[Medical societies in Germany call for a ban on flavors in e-cigarettes - A Position Paper of the German Respiratory Society (DGP) in cooperation with other professional associations and organizations]. / Medizinische Fachgesellschaften fordern ein Verbot von Aromen in E-Zigaretten.

E-cigarettes are primarily used by teenagers and young adults. Flavors in e-cigarettes increase their attractiveness and encourage young people and adults to start using them. This exposes young people in particular to the risk of nicotine addiction and various toxic substances from the aerosol of e-cigarettes. There are indications that various flavors in e-cigarettes are harmful to health, although toxicological studies are still lacking for the majority of flavors. There is a need for independent scientific investigations in this area. The scientific societies involved are calling for a ban on flavors in e-cigarettes, a ban on disposable e-cigarettes, effective regulation of the sale of e-cigarettes and effective control and implementation of the provisions for the protection of minors.

[Harmful health effects of flavors in e-cigarettes]. / Gesundheitsschädliche Wirkungen von Aromen in E-Zigaretten.

BACKGROUND: Almost all e-cigarettes contain flavorings that make the product more attractive. In the evaluation of e-cigarettes on health, flavors have so far played a subordinate role. METHOD: Selective literature search in PubMed, supplemented by legal regulations on the use of flavors in e-cigarettes. RESULTS: Flavors make it easier to start using e-cigarettes and have a consumption-promoting effect. Deeper inhalation increases nicotine uptake and the absorption of toxic substances from the e-cigarette liquid. For some flavors, pathological effects have been demonstrated in addition to other toxic components of the e-cigarette. To date, no toxicological analyses are available for the vast majority of flavors contained in e-cigarettes. CONCLUSIONS: The proven consumption-promoting effect and the health risks that can be extrapolated from preclinical data are significant for the political discussion of a ban on flavors for e-cigarettes, analogous to the ban on flavors in tobacco products already in force.

[Statement paper on the implementation of a national organized program in Germany for the early detection of lung cancer in risk populations using low-dose CT screening including management of screening findings]. / Positionspapier zur Implementierung eines nationalen organisierten Programms in Deutschland zur Früherkennung von Lungenkrebs in Risikopopulationen mittels Low-dose-CT-Screening inklusive Management von abklärungsbedürftigen Screeningbefunden.

The process of implementing early detection of lung cancer with low-dose CT (LDCT) in Germany has gained significant momentum in recent years. It is expected that the ordinance of the Federal Ministry for the Environment, Nature Conservation, Nuclear Safety and Consumer Protection (BMUV) on the early detection of lung cancer, which has been commented on by the professional societies, will come into effect by the end of 2023. Based on this regulation, the Federal Joint Committee (G-BA) will set up a program for early lung cancer detection with LDCT in the near future. In this position paper, the specialist societies involved in lung cancer screening present key points for a uniform, structured and quality-assured early detection program for lung cancer in Germany to make a constructive contribution to this process. CITATION FORMAT: · Vogel-Claussen J, Blum TG, Andreas S et al. Position paper on the implementation of a nationally organized program in Germany for the early detection of lung cancer in high-risk populations using low-dose CT screening including the management of screening findings requiring further workup. Fortschr Röntgenstr 2024; 196: DOI 10.1055/a-2178-2846.

[Statement paper on the implementation of a national organized program in Germany for the early detection of lung cancer in risk populations using low-dose CT screening including management of screening findings]. / Positionspapier zur Implementierung eines nationalen organisierten Programms in Deutschland zur Früherkennung von Lungenkrebs in Risikopopulationen mittels Low-dose-CT-Screening inklusive Management von abklärungsbedürftigen Screeningbefunden.

The process of implementing early detection of lung cancer with low-dose CT (LDCT) in Germany has gained significant momentum in recent years. It is expected that the ordinance of the Federal Ministry for the Environment, Nature Conservation, Nuclear Safety and Consumer Protection (BMUV) on early detection of lung cancer, which has been commented on by the professional societies, will come into effect by the end of 2023. Based on this regulation, the Federal Joint Committee (G-BA) will set up a program for early lung cancer detection with LDCT in the near future. In this position paper, the specialist societies involved in lung cancer screening present concrete cornerstones for a uniform, structured and quality-assured early detection program for lung cancer in Germany to make a constructive contribution to this process.

