Using pedometers to monitor walking activity in outcome assessment for pulmonary rehabilitation.

BACKGROUND: The purpose of this study was to determine whether a commercially available pedometer could detect changes in home-based walking activity among chronic obstructive pulmonary disease (COPD) patients completing pulmonary rehabilitation (PR). METHODS: Patients with COPD referred to outpatient PR wore a pedometer to count steps for 1 week at the beginning and 1 week at the end of PR. Patients also completed the 6-min walk test (6MWT), the Medical Research Council (MRC) dyspnea scale and the self-administered chronic respiratory disease questionnaire (CRQ) at the beginning and the end of PR. Paired t tests were used to compare pre- and post-PR changes in outcome variables. RESULTS: 45 patients with severe COPD (forced expiratory volume in 1 second [FEV(1)] 45% +/- 18% of predicted) participated in a total of 17.4 +/- 4.6 PR sessions. Significant improvements in 6MWT (49 +/- 59 m; p < .0001), MRC dyspnea score (-0.64 +/- 0.96 units; p = .003) and CRQ score (10 +/- 18 units; p = .0007) were noted following PR. Patients whose pedometer-measured steps were within 20% of observed counted steps were included in the analysis. Pedometer counts increased by 33 +/- 149 steps per hour worn after, as compared with before PR (p = .14). There was a significant inverse relationship between baseline pedometer counts and change in pedometer counts per hour post-PR (r = -.46; p = .001). Patients with low baseline activity levels had significant increases in pedometer activity (88 +/- 30 counts per hour worn) and a greater reduction in MRC dyspnea score (-0.94 vs -0.29; p = .04) following PR, whereas those with higher baseline activity levels had a decrease in pedometer activity (-19 +/- 29 counts/hour; p = .015). CONCLUSIONS: A standard pedometer worn at the waist did not detect changes in lower extremity activity following PR. This negative finding occurred despite demonstrated improvements in dyspnea, exercise tolerance and quality of life measures. Although pedometers are inexpensive and easy to use, they may not be sensitive enough to be used routinely as an outcome measure for PR.

Respi-Care. An innovative home care program for the patient with chronic obstructive pulmonary disease.

The purpose of the present study was to evaluate the effectiveness of a hospital-based home care program for a group of patients with severe COPD. Respi-Care was a multidisciplinary home care program administered by Norwalk Hospital in cooperation with the public health nursing departments of the city of Norwalk and the town of Wilton, Conn. The overall goal of Respi-Care was to provide more comprehensive home care services to patients previously requiring frequent hospitalizations by combining the advantages of hospital resources and community agencies through a unique cooperative effort. Preprogram and on-program data were collected on the following variables for the 48 months of Respi-Care operation: hospitalizations; hospital days; emergency room visits; home care services; and the costs of these services. Costs of operating the Respi-Care program were included in on-program data. Seventeen subjects completed 320.5 months on Respi-Care. Each subject was matched to an equal length of time prior to entering the program, for a total of 641 months analyzed. There were 88 preprogram hospitalizations for the group; hospitalizations while participating in Respi-Care dropped to 53 (p = 0.022; paired t statistics). On-program hospital days showed a significant decrease, from 1,181 preprogram days to 667 on-program days (p = 0.024). Emergency room visits decreased from 105 before the program to 64 during the program (p = 0.017). Costs of care also decreased. Costs for hospitalizations, emergency room visits, and home care fell from $908,031 to $802,999, resulting in a $105,032 savings or $328 per patient per month.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous pneumothorax in AIDS patients with recurrent Pneumocystis carinii pneumonia despite aerosolized pentamidine prophylaxis.

Aerosolized pentamidine prophylaxis for Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome (AIDS) may predispose these patients to recurrent apical Pneumocystis infection. Bullous changes and pulmonary cysts develop in the lung apices due to repeated episodes of inflammation and cytotoxic effects of HIV on pulmonary macrophages. These changes progress despite prophylaxis against recurrent Pneumocystis infection with aerosolized pentamidine, increasing the risk of spontaneous pneumothorax. Two cases are presented of bilateral pneumothoraces in patients with AIDS and recurrent P carinii pneumonia despite aerosolized pentamidine prophylaxis. Patients receiving aerosolized pentamidine prophylaxis for Pneumocystis pneumonia appear to have an increased risk of pneumothorax due to recurrent apical infections with P carinii.

Functional status and survival following pulmonary rehabilitation.

