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1.  Do obstructive sleep apnea syndrome patients underestimate their daytime symptoms before continuous positive airway pressure treatment? 
The sleep fragmentation caused by obstructive sleep apnea (OSA) has several health-related consequences in addition to a reduced quality of life, the full impact of which are not realized by patients until they initiate therapy for OSA. Because OSA symptoms are not always overtly apparent, health care providers may not inquire about sleep history, which leads to delays in diagnosis and treatment. This study used scores derived from the Epworth Sleepiness Scale and the Quebec Sleep Questionnaire, two widely used instruments to assess hypersomnolescence, as an alternative to quality of life questionnaires to evaluate diurnal sleepiness.
BACKGROUND:
Daytime somnolence is an important feature of the obstructive sleep apnea (OSA) hypopnea syndrome and is usually subjectively assessed using the Epworth Sleepiness Scale (ESS).
OBJECTIVE:
To compare the scores of the ESS and different domains of the Quebec Sleep Questionnaire (QSQ) assessed before and after the first months of continuous positive airway pressure (CPAP) treatment, as well as retrospectively without treatment.
METHODS:
The ESS score and domain scores of the QSQ were obtained before and after a three-month period of CPAP treatment using a retrospective assessment of the pretreatment scores in 76 untreated OSA patients.
RESULTS:
Fifty-two patients completed the study. The ESS and QSQ scores significantly improved following CPAP therapy. Retrospective evaluation of the ESS score was significantly worse than pre- and post-treatment values (mean [± SD] pretreatment score 11.0±4.8; retrospective pretreatment score 13.5±5.1). Such differences were not observed in any domain of the QSQ, including the domain assessing hypersomnolence.
CONCLUSION:
OSA patients underestimated their sleepiness according to the most widely used instrument to assess hypersomnolence. This finding may not be observed with other methods used to assess OSA-related symptoms such as quality of life questionnaires.
PMCID: PMC4173888  PMID: 24712013
Daytime somnolence; Quality of life
2.  Validity of chronic obstructive pulmonary disease diagnoses in a large administrative database 
BACKGROUND:
Administrative databases are often used for research purposes, with minimal attention devoted to the validity of the included diagnoses.
AIMS:
To determine whether the principal diagnoses of chronic obstructive pulmonary disease (COPD) made in hospitalized patients and recorded in a large administrative database are valid.
METHODS:
The medical charts of 1221 patients hospitalized in 40 acute care centres in Quebec and discharged between April 1, 2003 and March 31, 2004, with a principal discharge diagnosis of COPD (International Classification of Diseases, Ninth Revision codes 491, 492 or 496) were reviewed. The diagnosis of COPD was independently adjudicated by two pulmonologists using clinical history (including smoking status) and spirometry. The primary outcome measure was the positive predictive value (PPV) of the database for the diagnosis of COPD (ie, the proportion of patients with an accurate diagnosis of COPD corroborated by clinical history and spirometry).
RESULTS:
The diagnosis of COPD was validated in 616 patients (PPV 50.4% [95% CI 47.7% to 53.3%]), with 372 patients (30.5%) classified as ‘indeterminate’. Older age and female sex were associated with a lower probability of an accurate diagnosis of COPD. Hospitalization in a teaching institution was associated with a twofold increase in the probability of a correct diagnosis.
CONCLUSIONS:
The results support the routine ascertainment of the validity of diagnoses before using administrative databases in clinical and health services research.
PMCID: PMC3373291  PMID: 22536584
Chronic obstructive lung disease; Database; Epidemiology; Validity
3.  The laval questionnaire: a new instrument to measure quality of life in morbid obesity 
Background
Our recent review of the literature uncovered eleven obesity-specific quality of life questionnaires, all with incomplete demonstration of their measurement properties. Our objective was to validate a new self-administered questionnaire specific to morbid obesity to be used in clinical trials. The study was carried out at the bariatric surgery clinic of Laval Hospital, Quebec City, Canada.
