[Sleep disorders in patients with chronic tinnitus]. / Schlafstörungen bei Patienten mit chronischem Tinnitus.

Tinnitus has a lifetime prevalence of 25% in Germany. A common comorbidity in chronic cases are sleep disorders. The aims of this study were to detect sleep disorders and to identify possible associations with tinnitus parameters.Fifty patients with chronic tinnitus were recruited. The patients underwent audiometry, polysomnography, and completed standardised questionnaires on tinnitus and sleep behaviour.Data were available in 30 men and 9 women (age 50.2 ± 11 y, BMI 28.8 ± 4.4 kg/m²). The median duration of tinnitus was 36 (9; 120) months with a severity score of 2.00 (1.00; 3.00). The mean Tinnitus Questionnaire (TF) score was 43.6 ± 17.1, the Epworth Sleepiness Scale (ESS) score was 8.41 ± 4.27, the Pittsburgh Sleep Quality Index (PSQI) score was 9.21 ± 4.32, and the Screening Scale for Chronic Stress (SSCS) score was 58.13 ± 9.58.Sleep diagnoses included 18 cases of insomnia, 4 cases of RLS, and 11 cases of OSA. Patients with sleep comorbidities showed higher tinnitus severity, PSQI scores, and body weight compared to those without sleep disorders.Worse sleep quality was associated with higher tinnitus severity (p=0.038) and more disruptive tinnitus (p=0.03). Patients with subjectively highly disruptive tinnitus reported higher chronic stress scores. Tinnitus duration was correlated with OSA-severity (p=0.026).More than two-thirds of tinnitus patients showed sleep disorders as comorbidity. A sleep screening appears useful in cases of increased tinnitus severity. Whether CPAP therapy is helpful in reducing tinnitus symptoms could not be conclusively determined but deserves further attention.

[From "processing" and "fermentation" to oxidative metabolism]. / Über "Kochung" und "Gärung" zum oxidativen Stoffwechsel.

The theory of the four humors or humorism (Hippocrates of Kos) viewed disease as an imbalance of the humors. Galen of Pergamon further developed the theory by describing digestion as a sequence of chemical reduction processes that convert into the various humours. Theophrastus von Hohenheim attempted to overcome humorism in the 16th century and establish medicine on a natural-philosophical-alchemical basis. The era of empirical-experimental chemically oriented medicine began with "iatrochemistry" in the 17th century. Franciscus Sylvius' concept of disease is based on an imbalance of acidic and alkaline fermentation. It was Lazarro Spallanzani who understood the digestive processes in the stomach as a chemical dissolution of food. The discovery of oxygen and the process of oxidation by Lavoisier laid the foundation for our understanding the physiology of metabolism.

[The search for the "node of life": breathing regulation]. / Die Suche nach dem "Knoten des Lebens" ­ die Atemregulation.

The article provides a historical overview of developments in the understanding of respiratory rhythm and its control mechanisms over the last two centuries. In the 19th century, a structure in the medulla oblongata was first described as the "node of life". In 1743, Taube discovered the carotid body, and in 1927 the Spaniard de Castro described its morphology and innervation. It was only with the work of father and son Heymans that the physiological and pharmacological significance of the carotid and aortic body was recognized. Today we understand that the generation and control of respiration are mediated by a complex neuronal network in the brainstem. Chemo-, mechano- and proprioreceptos convey information from blood, airways and muscles to the control centre. The respiratory centre integrates the afferent input from the receptors, the autonomic nervous system, the cardiovascular system, and voluntary input from the cerebral cortex to modulate the degree of respiratory activation of motoneurons and respiratory muscles.

[Valsalva and Müller maneuvers: who is who and what is what?] / Valsalva- und Müller-Manöver: Wer ist wer und was ist was?

The original Valsalva manoeuvre (VM) was described in detail by the Italian anatomist, physician and surgeon Antonio Maria Valsalva (1666-1723). The VM consists of a voluntary forced expiratory effort against a closed upper airway. It was used tradionally in otolaryngology for testing the openess of the eustachian tubes and expelling pus/fluid from the middle to the external ear. VM is associated with increased intrathoracic and -abdominal pressure and leads to hemodynamic changes. The use of VM for cardiovascular purposes was first described by Eduard Friedrich Weber, a German physiologist. The Müller manoeuvre (MM) represents the opposite of the VM by forced inspiration against a closed upper airway. Negative intrathoracic and abdominal pressure (ITP) with direct effects on cardiac function and hemodynamics can be generated by the MM. MM has also been used to simulate the hemodynamic effects of negative ITP in obstructive sleep apnea patients. The Müller manoeuvre was first described by the German anatomist and physician Johannes Müller (1801-1858).

