Clinical Functional Assessment Research Articles

Clinical and functional variables associated to long-term mortality in COPD patients

Background: Identifying risk factors for long-term mortality in patients with chronic obstructive pulmonary disease (COPD) could improve their clinical management. Aim: To examine the clinical variables associated to long-term mortality in a cohort of COPD patients. Patients and methods: A clinical and respiratory functional assessment, chest computed tomography and clinical follow up for five years was carried out in 202 COPD patients aged 66 ± 9 years (59% males), active or former smokers of 10 or more pack-years. Results: Thirty four percent of patients were active smokers, consuming 46 ± 23 packs/year, 86% had comorbidities, especially chronic cardiovascular and metabolic diseases. Forty-six patients died in the five years follow up (5-year mortality was therefore 22.8%). In the univariate analysis, the main risk factors associated to long-term mortality were an older age, male sex, dyspnea severity, severe exacerbation risk, chronic respiratory failure, magnitude of lung emphysema, airflow obstruction and lung hyperinflation, reduction of thigh muscle cross-sectional area and physical activity limitation. In the multivariate analysis, the three independent risk factors for long-term mortality were dyspnea severity, chronic hypoxemia and exercise limitation measured with the six minutes’ walk test. Conclusions: Systematic clinical assessment allowed to identify the main risk factors associated with long-term mortality in patients with COPD, which could be used in planning preventive and management programs aimed at the high-risk population.

Point-of-care gastrointestinal and urinary tract sonography in daily evaluation of gastrointestinal dysfunction in critically ill patients (GUTS Protocol).

There is currently a lack of universally accepted criteria for gastrointestinal (GI) failure or dysfunction in critical care. Moreover, the clinical assessment of intestinal function is notoriously difficult and thus often goes unrecognized, contributing to poor outcomes. A recent grading system has been proposed to define acute gastrointestinal injury (AGI) in conjunction with other organ function scores (e.g., SOFA). Ultrasonography has become widely accepted as a diagnostic tool for GI problems and pathology. We propose a sonographic examination of the abdomen, using the GUTS protocol (gastrointestinal and urinary tract sonography) in critically ill patients as part of the point-of-care ultrasound evaluation in patients with AGI. This article reviews possible applications of ultrasonography that may be relevant to monitor the GI function in critically ill patients. The GI ultrasound protocol (GUTS) focuses on four gastrointestinal endpoints: gastrointestinal diameter, mucosal thickness, peristalsis, and blood flow. Moreover, it is possible to examine the urinary tract and kidney function. Real-time ultrasound with the GUTS protocol is a simple, inexpensive, bedside imaging technique that can provide anatomical and functional information of the GI tract. Further studies are needed to investigate the utility of GUTS with other parameters, such as GI biomarkers, AGI class, and clinical outcomes.

Adherence to standardized assessments through a complexity-based model for categorizing rehabilitation\xa9: design and implementation in an acute hospital

BackgroundThe use of measurement instruments has become a major issue in physical therapy, but their use in daily practice is rare. The aim of this paper is to describe adherence to standardized assessments by physical therapists using a complexity-based model for categorizing rehabilitation (CMCR) at the Clínica Alemana of Santiago, an acute hospital in Chile.MethodsThis retrospective cohort study used 145,968 participant records that were stored in the inpatient database between July 2011 and December 2015. Adherence to the CMCR by 31 physical therapists working with intensive care unit (ICU) and non-ICU inpatients was assessed every quarter using the electronic patient records (EPR). This instrument (CMCR) linked clinical functional assessment to the degree of severity, thereby setting a score used to categorize patients as low, medium and high complexity. 96,400 instances of inpatient care where the physician recommended physical therapy were categorized. This was from a total of 145,968 instances of inpatient care recorded throughout the duration of the study (17 quarters). Trends in adherence were analyzed using a Prais-Winsten regression (a first-order autoregressive model). The trends were compared using a repeated measures ANOVA for mixed models with a significance level of 0.05. The use of the CMCR was included as one of the organization’s quality indicators associated with the hospital’s accreditation processes.ResultsAdherence increased by 1.48% every quarter (p = 0.005) for both ICU and non-ICU patients. On average, adherence with ICU patients was 16.98% greater than with non-ICU patients. Although adherence was always greater with ICU patients, the rate of increase with non-ICU patients was significantly greater: 1.62% (p = 0.007) vs. 1.28% (p = 0.003), respectively.ConclusionThe CMCR facilitated adherence to standardized assessments by physical therapists working with ICU and non-ICU inpatients in an acute hospital, while linking this instrument to the organization’s quality management process proved to be an effective strategy for the duration of this study (17 quarters).

