Psychological and immunological characteristics of fatigued women undergoing radiotherapy for early-stage breast cancer.

PURPOSE: The amelioration of fatigue in radiotherapy patients is limited by an equivocal aetiology and uncertainty regarding who is likely to experience significant fatigue. The research objective was to characterise fatigue in women undergoing radiotherapy for breast cancer, in order to evaluate associations with elevations in anxiety, depression and a marker of systemic inflammation. METHODS: Participants comprised 100 women, diagnosed with stages 0-IIA breast cancer and prescribed with 40 Gy in 15 fractions over 3 weeks. Fatigue was assessed at baseline between 10 and 22 days before radiotherapy, after 10 and 15 fractions of radiotherapy and 4 weeks after the completion of radiotherapy, using the Functional Assessment of Chronic Illness Therapy Fatigue Subscale. Psychological status was self-reported using the Hospital Anxiety and Depression Scale. Sera concentrations of interleukin-6-soluble receptor were established via enzyme-linked immunosorbent assay. The contributions of pretreatment factors to fatigue were analysed using multivariable regression. RESULTS: Thirty-eight percent of participants experienced significant fatigue during radiotherapy, with the remainder little are affected. After controlling for baseline fatigue, anxiety before treatment was the strongest unique predictor of subsequent fatigue. During radiotherapy, interleukin-6-soluble receptor was significantly elevated in the fatigued group compared to the non-fatigued group (p = 0.01). This association was not mediated by depression. CONCLUSIONS: The data are consistent with the concept that psychological distress prior to radiotherapy relates to a distinct immunological and behavioural response during radiotherapy. Patients reporting elevated anxiety should benefit from interventions that appropriately address the underlying psychological distress and have the potential to ameliorate disabling treatment-related fatigue.

Systemic comorbidities in bronchiectasis.

Bronchiectasis is a chronic inflammatory lung disease, which has similarities to chronic obstructive pulmonary disease (COPD). Comorbidities of COPD include increased risk of cardiovascular (CV) disease, loss of bone mineral density (BMD) and loss of skeletal muscle mass and function, all linked to systemic inflammation. The potential for such comorbidities has not been explored in bronchiectasis. We hypothesised that patients with bronchiectasis would have similar increased comorbidities. A total of 20 patients with noncystic fibrosis bronchiectasis were compared to 20 controls similar in age, gender and smoking exposure. Assessments included aortic pulse wave velocity (PWV; (a measure of arterial stiffness and an independent predictor of CV risk), blood pressure (BP) as well as levels of interleukin-6 (IL-6), albumin, fasting glucose and lipids. Body composition (fat free mass index (FFMI)), BMD, the 6-min walk distance (6MWD) and self-reported physical activity were also determined. Patients with bronchiectasis had increased aortic PWV, 10.5 (3.0) m/second, when compared with controls, 8.8 (1.6) m/second (p < 0.05), despite similar central and peripheral BP and lipid profile. Patients also had increased IL-6 and reduced albumin and glucose. Although mean body mass index, FFMI and BMD were similar in patients and controls, only 20% of patients had a healthy BMD compared with 50% of controls. Patients had reduced 6MWD and reported less physical activity (p < 0.05). Patients with bronchiectasis had increased arterial stiffness (an indicator of increased CV risk), increased inflammation, reduced exercise capacity and bone thinning. These additional comorbidities require further evaluation for their management in these patients.

Does pulmonary rehabilitation address cardiovascular risk factors in patients with COPD?