[The upper airway in obstructive sleep apnea patients is pathological even when awake]. / Der obere Atemweg bei OSA-Patienten ist auch im Wachzustand pathologisch.

Obstructive sleep apnea (OSA) is characterized by partial or complete obstruction of the pharyngeal airway. Anatomical factors can be distinguished from non-anatomical factors. Age and obesity are the main risk factors for OSA; however, approximately 50% of patients are not obese. In older patients (>60 years), the importance of obesity decreases. There is an increased prevalence of OSA among patients with normal weight. The effects of chronic intermittent hypoxemia, low-grade inflammation, increased sympathetic tone and mechanical stress contribute to a transformation of muscle fibers in the upper airway, resulting in reduced muscle mass and strength. Less frequently encountered non-anatomical factors include decreased muscle tone, increased arousal threshold, and altered sensitivity of CO2 chemoreceptors.

Chronic cough in postmenopausal women and its associations to climacteric symptoms.

BACKGROUND: Postmenopausal women often have chronic cough. Hormonal changes might be affecting lung function and the mucous membrane of the airways, causing hypersensitivity of the cough reflex. Therefore, postmenopausal hormonal changes could play a key role in the association between increased cough and menopause. The aim of this study is to evaluate the relation of chronic cough and postmenopausal symptoms. METHODS: We performed a questionnaire-based cohort study in generally healthy postmenopausal women (age 45-65 years). Women with cough explained by a pre-existing diagnosis were excluded. Comorbidities, medication and baseline data were collected. The Menopause Rating Scale II (MRS II) was combined with the Leicester Cough Questionnaire. Groups were divided in chronic cough versus non-coughing participants, chronic cough was defined as symptoms over 8 weeks. We performed correlations and logistic regression for predicting cough based on postmenopausal symptoms. RESULTS: Sixty-six of 200 women (33%) reported symptoms of chronic cough over 8 weeks. No significant differences in baseline data (age, BMI, onset of menopause, years since menopause, concomitant diseases, and medication) were found between coughing and non-coughing women. The MRS II showed higher menopausal symptoms in patients with cough, with significant differences in 2 of the 3 MRS-domains (urogenital (p < 0.001) and somato-vegetative (p < 0.001)). Climacteric symptoms correlated strongly with parameters of cough (p < 0.001). On the basis of the MRS total score (p < 0.001) and the somato-vegetative and urogenital domains (p < 0.05), the prediction for respiratory complaints could be shown. DISCUSSION: Chronic cough was significantly associated with menopausal symptoms. Therefore chronic cough as a possible climacteric symptom and its underlying mechanisms should be further explored.

[Adherence to CPAP Three Months after Starting Therapy in 1078 Patients with Obstructive Sleep Apnea (OSA)]. / Therapieadhärenz drei Monate nach Einleitung einer nichtinvasiven CPAP-Therapie bei 1078 Patienten mit obstruktiver Schlafapnoe (OSA).

