Peak inspiratory flow through Diskus and Turbuhaler, measured by means of a peak inspiratory flow meter (In-Check DIAL®)

AbstractWith a handheld peak inspiratory flow (PIF) meter (In-Check DIAL®), the internal resistance of the Diskus® (DKR) and the Turbuhaler® (THR) can be simulated by means of calibrated resistances. This study investigated whether patients with asthma or chronic obstructive pulmonary disease could generate a PIF which is optimal for the Diskus (DK) (30 l/min) and the Turbuhaler (TH) (60 l/min). Peak expiratory flow (PEF) and maximal inspiratory pressure (MIP) were also assessed. All 50 patients (30 males, mean age 56.9) achieved the required flow of 30 l/min with the DKR, while six patients (five females) could not generate the optimal flow of 60 l/min via the THR. Analysis showed that MIP was an independent predictor of an adequate PIF through the THR. During the study, eight patients were treated for an exacerbation of which four could not generate an adequate PIF via the THR. Analysis showed that the female gender and an exacerbation appeared to be independent predictors of the inability to generate an adequate PIF via the THR. Twelve per cent of patients (25% of females) could not generate the optimal inspiratory flow via the THR. When in doubt whether the patient can generate an adequate inspiration, measurement with the In-Check DIAL® is recommended

Mixture randomized item-response modeling:a smoking behavior validation study

Misleading response behavior is expected in medical settings where incriminating behavior is negatively related to the recovery from a disease. In the present study, lung patients feel social and professional pressure concerning smoking and experience questions about smoking behavior as sensitive and tend to conceal embarrassing or threatening information. The randomized item-response survey method is expected to improve the accuracy of self-reports as individual item responses are masked and only randomized item responses are observed. We explored the validation of the randomized item-response technique in a unique experimental study. Therefore, we administered a new multi-item measure assessing smoking behavior by using a treatment–control design (randomized response (RR) or direct questioning). After the questionnaire, we administered a breath test by using a carbon monoxide (CO) monitor to determine the smoking status of the patient. We used the response data to measure the individual smoking behavior by using a mixture item-response model. It is shown that the detected smokers scored significantly higher in the RR condition compared with the directly questioned condition. We proposed a Bayesian latent variable framework to evaluate the diagnostic test accuracy of the questionnaire using the randomized-response technique, which is based on the posterior densities of the subject's smoking behavior scores together with the breath test measurements. For different diagnostic test thresholds, we obtained moderate posterior mean estimates of sensitivity and specificity by observing a limited number of discrete randomized item response

Relationship between infarct tissue characteristics and left ventricular remodeling in patients with versus without early revascularization for acute myocardial infarction as assessed with contrast-enhanced cardiovascular magnetic resonance imaging

Left ventricular (LV) remodeling following myocardial infarction (MI) is the result of complex interactions between various factors, including presence or absence of early revascularization. The impact of early revascularization on the relationship between infarct tissue characteristics and LV remodeling is incompletely known. Therefore, we investigated in patients with versus without successful early revascularization for acute MI potential relations between infarct tissue characteristics and LV remodeling with contrast-enhanced (CE) cardiovascular magnetic resonance (CMR). Patients with versus without successful early revascularization underwent CE-CMR for tissue characterization and assessment of LV remodeling including end-diastolic and end-systolic volumes, LV ejection fraction, and wall motion score index (WMSI). CE-CMR images were analyzed for infarct tissue characteristics including core-, peri- and total-infarct size, transmural extent, and regional scar scores. In early revascularized patients (n = 46), a larger area of infarct tissue correlated significantly with larger LV dimensions and a more reduced LV function (r = 0.39-0.68; all P ≤ 0.01). Multivariate analyses identified peri-infarct size as the best predictor of LV remodeling parameters (R2 = 0.44-0.62). In patients without successful early revascularization (n = 47), there was no correlation between infarct area and remodeling parameters; only peri-infarct size versus WMSI (r = 0.33; P = 0.03) and transmural extent versus LVEF (r = -0.27; P = 0.07) tended to be related. A correlation between infarct tissue characteristics and LV remodeling was found only in patients with early successful revascularization. Peri-infarct size was found to be the best determinant of LV remodeling. Our findings stress the importance of taking into account infarct tissue characteristics and success of revascularization when LV remodeling is studie

Inhalation technique of 166 adult asthmatics prior to and following a self-management prograM

Self-management of asthma and self-treatment of exacerbations are considered important in the treatment of asthma. For successful self-treatment, medication has to be inhaled correctly, but the percentage of patients inhaling effectively varies widely. As part of a self-management program we checked and corrected inhalation technique. This paper addresses differences among inhalers in relation to patient characteristics and the effect of instruction, 1 year after enrollment. Maneuvers that are essential for adequate inhalation were identified. When errors in inhalation technique were observed, patients were instructed in the correct use of their devices. One year later, inhalation technique was checked again. Only patients who used the same inhaler throughout the entire study period were analyzed. Of the 245 adult asthmatic patients who were enrolled in the self-management program, 166 used the same inhaler throughout the study period. One hundred twenty patients (72%) performed all key items correctly at baseline and this increased to 80% after 1 year. At follow-up, older patients were less likely to demonstrate a perfect inhalation. Patients with a Diskhaler(r) made fewest errors. Adjustment for differences in patient characteristics did not significantly change the results. Because many patients with asthma use their inhaler ineffectively, there is a need to know which inhaler leads to fewest errors. Diskhaler was nominated by this study. When patients are not able to demonstrate adequate inhalation technique in a “tranquil” setting, it is doubtful that they can do so when they experience an exacerbation. Therefore, inhalation instruction should be considered an essential ingredient, not only of self-management programs, but also of asthma patient care in general