BACKGROUND: Patients with COPD have an increased risk of cardiovascular disease. Whilst pulmonary rehabilitation has proven benefit for exercise tolerance and quality of life, any effect on cardiovascular risk has not been fully investigated. We hypothesised that pulmonary rehabilitation, through the exercise and nutritional intervention, would address these factors. METHODS: Thirty-two stable patients with COPD commenced rehabilitation, and were compared with 20 age and gender matched controls at baseline assessment. In all subjects, aortic pulse wave velocity (PWV) an independent non-invasive predictor of cardiovascular risk, blood pressure (BP), interleukin-6 (IL-6) and fasting glucose and lipids were determined. These measures, and the incremental shuttle walk test (ISWT) were repeated in the patients who completed pulmonary rehabilitation. RESULTS: On commencement of rehabilitation aortic PWV was increased in patients compared with controls (p<0.05), despite mean BP, age and gender being similar. The IL-6 was also increased (p<0.05). Twenty-two patients completed study assessments. In these subjects, rehabilitation reduced mean (SD) aortic PWV (9.8 (3.0) to 9.3 (2.7) m/s (p<0.05)), and systolic and diastolic BP by 10 mmHg and 5 mmHg respectively (p<0.01). Total cholesterol and ISWT also improved (p<0.05). On linear regression analysis, the reduction in aortic PWV was attributed to reducing the BP. CONCLUSION: Cardiovascular risk factors including blood pressure and thereby aortic stiffness were improved following a course of standard multidisciplinary pulmonary rehabilitation in patients with COPD.

The influence of body composition on respiratory muscle, lung function and diaphragm thickness in adults with cystic fibrosis.

BACKGROUND: Weight loss and loss of fat-free mass (FFM) are associated with peripheral muscle wasting in cystic fibrosis (CF) although whether this co-exists with loss of diaphragm mass remains unclear. METHODS: FFM was determined by dual-energy X-ray absorptiometry and bioelectrical impedance in 40 adults with CF and 30 age-matched healthy subjects (HS). Diaphragm thickness at functional residual capacity (FRC) [TDIrel] and total lung capacity (TLC) [TDIcont] and thickening ratio (TR) were assessed by ultrasonography. Inspiratory muscle strength and work capacity were determined by maximal inspiratory pressure (PImax), and sustained PImax (SPImax); pulmonary function (RV, VC and TLC) and physical activity status (PAS) were also determined. RESULTS: When the CF patients were assessed as a group (low and normal FFM) they had similar age, weight, height and PAS compared to the HS, although patients had lower FFM (p<0.05), VC and TLC than the HS (p<0.01). In addition, although PImax, TDIrel, TDIcont and TR were similar between the patients and the HS, SPImax was lower in the patients (p<0.01). When analyses were made between patients with low versus normal FFM and between patients with low FFM and HS no significant differences were found between overall weight although TDIrel, TDIcont, TR and PAS were all reduced in patients with low FFM (p<0.01). CONCLUSIONS: PImax is relatively well preserved in adults with CF although there is a relationship between the loss of inspiratory muscle work capacity, FFM, PAS and pulmonary function. Furthermore loss of FFM is associated with loss of diaphragm muscle mass.

The effects of a back rehabilitation programme for patients with chronic low back pain.

AIM: The aim of this paper was to perform a pragmatic before-after analysis of a back rehabilitation programme (BRP) for patients with chronic low back pain (LBP). A total of 877 patients were recruited onto the BRP, which were carried out at four centres within the Wrightington, Wigan and Leigh NHS Trust. The BRP consisted of nine 2-hour group sessions of therapy run over 5 weeks and included 1 hour of exercise and 1 hour of education, advice problem solving and goal setting. METHOD: Using the Wilcoxen signed rank tests and paired t-tests levels of pain, disability, anxiety and depression were significantly reduced pre-post programme (P < 0.001). In addition, the levels of fitness and perceived control improved significantly (P < 0.001) suggesting that participants were better able to manage their LBP. CONCLUSION: Overall, the BRP proved to be effective in reducing pain, disability, anxiety and depression levels for people with chronic LBP. However, despite significant improvements in outcome measures only 50% of the patients completed the BRP and questionnaires post BRP. The implications of the findings are discussed with respect to modified programmes and alternative management for patients within different subgroups of LBP.

Reproducibility of measurements of inspiratory work capacity in cystic fibrosis patients.

