and more women are entering pregnancy with a higher body mass index (BMI) than in the past. Pregnant women who are overweight or obese have a higher risk of pregnancy-related complications than women of normal weight. Gestational weight gain (GWG) is also associated with childhood obesity. Although the factors influencing weight gain during pregnancy are multifaceted, little is known about the social inequality of GWG. This review will address some of the socioeconomic factors and maternal characteristics influencing weight gain and the impact that excessive GWG has on health outcomes such as post-partum weight retention. The effects of an overweight or obese pre-pregnancy BMI on GWG and neonatal outcomes will also be addressed. The timing of weight gain is also important, as recommendations now include trimester-specific guidelines. While not conclusive, preliminary evidence suggests that excessive weight gain during the first trimester is most detrimental.

University Students Intend to Eat Better but Lack Coping Self-Efficacy and Knowledge of Dietary Recommendations

OBJECTIVE

To assess university students' knowledge, intentions, and coping self-efficacy related to dietary recommendations.

DESIGN

The study used a cross-sectional online survey.

SETTING

Large university campus.

PARTICIPANTS

Students (n = 6,638; 22% response).

VARIABLES MEASURED

Self-efficacy and intentions were measured using 11-point scales. Students' perceived dietary recommendations were evaluated as correct or incorrect.

ANALYSIS

Categorical variables were analyzed using chi-square and continuous variables by t tests or ANOVAs. Significance was set at P ≤ .05 and multiple comparisons at P ≤ .01.

RESULTS

Respondents believed that they need fewer vegetables and fruit and more milk or alternatives servings/d than recommended; eg, males aged ≥ 19 years perceived milk or alternatives recommendations to be 4.3 ± 2.1 servings/d, significantly more than the 2 servings/d recommended (P < .001). Students in health sciences or with a food or nutrition course were significantly more likely to claim that they met recommendations (eg, 56% with vs 47% without a food or nutrition course for vegetables and fruit; P < .001); however, they were no more likely to identify them correctly. Males aged < 19 years had higher coping self-efficacy than females aged < 19 years to consume vegetables (68.3 ± 24.2 vs 64.0 ± 24.7; P < .01) and avoid high-calorie foods and beverages (HCFB) (56.2 ± 27.2 vs 49.0 ± 25.2; P < .01) when under stress; however, they had significantly lower intentions to consume vegetables (72.1 ± 24.5 vs 80.9 ± 20.3; P < .01) and avoid HCFB (60.5 ± 30.3 vs 77.7 ± 22.8; P < .01).

CONCLUSIONS AND IMPLICATIONS

Students do not have adequate knowledge of age- and sex-specific food guide recommendations. Simpler food guide recommendations or age- and sex-targeted campaigns may enhance knowledge. Students intend to consume more vegetables and less HCFB; however, they have low coping self-efficacy, all of which could be targeted in nutrition interventions.

Development and implementation of FRESH--a post-secondary nutrition education program incorporating population strategies, experiential learning and intersectoral partnerships

OBJECTIVES

The FRESH (Food Resources and Education for Student Health) peer nutrition education program engages undergraduate and graduate students in experiential learning to improve the campus food and nutrition environment and promote healthy behaviours among university students.

TARGET POPULATION

University students in general, and graduate and undergraduate food and nutrition students as program designers and peer educators, respectively.

SETTING

Large university campus in southwestern Ontario.

INTERVENTION

A peer nutrition education program, utilizing multiple population strategies and intersectoral partnerships, was created by and for university students with faculty and food service personnel as mentors. The population health strategies employed were building awareness and program branding; developing personal skills through peer nutrition education and hands-on cooking demonstrations; and creating supportive environments through incentive programs for fruit and dairy as well as point-of-purchase menu labelling.

OUTCOMES

The program has reached students, staff and faculty through over 60 interactive FRESH displays and education sessions. Website and social media have also had a significant reach with over 4,000 website visits and 277 Facebook "likes". FRESH has also improved the food environment for over 5,000 students in residence, e.g., 1,931 FRESH Fruit/Dairy Cards have been returned for free fruit/milk cartons. Graduate students in Foods and Nutrition continue to participate every year (cumulative n=60) in ongoing program development. Peer educators have developed enhanced leadership, public speaking and group facilitation skills, and the ability to creatively apply what they have learned in the classroom to new contexts.

CONCLUSION

Increased nutrition knowledge and an improved food environment could, over the long term, support improved university student health.

