Mapping low-resource contexts to prepare for lung health interventions in four countries (FRESH AIR): a mixed-method study.

BACKGROUND: Effectiveness of health programmes can be undermined when the implementation misaligns with local beliefs and behaviours. To design context-driven implementation strategies, we explored beliefs and behaviours regarding chronic respiratory disease (CRD) in diverse low-resource settings. METHODS: This observational mixed-method study was conducted in Africa (Uganda), Asia (Kyrgyzstan and Vietnam) and Europe (rural Greece and a Roma camp). We systematically mapped beliefs and behaviours using the SETTING-tool. Multiple qualitative methods among purposively selected community members, health-care professionals, and key informants were triangulated with a quantitative survey among a representative group of community members and health-care professionals. We used thematic analysis and descriptive statistics. FINDINGS: We included qualitative data from 340 informants (77 interviews, 45 focus group discussions, 83 observations of community members' households and health-care professionals' consultations) and quantitative data from 1037 community members and 204 health-care professionals. We identified three key themes across the settings; namely, (1) perceived CRD identity (community members in all settings except the rural Greek strongly attributed long-lasting respiratory symptoms to infection, predominantly tuberculosis); (2) beliefs about causes (682 [65·8%] of 1037 community members strongly agreed that tobacco smoking causes symptoms, this number was 198 [19·1%] for household air pollution; typical perceived causes ranged from witchcraft [Uganda] to a hot-cold disbalance [Vietnam]); and (3) norms and social structures (eg, real men smoke [Kyrgyzstan and Vietnam]). INTERPRETATION: When designing context-driven implementation strategies for CRD-related interventions across these global settings, three consistent themes should be addressed, each with common and context-specific beliefs and behaviours. Context-driven strategies can reduce the risk of implementation failure, thereby optimising resource use to benefit health outcomes. FUNDING: European Commission Horizon 2020. TRANSLATIONS: For the Greek, Russian and Vietnamese translations of the abstract see Supplementary Materials section.

Dysfunctional breathing: what do we know? / Disfunção respiratória: o que sabemos?

ABSTRACT Dysfunctional breathing (DB) is a respiratory condition characterized by irregular breathing patterns that occur either in the absence of concurrent diseases or secondary to cardiopulmonary diseases. Although the primary symptom is often dyspnea or "air hunger", DB is also associated with nonrespiratory symptoms such as dizziness and palpitations. DB has been identified across all ages. Its prevalence among adults in primary care in the United Kingdom is approximately 9.5%. In addition, among individuals with asthma, a positive diagnosis of DB is found in a third of women and a fifth of men. Although DB has been investigated for decades, it remains poorly understood because of a paucity of high-quality clinical trials and validated outcome measures specific to this population. Accordingly, DB is often underdiagnosed or misdiagnosed, given the similarity of its associated symptoms (dyspnea, tachycardia, and dizziness) to those of other common cardiopulmonary diseases such as COPD and asthma. The high rates of misdiagnosis of DB suggest that health care professionals do not fully understand this condition and may therefore fail to provide patients with an appropriate treatment. Given the multifarious, psychophysiological nature of DB, a holistic, multidimensional assessment would seem the most appropriate way to enhance understanding and diagnostic accuracy. The present narrative review was developed as a means of summarizing the available evidence about DB, as well as improving understanding of the condition by researchers and practitioners.

RESUMO A disfunção respiratória (DR) é um quadro respiratório caracterizado por padrões respiratórios irregulares que ocorrem na ausência de doenças concomitantes ou secundariamente a doenças cardiopulmonares. Embora o principal sintoma seja frequentemente dispneia ou "fome por ar", a DR também está associada a sintomas não respiratórios, como vertigem e palpitações. A DR pode ser identificada em todas as idades. Sua prevalência entre adultos na atenção primária no Reino Unido é de aproximadamente 9,5%. Além disso, entre indivíduos com asma, um diagnóstico positivo de DR é encontrado em um terço das mulheres e um quinto dos homens. Embora a DR tenha sido investigada por décadas, ela permanece pouco compreendida devido a uma escassez de ensaios clínicos de alta qualidade e de variáveis de desfecho validadas especificamente para essa população. Assim, a DR é frequentemente subdiagnosticada ou diagnosticada incorretamente, devido à similaridade de seus sintomas associados (dispneia, taquicardia e vertigem) aos de outras doenças cardiopulmonares comuns, como DPOC e asma. As altas taxas de diagnóstico incorreto de DR sugerem que os profissionais de saúde não entendam completamente esse quadro e possam, portanto, não fornecer aos pacientes um tratamento adequado. Dada à natureza multifatorial e psicofisiológica da DR, uma avaliação holística e multidimensional parece ser a maneira mais apropriada de melhorar a compreensão e a precisão do diagnóstico. A presente revisão foi desenvolvida como um meio de resumir as evidências disponíveis sobre DB, bem como de melhorar a compreensão do quadro por pesquisadores e profissionais.

