[Guideline for the Diagnosis and Treatment of Asthma - Addendum 2020 - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]. / S2k-Leitlinie zur Diagnostik und Therapie von Patienten mit Asthma ­ Addendum 2020.

The present addendum of the guideline for the diagnosis and treatment of asthma (2017) complements new insights into the diagnosis and management of asthma as well as for the newly approved drugs for the treatment of asthma. Current, evidence-based recommendations on diagnostic and therapeutic approaches are presented for children and adolescents as well as for adults with asthma.

[Diagnostic Challenges of Mixed Dust Silicosis (Mixed Dust Pneumoconiosis) - 5 Case Reports]. / Diagnostische Herausforderungen bei Mischstaub-Pneumokoniosen ­ 5 Fallbeispiele.

Exposure to granular or fibrous inorganic dusts of the alveolar dust fraction initiates inflammatory and fibrotic lung processes. Furthermore, such exposures are associated with an increased risk for lung cancer. By taking a detailed occupational history into consideration the diagnosis of relatively frequent pneumoconioses such as silicosis or asbestosis with dominating pictures, i. e. with its predominant rounded or irregular opacities located especially in the upper and lower lung fields, respectively, is mostly not difficult. However, rarely exposure to a single agent exists. Rather, mixed dust exposures occurring at the same time or in the follow-up have to be taken into consideration, e. g. quartz and carbon in hard coal mines, quartz, asbestos, various other components of cement and concrete dusts in the construction industry. It is also important that during the working life, changes of working processes and used raw materials as well as changes of jobs are associated with variations of type and intensity of exposures. This heterogenicity of exposures and of the associated intrapulmonary depositions result in variations of the pulmonary structural changes, i. e. more or less modifications of the pictures of pneumoconioses as described being typical in textbooks. This is associated with diagnostic difficulties, especially with regard to the differential diagnosis of idiopathic interstitial lung diseases. There is also evidence for genetic influence on disease susceptibility and on the degree of pathohistological changes.This publication includes 5 case reports; all of them were initially diagnosed as idiopathic pulmonary fibrosis, but a detailed workup of the author, mostly during social court litigations, showed that mixed dust pneumoconioses were the most likely diagnoses.

[Assessment of Asbestos-related Occupational Diseases: Socio-medical and Legal Aspects]. / Sozialmedizinische und sozialjuristische Aspekte in der Zusammenhangsbegutachtung asbestbedingter Berufskrankheiten.

Occupational diseases are certain diseases designated as such by law. Whereas the medical conditions are described in guidelines, their recognition is based on judicial administrative procedures. Establishing causality is based on requirements of social law. The basic socio-legal concepts are mentioned and the principles of causality in asbestos-related occupational diseases are listed. Exemplary social court judgments are cited. Judgements may not infrequently differ from the medical point of view. The aim of this article is to describe the correct use of social medical understanding in order to carry out adequate assessment of occupational diseases, which implements the legal requirements.

[COPD due to Occupational Noxae]. / COPD durch berufliche Noxen.

The chronic obstructive pulmonary disease (COPD) is characterised by mainly non-reversible bronchial obstruction with airflow limitation. Typically, it exhibits a progressive course. It is one of the leading causes of morbidity and mortality worldwide. In addition to dominating causative smoking and environmental exposures (especially biomass smoke from cooking with open fire stoves), about 15 % are due to occupational exposure. Relatively rare cases (ca. 6 %) do not show an external noxious influence. Occupational causes are frequently not recognised because a detailed occupational history has not been taken. This is especially evident by the discrepancy in the identified COPD prevalences and incidences shown in many studies on the one hand and relatively low numbers in the official statistics on reports, acknowledgements and compensations of the disorder on the other hand. Whether occupational exposures to inhalative noxae are - in addition to non-occupational factors (e. g. smoking) - causative according to legal definitions is frequently a challenging question. Respective decisions of social courts in litigations are presented.

Misleading "New Insights into the Chrysotile Debate".

