Safety and efficacy of bleomycin/pingyangmycin-containing chemotherapy regimens for malignant germ cell tumor patients in the female genital system.

OBJECTIVES: To comprehensively evaluate the safety and effectiveness of bleomycin/pingyangmycin-containing chemotherapy for female patients with malignant germ cell tumors in their genital system; to assess the diagnostic value of pulmonary function tests for bleomycin-induced pulmonary toxicity. METHODS: Data from a cohort of 120 patients, collected across 25 years, was reviewed. Chemotherapy-related adverse events were routinely monitored. Pulmonary toxicity was diagnosed and graded according to serial pulmonary function testing results, and potential impact factors were explored. Short-term remission probability and long-term prognosis were evaluated. RESULTS: Overall, 49.2% of the patients had pulmonary dysfunction, and the majority manifested as diffusion function impairment. A moderate reduction of carbon monoxide diffusion capacity was detected in 45.0% of all patients, and was severe in 3 patients. Thrombocytopenia, renal dysfunction, and accumulating dose of bleomycin/pingyangmycin significantly increased the risk of lung injury (P<0.05). Thorough surgical removal of tumors enhanced both remission and survival rate. Full-dose delivery of bleomycin/pingyangmycin and patients' sensitivity to chemotherapy also improved long-term survival (P<0.05). CONCLUSIONS: BPT could be sensitively detected and elaborately graded by PFTs, but the appropriate cut-off value for diagnosis needs further investigations. Timely recognition and control of renal dysfunction and thrombocytopenia could avail the patients of the opportunity to complete curative antineopalstic treatment. Prescriptive bleomycin/pingyangmycin-containing chemotherapy after optimal surgical resection could benefit MGCT patients maximally by improving both remission and survival rate.

Tailored therapy and long-term surveillance of malignant germ cell tumors in the female genital system: 10-year experience.

OBJECTIVE: To explore the appropriate treatment of malignant germ cell tumor (MGCT) in the female genital system, and to analyze the factors influencing both therapeutic response and survival outcome. METHODS: A cohort of 230-Chinese women diagnosed with MGCT of the genital system was retrospectively reviewed and prospectively followed. The demographic and pathological features, extent of disease and surgery, treatment efficiency, recurrence and survival were analyzed. RESULTS: MGCTs from different genital origins shared a similar therapeutic strategy and response, except that all eight vaginal cases were infantile yolk sac tumors. The patients' cure rate following the initial treatment, 5-year overall survival and disease-free survival (DFS) were 85.02%, 95.00%, and 86.00%, respectively. Although more extensive excision could enhance the remission rate; it did not improve the patients' survival. Instead, the level of the medical institution, extent of surgery and disease were independent prognostic factors for relapse (p<0.05). Approximately 20% of patients had recurrent or refractory disease, more than half of whom were in remission following secondary cytoreductive surgery with salvage chemotherapy. CONCLUSION: Fertility-sparing surgery with or without standardized PEB/PVB (cisplatin, etoposide/vincristine, and bleomycin) chemotherapy is applicable for female MGCTs of different origins. Comprehensive staging is not required; nor is excessive debulking suggested. Appropriate cytoreduction by surgery and antineoplastic medicine at an experienced medical institution can bring about an excellent prognosis for these patients.

Breathlessness or health status in chronic obstructive pulmonary disease: the impact of different definitions.

