Respiratory muscle endurance training in chronic obstructive pulmonary disease: impact on exercise capacity, dyspnea, and quality of life.

Inspiratory muscle training may have beneficial effects in certain patients with chronic obstructive pulmonary disease (COPD). Because of the lack of a home training device, normocapnic hyperpnea has rarely been used as a training mode for patients with COPD, and is generally considered unsuitable to large-scale application. To study the effects of hyperpnea training, we randomized 30 patients with COPD and ventilatory limitation to respiratory muscle training (RMT; n = 15) with a new portable device or to breathing exercises with an incentive spirometer (controls; n = 15). Both groups trained twice daily for 15 min for 5 d per week for 8 wk. Training-induced changes were significantly greater in the RMT than in the control group for the following variables: respiratory muscle endurance measured through sustained ventilation (+825 +/- 170 s [mean +/- SEM] versus -27 +/- 61 s, p < 0.001), inspiratory muscle endurance measured through incremental inspiratory threshold loading (+58 +/- 10 g versus +21.7 +/- 9.5 g, p = 0.016), maximal expiratory pressure (+20 +/- 7 cm H(2)O versus -6 +/- 6 cm H(2)O, p = 0.009), 6-min walking distance (+58 +/- 11 m versus +11 +/- 11 m, p = 0.002), V O(2peak) (+2.5 +/- 0.6 ml/kg/min versus -0.3 +/- 0.9 ml/kg/min, p = 0.015), and the SF-12 physical component score (+9.9 +/- 2.7 versus +1.8 +/- 2.4, p = 0.03). Changes in dyspnea, maximal inspiratory pressure, treadmill endurance, and the SF-12 mental component score did not differ significantly between the RMT and control groups. In conclusion, home-based respiratory muscle endurance training with the new device used in this study is feasible and has beneficial effects in subjects with COPD and ventilatory limitation.

Efficacy, safety, and tolerance of piperacillin/tazobactam compared to co-amoxiclav plus an aminoglycoside in the treatment of severe pneumonia.

An open, randomized, multicenter study was conducted to compare the efficacy and safety of piperacillin/tazobactam and co-amoxiclav plus aminoglycoside in the treatment of hospitalized patients with severe community-acquired or nosocomial pneumonia. Of the 89 patients who entered the study, 84 (94%) were clinically evaluable. A favorable clinical response was observed in 90% of the piperacillin/ tazobactam group and in 84% of the co-amoxiclav/aminoglycoside group (not significant). The bacteriological efficacy was comparable in both groups (96% vs. 92%; not significant). There was only one fatal outcome in the piperacillin/tazobactam group compared to six in the co-amoxiclav/aminoglycoside group regimen (P=0.058). The adverse event rate was non-significantly lower in the piperacillin/ tazobactam group compared to the co-amoxiclav/aminoglycoside group (2% vs. 7%; P=0.32). Piperacillin/tazobactam is safe and highly efficacious in the treatment of serious pneumonia in hospitalized patients. It compares favorably with the combination of co-amoxiclav/aminoglycoside.

Therapeutic embolization of a systemic arterialization of lung without sequestration.

We report the case of a 51-year-old man with massive haemoptysis due to a systemic arterialization of lung without sequestration. Unlike bronchopulmonary sequestration there was a normal bronchial distribution and the involved lung parenchyma was normal. Therefore a therapeutic transarterial embolization of the aberrant systemic vessel from the distal thoracic aorta was performed. The embolization was successful and the patient did not suffer from further haemoptysis during the subsequent follow-up of ten months. A postembolization aortogram 6 months later demonstrated a complete occlusion of the embolized aberrant artery; in the lung perfusion scan there was only a small perfusion defect, but normal ventilation in the embolized basal part of the left lower lobe. Our case represents an alternative treatment to surgery for this rare anomaly.

Time requirements of psychological testing: a survey of practitioners.

Surveys regarding practitioner perceptions of time requirements for psychological testing were mailed to a national sample of clinical psychologists. There were 228 (36%) returns from 630 mailings actually received. On the basis of 151 usable returns from respondents who conduct psychological testing services, data are presented separately for time requirements associated with administering, scoring, and interpreting the 24 most commonly used tests. Data are also presented regarding the composition of typical test batteries and practitioner usage of technician and/or computer assistance in psychological testing. The implications of these data for research and practice are discussed.

