[Prevalence of obstructive airway disease in middle-age adults. Cross sectional study in three different occupations]. / Prävalenz obstruktiver Atemwegserkrankungen im mittleren Erwachsenenalter - Vergleichende Querschnittuntersuchung in drei Berufsgruppen.

Medical management of COPD begins with an awareness of risk factors and identification of risk patients. To identify this patients, 179 healthy volunteers with no known obstructive airway disease (81 women, 98 men, 40,5 +/- 11,2 years) and three different occupations (43 factory workers, 33 community workers, mainly working outside and 113 office employees) participated in the cross sectional spirometry study. Demographic data concerning age, height and body weight were comparable. In the first two groups were more men and more smokers. After adjustment to sex, age and height smokers revealed significant lower data for FEV 1 (3,16 l vs. 3,44 l) and FEV 1 /IVC (74,5 % vs. 77,6 %) in the factory workers. Comparable data exists for smokers in the community workers for FEV 1 (3,21 l vs. 3,59 l) and FEV 1 /IVC (74,8 % vs. 79,6 %), but not for office employees (FEV 1 3,51 l vs. 3,54 l; FEV 1 /IVC 76,1 % vs. 78,4 %). Airway obstruction, defined by FEV 1 /IVC below 70 % could be identified in thirteen of 57 smokers (22,8 %) and in twelve of 122 non-smokers (9,8 %) or in 25 of all 179 volunteers (14 %). The influence of smoking was significant (P = 0,0123). As a consequence, first there is a need for an increased awareness and routine spirometry in ad-risk patients; second, education and smoking cessation programs have to be initiated.

[Functional effects of different training in patients with COPD]. / Funktionelle Effekte unterschiedlicher Trainingsformen bei Patienten mit COPD.

Disability and exertional dyspnea associated with chronic obstructive pulmonary disease has led to the development of rehabilitation programmes that aim to increase exercise tolerance and relief of dyspnea. To evaluate whether aerobic training (training groups P1 and P4), strength training (P2 and P5) or a combination of both (P4 and P6) is useful, 69 patients (44 m/25 f) with moderate to severe COPD were randomised to a three week inpatient training program. The training consisted of three weekly twenty minute exercise sessions without (P1 - P3) or with supplemental oxygen (P4 - P6) on a calibrated ergocycle (70 % W(max)) or three weekly sessions of 20 - 25 repetitions of 2 - 4 training series (40 % W(max)) or a combination of both. In general, the programme failed to demonstrate significant changes in lung function and arterial blood gases. Evaluation of exercise capacity via the six-minute-walking test (6MT) yielded a significant increase of the walking distance in all groups except P2 (60 - 83 m), The time to finish a test-set of daily activities (TAF) was reduced in all groups (5 - 58 sec) and reached significance in P1, P3, P5 and P6. After the 6MT, exertional dyspnea improved in all groups except P4 and was significant in P1 and P3; after the TAF, dyspnea again was reduced in all groups with a significant change in P2 and P5. These data support the hypotheses that a short term inpatient training programme is suitable to improve exercise-capacity and dyspnea. Patients with advanced disease (P4 - P6) show greater benefits with strength training (alone or in combination with aerobic training) while for patients with moderate disease (P1 - P3) aerobic training is favourable. These changes may translate into improved performance of daily activities and general well-being.

[The significance of health related quality of life for the evaluation of interventional measures in patients with COPD]. / Die Bedeutung der gesundheitsbezogenen Lebensqualität für die Bewertung interventioneller Massnahmen bei Patienten mit COPD.