OBJECTIVE: The GOLD 2011 report recommends the use of symptoms, exacerbation history, and FEV1% predicted to categorise patients into groups A-D. We investigated the choice of mMRC or CAT on category assignment and characterization of the categories. METHODS: Patients were prospectively recruited from tertiary hospitals in China, as part of the INTACT study, with a prior diagnosis of COPD. The GOLD categories were defined using mMRC and CAT, along with exacerbations in the previous year, and FEV1% predicted. RESULTS: 1,465 patients were included. The most prevalent group was group D. However, proportions of patients categorised into groups A to D differed depending on symptom instruments. The use of CAT resulted in more patients being placed into groups B and D. Cardiac co-morbid conditions, particularly ischaemic heart disease, heart failure, and arrhythmia were highly prevalent in groups B and D. Group B appeared to have a similar burden of cardiac co-morbidities to group D, in spite of a higher FEV1 level. Although mMRC assigned a smaller proportion of patients to groups B and D, the patients it did assign had a higher burden of cardiac co-morbidities than patients assigned by CAT. When patients were assessed according to LLN, 14.2% had normal airflow according to ECSC 1993 equations, with 12.6% having normal airflow according to GLI 2012 formulae. CONCLUSIONS: The choice of symptom assessment is one potential confounder impacting the patient assignment. Breathlessness may be an important marker of overall disease severity, indicating the presence of cardiac co-morbidities in the GOLD categories.

Indacaterol on dyspnea in chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized placebo-controlled trials.

BACKGROUND: Indacaterol is a novel, once-daily (od), inhaled, long-acting ß(2)-agonist bronchodilator for maintenance treatment of airflow limitation in patients with COPD. The aim of this study was to evaluate the efficacy of indacaterol on dyspnea, using available randomized placebo-controlled trials. METHODS: A systematic search was made of MEDLINE, EMBASE, the Cochrane trials databases, and a manual search of journals. Randomized placebo-controlled trials of 12 weeks or more comparing indacaterol with placebo were reviewed, and eligible studies were included in a meta-analysis. The odds ratio (OR) for likelihood of achieving TDI score ≥ 1 after 12 weeks of treatment was used as an outcome measure to compare indacaterol to placebo. RESULTS: Six trials were included in the analysis. Relative to placebo, the overall ORs for response were: indacaterol 75 µg od 1.784 (95% CI 1.282 to 2.482); indacaterol 150 µg od 2.149 (95% CI 1.746 to 2.645); and indacaterol 300 µg od 2.458 (95% CI 2.010 to 3.006). Overall OR for response in TDI tended to increase with higher indacaterol doses. CONCLUSIONS: Patients receiving indacaterol had clinically significant improvements in symptoms of dyspnea compared to placebo. Incremental benefits in TDI were observed with increasing doses. Indacaterol may provide patients and physicians with a useful treatment option in symptomatic patients with dyspnea.

Multiple dimensions of cardiopulmonary dyspnea.

BACKGROUND: The current theory of dyspnea perception presumes a multidimensional conception of dyspnea. However, its validity in patients with cardiopulmonary dyspnea has not been investigated. METHODS: A respiratory symptom checklist incorporating spontaneously reported descriptors of sensory experiences of breathing discomfort, affective aspects, and behavioral items was administered to 396 patients with asthma, chronic obstructive pulmonary disease (COPD), diffuse parenchymal lung disease, pulmonary vascular disease, chronic heart failure, and medically unexplained dyspnea. Symptom factors measuring different qualitative components of dyspnea were derived by a principal component analysis. The separation of patient groups was achieved by a variance analysis on symptom factors. RESULTS: Seven factors appeared to measure three dimensions of dyspnea: sensory (difficulty breathing and phase of respiration, depth and frequency of breathing, urge to breathe, wheeze), affective (chest tightness, anxiety), and behavioral (refraining from physical activity) dimensions. Difficulty breathing and phase of respiration occurred more often in COPD, followed by asthma (R(2) = 0.12). Urge to breathe was unique for patients with medically unexplained dyspnea (R(2) = 0.12). Wheeze occurred most frequently in asthma, followed by COPD and heart failure (R(2) = 0.17). Chest tightness was specifically linked to medically unexplained dyspnea and asthma (R(2) = 0.04). Anxiety characterized medically unexplained dyspnea (R(2) = 0.08). Refraining from physical activity appeared more often in heart failure, pulmonary vascular disease, and COPD (R(2) = 0.15). CONCLUSIONS: Three dimensions with seven qualitative components of dyspnea appeared in cardiopulmonary disease and the components under each dimension allowed separation of different patient groups. These findings may serve as a validation on the multiple dimensions of cardiopulmonary dyspnea.