[Antibiotic-resistant pneumonia]. / Antibiotikaresistente Pneumonie.

A 77-year-old lady with malaise, cough, weight loss, an elevated ESR and bilateral patchy infiltrates on the chest X-ray is described. The symptoms progressed inspite of antibiotic treatment. On the basis of clinical findings, transbronchial biopsy, bronchoalveolar lavage and lung function tests the diagnosis of a bronchiolitis obliterans, organizing pneumonia (BOOP) was established. The clinicopathological entity of BOOP, its differential diagnosis and treatment are discussed.

[Febrile status and micronodular changes of the lung parenchyma in HIV infection]. / Status febrilis und feinnoduläre Lungenparenchymveränderung bei HIV-Infektion.

This 49-year-old man with the acquired immunodeficiency syndrome (AIDS) was admitted to the hospital because of fever, weight loss and respiratory symptoms. The radiograph of the chest showed diffuse fine nodular opacities. Histology of lung and lymph node revealed a necrotising granulomatosis and yeasts suggesting histoplasmosis. It's identity was confirmed by positive cultures for Histoplasma capsulatum in blood, urine, lung specimen and lymph node. There was a successful induction treatment and a maintenance therapy with amphotericin B. We discuss disseminated histoplasmosis in the immunodeficiency syndrome.

[Severe hemoptysis in pulmonary vasculitis]. / Schwere Hämoptoe bei pulmonaler Vaskulitis.

A 27-year-old man, in good health but a moderate smoker, suddenly had two episodes of haemoptysis. Routine clinical examination was unremarkable. Erythrocyte sedimentation rate was increased to 34 mm/h. The chest radiography showed ill-defined, contrast-poor infiltrations bilaterally, as well as left hilar enlargement. Lung scintigraphy and pulmonary arteriogram suggested pulmonary embolism, possible from a "pelvic vein spur", i.e. an intimal proliferation due to crossing of the common iliac artery over the pelvic vein. He was placed on oral anticoagulants. Three months later he had another severe haemoptysis, providing the indication for an exploratory thoracotomy. This revealed the left pulmonary artery wall to have inflammatory changes with aneurysmal dilatation. The aneurysm was plicated. Histological examination demonstrated chronic vasculitis as seen in Behçet's syndrome, a diagnosis confirmed by the findings of ulcers of the oral mucosa and the presence of HLA B5 allo-antigens. Immunosuppressive treatment was given with prednisone (1 mg/kg), azathioprine (2.5 mg/kg) and ciclosporin (5 mg/kg). Over the next 12 months there has been only one further haemoptysis.

Multiple organ failure and coma as initial presentation of pheochromocytoma in a patient with multiple endocrine neoplasia (MEN) type II A.

The unusual case of a 65-year-old woman with intermittent hypotension, fever, pulmonary edema and coma as initial presentation of pheochromocytoma is reported. The patient developed respiratory, cardiac and renal failure, disseminated intravascular coagulation and liver dysfunction. She had to be defibrillated on multiple occasions, occurring in periods of severe hypertension. After successful surgical removal of a pheochromocytoma a thyroid medullary carcinoma was detected. Several members of the patients family had presented with multiple endocrine neoplasia (MEN II).

Comparison of bronchodilator effects of fenoterol/ipratropium bromide and salbutamol in patients with chronic obstructive lung disease.

A double-blind, randomized cross-over trial was carried out in 24 patients with chronic airflow obstruction. The patients were required to demonstrate a minimum 15% absolute increase in forced expiratory volume (FEV1) after a standard dose (0.4 mg) of fenoterol (F). On a separate occasion the effect of ipratropium bromide (IB; 0.04 mg) on FEV1 was tested also; according to the increase in FEV1 the patients were grouped into IB responders (delta FEV1 > 15%) and IB nonresponders (delta FEV1 < 15%). Two puffs of F/IB (0.1 mg/0.04 mg), salbutamol (S; 0.2 mg) and placebo (P) were given by metered-dose inhaler at the same time of the day on three different occasions. FEV1 and specific airway resistance (sRaw) were assessed before and at specific intervals following inhalation. The results showed that F/IB and S produced similar maximal increases in FEV1 (delta FEV1 32% for F/IB and 31% for S) and decreases in sRaw (delta sRaw 24% for F/IB and 21% for S). These effects were significantly different both from baseline values and from P. FEV1 was still significantly different 8 h after inhalation from P in the F/IB group, but not in the group that received S. The effect of IB on FEV1 in the pretest was compared with the subsequent response to F/IB. In IB responders F/IB seemed to produce slightly more effective bronchodilation. Side effects were minimal and clinically insignificant. In conclusion, F/IB, with its ability to effect sustained bronchodilation without adverse side effects, is a viable alternative to a monotherapy in chronic obstructive pulmonary disease.