The mediating role of risk perception in the association between industry-related air pollution and health.

BACKGROUND: Heavy industry emits many potentially hazardous pollutants into the air which can affect health. Awareness about the potential health impacts of air pollution from industry can influence people's risk perception. This in turn can affect (self-reported) symptoms. Our aims were to investigate the associations of air pollution from heavy industry with health symptoms and to evaluate whether these associations are mediated by people's risk perception about local industry. METHODS: A cross-sectional questionnaire study was conducted among children (2-18 years) and adults (19 years and above) living in the direct vicinity of an area with heavy industry. A dispersion model was used to characterize individual-level exposures to air pollution emitted from the industry in the area. Associations between PM2.5 and NOX with presence of chronic diseases (adults) and respiratory symptoms (adults and children) were investigated by logistic regression analysis. Risk perception was indirectly measured by worries about local industry (0-10 scale). Mediation analyses were performed to investigate the role of mediation by these worries. RESULTS: The response was 54% (2,627/4,877). In adults exposure to modelled PM2.5 from industry (per µg/m3) was related with reported high blood pressure (OR 1.56, 95% CI 1.13-2.15) and exposure to modelled NOX (per µg/m3) was inversely related with cardiovascular diseases (OR 0.91, 95% CI 0.84-0.98). In children higher PM2.5 and NOX concentrations (per µg/m3) were related with wheezing (OR 2.00, 95% CI 1.24-3.24 and OR 1.13, 95% CI 1.06-1.21 respectively) and dry cough (OR 2.33, 95% CI 1.55-3.52 and OR 1.16, 95% CI 1.10-1.22 respectively). Parental worry about local industry was an important mediator in exposure-health relations in children (indirect effect between 19-28%). CONCLUSION: Exposure from industry was associated with self-reported reported high blood pressure among adults and respiratory symptoms among their children. Risk perception was found to mediate these associations for children.

Risk factors for persistence of lower respiratory symptoms among community members exposed to the 2001 World Trade Center terrorist attacks.

OBJECTIVES: We studied the course of lower respiratory symptoms (LRS; cough, wheeze or dyspnoea) among community members exposed to the 9/11/2001 World Trade Center (WTC) attacks during a period of 12-13 years following the attacks, and evaluated risk factors for LRS persistence, including peripheral airway dysfunction and post-traumatic stress disorder (PTSD). METHODS: Non-smoking adult participants in a case-control study of post-9/11-onset LRS (exam 1, 2008-2010) were recruited for follow-up (exam 2, 2013-2014). Peripheral airway function was assessed with impulse oscillometry measures of R5 and R5-20. Probable PTSD was a PTSD checklist score ≥44 on a 2006-2007 questionnaire. RESULTS: Of 785 exam 1 participants, 545 (69%) completed exam 2. Most (321, 59%) were asymptomatic at all assessments. Among 192 participants with initial LRS, symptoms resolved for 110 (57%) by exam 2, 55 (29%) had persistent LRS and 27 (14%) had other patterns. The proportion with normal spirometry increased from 65% at exam 1 to 85% at exam 2 in the persistent LRS group (p<0.01) and was stable among asymptomatic participants and those with resolved LRS. By exam 2, spirometry results did not differ across symptom groups; however, R5 and R5-20 abnormalities were more common among participants with persistent LRS (56% and 46%, respectively) than among participants with resolved LRS (30%, p<0.01; 27%, p=0.03) or asymptomatic participants (20%, p<0.001; 8.2%, p<0.001). PTSD, R5 at exam 1, and R5-20 at exam 1 were each independently associated with persistent LRS. CONCLUSIONS: Peripheral airway dysfunction and PTSD may contribute to LRS persistence. Assessment of peripheral airway function detected pulmonary damage not evident on spirometry. Mental and physical healthcare for survivors of complex environmental disasters should be coordinated carefully.

Daytime napping and increased risk of incident respiratory diseases: symptom, marker, or risk factor?