Validation of the Chinese version of the Functional Performance Inventory Short Form in patients with chronic obstructive pulmonary disease.

AIMS AND OBJECTIVE: To determine the reliability and validity of the Chinese version of the Functional Performance Inventory Short Form (FPI-SF-C) in patients with chronic obstructive pulmonary disease in Beijing, China. BACKGROUND: The Functional Performance Inventory Short Form (FPI-SF) is a 32-item instrument designed to measure self-reported functional performance of patients with chronic obstructive pulmonary disease. This instrument had not been translated into Mandarin Chinese and tested for use in mainland China. DESIGN: Cross-sectional validation study with a two-week test of reproducibility. METHOD: The FPI-SF was translated using forward and backward translation procedures and administered to 108 stable chronic obstructive pulmonary disease patients from outpatient clinics of three hospitals in Beijing, China. Pulmonary function and six-minute walking distance (6-MWD) tests were performed on the same day or within one week before the FPI-SF-C completion. Thirty of the patients participated in the reproducibility assessment. RESULTS: Cronbach's alpha for the FPI-SF-C total score was 0·89; subscales ranged from 0·70 (Body Care)-0·89 (Spiritual activities). Test-retest reliability (intraclass correlation coefficient) was 0·93 with subscales ranging from 0·73 (Body Care)-0·96 (Household Maintenance). No ceiling or floor effects were observed for total FPI-SF-C score. Total scores correlated significantly (p<0·05) with 6-MWD (r=0·56), modified Medical Research Council Dyspnoea Scale (MMRC) (r=-0·55), BODE index (r=-0·47), forced expiratory volume in one second (FEV(1)) (r=0·41) and FEV(1) % of predicted (r=0·26) and differentiated patients based on GOLD rating of COPD severity (χ(2)=16·22, p<0·001). CONCLUSIONS: Results suggest the FPI-SF-C is a reliable and valid instrument for measuring functional performance in mainland Chinese patients with chronic obstructive pulmonary disease. Further psychometric testing in a wide range of subjects and an evaluation of its utility in clinical practice are warranted. RELEVANCE TO PRACTICE: The FPI-SF-C may be useful for understanding difficulties in functional performance and evaluating the effect of treatment in Chinese patients with chronic obstructive pulmonary disease.

Scoliosis on pulmonary function / 中国医学科学院学报

Scoliosis is a common disease in children that causes deformity of spine and thoracic cage. The deformity not only affects the appearance, but also leads to irreversible impairment of lung function and respiratory failure in severe cases. This systematic review on publications over past 50 years demonstrates that scoliosis impairs growth and development of lungs, limits chest wall movement, and results in restrictive ventilation defect and gas exchange dysfunction. Respiratory failure occurs primarily in early-onset scoliosis and/or during latter half of gestation. Surgery corrects deformity and may slow down its progression. However, invasive procedure itself impairs lung function. Non invasive procedures prevent the deterioration of lung function rather than promoting growth and development of lungs. As a consequence, reserve of pulmonary function is recommended when surgical intervention is considered.