Methods
This study followed our description of health-related quality of life in morbid obesity from which we constructed the Laval Questionnaire. Its construct validity and responsiveness were tested by comparing the baseline and changes at 1-year follow-up in 6 domain scores (symptoms, activity/mobility, personal hygiene/clothing, emotions, social interactions, sexual life) with those of questionnaires measuring related constructs (SF-36, Impact of Weight on Quality of Life-Lite, Rosenberg Self-Esteem Scale and Beck Depression Inventory-II).
Results
112 patients (67 who got bariatric surgery, 45 who remained on the waiting list during the study period) participated in this study. The analysis of the discriminative function of the questionnaire showed moderate-to-high correlations between the scores in each domain of our instrument and the corresponding questionnaires. The analysis of its evaluative function showed (1) significant differences in score changes between patients with bariatric surgery and those without, and (2) moderate-to-high correlations between the changes in scores in the new instrument and the changes in the corresponding questionnaires. Most of these correlations met the a priori predictions we had made regarding their direction and magnitude.
Conclusion
The Laval Questionnaire is a valid measure of health-related quality of life in patients with morbid obesity and is responsive to treatment-induced changes.
doi:10.1186/1477-7525-9-66
PMCID: PMC3168398  PMID: 21843326
4.  Six‐minute walking versus shuttle walking: responsiveness to bronchodilation in chronic obstructive pulmonary disease 
Thorax  2006;62(4):291-298.
Background
The responsiveness of the endurance shuttle walk to functional changes following bronchodilation has recently been reported. The current literature suggests that the 6 min walking test (6MWT) is less responsive to bronchodilation than the endurance shuttle walk.
Aim
To compare bronchodilator‐induced changes in exercise performance with the 6MWT and the endurance shuttle walk.
Methods
In a randomised, double‐blind, placebo‐controlled, crossover trial, 14 patients with chronic obstructive pulmonary disease (forced expiratory volume in 1 s (FEV1) 50 (8)% predicted) completed two 6MWTs and two endurance shuttle walks, each preceded by nebulised placebo or 500 μg ipratropium bromide. Cardiorespiratory parameters were monitored during each walking test with a portable telemetric gas analyser. Quadriceps twitch force was measured by magnetic stimulation of the femoral nerve before and after each walking test.
Results
The 6 min walking distance did not change significantly after bronchodilation despite a significant increase in FEV1 of 0.18 (0.09) litres (p<0.001). A similar change in FEV1 (0.18 (0.12) litres, p<0.001) was associated with a significant improvement in the distance walked on the endurance shuttle walk (Δdistance ipratropium bromide – placebo  =  144 (219) m, p = 0.03). Quadriceps muscle fatigue was infrequent (<15% of patients) after both walking tests.
Conclusion
The endurance shuttle walk is more responsive than the 6MWT for detecting changes in exercise performance following bronchodilation.
doi:10.1136/thx.2006.065540
PMCID: PMC2092479  PMID: 17099077
5.  Effects of aerobic exercise training and irbesartan on blood pressure and heart rate variability in patients with chronic obstructive pulmonary disease 
BACKGROUND AND OBJECTIVES:
The present pilot study was undertaken to evaluate the efficacy of an aerobic exercise training (AET) program alone or combined with an antihypertensive agent (irbesartan) to reduce blood pressure (BP) and enhance heart rate variability (HRV) in chronic obstructive pulmonary disease patients.
METHODS:
Twenty-one patients were randomly assigned to a double-blind treatment with exercise and placebo (n=11) or exercise and irbesartan (n=10). Subjects underwent 24 h BP monitoring and 24 h electrocardiographic recording before and after the 12-week AET. HRV was investigated using three indexes from the power spectral analysis and three indexes calculated from the time domain. The AET program consisted of exercising on a calibrated ergocycle for 30 min three times per week. Five patients in the placebo group were excluded during follow-up because they were not compliant.