BACKGROUND: Functional exercise capacity has been shown to be a strong predictor of survival following pulmonary rehabilitation. This study evaluated whether questionnaire-rated functional status is also predictive of survival. PATIENTS AND METHODS: Following pulmonary rehabilitation, patients with advanced chronic lung disease were evaluated for survival, 6-min walk distance, and questionnaire-rated functional status. The latter was measured using the pulmonary functional status scale, which has subscores of functional activities, psychological status, and dyspnea. Information on survival was available on 149 patients. RESULTS: The mean age was 69 years, and 45% of patients were male. Eighty-nine percent had a diagnosis of COPD, and their FEV(1) was 37+/-18% of predicted. Ninety-one (61%) were married. The 3-year survival for the group was 85%. Age, gender, body mass index, and primary diagnosis were not related to survival. Variables strongly associated with increased survival following pulmonary rehabilitation included a higher postrehabilitation Functional Activities score, a longer postrehabilitation 6-min walk distance, and being married (vs widowed, single, or divorced). Disease severity variables associated with survival included an initial referral to outpatient pulmonary rehabilitation, no supplemental oxygen requirement, and a higher percent-predicted FEV(1). CONCLUSION: Indicators of functional status are strong predictors of survival in patients with advanced lung disease.

Localization of eigenfunctions in the stadium billiard.

We present a systematic survey of scarring and symmetry effects in the stadium billiard. The localization of individual eigenfunctions in Husimi phase space is studied first, and it is demonstrated that on average there is more localization than can be accounted for by random-matrix theory, even after removal of bouncing-ball states and visible scars. A major point of the paper is that symmetry considerations, including parity and time-reversal symmetries, enter to influence the total amount of localization. The properties of the local density of states are also investigated, as a function of phase space location. Aside from the bouncing-ball region of phase space, excess localization is found on short periodic orbits and along certain symmetry-related lines; the origin of all these sources of localization is discussed quantitatively and comparison is made with analytical predictions. Scarring is observed to be present in all the energy ranges considered. In light of our results, the excess localization in individual eigenstates is interpreted as being primarily due to symmetry effects.

Excretion of estrone, estradiol, and progesterone in the urine and feces of the female cotton-top tamarin (Saguinus oedipus oedipus).

The excretion of three gonadal steroids was studied in the urine and feces of female cotton-top tamarins (Saguinus oedipus oedipus). Each steroid, 14C-estrone, 14C-estradiol, and 14C-progesterone, was injected into a separate female cotton-top tamarin. Urine and feces were collected at 8 hr intervals for 5 days on the three tamarins. Samples were analyzed to determine the proportion of free and conjugated steroids. Steroid excretion patterns were determined by sequential ether extraction, enzyme hydrolysis, and chromatography. Labeled estrone was excreted in a slow and continuous manner into the urine (57%) and feces (43%) with 90% of the steroid conjugated. The nonconjugated form had an elution profile identical to 3H estrone, but the conjugated portion was not completely hydrolyzed by enzyme. Labeled estradiol was excreted primarily in the urine (87%) and was released rapidly. Over 90% of the injected 14C-estradiol was excreted in urine as a conjugate, of which 41% was converted to an estrone conjugate and the remaining 59% was excreted as a polar estradiol conjugate. Labeled progesterone was excreted primarily in the feces (95%), 61% of which was free steroid. Four to six individual peaks of radioactivity were found when using celite chromatography and high performance liquid chromatography (HPLC), indicating that progesterone is metabolized into several urinary and fecal metabolites. One of these peaks matched 3H-progesterone and others may be pregnanediols, pregnanetriols, and 17-hydroxyprogesterone. These steroidal excretion patterns help explain the atypical hormonal patterns seen during the tamarin ovarian cycle.

Metabolites of estradiol in serum, bile, intestine and feces of the domestic cat (Felis catus ).

