First Hard Proof of Secondhand Smoke Damage to Lungs Revealed

Martha Kerr


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November 27, 2007 (Chicago) — Although it has been speculated about for years, investigators have now revealed the first real, hard evidence that secondhand smoke does, in fact, damage the lungs.
The findings of a study using long-time-scale, global, helium-3 diffusion magnetic resonance imaging (MRI) of nonsmokers with high and low secondhand-smoke exposure and of smokers were announced here yesterday during the Radiological Society of North America 93rd Annual Scientific Assembly.
The study involved 60 volunteers, all with normal spirometry measures, with forced expiratory volumes in 1 second ranging between 58% and 92%, and all without other symptoms of lung disease.
Of these, 23 participants were nonsmokers with low levels of secondhand-smoke exposure, defined as no family members who smoked and no exposure to smoke in the workplace; 22 were nonsmokers with high secondhand-smoke exposure; and 15 were past or current smokers. All had at least 10 years of exposure in their respective categories.
Lung structure was assessed using helium-3 diffusion MRI, with apparent diffusion coefficient (ADC) values calculated for each participant. The lower the ADC value, the better the lung function. Higher ADC values reflect enlargement of the alveoli.
Only 4% of those with low secondhand-smoke exposure had elevated ADC values, reported principal investigator Chengbo Wang, PhD, a magnetic resonance physicist in the Department of Radiology at The Children's Hospital of Philadelphia, Pennsylvania. Of those with high levels of secondhand-smoke exposure, 27% had elevated ADC values, whereas 67% of past and current smokers had high ADC values.
"Nonsmokers with high secondhand-smoke exposure were not as bad as the smokers but were much worse than those with low exposure," Dr. Wang pointed out.
"Helium-3 diffusion MRI detects changes [in lung structure] before symptoms are evident," he told Medscape Radiology. "These were all basically healthy people with normal lung function tests.
"We know that about half of smokers have normal lung function. They just don't seem to be sensitive to smoke," Dr. Wang noted.
"If we want to find proof [of secondhand smoke damage to the lung], we can see it now. This is a very solid finding," Dr. Wang said. "This is very exciting that we can see this difference."
The findings have important public health implications, he added. "We really need to prohibit smoking in public places."
The Philadelphia investigator said that helium-3 diffusion MRI could also be useful in evaluating the efficacy of inhalation therapy such as albuterol on the lung. "Before, we had to guess."
Dr. Wang cautioned that this is still an investigational technique, noting, "It is not yet FDA approved."
Katarzyna J. Macura, MD, assistant professor at the Russell H. Morgan Department of Radiology and Radiological Sciences at Johns Hopkins Medical Institution in Baltimore, Maryland, commented that Dr. Wang "is using a very sophisticated, very expensive technique. We first need more validation of this technology," she told Medscape Radiology. "For screening, we need to see that lung damage is occurring. This [study] appears to show that [damage]."
The scanner for Dr. Wang's study was provided by Siemans, AG, of Munich, Germany, but he developed the software himself. Dr. Wang and Dr. Macura have disclosed no relevant financial relationships.
Radiological Society of

First Hard Proof of Secondhand Smoke Damage to Lungs Revealed

November 27, 2007 (Chicago) — Although it has been speculated about for years, investigators have now revealed the first real, hard evidence that secondhand smoke does, in fact, damage the lungs.
The findings of a study using long-time-scale, global, helium-3 diffusion magnetic resonance imaging (MRI) of nonsmokers with high and low secondhand-smoke exposure and of smokers were announced here yesterday during the Radiological Society of North America 93rd Annual Scientific Assembly.
The study involved 60 volunteers, all with normal spirometry measures, with forced expiratory volumes in 1 second ranging between 58% and 92%, and all without other symptoms of lung disease.
Of these, 23 participants were nonsmokers with low levels of secondhand-smoke exposure, defined as no family members who smoked and no exposure to smoke in the workplace; 22 were nonsmokers with high secondhand-smoke exposure; and 15 were past or current smokers. All had at least 10 years of exposure in their respective categories.
Lung structure was assessed using helium-3 diffusion MRI, with apparent diffusion coefficient (ADC) values calculated for each participant. The lower the ADC value, the better the lung function. Higher ADC values reflect enlargement of the alveoli.
Only 4% of those with low secondhand-smoke exposure had elevated ADC values, reported principal investigator Chengbo Wang, PhD, a magnetic resonance physicist in the Department of Radiology at The Children's Hospital of Philadelphia, Pennsylvania. Of those with high levels of secondhand-smoke exposure, 27% had elevated ADC values, whereas 67% of past and current smokers had high ADC values.
"Nonsmokers with high secondhand-smoke exposure were not as bad as the smokers but were much worse than those with low exposure," Dr. Wang pointed out.
"Helium-3 diffusion MRI detects changes [in lung structure] before symptoms are evident," he told Medscape Radiology. "These were all basically healthy people with normal lung function tests.
"We know that about half of smokers have normal lung function. They just don't seem to be sensitive to smoke," Dr. Wang noted.
"If we want to find proof [of secondhand smoke damage to the lung], we can see it now. This is a very solid finding," Dr. Wang said. "This is very exciting that we can see this difference."
The findings have important public health implications, he added. "We really need to prohibit smoking in public places."
The Philadelphia investigator said that helium-3 diffusion MRI could also be useful in evaluating the efficacy of inhalation therapy such as albuterol on the lung. "Before, we had to guess."
Dr. Wang cautioned that this is still an investigational technique, noting, "It is not yet FDA approved."
Katarzyna J. Macura, MD, assistant professor at the Russell H. Morgan Department of Radiology and Radiological Sciences at Johns Hopkins Medical Institution in Baltimore, Maryland, commented that Dr. Wang "is using a very sophisticated, very expensive technique. We first need more validation of this technology," she told Medscape Radiology. "For screening, we need to see that lung damage is occurring. This [study] appears to show that [damage]."
The scanner for Dr. Wang's study was provided by Siemans, AG, of Munich, Germany, but he developed the software himself. Dr. Wang and Dr. Macura have disclosed no relevant financial relationships.
Radiological