Urological complications after radical hysterectomy with postoperative radiotherapy and radiotherapy alone for cervical cancer.

Radiotherapy is a reliable method to cure cervical cancer patients, but it could cause serious urological complications after the treatment due to the anatomical location of the cervix. The main purpose of this retrospective analysis is to study the incidence, latency, and therapeutic efficacy of urological complications caused by radical hysterectomy with postoperative radiotherapy or radiotherapy alone in patients with cervical cancer.A retrospective analysis was conducted on patients with cervical cancer who received radical hysterectomy with postoperative radiotherapy or radiotherapy alone at the First Hospital of Jilin University between January 2010 and May 2016. The urological complications were confirmed by clinical manifestation, ultrasound, computed tomography (CT), nuclear scintigraphy, and assessment of renal function. All the patients with urological complications received conventional treatment, including conservative, electrosurgery, ureteral stents, nephrectomy, and neoplasty. The onset time of radiation injury symptoms was confirmed according to the medical history and follow-up. The surveillance for the therapeutic effects for these complications was accomplished by cystoscopy, imaging, and laboratory assessment.The overall rate of urological complications after treatment was 3.26%, comprising 2.12% ureteral obstruction, 0.98% radiocystitis, and 0.16% vesicovaginal fistula. The incidence of ureteral obstruction in patients treated with radical hysterectomy with postoperative radiotherapy and radiotherapy alone was not statistically significant (2.18% vs 1.59%, P > .05). The median onset time of radiocystitis and ureteral obstruction was 10 months (0–75 months) and 12 months (2–66.3 months), respectively. The onset time of vesicovaginal fistula was 3.5 months. After the appropriate treatment, the majority of the complications were under control.The incidence of urological complications is acceptable. There was no statistical difference in the risk between patients treated with radical hysterectomy with postoperative radiotherapy and radiotherapy alone. The latency period between radiotherapy and the manifestation of urological complications may be relatively long. So it is crucial to underline long-term follow-up after radiotherapy. The majority of urological complications were alleviated after symptomatic treatment and the patients with cervical cancer achieved long-term remissions or cures.

Laboratory examinations for the vestibular system.

In the last decades, researchers suggested that clinical assessment of labyrinthine function in detail became easy thanks to video head impulse tests (VHITs), vestibular evoked myogenic potential test (VEMP) and video-oculography (VOG). It has been argued that they can replace electronystagmography, the caloric and rotatory chair tests. This review addresses the latest evaluations of these tests and the opportunities they offer, but also the limitations in clinical practice. The VHIT and suppression head impulse test (SHIMP) are under ideal circumstances able to accurately identify deficits of the VOR in 3D. However, in a relevant part of the patient population, pupil tracking is inaccurate, video-goggles slip and VOR quantification is problematic. The dissociation between the VHIT and caloric test suggests that these tests are complementary. A new 3D-VOG technique claims to quantify eye torsion better than before, opening multiple diagnostic possibilities. VEMPs remain difficult to standardize. Variability in normal cervical vestibular-evoked myogenic potential amplitude is large. VEMPs become smaller or absent with age, raising questions of whether there is a lower normal limit at all. Recent research shows that the labyrinth is directly stimulated in the MRI offering new opportunities for diagnostics and research. In clinical practice, the VHIT, SHIMP, VEMP and new 3D-VOG techniques improve diagnostic power. Unfortunately, technical issues or variability prevent reliable quantitative evaluation in a part of the regular patient population. The traditional caloric and rotatory chair test can still be considered as valuable complementary tests.

