Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study.

BACKGROUND: The Duke Activity Status Index (DASI) questionnaire might help incorporate self-reported functional capacity into preoperative risk assessment. Nonetheless, prognostically important thresholds in DASI scores remain unclear. We conducted a nested cohort analysis of the Measurement of Exercise Tolerance before Surgery (METS) study to characterise the association of preoperative DASI scores with postoperative death or complications. METHODS: The analysis included 1546 participants (≥40 yr of age) at an elevated cardiac risk who had inpatient noncardiac surgery. The primary outcome was 30-day death or myocardial injury. The secondary outcomes were 30-day death or myocardial infarction, in-hospital moderate-to-severe complications, and 1 yr death or new disability. Multivariable logistic regression modelling was used to characterise the adjusted association of preoperative DASI scores with outcomes. RESULTS: The DASI score had non-linear associations with outcomes. Self-reported functional capacity better than a DASI score of 34 was associated with reduced odds of 30-day death or myocardial injury (odds ratio: 0.97 per 1 point increase above 34; 95% confidence interval [CI]: 0.96-0.99) and 1 yr death or new disability (odds ratio: 0.96 per 1 point increase above 34; 95% CI: 0.92-0.99). Self-reported functional capacity worse than a DASI score of 34 was associated with increased odds of 30-day death or myocardial infarction (odds ratio: 1.05 per 1 point decrease below 34; 95% CI: 1.00-1.09), and moderate-to-severe complications (odds ratio: 1.03 per 1 point decrease below 34; 95% CI: 1.01-1.05). CONCLUSIONS: A DASI score of 34 represents a threshold for identifying patients at risk for myocardial injury, myocardial infarction, moderate-to-severe complications, and new disability.

Dietary restriction and exercise improve airway inflammation and clinical outcomes in overweight and obese asthma: a randomized trial.

BACKGROUND: Obesity and asthma are associated conditions; however, the mechanisms linking the two remain unclear. Few studies have examined the effects of weight loss on inflammation and clinical outcomes in obese-asthma. OBJECTIVE: To compare the effects of weight loss achieved by dietary restriction, exercise or combined dietary restriction and exercise on airway inflammation and clinical outcomes in overweight and obese adults with asthma. METHODS: Participants (n = 46; 54.3% female, body mass index (mean ± SD) 33.7 ± 3.5 kg/m(2) ) were randomized to complete a 10-week dietary, exercise or combined dietary and exercise intervention. Dual-energy x-ray absorptiometry was performed, the Juniper Asthma Control Questionnaire and Juniper Asthma Quality of Life Questionnaire completed and inflammatory markers, dietary intake and physical activity measured. The trial was registered with the Australian Clinical Trials Registry: ACTRN12611000235909. RESULTS: Retention was 82.6%. Mean ± SD weight loss was 8.5 ± 4.2%, 1.8 ± 2.6% and 8.3 ± 4.9% after the dietary, exercise and combined interventions respectively. Asthma control improved after the dietary (mean ± SD; -0.6 ± 0.5, P ≤ 0.001) and combined interventions (-0.5 ± 0.7, P = 0.040), whereas quality of life improved after the dietary [median (IQR); 0.9 (0.4, 1.3), P = 0.002], exercise [0.49 (0.03, 0.78), P = 0.037] and combined [0.5 (0.1, 1.0), P = 0.007] interventions. A 5-10% weight loss resulted in clinically important improvements to asthma control in 58%, and quality of life in 83%, of subjects. Gynoid adipose tissue reduction was associated with reduced neutrophilic airway inflammation in women [ß-coefficient (95% CI); 1.75 (0.02, 3.48), P = 0.047], whereas a reduction in dietary saturated fat was associated with reduced neutrophilic airway inflammation in males (r = 0.775, P = 0.041). The exercise intervention resulted in a significant reduction to sputum eosinophils [median (IQR); -1.3 (-2.0, -1.0)%, P = 0.028]. CONCLUSION AND CLINICAL RELEVANCE: This study suggests a weight-loss goal of 5-10% be recommended to assist in the clinical management of overweight and obese adults with asthma. The obese-asthma phenotype may involve both innate and allergic inflammatory pathways.

Multicentre audit of inpatient management of acute exacerbations of chronic obstructive pulmonary disease: comparison with clinical guidelines.