Exercise dysfunction in patients seropositive for the human immunodeficiency virus

To confirm the presence of exercise dysfunction in patients seropositive for the human immunodeficiency virus (HIV), 32 such patients without AIDS were evaluated with cardiopulmonary exercise testing, pulmonary function testing, bronchoalveolar lavage, chest roentgenography, and gallium scanning. No evidence of pulmonary opportunistic infection was found. When compared to an otherwise similar group of HIV-seronegative controls, the patients exercised to a significantly lower workload (195 +/- 30 versus 227 +/- 31 W, p less than 0.001). The ventilatory anaerobic threshold (VAT) values were also significantly lower for the patients (49.2 +/- 13.0 versus 61.9 +/- 9.1% of maximum predicted VO2, p less than 0.001). Nine of the patients had VAT values less than the 95% confidence interval for the controls. This subgroup exercised to a significantly lower maximum VO2 (69.9 +/- 11.2 versus 95.9 +/- 17.5% of maximum predicted VO2, p less than 0.001) and workload (165 +/- 21 versus 227 +/- 31 W) when compared to the control group. These patients demonstrated a mild tachypnea throughout exercise relative to the controls and had a significant increase in the slope of the heart rate to VO2 relationship. These findings are most consistent with a limitation of oxygen delivery to exercising muscles, which may represent occult cardiac disease in this group.

Exercise responses during incremental and high intensity and low intensity steady state exercise in patients with obstructive lung disease and normal control subjects

A study was undertaken to compare the cardiac and ventilatory responses to different types of exercise between 12 patients with COPD and ten normal age-matched control subjects. Both groups attained comparable heart rates and the percentage of their maximum predicted heart rate. Patients had a higher heart rate and VE with a lower O2P at every level of work load. Patients had a mean VT which approximated their FEV1 and increased their VE predominantly by increasing their respiratory frequency. During the low intensity test, despite the differences in work load, the patients had comparable heart rates and VE. No resting spirometric value accurately predicted work load, VE, or maximal VO2. We conclude that patients have a reduced work tolerance that is not adequately explained by their reduced lung function. Thus, cardiac factors, deconditioning, and the dyspneic sensation may be determinants of exercise limitation in some patients.

A comparison between a conventional and a fiberoptic flow-directed thermal dilution pulmonary artery catheter in critically ill patients

Invasive hemodynamic monitoring is frequently required in the management of patients in intensive care units. A fiberoptic flow-directed thermal dilution pulmonary artery catheter capable of continuously monitoring the mixed venous saturation, while more expensive than a conventional pulmonary artery catheter, theoretically could result in better patient care, and might be cost-effective if it resulted either in fewer blood tests being ordered or in less time in the intensive care unit. To test this hypothesis, we designed a randomized trial in our Medical Intensive Care Unit to compare a standard pulmonary artery catheter with a fiberoptic catheter. Twenty-six patients received a standard catheter and 25 patients received the fiberoptic catheter. There were no statistical differences between the groups in age, time in the intensive care unit, number of tests ordered, hours of mechanical ventilator therapy, hours of vasoactive drug therapy, or mortality rate. The only statistically significant differences between the groups were that (1) the fiberoptic catheter required a longer insertion time and (2) there were more technical problems in consistently obtaining the wedge pressure in the patients with the fiberoptic catheters. We conclude that routine substitution of a fiberoptic catheter for the standard pulmonary artery catheter is not indicated.

Transbronchial biopsy without fluoroscopy. A seven-year perspective

The use of fluoroscopic guidance for transbronchial biopsy (TBB) during flexible fiberoptic bronchoscopic examination has been controversial. Patient records and bronchoscopy reports for 112 transbronchial biopsies performed with fluoroscopy over a seven-year period were reviewed and compared with those of 135 transbronchial biopsies performed without fluoroscopy over the same interval. Complication rates with regard to pneumothorax, fever, and hemorrhage were compared, as were yield data for neoplasm, sarcoidosis, and other miscellaneous pulmonary diagnoses. Complication rates were low in both groups and not statistically different; yield data were likewise comparable, particularly in diffuse neoplasm and sarcoidosis. This report suggests that TBB without fluoroscopy (in the basilar segments) is safe and that diagnostic yield, particularly in sarcoidosis and diffuse neoplasm, is good.

