Estructura y propiedades métricas de un cuestionario para medir discapacidad en las actividades de movilidad en pacientes con enfermedad pulmonar obstructiva crónica (cuestionario DIAMO-EPOC) / Structure and metric properties of a questionnaire to measure disability in mobility activities in patients with chronic obstructive pulmonary disease (DIAMO-COPD questionnaire)

OBJETIVO: El objetivo del estudio fue adaptar un cuestionario de discapacidad en actividades de movilidad (DIAMO-EPOC) incorporando escalas basadas en el marco conceptual de la Clasificación Internacional del Funcionamiento, Discapacidad y Salud, y examinar su estructura, fiabilidad y validez en una cohorte de pacientes con EPOC. MÉTODOS: Un total de 137 pacientes con EPOC estable fueron reclutados. Se diseñaron dos escalas de cuatro ítems cada una y se verificó su estructura mediante análisis factorial y de multirrasgo. Adicionalmente, se calcularon los índices de fiabilidad (consistencia interna y test-retest). La validez de constructo se analizó mediante grupos conocidos y la convergencia-divergencia. RESULTADOS: El cuestionario resultó tener 2 escalas, con 4 ítems cada una, correspondientes a los dominios de la Clasificación Internacional del Funcionamiento, Discapacidad y Salud «cambiar y mantener la posición del cuerpo» y «andar y moverse». La fiabilidad y consistencia interna de las escalas resultaron aceptables y el test-retest excelente con CCI de 0,86 y 0,94, respectivamente. Las escalas mostraron una asociación moderada con la disnea, el estado de salud y la fuerza muscular de los pacientes y una diferente puntuación entre sujetos con distinto desempeño físico en la Short Physical Performance Battery. CONCLUSIONES: Las dos escalas del cuestionario DIAMO-EPOC son unidimensionales y tienen una sólida consistencia interna, estabilidad test-retest y validez, permitiendo identificar áreas específicas de movilidad limitada en pacientes con EPOC

OBJECTIVE: The aim of this study was to adapt a disability questionnaire in mobility activities (DIAMO-EPOC) incorporating scales based on the conceptual framework of the International Classification of Functioning, Disability and Health, and to examine its structure, reliability and validity in a cohort of patients with COPD. METHODS: A total of 137 patients with stable COPD were recruited. Two scales of 4 items each were designed and their structure was verified by exploratory factor analysis and multitrait scaling analysis. Additionally, reliability indices (internal consistency and test-retest) were calculated. Construct validity was analysed by known groups and convergence-divergence. RESULTS: The questionnaire had 2 scales, with 4 items each, corresponding to the domains of the International Classification of Functioning, Disability and Health "change and maintain the position of the body" and "walk and move". The reliability and internal consistency of the scales were acceptable and the test-retest was excellent with an ICC of 0.86 and 0.94, respectively. The scales showed a moderate association with dyspnoea, health status and muscle strength and a different score among participants with different physical performance in the Short Physical Performance Battery. CONCLUSIONS: The 2 scales of the DIAMO-EPOC questionnaire are one-dimensional and have a solid internal consistency, test-retest stability and validity, allowing the identification of specific areas of limited mobility in patients with COPD

Comparison of World Health Organization and Asia-Pacific body mass index classifications in COPD patients.

INTRODUCTION: A low body mass index (BMI) is associated with increased mortality and low health-related quality of life in patients with COPD. The Asia-Pacific classification of BMI has a lower cutoff for overweight and obese categories compared to the World Health Organization (WHO) classification. The present study assessed patients with COPD among different BMI categories according to two BMI classification systems: WHO and Asia-Pacific. PATIENTS AND METHODS: Patients with COPD aged 40 years or older from the Korean COPD Subtype Study cohort were selected for evaluation. We enrolled 1,462 patients. Medical history including age, sex, St George's Respiratory Questionnaire (SGRQ-C), the modified Medical Research Council (mMRC) dyspnea scale, and post-bronchodilator forced expiratory volume in 1 second (FEV1) were evaluated. Patients were categorized into different BMI groups according to the two BMI classification systems. RESULT: FEV1 and the diffusing capacity of the lung for carbon monoxide (DLCO) percentage revealed an inverse "U"-shaped pattern as the BMI groups changed from underweight to obese when WHO cutoffs were applied. When Asia-Pacific cutoffs were applied, FEV1 and DLCO (%) exhibited a linearly ascending relationship as the BMI increased, and the percentage of patients in the overweight and obese groups linearly decreased with increasing severity of the Global Initiative for Chronic Obstructive Lung Disease criteria. From the underweight to the overweight groups, SGRQ-C and mMRC had a decreasing relationship in both the WHO and Asia-Pacific classifications. The prevalence of comorbidities in the different BMI groups showed similar trends in both BMI classifications systems. CONCLUSION: The present study demonstrated that patients with COPD who have a high BMI have better pulmonary function and health-related quality of life and reduced dyspnea symptoms. Furthermore, the Asia-Pacific BMI classification more appropriately reflects the correlation of obesity and disease manifestation in Asian COPD patients than the WHO classification.

