Pulmonary mucosa-associated lymphoid tissue lymphoma in a patient with common variable immunodeficiency syndrome.

Common variable immunodeficiency syndrome (CVID) is a primary immunodeficiency typically presenting with recurrent sinopulmonary infections. Non-Hodgkin's lymphoma and other secondary cancers are typical late complications of CVID. We report on a patient suffering from CVID with a history of recurrent sinopulmonary infections, interstitial pulmonary changes and hepatic granulomas. Despite treatment with intravenous immunoglobulin followed by a reduction in the number of pulmonary infections, reticular and nodular lung changes progressed. Video-assisted thoracoscopic lung biopsy showed a low-grade B cell lymphoma of the mucosa-associated lymphoid tissue (MALT) of the bronchus without evidence of pulmonary infection. In conclusion, MALT lymphoma of the lung should be considered in the differential diagnosis of progressive lung disease in CVID.

[Is self-management practical in bronchial asthma?]. / Sind Selbstkontrolle und Selbstbehandlung beim Asthma bronchiale sinnvoll?

The threat and uncertainty involved in an asthma attack reduce the quality of life for the patient. Life quality can be improved if the patient learns self-management principles. This is easy to learn and involves a simple procedure requiring the patient to refer to written instructions in the event of an asthma exacerbation. As a basis for treatment the patient needs to measure maximum peak flow, which can be done with an easy-to-use peak flow meter. A value above 80% of the personal best indicates that the treatment has been successful. By means of printed instructions in credit card format, the appropriate treatment for particular peak flow values and/or symptoms can be looked up and administered. So far there have been no self-management studies providing a definite answer on what interventions are effective and cost-effective. One clear result is that inhaled steroid therapy must be initiated early. Learning self-management patently leads to improvement in the patient's life quality and safety. In the long run this concept appears to be cost-saving with regard to days lost through sickness and hospitalization.

[Asylum seekers and refugees in the medical polyclinic: a comparison between the Basel, Bern and Geneva polyclinics]. / Asylsuchende und Flüchtlinge in der medizinischen Poliklinik: Ein Vergleich zwischen den Polikliniken Basel, Bern und Genf.

This cross-sectional study describes the state of health of asylum seekers and refugees and the health services provided to them by the medical outpatient departments of three major Swiss university hospitals, Basel, Berne and Geneva. The comparison of outpatient departments differing in organisational structure facilitated the identification of positive and negative determinants of health service provision. Questionnaires have been filled in by all physicians of the three medical outpatient departments (Basel: 10, Berne: 1, Geneva: 36). All consultations of asylum seekers and refugees have been recorded during the study period (Basel: 42, Berne: 93, Geneva: 187). Interviews have been done with the physicians who coordinated the study. During the study period the majority of the patients originated from former Yugoslavia, Turkey, Sri Lanka, Somalia, Angola and Zaire. One of the most prominent features of the population investigated has been its diversity in respect to countries of origin, languages, ability to communicate and education. Diversity and low consultation rates per physician could explain many of the problems which have been observed, e.g. the lack of experience in specific approaches to these patients or difficulties to provide interpreters. To improve the health care for this group of patients in medical outpatient departments small teams of physicians should be selected. By these means adequate levels of experience could be achieved and organizational problems could be dealt with more effectively. In addition, the relationship between specific problems of asylum seekers and refugees and more general issues of the interaction between physicians and patients are discussed in view of tasks in research and training.

Pulmonary function and exercise capacity after lung resection.