Although there is no dispute among independent scientists about the carcinogenic and fibrogenic effects of chrysotile, the asbestos industry has been continuously and successfully acting to cast doubts on its harm. Another approach including asbestos insurance entities is to refuse compensation by raising the bar and fight criminal prosecution for asbestos-related diseases by the help of paid scientists. A recent publication on asbestos fibre burden in human lungs fits well in this context. The claim that chrysotile fibres are biopersistent in human lung is not based on the data provided by these authors, and, additionally, exhibits serious inconsistencies and obvious mismeasurements and significant methodological problems. The conclusion of the authors that fibre analysis of workers' lungs "is of high significance for differential diagnosis, risk assessment and occupational compensation" is unfounded and reprehensible. Also the available literature, the statements of the WHO, IARC, other decisive independent international organizations, and all our experience provide abundant evidence to the contrary. Note, the method is generally restricted to research only and is not recognized for diagnostic purpose and compensation in any other country. In conclusion, fibre counting in lung tissues should not be used to estimate former exposure to chrysotile comprising c. 94 % of applied asbestos in Germany. The authors claim that the analyses can improve the compensation rates in Germany. However, the opposite has been the case; it significantly worsens the non-justified denial of well-substantiated compensation claims.

[Differential Diagnosis of Mediastinal and Hilar Lymphadenopathy with Focus on Occupational Diseases]. / Differenzialdiagnose bei mediastinaler und hilärer Lymphadenopathie mit Fokus auf berufsbedingte Krankheitsbilder.

Hilar and mediastinal lymphadenopathy may represent a diagnostic challenge in clinical practice. This article is intended to facilitate differential diagnosis by a systematic description of relevant pathologies, notably with occupational etiology. Clinical findings of relevant diseases, i. e. of tuberculosis, chronic beryllium disease, sarcoidosis, lung cancer, malignant lymphoma, Epstein-Barr virus infection, and histoplasmosis are compared.Case history, imaging and laboratory tests have important diagnostic impact. But also invasive methods can be necessary in order to exclude and prove malignancy, infection or autoimmune disease.

[Guideline for the Diagnosis and Treatment of Asthma - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]. / S2k-Leitlinie zur Diagnostik und Therapie von Patienten mit Asthma.

The present guideline is a new version and an update of the guideline for the diagnosis and treatment of asthma, which replaces the previous version for german speaking countries from the year 2006. The wealth of new data on the pathophysiology and the phenotypes of asthma, and the expanded spectrum of diagnostic and therapeutic options necessitated a new version and an update. This guideline presents the current, evidence-based recommendations for the diagnosis and treatment of asthma, for children and adolescents as well as for adults with asthma.

Asbestos: Socio-legal and Scientific Controversies and Unsound Science in the Context of the Worldwide Asbestos Tragedy - Lessons to be Learned.

Eight to fifteen per cent of lung cancer cases and nearly all mesothelioma cases are caused by asbestos. Problems in compensation issues ensue from strict legal requirements for eligibility and regulations of the statutory accident insurance institution pertaining to eligibility for occupational disease benefits. The latter include the unscientific requirement for set numbers of asbestos bodies or fibers to be found in lung tissue in order to "prove" disease causation if lung specimen are available. Although the validity of such evidence has been discredited by independent scientists, it is still used as evidence by an influential US pathology department. Frequently, epidemiological evidence regarding causal relationships and exposure histories is also often being ignored by insurance-affiliated medical experts.Similar misleading arguments are currently being used in newly industrialized countries where white asbestos - which is carcinogenic and fibrogenic like other asbestos types - is efficiently promoted as being less harmful. As a result, asbestos use is increasing in some of these countries. Behind the worldwide asbestos tragedy, a well-designed strategy orchestrated by certain transnational or multinational industrial interest groups can be perceived.Beyond the asbestos tragedy their covert plan is motivated by economic interests and discounts the ensuing damage to health and the impact of the diseases they create on public health systems.

[Case Report with Differential Diagnostic Aspects of Sarcoidosis]. / Differenzialdiagnostische Aspekte der Sarkoidose anhand eines Fallberichts.