BACKGROUND: We have identified a strong association between daytime napping and increased mortality risk from respiratory diseases, but little is known about the relationship between daytime napping and respiratory morbidity. METHODS: Data were drawn from the European Prospective Investigation into Cancer and Nutrition-Norfolk cohort. Participants reported napping habits during 1998-2000 and were followed up for respiratory disease hospital admissions until March 2009. Cox proportional hazards regression was used to examine the association between daytime napping and respiratory disease incidence risk. RESULTS: The study sample included 10,978 men and women with a mean age of 61.9 years, and a total of 946 incident respiratory disease cases were recorded. After adjustment for age, sex, social class, education, marital status, employment status, nightshift work, body mass index, physical activity, smoking, alcohol intake, self-reported general health, hypnotic drug use, habitual sleep duration, and preexisting health conditions, daytime napping was associated with an increase in the overall respiratory disease incidence risk (hazard ratio (HR) = 1.32, 95% confidence interval (CI) 1.15, 1.52 for napping <1 h; HR = 1.54, 95% CI 1.14, 2.09 for napping ≥1 h). This association was more pronounced for lower respiratory diseases, especially for the risk of chronic lower respiratory diseases (HR = 1.52, 95% CI: 1.18, 1.96 for napping <1 h; HR = 1.72, 95% CI: 1.01, 2.92 for napping ≥1 h, overall p = 0.003). CONCLUSIONS: Excessive daytime napping might be a useful marker of future respiratory disease incidence risk. Further studies are required to confirm these findings and help understand potential mechanisms.

Contribuição do brinquedo terapêutico estruturado em um modelo de cuidado de enfermagem para crianças hospitalizadas / Contribución del juego terapéutico estructurado en un modelo de atención en el cuidado de niños hospitalizados / Contribution of structured therapeutic play in a nursing care model for hospitalised children

RESUMO Objetivo Analisar como o Brinquedo Terapêutico estruturado em um Modelo de Cuidado de Enfermagem contribui no cuidado à criança hospitalizada. Método Trata-se de uma Pesquisa Convergente Assistencial (PCA), de abordagem qualitativa. Participaram do estudo sete crianças. A coleta de dados foi realizada entre setembro e outubro de 2014, por meio de entrevista aberta e de observação participante de sessões de BT dramático e/ou instrucional através das etapas “Acolhendo/Brincando/Finalizando” do Modelo de Cuidado de Enfermagem Cuidar Brincando. Os dados foram analisados de acordo com as fases de análise e interpretação da PCA. Resultados Três categorias: Significados atribuídos pela criança à hospitalização e sua influência no cuidado de enfermagem, Percepção quanto aos procedimentos terapêuticos por meio do brinquedo terapêutico e Importância da inserção da família no cuidado. Considerações finais Conclui-se que aplicar o BT estruturado em um Modelo de Cuidado pode contribuir para um cuidado de enfermagem sistematizado e especializado.

RESUMEN Objetivo Objetivo de analizar como Juego Terapéutico estructurado en un modelo de atención de enfermería ayuda en el cuidado de niños hospitalizados. Método Se trata de una investigación cualitativa del tipo convergente asistencial. Participaron del estudio siete niños. Los datos fueron recolectados entre septiembre y octubre de 2014, por medio de entrevistas abiertas y observación participante de sesiones de juguete terapéutico dramático y de instrucción por los pasos “Acogiendo/Jugando/Finalizando” del Modelo de Atención de Enfermería Cuidar Jugando”. Los datos se analizaron de acuerdo a las fases de análisis e interpretación. Resultados Tres categorías: Significados atribuidos por el niño a la hospitalización y su influencia en los cuidados de enfermería, Percepción acerca de los procedimientos terapéuticos a través del juego y La Importancia de la inserción de la familia en la atención terapéutica. Consideraciones finales La aplicación de la BT estructurada en un modelo de atención puede contribuir a un cuidado de enfermería especializada y sistematizadas.

ABSTRACT Objective To analyse how therapeutic play structured in a nursing care model contributes to the care of hospitalised children. Method This is a qualitative study based on convergent care research (CCR). Seven children participated in the study. Data were collected in September and October of 2014 by means of interviews with open-end questions and participant observation of therapeutic and dramatic play sessions and/or instructional play sessions based on the stages “Welcoming/Playing/Concluding” of the nursing model Care with Play. Data were analysed according to the analysis and interpretation stages of the CCR. Results The following three categories emerged: Meanings attributed by the child to hospitalisation and its influence on nursing care; Perception of the therapeutic procedures through therapeutic play, and Importance of the family in care. Final considerations It is concluded that the application of therapeutic play structured in the care model contributes to systematic and specialised nursing care.