Health related quality of life (HRQOL) is an important criterion for the evaluation of rehabilitation measures in patients with chronic obstructive pulmonary disease (COPD). The present paper reviews the current literature about the effects of pulmonary rehabilitation on the HRQOL of patients with COPD. The aim is to summarize critically methods, results and unanswered issues of the present research on the effects of pulmonary rehabilitation on HRQOL. The rehabilitation of patients suffering of COPD is mainly based on six types of interventions: 1. long-term oxygen therapy (LTO), 2. pharmacological management, 3. surgical therapy (bilateral reduction of lung volume), 4. physical therapy, 5. nutritional therapy (special diets), and 6. psycho-social interventions (e.g. psychotherapy, training and education). Thirty-one studies could be included in which HRQOL served as an outcome criterion for the rehabilitation of COPD patients. In 14 (45%) studies exclusively a disease-specific measure for the assessment of HRQOL was employed, while in 12 (39%) studies a generic instrument was applied. In the remaining five (16%) studies two ore more measures were used, whereas four of them combined a generic and a disease-specific method. The St. Georges Respiratory Questionnaire (SGRQ) und the Chronic Respiratory Disease Questionnaire (CRDQ) belonged to the group of the specific instruments, while among the generic measures the Sickness Impact Profile (SIP), the Nottingham Health Profile (NHP), the SF-36 and the Quality of Well-Being Scale (QWB) were most frequently used in COPD patients. The surgical bilateral reduction of lung volume, pharmacological therapy, upper extremities muscle training and psychological measures as single interventions proved to have persistent positive effects on the HRQOL. Several rehabilitation programs, composed of a wide variety of different interventions were effective in terms of HRQOL. On the other hand, at follow-up, the short-term positive effects had decreased in two of the three studies, where the rehabilitation took place exclusively in an inpatient setting. However, in three of four programs implemented in an outpatient setting, a persistent positive effect on HRQOL could be demonstrated. In conclusion from the as of yet available findings, we suggest for future studies to use only such measures of HRQOL which have been tested psychometrically in patients with COPD and to combine disease-specific and generic measures. In order to achieve lasting positive effects of rehabilitation on HRQOL, outpatient settings or ambulatory refreshment sessions following rehabilitation on an inpatient basis should be preferred.

Health-related quality of life, psychological adjustment and compliance to treatment in patients on domiciliary liquid oxygen.

The purpose of this study was to investigate the effects of two different aspects of compliance with liquid oxygen (LOX) therapy on quality of life and to explore possible pulmonary and psychosocial concomitants. The study sample consisted of 57 oxygen-dependent patients with chronic obstructive pulmonary disease under LOX therapy. Compliance was defined as continuous oxygen use as prescribed and also as readiness to use LOX outdoors. The study design encompassed three major measuring points, the first of which was an initial assessment, the second 3 months later and the third follow-up after 14 months. Furthermore, during the course of the study, two telephone interviews were conducted. The psychosocial variables studied included quality of life, psychological adjustment and two different aspects of compliance with LOX therapy. Seven (12%) patients used LOX less than prescribed and 13 (23%) refused to use LOX away from home. Those patients who used LOX insufficiently had a significantly lower life-satisfaction than those who were compliant (p = 0.02). The discriminance analysis included several psychosocial variables discriminating between both groups, allowing the correct classification of 85% of the patients who used LOX as prescribed and 83% of the noncompliant patients (p = 0.01). At follow-up, the data of 25 patients were available. Of these, five refused outdoor LOX use. Their quality of life was significantly worse in almost all areas examined as compared to the outdoor LOX-users (p < 0.05, respectively). Compliance is an essential prerequisite for the beneficial effects of liquid oxygen on quality of life. Because psychological factors influence adherence to liquid oxygen therapy, patients should receive individual psychological counselling and training before transfer to liquid oxygen therapy.

[Functional capacity (dyspnea) and quality of life in patients with chronic obstructive lung disease (COPD): instruments of assessment and methodological aspects]. / Funktionelle Kapazität (Dyspnoe) und Lebensqualität bei Patienten mit chronisch obstruktiven Lungenerkrankungen (COPD): Erhebungsinstrumente und methodische Aspekte.

Functional capacity (dyspnea) and quality of life are important criteria for the assessment of disease impact and treatment outcome in patients with chronic obstructive pulmonary disease (COPD). We will review measures for dyspnea and quality of life with particular emphasis on their methodological properties. Because asthma and COPD exhibit important differences and are therefore not comparable, we discuss only those measures which have been verified methodologically in patients with COPD. A critical review of current measures for dyspnea reveals at best an only fair association between perceived dyspnea and physiological lung function, sharing not more than 30% of common variance. Moreover, the affective state of the patients, their individual adaptation level and further psychological variables serve as mediators between lung function and perceived dyspnea. However, several valid and reliable measures for dyspnea are available for research and clinical practice. While the term "quality of life" is rather broad and unspecified, many researches in the field prefer the more restrictive term "health-related quality of life (HRQOL), that is the quality of life as affected by health status. The concept of HRQOL encompasses the impact of the individual's health on his or her ability to perform activities of daily living such as social role functioning, home management, social and family relationships, self-care, mobility, recreation and hobbies. In the past 15 years there has been an increasing body of literature on the measurement of HRQOL in patients with COPD. Several disease-specific and generic instruments for the use in COPD patients have been published. There is a growing consensus about the methodological criteria a given instrument has to fulfill. These are validity, sensitivity (for change) and reliability. They have to be tested in patients suffering from the illness for which the HRQOL instrument is planned to be applied in clinical studies or routine. The disease-specific instruments are supposed to be more sensitive to small therapeutically induced changes. However, the empirical results in patients with COPD are mixed and do not clearly favour disease-specific instruments. Lung function, dyspnea measures and exercise tolerance as well do not correlate strongly with HRQOL. Most associations cover only between 10% and 16% of shared variance. Exercise tolerance is not well associated with lung function but correlates better with HRQOL. Nowadays we can rely on several measures for dyspnea and HRQOL which have been thoroughly verified methodologically in COPD patients. However, some disease-specific and generic instruments exhibit substantial flaws, so that they need to be revised and it seems better not to use them at present. Many methodological and conceptual questions remain unanswered in the field indicating a strong need for more research.