Short-term Efficacy of Hand-Arm Bimanual Intensive Training on Upper Arm Function in Acute Stroke Patients: A Randomized Controlled Trial.

Rehabilitation training during the acute phase of stroke (<48 h) markedly improves impaired upper-limb movement. Hand-arm bimanual intensive training (HABIT) represents an intervention that promotes improvements in upper extremity function in children with cerebral palsy. This study repurposed HABIT in acute stroke patients and assessed recovery of upper extremity function when compared with a conventional rehabilitation program (CRP). In a randomized trial, 128 patients with acute stroke were assigned to the HABIT or the CRP groups. The primary endpoint was clinical motor functional assessment that was guided by the Fugl-Meyer motor assessment (FMA) and outcomes of the action research arm test (ARAT). The secondary endpoint was an improved neurophysiological evaluation according to the motor-evoked potential amplitude (AMP), resting motion threshold (RMT), and central motor conduction time (CMCT) scores over the 2-week course of therapy. In both groups, scores were evaluated at baseline, 1 week from commencing therapy, and post-therapy. After 2 weeks, the HABIT group showed improved scores as compared the CRP group for FMA (51.7 ± 6.44 vs. 43.5 ± 5.6, P < 0.001), ARAT (34.5 ± 6.2 vs. 33.3 ± 6.3, P = 0.022), and AMP (1.1 ± 0.1 vs. 1.0 ± 0.1, P < 0.001). However, CMCT (8.6 ± 1.0 vs. 9.1 ± 0.6, P = 0.054) and RMT (55.3 ± 4.2 vs. 57.5 ± 4.1, P = 0.088) were similar when comparing between groups. HABIT significantly improved motor functional and neuro-physiological outcomes in patients with acute stroke, which suggested that HABIT might represent an improved therapeutic strategy as compared CRP.

The 8-foot up and go test is the best way to assess physical function in the rheumatoid arthritis clinic.

ObjectivesRA is characterized by poor physical function, which compromises patients’ quality of life and outcome. Clinical assessment of function is usually performed using self-reported questionnaires, such as the Multi-Dimensional HAQ (MDHAQ) and the Short Form-36 (physical component) (SF36-PC). However, such subjective measures may not accurately reflect real functional status. This study aimed to determine: (i) which clinically practicable objective test best represents overall physical function; and (ii) the extent to which self-reported subjective functional measures reflect objectively assessed function. MethodsObjective [isometric knee extensor strength, handgrip strength, sit-to-stands in 30 s, 8-foot up and go (8′UG), 50-foot walk (50′W) and estimated aerobic capacity (V̇O2max)] and subjective (MDHAQ and SF36-PC) measures of function were correlated with one another to determine the best overall test of functional status in 82 well-controlled RA patients (DAS28 (s.d.) = 2.8 (1.0)).ResultsIn rank order of size, averaged correlations (r) to the other outcome measures were as follows: 8′UG: 0.650; 50′W: 0.636; isometric knee extensor strength: 0.502; handgrip strength: 0.449; sit-to-stands in 30 s: 0.432; and estimated V̇O2max: 0.358. The MDHAQ was weakly (0.361) and the SF36-PC moderately correlated (0.415) with objective measures.ConclusionOur results show that the most appropriate measure of objective physical function in RA patients is the 8′UG, followed by the 50′W. We found discordance between objectively and subjectively measured function. In clinical practice, an objective measure that is simple and quick to perform, such as the 8′UG, is advocated for assessing real functional status.

Flexion Deformities of the Wrist and Fingers in Spastic Cerebral Palsy: A Protocol of Management.