Pulmonary function, chronic respiratory symptoms, and health-related quality of life among adults in the United States--National Health and Nutrition Examination Survey 2007-2010.

BACKGROUND: We examined the association of impaired lung function and respiratory symptoms with measures of health status and health-related quality of life (HRQOL) among US adults. METHODS: The sample included 5139 participants aged 40-79 years in the National Health and Nutrition Examination Survey 2007-2010 who underwent spirometric testing and responded to questions about respiratory symptoms, health status, and number of physically unhealthy, mentally unhealthy, or activity limitation days in the prior 30 days. RESULTS: Among these adults, 7.2% had restrictive impairment (FEV1/FVC ≥ 70%; FVC < 80% of predicted), 10.9% had mild obstruction (FEV1/FVC < 70%; FEV1 ≥ 80% predicted), and 9.0% had moderate-severe obstruction (FEV1/FVC < 70%; FEV1 < 80% predicted). Individuals with restrictive impairment or moderate-severe obstruction were more likely to report fair/poor health compared to those with normal lung function (prevalence ratio (PR) =1.5 [95% CI: 1.2-1.9] and 1.5 [1.3-1.8]), after controlling for sociodemographics, non-respiratory chronic diseases, body mass index, smoking, and respiratory symptoms. Frequent mental distress (FMD; ≥14 mentally unhealthy days), frequent physical distress (FPD; ≥14 physically unhealthy days), and frequent activity limitation (FAL; ≥14 activity limitation days) did not differ by lung function status. Adults who reported any respiratory symptoms (frequent cough, frequent phlegm, or past year wheeze) were more likely to report fair/poor health (PR = 1.5 [1.3-1.7]), FPD (PR = 1.6 [1.4-1.9]), FMD (PR = 1.8 [1.4-2.2]), and FAL (PR = 1.4 [1.1-1.9]) than those with no symptoms. CONCLUSIONS: These results suggest the importance of chronic respiratory symptoms as potential risk factors for poor HRQOL and suggest improved symptom treatment and prevention efforts would likely improve HRQOL.

The carbon dioxide challenge test in panic disorder: a systematic review of preclinical and clinical research

This systematic review assesses the current state of clinical and preclinical research on panic disorder (PD) in which the carbon dioxide (CO2) challenge was used as a trigger for panic attacks (PAs). A total of 95 articles published from 1984 to 2012 were selected for inclusion. Some hypotheses for PD evolved greatly due to the reproducibility of PAs in a controlled environment using the safe and noninvasive CO2 test. The 35% CO2 protocol was the method chosen by the majority of studies. Results of the test report specific sensitivity to hypercapnia in PD patients of the respiratory PD subtype. The CO2 challenge helped assess the antipanic effects of medication and non-pharmaceutical approaches such as physical exercise and cognitive behavioral therapy. The test was also used in studies about the genetic component of PD, in which twins and relatives of PD patients were analyzed.

Impact of chronic respiratory symptoms in a rural area of sub-Saharan Africa: an in-depth qualitative study in the Masindi district of Uganda.

BACKGROUND: Chronic obstructive pulmonary disease (COPD), once regarded as a disease of developed countries, is now recognised as a common disease in low- and middle-income countries. No studies have been performed to examine how the community in resource poor settings of a rural area in sub-Saharan Africa lives with chronic respiratory symptoms. AIMS: To explore beliefs and attitudes concerning health (particularly respiratory illnesses), use of biomass fuels, tobacco smoking, and the use of health services. METHODS: A qualitative study was undertaken in a rural area of Masindi district in Uganda, using focus group discussions with 10-15 members of the community in 10 randomly selected villages. RESULTS: Respiratory symptoms were common among men, women, and children. In several communities respiratory symptoms were stigmatised and often associated with tuberculosis. Almost all the households used firewood for cooking and the majority cooked indoors without any ventilation. The extent of exposure to tobacco and biomass fuel smoke was largely determined by their cultural tradition and gender, tribal origin and socioeconomic factors. Many people were unaware of the damage to respiratory health caused by these risk factors, notably the disproportionate effect of biomass smoke in women and children. CONCLUSIONS: The knowledge of chronic respiratory diseases, particularly COPD, is poor in the rural community in sub-Saharan Africa. The lack of knowledge has created different beliefs and attitudes concerning respiratory symptoms. Few people are aware of the relation between smoke and respiratory health, leading to extensive exposure to mostly biomass-related smoke.