Sensing the Airs: The Cultural Context for Breathing and Breathlessness in Uruguay.

The sensory experience of breathing, particularly the sensation of breathlessness in the case of chronic obstructive pulmonary disease (COPD), is a rich though understudied topic in medical anthropology. Fieldwork in Uruguay made it clear to me that to study the sensorial experience of breathlessness, I would also have to study the widely shared cultural conceptualizations and practices surrounding air, breath, and health. In this article, I illustrate ethnographically how the experience of breathing and breathlessness is closely tied to perceptions of air outside the body - in particular humidity, temperature change, wind, and contamination. In conceptualizing breath as the mechanism and air the medium for environmental embodiment, I bring together sensorial medical anthropology, anthropology of the body, and the anthropology of wind and climate. My findings, in light of similar findings across contexts, suggest that a body transformed by COPD is hyperperceptive and hypersensitive to changes in air.

Association Between Expiratory Central Airway Collapse and Respiratory Outcomes Among Smokers.

IMPORTANCE: Central airway collapse greater than 50% of luminal area during exhalation (expiratory central airway collapse [ECAC]) is associated with cigarette smoking and chronic obstructive pulmonary disease (COPD). However, its prevalence and clinical significance are unknown. OBJECTIVE: To determine whether ECAC is associated with respiratory morbidity in smokers independent of underlying lung disease. DESIGN, SETTING, AND PARTICIPANTS: Analysis of paired inspiratory-expiratory computed tomography images from a large multicenter study (COPDGene) of current and former smokers from 21 clinical centers across the United States. Participants were enrolled from January 2008 to June 2011 and followed up longitudinally until October 2014. Images were initially screened using a quantitative method to detect at least a 30% reduction in minor axis tracheal diameter from inspiration to end-expiration. From this sample of screen-positive scans, cross-sectional area of the trachea was measured manually at 3 predetermined levels (aortic arch, carina, and bronchus intermedius) to confirm ECAC (>50% reduction in cross-sectional area). EXPOSURES: Expiratory central airway collapse. MAIN OUTCOMES AND MEASURES: The primary outcome was baseline respiratory quality of life (St George's Respiratory Questionnaire [SGRQ] scale 0 to 100; 100 represents worst health status; minimum clinically important difference [MCID], 4 units). Secondary outcomes were baseline measures of dyspnea (modified Medical Research Council [mMRC] scale 0 to 4; 4 represents worse dyspnea; MCID, 0.7 units), baseline 6-minute walk distance (MCID, 30 m), and exacerbation frequency (events per 100 person-years) on longitudinal follow-up. RESULTS: The study included 8820 participants with and without COPD (mean age, 59.7 [SD, 6.9] years; 4667 [56.7%] men; 4559 [51.7%] active smokers). The prevalence of ECAC was 5% (443 cases). Patients with ECAC compared with those without ECAC had worse SGRQ scores (30.9 vs 26.5 units; P < .001; absolute difference, 4.4 [95% CI, 2.2-6.6]) and mMRC scale scores (median, 2 [interquartile range [IQR], 0-3]) vs 1 [IQR, 0-3]; P < .001]), but no significant difference in 6-minute walk distance (399 vs 417 m; absolute difference, 18 m [95% CI, 6-30]; P = .30), after adjustment for age, sex, race, body mass index, forced expiratory volume in the first second, pack-years of smoking, and emphysema. On follow-up (median, 4.3 [IQR, 3.2-4.9] years), participants with ECAC had increased frequency of total exacerbations (58 vs 35 events per 100 person-years; incidence rate ratio [IRR], 1.49 [95% CI, 1.29-1.72]; P < .001) and severe exacerbations requiring hospitalization (17 vs 10 events per 100 person-years; IRR, 1.83 [95% CI, 1.51-2.21]; P < .001). CONCLUSIONS AND RELEVANCE: In a cross-sectional analysis of current and former smokers, the presence of ECAC was associated with worse respiratory quality of life. Further studies are needed to assess long-term associations with clinical outcomes.