We wished to develop an efficient, noninvasive method for monitoring ovarian function in domestic and nondomestic Felidae. We hypothesized that the method could be based on measurement of one of the major excreted estrogen metabolites. To identify and characterize the major excreted metabolites, a bolus of (14)C-estradiol was administered into the femoral vein of adult female cats. We measured the amounts of total radioactivity per unit time contained in unconjugated and conjugated estradiol metabolites, in conjugated metabolites that were hydrolyzable, and in those not hydrolyzable by beta Glucuronidase / aryl sulfatase (the enzyme). Radionuclide levels were determined in voided feces and urine, in jugular vein plasma, bile, contents of the duodenum, and in the small intestine. Metabolites of (14)C-estradiol were voided preferentially in feces and in equal amounts either as unconjugated estradiol or as conjugates not hydrolyzable by the enzyme. In plasma, conjugated estrogens comprised an increasing proportion of the total radioactivity during the first 40 min after administration. Plasma pools of samples from 0.5 to 30 min and 40 to 360 min contained a monoconjugate and a diconjugate, respectively; both were hydrolyzable by the enzyme. Bile and intestinal samples were collected at 360 min after administration. In the bile, 99% of the total radioactivity was in conjugated compounds, only 20% of which were not hydrolysable by the enzyme. The proportion of unconjugated metabolites increased to 18% in the duodenum and to 45% in the small intestine. The major conjugates contained in voided feces not hydrolyzable by the enzyme were estradiol sulfate (m/z = 351.6836), distributed as the 3-sulfate (20%) and 17-sulfate (80%); of the latter, 70% were 17alpha- and 30% 17beta-estradiol sulfates. These data document the fate of estradiol in the circulation of the cat, they demonstrate that a large portion of the voided estradiol metabolites are not hydrolyzable by the enzyme, and account for those conjugates previously termed nonhydrolyzable.

Periodic orbits of nonscaling Hamiltonian systems from quantum mechanics.

Quantal (E,tau) plots are constructed from the eigenvalues of the quantum system. We demonstrate that these representations display the periodic orbits of the classical system, including bifurcations and the transition from stable to unstable. (c) 1995 American Institute of Physics.

Outpatient management of common problems in patients with chronic obstructive pulmonary disease.

Dyspnea, ineffective secretion clearance, and the potential for exacerbation are three common problems of patients with chronic obstructive pulmonary disease. Assessment and management of these problems are important in the overall care of this population. Teaching patients breathing exercises and secretion clearance techniques and referring them to comprehensive pulmonary rehabilitation programs improves functional capacity and quality of life.

Stability of dilute solutions of gentamicin and tobramycin.

Dilution of sera containing gentamicin or tobramycin in glass containers results in substantial adsorption of the antibiotic to the surface of the container, which can be prevented if acidic or basic solutions are used to dilute such sera. We describe protocols for radioimmunoassays of gentamicin and tobramycin that include solutions and containers that obviate this problem.

Magnetic resonance imaging of intrauterine synechiae.

Magnetic resonance imaging (MRI) is a sensitive method to diagnose a variety of gynecologic conditions. Uterine anatomy may be accurately imaged with MRI providing a noninvasive method to assess both myometrial and endometrial architecture. MRI was used in 2 patients with amenorrhea and intrauterine synechiae to determine the possible role of this technique in assessing the endometrial cavity. MRI signal features in both patients provided an assessment of the endometrium complementary to the anatomy demonstrated on hysterosalpingography and suggested markedly different etiologies for similar clinical presentations. MRI may have a role supplementary to conventional studies in the evaluation of intrauterine synechiae.

A comparison of pelvic ultrasound and magnetic resonance imaging as diagnostic studies for müllerian tract abnormalities.

OBJECTIVE: The purpose of the present study was to compare prospectively the accuracy of pelvic US examination and MR imaging in the assessment of müllerian tract abnormalities. PATIENTS AND METHODS: Sixteen patients with congenital müllerian defects underwent US examination, MR imaging, diagnostic laparoscopy, and hysteroscopy. Abnormalities included unicornuate (n = 2), bicornuate (n = 6), and septate (n = 6) uteri, and normal uteri with septate vagina (n = 2). Patients with müllerian abnormalities were referred after hysterosalpingogram or clinical examination revealed uterine, cervical, and/or vaginal congenital abnormalities. Laparoscopic and hysteroscopic confirmation of these radiologic impressions was made in all patients. RESULTS: Pelvic US examination and MR imaging for all abnormalities had an overall sensitivity of 57% and 77%, specificity of 50% and 33%, a positive predictive value of 89% and 83%, and a negative predictive value of 14% and 25%, respectively. Pelvic US examination and MR imaging correctly diagnosed septate uterus in 2/6 cases (33%) and 3/6 cases (50%), respectively. This abnormality was most commonly misdiagnosed as a normal or bicornuate uterine cavity. For bicornuate uterus, pelvic US and MR, however, correctly diagnosed 6/6 cases (100%) and 5/6 cases (83%), respectively. Accurate diagnoses were made for bicornuate uteri using either modality owing mainly to the presence of a characteristic fundal notch. US examination was nonspecific for unicornuate uterus (0/2 cases diagnosed), defining only a single cavity, but without sufficient details of adnexal regions. MR imaging of unicornuate uteri, however, provided detailed images of both uterine cavity configuration (2/2 cases diagnosed) and adnexal anatomy. CONCLUSIONS: Our data suggest that pelvic US examination and MR imaging are not sufficiently accurate to qualify as sole diagnostic studies for septate uteri. Though less expensive and less invasive than diagnostic laparoscopy, they do not provide a sufficiently sensitive and specific method to differentiate septate from bicornuate uteri, a critical aspect for surgical planning. Though more costly, diagnostic laparoscopy appears to be the most accurate diagnostic study for the assessment of uterine anatomy and definition of müllerian abnormalities.