Panic disorder and the respiratory system: clinical subtype and challenge tests / Transtorno do pânico e sistema respiratório: subtipo clínico e testes de provocação

INTRODUCTION: Respiratory changes are associated with anxiety disorders, particularly panic disorder (PD). The stimulation of respiration in PD patients during panic attacks is well documented in the literature, and a number of abnormalities in respiration, such as enhanced CO2 sensitivity, have been detected in PD patients. Investigators hypothesized that there is a fundamental abnormality in the physiological mechanisms that control breathing in PD. METHODS: The authors searched for articles regarding the connection between the respiratory system and PD, more specifically papers on respiratory challenges, respiratory subtype, and current mechanistic concepts. CONCLUSIONS: Recent evidences support the presence of subclinical changes in respiration and other functions related to body homeostasis in PD patients. The fear network, comprising the hippocampus, medial prefrontal cortex, amygdala and its brainstem projections, may be abnormally sensitive in PD patients, and respiratory stimulants like CO2 may trigger panic attacks. Studies indicate that PD patients with dominant respiratory symptoms are particularly sensitive to respiratory tests compared to those who do not manifest dominant respiratory symptoms, representing a distinct subtype. The evidence of changes in several neurochemical systems might be the expression of the complex interaction among brain circuits.

INTRODUÇÃO: As anormalidades respiratórias estão associadas a transtornos de ansiedade, especialmente ao transtorno do pânico (TP). A estimulação respiratória em pacientes com TP durante os ataques de pânico está bem documentada na literatura, e vários problemas respiratórios como uma elevada sensibilidade ao CO2 foram detectados em pacientes com TP. Os pesquisadores levantam a hipótese de que existe um distúrbio fundamental nos mecanismos fisiológicos que controlam a respiração no TP. MÉTODOS: Os autores pesquisaram artigos sobre a conexão entre o sistema respiratório e TP, mais especificamente artigos sobre testes respiratórios, subtipo respiratório e conceitos mecanicistas atuais. CONCLUSÕES: Evidências recentes apoiam a existência de alterações subclínicas na respiração e em outras funções relacionadas à homeostase corporal em pacientes com TP. O circuito do medo, composto pelo hipocampo, córtex pré-frontal medial, amígdala e suas projeções para o tronco encefálico, pode estar anormalmente sensível em pacientes com TP, e os estimulantes respiratórios, como o CO2, podem desencadear ataques de pânico. Estudos indicam que os pacientes com TP que apresentam sintomas respiratórios dominantes são particularmente sensíveis a testes respiratórios, comparados àqueles que não manifestam sintomas respiratórios dominantes, representando um subtipo distinto. A constatação de anormalidades em vários sistemas neuroquímicos pode ser a expressão da interação complexa entre os circuitos cerebrais.

Panic disorder respiratory subtype: psychopathology, laboratory challenge tests, and response to treatment.

OBJECTIVE: Our objective is to summarize the new findings concerning the respiratory subtype (RS) of panic disorder (PD) since its first description. METHODS: Two searches were made in the Institute for Scientific Information Web of Science: with the keywords "panic disorder" and "respiratory symptoms," and all articles that cited Briggs and colleagues' 1993 article "Subtyping of Panic Disorder by Symptom Profile" (Br J Psychiatry 1993;163:201-9). Altogether, 133 articles were reviewed. RESULTS: We describe and discuss RS epidemiology, genetics, psychopathology, demographic features, clinical features, correlations with the respiratory system, traumatic suffocation history, provocative tests, and nocturnal panic. Compared to patients with the nonrespiratory subtype (non-RS), the RS patients had higher familial history of PD, lower comorbidity with depression, longer duration of illness, lower neuroticism scores, and higher scores in severity scales, such as the Panic and Agoraphobia Scale, Panic-Agoraphobia Spectrum scale and the Clinical Global Impression scale. Tests to induce panic attacks, such as those with CO(2), hyperventilation, and caffeine, produce panic attacks in a higher proportion of RS patients than non-RS patients. Differences in the subtypes' improvement with the pharmacologic treatment were found. There are also some controversial findings regarding the RS, including the age of onset of PD, and alcohol and tobacco use in RS patients. CONCLUSIONS: Some characteristics, such as the increased sensitivity to CO(2) and the higher familial history of PD, clearly distinguish the RS from the non-RS. Nevertheless, there are also controversial findings. More studies are needed to determine the validity of the RS subtype.

Non-respiratory symptoms and well-being in asthmatics from a general population sample.