Improving house staff ordering of three common laboratory tests. Reductions in test ordering need not result in underutilization

Most studies of modifying test ordering have focused on costs. Questions not addressed are whether programs to reduce testing lead to a higher proportion of clinically indicated tests and is underutilization an adverse outcome of such programs? To investigate this, we studied the house staff's ordering of three common laboratory tests at baseline and after educational and administrative interventions. Over a 2-year period, 3,603 urine cultures, sputum cultures, and admission urinalyses were reviewed. A lecture emphasizing the indications for these tests followed by chart audit and weekly feedback increased the proportion of clinically indicated tests. Subsequently, an administrative intervention requiring the intern to list the reason for ordering the test on the laboratory request form further improved test ordering. Underutilization, defined as a failure to order a potentially indicated test, was assessed during two representative periods. The "underutilization rate" (omitted tests per 100 patients) was no worse during maximal intervention than it was 9 months after the last intervention (7.7 vs. 11.1, NS). No immediate adverse consequences resulted from tests not ordered. Our findings indicate that it may be possible to selectively reduce the ordering of unnecessary tests without sacrificing quality of care.

Microprocessor exercise physiology systems vs a nonautomated system. A comparison of data output

Several microprocessor exercise physiology systems have been introduced recently. Comparison of the data output between these systems and more traditional nonautomated systems has not been reported extensively. Twelve normal adult men were exercised in random sequence on different days on a Sensormedics MMC Horizon system, the Medical Graphics Corporation System 2000, and a nonautomated system. heart rate, minute ventilation, tidal volume, respiratory frequency, oxygen consumption, and carbon dioxide production were compared at each level of work during a maximal incremental test and during a constant work load test. The overall data output between the three systems was comparable. However, minute ventilation was consistently higher on the Medical Graphics system, oxygen consumption was consistently lower on the Horizon system, and a technical error was discovered in the Medical Graphics system which resulted in a systematic overestimation of carbon dioxide production. Different methods of analyzing the data from the same test (60-s average, 15-s average, breath-by-breath, and 8-breath average) resulted in differences of up to 20 percent in the maximal values. This was greater than the differences between the three systems. Despite the comparability of the data output, important differences did exist which can be potentially significant when data output from one system are compared to predicted normal values obtained under different conditions.

Diagnosis of parenchymal Hodgkin's disease using bronchoalveolar lavage

The usefulness of bronchoalveolar lavage in the diagnosis of parenchymal Hodgkin's disease is illustrated in this case report. Recovery of characteristic Reed-Sternberg cells from the lavage fluid may serve as both a diagnostic and staging procedure and potentially may obviate more invasive steps such as thoracotomy.

Thoracic computed tomography in the preoperative evaluation of primary bronchogenic carcinoma

One hundred seventy-four patients with bronchogenic carcinoma underwent computed tomography (CT) as part of their preoperative evaluation. Overall, CT had a sensitivity of 86%, a specificity of 78%, and an accuracy of 81% in identifying mediastinal lymph node metastases. In patients with a central tumor, the sensitivity was 93%, the specificity 74%, and the accuracy 83%. In patients with a peripheral tumor, the respective percentages were 55%, 82%, and 77%. Only 11 of 66 patients with a peripheral tumor had mediastinal metastases, and five of these patients had a normal CT scan. Conversely, 43 of 64 patients with a central tumor and mediastinal lymph node enlargement on the CT scan had unresectable disease, compared with only one of 44 patients without such enlargement. We conclude that CT is not useful in the evaluation of patients with a peripheral tumor; however, it is useful in determining which patients with a central tumor do not require a surgical staging procedure prior to thoracotomy.

The admission urinalysis: impact on patient care

Although urinalysis is one of the most frequently ordered tests in primary care, its usefulness in screening has not been demonstrated. A retrospective review of 1,607 admission urinalyses for inpatients in a referral/community hospital identified 861 as clinically indicated and 746 as routine. Routine urinalyses were abnormal less frequently than clinically indicated urinalyses (18.1% vs 39.6%) and when abnormal, were responded to less often (33.3% vs 75.4%). Forty-five (6.0%) of the routine urinalyses yielded an abnormality that led to diagnostic action. Of these, 18 were normal on repeat testing and 17 were considered unlikely to represent significant disease. Therefore, only ten (1.3%) of the routine urinalyses affected patient therapy. In eight of these cases, the abnormality was pyuria, of which six proved to be asymptomatic bacteriuria. The admission urinalysis as a routine test had little impact on patient care in the authors' institution.