Measurement of Dyspnea in Ambulatory African Americans With Heart Failure and a Preserved or Reduced Ejection Fraction.

BACKGROUND: Dyspnea is a burdensome and disabling heart failure (HF) symptom. Few studies examining dyspnea in HF have included African Americans (AAs), despite their developing HF at a younger age and having the highest mortality rates. OBJECTIVE: The purpose of this cross-sectional study was to examine dyspnea in AA patients with HF and a preserved ejection fraction (HFpEF) compared with those with a reduced ejection fraction (HFrEF), before and after the 6-minute walk test (6MWT). METHODS: A convenience sample of ambulatory AA patients (HFrEF, n = 26; HFpEF, n = 19) 50 years or older was recruited from an urban HF clinic. The Borg Scale and a visual analog scale (VAS) were used to measure dyspnea intensity before and after the 6MWT. Activity limitations related to dyspnea were described using the modified Medical Research Council Dyspnea Scale. Group comparisons were analyzed using repeated-measures analysis of variance and χ 2tests. Convergent validity was determined between the Borg and VAS using Bland-Altman plots. RESULTS: No significant differences were found in age, gender, and comorbidities between HF groups. Most HFpEF patients reported dyspnea at baseline (Borg, 63%; VAS, 73%) and after the 6MWT (Borg, 78%; VAS, 79%). In the HFrEF group, the prevalence of baseline dyspnea was greater when measured with the VAS (Borg, 34%; VAS, 80%) but was similar between instruments after the 6MWT (Borg, 64%; VAS, 77%). Both groups reported a similar change in dyspnea intensity during and after the 6MWT. The Bland-Altman plots indicated moderate agreement at each time point. Most patients described walking hurriedly or uphill as dyspnea-provoking on the Modified Respiratory Council Dyspnea Scale. CONCLUSIONS: The prevalence of dyspnea at baseline and after the 6MWT was high for both groups, but intensity varied with the dyspnea instrument used.

Efficacy and safety of once-daily glycopyrronium in predominantly Chinese patients with moderate-to-severe chronic obstructive pulmonary disease: the GLOW7 study.

BACKGROUND: Glycopyrronium is a once-daily (od) long-acting muscarinic antagonist for the maintenance treatment of chronic obstructive pulmonary disease (COPD). The GLOW7 study evaluated the efficacy and safety of od glycopyrronium 50 µg in predominantly Chinese patients with moderate-to-severe COPD. METHODS: In this 26-week, multi-center, double-blind, placebo-controlled, parallel-group study, men and women ≥40 years with moderate-to-severe COPD were randomized to glycopyrronium 50 µg od or placebo (2:1). The primary objective was to confirm the significant improvement of trough forced expiratory volume in 1 second (FEV1) following 12 weeks of treatment with glycopyrronium compared with placebo. Secondary objectives included the effect of glycopyrronium on health status (St George's Respiratory Questionnaire), breathlessness (Transition Dyspnea Index), other lung function parameters, rescue medication use, and COPD exacerbations. Safety and tolerability were also evaluated. RESULTS: Of the 460 patients randomized, 459 were included in the full analysis set (glycopyrronium, n=306; placebo, n=154; mean age 64.7 years; mean post-bronchodilator FEV1: 50.8% predicted); 425 (92.4%) completed the study. At Week 12, glycopyrronium signifcantly improved trough FEV1 with a least square means treatment difference of 141 mL (95% confidence interval 111 mL, 171 mL; P<0.001) compared with placebo. The mean treatment effect of glycopyrronium was greater than the minimum clinically important difference versus placebo in both St George's Respiratory Questionnaire total score (-4.92; P<0.001) and Transition Dyspnea Index focal score (1.0; P<0.001) at week 26. Glycopyrronium reduced the risk of exacerbations in terms of time to first moderate or severe exacerbation by 28% (P=0.153) and rate of moderate or severe COPD exacerbation by 29% (P=0.119) compared with placebo. Incidence of death was 1.3% with glycopyrronium and 0% in placebo during the treatment period. Overall incidence of adverse events (glycopyrronium 43.6%; placebo 47.4%) and serious adverse events (glycopyrronium 5.6%; placebo 9.1%) were similar. CONCLUSION: In predominantly Chinese patients with moderate-to-severe COPD, od glycopyrronium 50 µg significantly improved lung function, dyspnea, and health status compared with placebo. The safety and tolerability profile of glycopyrronium was comparable to placebo.

