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Importance: Overdose is the leading cause of death among people experiencing homelessness (PEH), but engagement in medication treatment is low in this population. Shelter-based buprenorphine may be a strategy for increasing initiation and retention on lifesaving medications., Objective: To estimate clinical outcomes and conduct an economic analysis of statewide shelter-based opioid treatment in Massachusetts., Design, Setting, and Participants: This economic evaluation study in Massachusetts used a cohort state-transition simulation model. Two cohorts were modeled starting in 2013, including (1) a closed cohort of a fixed population of PEH with history of high-risk opioid use over their lifetimes and (2) an open cohort in which membership could change over time, allowing assessment of population-level trends over a 10-year period. Data analysis occurred from January 2023 to April 2024., Exposures: Model exposures included (1) no shelter-based buprenorphine (status quo) and (2) offering buprenorphine in shelters statewide., Main Outcomes and Measures: Outcomes included overdose deaths, quality-adjusted life-years (QALYs) gained, and health care and modified societal perspective costs. Sensitivity analyses were conducted on key parameters., Results: In the closed cohort analysis of 13 800 PEH (mean [SD] age, 40.4 [13.1] years; 8749 male [63.4%]), shelter-based buprenorphine was associated with an additional 65.4 person-weeks taking buprenorphine over an individual's lifetime compared with status quo. Shelter-based buprenorphine was cost saving when compared with the status quo, with a discounted lifetime cost savings from the health sector perspective of $1300 per person, and 0.2 additional discounted QALYs per person and 0.9 additional life-years per person. In the population-level simulation, 254 overdose deaths were averted over the 10-year period with the shelter-based buprenorphine strategy compared with the status quo (a 9.2% reduction of overdose deaths among PEH in Massachusetts). Overdose-related and other health care utilization undiscounted costs decreased by $3.0 million and $66.4 million, respectively. Shelter-based opioid treatment generated $44.7 million in additional medication and clinical costs, but saved $69.4 million in overdose and other health costs., Conclusions and Relevance: In this economic evaluation of clinical and economic outcomes among PEH, shelter-based buprenorphine was associated with fewer overdose deaths and was cost saving. These findings suggest that broad rollout of shelter-based buprenorphine may be an important tool in addressing the overdose crisis.

Background: Community Health Workers (CHWs) provide vital services during disease outbreaks. Appropriate burials of those who died from an infectious disease outbreak is a critical CHW function to prevent infection and disease spread. During the 2018 Ebola Virus Disease (EVD) outbreak in Beni Town, North Kivu, Democratic Republic of the Congo, we sought to understand the levels of understanding, trust, and cooperation of the community in response to the outbreak, the barriers burial workers faced in their health work and its impact on local burial workers and other CHWs., Methods: 12 EVD burial CHWs in Beni Town completed an hour-long qualitative in-depth interview on their experiences. They were recruited from a local counseling center. Interviews were recorded, transcribed and translated into English. A team of 3 researchers identified structural and emergent themes using applied thematic analysis., Results: Workers reported major misconceptions in the community surrounding the initiation of the outbreak. Community misconceptions were based on widespread governmental mistrust as well as a belief system that intertwines traditional and scientific understandings of the world. EVD burial workers identified violence directed at them and community misinformation as the two largest barriers to effectively carrying out their work. They named several important support systems including family and friends, personal relaxation techniques, and a local counseling center., Conclusions: As with other disease outbreaks globally, we found that government mistrust and religious beliefs strongly impacted community perceptions of the EVD outbreak. Previous studies have demonstrated clinic-based medical personnel are often the targets of violence. Our research shows that burial workers were also targeted and exposed to extreme levels of violence in their work. Along with their ability to effectively respond to the outbreak, violence has a negative impact on their own mental wellbeing. Burial workers found group counseling sessions to be an effective tool for managing the stress associated with their work. Further developing and testing of group-based interventions for this group is a priority for future research., (© 2023. The Author(s).)

