Psychological Characteristics of Adults with Cystic Fibrosis

hemorrhage in the Third World.• Other causes of hemoptysis include (in descending order of frequency) bronchiectasis of nontuberculous origin, chronic bnmchitis, lung abscess, pulmonary fungal infections, mitral stenosis, and lung cancer. Hemoptysis in the Third World also tends to present in young patients, which possibly explains why lung cancer and chronic bnmchitis are reported to be rare causes of hemoptysis in this part of the world. In pulmonary tuberculosis, hemoptysis is more severe in patients with new active and radiologically extensive disease, PTB relapse, and old inactive PTB with secondary pulmonary infection. It is more common in female patients and more severe and recurrent in elderly patients. Routinely, all patients presenting with hemoptysis undergo sputum examination with Ziehi-Neelsen stain for Mycobacterium tuberculosis and a posteroanterior chest radiograph, which is usually diagnostic of a pulmonary condition. Fiberoptic bronchoscopy is mainly reserved for patients who present with massive hemoptysis (more than 1,000 ml during a period of24 h) and in those with recurrent pulmonary hemorrhage. Cold saline lavage may be attempted at the same time as bronchoscopy in order to arrest the bleeding.' Bronchography is still done in some centers, but chest computed tomography, radionuclide scanning, and bronchial and pulmonary angiography are performed in only a few specialized centers. Most patients receive conservative medical management with strict bed rest, nothing by mouth, placement of a large-bore intravenous line, a 7-day course of a broad-spectrum antibiotic or a standard antimymbacterial chemotherapy regimen, and H,-blockade with cimetidine.' Fortunately, many of our patients respond to this mnservative treatment. Only a few patients undergo surgical resection of the bleeding segment or lobe; this is because of the radiologically extensive nature of the disease, poor pulmcmary reserve, and anesthetic risks in the majority of the patients. Surgical resection of untreated tuberculosis residual is well known to be associated with a high morbidity and mortality:' Specialized treatment techniques, such as bnmchial artery emholization,"·' thrombin infusion,"·" and fibrinogen-thromhin infusion• popularly used via a fiberoptic hronchoscope, which are l>el~>ming in Europe, North America, and Japan, are seldom employed in the Third World due to lack of elahorate equipment and skills. Bronchial artery emholization may not l>e SUL'Cessful in 10 to 25 percent of patients,'·"·"' especially in those in whom the hleeding is from the pulmonary arterial system or the intermstal arteries; it can Ol'Casionally cause serious L~>mplications, such as spinal injuries." Nightingale Syabbalo, M.B., Ch.B., Ph.D., f:C.C.P., Umtata Chest Hospital, Umtata, Transkei, South Africa

7 Remy J, Arnaud, Fardou R, Voisin C. Treatment of hemoptysis by embolization of the bronchial arteries. Radiology 1977; 122:33-37 8 Kinoshita M, Sbiraki R, Waga, Watanabe H, Kitamura S. Thrombin instillation therapy through the fiberoptic bronchosmpe in cases of haemoptysis. Jpn J Thorac Dis 1982; 20:25154 9 Tsukamoto T, Sasaki, Nakamura H. Treatment of hemoptysis patients by thrombin and fibrinogen-thrombin infusion therapy using a fiberoptic bronchoscope. Chest 1989; 96:473-76 10 Katoh 0, Kishiwaka T, Yamada H, Matsumoto S, Kudo S. Recurrent bleeding after arterial embolization in patients with hemoptysis. Chest 1990; 97:541-46 11 Remy J, Marache P, Lemaitre ML, Lafitte JJ, Tonne! AB, Voisin C. Accident de emlx>lisation dans le traitement des hemoptysis. Nouv Presse Med 1978; 7:4306

The Effects of Heterologous Platelet Transfusion on Pulmonary Function during ARDS To the Editor:

I read with interest the recent article by Eichacker et al (Chest 1990; 97 :923-26), on the effects of heterologous platelet transfusion on pulmonary function during ARDS. This article adds important new inli>rmation to the ongoing investigation of the role of the platelet in the pathogenesis ofthis syndrome. I have one criticism of this article, which relates to their use of the term "heterologous platelet tr.msfusicm." I take the authors to mean by this that the transfused platelets were not autologous platelets. However, the correct term li>r this situation is "allogeneic platelet transfusion." In transfusion medicine, the term "heterologcms" is used for the tmnsfusion ofblcx>d pn>ducts from one species to another. The use of this term to signify a nonautologous platelet transfusion creates confusion. As is usual in clinical practice, the authors did not l~mtrol for the length of time that the platelets were stored. It would l>e of interest to know what the average time of storage was. Changes in the biochemicall~mstituents of platelets and the memhrane properties of platelets may occur with storage, and it is fX>Ssible that these changes could have influenL-ed the outl'<>me of the study. It would l>e of interest to l'<>mpare the authors' findings with those in a group of patients who ra-eived tr.msfusions of platelets that had been drawn within 4 h of L'<>llection, li>r example. Another pia-e of inlimnation that would be of interest would be the resfX>nSe to the platelet transfusion. Were 1-h platelet increments obtained? If the platelets did not circulate li>r immunologic or other reasons, it could l>e that this might explain the ahsence of any effect on ARDS. james P. Cmwley, M.D., Division of Clinical Hematology, Rhocle Island Hospital, Prvvldence, Rhode Island

REFERENCES 2 3

4 5 6

Haponik EF, Chin R. Hemoptysis: clinicians' perspectives. Chest 1990; 97:469-75 Delfabach ME, Charan NB, Lakshminarayan S, Butler J. The bronchial circulation: small, hut a vital attribute of the lung. Am Rev Respir Dis 1987; 135:463-81 Muthuswamy PP, Akhik F, Franklin C, Spigos D, Barker \V, Management of massive or major hemoptysis in acute pulmonary tuherculosis hy bronchial arterial embolization. Chest 1987; 92:77-82 Syahhalo NC. Medical management of hemoptysis. Chest 1989; 96:1441 Conlan AA, Hurwitz SS, Krige L, Nil~>laone V, Ptx>l R. Manageand ment of massive haemoptysis with the rigid hronchoSL~>pe cold saline lavage. Thorax 1980; 35:901-04 Wholev Mil, Chamorro HA, Rao G, Gord WB, Miller WH. Bronchial arterial emlx>lization li>r massive hemoptysis. JAMA 1976; 236:2501-04

Psychological Characteristics Adults with Cystic Fibrosis

of

To the Editor:

I read with interest the refX>rt by Shepherd et al (Chest 1990; 97: 1310-16), which demonstrated adequate social functioning among the adult population with cystic fibrosis (CF), but I feel that the psychological characteristics need further investigation. The authors' findings of gcx>d functioning in terms of employment, education, and so forth are consistent with those of other studies.' CHEST I 99 I 5 I MAY, 1991

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"Life satisfaction," which Shepherd et al also measured, is only a general measure of psychological distress. When psychological distress was investigated in a much larger sample (n = 176), less favorable results were found. • This may justify investigating the psychological difficulties of adult CF sufferers in more detail. Adult CF patients do not, except rarely, suffer from mental illness. They may experience neurotic symptoms, such as anxiety, low mood, or stress. All people experience these to some extent, so the choice of where to draw a line in psychiatric investigations to define some symptoms as abnormal is critical. 3 The questionnaires that Shepherd et al developed for their study do appear to genuinely inquire about those areas of life and social satisfaction that the authors intended to investigate. Since these questionnaires are not supported by reliability or validity data, there must remain some doubt that the authors drew their lines in acceptable positions. The authors failed to interview a third of the patients, and this may introduce bias. The adult CF population is expanding. Shepherd et al have increased our knowledge of how they fare. Perhaps future studies should use interviews as a more reliable way of producing psychological data and should use recognized rating scales of known reliability and validity to address in more detail the occurrence of psychological symptoms.

Andrew]. Aspin, M. R. C. Psych., Department of Psychiatry, Mapperley Hospital, Nottingham, England REFERENCES 1 Moise JR, Drotar D, Doershuk CF, Stem RC. Correlates of psychosocial adjustment among young adults with cystic fibrosis. J Dev Behav Pediatr 1987; 8:141-48 2 Cowen L, Carey M, Simmons R, Keenan N, Robertson J, Levison H. Growing older with cystic fibrosis: psychosocial adjustment of patients more than 16 years old. Psychosom Med 1984; 46:36376 3 Freeman CP. Neurotic disorders. In: Kendell RE, Zealley AK, eds. Companion to psychiatric studies. 4th ed. New York: Churchill Livingstone, 1988; 330-54