BACKGROUND: Different instruments have been developed to assess health-related quality of life (HRQL) in asthma patients. However, relatively few studies have assessed HRQL in asthma patients from a general population, and it is still unclear which instrument is most suitable. The purpose of this study was to compare HRQL in clinically verified asthmatics with subjects with respiratory symptoms without asthma and with subjects with no respiratory symptoms from a general population. The generic instrument Gothenburg Quality of Life (GQL) was used. A secondary aim was to study if GQL had any prognostic value in asthma. METHODS: A cohort of three age groups in Sweden was investigated in 1990 using a respiratory questionnaire and GQL. The cohort consisted of 616 subjects with asthma, 488 subjects with respiratory symptoms but no asthma, and 347 subjects without respiratory symptoms. The participants were also investigated by spirometry and allergy testing. In a follow-up study, subjects were identified who had persistent and improved asthma. RESULTS: The prevalence of 28 of the 30 common symptoms in GQL was significantly increased (p < 0.001) in subjects with asthma as compared to non-asthmatics. All symptoms in the domains heart and lung, head, musculoskeletal, tension, and depression were significantly increased among the asthmatics. The asthmatics also rated their physical well-being lower (p < 0.001) than subjects with no respiratory symptoms. Subjects with persistent asthma had a significantly higher prevalence of 7 of the 30 symptoms and lower social well-being than subjects showing improvement in asthma during the follow-up. All differences remained significant after adjusting for age, sex, and smoking habits. CONCLUSION: Subjects with asthma had different symptom-profiles compared to those of non-asthmatics, with a higher prevalence of both respiratory and non-respiratory symptoms. Asthma is also a disease that is related to low well-being. The use of quality-of-life questionnaires such as the GQL may provide useful information for evaluating the non-respiratory aspects of asthma as well as for assessing the impact of disease on health status and well-being.

Respiratory and non-respiratory panic disorder subtypes: clinical and quality of life comparisons.

AIM: to compare the scores of the WHOQOL quality of life domains with the clinical features of patients with respiratory and non-respiratory panic disorders (PD) treated at the UFRJ Panic and Respiration Laboratory. METHOD: cross sectional study. Thirty-two PD outpatients under treatment were consecutively selected and evaluated by the MINI v.4.4. They were divided into two different groups according to Briggs et al. classification of respiratory and non-respiratory PD subtypes. Twelve (37.5%) patients had the respiratory subtype (SR) and 20 (62.5%) the non-respiratory subtype (SN). RESULTS: the SN patients presented worse scores in the psychological domain of the WHOQOL. There were no differences between groups in gender, age, level of schooling, occupational status, marital status, smoking and comorbidities. There were no differences in the anxiety questionnaires and PD questionnaire (BAI, STAI-T, STAI-S, PAS) scores and in the age at the beginning of the disorder and the disorder's duration. CONCLUSION: non-respiratory subtype patients presented worse scores in the psychological domain of WHOQOL than the respiratory subtype group, when they had similar anxiety and PD scores.

Respiratory manifestations of panic disorder: causes, consequences and therapeutic implications: [revision] / Manifestações respiratórias do transtorno de pânico: causas, consequências e implicações terapêuticas: [revisão]

Multiple respiratory abnormalities can be found in anxiety disorders, especially in panic disorder (PD). Individuals with PD experience unexpected panic attacks, characterized by anxiety and fear, resulting in a number of autonomic and respiratory symptoms. Respiratory stimulation is a common event during panic attacks. The respiratory abnormality most often reported in PD patients is increased CO2 sensitivity, which has given rise to the hypothesis of fundamental abnormalities in the physiological mechanisms that control breathing in PD. There is evidence that PD patients with dominant respiratory symptoms are more sensitive to respiratory tests than are those who do not manifest such symptoms, and that the former group constitutes a distinct subtype. Patients with PD tend to hyperventilate and to panic in response to respiratory stimulants such as CO2, triggering the activation of a hypersensitive fear network. Although respiratory physiology seems to remain normal in these subjects, recent evidence supports the idea that they present subclinical abnormalities in respiration and in other functions related to body homeostasis. The fear network, composed of the hippocampus, the medial prefrontal cortex, the amygdala and its brain stem projections, might be oversensitive in PD patients. This theory might explain why medication and cognitive-behavioral therapy are both clearly effective. Our aim was to review the relationship between respiration and PD, addressing the respiratory subtype of PD and the hyperventilation syndrome, with a focus on respiratory challenge tests, as well as on the current mechanistic concepts and the pharmacological implications of this relationship.