INTRODUCTION: Nocturnal Continuous Positive Airway Pressure (CPAP) is considered the gold standard treatment for obstructive sleep apnoea (OSA). The CPAP therapy is a long-term treatment but does come with few possible side effects. The adherence to the therapy is frequently suboptimal. In this paper, adherence to therapy was assessed and typical problems were classified. METHODS: 1078 OSA patients received CPAP therapy after a diagnostic polygraphy (PG) or polysomnography (PSG). Adherence to therapy was followed up three months after treatment induction. The following therapy adherence groups were defined: 1. correctly calibrated CPAP and good adherence, 2. CPAP non-acceptance, after initial use, 3. CPAP intolerance use due to side effects, 4. discontinuation due to lack of motivation/low rates of symptoms. 5. mask intolerance, 6. CPAP failure due to a lack of perceived treatment effect, 7. Change to another non-invasive ventilation method, 8. No control carried out. RESULTS: Out of 1078 OSA patients a therapy control was performed in 830 patients (77%). Of these, 450 patients (54.2%) were placed in group 1, 216 patients (26 %) in group 2, 71 patients (8.5 %) in group 3, 35 patients (4.2 %) in group 4, 14 patients (1.7 %) in group 5, 3 patients (0.4 %) in group 6 and 41 patients (4.9%) in group 7. A mild obstructive index, low CPAP pressure and, as a trend, a low Epworth-Sleepiness score were predictors of CPAP failure. No significant predictors could be shown for adherence to therapy. DISCUSSION: An effective treatment use of 54% after 3 months is a suboptimal result. Predictors of CPAP failure were parameters that indicated that the patient was less symptomatic prior to therapy. Despite a large patient cohort, neither anthropometric nor PSG-data provided any significant CPAP adherence predictors. Rather, experiences in the first nights of use could be decisive. CPAP devices offer comfort settings that have to be personalised to patients' needs and wants. A large selection of different mask shapes requires experience and training in patient-centred mask fitting. A three-month follow-up appointment seems too long to discuss therapy problems with the patient in a timely manner. Telemedical options or short-term telephone appointments should be considered.

[Analysis of Snoring in Patients with Obstructive Sleep Apnea (OSA) by Polysomnography and LEOSound]. / Die Analyse von Schnarchen bei Patienten mit obstruktiver Schlafapnoe (OSA) anhand von Polysomnographie und LEOSound.

INTRODUCTION: Snoring was monitored in patients with obstructive sleep apnea (OSA) using the LEOSound-Monitor and simultaneously polysomnographic (PSG) recording. In obstructive apneas snoring is normally apparent after apnea termination and the beginning of ventilation. We wanted to know how often obstructive apneas are terminated by ventilation in combination with snoring. METHODS AND INTENTION: In 40 patients with OSA (AHI > 15/h) simultaneous polysomnographic recordings were performed amongst long-term respiratory sound monitoring using the LEOSound monitor. Patients' average age was 57±11 years. Average weight was 100±19 kg by a mean body mass index (BMI) of 33±7 kg/m2. 12 out of 40 recordings had to be rejected for further analysis because of artifacts. Snoring recorded by polysomnography was compared with snoring monitored by LEOSound. RESULTS: 3778 obstructive apnea episodes were monitored. LEOSound identified snoring in 1921 (51,0%), polysomnography in 2229 (58,8%) obstructive apneas. Only in one patient there was a higher difference in snoring episodes between PSG and LEOSound. DISCUSSION: In nearly 60% of obstructive apnea events we found snoring during apnea-terminating hyperpnoea. LEOSound is a good diagnostic tool to monitor snoring. It is necessary to clarify why only 60% of all obstructive events/hyperpnoea develop snoring. From a pathophysiological point of view opening of collapsed upper airway should lead in a very high percentage to turbulences in airstream and committed snoring.

[In commemoration of Adolf Kussmaul's 200th birthday: Describer of the Kussmaul Breathing and pioneer of endoscopy]. / Zum 200. Geburtstag von Adolf Kussmaul (1822­1902): Beschreiber der Kussmaul-Atmung und Wegbereiter der Endoskopie.

Adolf Kussmaul (1822-1902) studied medicine in Heidelberg. The name Kussmaul is known worldwide for the panarteritis nodosa, the pulsus paradoxus and the venous pulse in callous mediastinopericarditis as well as the high-frequency and deep breathing in diabetic ketoacidosis. Kussmaul was also a pioneer in the endoscopic diagnosis and treatment of diseases of the oesophagus and stomach. He had to close the medical practice he had started in 1850 in the black Forrest town of Kandern after three years, having developed health problems. Kussmaul's approach to his studies was clinical-scientific. In 1855, under the guidance of Virchow, he received his doctorate from the university of Würzburg. From 1859-1888 he held a chair in Erlangen, Freiburg and Strasbourg. He continued working as a physician after retirement at Heidelberg and wrote his memoirs "Jugenderinnerungen eines alten Arztes".

[Negative-pressure pulmonary edema and alveolar hemorrhage are potentially life-threatening complications of upper airway obstruction]. / "Negativdruck-Lungenödem" und "alveoläre Hämorrhagie" als Komplikationen einer oberen Atemwegsobstruktion.