RESULTS:
There was no change in 24 h systolic and diastolic BP before (130±14 mmHg and 70±3 mmHg, respectively) and after (128±8 mmHg and 70±8 mmHg, respectively) exercise training in the placebo group, whereas in the irbesartan group systolic and diastolic BP decreased from 135±9 mmHg and 76±9 mmHg to 126±12 mmHg and 72±8 mmHg, respectively (P<0.02). There were no changes in HRV parameters in either group.
CONCLUSIONS:
The present study suggests that a 12-week AET program is not associated with a significant reduction in BP or enhancement in HRV, whereas an AET program combined with irbe-sartan is associated with a reduction in 24 h BP.
PMCID: PMC2679570  PMID: 18949104
Autonomic nervous system; Exercise training; Hypertension; Respiratory disease
6.  Adjuvant chemotherapy in resected lung cancer: Two-year experience in a university hospital 
BACKGROUND:
Randomized trials have confirmed the benefits of adjuvant chemotherapy in improving survival in resected early-stage non-small-cell lung cancer (NSCLC). The extent to which these results have translated into clinical practice is unknown.
OBJECTIVE:
To examine the referral pattern of patients with resected lung cancer to adjuvant chemotherapy, and to compare compliance and toxicities with current literature.
METHODS:
A retrospective analysis of all patients who underwent a surgical resection for lung cancer at Laval Hospital (Quebec City, Quebec) from March 2004 to January 2006 was conducted.
RESULTS:
A total of 258 patients underwent surgery. Seven patients were excluded because of early postoperative death, and two patients were excluded because of incomplete data. Data from 249 patients were analyzed (94% NSCLC). Fifty per cent were referred to medical oncology for consideration of adjuvant chemotherapy, including 37 of 61 patients with stage II NSCLC. One hundred patients received chemotherapy. No significant difference in age, sex, comorbidities and surgical procedures was observed between those who received chemotherapy and those who did not. Chemotherapy was initiated 47 days (median) after the surgery and consisted mainly of cisplatin-vinorelbine (38%), cisplatin-etoposide (22%) and carboplatin-paclitaxel (20%). Sixty-six per cent of the patients completed all four cycles. Grade 3 or 4 toxicities consisted mainly of fatigue (23%) and cytopenia (40%). No death was registered; 15% had to be hospitalized because of adverse effects.
CONCLUSION:
Although adjuvant chemotherapy is gaining acceptance in clinical practice, more patients should be referred to medical oncology following surgical resection. Compliance and toxicity are similar to or better than those described in published randomized trials.
PMCID: PMC2679550  PMID: 18716690
Adjuvant chemotherapy; Lung cancer; Referral patterns; Treatment compliance; Treatment toxicity
7.  Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease – 2008 update – highlights for primary care 
Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is preventable and treatable but unfortunately remains underdiagnosed. The purpose of the present article from the Canadian Thoracic Society is to provide up-to-date information so that patients with this condition receive optimal care that is firmly based on scientific evidence. Important summary messages for clinicians are derived from the more detailed Update publication and are highlighted throughout the document. Three key messages contained in the update are: use targeted screening spirometry to establish a diagnosis and initiate prompt management (including smoking cessation) of mild COPD; improve dyspnea and activity limitation in stable COPD using new evidence-based treatment algorithms; and understand the importance of preventing and managing acute exacerbations, particularly in moderate to severe disease.
PMCID: PMC2802325  PMID: 18292855
Chronic obstructive pulmonary disease; Management; National guidelines
8.  Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease – 2007 update 
Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.
PMCID: PMC2806792  PMID: 17885691
Management; National guidelines; Obstructive pulmonary disease
9.  Nocturnal oxygen therapy in patients with chronic obstructive pulmonary disease: A survey of Canadian respirologists 
BACKGROUND:
Current evidence does not clearly support the provision of nocturnal oxygen therapy in patients with chronic obstructive pulmonary disease (COPD) who desaturate during sleep but who would not otherwise qualify for long-term oxygen therapy (LTOT).
