The investigation and management of patients with life threatening haemoptysis is a common clinical problem in South African Hospitals. Establishing the aetiology and origin of the haemorrhage and treating these patients is both difficult and expensive in terms of human and financial resources. The purpose of this study was to identify common local aetiologies for severe haemoptysis, review the investigation and treatment of these patients at Wentworth Hospital, Durban and to formulate a plan of management. Retrospective and prospective studies of consecutive patients treated at Wentworth Hospital were performed. In the prospective study a new embolic material gelatin linked acryl microspheres (embospheres) was used for bronchial artery embolization (BAE). The study demonstrated a change in the spectrum of aetiologies of haemoptysis, from bronchiectasis following tuberculosis to destructive pneumonias. The chest radiograph was always the initial imaging investigation but was found to be inaccurate in detecting the origin of the bleeding. High resolution computed tomography of the lungs (HRCT) was the single best investigation to detect the cause and origin of the haemoptysis. HRCT detected focal bronchiectasis and intracavitatory aspergillomas that were undetected on the chest radiograph. Pleural thickening detected on CT was a good indicator of the presence of transpleural collaterals. The major limitation with HRCT was that it could not be performed if the patient was too dyspnoeic to cooperate during the scan. The role of bronchoscopy appears limited in patients with severe haemoptysis to those patients who are potential surgical candidates. I found that bronchoscopy was not accurate in detecting the source of bleeding in the few patients in which it was performed. Bronchial arteriography remains the gold standard in the detecting the source of haemorrhage. Bleeding sites were detected on angiography in the presence of focal hypervascularity, neovascularity and the presence of broncho-pulmonary shunts. Bronchial arteries were hypertrophied in bronchiectasis but were normal in size in some patients who had acute pneumonias. Bronchial artery embolization was the treatment of choice for severe haemoptysis in the patients studied. The use of gelatin cross linked micro spheres has significantly improved the initial success rate following the procedure with less complications compared to the use of polyvinyl alcohol particles (PVA). It is important to identify systemic transpleural collaterals at arteriography and to embolize them to reduce recurrent haemoptysis. Patients with aspergillomas responded well to embolization. Recurrent haemoptysis remains the major limitation of BAE but is reduced with the use of micro spheres as embolic agents and thorough embolization of systemic collaterals on the affected side. Surgical resection was an option for a limited number of patients with focal disease in one lung and good respiratory reserve. The major limitation of the study was the absence of long term follow up to detect those patients with late recurrent haemoptysis. / Thesis (D. Med.)-University of Natal, Durban, 2003.

Despite the acknowledged importance of nutritional support for COPD patients, it is difficult to accomplish in acutely stressed individuals. A randomized trial of nutritional supplementation during an acute exacerbation was carried out in 16 hospitalized patients for a 2 week period. Six control patients consumed a standard diet supplying 1,951 $ pm$ 130 (mean $ pm$ SEM) kcal and 80 $ pm$ 6 g protein/d, while ten treatment patients, in addition to the usual diet received oral supplements (Ensure) or snacks, resulting in an intake of 2,516 $ pm$ 129 kcal (p = 0.012) and 99 $ pm$ 6 g protein/d (p = 0.059). Although the treatment subjects improved their intake over the control group, no significant improvement in nutritional status occurred in either group. / Forced vital capacity (FVC % predicted) improved significantly over the study period in treated vs control subjects (+11.10 $ pm$ 4.63 vs $-$4.50 $ pm$ 2.14; p = 0.026). Nitrogen balances were calculated for 9 subjects, and all were in negative balance ($-$8.42 $ pm$ 1.74 g nitrogen/d) with no difference between groups. / Because of the high doses of methylprednisolone administered (69.6 $ pm$ 8.3 mg/d), and their known catabolic effects, we examined whether the dose affected nitrogen balance and muscle strength. Both nitrogen balance (r = $-$0.73; p = 0.025) and grip strength (r = $-$0.76; p $<$ 0.001) worsened with higher doses of steroids. The catabolic process may have resulted from elevated energy requirements, inadequate intake of protein and energy or been induced by high doses of steroids. / Hospitalized COPD patients are highly stressed and catabolic, and the means to preventing protein wasting during an acute exacerbation of their disease remains to be established. (Abstract shortened by UMI.)