Background:Literature is confusing regarding grading and treatment of flexion deformities of wrist and fingers in spastic cerebral palsy (CP). The most established classification is that described by Zancolli; unfortunately, it has its shortcomings which we experienced in the beginning of our approach to manage this rather difficult deformity. We thus modified Zancolli's classification and developed a classification system and treatment protocol.Materials and Methods:Thirty patients with spastic CP were operated upon due to flexion deformity of the wrist and fingers and were included in this study. Age ranged from 4 to 14 years, average 7 years. There were twenty boys and ten girls.Results:The average followup was 18 months (range 9 months - 3 years). The power of wrist dorsiflexion, the “House's classification of upper extremity functional use” and the clinical assessment of hand function were used for evaluation; they improved in all patients and this improvement was statistically significant. In all patients, cosmetic appearance improved without any residual flexion deformity.Conclusion:This study introduces a new grading system for flexion deformity of wrist and fingers in spastic CP that correlates with severity of the condition and allows a treatment protocol to be established.

Effects of the Integration of Dynamic Weight Shifting Training Into Treadmill Training on Walking Function of Children with Cerebral Palsy: A Randomized Controlled Study.

The aim of the study was to determine whether applying an assistance force to the pelvis and legs during treadmill training can improve walking function in children with cerebral palsy. Twenty-three children with cerebral palsy were randomly assigned to the robotic or treadmill only group. For participants who were assigned to the robotic group, a controlled force was applied to the pelvis and legs during treadmill walking. For participants who were assigned to the treadmill only group, manual assistance was provided as needed. Each participant trained 3 times/wk for 6 wks. Outcome measures included walking speed, 6-min walking distance, and clinical assessment of motor function, which were evaluated before, after training, and 8 wks after the end of training, and were compared between two groups. Significant increases in walking speed and 6-min walking distance were observed after robotic training (P = 0.03), but no significant change was observed after treadmill training only. A greater increase in 6-min walking distance was observed after robotic training than that after treadmill only training (P = 0.01). Applying a controlled force to the pelvis and legs, for facilitating weight-shift and leg swing, respectively, during treadmill training may improve walking speed and endurance in children with cerebral palsy. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) discuss the importance of physical activity at the participation level (sports programs) for children with cerebral palsy; (2) contrast the changes in walking ability and endurance for children in GMFCS level I, II and III following sports programs; and (3) identify the impact of higher frequency of sports program attendance over time on walking ability. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Randomized trial of a cognitive-behavioral therapy mobile app for anxiety in patients with incurable cancer.

175 Background: Patients with incurable cancer often experience marked anxiety that is associated with poor quality of life (QOL), high symptom burden, and complications with medical treatment. The aim of this study was to test the efficacy of a mobile app-based cognitive-behavioral therapy (CBT) intervention to treat anxiety symptoms in patients with incurable cancer. Methods: From 2/15 to 8/16, 145 patients with incurable cancers (e.g., advanced lung, breast, GI/GU, sarcoma, melanoma) who screened positive for at least mild anxiety symptoms (Hospital Anxiety &amp; Depression Scale-Anxiety subscale, HADS-A &gt; 7) were randomized 1:1 at two cancer centers to receive either the CBT mobile app for anxiety or a mobile health education program (control), delivered via tablet computers. The CBT app consisted of 7 modules teaching skills to relax the body, reduce worry, stay present-focused, improve communication, and plan/pace activities, which patients completed over 12 weeks. To assess anxiety, mood, and QOL, we administered the Hamilton Anxiety Rating Scale (HAM-A), Clinical Global Impression Scale (CGI), HADS, and Functional Assessment of Cancer Therapy-General at baseline and 12 weeks. General linear models were used to assess the effect of the intervention on patient outcomes over time. Results: The sample was predominantly female (73.8%) and white (91.7%), with a mean age of 56.45 ( SD= 11.30) years. Both study groups reported significant improvements in anxiety, depression, and QOL from baseline to post-assessment (all p-values &lt; .002), with no differences in the improved outcomes between groups. Secondary analyses revealed interaction effects on anxiety between the intervention and baseline HAM-A scores. Among patients with higher baseline anxiety, those randomized to the CBT app had greater improvements on the HAM-A ( p= .043), CGI ( p= .048), and HADS-A ( p= .001) compared to the health education control group. Conclusions: Patients with incurable cancer who received either a CBT mobile app intervention or mobile health education program reported improvements in anxiety, depression, and QOL. However, the CBT mobile app had better outcomes than health education for patients with higher baseline anxiety. Clinical trial information: NCT02286466.