Dacron or ePTFE for Femoro-popliteal above-knee bypass grafting:short and long-term results of a multicentre randomised trial

AbstractObjectivesTo compare expanded polytetrafluoroethylene (ePTFE) prosthesis and collagen-impregnated knitted polyester (Dacron) for above-knee (AK) femoro-popliteal bypass grafts.DesignA prospective multicentre randomised clinical trial.Patients and MethodsBetween 1992 and 1996, 228 AK femoro-popliteal bypass grafts were randomly allocated to either an ePTFE (n=114) or a Dacron (n=114) vascular graft (6mm in diameter). Patients were eligible for inclusion if presenting with disabling claudication, rest pain or tissue loss.Follow-up was performed and included clinical examination and duplex ultrasonography at all scheduled intervals. All patients were treated with warfarin.The main end-point of this study was primary patency of the bypass graft at 2, 5 and 10 years after implantation. Secondary end-points were mortality, primary assisted patency and secondary patency. Cumulative patency rates were calculated with life-table analysis and with log-rank test.ResultsAfter 5 years, the primary, primary assisted and secondary patency rates were 36% (confidence interval (CI): 26–46%), 46% (CI: 36–56%) and 51% (CI: 41–61%) for ePTFE and 52% (CI: 42–62%) (p=0.04), 66% (CI: 56–76%) (p=0.01) and 70% (CI: 60–80%) (p=0.01) for Dacron, respectively. After ten years these rates were respectively 28% (CI:18-38%), 31% (CI:19-43%) and 35% (CI: 23-47%) for ePTFE and 28% (CI: 18-38%), 49% (CI: 37-61%) and 49% (CI: 37-61%) for Dacron.ConclusionDuring prolonged follow-up (10 years), Dacron femoro-popliteal bypass grafts have superior patency compared to those of ePTFE grafts. Dacron is the graft material of choice if the saphenous vein is not available

Predictors for adherence to action plans for self-treatment of COPD exacerbations

Introduction/Aim: A minority of patients with chronic obstructive pulmonary disease (COPD) derives benefit fromself-management interventions that include action plans for self-treatment of COPD exacerbations. The aimof this studywas to identify predictors for adherence to action plans for self-treatment of exacerbations in COPD patients. Methods: Self-reported diary data from a subset of COPD patients who participated in a randomized controlled trial (COPE-II study) in the Netherlands was used to assess adherence to COPD action plans within a self-management intervention. Only patients with exacerbations were included. Successful self-treatment was defined as self-initiating a course of oral steroids/antibiotics within 2 days from the start of an exacerbation. A patient was defined as being adherent when in ≥75% of all exacerbations the self-treatment action plan was followed. Patient-level factors that showed a univariate association (P <0.10) with adherence were included in a multivariate logistic regression model to identify the predictors for adherence toCOPD self-treatment action plans (P <0.05). Results: Data from 66 patients (mean age 63.6 ± 8.0;men 56.1%) showed 387 exacerbations within 2 years of follow-up. Adherence to the action plans was observed in 37.9% of the patients and in 216 COPD exacerbations. Multivariate logistic regression analyses showed that being male (OR: 5.1; 95% CI: 1.5-17.3) and having no walking problems (EQ5D mobility, OR: 4.9; 95%CI: 1.5-16.4) were positively associatedwith being adherent to the action plan for self-treatment of COPD exacerbations. Conclusion: Our study results indicate that being male and having no walking problems are predictors for better adherence to COPD exacerbation action plans. This implies that exploring patients' mobility and offering more support to femaleCOPDpatients who are lessmobilemay positively influence the adherence to COPD exacerbation self-treatment action plans. More research is, however, required to confirm this

Infarct tissue characterization in implantable cardioverter-defibrillator recipients for primary versus secondary prevention following myocardial infarction: a study with contrast-enhancement cardiovascular magnetic resonance imaging

Knowledge about potential differences in infarct tissue characteristics between patients with prior life-threatening ventricular arrhythmia versus patients receiving prophylactic implantable cardioverter-defibrillator (ICD) might help to improve the current risk stratification in myocardial infarction (MI) patients who are considered for ICD implantation. In a consecutive series of (ICD) recipients for primary and secondary prevention following MI, we used contrast-enhanced (CE) cardiovascular magnetic resonance (CMR) imaging to evaluate differences in infarct tissue characteristics. Cine-CMR measurements included left ventricular end-diastolic and end-systolic volumes (EDV, ESV), left ventricular ejection fraction (LVEF), wall motion score index (WMSI), and mass. CE-CMR images were analyzed for core, peri, and total infarct size, infarct localization (according to coronary artery territory), and transmural extent. In this study, 95 ICD recipients were included. In the primary prevention group (n = 66), LVEF was lower (23 ± 9 % vs. 31 ± 14 %; P < 0.01), ESV and WMSI were higher (223 ± 75 ml vs. 184 ± 97 ml, P = 0.04, and 1.89 ± 0.52 vs. 1.47 ± 0.68; P < 0.01), and anterior infarct localization was more frequent (P = 0.02) than in the secondary prevention group (n = 29). There were no differences in infarct tissue characteristics between patients treated for primary versus secondary prevention (P > 0.6 for all). During 21 ± 9 months of follow-up, 3 (5 %) patients in the primary prevention group and 9 (31 %) in the secondary prevention group experienced appropriate ICD therapy for treatment of ventricular arrhythmia (P < 0.01). There was no difference in infarct tissue characteristics between recipients of ICD for primary versus secondary prevention, while the secondary prevention group showed a higher frequency of applied ICD therapy for ventricular arrhythmia.\u