Objectives: Person-centred care (PCC) meets the needs of individuals by increasing convenience, providing supportive and culturally appropriate services to diverse populations, and engaging families, communities, and stakeholders in planning and provision of care. While the evidence demonstrates that PCC approaches can lead to clinical improvements across the HIV care continuum, it is not yet well defined in the context of HIV service delivery., Methods: A systematic review was conducted to define PCC practices for HIV treatment services in health facilities in sub-Saharan Africa. Data synthesis led to the development of a PCC framework including domain and sub-domain development. The study team used the Effective Public Health Project Practice tool for quantitative studies to assess the quality of the included studies., Results: Thirty-one studies from 12 countries met the inclusion criteria, including 56,586 study participants (females 42%-100% and males 0%-58%), resulting in three major domains and 11 sub-domains. These include staffing (sub-domains of composition, availability, and competency); service delivery standards (sub-domains of client feedback mechanisms; service efficiency and integration; convenience and access; and digital health worker support tools); and direct client support services (sub-domains of psychosocial services, logistics support, client-agency, and digital client support tools). Twenty-five of the person-centred interventions within these domains resulted in improvements in linkage to care, treatment retention, and/or viral suppression., Conclusions: The PCC framework can help to provide a more consistent classification of HIV treatment interventions and will support improved assessment of these interventions to ensure that people receive personalised care., (© 2022 The Authors Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Background: The aim of our study was to determine the effect of one year of pulmonary rehabilitation (PR) on functional parameters and exacerbation rates in patients with chronic obstructive pulmonary disease (COPD)., Methods: A total of 100 patients were enrolled in a multidisciplinary PR program. PR included endurance, resistance and respiratory muscle training. We performed spiroergometry, a modified Bruce Test and measurements of upper and lower limb contractility as well as inspiratory muscle strength before, six and 12 months after beginning rehabilitation. Additionally, we assessed the quality of life and the number of exacerbations and exacerbation days one year before and after starting rehabilitation., Results: 100 patients (42 female/58 male) with COPD (COPD IV-N=36, COPD III-N=42, COPD II-N=22), a mean age of 60.5+/-9.6 years, BMI 25.8+/-6.0 attended a rehabilitation training program over a time period of one year. Spiroergometry (VO2max from 1.1 to 1.3 l/min, P<0.05), modified Bruce Test (from 13+/-7 Min to 18+/-9 Min; P<0.001), upper limb (from 39.9+/-3 to 52.9+/-8 kg; P<0.001) and lower limb strength increased significantly (from 85.3+/-45 to 131.5+/-57 kg; P<0.001). The maximal inspiratory pressure rose from 81.1 mbar to 108.8 mbar (p<0.001). There was no improvement in FEV1 or FEV1/FVC but Saint Georges Respiratory Questionnaire (total score) improved from 37.2+/-3.6 to 26.5+/-2.8; P<0.001. The same was true for exacerbation rates (they dropped from 2.8 to 0.8; P=0.006) and the number of hospitalization days (from 27.3 to 3.3, P<0.001)., Conclusions: One year of outpatient pulmonary rehabilitation is an effective intervention leading to a significant improvement in exercise tolerance and quality of life in patients with COPD also reducing COPD exacerbation rates and hospitalizations.

Objective: To determine whether methylprednisolone or indomethacin can enhance photoreceptor survival after laser retinal injury in an animal model., Design: Experimental study., Participants: Twenty rhesus monkeys., Methods: Twenty rhesus monkeys (Macaca mulatta) received a grid of argon green (514.5 nm, 10 ms) laser lesions in the macula of the right eye and a grid of neodymium:yttrium-aluminum-garnet (Nd:YAG; 1064 nm, 10 ns) lesions in the macula of the left eye, followed by randomization to 2 weeks of treatment in 1 of 4 treatment groups: high-dose methylprednisolone, moderate-dose methylprednisolone, indomethacin, or control. The lesions were assessed at day 1, day 14, 2 months, and 4 months. The authors were masked to the treatment group. This report discusses the histologic results of ocular tissue harvested at 4 months., Main Outcome Measure: The number of surviving photoreceptor cell nuclei within each lesion was compared with the number of photoreceptor nuclei in surrounding unaffected retina. The proportion of surviving photoreceptor nuclei was compared between each treatment group., Results: Argon retinal lesions in the high-dose steroid treatment group and the indomethacin treatment group demonstrated improved photoreceptor survival compared with the control group (P = 0.004). Hemorrhagic Nd:YAG lesions demonstrated improved survivability with indomethacin treatment compared with controls (P = 0.003). In nonhemorrhagic Nd:YAG laser retinal lesions, the lesions treated with moderate-dose steroids demonstrated improved photoreceptor survival compared with the control group (P = 0.004)., Conclusions: Based on histologic samples of retinal laser lesions 4 months after injury, treatment with indomethacin resulted in improved photoreceptor survival in argon laser lesions and hemorrhagic Nd:YAG laser lesions. Treatment with systemic methylprednisolone demonstrated improved photoreceptor survival in argon retinal lesions and in nonhemorrhagic Nd:YAG lesions.