Minimally invasive elastic intramedullary nailing for the treatment of radial neck fracture in children: a report of 18 cases

To investigate effects of elastic stable intramedullary nails(ESIN) for the treatment of radial neck fracture in children. From January 2014 to April 2017, 18 children with radial neck fractures were treated with minimally invasive internal fixation including 6 males and 12 females with an average age of 8.6 years old ranging from 4 to 15 years old; 7 cases were on the left, 11 cases on the right. According to Judet type, 5 cases were type II, 9 cases were type III, 1 case was type IVa, 3 cases were type IVb. Postoperative radial neck fracture healing, elbow pain, deformity and range of activities were recorded. All children were followed up for 3 to 14 months with an average of 8 months. All fractures were healed well. There was 1 case of nail tail irritation, and the fracture healed and pain disappeared after removal. Satisfactory results were achieved in 1 case after reduction and fixation, but a lateral and angulation shift in 20 degrees was observed after 2 days, while the elbow joint function seen well at 6 months. According to Tibone-Stoltz clinical function assessment criteria, the results were excellent in 11 cases, good in 5 cases, fair in 2 cases. The operation of elastic intramedullary nail fixation for the treatment of radial neck fracture in children is simple, reliable and minimally invasive, which can restore functional activity and less complication as soon as possible.

Evaluation of various equations for estimating renal function in elderly Chinese patients with type 2 diabetes mellitus.

BackgroundThe clinical assessment of kidney function based on the estimated glomerular filtration rate (GFR) in older patients remains controversial. This study evaluated the concordance and feasibility of using various creatinine-based equations for estimating GFR in elderly Chinese patients with type 2 diabetes mellitus (T2DM).MethodsA cross-sectional analytical study was conducted in 21,723 older diabetic patients (≥60 years) based on electronic health records (EHR) for Minhang District, Shanghai, China. The concordance of chronic kidney disease (CKD) classification among different creatinine-based equations was assessed based on Kappa values, intraclass correlation coefficient (ICC) statistics, and the eGFR agreement between the equations was tested using Bland–Altman plots. The GFR was estimated using the Cockcroft–Gault (CG), Berlin Initiative Study 1 (BIS1), simplified Modification of Diet in Renal Disease (MDRD), MDRD modified for Chinese populations (mMDRD), chronic kidney disease epidemiology collaboration (CKD-EPI), CKD-EPI in Asians (CKD-EPI-Asia), and Ruijin equations.ResultsOverall, the proportion of CKD stages 3–5 (eGFR <60 mL/min/1.73 m2) was calculated as 28.9%, 39.1%, 11.8%, 8.4%, 14.3%, 11.5%, and 12.7% by the eGFRCG, eGFRBIS1, eGFRMDRD, eGFRmMDRD, eGFRCKD-EPI, eGFRCKD-EPI-Asia, and eGFRRuijin equations, respectively. The concordance of albuminuria and decreased eGFR based on the different equations was poor by both the Kappa (<0.2) and ICC (<0.4) statistics. The CKD-EPI-Asia equation resulted in excellent concordance with the CKD-EPI (ICC =0.931), MDRD (ICC =0.963), mMDRD (ICC =0.892), and Ruijin (ICC =0.956) equations for the classification of CKD stages, whereas the BIS1 equation exhibited good concordance with the CG equation (ICC =0.809). In addition, significant differences were observed for CKD stage 1 among all these equations.ConclusionAccurate GFR values are difficult to estimate using creatinine-based equations in older diabetic patients. Kidney function is complex, and the staff need to be aware of the individualized consideration of other risk factors or markers of reduced renal function in clinical practice.