Mycotic aneurysm of the aorta: MRI and MRA features.

Mycotic aneurysms of the abdominal aorta are potentially fatal but uncommon. We report the MRI and MRA features of an abdominal aortic mycotic aneurysm in a patient who presented with nonspecific low back pain. By delineating the saccular nature of the aneurysm and identifying the coexistence of vertebral enhancement, MRI was crucial for the final diagnosis. A potential pitfall of contrast-enhanced MRA is also demonstrated.

Sensitivity of hysterosalpingography after tubal surgery.

Hysterosalpingography (HSG) to assess tubal patency in the postoperative evaluation of the infertile patient has been well described. However, the sensitivity and specificity of HSG after tubal surgery has not been reported. We correlated HSG and laparoscopic findings in 25 patients who had tubal surgery (microsurgical tubal reanastomoses [11] and distal salpingostomies [14]). HSG provided a more reliable means of assessing tubal patency (sensitivity and specificity of 96% and 61% respectively) than in detecting pelvic adhesive disease (PAD) (sensitivity and specificity of 12% and 75% respectively) regardless of tubal surgical procedure. HSG was associated with a high false negative rate (60%) due primarily to the inability to detect PAD. Complete agreement between HSG and laparoscopy was noted in only 15% of cases. These data suggest that HSG is a sensitive means to determine tubal patency, but was not sufficiently sensitive or specific to detect PAD after tubal surgery. These limitations should be noted in the interpretation of HSG in any infertile patient with a history of tubal surgery, and severely limits the application of HSG to the management of the post-operative infertile patient.

PIP: Researchers analyzed data on 25 women who underwent either tubal reanastomosis or distal salpingostomy at least 12 months earlier and came to the Tripler Army Medical Center in Honolulu, Hawaii, for hysterosalpingography (HSG) to compare HSD findings with those of laparoscopy, thereby determining HSG's sensitivity and specificity after tubal repair. They were only able to evaluate 42 tubes, since 2 patients had severe pelvic adhesive disease. HSG was more reliable in determining tubal patency (sensitivity of 96% and specificity of 61%) than in detecting pelvic adhesive disease (12% and 75%, respectively). HSG and laparoscopy findings agreed in just 15% of cases. HSG's inability to detect pelvic adhesions was responsible for this low agreement rate. Specifically, HSG found adhesions in only 6% of patients compared to 65% for laparoscopy (false negative rate = 60%). The adhesions completely covered all pelvic structures in 8% of cases at the same frequency for both reanastomosis and salpingostomy, thereby making it impossible to evaluate the anatomy. Further, HSG did not detect other pelvic pathologies (mild endometriosis, uterine fibroids, and ampullary fistulae) in 10% of cases. These findings suggest that HSG is sensitive and specific enough to assess tubal patency following reanastomosis, but is basically not specific enough to do so after distal salpingostomy. Therefore, clinicians should be aware of HSG's limitations when interpreting any HSG findings in infertile patients who had tubal surgery. Further, it limits their ability to manage postoperative infertile patients.

Functional status in pulmonary rehabilitation participants.