Pulmonary patients attending outpatient rehabilitation experience an enhanced ability for physical activity. The current study assessed and characterized domestic physical activity levels of new and maintenance patients to 1) compare physical activity levels of pulmonary patients on rehabilitation and non-rehabilitation days, 2) to identify factors that may contribute to low physical activity levels and 3) to compare step count levels between 2 activity monitors.Eighteen patients (age, 66.2 ± 8.8 y; FEV1, 52.1 ± 11.8%) participating in pulmonary rehabilitation wore an accelerometer and pedometer for 7 consecutive days. Patients new to pulmonary rehabilitation and maintenance patients participated in the study. Upon returning the monitors, patients returned a log sheet with the times monitors were put on and taken off each morning and night.The participants who completed the one week assessment had an average step count of 3,800 ± 1,651 steps/day, with a significant difference (p < .05) between rehabilitation days (5,468 ± 2,810 steps/day) and non-rehabilitation days (2,874 ± 1,490 steps/day). The number of minutes/day spent in moderate walking activities was also significant (p < .05) between rehabilitation (10.9 ± 16.0 minutes/day) and non-rehabilitation days (3.1 ± 5.8 minutes/day). Male waist circumference and occupational status were significantly correlated with low physical activity levels. The pedometer and accelerometer step count values were not significantly different from each other.Patients participating in pulmonary rehabilitation have significantly different activity levels between rehabilitation and non-rehabilitation days. To increase activity benefits, patients with COPD should increase activity levels on rehabilitation and non-rehabilitation days. Special consideration should be taken to help patients increase physical activity levels on non-rehabilitation days.(key words: chronic obstructive pulmonary disease, pedometer, accelerometer, pulmonary rehabilitation. / School of Physical Education, Sport, and Exercise Science

Chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) patients show a marked reduction in exercise capacity compared to that of healthy age-matched individuals. While inadequate gas exchange and resulting hypoxemia appears as the primary factor in COPD, an impaired cardiac output is the predominant explanation for the reduced oxygen delivery in CHF. However, the extent of the contributions of other systemic factors remains unclear. In light of the potential interactions between cardiac output (Qc) and pulmonary hyperinflation, there is surprisingly little data thus far on ventilatory constraints in CHF and on the role of blood flow delivery in COPD which may further limit the exercise capacity. Thus, the purpose of this study was to compare the slope of the Qc versus oxygen uptake (VO2) response through several submaximal cycling loads in patients with moderately severe COPD and with that of moderate to severe CHF patients as well as age-matched healthy control subjects (CTRL). Also examined was the possibility that ventilatory constraints such as dynamic hyperinflation contribute to an abnormal stroke volume response in both diseases. Cardiac output was measured using the CO 2-rebreathing equilibrium technique during baseline conditions and cycling at 20, 40 and 65% of peak power in 17 COPD (Age: 64 +/- 8 yrs; FEV 1/FVC: 37 +/- 11%; FEV1: 41 +/- 15 % predicted), 10 CHF (Age: 57+/- 10 yrs; FEV1/FVC: 73.8 +/- 5.6%; FEV 1: 93 +/- 13% predicted) and 10 age-matched CTRL subjects. Inspiratory capacity (IC) was also measured for the determination of dynamic hyperinflation during the steady state exercise bouts. The results indicate that while the absolute Qc values are lower in COPD and in CHF than in CTRL during 65% peak power cycling (11.30 +/- 2.38 vs 12.40 +/- 2.08 vs 15.63 +/- 2.15 L&bull;min-1 respectively, p &lt; 0.01), likely due to their lower exercise metabolic demand. The Qc/VO2 response to increasing levels of exercise intensity was lower or normal in CHF patients compared to CTRL, while normal or hyperdynamic in most COPD patients. Indeed, the majority of patients with COPD exhibited Qc/VO2 slopes greater than 7.0, which may be indicative of a peripheral muscle bioenergetic disturbance that may drive the need for greater oxygen delivery, and thus result in an exaggerated central circulatory response.

