This thesis examined associations between ecological indicators of residential radon and fine particulate matter air pollution (PM2.5) and lung cancer mortality using data from the American Cancer Society Cancer Prevention Study-II (CPS-II) prospective cohort. Nearly 1.2 million CPS-II participants were recruited in 1982. Mean county-level residential radon concentrations were linked to study participants according to ZIP code information at enrollment (mean (SD) = 53.5 (38.0) Bq/m3). Cox proportional hazards regression models were used to obtain adjusted hazard ratios (HRs) and 95% confidence intervals (CI) for lung cancer mortality associated with radon. After necessary exclusions, a total of 811,961 participants in 2,754 counties were retained for analysis. A significant positive linear trend was observed between categories of radon concentrations and lung cancer mortality (p = 0.02). A 15% (95% CI 1 - 31%) increase in the risk of lung cancer mortality was observed per each 100 Bq/m3 radon. Radon was also positively associated with chronic obstructive pulmonary disease mortality (HR per each 100 Bq/m3 = 1.13, 95% CI 1.05 - 1.21). No clear associations were observed between radon and non-respiratory mortality. In lifelong never smokers (n = 188,699), each 10 µg/m3 increase in mean metropolitan statistical area PM2.5 concentrations was associated with a 15-27% increase in the risk of lung cancer death which strengthened among individuals with a history of asthma or any prevalent chronic lung disease at enrollment (p for interaction < 0.05). There was no association between PM2.5 and mortality from non-malignant respiratory disease. In conclusion, this thesis observed significant positive associations between ecological indicators of residential radon and PM2.5 concentrations and lung cancer mortality. These findings further support efforts to reduce radon concentrations in homes to the lowest possible level and strengthens the evidence that ambient concentrations of PM2.5 measured in recent decades are associated with small but measurable increases in lung cancer mortality. Further research is needed to better understand possible complex inter-relationships between environmental risk factors, chronic lung disease, and lung cancer.

Syftet med studien var att beskriva vilka metoder till rökstopp som fanns uttryckta i litteraturen samt beskriva vilken effekt dessa metoder hade, då detta är en avgörande behandling för patienter med Kronisk Obstruktiv Lungsjukdom. För att påvisa artiklarnas kvalitet granskades dessa med avseende på urvalsgrupp i relation till föreliggande studies syfte. Studiens metod utformades med en deskriptiv design. Litteratursökning utfördes i databaserna Cihnal och Pubmed (Medline) vilket resulterade i 15 artiklar som denna studie baserats på. Resultatet som framkom var att metoderna antingen var ickefarmakologiska eller farmakologiska. De ickefarmakologiska var: rådgivning, spirometri, presenterad lungålder. De farmakologiska metoderna var: NRT (plåster, tuggummi, nässpray, inhalator, sublingualtablett, sugtablett), antidepressivum (Bupropion, Nortriptylin), Vareniclin (binder till samma receptor som nikotin) och Selegilin (MAO-B hämmare). De flesta metoderna visade sig effektiva i förhållande till placebo och ofta uppmättes statistiskt signifikanta skillnader där emellan. Kunde inte statistisk signifikans uppmätas, visade sig resultaten ändå vara positiva. Slutsatsen av studien tyder på att alla metoder till rökstopp är bra, men vissa gav ett bättre intryck av effektivitet. Med mer utbildning och framtida forskning hoppas föreliggande studies författare att valet av rökstoppsmetod anpassas individuellt beroende på patientens förutsättningar och behov. / The aim of this study was to describe methods for smoking cessation that has been expressed in literature and to describe the efficacy of the methods, thus it is a crucial treatment for patients with Chronic Obstructive Pulmonary Disease. To show the quality of the articles, their sample groups were examined in relation to the aim of present study. The method of the study was formed with a descriptive design. The articles were obtained via databases Cihnal and Pubmed (Medline) which resulted in 15 articles that based this study. The results showed that the methods either were non-pharmacological or pharmacological. The non-pharmacological methods were: counseling, spirometry, presentation of lung-age. The pharmacological methods were: NRT (patch, chewing gum, nasal spray, inhalator, sublingual tablet, lozenge), antidepressants (Bupropion, Nortriptyline), Varenicline (binds to the same receptor as nicotine) and Selegilin (MAO-B inhibitor). Most of the methods showed efficacy in relation to placebo and statistical significance was often measured. Even if the difference was not significant, the results were often positive. The conclusion of the study showed that all methods were good, but some of them were more effective. With more education and future research the authors of this study hope that the choice of method for smoking cessation adapts individually regarding to the patient’s condition and needs.

