[Development of two questionnaires for the assessment of knowledge and self-management in patients with chronic-obstructive pulmonary disease (COPD)]. / Entwicklung zweier Fragebögen zum Krankheitswissen und Umgang mit der Erkrankung für Patienten mit chronisch-obstruktiver Lungenerkrankung (COPD).

INTRODUCTION: As with other chronic diseases, the course of chronic obstructive pulmonary disease (COPD) can be expected to be positively influenced if patients are well informed about their disease and undertake appropriate self-management. Assessments of the level of knowledge and management that are comparable should benefit from structured, systematically developed questionnaires. These, however, have not been published in Germany. METHODS: A total of 310 patients with COPD were recruited from three pneumological practices and one hospital to develop the questionnaires. Based on statistical criteria and content assessments by medical specialists, two questionnaires on knowledge (17 questions) and self-management (25 questions) were developed by selecting and modifying questions from published studies and training programs. In addition, two short versions with 5 and 3 questions were created to enable a quick assessment of the patients' knowledge and self-management. All questionnaires also included a visual analogue scale for self-assessment of knowledge and self-management. The statistical procedures for systematically guided selection comprised correlation and regression analyses. RESULTS: The questionnaires revealed considerable knowledge deficits in many patients and remarkably unsystematic, incoherent knowledge. The extent of this knowledge was negatively correlated with higher age and positively correlated with participation in training programs; this also applied to self-management. Correlations between the answers to the knowledge questions were higher in patients who had participated in training programs. The visual analogue scales for self-assessment of knowledge and management always correlated with the total number of correct answers. DISCUSSION: The questionnaires on knowledge and self-management in patients with COPD could be used in outpatient settings, including by non-medical staff, in order to quickly identify and correct deficits or as a reason to recommend training programs. The short versions and the analogue scales for self-assessment can give at least first hints. Potentially, training programs should focus more on promoting the coherence of knowledge through better understanding, as this presumably favors long-term knowledge. Older patients and those with a low level of education appear to be particularly in need of specially adapted training programs.

Characteristics of Current Smokers versus Former Smokers with COPD and Their Associations with Smoking Cessation Within 4.5 Years: Results from COSYCONET.

Background: Many patients with chronic obstructive pulmonary disease (COPD) continue smoking. We used data from the "real-life" COSYCONET COPD cohort to evaluate whether these patients differed from patients with COPD who either had ceased smoking prior to inclusion or ceased during the follow-up time of the study. Methods: The analysis was based on data from visits 1-5 (covering 4.5 years), including all patients with the diagnosis of COPD who were either ex-smokers or smokers and categorized as GOLD 1-4 or the former GOLD 0 category. We compared the characteristics of smokers and ex-smokers at baseline (visit 1), as well as the course of lung function in the follow-up of permanent ex-smokers, permanent smokers and incident ex-smokers (smokers at visit 1 who ceased smoking before visit 5). We also identified baseline factors associated with subsequent smoking cessation. Results: Among 2500 patients who were ever-smokers, 660 were current smokers and 1840 ex-smokers at baseline. Smokers were younger than ex-smokers (mean 61.5 vs 66.0 y), had a longer duration of smoking but fewer pack-years, a lower frequency of asthma, higher forced expiratory volume in 1 sec (FEV1, 59.4 vs 55.2% predicted) and higher functional residual capacity (FRC, 147.7 vs 144.3% predicted). Similar results were obtained for the longitudinal subpopulation, comprising 713 permanent ex-smokers, 175 permanent smokers, and 55 incident ex-smokers. When analyzing the time course of lung function, higher FRC, lower FEV1 and the presence of asthma (p < 0.05 each) were associated with incident cessation prior to visit 5, while less airway obstruction was associated with smoking continuation. Conclusion: These findings, which were consistent in the cross-sectional and longitudinal analyses, suggest that lung hyperinflation was associated with being or becoming ex-smoker. Possibly, it is perceived by patients as one of the factors motivating their attempts to quit smoking, independent from airway obstruction.

Intracaval and intracardiac leiomyomatosis of uterine origin.

A 37-year-old woman, gravida 2, para 1 presented in the outpatient ward with dyspnoea and tachycardia of unknown origin. The physical examination was unremarkable. Echocardiography revealed an intracardiac mass protruding through the tricuspid orifice into the right ventricle during diastole. The patient was admitted to the intensive care unit with the suspicion of vena cava thrombosis with intracardiac expansion. An abdominal sonography showed a mass in the uterus, presumed to be a benign tumour, with extension into the vena cava inferior. Owing to the extent of the mass in the right atrium and the risk for pulmonary embolism, after interdisciplinary discussion, a decision to remove the atrial mass was made. The case was managed by a two-stage procedure. Pathological examination of the intracardiac portions of the tumour revealed a benign tumour that consisted of proliferating smooth muscle fibres without abnormal mitotic activity.

Effects of Renal Sympathetic Denervation on 24-hour Blood Pressure Variability.