Negative pressure pulmonary edema and alveolar hemorrhage are potentially life-threatening complications after relief of upper airway obstruction. The laryngeal-pharyngeal obstruction results in high negative intrapleural pressures. The increased intrapleural pressures affect the integrity of the alveolo-capillary membrane due to various factors. This review describes clinical symptoms, etiologic factors, pathophysiology and treatment strategies associated with each of these factors. The aim of this review is to equip clinicians with the knowledge base necessary to identify patients at increased risk for negative pressure pulmonary edema and alveolar hemorrhage.

[Why you should know the "nose cycle" as a pneumologist and sleep medicine specialist]. / Warum man auch als Pneumologe und Schlafmediziner den "Nasenzyklus" kennen sollte.

The nasal cycle refers to the anticyclic swelling and decongestion of the two nasal cavities that occur during the day and during sleep, while the overall nasal flow remains constant. The nasal cycle was first described by R. Kayser in 1895. Each cycle consists of a working phase and a subsequent resting phase, the purpose of which is the rehydration and regeneration of the mucosa. A nasal cycle occurs in about 70-90% of people. The duration of the phase is affected by age, body position, physical activity, mucociliary clearance and time of day. Typically, the cycle lengthens during sleep. Long-term rhinoflowmetry enables assessment of the circadian course of the alternating cyclic changes of the nasal mucosa.

Predisposing factors of daytime sleepiness in obese OSA patients.

Excessive daytime sleepiness is a common symptom in obese patients with obstructive sleep apnea. We investigated predisposing factors of excessive daytime sleepiness by comparing obese non-sleepy with sleepy patients with obstructive sleep apnea. Excessive daytime sleepiness was determined by the Epworth Sleepiness Scale in 43 patients (34 men and 9 women) with obstructive sleep apnea (apnea-hypopnea index ≥ 15 events per hr) and obesity (body mass index ≥ 30 kg m-2 ). Two subgroups were formed with (Epworth Sleepiness Scale ≥ 11) and without (Epworth Sleepiness Scale < 11) excessive daytime sleepiness. The concept of excessive daytime sleepiness was compared with other established daytime performance tests (Stanford Sleepiness Scale, Multiple Sleep Latency Test, Pupillographic Sleepiness Test, Marburger Vigilance test). Associations were calculated between excessive daytime sleepiness and demographic, metabolic and polysomnographic data. We included 19 sleepy patients (mean Epworth Sleepiness Scale score 15.2) and 24 non-sleepy patients (mean Epworth Sleepiness Scale score 5.8). Epworth Sleepiness Scale was negatively correlated with age and morning cortisol. Epworth Sleepiness Scale was positively correlated with body mass index, Stanford Sleepiness Scale, Beck's Depression Inventory and Marburger Vigilance test. Sleepy obese patients were significantly younger (mean 49.1 years), showed lower morning cortisol level (mean 9.41 µg L-1 ) and a trend to higher body mass index (mean 37.5 kg m- ²) compared with non-sleepy obese patients (mean: 59.3 years, 5.7 µg L-1 , 34.6 kg m- ², respectively). Many different excessive daytime sleepiness phenotypes are probably enclosed in obese patients with obstructive sleep apnea. Epworth Sleepiness Scale scores were best reflected by the objective Marburger Vigilance test results. The objective test can be particularly useful in cohorts where subjective reports are unreliable and operational readiness is paramount. Sleepy and non-sleepy obese patients with obstructive sleep apnea were similar in all polysomnographic parameters. Sleepy patients were younger, heavier and showed lower morning cortisol levels than non-sleepy patients.

[The Road to Discovery of the Pulmonary Gas Exchange - From the "Phlogiston-" to the "Oxygen Theory"]. / Der Weg zur Entdeckung des pulmonalen Gasaustausches.