Spinal factors affecting pulmonary function in patients with scoliosis / 中国医学科学院学报

<p><b>OBJECTIVE</b>To investigate pulmonary function impairment and the spinal factors that may determine pulmonary function in patients with scoliosis.</p><p><b>METHODS</b>Seventy-eight patients with idiopathic scoliosis or congenital scoliosis and 78 age- and gender-matched healthy subjects were enrolled in this study. The radiographic parameters of spinal deformity were obtained from patients with scoliosis. Both two groups received pulmonary function tests.</p><p><b>RESULTS</b>Patients with scoliosis demonstrated a restrictive pattern of pulmonary function impairment with a proportional decrease in both forced expiratory volume in one second and forced vital capacity. Total lung capacity and functional residual capacity were reduced. Carbon monoxide diffusion capacity was decreased, while diffusion coefficient remained normal or slightly higher. Airway resistance and conductance were not affected. In addition, airway resistance and residual volume were found abnormal in patients with congenital scoliosis. Multiple linear regression analysis showed that three spinal factors including involved thoracic vertebrae, vertical height from C7 to S1, and Cobb angle were independently responsible for 40%-51% of total variances of forced vital capacity, forced expiratory volume in one second, total lung capacity, and functional residual capacity.</p><p><b>CONCLUSIONS</b>Patients with scoliosis have restrictive ventilation defects. More thoracic vertebrae involvement, lower vertical height, and larger Cobb angle are associated with severer impairment of lung volume.</p>

[Reliability and validity of modified pulmonary functional status and dyspnea questionnaire in Chinese patients with chronic obstructive pulmonary disease].

OBJECTIVE: To determine the reliability and validity of the modified pulmonary functional status and dyspnea questionnaire (PFSDQ-M) Chinese version in patients with chronic obstructive pulmonary disease (COPD) at 2 hospitals in Beijing, China. METHODS: PFSDQ-M has three domains, i.e., change experienced by patient with activities or activity restriction (CA), dyspnea with activities (DA) and fatigue with activities (FA). Sixty-one patients with COPD in stable condition were assessed by interview with PFSDQ-M Chinese version, modified Medical Research Council dyspnea scale (MMRC), respectively, and underwent pulmonary function test (PFT) and 6-minute walking test (6MWT) on the same day or within one week before interview. RESULTS: Cronbach's alpha was 0.84, 0.85 and 0.89 for domains of CA, DA and FA of the PFSDQ-M, respectively. Scores of change in activities, dyspnea and fatigue with activities in patients of COPD correlated to their 6-minute walking distance (r = -0.39 to -0.50), FEV(1) (r = -0.28 to -0.36), FEV(1)/FVC (r = -0.27 to -0.37), FEV(1)% of predicted (r = -0.27 to -0.37), dyspnea score in MMRC (r = 0.59 to 0.66) and BODE index (r = 0.40 to 0.51), respectively (all P < 0.01). Degrees of restriction of activity, dyspnea and fatigue with activities varied significantly in patients with different severity of COPD (chi(2) = 7.35 to 15.21, P < 0.05, P < 0.01, respectively). CONCLUSIONS: Results of 61 patients with COPD interviewed with PFSDQ-M Chinese version suggest its good reliability and validity in discriminating patients with COPD of varied severity and stages.

Effect of ventilator circuit changes on ventilator-associated pneumonia: a systematic review and meta-analysis.

BACKGROUND: Recent guidelines concerning prevention of ventilator-associated pneumonia recommend that ventilator circuits should not be changed routinely, but in practice circuit changes at regular intervals persist. METHODS: We searched the MEDLINE, EMBASE, and SCOPUS databases and reviewed citations to identify articles that reported the results of randomized controlled trials and sequential comparison studies that provided a clearly defined intervention of circuit changes (interval > or = 2 d) and the outcome measure of the development of ventilator-associated pneumonia in mechanically ventilated adult patients. Both authors independently assessed the validity of the included studies, and extracted data using a pre-designed data-collection form. We used a random-effect model to combine data from studies that compared circuit changes every 2 days versus every 7 days, and circuit changes at regular intervals versus no routine circuit change. RESULTS: The search yielded 10 reports, which included 19,169 patients. Compared to patients exposed to circuit changes every 7 days, patients who received circuit changes every 2 days had a higher risk of ventilator-associated pneumonia (odds ratio 1.928, 95% confidence interval 1.080-3.443). Compared to no routine circuit change, changing the ventilator circuit at a 2-day or 7-day interval was associated with an odds ratio of 1.126 (95% confidence interval 0.793-1.599). There was a trend of reduced risk of pneumonia as circuit-change intervals were extended. CONCLUSIONS: Frequent ventilator circuit changes are associated with a high risk of ventilator-associated pneumonia. No routine circuit change is safe and justified. Hospital infection-control policies and bedside practitioners should translate the evidence into clinical practice, if they haven't done so already.