OBJECTIVES:
To characterize the perception and clinical practice of Canadian respirologists regarding the indications and prescription of nocturnal oxygen therapy in COPD, and to determine what Canadian respirologists consider an important treatment effect of nocturnal oxygen therapy in a randomized, placebo-controlled trial.
METHODS:
A mail survey of all the respirologists registered in the 2006 Canadian Medical Directory was conducted.
RESULTS:
A total of 543 physicians were surveyed. The response rate was 60%, and 99% of the respondents indicated that the problem of nocturnal oxygen desaturation is clinically relevant. Eighty-two per cent interpret oximetry tracings themselves, and 87% have access to a sleep laboratory. Forty-two per cent believe that all COPD patients with significant nocturnal desaturation should have a polysomnography to rule out sleep apnea, and 41% would prescribe nocturnal oxygen therapy to active smokers. Assuming a risk of death or progression to LTOT of 40% over a three-year period, the respirologists indicated that to declare nocturnal oxygen therapy effective in reducing the rate of major clinical events in a clinical trial, the minimal absolute risk difference of death or progression to LTOT between oxygen and room air breathing should be 14%.
CONCLUSIONS:
Canadian respirologists are interested in the issue of nocturnal oxygen desaturation in COPD. There is variation in clinical practices among Canadian respirologists in several aspects of the management of this problem.
PMCID: PMC2676407  PMID: 17885694
COPD; Mail questionnaire; Oxygen therapy; Survey
10.  Reliability of home CPAP titration with different automatic CPAP devices 
Respiratory Research  2008;9(1):56.
Background
CPAP titration may be completed by automatic apparatus. However, differences in pressure behaviour could interfere with the reliability of pressure recommendations. Our objective was to compare pressure behaviour and effective pressure recommendations between three Automatic CPAP machines (Autoset Spirit, Remstar Auto, GK 420).
Methods
Sixteen untreated obstructive sleep apnea patients were randomly allocated to one of the 3 tested machines for a one-week home titration trial in a crossover design with a 10 days washout period between trials.
Results
The median pressure value was significantly lower with machine GK 420 (5.9 +/- 1.8 cm H2O) than with the other devices both after one night and one week of CPAP titration (7.4 +/- 1.3 and 6.6 +/- 1.9 cm H2O). The maximal pressure obtained over the one-week titration was significantly higher with Remstar Auto (12.6 +/- 2.4 cm H2O, Mean +/- SD) than with the two other ones (10.9 +/- 1.0 and 11.0 +/- 2.4 cm H2O). The variance in pressure recommendation significantly differed between the three machines after one night and between Autoset Spirit and the two other machines after 1 week.
Conclusion
Pressure behaviour and pressure recommendation significantly differ between Auto CPAP machines both after one night and one week of home titration.
doi:10.1186/1465-9921-9-56
PMCID: PMC2515310  PMID: 18652688
11.  Chronic obstructive pulmonary disease in women 
BACKGROUND:
Little is known about the comparative impact of chronic obstructive pulmonary disease (COPD) between women and men and about women’s response to pulmonary rehabilitation.
OBJECTIVES:
To compare lung function, disability, mortality and response to pulmonary rehabilitation between women and men with COPD.
METHODS:
In the present retrospective study, 68 women (mean age 62.5±8.9 years) and 168 men (mean age 66.3±8.4 years) were evaluated by means of pulmonary function testing and an incremental symptom-limited cycle exercise test. Forty women and 84 men also participated in a 12-week pulmonary rehabilitation program. A 6 min walking test and the chronic respiratory questionnaire were used to assess the effects of pulmonary rehabilitation. Survival status was also evaluated.
RESULTS:
Compared with men, women had a smaller tobacco exposure (31±24 versus 48±27 pack-years, P<0.05), displayed better forced expiratory volume in 1 s (44±13 versus 39±14 % predicted, P<0.05), a higher functional residual capacity (161±37 versus 149±36 % predicted, P<0.05) and total lung capacity (125±20 versus 115±19 % predicted, P<0.001). Peak oxygen consumption was not different between women and men when expressed in predicted values but lower in women when expressed in absolute values. Pulmonary rehabilitation resulted in significant improvements in 6 min walking test and quality of life in both sexes, but women had a greater improvement in chronic respiratory questionnaire dyspnea. Survival status was similar between sexes, but predictors of mortality were different between sexes.