Initial staging of non-small cell lung cancer: value of routine radioisotope bone scanning.

The exclusion of bone metastases is important in the initial staging of non-small cell lung cancer, though there is debate about whether bone scans should be performed routinely or restricted to patients who present with clinical or laboratory indicators suggesting skeletal metastases. In a prospective study of 110 consecutive patients referred for initial staging of non-small cell lung cancer, we assessed the sensitivity of a group of clinical indicators (chest pain, skeletal pain, bone tenderness on physical examination, serum alkaline phosphatase, and serum calcium) for the presence of skeletal metastases as determined by bone scanning. The final staging result was validated with follow up data over at least three years. At the initial staging 37 of 110 bone scans (34%) showed areas of increased uptake, of which only nine were confirmed to be metastases (by tomography, computed tomography, or biopsy). Half the patients (55) had at least one clinical indicator suggesting skeletal metastases, including all patients with proved skeletal metastases. Thus the sensitivity of these clinical indicators was 100% and the specificity 54%. Within one year three of 27 patients with non-confirmed positive bone scans had skeletal metastases, one of which was in the area that had shown increased uptake initially. All these patients had clinical indicators for skeletal metastases and all had inoperable advanced tumours. Four of 69 patients with an initially negative bone scan developed skeletal metastases within one year. It is concluded that in non-small cell lung cancer bone scanning can be restricted to patients with clinical indicators for skeletal metastases. This approach reduces the number of bone scans and consecutive investigations without loss of sensitivity in the detection of skeletal metastases.

Verapamil in the prophylaxis of bronchial asthma. Is the bronchoprotective effect related to the plasma level?

A single oral dose of verapamil 80 mg was shown significantly to inhibit histamine-induced broncho-constriction in 8 out of 16 asthmatic subjects (maximum increase in PD20FEVHi 416%). There was still significant protection (delta PD20FEV1Hi greater than 100%) in the responders 5 h after the oral dose. The relationship of the bronchoprotective effect to the plasma level of verapamil was also examined. Responders and non-responders did not differ significantly in the peak plasma level or the time course of the plasma verapamil concentration. The protective effect was not correlated with the peak plasma level of verapamil or with the baseline bronchial hyperreactivity.

Severe acute asthma. Pathophysiology, clinical assessment, and treatment.

Bronchial asthma is characterized as a disease with recurrent, reversible, and generalized airway obstruction and an increased airway responsiveness to nonspecific stimuli. Besides symptoms of airway hyperresponsiveness, episodic asthmatic attacks, and chronic airway obstruction, severe acute asthma, or 'status asthmaticus', is an important and life-threatening manifestation of the disease. This paper gives an overview of the pathophysiology, clinical risk assessment, and treatment of severe acute asthma.

PAF-dependent phosphatidylinositol turnover in platelets: differences between asthmatics and normal individuals.

The effects of nebulized platelet-activating factor (PAF) on the pulmonary and cardiovascular systems, and on the platelets present in peripheral blood were investigated in 9 normal individuals and in 6 patients with asthma and 3 individuals with lyso-PAF. The inhalation of PAF caused an acute decrease in specific airway conductance. The circulatory system parameters monitored showed an increase in heart rate while blood pressure decreased in both groups that were studied. The inhalation of PAF led to a significant increase in the differential count of polymorphonuclear leukocytes after 15 min; the count returned to the initial level after 24 h. However, the platelet count remained unchanged. The phosphatidylinositol (PI) turnover and in particular the formation of 1,4,5-inositoltrisphosphate (IP3) in platelets were investigated after PAF inhalation. It also mediated an increase in intracellular free calcium concentration, [Ca2+]i, in response to a second challenge with exogenous PAF. The basal levels of IP3 and [Ca2+]i were significantly greater in the platelets of patients with asthma than in those of normal individuals (p less than 0.01). Platelets that had been isolated from normal and asthmatic subjects had a higher concentration of IP3 and [Ca2+]i in the platelets after an in vitro exposure to PAF. After an inhalation challenge with PAF, the platelets of both the normal individuals and the patients with asthma showed a specific refractoriness to the in vitro exposure to PAF. Perhaps, this is an explanation for the PAF-dependent tachyphylaxis that is commonly observed in both normal and asthmatic individuals.(ABSTRACT TRUNCATED AT 250 WORDS)