BACKGROUND AND OBJECTIVE: Chronic obstructive pulmonary disease (COPD) exacerbations are a major cause of hospital admission and clinical guidelines for optimised management are available. However, few data assessing concordance with these guidelines are available. We aimed to identify gaps and document variability in clinical practices for COPD admissions. METHODS: Medical records of all admissions over a 3-month period as COPD with non-catastrophic or severe comorbidities or complications at eight acute-care hospitals within the Hunter New England region were retrospectively audited. RESULTS: Mean (SD) length of stay was 6.3 (6.1) days for 221 admissions with mean age of 71 (10), 53% female and 34% current smokers. Spirometry was performed in 34% of admissions with a wide inter-hospital range (4-58%, P < 0.0001): mean FEV1 was 36% (18) predicted. Arterial blood gases were performed on admission in 54% of cases (range 0-85%, P < 0.0001). Parenteral steroids were used in 82% of admissions, antibiotics in 87% and oxygen therapy during admission in 79% (with oxygen prescription in only 3% of these). Bronchodilator therapy was converted from nebuliser to an inhaler device in 51% of cases early in admission at 1.6 (1.7) days. Only 22% of patients were referred to pulmonary rehabilitation (inter-hospital range of 0-50%, P = 0.002). Re-admission within 28 days was higher in rural hospitals compared with metropolitan (27% vs 7%, P < 0.0001). CONCLUSIONS: We identified gaps in best practice service provision associated with wide inter-hospital variations, indicating disparity in access to services throughout the region.

Threshold pressure training, breathing pattern, and exercise performance in chronic airflow obstruction.

The effects of six weeks of threshold pressure inspiratory muscle training (IMT) on inspiratory muscle performance, breathing pattern and exercise performance were studied in eight patients with severe airflow obstruction. The results indicated that IMT improved inspiratory muscle performance but did not affect exercise performance or breathing pattern during maximal exercise.

Antifungal activity of fractions and two pure compounds of flowers from Wedelia paludosa (Acmela brasiliensis) (Asteraceae).

Wedelia paludosa (Acmela brasiliensis) (Asteraceae), a traditionally used native Brazilian medicinal plant, showed antifungal activity against dermatophytes in dilution tests. The hexane, dichloromethane and butanol fractions displayed activity against Epidermophyton floccosum, Trichophyton rubrum and Trichophyton mentagrophytes, with minimal inhibitory concentrations between 250 and 1000 microg/mL. Two pure compounds, identified as kaurenoic acid (1) and luteolin (2), also showed activity against these dermatophytes.

Breath testing in patients with respiratory disability.

The presence of chronic respiratory disease is sometimes claimed as a defence by drivers who refuse or fail a breath test. Trials have been conducted with two breath analysis instruments used in the state of Victoria, Australia in order to determine the respiratory parameters compatible with a satisfactory test. Patients with restrictive and obstructive conditions participated in the trial that was conducted in the respiratory unit of a large teaching hospital. The results showed that the evidential breath analyzer currently used in Victoria was able to accept breath samples from subjects at the limit of respiratory function likely to be encountered in drivers. It was also found that a subject capable of providing a breath sample for the current screening device should also be able to provide an evidential sample. The trials provided useful information in evaluating defences of inability to provide a breath sample due to respiratory incapacity.

Calcified aneurysms in coronary arteries of a 48-year-old patient.

This is a case report of a 48-year-old female patient with a compatible history of Kawasaki disease during childhood, who was admitted to the emergency coronary unit with unstable angina pectoris. Coronary angiography identified two coronary aneurysms, one causing right coronary occlusion and the other causing severe obstruction of the left anterior descending coronary artery. Coronary artery bypass surgery was indicated.

Effects of sample storage time, temperature and syringe type on blood gas tensions in samples with high oxygen partial pressures.

BACKGROUND: Although plastic arterial sampling syringes are now commonly used, the effects of sample storage time and temperature on blood gas tensions are poorly described for samples with a high oxygen partial pressure (PaO2) taken with these high density polypropylene syringes. METHODS: Two ml samples of tonometered whole blood (PaO2 86.7 kPa, PaCO2 4.27 kPa) were placed in glass syringes and in three brands of plastic blood gas syringes. The syringes were placed either at room temperature or in iced water and blood gas analysis was performed at baseline and after 5, 10, 20, 40, 60, 90, and 120 minutes. RESULTS: In the first 10 minutes measured PaO2 in plastic syringes at room temperature fell by an average of 1.21 kPa/min; placing the sample on ice reduced the rate of PaO2 decline to 0.19 kPa/min. The rate of fall of PaO2 in glass at room temperature was 0.49 kPa/min. The changes in PaCO2 were less dramatic and at room temperature averaged increases of 0.47 kPa for plastic syringes and 0.71 kPa for glass syringes over the entire two hour period. These changes in gas tension for plastic syringes would lead to an overestimation of pulmonary shunt measured by the 100% oxygen technique of 0.6% for each minute left at room temperature before analysis. CONCLUSIONS: Glass syringes are superior to plastic syringes in preserving samples with a high PaO2, and prompt and adequate cooling of such samples is essential for accurate blood gas analysis.