The evaluation of respiratory muscle endurance (RME) is regarded as being clinically relevant to the assessment of respiratory muscle function. The reproducibility of a non-invasive measure of assessing RME was determined by measuring inspiratory work capacity (IWC) (using a computerised system). Measurements were obtained on two occasions in 20 adult cystic fibrosis (CF) patients (22.7+/-3.4 years, mean+/-S.D.) and 20 age (23.4+/-4.4 years) and gender (10 male, 10 female in each group) matched healthy controls. The coefficients of reliability (CR), intra-class correlation coefficients (ICC) and limits of agreement (bias+/-2 S.D.) were determined. CR values for the CF patients and controls were above 90% and with ICC of 0.99 in both CF patients and controls. The differences in IWC between study days were within +/-2 S.D. of the mean difference in all but one CF and one control subject. These data suggest that measures of IWC may be considered reliable when used to assess RM function in both controls and in patients with CF.

Effect of high-intensity inspiratory muscle training on lung volumes, diaphragm thickness, and exercise capacity in subjects who are healthy.

BACKGROUND AND PURPOSE: Previous investigations have demonstrated that a regimen of high-intensity inspiratory muscle training (IMT) resulted in changes in ventilatory function and exercise capacity in patients with chronic lung disease, although the effect of high-intensity IMT in subjects who are healthy is yet to be determined. The purpose of this study, therefore, was to examine whether high-intensity IMT resulted in changes in ventilatory function and exercise capacity in subjects who were healthy. SUBJECTS: Twenty subjects were randomly assigned to 2 groups. METHODS: The training group completed an 8-week program of IMT set at 80% of maximal effort. The control group did not participate in any form of training. Baseline and posttraining measures of body composition, pulmonary function, inspiratory muscle function (including maximal and sustained maximal inspiratory pressures [MIP and SMIP]), relaxed and contracted diaphragm thickness and thickening ratio (Tdi.rel, Tdi.cont, and TR), and exercise capacity were determined. RESULTS: The training group demonstrated significant increases in MIP, SMIP, Tdi.cont, TR, VC, total lung capacity, and exercise capacity compared with the control group, which demonstrated no change from baseline measurements at 8 weeks. DISCUSSION AND CONCLUSION: The findings of this study suggest that high-intensity IMT results in increased contracted diaphragm thickness and increased lung volumes and exercise capacity in people who are healthy.

A mixed-method systematic review to investigate the effect of group singing on health related quality of life.

OBJECTIVE: To investigate the effect of group singing on health related quality of life (HRQoL) for adult, amateur singers with chronic health conditions. METHODS: A literature search for experimental and observational studies and qualitative studies published before February 2014 was undertaken using the following databases: ASSIA (Proquest), CINAHL (Ebsco), EMBASE (OVID), HMIC (OVID), MEDLINE (OVID), MEDLINE in Process (OVID), OpenGrey, PsycINFO (OVID) and PubMed for Epub ahead of print studies. Social Science searches included: Web of Science, Proquest, and Scopus (Elsevier). The records were screened independently by two reviewers. Studies were critiqued using Critical Appraisal Skills Programme tools. RESULTS: The literature search identified 573 papers, from which 18 were included (5 quantitative, 5 qualitative, 8 mixed-methods studies). These included a variety of patient populations including chronic respiratory disease, neurological conditions and mental health. The quantitative studies lacked consistency: two of the seven controlled studies demonstrated additional HRQoL benefits with singing compared to controls, while three of six uncontrolled studies showed improved HRQoL. Qualitative methods were recorded in variable depth. The qualitative data presented a range of benefits of group singing including increased confidence, increased mood and social support. Few negative effects of singing were reported. CONCLUSION: This systematic review indicates that group singing interventions may have beneficial effects on HRQoL, anxiety, depression and mood. Studies were heterogeneous with significant methodological limitations, allowing only a weak recommendation for group singing as an intervention for adults with chronic health problems. The undertaking of larger controlled and in-depth qualitative studies is warranted.

A simple and rapid test of physical performance inchronic obstructive pulmonary disease.