Dyspnea coping strategies in Korean immigrants with asthma or chronic obstructive pulmonary disease.

PURPOSE: Patients with lung disease develop coping strategies to relieve dyspnea. The coping strategies of Korean immigrants, however, are poorly understood. The purpose of this study was to describe the strategies that Korean immigrants with asthma or chronic obstructive pulmonary disease (COPD) use to cope with dyspnea and to compare similarities and differences in coping strategies between the two conditions. DESIGN: Outpatients with asthma (n = 25) or COPD (n = 48) participated in a cross-sectional descriptive study. METHOD: Open-ended questions and a structured instrument were used to describe coping strategies for dyspnea. Descriptive and inferential statistics were used to analyze the data. RESULTS: The most prevalent strategy was "I keep still or rest." Korean immigrants also used traditional therapies to manage dyspnea. CONCLUSIONS: Although the coping strategies of Korean immigrants were similar to those of other ethnic groups, they incorporated elements of Asian medical practice and herbs. This finding enables health care providers to better understand Korean immigrants' efforts to overcome dyspnea and to guide their patients' approach to coping.

Overestimation of physical activity among a nationally representative sample of underactive individuals with diabetes.

OBJECTIVES: Using data from the national Health and Retirement Study, we sought to: (a) estimate the proportion of the US adults with diabetes above the age of 50 who do not meet physical activity guidelines but believe they are sufficiently active; and (b) examine demographic and health-related correlates of such "overestimation." RESEARCH DESIGN: Respondents who were classified as underactive according to a detailed activity inventory but reported exercising at least the "right amount," were designated as overestimating their physical activity. Multiple logistic regression was used to examine the association of demographic and health-related correlates with the odds of overestimation. RESULTS: Fifty-four percent of the survey sample did not meet physical activity guidelines, and one quarter of this underactive group overestimated their physical activity. The adjusted odds of overestimation were higher among respondents who held the perception that they were about the right weight or underweight [odds ratio (OR)=2.42; 95% confidence interval (CI), 1.49-3.94), who had good or better self-assessed diabetes control (OR=1.84; 95% CI, 1.12-3.04), and who were Black or Hispanic (OR=1.89; 95% CI, 1.13-3.16). Experiencing shortness of breath reduced the odds of overestimation (OR=0.34; 95% CI, 0.19-0.61). CONCLUSIONS: Overestimation of physical activity is common among adults with diabetes, and is associated with the perceptions that one is about the right weight and that one has good control of diabetes, and with being Black or Hispanic. Clinicians should be aware that these factors may affect their patients' beliefs about how much physical activity is adequate.

Methods used in cross-cultural comparisons of somatic symptoms and their determinants.

This paper is the third in a series of reviews of cross-cultural studies of symptoms at midlife. The goal of this review is to examine methods used previously in cross-cultural studies of menopause and women's health at midlife to (1) identify challenges in the measurement of somatic symptoms across cultures and (2) recommend questions and tools that can be used in future research. This review also aims to examine the determinants of somatic symptoms. The review concludes that methods used for assessing somatic symptoms differ across studies. Somatic symptoms, particularly, aches, pain, and fatigue have a high prevalence. Statistically significant differences were seen in the prevalence of somatic symptoms across cultures. Based on the number of studies that demonstrated cross-cultural differences in symptom prevalence, we recommend that the following symptoms be included in future studies of symptoms at midlife: headaches, aches/pain, palpitations, dizziness, fatigue, breathing difficulties, numbness or tingling, and gastrointestinal difficulties. We also recommend that objective measures of physical function be administered when possible to supplement subjective self-evaluation.

Prevalence of gastroesophageal reflux symptoms in adolescents: is there a difference in different racial and ethnic groups?