[Statement Paper on the Implementation of a National Organized Program in Germany for the Early Detection of Lung Cancer in Risk Populations Using Low-dose CT Screening Including Management of Screening Findings]. / Positionspapier zur Implementierung eines nationalen organisierten Programms in Deutschland zur Früherkennung von Lungenkrebs in Risikopopulationen mittels Low-Dose-CT-Screening inklusive Management von abklärungsbedürftigen Screening-Befunden.

The process of implementing early detection of lung cancer with low-dose CT (LDCT) in Germany has gained significant momentum in recent years. It is expected that the ordinance of the Federal Ministry for the Environment, Nature Conservation, Nuclear Safety and Consumer Protection (BMUV) on early detection of lung cancer, which has been commented on by the professional societies, will come into effect by the end of 2023. Based on this regulation, the Federal Joint Committee (G-BA) will set up a program for early lung cancer detection with LDCT in the near future. In this position paper, the specialist societies involved in lung cancer screening present concrete cornerstones for a uniform, structured and quality-assured early detection program for lung cancer in Germany to make a constructive contribution to this process.

[The e-cigarette - means of smoking cessation?] / Die E-Zigarette ­ Mittel zur Tabakentwöhnung?

After several years of declining tobacco consumption, the number of smokers in Germany is currently stagnating or rising again. The reasons seem to be manifold, e. g. stress caused by the pandemic with social isolation, rising cost of living and war in Europe.With tobacco use still widespread in the German population, evidence-based tobacco cessation is rarely implemented.According to recent studies, e-cigarettes are involved in the pathogenesis of lung disease, cardiac and vascular damage. In addition, their ingredients also have carcinogenic effects. However, clinical studies on long-term use are not yet available.E-cigarettes as a consumer product are not superior to nicotine replacement products and addiction-reducing medications recommended in guidelines. In the therapeutic setting, they are slightly more effective than nicotine replacement products. However, they are usually consumed continuously and thus perpetuate nicotine dependence. Their use increases the risk of relapse to tobacco smoking.Despite the various new approaches, such as Internet-based offerings, app, etc., talks and pharmacotherapy are the gold standard and more effective than any therapy on its own.

[The e-cigarette - means of smoking cessation?] / Die E-Zigarette ­ Mittel zur Tabakentwöhnung?

After several years of declining tobacco consumption, the number of smokers in Germany is currently stagnating or rising again. The reasons seem to be manifold, e. g. stress caused by the pandemic with social isolation, rising cost of living and war in Europe.With tobacco use still widespread in the German population, evidence-based tobacco cessation is rarely implemented.According to recent studies, e-cigarettes are involved in the pathogenesis of lung disease, cardiac and vascular damage. In addition, their ingredients also have carcinogenic effects. However, clinical studies on long-term use are not yet available.E-cigarettes as a consumer product are not superior to nicotine replacement products and addiction-reducing medications recommended in guidelines. In the therapeutic setting, they are slightly more effective than nicotine replacement products. However, they are usually consumed continuously and thus perpetuate nicotine dependence. Their use increases the risk of relapse to tobacco smoking.Despite the various new approaches, such as Internet-based offerings, app, etc., talks and pharmacotherapy are the gold standard and more effective than any therapy on its own.

[Tobacco Cessation - The Underused Potential in Clinical Routine]. / Tabakentwöhnung ­ die bisher wenig genutzte Chance im ärztlichen Alltag.

Tobacco control, psychosocial and medical assistance regarding tobacco cessation is still a hidden potential within the German health care system. So far doctors rarely talk to their patients about their smoking status and physical and psychological benefits of quitting.This paper focusses on recommended current diagnostic and treatment standards, as well as evidence-based methods to address the topic on how to stop smoking and its association with certain diseases such as COPD, lung cancer and COVID-19 infection. The role of e-cigarettes as a cessation tool and its health related risks are critically examined. Consequences and advice how to implement smoking cessation procedures into daily practice are presented.

[Smoking cessation - achievable and effective]. / Tabakentwöhnung ­ wirksam und kosteneffektiv.