[Quality of life in patients with chronic obstructive lung diseases: psychometric criteria of the German version of the Sickness Impact Profile and initial results of its application]. / Lebensqualität bein Patienten mit chronisch-obstruktiven Lungenerkrankungen: Psychometrische Gütekriterien der deutschen Version des Sickness Impact Profiles (SIP) und erste Ergebnisse der Anwendung.

BACKGROUND: Quality of life has become an important criterion for assessing disease impact and treatment outcome. The Sickness Impact Profile (SIP) is an internationally widely used generic instrument for the measurement of health related quality of life. Furthermore, it has been frequently employed for research in patients suffering from airway diseases. Therefore, we developed a German version of the SIP and investigated its psychometric properties in patients with chronic obstructive lung disease (COPD). PATIENTS AND METHODS: After translation of the SIP into German, the results of a pilot study suggested several changes. Some items had to be reformulated and the SIP subscales "Emotional and affective behavior", "Alertness" and "Body care and movement" had to be discarded because of insufficient psychometric properties. The reliability, validity and sensitivity of the resulting German SIP version were investigated in a sample of 58 O2-dependent patients with COPD. RESULTS: Internal consistency (Cronbach Alpha) was 0.93 for the entire instrument, while it was 0.85 for the SIP psycho-social scale and 0.89 for the SIP physical scale. The internal consistency ranged from 0.55 to 0.86 for the subscales of the German SIP version. The nutrition subscale was discarded because it showed an insufficient internal consistency (0.40). Indices of respiratory function (FEV1, FVC, Pa, O2, Sa, O2) and severity of dyspnea as assessed by the Baseline Dyspnea Index (BDI) were associated with the total SIP, psycho-social and physical score reaching from r = -0.19 to r = -0.48. Patients who improved after introduction of liquid oxygen therapy (LOX) showed a better total SIP score (p = 0.023) and less impairment in the SIP physical scale (p = 0.009). In order to evaluate the prognostic validity of the German SIP, a discriminance analysis between those patients who were alive 14 months later and those who had died of their illness was performed. A single discriminant function with an Eigenvalue of 0.59 (canonical correlation r = 0.61; CU2 = 21.213; df = 3; p < 0.001) was found. By means of the FVC, the severity of dyspnea (BDI), the SIP total score and the FEV1 85% of the survivors and 91 % of the fatalities could be predicted correctly. CONCLUSIONS: The present results demonstrate sufficient psychometric properties of the German SIP version for the use in patients with COPD and hypoxemia. However, the internal consistencies of the subscales "Work" and "Leisure pastimes and recreation" remain to be improved. Furthermore, the results of factor and cluster analyses suggest some changes in the internal structure of the German SIP.

Accuracy of nine commercially available pulse oximeters in monitoring patients with chronic respiratory insufficiency.

9 pulse oximeters (BIOX-III, Nellcor 250, Jaeger CNS, Micro2), Pulsox-8, Oxycount, PulsOXImeter, PalcoLabs and Pulsox-7) were studied in 90 COPD patients. The transcutaneus oxygen saturation (SaO2%) was compared with arterial oxygen saturation calculated simultaneously with drawn blood samples (AVL-995). The measurement of error distribution and the cumulative distribution function (CDF) of measurement errors allows ranking of the pulse oximeters, which can be divided in 3 groups. We conclude that the accuracy of the tested nine pulse oximeter does not enable precise absolute measurements, specially at lower oxygen saturation ranges.

Radiographic course of pulmonary manifestations in Wegener's granulomatosis under immunosuppressive therapy.