The study aims to determine if differences exist among racial/ethnic groups in the prevalence of gastroesophageal reflux symptoms in adolescents. A cross-sectional questionnaire was administered to a sample of students in four racially and ethnically diverse high schools in suburban Chicago. A total of 2561 questionnaires were analyzed: 33% Hispanics, 30% Caucasians, 22% African Americans, 15% Asians, 54% female, mean age 15.8 (±1.3) years. Thirty-two percent had at least one esophageal and/or respiratory symptom ≥once a week. Caucasians and African Americans had more dysphagia than Hispanics and Asians (7% vs. 4%; P= 0.04). Hispanics had more heartburn (13% vs. 9-11%; P= 0.06) but this was not statistically significant. There was no difference for regurgitation. Hispanic females had more dysphagia (6% vs. 3%; P= 0.02) and heartburn (17% vs. 9%; P= 0.0003) than Hispanic males. African Americans and Caucasians had more respiratory symptoms than Hispanics and Asians (29%, 24% vs. 18%; P= 0.000004). Students with esophageal symptoms were more likely to have respiratory symptoms (46% vs. 17%; P < 0.0005). African Americans and Caucasians with esophageal symptoms had more respiratory symptoms than Hispanics and Asians with esophageal symptoms (55%, 49% vs. 42%, 34%; P= 0.0003). Asians and Hispanics were less likely to treat symptoms than African Americans and Caucasians (26%, 33% vs. 47%, 49%; P= 0.001). We found that differences exist among the racial/ethnic groups with esophageal and respiratory symptoms; esophageal symptoms are a risk factor for respiratory symptoms, and Asians and Hispanics seek less medical help. Future research should focus on whether the differences found continue and reasons for them.

Long-term pulmonary complications of chemical warfare agent exposure in Iraqi Kurdish civilians.

The Iraqi government used a range of chemical weapons, including blistering and nerve agents, against Iraqi Kurdish civilians in the 1980s. Few data exist about the long-term respiratory consequences of this exposure. In this study, Kurdish subjects with a history of exposure to chemical weapons were invited to attend a clinical assessment, including a review of their history, physical examination, and a high-resolution computed tomography (CT) of the thorax. Blistering at the time of exposure was used to define significant exposure to mustard gas. Results were compared between two groups of blistering and nonblistering. Four hundred seventy-nine subjects were studied; 45.7% male and 54.3% female. The mean age and standard deviation (mean +/- SD) of the cases was 43.1 +/- 13.7. Spirometry was abnormal in 15.2% of subjects and air trapping was present on CT scan in 46.6% and did not differ between patients with (n = 278) or without a history of blistering. Respiratory symptoms, including dyspnea, cough, and sputum production, were more common in subjects with a history of blistering (all p < .005) and blistering was also associated with a lower forced expiratory volume in one second (FEV(1)) (p < .0001). Severe complications were most common in subjects from Halabja who also made up the majority of participants. These results show that objective abnormalities are common in people with symptoms attributed to prior exposure to chemical agent. Blistering at the time of exposure was associated with more respiratory symptoms and worse lung function, but not with CT appearances. The high proportion of severe cases in comparison to reports from Iran may reflect the historical absence of effective early treatment, including strategies to reduce prolonged early exposure in this population.

Development of an activity of daily living scale for patients with COPD: the Activity of Daily Living Dyspnoea scale.

BACKGROUND AND OBJECTIVE: Patients with COPD often experience restriction in their activities of daily living (ADL) due to dyspnoea. This type of restriction is unique to patients with COPD and cannot be adequately evaluated by the generic ADL scales. This study developed an ADL scale (the Activity of Daily Living Dyspnoea scale (ADL-D scale)) for patients with COPD and investigated its validity and internal consistency. METHODS: Patients with stable COPD were recruited and completed a pilot 26-item questionnaire. Patients also performed the Incremental Shuttle Walk Test (ISWT), and completed the St. George's Respiratory Questionnaire (SGRQ) and Medical Research Council (MRC) dyspnoea grade. RESULTS: There were 83 male participants who completed the pilot questionnaire. Following the pilot, eight items that were not undertaken by the majority of subjects, and three items judged to be of low clinical importance by physical therapists were removed from the questionnaire. The final ADL-D scale contained 15 items. Scores obtained with the ADL-D scale were significantly correlated with the MRC dyspnoea grades, distance walked on the ISWT and SGRQ scores. The ADL-D scores were significantly different across the five grades of the MRC dyspnoea grade. The ADL-D scale showed high consistency (Chronbach's alpha coefficient of 0.96). CONCLUSIONS: The ADL-D scale is a useful scale for assessing impairments in ADL in Japanese male patients with COPD.