In hospital, effective smoking cessation can be organized through counselling, pharmacological aids and, above all, continuous care in outpatient structures following discharge. Pharmacological treatment has proven to be effective and safe with nicotine replacement therapy as well as varenicline. Counselling plus pharmacotherapy is more effective in combination than either therapy is on its own. To better implement structures medical societies in Germany are seeking adequate funding e. g. in the DRG system for hospitalised patients.There are obvious and relevant benefits in smoking cessation. Not only for the main tobacco-related diseases such as coronary heart disease or chronic obstructive pulmonary disease (COPD), positive effects of quitting on morbidity and mortality have been confirmed by high-quality meta-analyses. Furthermore, quality of life is increasing following cessation. Presently, smoking is found to be a significant risk factor for severe disease and mortality following coronavirus infection.Do e-cigarettes offer an alternative in smoking cessation? No. Animal and human data are suggesting toxic effects especially following longer use. The long-term effectiveness of e-cigarettes in tobacco cessation is still uncertain and epidemiologic data clearly point toward ineffectiveness. Furthermore, dual use with potentiation of the toxic effects is common. Therefore, e-cigarettes cannot be recommended for tobacco cessation.

[COVID-19 and Smoking - A Position Paper by the DGP Taskforce for Smoking Cessation]. / COVID-19 und Rauchen.

Tobacco smoking is associated with severe health risks. In 2020, the WHO estimated that 8 million people have died due to smoking. Furthermore, smoking tobacco is a well-known risk factor for various infectious pulmonary diseases. The question raised, whether smoking is facilitating SARS-CoV-2-infections and increases adverse outcomes of COVID-19. To answer these questions a narrative review was conducted, finally including 7 systematic reviews with meta-analyses published in January and February 2021. Tobacco smoking was associated with an increased COVID-19 disease severity (odds ratio range of active vs. never smokers 1.55-2.19 and former vs. never smokers 1.20-2.48) and an increased COVID-19 in-hospital mortality (odds ratio range of active vs. never smokers 1.35-1.51 and former vs. never smokers 1.26-2.58). Beside immediate pulmonary toxic effects through active smoking, the cumulative livelong tobacco exposition and subsequent tobacco-associated diseases seem to predominantly predict adverse outcomes in patients with COVID-19. Data regarding an increased risk of infection among smokers is conflicting. However, a large observational study from England with 2.4 million persons reported an association between tobacco smoking and typical symptoms of COVID-19. For e-cigarettes and vaping less data exist, but experimental and first clinical investigations also suggest an increased risk for adverse outcomes for their use and SARS-CoV-2 infections. Especially during the current SARS-CoV-2 pandemic with limited therapeutic options it is particularly important to advise smokers of their increased risks for unfavourable COVID-19 outcomes. Evidence based support for smoking cessation should be offered. In Germany, the existing and well-established methods to support tobacco cessation need to be reimbursed by statutory health insurances.

Evaluation of long-term quitters: who stays smoke free forever?

BACKGROUND: Smoking cessation is one of the most powerful health promotion tools in the Western world. Behavioral group therapies are regarded as very promising interventions in this field. Quitting rates are usually evaluated after 6-12 months and lie between 30 and 45%. So far, there are no scientific data on potential protective indicators to remain successfully smoke free after this period. Therefore, the aim of this study was to detect the current smoking status of former participants of a cessation service in an urban German surrounding. We investigated reasons for relapses, quitting strategies, and psychosocial parameters. METHODS: In 2019, 130 former patients (2011-2017; mean age 54 years; 37 pack/years; Fagerstroem = 5.75; 58.5% male, 41.5% female; 66% physical comorbidities; 35% psychiatric diagnoses) were invited to participate in a mailed survey (including WHO 5, SF 12, self-efficacy scale) and were asked about their current smoking status, personal history of smoking, and individual experiences with stopping after the 1­year abstinence date. RESULTS: A total of 53 persons replied (RR 41%), 29 (54%) of whom are currently smoke free; 24 relapsed intermittently or permanently, 9 experimented with e­cigarettes, and 2 became dual users. Daily hassles as well as physical and mental challenges were the main reasons for relapsing. CONCLUSION: Due to the low response rate, conclusions are limited; however, the 1­year abstinence rate might not be as reliable as thought so far; long-term "sober" nicotine addicts remain at risk of relapse.