Impaired physical performance is common in chronic obstructive pulmonary disease (COPD), but its assessment can be difficult in routine clinical practice. We compared the timed up and go (TUG) test and other easily applied assessments of physical performance with the 6-minute walk distance (6MWD). In a longitudinal study of comorbidities in COPD, submaximal physical performance was determined in 520 patients and 150 controls using the TUG test and 6MWD. Spirometry, body composition, handgrip strength, the COPD assessment test, St George's Respiratory Questionnaire (SGRQ), and the modified Medical Research Council dyspnoea scale were also determined. Patients and controls were similar in age, body mass index, and sex proportions. The TUG in the patients was greater than that in the control group, P=0.001, and was inversely related to 6MWD (r=-0.71, P<0.001) and forced expiratory volume in one second predicted (r=-0.19, P<0.01) and was directly related to the SGRQ activity (r=0.39, P<0.001), SGRQ total (r=0.37, P<0.001), and total COPD assessment test scores (r=0.37, P<0.001). The TUG identified the difference in physical performance between patients and controls. The TUG test and validated questionnaires provide a measure of physical performance, which is rapid and could be used in clinical practice.

Critical Care Functional Rehabilitation Outcome Measure: developing a validated measure.

INTRODUCTION: In 2009, the National Institute for Health and Clinical Excellence (NICE) developed guidelines, which recognized that rehabilitation plays a vital role in recovery from illness and in returning patients to their previous activity levels. NICE recommended the use of valid and reliable "outcome measures" as an evaluation tool. AIM: To develop and evaluate the validity and reliability of a new Critical Care Functional Rehabilitation Outcome Measure (CcFROM). METHOD: The CcFROM was developed by physiotherapists working within the authors' institution and was based on an evaluation of current measures. Face and content validity were investigated using a questionnaire posted to 21 physiotherapists. Same-day and between-day intra-rater reliability and inter-rater reliability were investigated by three physiotherapists viewing 20 physiotherapy rehabilitation sessions and completing the CcFROM. Data were analysed for relative and absolute reliability. RESULTS: The questionnaire demonstrated very high face validity and moderate content validity. 43% of the physiotherapists also suggested including an upper limb activity. Clinically acceptable same-day and between-day intra-rater reliability was demonstrated with ICCs of 0.985 (CI, 0.968-0.993) and 0.985 (CI, 0.871-0.972), respectively. Inter-rater reliability was recorded with an ICC of 0.906 (CI: 0.816-0.959). CONCLUSION: This study has shown that the CcFROM is a valid and reliable outcome measure for use in Critical Care.

Inspiratory muscle training improves lung function and exercise capacity in adults with cystic fibrosis.

STUDY OBJECTIVES: To investigate the effects of high-intensity inspiratory muscle training (IMT) on inspiratory muscle function (IMF), diaphragm thickness, lung function, physical work capacity (PWC), and psychosocial status in patients with cystic fibrosis (CF). DESIGN: Twenty-nine adult patients with CF were randomly assigned to three groups. Two groups were required to complete an 8-week program of IMT in which the training intensity was set at either 80% of maximal effort (group 1; 9 patients) or 20% of maximal effort (group 2; 10 patients). A third group of patients did not participate in any form of training and acted as a control group (group 3; 10 patients). INTERVENTIONS: In all patients, baseline and postintervention measures of IMF were determined by maximal inspiratory pressure (Pimax), and sustained Pimax (SPimax); pulmonary function, body composition, and physical activity status were also determined. In addition, diaphragm thickness was measured at functional residual capacity (FRC) and total lung capacity (TLC) [TDIcont], and the diaphragm thickening ratio (TR) was calculated (TR = thickness during Pimax at FRC/mean thickness at FRC). Subjects also completed an incremental cycle ergometer test to exhaustion and two symptom-related questionnaires, prior to and following training. RESULTS: Following training, significant increases in Pimax and SPimax (p < 0.05), TDIcont (p < 0.05), TR (p < 0.05), vital capacity (p < 0.05), TLC (p < 0.05), and PWC (p < 0.05) were identified, and decreases in anxiety scores (p < 0.05) and depression scores (p < 0.01) were noted in group 1 patients compared to group 3 patients. Group 2 patients significantly improved Pimax and SPimax (both p < 0.05) only with respect to group 3 patients. No significant differences were observed in group 3 patients. CONCLUSION: An 8-week program of high-intensity IMT resulted in significant benefits for CF patients, which included increased IMF and thickness of the diaphragm (during contraction), improved lung volumes, increased PWC, and improved psychosocial status.

Effect of inspiratory muscle training intensities on pulmonary function and work capacity in people who are healthy: a randomized controlled trial.