Total body fat and muscle mass depletion has been reported in some patients with COPD. This study used simple anthropometric measurements to compare the body composition of patients with moderate-severe COPD to that of healthy controls, and examines relationships between body composition, disease severity, habitual physical activity and resting and exercise energy expenditure. Results show no significant differences in overall Heath-Carter somatotype characteristics, percent body fat, fat free mass and girth measurements between COPD and control subjects although when stratified by gender, female COPD patients exhibited a greater body fat component. Measured VO2 (L/min) at rest or during steady-state exercise was not significantly different between COPD and control subjects despite a higher exercise ventilation in patients. Neither resting or exercise energy expenditure was related to body composition, however it was related to DLCO/VA (ml·min-1·mmHg -1·L-1). Findings from this study suggest that COPD patients capable of participating in dynamic exercise studies do not exhibit total body fat and muscle depletion. Findings in women suggest that the relative decrease in FFM may be related to a relatively higher proportion of body fat and not a decrease in absolute muscle mass.

Thesis (M. S.)--Biomedical Engineering, Georgia Institute of Technology, 2009. / Committee Chair: Barker, Thomas; Committee Member: Murthy, Niren; Committee Member: Roman, Jesse

Introduction: COPD is a progressive disease, characterised by symptoms of dyspnoea, fatigue, exercise intolerance and reduced physical activity, resulting in impaired quality of life. Furthermore, the disease poses a significant burden on healthcare systems around the world. SPACE FOR COPD is a new self-management programme which aims to support individuals in acquiring the knowledge and skills required to optimise their emotional and medical well-being. Methods: This thesis describes a randomised controlled trial which aims to establish the effectiveness of a SPACE FOR COPD compared with usual care alone. 184 people with COPD were recruited from primary care. Individuals were randomly allocated to receive either the SPACE FOR COPD intervention or to continue with their usual care. The primary outcome was a measure of health-related quality of life (HRQoL), the Chronic Respiratory Questionnaire – Self Report (CRQ-SR) dyspnoea domain. Secondary measures included exercise performance, anxiety, depression, knowledge, self-efficacy and physical activity. Outcome measures were recorded at baseline, six weeks and six months. Results: There was no significant between-group difference in the change in dyspnoea at six months, therefore our hypothesis was rejected. In secondary outcomes, there were significant gains in HRQoL, exercise, performance, anxiety, knowledge and steps at six weeks, and at six months changes in exercise performance and anxiety remained statistically significant. Correction for multiple comparisons, however, had not been made. Conclusions: SPACE FOR COPD did not result in improved dyspnoea, over and above usual care at six months. The programme may confer significant benefits in HRQoL, exercise performance, anxiety, knowledge and physical activity over and above usual care in the short-term, and gains in anxiety and exercise performance maintained at six months. Although these patients were relatively early within the course of their disease, physical activity was low, highlighting the need for a lifestyle intervention in this group of patients. Exploration of the potential benefit of additional on-going support, and delivery within group settings may of value in order to support the maintenance of these benefits in the medium- and longer-term.