PURPOSE: This study examined functional status abnormalities in pulmonary rehabilitation patients, its responsiveness to pulmonary rehabilitation intervention, and its relationship to patient characteristics and traditional measures of disease severity. METHODS: One hundred sixty-four men and women age 69 years (SD +/- 8), who participated in 1 of 10 pulmonary rehabilitation programs in Connecticut, were studied pre- and postrehabilitation with the following outcome measures: (1) the 6-minute walk distance, (2) the Pulmonary Functional Status Scale (PFSS), and (3) in a subset of 60 subjects, health-related quality of life was measured using the Chronic Respiratory Disease Questionnaire (CRDQ). Patient characteristics were compared to baseline values of these measures using Spearman correlations and Wilcoxon Rank Sum tests, whereas pre- to post-changes in outcome measures were evaluated using Wilcoxon signed-ranks tests. Effect size, representing a standardized measure of change, was calculated for the PFSS. RESULTS: The mean FEV1 was 0.95 +/- 0.50 liters (38 +/- 18% predicted). Rehabilitation resulted in significant increases in the 6-minute walk distance (24%, P < 0.001, the total PFSS scores [13%, P < 0.001, effect size 1.0]) and the total CRDQ (18% P < 0.001). The prerehabilitation function subscore and total PFSS score correlated strongly with the 6-minute walk distance (r = 0.76, 0.73; P < 0.001) and to a lesser degree with the FEV1 (r = 0.31, 0.33; P < 0.001). Males scored higher baseline scores in several PFSS subscales, the total PFSS score, and the 6-minute walk distance; females showed more improvement in some of the PFSS scores. CONCLUSION: The 6-minute walk distance, the PFSS, and CRDQ all improved significantly with rehabilitation. Functional status, as measured by the PFSS is very strongly correlated with the 6-minute walk. Gender differences in the timed walk distance and functional status highlight the need to study this variable more thoroughly.

Effect of relaxation therapy on post-myocardial infarction patients' rehabilitation.

This research measured the physical and psychosocial effects of the practice of Benson's relaxation technique by male postmyocardial infarction patients enrolled in a cardiac rehabilitation program and determined if the patient's behavioral style (Type A or Type B) was related to the outcomes. Twenty-seven subjects completed the experimental condition; 30, the control condition. Outcome measures included blood pressure, heart rate, aerobic conditioning level (MET level), and psychosocial functioning, as measured by the Sickness Impact Profile. Repeated measures analysis of variance was used to determine if relaxation therapy and/or behavior style had an effect on measures of the effectiveness of cardiac rehabilitation. The practice of relaxation was found to have a significant effect on diastolic blood pressure. Behavior style was unrelated to the outcome measures.

Localization of the portal vein for transjugular catheterization: percutaneous placement of a metallic marker with real-time US guidance.

Transjugular catheterization of the portal vein can be used to form a portosystemic shunt. Conventionally, the passage of a needle from the hepatic vein into the portal vein is performed with fluoroscopic monitoring only. Several methods to target the portal vein have been previously reported, including transhepatic venous catheterization, indirect portography (arterial catheterization), or skin marking based on ultrasound (US) mapping of portal landmarks. The authors used realtime US guidance to percutaneously place a small marking wire in the parenchyma next to the portal bifurcation. A 0.018-inch-diameter, 5-mm-long platinum wire is delivered through a 22-gauge echo-tipped needle placed adjacent to the right portal vein. This marking wire enabled rapid entry into the portal vein, helped avoid extrahepatic puncture, and was useful during stent deployment and positioning.

ECFMG assessment of clinical competence of graduates of foreign medical schools. Educational Commission for Foreign Medical Graduates.

OBJECTIVE: To develop an assessment of clinical competence of graduates of foreign medical schools and to determine the reliability and validity of the assessment and the feasibility of large-scale administration. DESIGN: The Educational Commission for Foreign Medical Graduates (ECFMG) clinical competence study included (1) clinical encounters with standardized patients to assess history taking, physical examination, and communication skills; (2) laser videodisk pictorials to assess identification and interpretation of diagnostic procedures; (3) written clinical vignettes to assess diagnosis and management skills; and (4) assessment of spoken English. A uniform method of operating the test centers and of training the standardized patients was developed. SETTING: Medical schools and their primary teaching hospitals and affiliated hospitals. PARTICIPANTS: Six hundred twenty-four first-year residents, of whom 525 are graduates of foreign medical schools. MAIN OUTCOME MEASURES: Scores, reliability coefficients, validity measures, feasibility of multisite administration, trends of scores over time, and acceptability by examinees. RESULTS: The ECFMG clinical competence assessment was conducted at four geographically separate test centers. Reliability coefficients were high (.85) for the integrated clinical encounter and were in a reasonable range (.71 to .82) for all test components. The assessment adds to the predictability of the residents' performance in the hospital over that of current ECFMG certification examinations. Test security was addressed by demonstrating no consistent pattern of change in scores over testing dates. Virtually all examinees thought the assessment was appropriate. Standardized patients were able to assess spoken English accurately. CONCLUSION: The feasibility of conducting a reliable and valid test of clinical competence for graduates of foreign medical schools was demonstrated for this test population.