Patient compliance with assessing and monitoring of asthma.

BACKGROUND: The current asthma guidelines encourage use of a diary for assessing and monitoring symptoms and airway function. However, patient compliance and acceptability are usually poor owing to the burden of frequent and prolonged assessment. OBJECTIVE: We investigated whether better patient compliance could be ensured if a study was more relevant to patient convenience and had less impact on their daily life. METHODS: A total of 106 patients with symptomatic asthma underwent a fixed-time thrice-daily assessment schedule for a period lasting 2 weeks, and they were assigned to a doctor visit after the assessment. Symptoms and medication use were recorded in a booklet (paper diary) and airway function measured by a portable spirometer (electronic diary). RESULTS: Of 4,452 expected entries, the paper diary yielded 3,186 compliant entries and the electronic diary yielded 3,557 compliant entries; 71% of patients completed at least 30 compliant entries in the paper diary and 79% in the electronic diary. Use of an electronic device was associated with better compliance compared with paper technique (80.0% vs. 71.7%, p < 0.0001). Patient compliance decreased in the second week compared with the first week of diary keeping for both types of diaries (paper diary: 68.6% vs. 74.8%, p < 0.0001; electronic diary: 76.7% vs. 83.4%, p < 0.0001). The morning compliance was the least good, the afternoon better, and the evening best (paper diary: 68.2% vs. 71.0% vs. 75.9%, p < 0.0001; electronic diary: 77.2% vs. 79.0% vs. 83.9%, p < 0.0001). Among demographics and clinical factors, higher anxiety levels were linked to lower patient compliance. CONCLUSION: Good patient compliance and acceptability can be achieved when a study takes into account patient convenience, uses user friendly electronic devices, and is less disruptive to patients' daily life.

[Diagnostic specificity of dynamic assessment and monitoring of spirometry in asthma].

OBJECTIVE: To evaluate the diagnostic specificity of dynamic assessment and monitoring using a portable spirometer in diagnosis and differential diagnosis of asthma. METHODS: We retrospectively reviewed the results of dynamic monitoring of spirometry in 145 symptomatic patients with physician-diagnosed asthma. Flow-volume curve and simultaneous symptoms and mood were measured in a fixed-time thrice-daily assessment schedule for 2 weeks. Patients were allowed to make additional measurements in case of symptom exacerbations. RESULTS: The clinical data of 51 males and 94 females with a mean age of (39.1 +/- 13.0) years (ranged from 10 to 65 years) were analyzed. Duration of asthma before study was (6.7 +/- 9.9) years. Of 145 patients with physician-diagnosed asthma, 126 (87%) could be conclusively confirmed for a diagnosis of asthma. Asthma was misdiagnosed in 14 patients (9.7%). Overdiagnosis of asthma was observed in 5 patients (3.4%). CONCLUSION: Dynamic assessment and monitoring using a portable spirometer by revealing variability and reversibility of airway obstruction may provide an additional tool for diagnosis and differential diagnosis of asthma.

The language of medically unexplained dyspnea.

