Influence of repeated maximal exercise testing on biomarkers and fatigue in sarcoidosis.

Fatigue in the immune mediated inflammatory disease sarcoidosis is thought to be associated with impaired exercise tolerance. This prospective study assessed fatigue and recuperative capacity after repeated exercise, and examined whether changing concentrations in biomarkers upon exercise are associated with fatigue. Twenty sarcoidosis patients and 10 healthy volunteers performed maximal cardiopulmonary exercise tests on two successive days. Concentrations of cytokines, stress hormones, ACE and CK were assessed before and after the two exercise tests, and 3 days thereafter. All participants completed a sleep diary. Severely fatigued patients showed significant lower VO2 max (p=0.038, p=0.022) and maximal workload (p=0.034, p=0.028) on both exercise tests compared to healthy controls. No impairment of maximal exercise testing was demonstrated during the second cycling test in any group. Fatigue was not correlated with changes in concentrations of biomarkers upon exercise. Severely fatigued patients rated both tests as significantly more fatiguing, and reported significant lower mean subjective night sleeping time during the testing period. Fatigue in sarcoidosis patients cannot be objectified by reduction of exercise capacity after repeated maximal exercise testing, and is not correlated with significant changes in biomarkers. Severe fatigue is only and consistently featured by patient reported outcomes.

Metabolic acidosis improves airway conductance in patients with asthma.

The objective was to investigate whether acute metabolic acidosis could cause bronchodilation in patients with asthma. Twelve patients with asthma (8 females, mean age 39 (+/- SD 12) years, forced expiratory volume in 1 second [FEV(1)] 93 [+/-9] % predicted, PC(20) 1.9 (+/-1.0) mg/mL) participated in a double-blind, placebo-controlled trial. Subjects ingested calculated amounts of ammonium chloride to induce acidosis or saline as placebo, in random order, each on a separate day. Airway resistance (R(aw)), specific airway conductance (sG(aw)), FEV(1), and PEF were measured as primary variables. To evaluate the consequences of alterations in bronchial contractility on the airway responsiveness, the histamine provocation test (PC(20)) was measured as secondary variable. The intervention resulted in a mean (SD) decrease in base excess from -0.5 (+/-1.4) to -3.9 (+/-1.1) mmol/L (p < 0.01) and a decrease in pH from 7.41 (+/-0.02) to 7.36 (+/-0.02) (p < 0.01). This caused a statistically significant increase in sG(aw) from 1.15 (+/-0.16) to 1.26 (+/-0.13) 1/kPa.s) (p < 0.05). Tendencies towards increase were found in PEF (7.79 (+/-2.2) versus 8.09 (+/-1.9) (NS, p = 0.10) and in FEV(1) (2.98 (+/-0.9) versus 3.06 (+/-0.9) (NS, p = 0.15). PC(20) did not change significantly. It was concluded that acute metabolic acidosis has a modest bronchodilating effect in patients with asthma.

[Dyspnoea caused by upper-airway obstruction: simple diagnosis by establishing a flow-volume loop]. / Dyspneu door vernauwing in de bovenste luchtwegen: eenvoudige diagnostiek met een flowvolumecurve.

Three patients, men aged 72, 78 and 19 years, experienced shortness of breath and laboured breathing. All three had an upper-airway obstruction detected by a flow-volume loop and confirmed by bronchoscopy. The first patient had oesophageal carcinoma with vocal-cord paralysis and soon died. The second patient had a large struma; flow-volume loop improved after strumectomy. The third patient was diagnosed with extragonadal testicular carcinoma. The flow-volume loop improved after the first chemotherapy session. Flow-volume loop is an easy, non-invasive diagnostic tool that can be used even in severely-ill patients. It can provide information about the location of the obstruction and can differentiate between obstructive pulmonary disease and upper-airway obstruction. Therefore, it is recommended to obtain a flow-volume loop during the assessment of patients with upper airway obstruction.

Tension pneumopericardium caused by positive pressure ventilation complicating anaerobic pneumonia.

A 22-year-old man was admitted with pneumonia. He was immediately intubated and positive pressure ventilation was initiated. Blood and sputum cultures showed Bacteroides fragilis and Corynebacterium sp., which were treated with metronidazole and clindamycin. Three weeks later his blood pressure suddenly dropped with an elevation of the central venous pressure. Chest X-ray revealed a pneumopericardium. A parasternal mediastinotomy with partial pericardiectomy was immediately performed. On opening the pericardium his blood pressure normalised. The patient gradually recovered and six weeks after admission he was extubated. Two weeks later he was discharged. A pneumopericardium without previous thorax trauma is very rare and early recognition is imperative because a tension pneumopericardium with cardiac tamponade may develop, as happened in this case. A tension pneumopericardium has to be treated with immediate pericardiocentesis followed by partial pericardiectomy to avoid recurrence.