Rounded atelectasis: a new criterion for benignancy

A malignancy must be considered whenever a mass lesion is encountered on a chest roentgenogram. Unless an unequivocal diagnosis of a benign lesion is made, thoracotomy is usually indicated. Rounded atelectasis, while only having been recently described, is being encountered with increasing frequency. As illustrated by our three cases, radiologic diagnosis of this entity is a major criterion for judging the benignity of a mass and obviates the need for a thoracotomy.

Zinc chloride (smoke bomb) inhalational lung injury

Physicians, military and civilian alike, may be called upon to recognize, treat, and provide long-term care to patients who have suffered a zinc chloride (smoke bomb) inhalational injury. Pathologic changes described in the literature include laryngeal, tracheal, and bronchial mucosal edema and ulceration; interstitial edema; interstitial fibrosis; alveolar obliteration; and bronchiolitis obliterans. Acute injury is associated with a high mortality. Following is a report of a patient with a zinc chloride smoke injury which resulted in subpleural emphysematous blebs complicated by pneumothorax and abnormal exercise physiology. Gradual recovery occurred over several months. However, the chest roentgenogram remains abnormal with emphysematous blebs.

Lung cancer. An update

Lung cancer is the leading cause of cancer mortality in the United States in 1985. Early diagnosis and an aggressive surgical approach offer the best chance for a cure. Unfortunately, the majority of patients will be diagnosed after the disease has metastasized. Radiation therapy and chemotherapy, despite recent advances, are still basically palliative modalities. The most efficacious approach to the control of lung cancer is an effective anti-smoking campaign.

Nifedipine does not alter methacholine-induced bronchial reactivity

Calcium ions have been shown to be involved in smooth muscle contraction and various secretory processes. Nifedipine, a calcium channel blocking drug, does not have any intrinsic bronchodilatory effect, but it has been suggested to possibly inhibit bronchial reactivity. Eight patients, with normal baseline pulmonary function studies and methacholine-induced bronchial reactivity, had a repeat metacholine challenge after nifedipine. Spirometry was obtained at baseline and three minutes after successive inhalations of normal saline and five, 15, 30, 50, 100 and 200 inhalation units of 0.5% methacholine. Plethysmographic lung volumes and airways resistance were measured at the start of the test and after the last inhalation of methacholine. The FEV1, FVC, MMEF and PEFR were reduced by an average of 35.6%, 20.6%, 54.4% and 30.6%, respectively, on the initial study, and by 35.4%, 20.5%, 54.8% and 34.5% after nifedipine. Airways resistance was increased by 249.3% in the initial study and by 265.7% after nifedipine. There was no statistical difference in baseline spirometry, spirometry obtained at any level of methacholine inhalation, or in airways resistance between the two studies. Despite comparable decreases in lung function, all patients were less symptomatic after receiving nifedipine. Nifedipine does not alter methacholine-induced bronchial reactivity. Until the role of nifedipine in asthma is better defined, caution should be used in prescribing nifedipine to asthmatic patients with heart disease, because their perception of airways resistance may be altered.

Endobronchial tuberculosis simulating lung cancer

Endobronchial tuberculosis, while relatively common before the advent of effective antituberculosis chemotherapy, is seldom recognized now. Four patients with what appeared to be primary tuberculosis complicated by endobronchial spread were recently seen by us. Three of the four patients presented with anterior segment upper lobe disease with partial segmental collapse. Clinically and roentgenographically, all four patients were felt to have primary bronchogenic carcinoma. Definitive diagnosis was established via the fiberoptic bronchoscope. The declining incidence of tuberculosis in the United States has altered the clinical and roentgenographic presentation. The diagnosis of tuberculosis should be considered even when the clinical features are atypical.

Methacholine challenge test

Methacholine challenge has been proposed as a diagnostic test in situations where clinical asthma is suspected but reversible airway obstruction cannot be demonstrated spirometrically. Methacholine challenge was used in 14 patients with suspected asthma and five normal controls. Eight individuals (six patients and two controls) had a reduction in the forced expiratory volume at 1 s (FEV1) of 20% or more with 100 inhalation units (IUs) of methacholine; seven additional individuals (six patients and one control) met one or more of the American Thoracic Society's criteria for a positive bronchoprovocation test; and four individuals (two patients and two controls) were not sensitive to methacholine by any criteria. The diagnosis of asthma can be excluded if methacholine does not induce reversible obstruction. However, provocation of reversible obstruction with methacholine is not specific for asthma. More stringent criteria, such as reduction of FEV1 by 20% by 20 IUs of methacholine, would be less sensitive but more specific for asthma.