BACKGROUND: Inspiratory muscle training (IMT) has been shown to improve inspiratory muscle function, lung volumes (vital capacity [VC] and total lung capacity [TLC]), work capacity, and power output in people who are healthy; however, no data exist that demonstrate the effect of varying intensities of IMT to produce these outcomes. OBJECTIVES: The purpose of this study was to evaluate the impact of IMT at varying intensities on inspiratory muscle function, VC, TLC, work capacity, and power output in people who are healthy. DESIGN: This was a randomized controlled trial. SETTING: The study was conducted in a clinical laboratory. PARTICIPANTS: Forty people who were healthy (mean age=21.7 years) were randomly assigned to 4 groups of 10 individuals. INTERVENTIONS: Three of the groups completed an 8-week program of IMT set at 80%, 60%, and 40% of sustained maximum inspiratory effort. Training was performed 3 days per week, with 24 hours separating training sessions. A control group did not participate in any form of training. MEASUREMENTS: Baseline and posttraining measurements of body composition, VC, TLC, inspiratory muscle function (including maximum inspiratory pressure [MIP] and sustained maximum inspiratory pressure [SMIP]), work capacity (minutes of exercise), and power output were obtained. RESULTS: The participants in the 80%, 60%, and 40% training groups demonstrated significant increases in MIP and SMIP, whereas those in the 80% and 60% training groups had increased work capacity and power output. Only the 80% group improved their VC and TLC. The control group demonstrated no change in any outcome measures. LIMITATIONS: This study may have been underpowered to demonstrate improved work capacity and power output in individuals who trained at 40% of sustained maximum inspiratory effort. CONCLUSION: High-intensity IMT set at 80% of maximal effort resulted in increased MIP and SMIP, lung volumes, work capacity, and power output in individuals who were healthy, whereas IMT at 60% of maximal effort increased work capacity and power output only. Inspiratory muscle training intensities lower than 40% of maximal effort do not translate into quantitative functional outcomes.

Upper and lower trapezius muscle activity in subjects with subacromial impingement symptoms: is there imbalance and can taping change it?

OBJECTIVES: To investigate (i) whether subacromial impingement symptoms (SIS) were associated with upper and lower trapezius muscle imbalance and (ii) the effect of a scapula taping technique on upper and lower trapezius muscle activity. DESIGN: Cross-sectional study with nested within-subject intervention. SETTING: University research laboratory. PARTICIPANTS: Subjects who demonstrated SIS (n=16) on clinical testing and an age and gender matched group of asymptomatic subjects (n=32). MAIN OUTCOME MEASURES: Surface electromyography (EMG) to measure activity in the upper (UFT) and lower (LFT) fibres of trapezius during repeated humeral elevation in the scapular plane. RESULTS: Symptomatic subjects demonstrated a significantly (95% CI 2.13 to 4.17, p=0.019) higher ratio of UFT:LFT activity than the asymptomatic subjects (95% CI 1.35 to 2.25). With tape in situ the symptomatic subjects demonstrated a significant (95% CI -8.6% to -17.3%, p<0.001) reduction in UFT activity but no significant (95% CI +2.8% to -17.5%, p=0.145) change in activity of LFT. No relationship (r=- 0.116, p=0.669) was found between the degree of underlying muscle imbalance and the reduction in UFT under the taped condition for the symptomatic group. CONCLUSION: Subacromial impingement symptoms are associated with altered upper and lower trapezius muscle activity which can be partially addressed by the application of tape.

Phenolic metabolites in leaves of the invasive shrub, Lonicera maackii, and their potential phytotoxic and anti-herbivore effects.