Correction of Vision in Nursing Home Residents Relieves Depression

November 20, 2007 — The simple gesture of providing nursing home residents with corrective eyeglasses not only improves their vision but also reduces depressive symptoms and improves psychological well-being, according to a study in the November issue of the Archives of Ophthalmology.
Vision impairment rates among nursing home residents are an estimated 3 to 15 times higher than among older adults living in the community, the authors write, despite the fact that about one-third of this vision impairment could be reversed by treatment of uncorrected refractory error.
These high vision impairment rates are "shocking," corresponding author Cynthia Owsley, PhD, Nathan E. Miles Chair of Ophthalmology and vice chair for clinical research, department of ophthalmology, school of medicine, University of Alabama, in Birmingham, told Medscape Psychiatry.
"There are so many chronic eye diseases of aging that you can't really reverse, but things like nearsightedness, farsightedness, needing glasses to see up close" are not among them, she said. "There's really not a routine provision of eye care in nursing homes. It might be considered on paper as a part of comprehensive medical care, but it's simply not happening."
This is unfortunate, since people with vision problems are at higher risk for depression, she said. Depression rates in nursing homes are as high as 43%, the study authors note.
"Modest Yet Consistent Effect"
The current study included residents aged 55 years and older in 17 nursing homes in the Birmingham, Alabama area who had uncorrected refractive error (myopia, hyperopia, and/or presbyopia) in 1 or both eyes and could answer simple questions about vision. The residents completed quality-of-life questionnaires, and researchers measured their depressive symptoms using the 15- item Geriatric Depression Scale (GDS).
Following the baseline assessment, each participant selected a pair of eyeglass frames at no charge. The residents were then randomly assigned to either the "immediate" group, who received their spectacles within about a week, or to a "delayed" group, who did not receive their glasses until 2 months later.
Residents in both groups had similar demographics and medical characteristics. On average, participants were in their late 70s and had 5 to 6 chronic medical conditions. The distribution of refractory error was similar in both groups.
At the end of the protocol, there were 78 residents still in the "immediate" group and 64 in the "delayed" group.
At follow-up, the researchers found that the "immediate" group had a score of 3.6 on the GDS, compared with 4.9 in the delayed group. "It's somewhat misrepresentational to look at averages, but on average it [the depression score] changed by about 1.5 symptoms," said Dr. Owsley. "It doesn't sound like a lot, but some individuals had more of an effect than others. It was a modest yet consistent effect."
The "immediate" group also had higher scores on subscales of general vision, reading, psychological distress (eg, worry, frustration), activities and hobbies, and social interaction.
Communication Problems a Possible Factor
One possible contributing factor for these high vision impairment rates is the pervasive opinion among health providers and others that nursing home residents would not benefit from treatments to improve vision because of cognitive impairment. Communication problems among medical staff could also play a role, said Dr. Owsley, adding that eye specialists may not consider nursing homes a venue for providing care. Only half of nursing homes in the United States report having contracts for vision services, according to the study.
Dr. Owsley also thinks that families may put corrective eye wear low on a list of priorities for a loved one who is dealing with so many other health issues. "I'm not disputing that individuals who reside in nursing homes have very serious chronic conditions, many of which are dementia related, but you have to think beyond that," she said. "We're visual entities. That's how we interact with our environment. It just adds an additional frustration in your day when you can't see."
Nursing home residents, she said, spend a good deal of time reading, watching TV, interacting with other people, and doing hobbies. "Much of their work is up-close work, and that's why it's so important that their presbyopia be corrected."
In most cases, financial barriers are not keeping these residents from getting glasses. Vision correction is covered by Medicaid, and most people (68%) in nursing homes are on Medicaid or similar coverage, the authors note. Therefore, supplying corrective eyeglasses to nursing home residents is not something that requires huge policy changes, said Dr. Owsley.
The researchers now plan to do another study to "see where the breakdown in the system lies . . . so we can make very practical practice-oriented recommendations," said Dr. Owsley.
The research was supported by the Retirement Research Foundation, the EyeSight Foundation of Alabama, the Pearle Vision Foundation, the National Institutes of Health, and Research to Prevent Blindness Inc. The authors report no conflicts of interest.
Arch Ophthalmol. 2007;125:1471-1477. Abstract