BACKGROUND: Medically unexplained dyspnea (MUD) refers to a condition characterized by a sensation of dyspnea and is typically applied to patients presenting with anxiety and hyperventilation without cardiopulmonary explanations for their dyspnea. The diagnosis is difficult. We investigated whether descriptors of dyspnea and associated symptoms of MUD are differentially diagnostic. METHODS: A respiratory symptom checklist incorporating 61 spontaneously reported descriptors of dyspnea was administered to 96 patients with MUD and 195 patients with cardiopulmonary diseases. Symptom factors measuring different qualitative aspects of dyspnea were derived by a principal component analysis. The separation of two patient groups in terms of symptom factors was achieved by a discriminant analysis. RESULTS: Five factors grouped different attributes of dyspnea: urge to breathe, depth and frequency of breathing, difficulty breathing and phase of respiration, wheezing, and affective dyspnea. The other five factors grouped symptoms of anxiety, tingling, cough and sputum, palpitation, and out of control. A discriminant analysis allowed to separate two patient groups (R(2) = 0.45, p < 0.0001). The presence of urge to breathe, affective dyspnea, anxiety, and tingling pointed to the diagnosis of MUD, whereas the reporting of wheezing, cough and sputum, and palpitation indicated cardiopulmonary diseases. The sensitivity was 85%, and specificity was 88%. CONCLUSIONS: Descriptors of dyspnea and associated symptoms allows satisfactory separation of patients with MUD from patients with cardiopulmonary diseases. A prospective study will be required to test the validity and predictive values of the descriptor model in another cohort of patients.

Fearful imagery induces hyperventilation and dyspnea in medically unexplained dyspnea.

BACKGROUND: Medically unexplained dyspnea refers to a condition characterized by a sensation of dyspnea and is typically applied to patients presenting with anxiety and hyperventilation without underlying cardiopulmonary pathology. We were interested to know how anxiety triggers hyperventilation and elicits subjective symptoms in those patients. Using an imagery paradigm, we investigated the role of fearful imagery in provoking hyperventilation and in eliciting symptoms, specifically dyspnea. METHODS: Forty patients with medically unexplained dyspnea and 40 normal subjects matched for age and gender were exposed to scripts and asked to imagine both fearful and restful scenarios, while end-tidal PCO(2) (PetCO(2)) and breathing frequency were recorded and subjective symptoms evaluated. The subject who had PetCO(2) falling more than 5 mmHg from baseline and persisting at this low level for more than 15 seconds in the imagination was regarded as a hyperventilation responder. RESULTS: In patients with medically unexplained dyspnea, imagination of fearful scenarios, being blocked in an elevator in particular, induced anxious feelings, and provoked a significant fall in PetCO(2) (P < 0.05). Breathing frequency tended to increase. Eighteen out of 40 patients were identified as hyperventilation responders compared to 5 out of 40 normal subjects (P < 0.01). The patients reported symptoms of dyspnea, palpitation or fast heart beat in the same fearful script imagery. Additionally, PetCO(2) fall was significantly correlated with the intensity of dyspnea and palpitation experienced during the mental imagery on one hand, and with anxiety symptoms on the other. CONCLUSIONS: Fearful imagery provokes hyperventilation and induces subjective symptoms of dyspnea and palpitation in patients with medically unexplained dyspnea.

[Clinical application of portable spirometry in asthma].

OBJECTIVE: To investigate the clinical applications of portable spirometry in asthma. METHODS: Twenty patients with asthma were recruited from Peking Union Medical College Hospital. Flow-volume loop, simultaneous asthma symptoms, and mood were monitored three times a day for consecutive 14 days. RESULTS: In patients with a normal daytime spirometry, marked decline of forced expiratory volume in one second (FEV1) and peak expiratory flow (PEF) were observed at night and/or in the early morning. A within subject correlation analysis between FEV1, PEF, and asthma symptoms showed that the correlation between symptoms and airway obstruction was found only in seven out of twenty patients (35%). Four patients (20%) reported many symptoms with nearly normal portable spirometry. Accordingly, their symptoms were not correlated with FEV1 and PEF. This group of patients was defined as over-perceivers. On the contrary, another two patients (10%) did not report any symptoms while obvious airways obstruction was recorded by a portable spirometry. These patients were defined as under-perceivers. CONCLUSIONS: Dynamic monitoring of flow-volume loop with a portable spirometry is more accurate than routine lung function test in assessment of asthma severity. In addition, combined with simultaneous monitoring of symptoms, it would be of particularly helpful in identifying two specific types of asthma patients, e.g. over-perceivers and under-perceivers.