Single passive leg movement assessment of vascular function: contribution of nitric oxide.

Broxterman RM, Trinity JD, Gifford JR, Kwon OS, Kithas AC, Hydren JR, Nelson AD, Morgan DE, Jessop JE, Bledsoe AD, Richardson RS. Single passive leg movement assessment of vascular function: contribution of nitric oxide. J Appl Physiol 123: 1468-1476, 2017. First published August 31, 2017; doi:10.1152/japplphysiol.00533.2017.-The assessment of passive leg movement (PLM)-induced leg blood flow (LBF) and vascular conductance (LVC) is a novel approach to assess vascular function that has recently been simplified to only a single PLM (sPLM), thereby increasing the clinical utility of this technique. As the physiological mechanisms mediating the robust increase in LBF and LVC with sPLM are unknown, we tested the hypothesis that nitric oxide (NO) is a major contributor to the sPLM-induced LBF and LVC response. In nine healthy men, sPLM was performed with and without NO synthase inhibition by intra-arterial infusion of NG-monomethyl-l-arginine (l-NMMA). Doppler ultrasound and femoral arterial pressure were used to determine LBF and LVC, which were characterized by the peak change (ΔLBFpeak and ΔLVCpeak) and area under the curve (LBFAUC and LVCAUC). l-NMMA significantly attenuated ΔLBFpeak [492 ± 153 (l-NMMA) vs. 719 ± 238 (control) ml/min], LBFAUC [57 ± 34 (l NMMA) vs. 147 ± 63 (control) ml], ΔLVCpeak [4.7 ± 1.1 (l-NMMA) vs. 8.0 ± 3.0 (control) ml·min-1·mmHg-1], and LVCAUC [0.5 ± 0.3 (l-NMMA) vs. 1.6 ± 0.9 (control) ml/mmHg]. The magnitude of the NO contribution to LBF and LVC was significantly correlated with the magnitude of the control responses ( r = 0.94 for ΔLBFpeak, r = 0.85 for LBFAUC, r = 0.94 for ΔLVCpeak, and r = 0.95 for LVCAUC). These data establish that the sPLM-induced hyperemic and vasodilatory response is predominantly (~65%) NO-mediated. As such, sPLM appears to be a promising, simple, in vivo assessment of NO-mediated vascular function and NO bioavailability. NEW & NOTEWORTHY Passive leg movement (PLM), a novel assessment of vascular function, has been simplified to a single PLM (sPLM), thereby increasing the clinical utility of this technique. However, the role of nitric oxide (NO) in mediating the robust sPLM hemodynamic responses is unknown. This study revealed that sPLM induces a hyperemic and vasodilatory response that is predominantly NO-mediated and, as such, appears to be a promising simple, in vivo, clinical assessment of NO-mediated vascular function and, therefore, NO bioavailability.

Different Characteristics of the Female Sexual Function Index in a Sample of Sexually Active and Inactive Women

BackgroundThe Female Sexual Function Index (FSFI) is a widely used measurement tool to assess female sexual function along the six dimensions of desire, arousal, lubrication, orgasm, satisfaction, and pain. However, the structure of the questionnaire is not clear, and several studies have found high correlations among the dimensions, indicating that a common underlying “sexual function” factor might be present. AimTo investigate whether female sexual function is best understood as a multidimensional construct or, alternatively, whether a common underlying factor explains most of the variance in FSFI scores, and to investigate the possible effect of the common practice of including sexually inactive women in studies using the FSFI. MethodsThe sample consisted of 508 women: 202 university students, 177 patients with endometriosis, and 129 patients with polycystic ovary syndrome. Participants completed the FSFI, and confirmatory factor analyses were used to test the underlying structure of this instrument in the total sample and in samples including sexually active women only. OutcomesThe FSFI is a multidimensional self-report questionnaire composed of 19 items. ResultsStrong positive correlations were found among five of the six original factors on the FSFI. Confirmatory factor analyses showed that in the total sample items loaded mainly on the general sexual function factor and very little variance was explained by the specific factors. However, when only sexually active women were included in the analyses, a clear factor structure emerged, with items loading on their six specific factors, and most of the variance in FSFI scores was explained by the specific factors, rather than the general factor. University students reported higher scores, indicating better functioning compared with the patient samples. Clinical TranslationThe reliable and valid assessment of female sexual function can contribute to better understanding, prevention, and treatment of different sexual difficulties and dysfunctions. Strengths and LimitationsThis study provides a rigorous statistical test of the structure of the FSFI and an explicit decision rule for categorizing sexually inactive women. Limitations include a lack of control over the circumstances of data collection. ConclusionThis study supports the use of the FSFI as a multidimensional measurement of female sexual function but highlights the need to establish clear decision rules for the inclusion or exclusion of sexually active and inactive respondents.Hevesi K, Mészáros V, Kövi Z, et al. Different Characteristics of the Female Sexual Function Index in a Sample of Sexually Active and Inactive Women. J Sex Med 2017;14:1133–1141.