A 73-year-old non-atopic patient had developed at the age of 29 shortness of breath on exertion, general malaise, enlarged axillary lymph nodes and nodular cutaneous eruptions. Based on the presence of bihilar lymphadenopathy, the diagnosis of sarcoidosis was made at that time without any histological investigations and without taking detailed case history. Administration of systemic steroids resulted in remission. However, 12 years later, there was a relapse with alterations of lung parenchyma, followed by a more chronic course of the disorder. Since this relapse, an obstructive-restrictive ventilation defect requiring treatment has persisted till today. About five years ago and at the insistence of the patient, clarifying diagnostics were performed. The case shows the important role of a detailed case history including occupational history. Its failure not only led to disadvantages to the patient but also to incorrect social insurance handling and missing appropriate preventive measures with regard to co-workers.

[Lung Cancer as an Occupational Disease]. / Lungenkrebs als Berufskrankheit.

Lung cancer is one of the most frequently encountered cancer types. According to the latest WHO data, about 10 % of this disease are due to occupational exposure to cancerogens. Asbestos is still the number one carcinogen. Further frequent causes include quarz and ionizing radiation (uranium mining). Probable causes of the disease can be identified only with the help of detailed occupational history taken by a medical specialist and qualified exposure assessment. Without clarifying the cause of the disease, there is neither a correct insurance procedure nor compensation for the victim, and furthermore, required preventive measures cannot be initiated.

[Guideline (S2k, AWMF) of the Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin and the Deutsche Gesellschaft für Arbeitsmedizin und Umweltmedizin "Diagnostics and Expert Opinion in the Occupational Disease No. 4101 Silicosis (Including Coal Worker's Pneumoconiosis)"]. / S2k-Leitlinie nach AWMF-Schema der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin und der Deutschen Gesellschaft für Arbeitsmedizin und Umweltmedizin "Diagnostik und Begutachtung der Berufskrankheit Nr. 4101 Quarzstaublungenerkrankung (Silikose) der Berufskrankheitenverordnung".

During the last 1.5 years an update of the guideline on silicosis was made by an interdisciplinary working group. New medical and scientific knowledge and the experience in expert opinion practice were taken into account.By preparing the initial guideline in 2010 standardization of diagnostics and adaption of the "Moers convention" which was not based on medical knowledge was in the focus, whereas the current update deals with fine emendation and extension, especially of the compensation rate (adaption with the Reichenhall recommendation).The diagnosis of silicosis (including mixed dust pneumoconiosis) is based on a detailed occupational history, and predominantly on the typical radiological findings. However, at initial diagnosis the standardized LD-HRCT takes an important role because of its high sensitivity and specificity. Exceptional cases are those with characteristic findings in chest X-ray follow-up. Correspondingly, it is mentioned in the guideline: "The standardized appraisal of the Low-Dose-Volume HRCT requires application of the CT classification (ICOERD, International Classification of Occupational and Environmental Respiratory diseases). In order to diagnose silicosis in CT scan opacities with sharp borders in both central upper lung fields and their circumferencies have to be documented. By comparing with ILO standard radiographs at least profusion category 1 in the right and left upper lung fields has to be reached (total profusion category 2)."The pathologic minimal requirement for the diagnosis of silicosis which has undergone controversial discussion has now also been defined. Corresponding to Hnizdo et al. 2000 it is now mentioned: "Finding of less than 5 silicotic granuloma per lung lobe by palpation is regarded as insignificant." This is a convention and not a threshold based on detailed medical scientific and statistical studies; it is based on extended experience in the South African gold mines.This guideline also deals with silicotic hilar (and sometimes mediastinial) lymph nodes; according to the guideline working group they do not closely correlate with the degree of pulmonary involvement. Extended conglomerating and enduring lymph-node processes may lead to dislocation of the hili with impairment of large bronchi and vessels. Shell-like calcifications dominating in the periphery of lymph nodes produce so-called egg-shell hili.The paragraph on exercise testing is now extended: if neither ergometry nor spiroergometry can be performed a 6 minute walking test by measuring oxygen saturation should be done.Furthermore, in individual expert opinion examinations right heart catheterization (the patient is not obliged to give informed consent) may be recommended, if echo cardiography gives evidence for pulmonary hypertension or if it is difficult to differentiate between right and left heart failure. The presence of pulmonary hypertension which is of prognostic relevance has to be considered when grading reduction in earning capacity.For interpretation of spirometry values the new GLI reference values has to be applied. Grading of impairment is due to the recommendation of the DGP.According to current medical scientific knowledge it is unclear, whether certain disorders of the rheumatic group such is scleroderma or Caplan syndrome which are sometimes associated with silicosis (or coal workers' pneumoconiosis) belong in toto to the occupational disease number 4101 (silicosis). Within this context, additional studies are needed to clarify the role of occupational quartz exposure and other risk factors.The guideline working group hopes that this update will help to optimize diagnostics and expert opinion of silicotic patients.