Symptoms of acute coronary syndrome in women with diabetes: an integrative review of the literature.

OBJECTIVE: To review studies comparing multiple acute coronary syndrome (ACS) symptoms in white and Latina women with and without diabetes. METHODS: This empirical integrative review summarizes 8 studies and identifies the limitations of research to date. RESULTS: There are conflicting results about acute coronary syndrome (ACS) symptoms in women with diabetes. Differences were found in associated ACS symptoms and symptom characteristics; however, some studies found no differences in frequency of chest pain by diabetic status. Diabetes is an independent predictor of "atypical" presentation of acute myocardial infarction in women, and research to date suggests that shortness of breath may be an important ACS symptom in women with diabetes. CONCLUSIONS: There is a paucity of literature on ACS symptoms in women, particularly Latina women, with diabetes, and results are inconclusive. Future research should examine the full range of ACS symptoms in multiethnic samples of women with diabetes.

Symptom expression in coronary heart disease and revascularization recommendations for black and white patients.

OBJECTIVES: We examined whether symptoms of coronary heart disease vary between Black and White patients with coronary heart disease, whether presenting symptoms affect physicians' revascularization recommendations, and whether the effect of symptoms upon recommendations differs in Black and White patients. METHODS: We interviewed Black and White patients in Pittsburgh in 1997 to 1999 who were undergoing elective coronary catheterization. We interviewed them regarding their symptoms, and we interviewed their cardiologist decision-makers regarding revascularization recommendations. We obtained coronary catheterization results by chart review. RESULTS: Black and White patients (N=1196; 9.7% Black) expressed similar prevalence of chest pain, angina equivalent, fatigue, and other symptoms, but Black patients had more shortness of breath (87% vs 72%, P=.001). When we considered only those patients with significant stenosis (n=737, 7.1% Black) and controlled for race, age, gender, and number of stenotic vessels, those who expressed shortness of breath were less likely to be recommended for revascularization (odds ratio=0.535; 95% confidence interval=0.375, 0.762; P<.001), but there was no significant interaction with race. CONCLUSIONS: Black patients reported shortness of breath more frequently than did White subjects. Shortness of breath was a negative predictor for revascularization for all patients with significant stenosis, but there was no difference in the recommendations by symptom by race.

Neither race nor gender influences the usefulness of amino-terminal pro-brain natriuretic peptide testing in dyspneic subjects: a ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) substudy.

BACKGROUND: Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is useful for the diagnosis and exclusion of congestive heart failure (HF). Little is known about the effect of race on NT-proBNP concentrations. Also, NT-proBNP levels may be higher in apparently well women, but the effect of gender on NT-proBNP concentrations in dyspneic patients is not known. METHODS AND RESULTS: NT-proBNP (Elecsys proBNP, Roche, Indianapolis, IN) was measured in 599 dyspneic patients in a prospective study. Of these, 44 were African American; 295 were female. NT-proBNP levels were examined according to race and gender in patients with and without acute HF using analysis of covariance. Receiver operating characteristic (ROC) curves assessed NT-proBNP by race and gender. Cutpoints for diagnosis (450, 900, and 1800 pg/mL for ages < 50, 50 to 75, and > 75 years) and exclusion (300 pg/mL) were examined in African-American and female subjects. There was no difference in the rates of acute HF between African-American and non-African-American (30% versus 35%, P = .44) or male and female (35% versus 35%, P = .86) subjects. In subjects with HF, there was no difference in median NT-proBNP concentrations between African American and non-African American (6196 versus 3597 pg/mL, P = .37). In subjects without HF, unadjusted NT-proBNP levels were lower in African-American subjects than in non-African-American subjects (68 versus 148 pg/mL, P < .03); however, when adjusted for factors known to influence NT-proBNP concentrations (age, prior HF, creatinine clearance, atrial fibrillation, and body mass index), race no longer significantly affected NT-proBNP concentrations. There was no statistical difference in median NT-proBNP concentrations between male and female subjects with (4686 versus 3622 pg/mL, P = .53) or without HF (116 pg/mL versus 150 pg/mL, P = .62). Among African Americans, NT-proBNP had an area under the ROC for acute HF of 0.96 (P < .0001), and at optimal cutpoints, had a sensitivity of 100% and a specificity of 90%. Among females, NT-proBNP had an area under the ROC for acute HF of 0.95 (P < .0001), and had a sensitivity of 89% and a specificity of 88%; 300 pg/mL had negative predictive value of 100% in African Americans and females. CONCLUSION: NT-proBNP is useful for the diagnosis and exclusion of acute HF in dyspneic subjects, irrespective of race or gender.

