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Neoplastic pericardial disease in lung cancer: Impact on outcomes of different treatment strategies. A multicenter study.

BACKGROUND: Local (intrapericardial) chemotherapy has been reported to be useful for the treatment of neoplastic pericardial disease, but it has never been compared to systemic chemotherapy, a combination of the two and simple pericardial drainage or sclerosis.

METHODS: We analyzed the clinical and echocardiographic data of 119 patients, suffering of neoplastic pericarditis due to lung cancer (97 with non-small-cell), comparing the outcomes of four different treatment strategies (extended catheter drainage/sclerosis, systemic chemotherapy, local chemotherapy, and combined - local plus systemic - chemotherapy) at the last available follow-up or at the change of therapy after a treatment failure. The outcomes (based on semiquantitative evaluation of pericardial disease) were classified as complete, partial, no response and progressing disease.

RESULTS: A complete response was achieved in 37/53 of patients with combined, in 12/22 with local, in 5/27 with systemic chemotherapy, respectively, and in 4/17 after drainage/sclerosis (p<0.001). Overall response was achieved in 51/53 with combined, 18/22 and 16/27 with local or systemic chemotherapy, respectively, and in 5/17 with drainage/sclerosis only (p<0.001). Survival was significantly better after combined chemotherapy (p<0.001) and 12/53 patients (23%) in this subgroup survived more than 1 year. The overall response rate was higher with intrapericardial cisplatinum than with other agents (98% vs 80%, χ(2)=7.69, p<0.01).

CONCLUSIONS: Local chemotherapy, alone or with systemic chemotherapy, is effective in treating pericardial metastases from lung carcinoma, leading to a good control of pericardial effusion in 92% of cases, and to complete disappearance of effusion and masses in 65%. Combined therapy is significantly better than any other treatment. Pericardiocentesis and intrapericardial chemotherapy should be used whenever possible in lung cancer neoplastic pericardial disease, not only in case of tamponade.

Annual change of respiratory functions in adult patients with asthma: the potential of antiasthma treatments for many years to repair irreversible changes of the airway.

BACKGROUND: Little is known regarding annual changes of respiratory functions among patients with asthma after asthma symptoms enter remission.

OBJECTIVE: Annual changes of respiratory function and influence of patient characteristics and treatment variables on these changes were assessed in patients with adult asthma.

METHODS: Respiratory function (pre- and postbronchodilator forced expiratory volume in one second [FEV₁] and reversibility by short-acting β₂-agonist) and their changes were retrospectively investigated and relationships between these changes, after symptomatic remission, and patient characteristics and treatments were analyzed in adult outpatients with asthma who had undergone spirometry (including a reversibility test) ≥5 times in >5 years.

RESULTS: In patients ≥40 years old, or with disease duration ≥10 years or receiving treatment for severe asthma (steps 4-5, high-dose inhaled glucocorticosteroids, or addition of other medications), both pre- and postbronchodilator FEV₁ values were significantly lower (p < .05). Mean annual change of prebronchodilator FEV₁ (Δpre-FEV₁), annual change of postbronchodilator FEV₁ (Δpost-FEV₁), and annual change of reversibility (Δ reversibility) were -13.8 ± 59.7 ml/year, -25.9 ± 51.0 ml/year, and -0.56% ± 1.89%/year, respectively. Multivariate analysis after stepwise selection for variables in patient characteristics or treatments showed that disease duration ≥10 years contributed to annual improvement of respiratory functions (Δpre-FEV₁: odds ratio [OR] 1.57, 95% confidence interval [CI] 1.01-2.46; Δpost-FEV₁: OR 2.13, 95% CI 1.25-3.66), treatment with long-acting β₂-agonists (LABAs) contributed to annual improvement of respiratory function (Δpre-FEV₁: OR 2.05, 95% CI 1.23-3.16; Δpost-FEV₁: OR 1.78, 95% CI 1.11-2.87), and poor compliance contributed to annual worsening of respiratory functions (Δpre-FEV₁: OR 0.43, 95% CI 0.24-0.76; Δpost-FEV₁: OR 0.39, 95% CI 0.22-0.70). In addition, duration of disease ≥10 years and severe treatment (steps 4-5) from the beginning contributed to decreasing Δreversibility (OR 0.55, 95% CI 0.34-0.87 and OR 0.50, 95% CI 0.29-0.83, respectively).