The discovery of oxygen and pulmonary gas exchange was a major advancement in our understanding of breathing. For centuries it was believed that the lungs were primarily necessary to cool the heart or to "refine" the blood. Richard Lower (1631-1691) observed that the blood had a different colour before and after passage through the lung. His assumption was that breathing must have been added a special substance to the blood. Georg Ernst Stahl (1660-1734) formulated a fire substance "phlogiston" (phlox = flame) with his phlogiston theory. He postulated that phlogiston is contained in all combustible substances and escapes when burned. John Mayow (1641-1679) recognised that about one fifth of the breathing gas is important for the breathing process. He called the gas "spiritus nitro aerius". Oxygen was first discovered in the early 1770 s by the Swedish-German pharmacist Carl Wilhelm Scheele (1742-1786) and the English chemist Joseph Priestley (1733-1804) - independently of each other. Antoine-Laurent Lavoisier (1743-1794) recognised oxygen as element and for the first time described the oxidation process accurately.

[The bronchial arteries: a small but vital contribution to lung perfusion after lung transplantation]. / Die Bronchialarterien ­ ein kleiner, aber lebenswichtiger Beitrag zur Lungenperfusion nach Lungentransplantation.

Blood supply to the lungs is carried out by the pulmonary and bronchial-arterial system. The bronchial-arterial vessels are involved in supplying the small airways all the way up to the terminal bronchioles. The bronchial-arterial system is also necessary for the regulation of airway temperature, humidity and mucociliary clearance. Chronic ischaemia of the small airways due to damage or injury to bronchial arterial supply increases the risk of fibrosis of the small airways (bronchiolitis obliteration), especially in lung transplantation (LTx). Although survival after LTx has improved over time, it is, with a 5-year survival rate of only 50 to 60%, still significantly worse than that of other organ transplants. It is likely that bronchial arterial revascularisation at the time of LTx plays an important transplant-preserving function.

[Adherence to CPAP Three Months after Starting Therapy in 1078 Patients with Obstructive Sleep Apnea (OSA)]. / Therapieadhärenz 3 Monate nach Einleitung einer nichtinvasiven CPAP-Therapie bei 1078 Patienten mit obstruktiver Schlafapnoe (OSA).

INTRODUCTION: Nocturnal Continuous Positive Airway Pressure (CPAP) is considered the gold standard treatment for obstructive sleep apnoea (OSA). The CPAP therapy is a long-term treatment but does come with few possible side effects. The adherence to the therapy is frequently suboptimal. In this paper, adherence to therapy was assessed and typical problems were classified. METHODS: 1078 OSA patients received CPAP therapy after a diagnostic polygraphy (PG) or polysomnography (PSG). Adherence to therapy was followed up three months after treatment induction. The following therapy adherence groups were defined: 1. correctly calibrated CPAP and good adherence, 2. CPAP non-acceptance, after initial use, 3. CPAP intolerance use due to side effects, 4. discontinuation due to lack of motivation/low rates of symptoms. 5. mask intolerance, 6. CPAP failure due to a lack of perceived treatment effect, 7. Change to another non-invasive ventilation method, 8. No control carried out. RESULTS: Out of 1078 OSA patients a therapy control was performed in 830 patients (77 %). Of these, 450 patients (54.2 %) were placed in group 1, 216 patients (26 %) in group 2, 71 patients (8.5 %) in group 3, 35 patients (4.2 %) in group 4, 14 patients (1.7 %) in group 5, 3 patients (0.4 %) in group 6 and 41 patients (4.9 %) in group 7. A mild obstructive index, low CPAP pressure and, as a trend, a low Epworth- Sleepiness score were predictors of CPAP failure. No significant predictors could be shown for adherence to therapy. DISCUSSION: An effective treatment use of 54 % after 3 months is a suboptimal result. Predictors of CPAP failure were parameters that indicated that the patient was less symptomatic prior to therapy. Despite a large patient cohort, neither anthropometric nor PSG-data provided any significant CPAP adherence predictors. Rather, experiences in the first nights of use could be decisive. CPAP devices offer comfort settings that have to be personalised to patients' needs and wants. A large selection of different mask shapes requires experience and training in patient-centred mask fitting. A three-month follow-up appointment seems too long to discuss therapy problems with the patient in a timely manner. Telemedical options or short-term telephone appointments should be considered.

[Recurrent Pulmonary Hemorrhages with Hemoptysis as a Result of Vocal Cord Dysfunction (VCD) - An Attempt to Explain]. / Rezidivierende pulmonale Hämorrhagien mit Hämoptoe als Folge einer Vocal Cord Dysfunction (VCD) ­ ein Erklärungsversuch.