[Asbestos: Social Legal and Scientific Controversies and Unsound Science in the Context with the Worldwide Asbestos Tragedy - Lessions to be Learned]. / Sozialjuristische und wissenschaftliche Kontroversen sowie Fehlinterpretationen im Kontext mit der weltweiten Asbest-Tragödie - Was ist daraus zu lernen?

8 to 15% of lung cancer cases and nearly all mesothelioma cases are caused by asbestos. Problems in compensation issues refer to high legal as well as insurance barriers in attesting the occupational diseases. Claiming of certain numbers of asbestos bodies or fibers in lung tissue is of special relevance in substantiating legal medical cases. Such evidence, which is disproved by a sound science, is also used by an influential US pathology department. Frequently, also epidemiological evidence with its causal relationships and exposure histories are ignored. Similar misleading arguments are currently found in industrializing countries where white asbestos which is carcinogenic and fibrogenic like other asbestos types, is efficiently promoted as less harm. As a result, the asbestos consumption is increasing in some of these countries. Beyond the worldwide asbestos tragedy a well-designed strategy of certain transnational or global acting industrial interest groups can be recognized. Their plan, hidden from the public eyes, follows rigorously sole economic interests, while leaving the resulting health harm to the public health systems.

[Standardization of spirometry: 2015 update. Published by German Atemwegsliga, German Respiratory Society and German Society of Occupational and Environmental Medicine]. / Leitlinie zur Spirometrie. Leitlinie der Deutschen Atemwegsliga, der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin und der Deutschen Gesellschaft für Arbeitsmedizin und Umweltmedizin zur Spirometrie.

Spirometry is a simple test and considered the gold standard in lung function. An obstructive ventilatory defect is a disproportionate reduction of maximal airflow from the lung in relation to the maximal volume that can be displaced from the lung. It implies airway narrowing and is defined by a reduced FEV1/FVC ratio below the 5th percentile of the predicted value (lower limit of normal, LLN). A restrictive disorder may be suspected when vital capacity (FVC) is reduced and FEV1/FVC is normal. It is definitely proven, however, only by a decrease in TLC below the 5th percentile of predicted value (LLN). The measurement of TLC by body plethysmography is necessary to confirm or exclude a restrictive defect or hyperinflation of the lung when FVC is below the LLN. 2012 a task force of the ERS published new reference values based on 74,187 records from healthy non-smoking males and females from 26 countries. The new reference equations for the 3-95 age range are now available that include appropriate age-dependent mean values and lower limits of normal (LLN). This presentation aims at providing the reader with recommendations dealing with standardization and interpretation of spirometry.

[Recommendation of new reference values for spirometry and body plethysmography]. / Empfehlungen aktueller Referenzwerte für die Spirometrie und Ganzkörperplethysmografie.

BACKGROUND AND METHODS: At the end of 2012, after 5 years of work, a task force of the ERS published new reference values for spirometry (mean values and Lower Limits of Normal, LLN) based on available studies, performed according to generally accepted quality criteria. RESULTS AND CONCLUSIONS: So far this is one of the most comprehensive work on reference values in pneumology (more than 74,000 healthy subjects, age range 3 to 95 years). These reference values are approximately 10 % higher (especially in the elderly population) than the still preferentially used ECCS reference values. It is recommended to combine and use them in combination with new reference values for body plethysmography by replacing the ECCS recommendations of 1983/1993 which show discrepancies to lung function data of our today population.

Guidelines for the management of work-related asthma.