Measurement of gas viscosity with a Fleisch pneumotachograph.

A simple rapid method of measuring gas viscosity using a standard Fleisch pneumotachograph and a 3-liter hand-driven syringe is described. Comparison of pneumotachographic and predicted viscosity of five pure gases (CO2, N2, He, O2, and Ar), two binary mixtures (He-O2 and N2-O2), and one quaternary mixture (He-air) gave an overall coefficient of correlation of 0.987 and an accuracy of better than 1.7%. Our data show the well-known marked curvilinear relationship between viscosity and the concentration of helium in air and oxygen mixtures. These studies indicate that a Fleisch pneumotachograph can be used as a simple accurate gas viscometer to characterize gas mixtures in terms of viscosity.

An evaluation of the Breath-Taker peak flow meter.

This study was designed to evaluate the Breath-Taker peak flow meter, recently released by the Asthma Foundation of Victoria. The performance characteristics of five Breath-Taker units were compared with those of five Wright and five mini-Wright peak flow meters. The between-unit reproducibility of each type of peak flow meter was measured using an explosive decompression device with a peak flow reproducibility of better than 1%. Each individual meter was used to measure the peak flow delivered by the decompression device three times for each of six flow rates (97-622 L/min). The coefficient of variation (CV) was lowest for the Wright meters (mean CV, 4.8%) and, similarly to the Breath-Taker units (mean CV, 8.4%), this decreased with increasing flow. The CV of the mini-Wright meters, however, increased as flow increased (mean CV, 7.5%). The Breath-Taker meter had less inter-unit variability than the mini-Wright meter at peak flows above 200 L/min. The accuracy of the three meter types was assessed by comparing measurements of peak expiratory flow rate (PEFR) made with each type and also with a computerized pneumotachograph system in 30 subjects with various degrees of irreversible airflow obstruction. Each subject performed at least three reproducible PEFR manoeuvres on the pneumotachograph and on each type of meter, in randomized order. The results showed that in comparison with the pneumotachograph system the Breath-Taker meter underestimated PEFRs by a mean of 27 L/min and the mini-Wright meter overestimated PEFRs by a mean of 45 L/min, whereas the Wright meter was not significantly different. Since the differences between the Breath-Taker meter and the pneumotachograph were independent of flow rate, a scale offset would suffice to "correct" the Breath-Taker readings.

Using baseline respiratory function data to optimize cycle exercise test duration.

BACKGROUND: It is often difficult to select an appropriate workload increment for progressive cycle exercise tests in order to achieve optimal test duration (8-12 min). We hypothesize that baseline respiratory function can be systematically used to select appropriate workload increment to optimize test duration in patients referred to the clinical laboratory. METHODOLOGY: One hundred and eighty consecutive exercise tests (with increments of 15 W/min) were retrospectively assessed. Using regression analysis, an equation was generated that predicts the work rate increment that would provide exercise duration of 8-12 min. The validity of this equation was tested prospectively in 231 consecutive tests performed with the calculated workload increment rounded to the nearest 5 watts (W). RESULTS: The best regression equation was: workload increment (W/min)=1.94 x FEV1 (L) + 0.63 x TLCO (mmol/min per kPa) - 0.07 x age + 1.94 x gender (male=1, female=0) + 4.12 (r=0.85, P < 0.0001). Using this equation allowed selection of the most appropriate workload increment in 79% of tests and reduced the number of tests of non-optimal duration from 72% (for a fixed increment of 15 W/min) to 38%. CONCLUSIONS: Utilization of this regression equation allows standardization in the selection of workload increment, and reduces the number of cycle exercise tests of inadequate duration.

Is normobaric simulation of hypobaric hypoxia accurate in chronic airflow limitation?