We present the case of an otherwise healthy 19-year-old student who has been affected by vocal cord dysfuntion (VCD) since she is fourteen. 3 years after that diagnosis she has also been coughing blood at an increasing rate (1-3 times per week). We postulate that the haemoptoe is the result of breathing against a closed airway which can lead to excessively high negative intrathoracic pressures. Which, in turn, rapture alveolar capillaries. After bilateral injection of Botulinum toxin injection into the muscles vocalis, VCD as well as haemoptoe episodes ceased for three months.

[Historical (cultural) view of the heart and cardiovascular system]. / Herz und Herz-Kreislauf-System in der (kultur-)historischen Betrachtung.

Who discovered the cardiovascular and capillary systems? When students in advanced semesters are asked about historical matters that have decisively influenced the path to present day medicine, as a rule no answer or a false answer is forthcoming. Whoever wants to understand scientific thinking and action, cannot do better than to grapple with the historical and cultural developments in medicine; however, more than any other science the natural sciences and medicine provide evidence that new ways and knowledge must be consistently sought for the benefit of patients. The aim of this article is to make a contribution to remembering how the cardiovascular system was discovered and the cultural and historical importance of the heart. Last but not least, however, the article aims to convey the impression of the huge personal sacrifice, including one's own life, and the stony path which led to the acquisition of this knowledge.

[From the anatomical teaching dissection to tuition at the bedside-A historical appraisal]. / Von der anatomischen Lehrsektion zum Unterricht am Krankenbett ­ eine geschichtliche Würdigung.

At all times anatomists endeavored to procure scientific foundations for medicine. The anatomist dissected corpses in order to serve the living. The knowledge of anatomy is a prerequisite for the understanding of physiological and pathophysiological processes. In the "Hippocratic corpus" there is no clear reference to the performance of human autopsies. Anatomy was taught on a human corpse for the first time in Alexandria around 300 B.C. For more than 1300 years anatomy and medicine then stood under the influence of Galen of Pergamon (131-201 A.D.). The Italian Mondino dei Luzzi (1275-1326) was the first to introduce systematic anatomy lessons with a regular inclusion of teaching dissections in the teaching curriculum in Bologna. Andreas Vesalius (1514-1564) from Belgium founded the scientifically based human anatomy during the modern era and corrected many errors in the traditional views on anatomy of Galen. In the seventeenth and eighteenth centuries the Dutch universities, particularly the University of Leiden, were the leaders with respect to the clinical and practical student training.

Time course of nocturnal cough and wheezing in children with acute bronchitis monitored by lung sound analysis.

Cough and wheezing are the predominant symptoms of acute bronchitis. Hitherto, the evaluation of respiratory symptoms was limited to subjective methods such as questionnaires. The main objective of this study was to objectively determine the time course of cough and wheezing in children with acute bronchitis. The impact of nocturnal cough on parent's quality of life was assessed as secondary outcome. In 36 children (2-8 years), the frequency of nocturnal cough and wheezing was recorded during three nights by automated lung sound monitoring. Additionally, parents completed symptom logs, i.e., the Bronchitis Severity Score (BSS), as well as the Parent-proxy Children's Acute Cough-specific Quality of Life Questionnaire (PAC-QoL). During the first night, patients had 34.4 ± 52.3 (mean ± SD) cough epochs, which were significantly reduced in night 5 (13.5 ± 26.5; p < 0.001) and night 9 (12.8 ± 28.1; p < 0.001). Twenty-two patients had concomitant wheezing, which declined within the observation period as well. All subjective parameters (BSS, Cough log and PAC-QoL) were found to be significantly correlated with the objectively assessed cough parameters.Conclusion: Long-term recording of cough and wheezing offers a useful opportunity to objectively evaluate the time course of respiratory symptoms in children with acute bronchitis. To assess putative effects of pharmacotherapy on nocturnal bronchitis symptoms, future studies in more homogeneous patient groups are needed. What is Known: • Cough and wheezing are the predominant symptoms of acute bronchitis. • There is a diagnostic gap in long-term assessment of these respiratory symptoms, which needs to be closed to optimize individual therapies. What is New: • Long-term recording of nocturnal cough and wheezing allows for objective evaluation of respiratory symptoms in children with acute bronchitis and provides a tool to validate the efficacy of symptomatic bronchitis therapies.