Respiratory complaints in Chinese: cultural and diagnostic specificities.

STUDY OBJECTIVES: We investigated the qualitative components of a wide range of Chinese descriptors of dyspnea and associated symptoms, and their relevance for clinical diagnosis. MEASUREMENTS: Sixty-one spontaneously reported descriptors were elicited in Chinese patients to make a symptom checklist, which was administered to new groups of patients with different cardiopulmonary diseases, to patients with medically unexplained dyspnea and to healthy subjects. RESULTS: Test-retest reliability was satisfactory for most of the descriptors. A principal component analysis on 61 descriptors yielded the following eight factors: dyspnea-effort of breathing; dyspnea-affective aspect; wheezing; anxiety; tingling; palpitation; coughing and sputum; and dying experience. Although the descriptors of dyspnea-effort of breathing resembled Western wordings and were shared by patients with a variety of diseases, the descriptors of dyspnea-affective aspect appeared to be more culturally specific and were primarily linked to the diagnosis of medically unexplained dyspnea, whereas wheezing was specifically linked to asthma. CONCLUSIONS: Three factors of breathlessness were found in Chinese. The descriptors of dyspnea-effort of breathing and wheezing appear to be similar to Western descriptors, whereas the dyspnea-affective aspect seems to bear cultural specificity.

[Medically unexplained dyspnea in children: a review of 34 cases].

OBJECTIVE: Medically unexplained dyspnea is common in adult and accounts for 14% patients complaining of dyspnea. Its occurrence in children is seldom recognized. In the present paper, 34 children with medically unexplained dyspnea (age 10 to 18 years) seen in Peking Union Medical College Hospital from 1996 to 2002 are reported. METHODS: The diagnosis of medically unexplained dyspnea was clinical: it was based on the presence of dyspnea and other complaints which cannot be explained by an organic disease. The patients answered Nijmegen questionnaire and state and trait anxiety (STAI), and performed hyperventilation provocation test. Twenty sessions of breathing therapy were applied and 13 out of 34 children were followed up after the therapy. RESULTS: Among the children, 75% started to have symptoms at the age of 13 to 16 years, though the age of first episode could be as early as 8 years. In most of the cases, the course was chronic clinically. In addition to marked dyspnea, their clinical profile included symptoms of hyperventilation i.e. blurred vision, dizziness, tingling, stiff fingers or arm. The symptoms of anxiety were less frequent in children and accordingly the level of anxiety evaluated by means of STAI was lower in children compared to adult patients. The precipitating psychological factors appeared to be related to middle school competition. Pressure from exams, reprimand from stern and unsympathetic teachers coupled with high parental expectation could be emotionally damaging to psychologically susceptible children. Thirteen patients were followed up after 2-3 months of breathing therapy with emphasis on abdominal breathing and slowing down of expiration. After therapy, the sum score of the Nijmegen Questionnaire was markedly decreased. Dyspnea and symptoms of hyperventilation were improved. The level of anxiety was minimally modified. CONCLUSION: The cases illustrated the need for careful diagnostic evaluation and treatment because of the high rate of chronicity of the disorder.

[Diagnosis and treatment of medically unexplained dyspnea].

Medically unexplained dyspnea refers to a group of patients presenting marked dyspnea without structural alterations of organs/systems after thorough examinations. This clinically neglected group of patients accounts for about 14% of patients with dyspnea in secondary health care. They appear very difficult to manage clinically. In this paper an organized approach used to diagnose medically unexplained dyspnea is presented. Breathing re-training is recommended as a therapy for those "difficult to treat patients".