Lonicera maackii is an invasive shrub in North America for which allelopathic effects toward other plants or herbivores have been suspected. We characterized the major phenolic metabolites present in methanol extracts of L. maackii leaves. In addition, we examined the effects of methanol-water extracts of L. maackii leaves on seed germination of a target plant species and on feeding preference and growth rate of a generalist insect herbivore. A total of 13 individual major and minor compounds were detected in crude leaf extracts by high-performance liquid chromatography coupled to electronspray ionization-tandem mass spectrometry (ESI-MS/MS). Extracts were dominated by two major flavones, apigenin and luteolin, and their glucoside derivatives, apigenin-7-glucoside and luteolin-7-glucoside. Quantities of these compounds, along with chlorogenic acid, varied between two sampling points. Leaf extracts that contained these compounds were inhibitory to seed germination of Arabidopsis thaliana. In addition, treatment of artificial diet with leaf extracts deterred feeding of the generalist herbivore, Spodoptera exigua, in choice experiments but had no effect on growth rate in short-term no-choice bioassays. Purified apigenin tended to deter feeding by S. exigua and inhibited seed germination of A. thaliana. We conclude that leaves of L. maackii contain phenolic compounds, including apigenin and chlorogenic acid, capable of having biological effects on other plants and insects.

Effects of fertilization and fungal and insect attack on systemic protein defenses of austrian pine.

Despite their economic and ecological importance, defense responses of conifers to pests are little understood. In a 3-year experiment, we monitored systemic fungal (Diplodia pinea)- and insect (Neodiprion sertifer)-induced defense protein activities and total soluble proteins in needles and phloem of Austrian pine (Pinus nigra) across a soil fertility gradient. In both years, total soluble protein content of foliage and phloem declined with increasing fertility across induction treatments, while defensive protein activities generally increased with increasing fertility. In 2005, total soluble protein content in branch phloem was increased by fungal inoculation of the stem. Peroxidase activity was suppressed in needles by insect defoliation in 2006, while polyphenol oxidase activity was systemically induced in branch phloem by insect attack in 2005. Trypsin inhibitor activities in phloem did not respond to any induction or fertility treatment. Nutritive quality of Austrian pine tissue declined with increasing fertility, while several protein-based defenses simultaneously increased.

Infection by powdery mildew Erysiphe cruciferarum (Erysiphaceae) strongly affects growth and fitness of Alliaria petiolata (Brassicaceae).

Garlic mustard (Alliaria petiolata) is an invasive biennial that negatively impacts plant and animal communities throughout North America and lacks significant herbivory in its invasive range. Throughout Ohio, many garlic mustard populations support the powdery mildew fungus Erysiphe cruciferarum, although disease incidence varies among populations and environments. Effects of infection on plant growth, as well as both plant and fungal responses to drought and light conditions, were examined on greenhouse-grown, first-year garlic mustard plants. Also, the effects of the fungus on plant growth and fitness were studied in a naturally growing population of second-year plants in the field. Powdery mildew significantly reduced growth of first-year plants in the greenhouse, eventually causing complete mortality. Simulated drought slowed both plant growth and disease development, independent of light conditions. In the field, plants with little incidence of disease after their first year grew taller during their second year, producing significantly more siliques and twice as many seeds as heavily diseased plants did. Seed germination rates did not differ between plants with different levels of disease severity. Consistent reductions in survival, growth, and fitness caused by fungal infection may reduce populations of garlic mustard. These effects may be more evident in moist sites that favor fungal development.

Expression of constitutive and inducible chemical defenses in native and invasive populations of Alliaria petiolata.

The Evolution of Increased Competitive Ability (EICA) hypothesis posits that invasive plants in introduced habitats with reduced herbivore pressure will evolve reduced levels of costly resistance traits. In light of this hypothesis, we examined the constitutive and inducible expression of five chemical defense traits in Alliaria petiolata from four invasive North American and seven native European populations. When grown under common conditions, significant variation among populations within continents was found for trypsin inhibitors and peroxidase activity, and glucosinolates and trypsin inhibitors were significantly jasmonate-inducible across populations. Across populations, constitutive levels of glucosinolates and trypsin inhibitors were negatively correlated with their degree of induction, with three North American populations tending to have lower constitutive levels and higher inducibility of glucosinolates than the seven European populations. Alliarinoside and isovitexin 6"-O-beta-glucopyranoside levels were both higher in North American plants than in European plants, but levels of these compounds were generally increased by jasmonate in European plants and decreased by the same treatment in North American plants. Aside from the tendency for invasive populations to have reduced constitutive glucosinolate levels coupled with increased inducibility, little support for the predictions of EICA was evident in the chemical defenses that we studied.