Source attribution of community-acquired cases of Legionnaires' disease-results from the German LeTriWa study; Berlin, 2016-2019.

INTRODUCTION: Sources of infection of most cases of community-acquired Legionnaires' disease (CALD) are unknown. OBJECTIVE: Identification of sources of infection of CALD. SETTING: Berlin; December 2016-May 2019. PARTICIPANTS: Adult cases of CALD reported to district health authorities and consenting to the study; age and hospital matched controls. MAIN OUTCOME MEASURE: Percentage of cases of CALD with attributed source of infection. METHODS: Analysis of secondary patient samples for monoclonal antibody (MAb) type (and sequence type); questionnaire-based interviews, analysis of standard household water samples for Legionella concentration followed by MAb (and sequence) typing of Legionella pneumophila serogroup 1 (Lp1) isolates; among cases taking of additional water samples to identify the infectious source as appropriate; recruitment of control persons for comparison of exposure history and Legionella in standard household water samples. For each case an appraisal matrix was filled in to attribute any of three source types (external (non-residence) source, residential non-drinking water (RnDW) source (not directly from drinking water outlet), residential drinking water (RDW) as source) using three evidence types (microbiological results, cluster evidence, analytical-comparative evidence (using added information from controls)). RESULTS: Inclusion of 111 study cases and 202 controls. Median age of cases was 67 years (range 25-93 years), 74 (67%) were male. Among 65 patients with urine typable for MAb type we found a MAb 3/1-positive strain in all of them. Compared to controls being a case was not associated with a higher Legionella concentration in standard household water samples, however, the presence of a MAb 3/1-positive strain was significantly associated (odds ratio (OR) = 4.9, 95% confidence interval (CI) 1.7 to 11). Thus, a source was attributed by microbiological evidence if it contained a MAb 3/1-positive strain. A source was attributed by cluster evidence if at least two cases were exposed to the same source. Statistically significant general source types were attributed by calculating the population attributable risk (analytical-comparative evidence). We identified an external source in 16 (14%) cases, and RDW as source in 28 (25%). Wearing inadequately disinfected dentures was the only RnDW source significantly associated with cases (OR = 3.2, 95% CI 1.3 to 7.8) and led to an additional 8% of cases with source attribution, for a total of 48% of cases attributed. CONCLUSION: Using the appraisal matrix we attributed almost half of all cases of CALD to an infectious source, predominantly RDW. Risk for LD seems to be conferred primarily by the type of Legionella rather than the amount. Dentures as a new infectious source needs further, in particular, integrated microbiological, molecular and epidemiological confirmation.

Increased vulnerability of COPD patient groups to urban climate in view of global warming.

PURPOSE: Patients with COPD show an increase in acute exacerbations (AECOPD) during the cold season as well as during heat waves in the summer months. Due to global climate changes, extreme weather conditions are likely to occur more frequently in the future. The goal of this study was to identify patient groups most at risk of exacerbations during the four seasons of the year and to determine at which temperature threshold the daily hospital admissions due to AECOPD increase during the summer. PATIENTS AND METHODS: We analyzed retrospective demographic and medical data of 990 patients, who were hospitalized for AECOPD in Berlin, Germany. The cases were grouped into the following cohorts: "spring" (admission between March and May), "summer" (June - August), "autumn" (September - November), and "winter" (December - February). AECOPD hospital admissions from 2006 and 2010 were grouped into a "hot summer" cohort and cases from 2011 and 2012 into a "cold summer" data-set. Climate data were obtained from the German Meteorological Office. RESULTS: Patients hospitalized for a COPD exacerbation during winter were significantly older than summertime patients (P=0.040) and also thinner than patients exacerbating in spring (P=0.042). COPD exacerbations during hot summer periods happened more often to patients with a history of myocardial infarction (P=0.014) or active smokers (P=0.011). An AECOPD during colder summers occurred in patients with a higher Charlson index, who suffered in increased numbers from peripheral vascular diseases (P=0.016) or tumors (P=0.004). Summertime hospital admissions increased above a daily minimum temperature of 18.3°C (P=0.006). CONCLUSION: The identification of COPD patient groups most at risk for climate related exacerbations enables climate-adapted prevention through patient guidance and treatment. In view of global climate changes, discovering vulnerabilities and implementing adaptive measures will be of growing importance.