Rehabilitation of COPD-patients is an important part of the therapeutic management. The effects of endurance- and resistance-training as well as respiratory muscle-training are evident. Smoking cessation therapy is standardized, effective and cheap, and is the prerequisite of a successful COPD management. Patients with severe or very severe COPD not only have to inhale their medication exactly, but also have to undertake physical exercise and optimize their body weight. This cannot normally be achieved without adequate education. A structured patients' education optimizes all therapeutic action and is an integral part of the management of COPD.

Bilateral diaphragmatic paralysis (BDP) can occur in the course of motor neuron disease, myopathy, or from mechanical damage or the use of "ice slush" during cardiac surgery. BDP has been observed during and after infections, associated with systemic lupus erythematosus and mediastinal tumors, or may have idiopathic etiology. It is a serious and life-threatening condition. A 62-yr-old man presented with slowly progressive dyspnoea that worsened in the supine position and on bending forward. Chest X-rays, fluoroscopy, lung-function parameters and blood-gas analysis revealed respiratory failure. BDP was confirmed from a phrenic nerve stimulation test and measurement of transdiaphragmatic pressure (Pdi). Since there was no evidence of an obvious etiology, BDP was considered idiopathic. Other muscles were not involved. The pathological basis was probably focal demyelination in segments of the phrenic nerve. Because of increasing diaphragmatic muscle fatigue, the patient was treated with a nasal mask providing bi-level positive airway pressure (BiPAP) ventilation during the night. Clinical suspicion of BDP should always be raised in patients suffering slowly progressive dyspnoea without any obvious cardiac, metabolic or traumatic predisposing factors, and orthopnoea and dyspnoea on bending forward. Electromyographic tests and measurement of Pdi can reveal the correct diagnosis.

Purpose: To evaluate choroidal perfusion following creation of a laser-induced macular hole in a nonhuman primate model., Methods: Six rhesus monkeys underwent macular exposures delivered by a Q-switched Nd:YAG laser. The lesions were evaluated with fluorescein angiography and indocyanine green angiography using scanning laser ophthalmoscopy., Results: Each lesion produced vitreous hemorrhage and progressed to a full-thickness macular hole. Indocyanine green angiography revealed no perfusion of the choriocapillaris beneath the lesion centers. Fluorescein angiography demonstrated mild enlargement of the foveal avascular zone due to loss of perifoveal capillaries. Histopathologic evaluation showed replacement of the choriocapillaris with fibroblasts and connective tissue., Conclusions: Nd:YAG laser-induced macular holes result in long-term impairment of choroidal perfusion at the base of the hole due to choroidal scarring and obliteration of the choriocapillaris. Evaluation of choroidal perfusion may be useful in assessment of laser-injured patients. Impairment in choroidal perfusion may have functional implications for surviving photoreceptors.

During long-term viewing of a continuous light source, head and eye movements affect the distribution of energy deposited in the retina. Previous studies of eye movements during a fixation task provided data used for revising the safety limits for long-term viewing of such sources. These studies have been continued to determine the effect of source brightness on the nature of fixational eye movements. Volunteers fixated for 50 s on a HeNe laser (lambda = 632.8 nm) masked by a small aperture to produce a target subtending approximately 0.03 mrad in the visual field. The source was attenuated to yield corneal irradiance values in the range 0.6 pW cm(-2) to 6 microW cm(-2). Eye movements were recorded using a Dual Purkinje Image Eyetracker. The data were characterized by fixation ellipses that represent areas of the retina in which the image of the spot was located 68% of the time of each trial. Significant variation across subjects in the tightness of fixation was observed. Over the eight orders of magnitude of source brightness used in this experiment (10(-13) to 10(-6) W cm(-2)), no subject showed more than roughly a factor of two variation in the area of the fixation ellipse. No statistically significant trend in tightness of fixation as a function of source brightness was observed. There was no loss of ability to fixate, nor any drive to aversion, at the higher source intensities.