Múltiplas anormalidades respiratórias podem ser encontradas em pacientes com transtornos de ansiedade, particularmente no transtorno de pânico (TP). Indivíduos com TP experimentam ataques de pânico inesperados, caracterizados por ansiedade, medo e diversos sintomas autonômicos e respiratórios. A estimulação respiratória é um fenômeno comum durante os ataques de pânico. A anormalidade respiratória mais citada em pacientes com TP é a sensibilidade aumentada para o CO2, que originou a hipótese de uma disfunção fundamental nos mecanismos fisiológicos de controle da respiração no TP. Há evidências de que pacientes com TP com sintomas respiratórios predominantes são mais sensíveis a testes respiratórios do que aqueles sem a manifestação de tais sintomas, representando um subtipo distinto. Pacientes com TP tendem a hiperventilar e a reagir com pânico como resposta a estimulantes respiratórios como o CO2, gerando uma ativação de um circuito de medo hipersensível. Apesar de a fisiologia respiratória desses pacientes permanecer normal, algumas evidências recentes apontam a presença de disfunções subclínicas na respiração e em outras funções relacionadas à homeostase corporal. O circuito do medo, composto pelo hipocampo, córtex pré-frontal medial, amígdala e projeções do tronco cerebral, pode estar hipersensível em pacientes com TP. Essa teoria pode explicar porque os medicamentos e a terapia cognitivocomportamental são claramente eficazes. Nosso objetivo foi revisar a relação entre respiração e TP, especialmente o subtipo respiratório de TP e a síndrome da hiperventilação, focalizando os testes respiratórios, bem como as hipóteses mecanísticas e as implicações farmacológicas dessa relação.

Percepción de riesgo a la salud por contaminación del aire en adolescentes de la Ciudad de México / Perception of health risks due to air pollution in adolescents in Mexico City

OBJETIVO: Analizar las relaciones que se establecen entre contaminación del aire y salud-enfermedad-muerte en una muestra de estudiantes de la Ciudad de México. MATERIAL Y MÉTODOS: Se realizó una encuesta a 1 274 alumnos de secundaria de 14 escuelas en cinco zonas del Distrito Federal, entre marzo y abril de 2003. Muestreo polietápico de áreas geoestadísticas básicas (AGEB). RESULTADOS: El 84.4 por ciento considera alta o muy alta la contaminación del aire en la Ciudad de México, que disminuye al aproximarse al espacio más inmediato del alumno. Los riesgos a la salud van desde efectos en la salud respiratoria, 66.9 por ciento, a otras consecuencias en la vida diaria, 2.2 por ciento. Los predictores de percibir la contaminación como grave/muy grave son: a) que la asocien con la posibilidad de causar la muerte (RM= 1.35, IC 95 por ciento= 1.02-1.77), y b) asistencia a escuelas en la zona de La Merced (RM= 2.23, IC 95 por ciento= 1.56-3.21). CONCLUSIONES: Los determinantes de la percepción para esta población de adolescentes son: género, zona de ubicación de la escuela y las diferencias en la calidad del aire percibidas en la ciudad/colonia/plantel educativo. Lo anterior permite sugerir que en la política ambiental debe incorporarse el componente de la focalización, de tal manera que los programas ambientales sean más eficientes en el ámbito local.

OBJECTIVE: Analyze the relations established between air pollution and health-disease-death in a sample of students in Mexico City. MATERIAL AND METHODS: Survey of 1274 students from 14 secondary schools in five areas in Mexico City was conducted between March and April of 2003. We used a multi-stage sampling, based in a basic geostatistical areas (AGEB). RESULTS: A total of 84.4 percent believed that Mexico City has a high, or very high air pollution; that valuation decreases as it approaches the most immediate place in which the students live. The health risks range from effects on respiratory health, 66.9 percent, to other effects on daily life, 2.2 percent. The predictors that air pollution is perceived as serious/very serious are: 1) that they associate it with the possibility of causing death (OR= 1.35, 95 percent CI=1.02-1.77), and 2) that they attend schools located in the La Merced zone, (OR= 2.23, 95 percent CI= 1.56-3.21). CONCLUSIONS: Determinants of perception, such as gender, zone where the school is located and the differences in air quality perceived in the city/area/schools, suggest that focalizing components must be involved in environmental policies, in order to make environmental programs more effective at the local level.

Physical symptoms of children receiving pediatric hospice care at home during the last week of life.