Research Objectives: Chronic obstructive pulmonary disease (COPD) is a major cause of disability and death worldwide. The prevalence of depression and anxiety in COPD patients is generally higher than those reported in other chronic illnesses, and these mental diseases significantly affect the health expenditures and the course of the diseases on elderly COPD patients. The COPD patients with co-morbid depression, anxiety or other chronic diseases are more impaired and have 50% to 100% higher medical costs than those without depression and anxiety. COPD affects approximately 1.8 million people in Taiwan every year, however, little studies have examined the impacts of mental diseases on elderly COPD patients. This study aims to investigate the depression and anxiety status on COPD patients¡¦ medical care utilizations and health outcomes. Study Design: This study analyzed the nationally representative research database from National Health Insurance program between 2002 and 2006 in Taiwan, by exploring outpatient visits, hospitalizations, and medical expenditures of COPD and its associated co-morbidities. The data analyses were carried out by Chi-square test, multiple linear regression and multivariate logistic regression. Population Studied: Patient aged over 65 with primary diagnosis of COPD and co-morbidity diseases based on ICD-9-CM in Taiwan. To investigate the complications in COPD patients, four diseases such as diabetes, hypertension, heart failure and ischemic heart disease were included in the analyses. Principle Findings: Among the 5,735 COPD patients (59.81%, male), most of them were aged over 80 (28.67%) , and lived in urban areas (62.28%) in northern Taiwan (43.71%). The results indicated that those who were suffered from depression or anxiety increased medical utilization and costs. Multiple linear regression model showed that age, and hospital level significantly affect the expenditures for medicine of COPD patients with depression or anxiety (p¡Õ0.001). Multivariate logistic regression model presented that number of complications significantly affect the probability of hospitalization among the COPD patients with mental diseases (p¡Õ0.001). Conclusions¡G COPD symptoms were usually getting worsen over time and depression or anxiety affect the COPD patients significantly, though the mental diseases are usually under-estimated. The study results demonstrated that COPD patients suffered from depression and anxiety increased the risks on longer length of stay, higher medical expenditures and more complications. WHO predicts that COPD will become the third leading cause of death worldwide by 2030. Since mental diseases may worsen elderly COPD patients¡¦ health outcomes, physicians are advised to pay more attention to these types of patients. With on time and appropriate treatments, thus may help to improve quality of care and reduce medical expenditures for these patients.

Rationale: Chronic obstructive pulmonary disease (COPD) is not only a common lung disease but is a major cause of morbidity and mortality worldwide. Pulmonary rehabilitation (PR) helps optimize function and independence by increasing exercise capacity, reducing symptoms and improving health related quality of life (HRQL). Exercise training is certainly a key component of the PR programs; however, many of its aspects still need to be better defined such as optimal exercise assessment and training modality for these patients. The general purpose of this thesis was to generate new knowledge that could contribute to new strategies for exercise assessment and training in patients with COPD. Methods and results: This thesis is comprised of four independent studies. Thigh muscle strength, endurance and fatigue were compared between 42 patients with moderate to severe COPD and 53 healthy controls (Study I). Impaired thigh muscle strength and endurance in patients with COPD was found, except for muscle strength in knee extension in male patients. Female patients had higher fatigue index than female controls while no difference was found between male patients and controls. The six-minute walk test (6MWD) performed on a non-motorized treadmill (6MWD-T) was compared with the 6MWD performed in a corridor (6MWD-C) in 16 healthy elderly subjects (Study II). They performed twelve tests (six 6MWD-C and six 6MWD-T) on two different days in a randomized order. An average discrepancy was found between the two methods with the subjects walking a shorter distance on the non-motorized treadmill. However, the results showed good test-retest reliability between days and test repetitions. A systematic review (Study III) was done of studies that investigated the effects of an arm training program in patients with COPD. The findings of this review indicated that there is evidence that an arm training program improves arm exercise capacity, but its effects on dyspnea, arm fatigue and healthy-related quality of life is unclear. Finally, a two-armed randomized controlled trial examined the effects of an arm training program on arm function, arm exercise capacity, muscle strength, symptoms and HRQL in patients with COPD (Study IV). The groups were randomized to arm training or sham. Compared with the changes observed in the control group, the magnitude of change in the intervention group was greater for arm function, arm exercise capacity and muscle strength. There was no difference between groups in HRQL or symptoms. Conclusions: Upper extremity resistance training improves arm exercise capacity, arm function and muscle strength in patients with COPD. Training and assessment of upper and lower limb muscles should be included into PR programs. The 6MWD performed on a non-motorized treadmill may offer an alternative option to the standard 6MWD when a 30-meter corridor is not available.