CONCLUSIONS: Long-term treatments for asthma are expected to normalize respiratory dysfunction, which cannot be repaired in the short term. Treatment with LABAs and patient compliance may be the most important factors associated with annual improvement of respiratory functions.

Treatment options in Cheyne-Stokes respiration.

About half of the patients suffering from heart failure present with sleep-disordered breathing. In most cases obstructive and central breathing disturbances (including Cheyne-Stokes respiration [CSR]) coexist.

CSR is defined by a waxing and waning pattern of the tidal volume. While its pathophysiology has not been elucidated completely, increased ventilatory sensitivity for CO(2) and therefore an imbalance of the respiratory drive and effort, a chronic hyperventilatory state, and changes of the apnoeic threshold are considered to play a relevant role. However, CSR in heart failure impairs survival and quality of life of the patients and is therefore a major challenge of respiratory sleep medicine. If CSR persists despite optimal medical and interventional therapy of the underlying cardiac disorder, oxygen supply, continuous positive airway pressure (CPAP), and bilevel pressure are often trialled. However, there is insufficient evidence to recommend oxygen or bilevel treatment. CPAP has proven to improve left ventricular function. In addition, retrospective analyses suggested a reduction of mortality under CPAP in heart failure patients with CSR. However, these findings could not be reproduced in the prospective controlled CanPAP trial.

More recently, adaptive servoventilation (ASV) has been introduced for treatment of CSR or coexisting sleep-related breathing disorders. ASV devices aim at counterbalancing the ventilatory overshoot and undershoot by applying variable pressure support with higher tidal volume (TV) during hypoventilation and reduced TV during hyperventilation. ASV has proven to be superior to CPAP but the long-term efficacy and the influences on cardiac parameters and survival are still under investigation.

Tuberculin skin test reactivity of health care students in a country with a low prevalence of tuberculosis.

To analyse the distribution of tuberculin skin test (TST) reactions and epidemiological factors related to TST reactivity.

DESIGN: TST reactivity was analysed in 1190 students. A linear regression model was created for the relative contribution of background factors of TST reactivity. A subgroup of 287 non-vaccinated subjects was comparatively skin-tested with Mycobacterium avium sensitin and tuberculin.

RESULTS: Among non-bacille Calmette-Guérin (BCG) vaccinated students, 91% had no TST reaction (0 mm induration) and reactions of ≥ 10 mm were found in 2.9%, whereas 34% of BCG-vaccinated students had no TST reaction and 42% had reactions of ≥ 10 mm. The expected contribution to TST reactivity was 6.0 mm for a history of BCG vaccination, 3.0 mm for a country of birth with medium/high incidence of TB and 1.6 mm per 10 years of age. The sensitin reactions exceeded the TST reactions by ≥ 3 mm in 52% of the comparatively tested subjects with TST reactions of ≥ 1 mm.

CONCLUSION: BCG vaccination, cross-reactivity with non-tuberculous mycobacteria, geographic origin and age had a decisive influence on TST reactivity. Most non-vaccinated health care students were non-reactive, which highlights the need to organise preventive measures in settings where TB exposure is expected.

A validated disease specific prediction equation for resting metabolic rate in underweight patients with COPD.

Malnutrition is a serious condition in chronic obstructive pulmonary disease (COPD). Successful dietary intervention calls for calculations of resting metabolic rate (RMR). One disease-specific prediction equation for RMR exists based on mainly male patients.

To construct a disease-specific equation for RMR based on measurements in underweight or weight-losing women and men with COPD, RMR was measured by indirect calorimetry in 30 women and 11 men with a diagnosis of COPD and body mass index <21 kg/m(2). The following variables, possibly influencing RMR were measured: length, weight, middle upper arm circumference, triceps skinfold, body composition by dual energy x-ray absorptiometry and bioelectrical impedance, lung function, and markers of inflammation. Relations between RMR and measured variables were studied using univariate analysis according to Pearson. Gender and variables that were associated with RMR with a P value <0.15 were included in a forward multiple regression analysis. The best-fit multiple regression equation included only fat-free mass (FFM): RMR (kJ/day) = 1856 + 76.0 FFM (kg).

To conclude, FFM is the dominating factor influencing RMR. The developed equation can be used for prediction of RMR in underweight COPD patients.

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