Pulmonary Function Testing

Intelligent management of pulmonary disease requires a fundamental understanding of the complex interrelationships between multiple elements that interact to maintain homeostasis in the respiratory system. This chapter discusses the physiologic basis for pulmonary function testing and the use of these tests to diagnose disease, quantitate functional impairments, and follow the effects of treatment. Figures illustrate the relationships between lung volume, airway conductance, and airway resistance; the relationship between forced expiratory volume and time (spirogram); the relationship between spirometry and maximum expiratory flow volume; dynamic airway compression; patterns of abnormalities seen on flow-volume curves; lung volumes and capacities; pressure-volume relationships in health and disease; and the clinical assessment of lung function. Tables list the capacities and volumes of gas contained in the lungs during various breathing maneuvers, conditions associated with alterations in diffusing capacity, and recommendations for tests for various clinical scenarios. This review contains 7 highly rendered figures, 3 tables, and 86 references.

Pulmonary Function Testing

Intelligent management of pulmonary disease requires a fundamental understanding of the complex interrelationships between multiple elements that interact to maintain homeostasis in the respiratory system. This chapter discusses the physiologic basis for pulmonary function testing and the use of these tests to diagnose disease, quantitate functional impairments, and follow the effects of treatment. Figures illustrate the relationships between lung volume, airway conductance, and airway resistance; the relationship between forced expiratory volume and time (spirogram); the relationship between spirometry and maximum expiratory flow volume; dynamic airway compression; patterns of abnormalities seen on flow-volume curves; lung volumes and capacities; pressure-volume relationships in health and disease; and the clinical assessment of lung function. Tables list the capacities and volumes of gas contained in the lungs during various breathing maneuvers, conditions associated with alterations in diffusing capacity, and recommendations for tests for various clinical scenarios. This review contains 7 highly rendered figures, 3 tables, and 86 references.

An ontology-driven tool for structured data acquisition using Web forms

BackgroundStructured data acquisition is a common task that is widely performed in biomedicine. However, current solutions for this task are far from providing a means to structure data in such a way that it can be automatically employed in decision making (e.g., in our example application domain of clinical functional assessment, for determining eligibility for disability benefits) based on conclusions derived from acquired data (e.g., assessment of impaired motor function). To use data in these settings, we need it structured in a way that can be exploited by automated reasoning systems, for instance, in the Web Ontology Language (OWL); the de facto ontology language for the Web.ResultsWe tackle the problem of generating Web-based assessment forms from OWL ontologies, and aggregating input gathered through these forms as an ontology of “semantically-enriched” form data that can be queried using an RDF query language, such as SPARQL. We developed an ontology-based structured data acquisition system, which we present through its specific application to the clinical functional assessment domain. We found that data gathered through our system is highly amenable to automatic analysis using queries.ConclusionsWe demonstrated how ontologies can be used to help structuring Web-based forms and to semantically enrich the data elements of the acquired structured data. The ontologies associated with the enriched data elements enable automated inferences and provide a rich vocabulary for performing queries.