Physical and psychosocial symptoms in advanced chronic obstructive pulmonary disease (COPD) are cumulative and profound; global financial and human costs are huge. COPD in late stages runs an unpredictable downward course of increasing, potentially fatal exacerbations. Nevertheless many physicians avoid advance care planning in this context, a choice that tends to promote last minute crisis decision-making. To explore a more ethically sound proactive approach to end-of-life care decision-making I conducted a qualitative study informed by the question: “What is required for meaningful and effective advance care planning in the context of advanced COPD?” Fifteen participants (eight patients with advanced COPD plus seven intimate others) participated in two in-home advance care planning discussions that incorporated patient-centred care principles. Session transcripts were analyzed using "interpretive description." Despite initial wariness, participants were able to discuss their care-related hopes and preferences and reported that the process was a positive one. Interpretation of the positive feedback suggested participants experienced the process as a chance to: a) talk with an attentive clinician, b) learn, c) consider care-related goals and preferences, and, d) have intimate others hear about these goals/preferences. Interpretation of the process that led to this positive assessment is described in terms of a thematic network. The overarching global theme of this network was "advance care planning as collaborative care," which involved three organizing themes--partnering, negotiating ambiguity, and being a resource--and a cluster of basic themes related to each of these. The "collaborative care" approach is discussed as a guide to advance care planning in advanced COPD. Like other advance care planning models, the study approach included a skilled clinician facilitator, provision of targeted information, and attention to readiness. There were four new elements: focus on caring, engaging hope, facilitator reflective praxis, and contextual sensitivity. While potentially enhancing the "care" dimension in advance care planning, the study approach may incidentally improve resource allocation and satisfaction with outcomes. Done well it may enhance decision-making and care planning, and, just as importantly, be experienced as care itself at a time and by those often neglected in this regard.

The majority of patients with chronic obstructive pulmonary disease (COPD) have milder airway obstruction and are not diagnosed in a timely fashion. Nevertheless, these patients are largely under-studied; this, despite new evidence of increased morbidity and mortality in this sub-population. Recent studies have highlighted the increased ventilatory requirements and abnormalities in respiratory mechanics as important features to explain the relatively reduced exercise tolerance and greater exertional dyspnea in these patients. However, it remains uncertain whether such abnormal mechanical factors actually limit exercise capacity in mild COPD. Accordingly, the objective of this study was to determine whether ventilatory constraints represent a primary factor in exercise limitation and increased dyspnea in this patient group. To determine the role of mechanical factors in exercise limitation in mild COPD, we selectively loaded the respiratory system by adding dead space (DS) to the breathing circuit. We compared ventilation, breathing pattern, operating lung volumes, and dyspnea intensity during incremental cycle exercise in 20 patients with GOLD stage I COPD (post-bronchodilator FEV1/FVC=61±5%, and FEV1=95±11% predicted; mean±SD) and 20 healthy age-, sex- and BMI-matched subjects under two conditions, in randomized order: unloaded control (CTRL) or ventilatory stimulation by 600mL of an added DS. Compared to the CTRL condition, both healthy and COPD participants had small decreases in peak work rate and no significant increase in peak ventilation with the added DS. At the highest equivalent work rate of 60 watts, DS caused a smaller increase in tidal volume (VT) in COPD compared with healthy subjects (+0.26±0.29 vs. +0.56±0.22 L respectively, p<0.01) with a correspondingly greater increase in dyspnea intensity (+1.8±1.8 vs. +0.2±0.6 Borg units, respectively, p<0.0001). At peak exercise, COPD patients failed to significantly increase VT, reflecting the fact that end-inspiratory lung volume (EILV) could not increase with DS vs. CTRL (5.25±0.91 vs. 5.16±0.84 L, respectively, p=0.41). This contrasts the results in health where EILV increased with DS vs. CTRL (5.40±1.01 vs. 5.13±0.90 L, respectively, p<0.05). We conclude that the lower exercise performance in mild COPD, compared with health, is explained by critical respiratory mechanical constraints which limit further increases in ventilation to support a higher metabolic load. / Thesis (Master, Physiology) -- Queen's University, 2012-09-28 12:04:50.507