Eleven patients with generalized Wegener's granulomatosis were studied. Pulmonary involvement occurred 1 month earlier than a rapid rise of serum creatinine value. Under immunosuppressive therapy, nodules and infiltrations abated slower in patients with bronchopulmonary superinfection (mean, 30 days) compared with patients without superinfection (mean, 18 days). In the short run, radiographic course was a better indicator for therapeutic success than the course of cytoplasmatic antineutrophil cytoplasm antibody titer. If the pulmonary findings did not begin to clear within 1 week after treatment had been started, either superinfection or insufficient immunosuppression was present. In this situation, a more aggressive therapy in combination with antibiotics is suggested.

[Nuclear spin tomographic findings in compensated chronic hemolysis. A case report of a hereditary spherocytosis]. / Kernspintomographische Befunde der kompensierten chronischen Hämolyse. Fallbericht über eine hereditäre Sphärozytose.

A case report of a 58-year-old patient with hereditary spherocytosis and large paravertebral masses in the thorax and abdomen is presented MRI detects the origin of the masses with typical signal intensities of the masses and the bone marrow in T1 and T2 weighted sequences as extramedullary hematopoiesis. In this special case there is bleeding into these masses and, as often, liver hemosiderosis and splenomegaly.

Sleep-related oxygen desaturation and daytime pulmonary haemodynamics in COPD patients.

It has been hypothesized that in chronic obstructive pulmonary disease (COPD), sleep-related hypoxaemia could lead to pulmonary hypertension (PH) and cor pulmonale, even in patients with only mild daytime hypoxaemia. We investigated the relationships between sleep variables and daytime pulmonary haemodynamics in 40 COPD patients with daytime arterial oxygen tension (PaO2) between 60-70 mmHg (8-9.3 kPa). Patients were considered as desaturators if they spent at least 30% of the sleep recording time with a transcutaneous O2 saturation (StcO2) less than 90%. Daytime arterial blood gases and pulmonary volumes could not discriminate desaturators "D" (n = 18) from non-desaturators "ND" (n = 22), but awake baseline StcO2, measured just prior to the onset of sleep, was lower in group D. Pulmonary artery mean pressure was significantly higher in group D (19.1 +/- 4.7 vs 16.8 +/- 1.9 mmHg, p less than 0.05) and all patients with PH (6 out of 40) belonged to group D. PH was observed in 6 of the 15 patients whose mean nocturnal StcO2 was less than 90% but in none of the 25 with a mean nocturnal StcO2 greater than 90%. The PH patients (n = 6), all desaturators, differed from the desaturators with no PH (n = 12), and from ND (n = 22) in having higher numbers of desaturation dips, longer durations of dips, and lower mean nocturnal arterial oxygen saturation (SaO2). We conclude that a causal relation between nocturnal desaturation and permanent PH is very likely. Further studies are needed to see whether oxygen therapy can prevent PH in these patients.

[Imaging in isolated pulmonary immunocytoma]. / Bildgebung bei isoliertem pulmonalem Immunozytom.

A extranodal pulmonary immunocytoma that originated from the lung is reported. It was hidden behind the picture of a mid-lobe syndrome at repeated imaging controls over a 1.5-year period. In the further course a local progression occurred displayed by roentgenography and computer tomography including calcifications within the pulmonary tumor. A newly developing monoclonal gammopathy was detected by immunoelectrophoresis at the same time. Bronchopulmonary symptoms due to the tumor did not exist. After local resection of the lymphoma monoclonal gammopathy disappeared. However, a recurrence of monoclonal gammopathy developed after eight months.

[The value of bronchoalveolar lavage in the diagnosis of interstitial lung diseases]. / Wertigkeit der bronchoalveolären Lavage bei der Diagnostik interstitieller Lungenerkrankungen.

Bronchoalveoläre lavage (BAL) allows microscopic, cytologic and immunocytologic diagnosis of alveolar and interstitial lung disease. The indications for BAL depend on chest X-rays, signs and symptoms and lung function tests, e.g., spirometry or whole-body plethysmography, CO-diffusion capacity and blood gases during exercise. Supporting laboratory parameters are angiotensin converting enzyme, antinuclear antibodies and serum precipitins. Pulmonary parenchymal pathology documented on chest X-rays or by high-resolution computed tomography of the chest allows selective investigation of the involved areas. Different typical patterns with predominantly neutrophils or lymphocytes and their subsets or the presence of malignant cells or Pneumocystis carinii in the BAL fluid allowed the diagnosis in 115 patients. If possible, histological confirmation should be achieved by transbronchial biopsy. When indications are carefully applied and are based on the history as well as the clinical signs and symptoms, BAL is an efficient diagnostic tool in interstitial lung disease, which can be performed in out-patients even if transbronchial biopsy is done.