PURPOSE/OBJECTIVES: To identify symptoms of greatest parental concern on the last day and during the last week of their children's lives, the five most common symptoms of parental concern, and symptom-management strategies used during the last week of the children's lives. RESEARCH APPROACH: Descriptive, exploratory, and retrospective. SETTING: A pediatric hospice program in St. Louis, MO. PARTICIPANTS: Convenience sampling of 28 bereaved parents. METHODOLOGIC APPROACH: The Krippendorff method for semantical content analysis of data collected from semistructured telephone interviews with parents. MAIN RESEARCH VARIABLES: Parents' perceptions of their children's symptoms and symptom-management strategies. FINDINGS: On the last day of life, change in the children's breathing was the most frequent symptom of concern. During the last week of life, loss of motor function was the most frequent symptom of concern. Physical comfort actions and use of pharmaceutical agents were the strategies perceived as most helpful in managing symptoms. CONCLUSIONS: The study is the first to document parents' perceptions of their children's symptoms and of symptom-management strategies during the last week of life while receiving care in the home from staff of the pediatric hospice program. INTERPRETATION: Symptoms experienced by dying children during the last week of life and symptom-management strategies used by pediatric hospice programs to support dying children and their families have not been well described. Additional research is warranted to further identify pediatric symptoms at the end of life and effective symptom-management strategies.

Violence exposure, a chronic psychosocial stressor, and childhood lung function.

OBJECTIVE: Chronic psychosocial stressors, including violence, and neuropsychological and behavioral development in children as well as physiologic alterations that may lead to broader health effects. METHODS: We studied the relationship between violence and childhood lung function in a prospective birth cohort of 313 urban children (age range = 6-7 years). Mothers reported on their child's lifetime exposure to community violence (ETV) and interparental conflict in the home (Conflict Tactics Scale (CTS)) within 1 year of the lung function assessment. RESULTS: In linear regression analyses, adjusting for maternal education, child's age, race, birthweight, tobacco smoke exposure, and medical history, girls in the highest CTS verbal aggression tertile had a 5.5% (95% confidence interval (CI) = -9.6, -1.5) decrease in percent predicted forced expiratory volume (FEV(1)) and a 5.4% (95% CI = -9.7, -1.1) decrease in forced vital capacity (FVC) compared with girls in the lowest tertile. The CTS verbal aggression subscale was associated with lung function among boys in the same direction, albeit this was not statistically significant. Boys in the highest ETV tertile had a 3.4% (95% CI = -8.0, 1.1) lower FEV(1) and 5.3% lower FVC (95% CI = -10.2, -0.4) compared with boys in the lowest tertile. The ETV score was not a significant predictor of girls' lung function. CONCLUSIONS: Interparental conflict, specifically verbal aggression, and ETV were associated with decreased childhood lung function independent of socioeconomic status, tobacco smoke exposure, birthweight, and respiratory illness history. Gender differences were noted based on the type of violence exposure, which may warrant further exploration.

Experiences of breathlessness: a systematic review of the qualitative literature.

OBJECTIVE: Breathlessness is one of the core symptoms in many advanced conditions. The subjective nature of the symptom has been acknowledged in many definitions, emphasizing that it can only be fully perceived and interpreted by the patients themselves. AIM: To review and assess the evidence on the psychosocial nature or experience of breathlessness. METHODS: Relevant literature was identified through electronic and hand searches. Studies with qualitative enquiry or mixed method designs were included. The methodological quality of studies was assessed with a standard grading scale. RESULTS: Twenty-two studies were identified, 12 from the United Kingdom, 4 from the United States, 3 from Canada, 1 from Sweden, 1 from Iceland, and 1 from Finland. The nature of the studies determined the themes in which the studies were subsumed. Studies on COPD (19) outnumbered "all other conditions" (3), one of which had COPD and cancer patients and so these were analyzed separately. Within the COPD category most studies (17) considered the experience of breathlessness from the perspective of the patient, 1 study from the informal carer, and 1 from the professional carer. Most of the papers sought to understand the meaning of the symptom in the patient's daily life. The other papers demarcated separate areas of the experience of acute exacerbations and the patient's view on care. The studies explored the subjective component of breathlessness, as part of human experience and social life. The papers showed the influence of the meaning the symptom has for those affected on their ability to cope and on their management. SIGNIFICANCE OF RESULTS: Although the work in this area is still dominated by research on COPD, the totality of the evidence now shows breathlessness as an intractable symptom in other advanced conditions. Practice recommendations focused on the holistic approach as part of palliative and nursing care.