This thesis examined associations between ecological indicators of residential radon and fine particulate matter air pollution (PM2.5) and lung cancer mortality using data from the American Cancer Society Cancer Prevention Study-II (CPS-II) prospective cohort. Nearly 1.2 million CPS-II participants were recruited in 1982. Mean county-level residential radon concentrations were linked to study participants according to ZIP code information at enrollment (mean (SD) = 53.5 (38.0) Bq/m3). Cox proportional hazards regression models were used to obtain adjusted hazard ratios (HRs) and 95% confidence intervals (CI) for lung cancer mortality associated with radon. After necessary exclusions, a total of 811,961 participants in 2,754 counties were retained for analysis. A significant positive linear trend was observed between categories of radon concentrations and lung cancer mortality (p = 0.02). A 15% (95% CI 1 - 31%) increase in the risk of lung cancer mortality was observed per each 100 Bq/m3 radon. Radon was also positively associated with chronic obstructive pulmonary disease mortality (HR per each 100 Bq/m3 = 1.13, 95% CI 1.05 - 1.21). No clear associations were observed between radon and non-respiratory mortality. In lifelong never smokers (n = 188,699), each 10 µg/m3 increase in mean metropolitan statistical area PM2.5 concentrations was associated with a 15-27% increase in the risk of lung cancer death which strengthened among individuals with a history of asthma or any prevalent chronic lung disease at enrollment (p for interaction < 0.05). There was no association between PM2.5 and mortality from non-malignant respiratory disease. In conclusion, this thesis observed significant positive associations between ecological indicators of residential radon and PM2.5 concentrations and lung cancer mortality. These findings further support efforts to reduce radon concentrations in homes to the lowest possible level and strengthens the evidence that ambient concentrations of PM2.5 measured in recent decades are associated with small but measurable increases in lung cancer mortality. Further research is needed to better understand possible complex inter-relationships between environmental risk factors, chronic lung disease, and lung cancer.

Background: Respiratory disease has been one of the top three causes of deaths in Macau in the past decade. As one of the chronic respiratory diseases, chronic obstructive pulmonary disease (COPD) is incurable, but is preventable and treatable. COPD patients suffer from recurrent and progressive respiratory symptoms, and this impacts the health and well-being of patients. Self-management education programmes (SMEP) provide teaching and learning guidance for understanding COPD, emotional support and behaviour change needed to carry out disease-specific care in chronic patients. Evidence has demonstrated that SMEP can mediate a change in health-related behaviours, improve symptom control and the quality of life of COPD patients, with an associated reduction in health care utilization. However, SMEP has never been conducted in Macau, and experiences of providing any form of chronic care for COPD patients in this place is lacking. Aims: This study aimed to explore the effects of a specifically designed self-management education programme on Stage II to IV COPD patients in Macau. Design: The study was conducted as an exploratory randomized controlled trial in a mixed methods approach. Both illness perception and self-efficacy beliefs were adopted to formulate the theoretical framework. In the quantitative strand, the assessment of primary outcomes included illness perception, self-efficacy and inhaler technique. The secondary outcomes included pulmonary function, healthcare utilization and health-related quality of life. In the qualitative strand, focus groups were conducted to explore the subjective perception and experiences of self-management of COPD patients. Fifty one eligible COPD patients were recruited and allocated to experimental (26 patients) and control group (25 patients) by block randomization. A SMEP for COPD patients was developed and validated according to Medical Research Council (MRC) framework. Results: Quantitative results indicated that the primary outcomes (illness perception, self-efficacy and inhaler technique) improved in the experimental group after the SMEP. In relating to the secondary outcomes, days of hospitalization were reduced and symptom dimension of disease-specific health related quality of life (St. George Respiratory Questionnaire) improved. Qualitative findings identified the emergence of a core theme ‘Essentiality’ and five sub-themes ‘Helplessness’, ‘Mutual involvement’, ‘Support’, ‘Control’ and ‘Beneficial’, indicating perception and experiences of participants for self-management. These findings indicate a potential relationship of illness perception and self-efficacy in guiding COPD patients to adapt to health-related behaviour. Discussion and Conclusion: This study has obtained evidence for supporting the proposed theoretical framework and expected experimental effect through employing the MRC guidelines. The study also confirms the estimates of recruitment for a definitive RCT, demonstrated readiness and positive impact in Macau COPD patients to receive self-management intervention, and SMEP as an acceptable and preferable mode of chronic care for COPD for the healthcare system of Macau.