Emerging Utility of Virtual Reality as a Multidisciplinary Tool in Clinical Medicine

Among the more recent products borne of the evolution of digital technology, virtual reality (VR) is gaining a foothold in clinical medicine as an adjunct to traditional therapies. Early studies suggest a growing role for VR applications in pain management, clinical skills training, cognitive assessment and cognitive therapy, and physical rehabilitation. To complete a review of the literature, we searched PubMed and MEDLINE databases with the following search terms: "virtual reality," "procedural medicine," "oncology," "physical therapy," and "burn." We further limited our search to publications in the English language. Boolean operators were used to combine search terms. The included search terms yielded 97 potential articles, of which 45 were identified as meeting study criteria, and are included in this review. These articles provide data, which strongly support the hypothesis that VR simulations can enhance pain management (by reducing patient perception of pain and anxiety), can augment clinical training curricula and physical rehabilitation protocols (through immersive audiovisual environments), and can improve clinical assessment of cognitive function (through improved ecological validity). Through computer-generated, life-like digital landscapes, VR stands to change the current approach to pain management, medical training, neurocognitive diagnosis, and physical rehabilitation. Additional studies are needed to help define best practices in VR utilization, and to explore new therapeutic uses for VR in clinical practice.

Arterial stiffness in symptomatic smokers with normal lung function.

Chronic obstructive pulmonary disease (COPD) is associated with cardiovascular morbidity and mortality. Arterial stiffness and endothelial dysfunction index are validated surrogate cardiovascular markers and are increased in subjects with COPD.We tested whether increased arterial stiffness and endothelial dysfunction occur in symptomatic smokers with no evidence of bronchial obstruction. Clinical and lung functional assessments were conducted in smoker subjects with chronic respiratory symptoms and in COPD patients. Pulse wave velocity (PWV), aortic augmentation index (AIx) and reactive hyperaemia index (RHI) were measured to estimate the cardiovascular risk.48 smokers (male n=37, female n=11; mean age 70±8.4 years) were studied. Smokers with respiratory symptoms without bronchial obstruction (n=13) did not differ from COPD patients (n=35) in terms of mean±sd PWV (12±3.2 m·s−1 versus 14±3.8 m·s−1; p=0.10), aortic AIx (25.2±11.8% versus 24.8±9.7%, p=0.89) and RHI (1.66±1.49 versus 1.62±1.43; p=0.79).The current investigation shows that the cardiovascular risk occurs in smokers with respiratory symptoms in the absence of bronchial obstruction. These findings need to be confirmed in larger populations in order to inform the design of intensive preventive programmes.

Clinical assessment of endothelial function in patients with chronic obstructive pulmonary disease: a systematic review with meta-analysis.

Patients with chronic obstructive pulmonary disease (COPD) have an increased cardiovascular morbidity and mortality. Flow-mediated (FMD) and nitrate-mediated dilatation (NMD) are considered non-invasive methods to assess endothelial function and surrogate markers of subclinical atherosclerosis. We performed a systematic review with meta-analysis and meta-regression to evaluate the impact of COPD on FMD and NMD. Studies were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. The random-effect method was used to take into account the variability among included studies. A total of eight studies were included in the final analysis, eight with data on FMD (334 COPD patients) and two on NMD (104 COPD patients). Compared to controls, COPD patients show a significantly lower FMD (MD -3.15%; 95% CI -4.89, -1.40; P<0.001) and NMD (MD -3.53%; 95% CI -7.04, -0.02; P=0.049). Sensitivity analyses substantially confirms the results. Meta-regression models show that a more severe degree of airway obstruction is associated with a more severe FMD impairment in COPD patients than in controls. Regression analyses confirm that the association between COPD and endothelial dysfunction is independent of baseline smoking status and most traditional cardiovascular risk factors. In conclusion, COPD is significantly and independently associated with endothelial dysfunction. These findings may be useful to plan adequate cardiovascular prevention strategies in this clinical setting, with particular regard to patients with a more severe disease.