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The purpose of this study was to assess the extent to which patients undergoing flexible bronchoscopy (FOB) experience pain and to identify patient factors and process of care factors that are associated with pain. We conducted a prospective cohort study on 481 patients undergoing FOB. Overall control of pain during FOB was the primary outcome. The mean age of the patients was 48 yr, 50% were male, and 32% required supplemental oxygen prior to FOB. Pain control was excellent in 36% of patients, but 10% considered it to be fair or poor. Patient factors associated with excellent pain control were excellent health (versus poor health, OR = 6.25 [95% CI, 2.28-16.67]), more education (college education versus high school education, OR = 1.72 [95% CI, 1.05-2.86]), and not having asthma (OR = 2.86 [95% CI, 1.09-7.14]). Process of care factors associated with excellent pain control were not being bothered by scope insertion (versus bothered, OR = 3.65 [95% CI, 1.99-6.98]), no memory of FOB (versus some memory, OR = 2.33 [95% CI, 1.24-4.44]), and higher ratings of information about the procedure (per 1-point increase on a 12-point scale, OR = 1.57 [95% CI, 1.41-1.78]). This is the first large-scale, prospective study to evaluate patient and process of care factors that influence pain control during FOB. It demonstrated that there are patient characteristics and process of care factors that need to be considered when evaluating pain during bronchoscopy. Improved preparation of patients with lower education, inferior health status, and asthma may lead to decreased pain during FOB. Bronchoscopists may be able to reduce pain during FOB by identifying methods to decrease pain on scope insertion, by improving the information provided to patients, and by achieving greater levels of amnesia during FOB.

The c-myc oncogene is frequently amplified in cells grown from lung tumors and has been linked to the malignancy of these cancers. In support of this, c-myc transfection enhances the in vitro proliferation and soft agar cloning of human small cell lung cancer (SCLC) cells. In this study, we surprisingly found that c-myc expression suppressed the formation of tumors by SCLC cells in athymic nude mice. c-myc expression down-regulated the protein and transcript for vascular endothelial growth factor (VEGF) in these SCLC cells, as well as VEGF transcript in rat fibroblasts manipulated for c-myc expression and in liver cells of c-myc-transgenic mice. Finally, bivariate and multivariate analyses demonstrated that the probability of tumor formation from lung cancer cell lines was negatively correlated with the relative expression of c-Myc, positively correlated with the relative expression of VEGF, and that the latent time to tumor formation was increased by the expression of c-Myc and decreased by the expression of VEGF. We hypothesize that, for lung cancer cells, c-Myc suppresses the formation of tumors in vivo by down-regulating VEGF, and that the amplification of c-myc seen in cells grown from lung tumors with a poor prognosis is an artifact of selection for growth in vitro.

Expenditure and utilization patterns of aged Medicare beneficiaries with chronic obstructive respiratory disease (COPD) (n = 42,472) were compared with all Medicare beneficiaries (n = 1,221,615) using a 5% nationally representative sample of aged Medicare beneficiaries participating in the fee-for-service program in 1992. Per capita expenditures for an aged Medicare beneficiary with COPD were 2.4 times the per capita expenditures for all Medicare beneficiaries. The most expensive 10% of Medicare beneficiaries with COPD accounted for nearly half of total expenditures for this population. Higher comorbidity, as measured by the Deyo-adapted Charlson index, was associated with higher expenditures. For Medicare Part B claims, internal medicine accounted for the largest portion of physician expenditures (14%). Per capita expenditures for pulmonologists were 7.5 times higher for beneficiaries with COPD compared with all Medicare beneficiaries. Results from this study suggest that there is a subgroup of individuals with COPD who are likely to be very expensive during the year. Additional analytic studies are needed to more specifically identify characteristics associated with these individuals. As more Medicare beneficiaries enroll in managed care and as physicians are increasingly being paid on a capitated basis this information will be useful to physicians as they monitor the care provided to patients and assess the financial risks they accept under capitation.