Thoracic CT scanning in the staging of bronchogenic carcinoma

The use of thoracic CT scans in the staging of bronchogenic carcinoma has been controversial. Previous studies have resulted in conflicting conclusions concerning the incidence of false positive and false negative scans. We attempted to determine if thoracic CT scans were of value in staging bronchogenic carcinoma using objective criteria and in a clinical situation applicable to most modern medical centers. Forty-eight patients who had a staging mediastinoscopy and/or thoracotomy and a CT scan prior to surgery were studied. Twenty-eight had evidence of mediastinal node enlargement on CT scan, and 19 of those patients had metastatic disease confirmed. One of 20 patients without evidence of mediastinal lymph node enlargement on CT scan had lymph node metastases at surgery. The CT scan was 68.0 percent specific, 95.0 percent sensitive, and 79.2 percent accurate in predicting mediastinal neoplastic involvement. No difference was noted between left upper lobe tumors and tumors arising in other areas of the lung. We conclude that the third generation chest CT scan is extremely sensitive in identifying enlarged mediastinal lymph nodes, but this is not specific for metastatic disease. Patients with a positive chest CT scan should have pathologic confirmation of metastatic disease with a surgical staging procedure. Patients with a negative chest CT scan, however, can be taken directly to thoracotomy.

Sarcoidosis. Reversal of respiratory failure 21 years after onset of disease

Patients with sarcoidosis who have roentgenographic evidence of interstitial lung disease for several years are assumed to have irreversible disease. Respiratory failure in this setting is usually ascribed to end-stage pulmonary fibrosis. We describe a 62-year-old man with this condition. Treatment with prednisone resulted in a dramatic improvement in both symptoms and respiratory values.

Exercise testing in pulmonary sarcoidosis

The variable natural history of sarcoidosis and the toxicity of corticosteroids result in many clinical situations where there is controversy concerning the need for treatment. Progressive incremental testing is an excellent method to identify physiologic mechanisms responsible for exercise limitation. It is therefore ideal to determine if subjective symptoms such as dyspnea are due to cardiac abnormalities, pulmonary abnormalities, or poor physical conditioning. Thirty-one patients with sarcoidosis underwent progressive incremental exercise testing. Four of 14 asymptomatic patients and eight of 17 symptomatic patients demonstrated pulmonary abnormalities which potentially limited exercise tolerance. These consisted of an abnormal respiratory pattern or gas exchange abnormalities, or both. Patients with completely normal routine pulmonary function studies almost always performed normally with exercise. Symptomatic patients with multiple abnormalities on routine pulmonary function studies invariably demonstrated a pulmonary limitation on exercise testing. Patients with one or two abnormalities on routine pulmonary function studies, regardless of the presence or absence of parenchymal infiltrates, required exercise testing to determine if symptoms were due to physiologically significant abnormalities of the respiratory system. The important variables necessary to be measured, arterial desaturation and an abnormal respiratory pattern, can be measured noninvasively with a minimum of equipment.

Bullous emphysema. Progressive incremental exercise testing to evaluate candidates for bullectomy

Various tests of both function and anatomy have been used in patients being considered for surgical resection of giant pulmonary bullae. A young patient had an excellent response to removal of a large bulla in the right lung. In addition to roentgenographic evaluation, ventilation perfusion scanning, and routine preoperative pulmonary function studies, we performed progressive incremental exercise testing to determine both preoperative and postoperative ventilatory and cardiac measurements. We feel that progressive incremental exercise pulmonary function adds another dimension to the selection and follow-up of patients being considered for operative bullectomy.

Hernia of Morgagni's foramen presenting as asymptomatic pleural mass

An asymptomatic 64-year-old black man presented with an enlarging left pleural mass. Preoperative evaluation failed to reveal an etiology. At thoractomy omental fat was found along the diaphragm, extending to the left costophrenic angle, and protruding through a hernia of Morgagni's foramen. The omentum was replaced into the abdomen and the defect was repaired.

Idiopathic bronchial stenosis in a young woman

An 18-year-old white woman presented with a severe obstructive ventilatory defect. An evaluation revealed a stenotic lesion of the right bronchus intermedius and the left mainstem bronchus. Treatment with prednisone followed by beclomethasone resulted in a marked improvement in her condition.