Strategies to Overcome Barriers to Effective Nurse Practitioner and Physician Collaboration

Introduction
Nurse practitioners (NPs) and physicians have worked together to manage patients since the inception of the NP role in the 1960s.[1] Because the underserved and rural areas lacked primary and specialty care physicians, the NP role eventually evolved to one of a collaborating midlevel provider.[2] The integrated use of NPs and physicians together has positively affected the health care system, yet barriers to effective collaboration continue to exist, and this may lead to a reduced level of quality health care for patients. The barriers to effective collaboration between NPs and physicians are important to consider because the main goals of any NP–physician collaborative team are positive patient care outcomes.
Numerous articles have been written on collaboration between NPs and physicians; each giving different perspectives on the barriers to collaboration. Current research examines the experiences of NPs and physicians in collaborative practice and lists the critical components of effective collaborative relationships. Formal orientation to collaborating between health care providers in different disciplines is essential to managing patients efficiently.[3] The use of theoretical frameworks was deemed helpful in developing an effective collaborative practice.[4] The aim of this literature review is to review common barriers to effective NP and physician collaboration to identify the strategies to overcome these obstacles. The hope is that once common barriers are clearly identified and the strategies to overcome these barriers are used, successful collaboration will occur, leading to improved patient outcomes.
Essentially, the role of the NP is similar or equal to that of a physician; therefore, the duties inadvertently overlap. A physician will do the same type of work as a NP but brings more in-depth knowledge and expertise to patient care. In addition, physicians have the ability to perform special procedures or make more advanced clinical decisions and therefore can serve as an excellent resource in practice. Regardless, an NP has had sufficient knowledge and training to accurately assess and treat patients who have common disorders. Sharing similar goals and mirroring each others' practice provides consistent and comparable patient medical management. Together their duties overlap, but ultimately physicians and NPs share the goal of improved or better patient outcomes.[5,6]
The effect of barriers to effective NP and physician collaboration on patient outcomes is depicted in Figure 1. Two circles at the top depict the interprofessional relationship and how many duties overlap. The obstacles of the path to better patient outcomes are the barriers. The common barriers found in the literature are presented as the peach-colored square. The strategies to eliminating the barriers are shown in gray. Because better patient outcomes are the ultimate goal, this concept is illustrated as a barrel to show the open door to improved quality of care provided by the NP and physician collaborative team.

High-Rising Epiglottis in Children: Should It

High-Rising Epiglottis in Children: Should It Cause Concern?
Posted 11/01/2007
Nadeem Petkar, MBBS, MS; Christos Georgalas, MBBS; Abir Bhattacharyya, MBBS, MSAuthor Information
Overview and Introduction
Overview
An omega-shaped epiglottis is frequently associated with laryngomalacia. However, an elongated high-rising epiglottis can represent a normal variation of the larynx in a majority of pediatric patients. It is important to consider this in a healthy child with no complaints apart from the sensation of a foreign body in throat. This will avoid triggering any unnecessary investigation or treatment. An elongated epiglottis projecting in the oropharynx can appear as a foreign body and be a source of anxiety for the parents as well as the unaware family practitioner. We present such a case, with a brief discussion of the pediatric larynx and the omega-shaped epiglottis.
Introduction
A 3-year-old girl was brought by her mother to the otolaryngology rapid access clinic. The girl had been complaining of an intermittent foreign body sensation in her throat. Her mother and the patient herself described a "googly" in the back of her throat when she popped her tongue out. There was no associated history of stridor, shortness of breath, or symptoms suggestive of a sleep apnea. There was no history of reflux disease or odynophagia.
During examination of the oral cavity, an anterior larynx was noted and an elongated high-rising epiglottis was clearly visible in the oropharynx (Figure 1). The tonsils were not inflamed and nasal examination was unremarkable. The extremely high-rising epiglottis was diagnosed as the cause of the foreign body sensation felt by the child. The child was not in respiratory distress and was maintaining good oxygen saturation on air. Both mother and child were reassured as to the benign nature of this condition and discharged.