Hypobaric hypoxemia is experienced by passengers during commercial aircraft flight. In order to assess the extent of hypoxemia and to test whether hypobaric hypoxia can be accurately estimated at sea level, the results of the normobaric hypoxia altitude simulation test (N-HAST) were compared with those of the hypobaric hypoxia altitude simulation test (H-HAST) in six normal control subjects and nine patients with chronic airflow limitation (CAL) at simulated cabin altitudes of 6,000 ft (1,829 m) and both at rest and during exercise at 8,000 ft (2,438 m). Serial arterial blood samples were drawn during the breathing of 15.1 and 16.3% inspired oxygen at sea level (N-HAST) at rest and during light exercise, and during the breathing of room air at simulated cabin altitudes (H-HAST) of 609 mm Hg (6,000 ft) and 565 mm Hg (8,000 ft) at rest and during light exercise. As measured with the H-HAST technique, the mean (+/- SD) PaO2 of the normal group fell from 96.2 +/- 6.2 mm Hg (sea level) to 70.1 +/- 6.0 mm Hg (6,000 ft), and to 61.7 +/- 1.6 mm Hg (8,000 ft at rest) and 54.8 +/- 7.1 mm Hg (8,000 ft during exercise) (p < 0.005 by analysis of variance [ANOVA]). In the CAL group, the mean (+/- SD) PaO2 fell from 75.8 +/- 8.2 mm Hg (sea level) to 57.0 +/- 6.3 mm Hg (6,000 ft), and 49.5 +/- 6.1 mm Hg (8,000 ft at rest), and 38.6 +/- 7.5 mm Hg (8,000 ft during exercise) (p < 0.005 by ANOVA).(ABSTRACT TRUNCATED AT 250 WORDS)

Lobar occlusion in the preoperative assessment of patients with lung cancer.

Bronchial occlusion during exercise was used to predict the functional effects of subsequent pulmonary resection in six high risk patients with lung cancer and severe airflow obstruction. Each patient underwent transnasal fibreoptic bronchoscopy whilst cycling in steady state at a load which had been selected as equivalent to walking at a brisk pace for that patient. The effects on minute ventilation and oxygen uptake were observed during occlusion of the bronchus to the diseased lobe. If the patient was able to continue cycling and maintain the same work load during occlusion this was regarded as indicating that he would withstand resection of the occluded lung tissue. In five of the patients, postoperative studies were performed. All were able to maintain the same level of steady state exercise postoperatively as that maintained during bronchial occlusion preoperatively. Resection resulted in a decrease in static lung volumes. Other routine whole lung function tests, walking capacity and incremental exercise indices, however, were largely unchanged.

Resolution of gas exchange abnormalities and intrapulmonary shunting following liver transplantation.

This prospective study evaluated pulmonary gas exchange in patients with severe liver disease, its relationship to intrapulmonary shunting, and its response to liver transplantation. Detailed clinical examinations, chest radiographs, and arterial blood gas estimations were performed on 74 consecutive patients before and after liver transplantation. Fifty percent of the 74 patients had a widened alveolar-arterial (A-a) oxygen gradient (> 15 mm Hg) and 45% a reduced PaCO2 (< 35 mm Hg). Twenty-two percent were hypoxemic (PaO2 < 80 mm Hg). Following transplantation mean PaO2 increased (pre-89 +/- 14 vs. post-94 +/- 8 mm Hg; P = .014) and A-a oxygen gradient decreased (pre-16 +/- 14 vs. post-8 +/- 9 mm Hg; P < .001), despite an increase in PaCO2 (pre-36 +/- 5 vs. post-39 +/- 4; P < .001). To examine this improvement in oxygen exchange further, a subgroup of 26 consecutive patients, with no obvious cardiorespiratory cause for abnormal gas exchange underwent, pre- and post-operative spirometry, measurement of carbon monoxide diffusion capacity (DLCO), intrapulmonary shunt estimations (100% oxygen technique), and echocardiography. In this subgroup, 23% were hypoxemic, 54% had a widened A-a oxygen gradient, and 85% had increased intrapulmonary shunting (> 5%) before transplantation. There was a significant correlation between the degree of pre-transplantation intrapulmonary shunting and A-a oxygen gradient (P < .01). Nineteen of the 22 patients with increased shunting improved following transplantation and improved A-a oxygen gradient correlated well with the reduction in shunting (P < .005). DLCO was reduced in 69% of these patients with a mean value of 73% of predicted. However, the post-transplantation mean DLCO did not increase despite the improvement in oxygen exchange. In conclusion, gas exchange abnormalities are common in patients with severe liver disease but these usually resolve post-transplantation. Intrapulmonary shunting is a major determinant of abnormal oxygen uptake in transplant candidates without evidence of cardiorespiratory disease. Finally, the mechanism for the reduced DLCO is unclear but appears different to that responsible for intrapulmonary shunting and abnormal oxygen exchange.