[Interstitial cancerous lung diseases. Lymphangiosis carcinomatosa and leukemic pulmonary infiltrates]. / Interstitielle Tumorerkrankungen der Lunge. Lymphangiosis carcinomatosa und leukämische Lungeninfiltrate.

The radiological findings in pulmonary lymphangitic carcinomatosis and in leukemic pulmonary infiltrates mirror the tumor-dependent monomorphic interstitial pathology of lung parenchyma. It is a proven fact that pulmonary lymphangitic carcinomatosis is caused by hematogenous tumor embolization to the lungs; pathogenesis by contiguous lymphangitic spread is the exception. High-resolution CT performed as a supplement to the radiological work-up improves the sensitivity for pulmonary infiltrates in general and thus makes the differential diagnosis decided easier. Radiological criteria cannot discriminate the different forms of leukemia. Plain chest X-ray allows the diagnosis of pulmonary involvement in leukemia due to tumorous infiltrates and of tumor- or therapy-induced complications. It is essential that the radiological findings be interpreted with reference to the stage of tumor disease and the clinical parameters to make the radiological differential diagnosis of opportunistic infections more reliable.

Biosynthesis and secretion of M- and Z-type alpha 1-proteinase inhibitor by human monocytes. Effect of inhibitors of glycosylation and of oligosaccharide processing on secretion and function.

The biosynthesis and secretion of M-type and Z-type alpha 1-antitrypsin was studied in human monocytes. In monocytes of PiMM individuals alpha 1-antitrypsin represented 0.08% of the newly synthesized proteins and 0.44% of the secreted proteins. Two molecular forms of alpha 1-antitrypsin could be identified: a 51-kDa intracellular form, susceptible to endoglucosaminidase H, thus representing the high-mannose type precursor form and a 56-kDa form resistant to endoglucosaminidase H which was secreted into the medium. Inhibition of de novo glycosylation by tunicamycin impaired the secretion of M-type alpha 1-antitrypsin by about 75% whereas inhibition of oligosaccharide processing by the mannosidase II inhibitor swainsonine did not alter the secretion of M-type alpha 1-antitrypsin. alpha 1-Antitrypsin secreted by human monocytes was functionally active as measured by complex formation with porcine pancreatic elastase. Even unglycosylated alpha 1-antitrypsin secreted by human monocytes treated with tunicamycin formed a complex with elastase. In monocytes of PiZZ individuals the secretion of alpha 1-antitrypsin was decreased. 72% of newly synthesized M-type alpha 1-antitrypsin, but only 35% of newly synthesized Z-type alpha 1-antitrypsin were secreted during a labeling period of 3 h with [35S]methionine. The 51-kDa form of Z-type alpha 1-antitrypsin accumulated intracellularly, whereas the 56-kDa form was secreted. Inhibition of oligosaccharide processing by swainsonine did not alter the decreased secretion of Z-type alpha 1-antitrypsin, whereas inhibition of de novo glycosylation by tunicamycin blocked the secretion of Z-type alpha 1-antitrypsin completely.

[Surfactant phospholipids in bronchoalveolar lavage fluid in smokers with healthy lungs and non-smokers]. / Surfactant-Phospholipide der BAL-Flüssigkeit bei lungengesunden Rauchern und Nichtrauchern.

The surfactant phospholipids were determined in the BA1 fluid of 9 smokers and 9 non-smokers with no disease of the lungs. The total phospholipid content was reduced significantly in smokers to 10 +/- 6 nmol/ml as compared with 24 +/- 10 nmol/ml in the non-smokers (p less than 0.02). The composition of major phospholipid fractions (phosphatidyl-choline and phosphatidyl-ethanolamine) did not differ between the two groups. Possible reasons for this reduction of surfactant in smokers are discussed.

[Immunocytochemical characterization of malignant pleural effusions of small cell bronchial cancer]. / Immunzytochemische Charakterisierung maligner Pleuraergüsse beim kleinzelligen Bronchialkarzinom.

In pleural effusions, histologically proven to be malignant in 13 patients with small cell lung cancer, the immunocytological profile of tumour cells, together with the distribution of the lymphocyte subpopulations, were established. In all cases, tumor cells were demonstrable with the monoclonal antibodies EMA, HEA-125, Sam 2, 6, 8 and 10. In contrast, conventional cytology was positive in only 6 of the 13 cases. As in other malignant or inflammatory effusions, phenotyping of the lymphocytes revealed an elevated T4/T8 ratio in comparison with the normal value for peripheral blood.