Orientador: Irma de Godoy / Resumo: Várias doenças pulmonares são associadas ou apresentam na sua evolução a hipoxemia crônica. A mais comum é a doença pulmonar obstrutiva crônica (DPOC), que é caracterizada pela obstrução ao fluxo aéreo devido a bronquite crônica e/ou enfisema. O tratamento para esta condição é a administração de oxigênio. A oxigenoterapia domiciliar prolongada (ODP) melhora a expectativa de vida, reduz a policitemia, aumenta o peso do corpo, melhora a atividade cardíaca e a função neuropsicológica e aumenta a capacidade para realização de exercícios e atividades da vida diária. Os objetivos desta pesquisa foram levantar as características dos pacientes cadastrados no Serviço de Oxigenoterapia, avaliar as condições de fornecimento e uso do oxigênio e orientá-los quanto ao manuseio dos materiais e equipamentos para o tratamento com oxigênio. Foi realizado estudo retrospectivo e prospectivo no período de janeiro de 1997 a janeiro de 1999, que avaliou o total de 70 pacientes. Foram analisados dados da avaliação clínica e nutricional, de exames laboratoriais e de função pulmonar, questionário geral e de qualidade de vida e visita domiciliar. Os resultados mostraram que maior prevalência era do sexo masculino (59%), idade de 61 ? 12 anos, com mínimo de 20 e o máximo de 89 anos, sendo que a maioria dos pacientes (58%) tinha idade acima dos 61 anos. A avaliação nutricional apontou peso médio do corpo de 63,6 ? 19,3 Kg, o IMC foi de 24,7 ? 7,2 kg/m e a pocentagem do peso ideal era de 103,1 ? 42,1%. O diagnóstico de DPOC ocorreu em 70% dos pacientes estudados. O resultado de gasometria arterial mostrou valores de PaO2 de 46,12 ? 9,10 mmHg, PaCO2 de 44,68 ? 8,75 mmHg e SaO2 de 79,30 ? 11,91%. O resultado da prova de função pulmonar mostrou que a maioria dos pacientes apresentava distúrbios ventilatórios restritivos ou obstrutivos... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Several pulmonary diseases are associated or in it's evolution is presented chronic hypoxemia. The most common is the chronic obstructive pulmonary disease (COPD): witch is characterized by the obstruction of the airflow due to a chronic bronchitis or na emphysema. The long term domiciliary oxygen therapy (LTOT) improves the life expectation, reduces the polycythemia and the neuropsychological and also increases the patient's faculty for exercises and daily activities. This research has as main objectives to study the registered patient's on Oxygen Therapy Services, evaluate the oxygen supplyng and using condictions and orientates these patients for the correct use of the materials and oxygen equipment used in treatment. A retrospective and prospective study was made in the period of January of 1997 to January of 1999; witch evaluated the total of 70 patients. Clinical and nutritional data were analysed and the patient's laboratory exams and pulmonary function, domiciliary visits survey and life conditions were as well analysed. The results shown a prevalence of male gender (59%) ages of 61 ? 12 years with the minimum average of 20 and the maximum average of 89 years, that the greatest part of the patients (58%) had their ages above 61 years. The nutritional evaluations shown a medium weigh average of 63,6 ? 19,3 Kg, the body mass index (BMI) was 24,7 ? 7,2Kg/m2 and the percentile of the patients with the ideal body weigh was 103,1 ? 42,1%. The COPD diagnoses occurred in 70% of the evaluated patients. The arterial gasometry results shown PaO2 levels of 46,12 ? 9,10 mmHg, PaCO2 levels of the 44,68 ? 8,75 mmHg and SaO2 levels of 79,30 ? 11,91%. The results of the pulmonary function testing shown that the greatest part of the studies patients has presented restrictives or obstructives ventilatory disturbs. The patient's characteristics results shown... (Complete abstract click electronic address below) / Mestre

Nato:s planeringsmodell Comprehensive Operations Planning Directive ska framgent användas för nationell militär planering. Anpassning till svenska förhållanden kommer att genomföras. Överbefälhavaren betonar redan i inledningen på ny Militärstrategisk doktrin att uppdragstaktik ska vara grunden för ledning i Försvarsmakten. Forskningen i uppsatsen fokuserar till mötet mellan planeringsmetod och betoning av att uppdragstaktik ska vara grunden för ledning. Syftet är att identifiera om operativ planering enligt COPD och doktrinens betoning av uppdragstaktik harmonierar. Genom det kan uppsatsen bidra med ny kunskap inom området och med ett analysverktyg för uppdragstaktik. För att genomföra analys av COPD har ett analysverktyg skapats, baserat på olika forskares teorier om vad som stödjer och motverkar uppdragstaktik. Forskningen visar att COPD i hög grad stödjer uppdragstaktik i ett filosofiskt perspektiv, men i lägre grad i praktiken. Svensk anpassning av COPD kräver ett ställningstagande om uppdragstaktik ska ses som en ledningsmetod eller filosofi.