The diagnosis of chronic obstructive pulmonary disease.

BACKGROUND: Estimates of the prevalence of chronic obstructive pulmonary disease (COPD) in Germany range from 1.9% to 13.2%, depending on the population studied and the investigative methods used. About 30% of all patients already have severe airway obstruction by the time the condition is diagnosed. METHODS: Review of pertinent literature retrieved by a selective search, including current guidelines and textbooks. RESULTS: Smoking is the main risk factor for COPD. The diagnosis is based on characteristic symptoms that patients at risk should be actively asked about-cough, dyspnea, diminished physical reserve, and frequent airway infections-together with abnormal pulmonary function tests. Spirometry usually suffices to document impaired air flow. The clinical evaluation and the treatment strategy are based on the severity of airway obstruction and dyspnea, and the frequency of exacerbations. According to a European study, dyspnea is present in 73% of persons with severe COPD, expectoration in 64%, cough in 59%, and wheezing in 42%. Asthma, congestive heart failure, and interstitial lung disease are the main differential diagnoses. CONCLUSION: COPD may begin with symptoms that are only mild at first even in a longstanding smoker. The available diagnostic techniques need better prospective validation with respect to relevant endpoints, including mortality, symptom progression, quality of life, and frequency of exacerbations.

Serial IGRA testing of trainees in the healthcare sector in a country with low incidence for tuberculosis - a prospective cohort study.

BACKGROUND: Healthcare workers (HCW) are a risk group for tuberculosis (TB). That is why interferon-gamma release assay (IGRA) serial testing is performed on HCWs repeatedly exposed to infectious patients or materials. However, the variability of IGRA in serial testing is not yet well understood. We therefore analysed the prevalence of positive IGRA results as well as conversion and reversion rates in the serial testing of healthcare trainees in a low-incidence country. METHODS: In a prospective cohort study, all trainees (n=194) who began training as a nurse or healthcare worker at the Vivantes Healthcare Training Institute in Berlin on 1 October 2008 or 1 April 2009 were IGRA-tested at three different times during the three years of training. Socio-demographic data and possible risk factors (e.g., TB contacts, time spent abroad, area of work) were recorded by means of a standardised questionnaire. The QuantiFERON Gold In-Tube (QFT) was used as an IGRA. RESULTS: At the beginning of the training the cohort comprised 194 trainees. 70% were female. Their average age was 23. The prevalence of positive QFT was 2.1% (4/194). In the first follow-up test, 2 out of 154 (1.3%) tested IGRA-positive, 151 (98%) had constantly negative results. One IGRA was constantly positive (0.6%) and there was one conversion and one reversion (0.6% respectively). In the second follow-up (n=142) there was again one conversion (0.7%), one reversion and the one constantly positive test result in all three QFT. This trainee had active TB in 2002. All other test results were constantly negative (n=139; 98%). No case of active tuberculosis was diagnosed over the three-year observation period. Contact with TB patients was reported by 42 (29.6%) trainees during the follow-up. The two trainees with a conversion in QFT had no known contact with TB patients. Discordant results in the three consecutive QFT were observed in three trainees (2.1%). Using a borderline zone from 0.2-0.7 IU/mL reduced the number of trainees with discordant results from three to one - a reversion. CONCLUSION: The prevalence rate of latent TB infection is low in healthcare trainees without known risk factors for TB infection in their history. The infection risk seems to be low in this population even though contacts with TB patients during the training were reported. Introducing a borderline zone for the interpretation of reversions and conversions in this cohort appears to be safe and reduces the number of discordant results and helps to avoid unnecessary chest X-rays and preventive treatment.

Smoking behaviour and attitudes among German nursing students.