The generation of oxygen free radicals by the cytosolic enzyme, xanthine oxidase (XO), has been implicated in post-ischemic or reperfusion damage in several organs. XO catalyzes the conversion of hypoxanthine to urate with the concomitant production of superoxide anion free radical (0₂̅˙) and hydrogen peroxide (H₂O₂). Oxygen free radical-mediated injury has also been demonstrated in inflammatory lung disease. The possible involvement of XO in oxidative injury in the lung has not yet been studied. Therefore, this research project was designed to determine whether XO is present in the lung and to investigate its characteristics in porcine, bovine, rat and human lung and other tissues. Immunochemical analysis of xanthine oxidase in the tissues employed on polyclonal antibody raised to bovine milk XO. Proteins were separated by SDS-polyacrylamide gel electrophoresis of tissue homogenates. Proteins were transfered from the gels to nitrocellulose filters by Western blotting. After incubating the filters with a antisera containing the antibody to the purified bovine XO. XO on the filter was detected by its reaction with an enzyme-conjugated second antibody. XO was immunologically detectable in bovine lung and milk. Rat lung, kidney and liver all showed XO reactivity. XO was detectable in porcine liver but not detectable in porcine lung or kidney. Thus, the antibody to bovine XO was cross-reactive with porcine and rat XO. XO protein was not immunologically detectable in human lung possibly because the antibody was not cross reactive with the bovine antibody. In vivo, xanthine oxidase exists predominantly as a dehydrogenase rather than an oxidase. In this form as xanthine dehydrogenase (XDH) the enxyme does not produce either 0₂̅˙ or H₂O₂. The activity of both XDH and XO was measured in several tissues using a fluorometric assay which uses an artifical substrate, pterin which is catalytically converted to the fluorescent product isoxanthopterin (IXP). XO activity in porcine liver was of 1.1 x 10⁻³ µg IXP/mg protein/min although XO activity was not detectable in porcine lung and kidney, in rat lung of 1.7 x 10⁻² µg IXP/mg protein/min, rat kidney of 1.5 x 10⁻² µg IXP/mg protein/min, and rat liver of 2.2 x 10⁻² µg IXP/mg protein/min. Seven human lung biopsy samples were obtained after lung resection and initially tested for viability by determination of NADH oxidase activity and then assayed for XO-XDH. Three of these samples showed NADH oxidase activity indicating tissue viability, but only one of these three showed measurable XO activity of 5.35 x 10⁻⁶ µg IXP/mg protein/min. Irreversible conversion of XDH to XO is thought to be the result of limited proteolysis by a Ca²⁺/calmodulin activated protease, whereas reversible conversion of the enzyme occurs by oxidation of critical thiol groups. Studies on the rate and nature of fluorescence assay to detect catalytic activities of both enzyme forms. Incubation of lung homogenates with trypsin for 60 min caused irreverisble conversion of 90% of the XDH to XO. In contrast, incubation of homogenates at 15°C for 10 hours caused conversion of 100% of the XDH to XO. This conversion was reversible to the extent of 80% by reduction of thiol groups with dithiothreitol (DTT). The effects of free Ca²⁺ on the conversion of XDH to X0 was examined by using EDTA, a chelator of Ca²⁺ and other divalent cations; and EGTA, a more specific chelator of Ca²⁺. The presence of these chelating agents during homogenization of either normoxic or ischemic rat lung tissue did not inhibit reversible enzyme conversion. Increased XO activity was reversible by DTT. In the normoxic rat lung, homogenates prepared with EDTA and EGTA showed a similar conversion of 95% of XDH to XO which was reversible to 70% with DTT. In the ischemic rat lung, samples prepared with EDTA and EGTA showed a'conversion of 80% and 95% XDH to XO which was similar to control samples. The extent of reversibility to XDH was 75% with DTT incubation. In addition, perfusion of rat lungs with EDTA and DTT via a pulmonary artery cannula prior to 60 min of ischemia and homogenization did not affect the extent of XDH to XO conversion. These results indicate that irreversible Ca²⁺-mediated proteolytic conversion of XDH to XO does not occur to a great extent in the rat lung during either normoxia or ischemia. However, reversible conversion of XDH to XO does occur, suggesting that reversible thiol dependent conversion may play a role in the lung under both physiological and pathophysiological states. / Medicine, Faculty of / Pathology and Laboratory Medicine, Department of / Graduate

No description available.

No description available.