Work-related asthma, which includes occupational asthma and work-aggravated asthma, has become one of the most prevalent occupational lung diseases. These guidelines aim to upgrade occupational health standards, contribute importantly to transnational legal harmonisation and reduce the high socio-economic burden caused by this disorder. A systematic literature search related to five key questions was performed: diagnostics; risk factors; outcome of management options; medical screening and surveillance; controlling exposure for primary prevention. Each of the 1,329 retrieved papers was reviewed by two experts, followed by Scottish Intercollegiate Guidelines Network grading, and formulation of statements graded according to the Royal College of General Practitioners' three-star system. Recommendations were made on the basis of the evidence-based statements, which comprise the following major evidence-based strategic points. 1) A comprehensive diagnostic approach considering the individual specific aspects is recommended. 2) Early recognition and diagnosis is necessary for timely and appropriate preventative measures. 3) A stratified medical screening strategy and surveillance programme should be applied to at-risk workers. 4) Whenever possible, removing exposure to the causative agent should be achieved, as it leads to the best health outcome. If this is not possible, reduction is the second best option, whereas respirators are of limited value. 5) Exposure elimination should be the preferred primary prevention approach.

Assessment of three conventional automated external defibrillators in seafaring telemedicine.

BACKGROUND: Germany was the first country worldwide to issue a directive regulating the provision of automated external defibrillators (AEDs) on board merchant ships. AIMS: To test the applicability and suitability for telemedicine in seafaring, including long-term electrocardiogram (ECG) monitoring, of three currently available AEDs. METHODS: Sixty nautical officers were asked to record and transmit a one-lead ECG with one of three AEDs under test. Subsequently, they evaluated the user-friendliness of the devices. RESULTS: The number of steps required for ECG transmission (as a pdf file) varied from three to six between the various AEDs. Correspondingly, differences were found in the subjects' understanding of the AED software. After theoretical instruction in the use of the AEDs, 55 officers (92%) succeeded in telemedical transmission of the pdf file without any help. At the time of our investigation, long-term ECG monitoring was possible with only one of the AEDs. CONCLUSIONS: The study results suggest that most trained lay rescuers can use conventional AEDs effectively for ECG transmission.

[Do advers health effects of chrysotile and amphibole asbestos differ?]. / Gibt es Unterschiede in den gesundheitsschädlichen Wirkungen von Chrysotil- und Amphibol-Asbest?

Due to the current query whether the predominantly used chrysotile (white) asbestos comprises health risks we performed a literature search including in vitro and animal experiments as well as epidemiological studies.As shown by epidemiological studies chrysotile causes less pleural fibrosis and mesotheliomas when compared with other asbestos types. However, its otherwise inflammatory, toxic, carcinogenic, and fibrosis-inducing effects correspond to those of other occupationally relevant asbestos types. This is based on clinical, animal as well as on in-vitro findings. This means that denying a causal relationship, e. g. in a case with lung fibrosis (= asbestosis) or lung cancer with an asbestos load of 25 fiber-years in the absence of identification of a significant concentration of asbestos fibers or asbestos bodies in the lung (see so-called "hit and run" phenomenon), contradicts the medical-scientific knowledge.

Management of occupational asthma: cessation or reduction of exposure? A systematic review of available evidence.

Reduction of exposure to sensitising agents causing occupational asthma has been proposed as an alternative to total avoidance in order to minimise the adverse socio-economic impact of the condition. The aim of this systematic review was to compare the effects of these two management options on asthma and socio-economic outcomes. A bibliographic search was conducted to identify studies examining the outcome of workers with occupational asthma after reduction or cessation of exposure to the causal agent. The changes in asthma symptoms and nonspecific bronchial hyperresponsiveness after reduction or cessation of exposure were described in nine and five studies, respectively. The meta-analysis of pooled data showed that a reduction of exposure was associated with a lower likelihood of improvement (OR 0.16, 95% CI 0.03-0.91) and recovery (OR 0.30, 95% CI 0.11-0.84) of asthma symptoms and a higher risk of worsening of the symptoms (OR 10.23, 95% CI 2.97-35.28) and nonspecific bronchial hyperresponsiveness (OR 5.65, 95% CI 1.11-28.82), compared with complete avoidance of exposure. This systematic review indicates that reduction of exposure cannot be routinely recommended as an alternative to cessation of exposure in the management of occupational asthma. However, further investigations are required before drawing evidence-based conclusions on the cost-effectiveness of this approach.