BACKGROUND: In patients with arterial hypertension, increased blood pressure (BP) variability contributes to end organ damage independently from mean levels of arterial BP. Increased BP variability has been linked to alterations in autonomic function including sympathetic overdrive. We hypothesized that catheter-based renal sympathetic denervation (RDN) confers beneficial effects on BP variability. METHODS AND RESULTS: Eleven consecutive patients with therapy-refractory arterial hypertension (age 68.9 ± 7.0 years; baseline systolic BP 189 ± 23 mmHg despite medication with 5.6 ± 2.1 antihypertensive drugs) underwent bilateral RDN. Twenty-four hour ambulatory BP monitoring (ABPM) was performed before RDN and 6 months thereafter. BP variability was primarily assessed by means of standard deviation of 24-h systolic arterial BP (SD(sys)). Secondary measures of BP variability were maximum systolic BP (MAX(sys)) and maximum difference between two consecutive readings of systolic BP (Δmax(sys)) over 24 h. Six months after RDN, SD(sys), MAX(sys), and Δmax(sys) were significantly reduced from 16.9 ± 4.6 to 13.5 ± 2.5 mmHg (p = 0.003), from 190 ± 22 to 172 ± 20 mmHg (p < 0.001), and from 40 ± 15 to 28 ± 7 mmHg (p = 0.006), respectively, without changes in concomitant antihypertensive therapy. Reductions of SD(sys), MAX(sys), and Δmax(sys) were observed in 10/11 (90.9%), 11/11 (100%), and 9/11 (81.8%) patients, respectively. Although we noted a significant reduction of systolic office BP by 30.4 ± 27.7 mmHg (p = 0.007), there was only a trend in reduction of average systolic BP assessed from ABPM (149 ± 19 to 142 ± 18 mmHg; p = 0.086). CONCLUSION: In patients with therapy-refractory arterial hypertension, RDN leads to significant reductions of BP variability. Effects of RDN on BP variability over 24 h were more pronounced than on average levels of BP.

Severe autonomic failure in moderate to severe aortic stenosis: prevalence and association with hemodynamics and biomarkers.

BACKGROUND: Severe autonomic failure (SAF) refers to combined abnormalities in reflex and tonic autonomic function. SAF indicates increased risk of death in post-infarction and heart failure patients, but has not been studied in aortic stenosis (AS). Here, we investigated SAF in patients with AS and tested its correlation with hemodynamic and biochemical markers. METHODS: We prospectively enrolled 174 patients with moderate to severe AS in sinus rhythm (age 76 ± 9 years; mean aortic valve area 0.9 ± 0.3 cm(2)). Heart rate turbulence (as marker of autonomic reflex activity) and deceleration capacity (as marker of autonomic tonic activity) were calculated from 24-h Holter recordings. According to the previously published technology, SAF was considered present if both factors were abnormal. RESULTS: 44 (25.3%) of the 174 patients had signs of SAF. Patients with SAF had lower left ventricular ejection fraction (LVEF: 48.1 vs. 54.8%; p = 0.002), lower mean aortic gradients (28 vs. 34 mmHg, p = 0.019), higher systolic pulmonary artery pressures (46.8 vs. 40.9 mmHg, p = 0.028), higher levels of brain natriuretic peptide (905 vs. 407 ng/l; p = 0.003) and higher levels of high sensitive troponin I (0.65 vs. 0.24 µg/l; p = 0.013). Impaired LVEF (≤50%) was the only independent factor associated with SAF, but only explained autonomic abnormalities in less than half of the patients. CONCLUSIONS: In patients with moderate to severe AS prevalence of SAF is high. SAF correlates with hemodynamic and biochemical markers indicating increased risk. Future studies should evaluate the prognostic value of SAF in patients with AS.

Prognostic value of mild-to-moderate pulmonary hypertension in patients with severe aortic valve stenosis undergoing aortic valve replacement.

BACKGROUND: Optimal timing of elective aortic valve replacement (AVR) for severe aortic stenosis (AS) is challenging. Hence, a sensitive marker in AS patients indicating increasing risk after AVR would be of great clinical value. In the present study, we hypothesized that mild-to-moderate pulmonary hypertension (PH) assessed prior to AVR is a sensitive marker for adverse events in patients after successful AVR. METHODS: We enrolled 200 consecutive patients with severe AS undergoing AVR. Among them, 176 patients (88%) were symptomatic. Patients were divided according to systolic pulmonary artery pressure (PAP(sys)) into three groups: no PH (PAP(sys) <30 mmHg), mild-to-moderate PH (PAP(sys) ≥30 and PAP(sys) <60 mmHg) and severe PH (≥60 mmHg). Multivariable analyses were adjusted for age and gender and included PH, left ventricular ejection fraction ≤35%, renal insufficiency and logistic EuroSCORE ≥20%. Primary endpoint was death of any cause within 5 years after AVR. RESULTS: During follow-up, 23 patients died (cumulative 5-year mortality rate 14.6%). Patients without (n = 78), mild-to-moderate (n = 99) and severe PH (n = 23) had 5-year mortality rates of 2.6, 15.2 and 26.1% (p = 0.001). PAPsys ≥30 mmHg yielded an excellent level of sensitivity of 92.8%. On multivariable analysis, mild-to-moderate PH was the only independent risk factor (hazard ratio 4.9, 95% confidence interval 1.1-21.8). CONCLUSIONS: In patients with severe AS undergoing AVR, mild-to-moderate PH is a strong and independent predictor of late mortality. Conversely, patients with normal PAP(sys) have an extremely good prognosis.