Development and validation of the Human Activity Profile into Chinese language: lessons in determining equivalence.

The Human Activity Profile (HAP), and associated Dyspnea Scale, is a self-report instrument for assessing levels of human activity. Although it has been used in studies examining the levels of activity in people, it is limited to people who are only able to understand English. However, many countries are multicultural with significant numbers of people whose native language is not English. This study sought to demonstrate the equivalence between the Chinese and English versions of the HAP and Dyspnea scales. Thirty-five bilingual university students completed both the Chinese and English versions of each questionnaire. There was 89% and 85% agreement between items across the HAP and Dyspnea Scale questionnaires, respectively. Although the psychometric evaluations suggested there was equivalence between the Chinese and English versions of both the HAP and Dyspnea Scale, lessons have been learnt regarding the different written forms of Chinese.

Respiratory complaints in Chinese: cultural and diagnostic specificities.

STUDY OBJECTIVES: We investigated the qualitative components of a wide range of Chinese descriptors of dyspnea and associated symptoms, and their relevance for clinical diagnosis. MEASUREMENTS: Sixty-one spontaneously reported descriptors were elicited in Chinese patients to make a symptom checklist, which was administered to new groups of patients with different cardiopulmonary diseases, to patients with medically unexplained dyspnea and to healthy subjects. RESULTS: Test-retest reliability was satisfactory for most of the descriptors. A principal component analysis on 61 descriptors yielded the following eight factors: dyspnea-effort of breathing; dyspnea-affective aspect; wheezing; anxiety; tingling; palpitation; coughing and sputum; and dying experience. Although the descriptors of dyspnea-effort of breathing resembled Western wordings and were shared by patients with a variety of diseases, the descriptors of dyspnea-affective aspect appeared to be more culturally specific and were primarily linked to the diagnosis of medically unexplained dyspnea, whereas wheezing was specifically linked to asthma. CONCLUSIONS: Three factors of breathlessness were found in Chinese. The descriptors of dyspnea-effort of breathing and wheezing appear to be similar to Western descriptors, whereas the dyspnea-affective aspect seems to bear cultural specificity.

[Dyspnoea in pregnant female immigrants due to unexpected mitral valve stenosis]. / Dyspnoe bij allochtone zwangeren door onverwachte mitralisklepstenose.

Three female patients, a 22-year-old Moroccan woman, a 25-year-old Turkish woman and a 35-year-old Iraqi woman, became increasingly dyspnoeic during their pregnancy; this was a symptom of congestive heart failure due to mitral valve stenosis. Since all patients were refractory to medical treatment, they underwent invasive therapy by percutaneous transvenous mitral balloon valvotomy (PTMV). In two patients this therapy was successful, but in one patient a closed mitral valvotomy was needed. All three women delivered healthy infants, two immediately following the PTMV; at follow-up 2-4 years later, the women and infants were all doing well. The prevalence of mitral valve stenosis in the western world is increasing because of changing immigration patterns. When pregnant patients start complaining about dyspnoea, especially if they are immigrants, one should be aware of the possibility of mitral valve stenosis. PTMV is a safe and successful treatment for these patients and is preferred above surgical therapy because of its low morbidity and mortality for both mother and foetus. PTMV must be performed in a thoracic surgery centre by an experienced team and the X-ray exposure should be minimised.

Ethnic differences: word descriptors used by African-American and white asthma patients during induced bronchoconstriction.

STUDY OBJECTIVES: To determine if African-American and white patients with asthma (1) differ in the words they use to describe their breathlessness, and (2) differ in their perception of breathlessness. DESIGN: Descriptive cross-sectional design. SETTING AND PARTICIPANTS: The study setting was located in Northern California, an ethnically and economically diverse area. A total of 32 subjects, 16 per group, completed the study. MEASUREMENTS: All had a provocation concentration of methacholine chloride causing a 30% fall in FEV(1) (PC(30)) of