The influence of pulmonary resection on functional capacity can be assessed in different ways. The aim of this study was to compare the effect of lobectomy and pneumonectomy on pulmonary function tests (PFT), exercise capacity and perception of symptoms. Sixty eight patients underwent functional assessment with PFT and exercise testing before (Preop), and 3 and 6 months after lung resection. In 50 (36 males and 14 females; mean age 61 yrs) a lobectomy was performed and in 18 (13 males and 5 females; mean age 59 yrs) a pneumonectomy was performed. Three months after lobectomy, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), total lung capacity (TLC), transfer factor of the lungs for carbon monoxide (TL,CO) and maximal oxygen uptake (V'O2,max) were significantly lower than Preop values, increasing significantly from 3 to 6 months after resection. Three months after pneumonectomy, all parameters were significantly lower than Preop values and significantly lower than postlobectomy values and did not recover from 3 to 6 months after resection. At 6 months after resection significant deficits persisted in comparison with Preop: for FVC 7% and 36%, FEV1 9% and 34%, TLC 10% and 33% for lobectomy and pneumonectomy, respectively; and V'O2,max 20% after pneumonectomy only. Exercise was limited by leg muscle fatigue in 53% of all patients at Preop. This was not altered by lobectomy, but there was a switch to dyspnoea as the limiting factor after pneumonectomy (61% of patients at 3 months and 50% at 6 months after resection). Furthermore, pneumonectomy compared to lobectomy led to a significantly smaller breathing reserve (mean +/- SD) (28 +/- 13 vs 37 +/- 16% at 3 months; and 24 +/- 11% vs 33 +/- 12% at 6 months post resection) and lower arterial oxygen tension at peak exercise 10.1 +/- 1.5 vs 11.5 +/- 1.6 kPa (76 +/- 11 vs 86 +/- 12 mmHg) at 3 months; 10.1 +/- 1.3 vs 11.3 +/- 1.6 kPa (76 +/- 10 vs 85 +/- 12 mmHg) at 6 months postresection. We conclude that measurements of conventional pulmonary function tests alone overestimate the decrease in functional capacity after lung resection. Exercise capacity after lobectomy is unchanged, whereas pneumonectomy leads to a 20% decrease, probably due to the reduced area of gas exchange.

[Therapeutic problems in pneumonia]. / Therapeutische Schwierigkeiten bei Pneumonien.

In Switzerland 10 out of 1000 adults suffer from pneumonia each year. It is of note that mycoplasma, influenza virus and pneumococci are the most common causative agents of community-acquired pneumonia. For the latter macrolides are presently the antibiotics of choice. Pneumonias occurring in patients with immune disorders should be treated primarily with amoxicillin + clavulanic acid or with cephalosporins of the second generation, because infestation with germs like haemophilus influenzae and klebsiella pneumoniae have to be considered. If the empirically chosen therapy should fail, the therapeutic strategy should not be changed blindly. Differential diagnosis and appropriate investigations are necessary (other germ, other disease, complications?). Problems in treating patients with pneumonia are illustrated by three case examples.

Exercise capacity as a predictor of postoperative complications in lung resection candidates.

Exercise testing with measurement of maximal oxygen uptake (VO2max) is increasingly used in the assessment of lung resection candidates, but its predictive value for postoperative complications remains controversial. We therefore sought to determine the prognostic value of VO2max compared with other pulmonary function tests. A consecutive group of 80 patients (mean age 61 yr; 57 males and 23 females) scheduled for lung resection (62 malignancies, 12 benign disorders, and 6 carcinoids) underwent pulmonary function tests and symptom-limited cycle ergometry. All patients underwent lung resections: 21 pneumonectomies, 45 lobectomies, and 14 segmental or wedge resections. Group A (64 patients, 80%) had an uneventful postoperative course, whereas Group B (16 patients, 20%) had complications; 3 of them died (4% overall mortality rate). In a stepwise logistic regression analysis used to determine independent risk factors for postoperative complications (within 30 d), VO2max expressed as a percentage of predicted (84 +/- 19 for Group A versus 61 +/- 11 for Group B) proved to be the best predictor (predictive value 85.5%). Although VO2max expressed in absolute values (ml/kg/min) was also highly predictive (79.5%), a ROC curve analysis proved the percentage predicted values to be significantly more sensitive. Of 9 patients with a VO2max < 60% of predicted, 8 had complications, including all 3 patients who died after resections of more than one lobe (sensitivity 50%, specificity 98%). The estimated probability (probit model SAS software package) of suffering no complication was 0.9 for VO2max > 75% of predicted and 0.1 for a VO2max < 43%.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of high-risk lung resection candidates: pulmonary haemodynamics versus exercise testing. A series of five patients.

We compared the value of exercise testing and measurement of pulmonary haemodynamics (PH) in the pre-operative assessment of 5 patients (mean age: 64 years, 3 men) with clinical stage I or II bronchogenic carcinoma and severe chronic obstructive pulmonary disease. They were considered at high risk due to poor pulmonary function tests (PFT); (one or more of the following): (1) radionuclide calculated postlobectomy FEV1 < 30% predicted, (2) diffusion capacity or transfer factor < 60% predicted, combined with a fall in PaO2 on maximal exercise of > 5 mm Hg, (3) a PaCO2 at rest of > 45 mm Hg. Maximal oxygen uptake (VO2max) during symptom-limited cycle ergometry and PH were measured in these 5 patients. They were considered eligible for lobectomy if they fulfilled at least one of the two criteria: (1) mean pulmonary artery pressure (PAP) of < 35 mm Hg and pulmonary vascular resistance of < 190 dyn.s.cm-5 at moderate exercise (40 W), (2) a VO2max of > or = 15 ml/kg/min. Six months postoperatively PFT and VO2max were measured again. PAP40W was 21, 38, 38, 46 and 52 mm Hg, respectively, which would have excluded 4/5 patients from surgery. VO2max was 21.7, 14.9, 13.4, 19.2 and 18.6 ml/kg/min, respectively, which would have excluded 2/5 patients. Expressed in percent predicted, however, VO2max was > or = 69% in all 5 patients, indicating only mild impairment of exercise capacity in the 2 patients with < 15 ml/kg/min VO2max. Therefore all 5 patients were offered surgery and underwent lobectomy. Apart from 1 prolonged air leak no complications occurred, the mean hospital stay was 16 days (13-21).(ABSTRACT TRUNCATED AT 250 WORDS)