1b the Editor: Dr Aspin correctly notes that only 67 percent of the eligible subjects participated in our study on the psychosocial functioning of adults with cystic fibrosis.' Yet a 100 percent participation rate is virtually never possible, and the participation rate in our study falls midway between the 59 percent and 85 percent achieved in the two studies cited by Dr Aspin. 2•3 Possible bias from the failure to include nonrespondents is always a concern. However, it is useful to consider what forms such bias might take. The reason for studying the psychosocial health of physically ill persons in the first place is the assumption that physical health can affect psychosocial health. On all the physical health variables available for comparison, however, we found no significant differences between the CF participants and nonparticipants in our study. Thus, to the extent that physical health does affect psychosocial health, it seems reasonable to assume that psychosocially the CF nonparticipants would resemble the CF participants. If the CF participants and nonparticipants did differ psychosocially, it would be for reasons other than their having CF. Dr Aspin also suggests that the findings of Cowen et al3 are at odds with our own. These investigators, however, never studied "psychological distress" (nor did they study 176 adults; when limited to patients aged 20 years or older, n = 105). The specific results of Cowen et al on which Dr Aspin bases his statement are in tum based on a nearly 40-year-old measurement tool of debatable

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validity, and the overall conclusions of Cowen et a1 are that older patients with CF possess "a generally normal self-concept" and "cope with their intellectual, developmental, and socioeconomic tasks commensurate with normal age expectations." As to the validity and reliability of our measures, the questions pertaining to social network density are closely adapted from those used in the RAND Health Insurance Study, and their validity and reliability have been thoroughly analyzed. • Other measurement tools that we used have been less well characterized,• and it would indeed be useful to know the psychometric properties of these instruments. However, we believe that the questions we used have high face validity. Moreover, the use of a controlled design reduces the possibility that measurement error is responsible for our results. Ifthe measures do have psychometric weaknesses, the responses of subjects with and without CF should be equally affected. The importance of using a controlled design is related to a more substantive question raised by Dr Aspin: where to draw the line between normal and abnormal. Such an endeavor raises a host of questions (many common traits and behaviors in our society should rightly be considered "abnormal'), and we make no claims as to where such a line of demarcation should fall. Our results do suggest, however, that wherever one chooses to draw such a line, the percentage of subjects who fall on either side of it will be similar both for adults with CF and for their healthy peers. Dr Aspin suggests that future studies may benefit from the use of psychological interviews rather than questionnaires. This is a matter of methodologic preference; but it should be kept in mind that no matter how well-conducted, valid, or reliable such interviews may be, in the absence of similarly obtained data from a control group, it is impossible to make valid conclusions about how normal or abnormal, healthy or unhealthy, one group may be relative to another.

Steven L. Shepherd, M.P.H., San Diego REFERENCES 1 Shepherd SL, Hovell MF, Harwood IR, Granger LE, Hofstetter CR, Molgaard C. A comparative study of the psychosocial assets of adults with cystic fibrosis and their healthy peers. Chest 1990; 97:1310-16 2 Moise JR, Drotar D, Doershuk CF, Stem RC. Correlates of psychosocial adjustment among adults with cystic fibrosis. J Dev Behav Pediatr 1987; 8:141-48 3 Cowen L, Corey M, Simmons R, Keenan N, Robertson J, Levison H. Growing older with cystic fibrosis: psychologic adjustment of patients more than 16 years old. Psychosom Med 1984; 46:36376 4 Brook RH, Ware JE, Davies-Avery A, Stewart AL, Donald CA, Rogers WH, et al. Overview of adult health status measures fielded in RAND's health insurance study. Med Care 1979; 17(suppl):1-131 5 Smilkstein G. The family APGAR: a proposal for a family function test and its use by physicians. J Fam Pract 1978; 6:1231-39

Mediastinal Pseudocyst Associated with Chronic Pleural Effusions 1b the Editor: We read with great interest the article by Zeilender et al (Chest 1990; 97:1014-16) on mediastinal extension of a pancreatic pseudocyst presenting as a chronic pleural effusion. We recently were faced with a similar case and had the same concern about how to proceed in treating the cyst in a patient who was not a surgical candidate. A 55-year-old black man was admitted to District of Columbia Communications to the Editor