CONCLUSIONS:
Women may be more susceptible to COPD than men. The clinical expression of COPD may differ between sexes with greater degree of hyperinflation in women, who also benefit from pulmonary rehabilitation.
PMCID: PMC2676379  PMID: 17372636
COPD; Pulmonary rehabilitation; Survival; Women
12.  Postoperative outcome after coronary artery bypass grafting in chronic obstructive pulmonary disease 
BACKGROUND:
It is uncertain if the presence and severity of airflow obstruction in chronic obstructive pulmonary disease (COPD) is predictive of surgical morbidity and mortality after coronary artery bypass grafting (CABG).
METHODS:
Retrospective study of patients who underwent CABG between 1998 and 2003 in a university-affiliated hospital for whom a preoperative spirometry was available. COPD was diagnosed in smokers or ex-smokers 50 years of age or older in the presence of irreversible airflow obstruction. Patients were divided into three groups depending on the spirometry: controls (forced expiratory volume in 1 s [FEV1] 80% or more, FEV1/forced vital capacity [FVC] greater than 0.7), mild to moderate COPD (FEV1 50% or more and FEV1/FVC 0.7 or less) and severe COPD (FEV1 less than 50% and FEV1/FVC 0.7 or less).
RESULTS:
Among the 411 files studied, 322 (249 men, 68±8 years of age) were retained (controls, n=101; mild to moderate COPD, n=153; severe COPD, n=68). The mortality rate (3.0%, 2.6% and 0%, respectively) was comparable among the three groups. Patients with severe COPD had a slightly longer hospital stay than controls (mean difference 0.7±1.4 days, P<0.05). Pulmonary infections were more frequent in severe COPD (26.5%) compared with mild to moderate COPD (12.4%) and controls (12.9%), P<0.05. Atrial fibrillation tended to be more frequent in severe COPD than in the other two groups.
CONCLUSION:
Mortality rate associated with CABG surgery is not influenced by the presence and severity of airflow obstruction in patients with COPD. The incidence of pulmonary infections and length of hospital stay were increased in patients with severe COPD.
PMCID: PMC2690441  PMID: 17315054
COPD; Coronary artery bypass; Heart surgery; Postoperative complications
13.  Hypersensitivity pneumonitis 
Hypersensitivity pneumonitis (HP) is a pulmonary disease with symptoms of dyspnea and cough resulting from the inhalation of an antigen to which the subject has been previously sensitized. The incidence of HP is unknown. A population-based study estimated the annual incidence of interstitial lung diseases as 30:100,000 and HP accounted for less than 2% of these cases. The diagnosis of HP can often be made or rejected with confidence, especially in areas of high or low prevalence respectively, using simple diagnostic criteria. Chest X-rays may be normal in active HP; High Resolution Computed Tomography is sensitive but not specific for the diagnosis of HP. The primary use of pulmonary function tests is to determine the physiologic abnormalities and the associated impairment. Despite the pitfalls of false positive and false negatives, antigen-specific IgG antibodies analysis can be useful as supportive evidence for HP. Bronchoalveolar lavage plays an important role in the investigation of patients suspected of having HP. A normal number of lymphocytes rules out all but residual disease. Surgical lung biopsy should be reserved for rare cases with puzzling clinical presentation or for verification the clinical diagnosis when the clinical course or response to therapy is unusual. Being an immune reaction in the lung, the most obvious treatment of HP is avoidance of contact with the offending antigen. Systemic corticosteroids represent the only reliable pharmacologic treatment of HP but do not alter the long-term outcome. The use of inhaled steroids is anecdotal. Treatment of chronic or residual disease is supportive.
doi:10.1186/1750-1172-1-25
PMCID: PMC1533805  PMID: 16817954

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