Tobacco consumption is a major public health threat. Healthcare workers can contribute to the reduction of tobacco use. The principles of intervention need to be provided already during vocational school. This research examines the smoking habits, the personal attitudes towards smoking and the professional beliefs of healthcare trainees. The aim of this study is to ascertain the necessity and the general conditions for multilevel interventions of prevention and health promotion. In 2010, a questionnaire survey was conducted in a Berlin vocational school for healthcare workers. Of 148 students (RR = 49.3%) 41.9% of the students are daily or occasional smokers. The nicotine dependency and the number of cigarettes per day are comparatively low. The majority of smoking students is willing to quit and has already undertaken several attempts. Non-smoking protection is evaluated to be very important and intervention rates in patient care range between 49% and 72%. In both questions, non-smokers and smokers differ significantly. The self-reported smoking prevalence in our population is considerably lower than in previous studies. However, the smoking rate among healthcare trainees is still higher than in the general population. The students' own smoking behaviours and its influences on the treatment of patients should be reflected during school. It is necessary to develop adequate recruitment strategies and attractive interventions for this target group.

Specificity of a whole blood IGRA in German nursing students.

BACKGROUND: Interferon-gamma release assays (IGRA) are used for tuberculosis (TB) screening in healthcare workers (HCWs). However, data on specificity of IGRA in serial testing of HCWs is sparse. Therefore the specificity and the negative predictive value of the IGRA - QuantiFERON-TB Gold In-Tube (QFT) - in German nursing students was investigated. METHODS: 194 nursing students at the start of their professional career were tested with the QFT. 14 nursing students were excluded from the specificity analysis, due to exposure to mycobacterium tuberculosis. Two of these subjects were QFT- positive. None of them developed disease during the year of follow-up. A study group of 180 students, all with very low risk of prior TB infection, remained in the specificity analysis. Subjects were monitored for at least two years with respect to the development of active TB disease. IGRA was performed at the start of the training and after one year. RESULTS: The mean age of the study group (n = 180) was 23 years (range 18-53) with 70.9% female and 99.4% German born. The specificity of QFT was 98.9% (178/180; 95% CI 0.96-0.99); lowering the cut-off from 0.35 IU/ml to 0.1 IU/ml would have decreased specificity only slightly to 97.8% (176/180; 95% CI 0.94-0.99). Of the 154 nursing students available for re-testing, one student who initially scored positive reverted to negative, and one student initially negative converted to positive. None of the monitored group with initially negative QFT results developed TB disease, indicating a high negative predictive value of the IGRA in this population. CONCLUSIONS: Following our data, QFT can serve as an effective tool in pre-employment TB screenings for HCWs. As its negative results were stable over time, specificity of the QFT in serial testing of HCWs is high. As the risk of acquiring TB infection in the German healthcare system appears to be low, our data supports the recommendation of performing TB screening only in those HCWs with known contact to TB patients or infectious materials.

Confirmation of Mycobacterium tuberculosis infection by flow cytometry after ex vivo incubation of peripheral blood T cells with an ESAT-6-derived peptide pool.

BACKGROUND: The presence of a T-cell response to the early secretory antigenic target-6 (ESAT-6) indicates previous infection with or exposure to Mycobacterium tuberculosis. Measuring this response is useful for identifying individuals infected with M. tuberculosis. It was also reported that the frequencies of ESAT-6-specific T cells correlate with disease state. Established procedures measure secreted T-cell cytokines following whole blood stimulation with recombinant ESAT-6 protein or use Elispot as a read-out. METHODS: A single ESAT-6- spanning pool of overlapping peptides (15 amino acids length with 11 overlaps) was used for overnight stimulation of peripheral blood mononuclear cells (PBMCs) from 15 patients infected with Mycobacterium tuberculosis and 11 healthy controls. T-cell responses were rated positive if interferon-gamma (IFN-gamma)-producing T cells were identified above background level, using 4-color cytokine flow cytometry. RESULTS: Thirteen of 15 (87%) patients, but none of the healthy controls, had a positive CD4 T-cell response to the ESAT-6 spanning peptide pool. The frequencies of IFN-gamma-producing cells varied between 1 and 167 per 10,000 CD4 T cells. The test performed as well as the tests described in the literature. CONCLUSIONS: Cytokine flow cytometry following PBMC stimulation with an ESAT-6 spanning peptide pool is a useful laboratory test for ESAT-6-specific T cells combining precise counting and multi-parameter phenotyping.