[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.

Lexicalization in an anomic patient.

Following a haemorrhage in the left temporal lobe, a 25 yr-old left-handed male patient presented a word finding difficulty, particularly in confrontation naming. The patient had extensive semantic knowledge of the items that he was not able to name. Several experiments showed that he had a poor phonological image of the target word and was poorly helped by phonological cues. He had a better knowledge of the graphological image, but it remained insufficient to result in word retrieval. On several occasions, when the patient failed to name a picture which happened to be lexicalized by a polysemous word, a residual covert word form could still operate as a link between different meanings of the target word; then, the patient produces a word or a circumlocution related to one meaning which was not the illustrated meaning. This kind of response could be called a parasemia. We postulate that the patient's deficit took place outside semantic treatment and before achievement of lexical (phonological or graphological) output.

Electrophysiological evidence for a shared representational medium for visual images and visual percepts.

Does mental imagery involve the activation of representations in the visual system? Systematic effects of imagery on visual signal detection performance have been used to argue that imagery and the perceptual processing of stimuli interact at some common locus of activity (Farah, 1985). However, such a result is neutral with respect to the question of whether the interaction occurs during modality-specific visual processing of the stimulus. If imagery affects stimulus processing at early, modality-specific stages of stimulus representation, this implies that the shared stimulus representations are visual, whereas if imagery affects stimulus processing only at later, amodal stages of stimulus representation, this implies that imagery involves more abstract, postvisual stimulus representations. To distinguish between these two possibilities, we repeated the earlier imagery-perception interaction experiment while recording event-related potentials (ERPs) to stimuli from 16 scalp electrodes. By observing the time course and scalp distribution of the effect of imagery on the ERP to stimuli, we can put constraints on the locus of the shared representations for imagery and perception. An effect of imagery was seen within 200 ms following stimulus presentation, at the latency of the first negative component of the visual ERP, localized at the occipital and posterior temporal regions of the scalp, that is, directly over visual cortex. This finding provides support for the claim that mental images interact with percepts in the visual system proper and hence that mental images are themselves visual representations.

An in vivo kinetic model with L-[35S]methionine for the determination of local cerebral rates for methionine incorporation into protein in the rat.

A method has been developed for the simultaneous in vivo measurement of local rates for methionine incorporation into cerebral protein in the rat. It is based on the use of L-[35S]methionine as a tracer for reflecting the bidirectional exchange of methionine between plasma and brain and its incorporation into cerebral protein, using a dynamic three-compartment model. An operational equation based on this model has been derived in terms of determinable variables. The method has been applied to the normal freely moving rat and to the rat under chloral hydrate anesthesia. In the freely moving rat, the values of methionine incorporation into cerebral protein in the gray matter vary widely from structure to structure (50-300 nmol/100 g/min), with the highest values in structures related to neurosecretory functions, e.g., supraoptic and paraventricular nuclei. The values for white matter are more uniform (24-28 nmol/100 g/min) at levels approximately six- to seven-fold lower than for gray matter. Chloral hydrate anesthesia depresses the rate of methionine incorporation in all the structures examined. Anesthesia did not reduce the heterogeneity normally present within gray matter.

[Measurement of in vivo incorporation of L-methionine-35S into cerebral proteins by quantitative autoradiography in freely-moving or anesthetized rats]. / Mesure in vivo de l'incorporation de L-méthionine-35S dans les protéines cérébrales par autoradiographie quantitative chez le rat libre de se mouvoir ou anesthésié.

Incorporation of L-35S-methionine in brain proteins was measured by quantitative autoradiography in the rat. This model was checked by biochemical procedures. In awake freely moving rat, methionine incorporation rates vary from 36 to 258 nmol/100g/min. During anaesthesia, protein synthesis in brain decreases (30 to 50%).