[Formaldehyde and phthalic anhydride asthma. Demonstration of specific IgE antibodies with RAST]. / Formaldehyd- und phthalisches Anhydrid-Asthma. Nachweis spezifischer IgE-Antikörper im RAST.

Two patients with positive formaldehyde RAST and 3 with positive phthalic anhydride RAST are described, of whom 3 presented with a typical history of occupational asthma and one had only work-related rhinitis. The fifth case with specific IgE antibodies to formaldehyde had only a domestic exposure-effect relationship; asthmatic symptoms had first started some weeks after renovation of the patient's apartment. Thus far, failing proof of specific IgE antibodies, a true allergic reaction to formaldehyde in particular has been doubted. Presenting respiratory symptoms were considered to be probably due to irritant effects. The reported cases indicate that formaldehyde and phthalic anhydride may also exert their effect through immunologic mechanisms.

[Pharmacotherapy of cough]. / Pharmakotherapie des Hustens.

The optimal approach to the treatment of cough consists, first, in determination of its precise cause. Treatment should be directed at the specific etiology or the pathophysiologic mechanism responsible for cough. The outcome of specific treatment is almost always successful. However, there are also situations in which the cause of cough is unknown or in which the cough does not serve any useful purpose but prevents rest and sleep. In such cases symptomatic treatment with antitussives may be indicated. Centrally acting antitussives such as opium alkaloids, dextromethorphan and noscapine are the most effective drugs. The indication for expectorants lacks scientifically based support.

[Solitary peripheral nodules--diagnostic assessment]. / Solitärer peripherer Rundherd--Abklärungsvorgang.

Most solitary pulmonary nodules are detected by chance on routine chest radiography in asymptomatic individuals. Diagnostic evaluation is necessary unless the nodule's size and shape has remained unchanged for at least 2 years, as documented on earlier x-rays. Radiographic techniques alone are insufficient in evaluating the nodule's malignity. For this purpose invasive diagnostic procedures (transthoracic biopsy, bronchoscopy) are mandatory. If these fail to establish a definite diagnosis, thoracotomy may be performed.

[Differential diagnosis of pneumonia and pulmonary infarct based on lung scintigraphy]. / Differentialdiagnose von Pneumonie und Lungeninfarkt mit Hilfe der Lungenszintigraphie.

The etiology of radiologic signs of circumscript parenchymatous lesions is multivarious. In some instances infarction of the lung has to be distinguished from pneumonia. The differential diagnosis has important therapeutic consequences for the patient. An important criterion for primary pneumonic infiltration is Xe-trapping within the area lacking perfusion, which can only be demonstrated by perfusion scintigraphy with Xe-133-NaCl. However, infarction of the lung lacks this pathologic feature. Pathophysiologically the various changes may occur as the result of obstruction of the vessel i.e. due to alveolar hypoxia and embolism. In order to improve the diagnostic methods a combination of perfusion scintigraphy using Xe-133-NaCl and Tc-99-macroaggregate and ventilation scintigraphy with Xe-127 was employed. We retrospectively evaluated 20 patients with the nuclear medical diagnosis of either pneumonia (n = 10) or infarction of the lung (n = 10). The following criteria were adopted: history, risk factors, X-ray of the chest, blood chemistry, ECG, phlebography, pulmonary angiography and histopathological diagnosis, as well as the course of the disease. According to our results the specificity of the scintigraphic diagnosis of pneumonia and infarction of the lung was 90%. However these results will have to be verified in a prospective study using pulmonary angiography as the reference method.