Tobacco smoking is the major cause of lung disease. This study aimed to determine: 1) the prevalence of tobacco smoking among office-based physicians; 2) their readiness to inquire about their patients' smoking habits and, if need be, to motivate them to stop smoking; 3) whether non-smoking doctors advise their patients more frequently to stop smoking than their smoker colleagues do. A self-designed questionnaire on a post card was sent to 7674 office-based general practitioners (GPs) and internists. 1395 (18.2%) questionnaires were returned. Independent telephone interviews with 91 doctors were also carried out to minimize the bias of self-presentation. Just under 11% of doctors were smokers. About 50% of all doctors who responded described themselves as ex-smokers. 38% of the smokers would accept outside help to stop smoking. About 50% of GPs and 90% of internists inquire about the smoking habits of their patients during history taking. Of these, 85% of GPs and 92% of internists recommend their patients to stop smoking. Doctors who themselves are smokers do so less than their non-smoker colleagues. For this reason, a further reduction in the smoking prevalence among doctors would be of special importance. Inquiry about smoking habits in the initial history taking should be stressed more to identify any smoker who can be subsequently encouraged to stop smoking.

Purpose: The aim of our study was to assess the long-term effects of specific inspiratory muscle training (IMT) in patients with neuromuscular disorders (NMDs) who have various degrees of respiratory impairment., Patients and Methods: Twenty-seven patients with NMDs (Duchenne's muscular dystrophy, 18 patients; spinal muscular atrophy, 9 patients) underwent 24 months of IMT. Patients were divided into three groups according to their vital capacity (VC) values. VC was measured as the parameter for the respiratory system involvement of the disease. Maximal inspiratory pressure (PImax) was assessed as the parameter for respiratory muscle strength, and the results of the 12-s maximum voluntary ventilation test (12sMVV) were assessed as the parameter for respiratory muscle endurance. Pulmonary and inspiratory muscle function parameters were assessed 6 months before training, at the beginning of training, and then every 3 months., Results: The PImax values improved in group A (VC, 27 to 50% predicted) from 51.45 to 87.00 cm H(2)O, in group B (VC, 51 to 70% predicted) from 59.38 to 94.4 cm H(2)O, and in group C (VC, 71 to 96% predicted) from 71.25 to 99.00 cm H(2)O. The 12sMVV values improved in group A from 52.69 to 69.50 L/min, in group B from 53.18 to 62.40 L/min, and in group C from 59.48 to 70.5 L/min. For all three groups, there was a significant improvement of PImax (p < 0.007) and 12sMVV (p < 0.015) until the 10th month when a plateau phase was reached with no decline in the following month until the end of training., Conclusion: With IMT, respiratory muscle function can be improved in the long term of up to 2 years.

For more than 30 years the ascarid Toxocara canis, a parasite of the dog, has been considered a possible cause of allergic-pulmonal irritations (i.e. asthma bronchial) in man. According to a British study thousands of people are presumably suffering from asthma bronchial as a consequence of Toxocara infestations. The aim of our recent study was the assessment of the Toxocara seroprevalence in patients of varying bronchial reactivity and status of atopy suffering from respiratory disturbances. 191 serum samples from 59 male (mean age: 31.7 years) and 132 female patients (mean age: 36.6 years) with varying atopy status and degree of bronchial reactivity, living in or near Vienna, were examined for specific IgG antibodies against excretory-secretory (E/S) Toxocara canis antigen with enzyme-linked immunosorbent assay (TES-ELISA) and Western blot (TES-WB). In total a Toxocara seroprevalence of 9.4% could be assessed among these patients. 10% of the patients with and 7.8% of the patients without bronchial hyperreactivity were Toxocara-positive. Atopic patients were serologically positive in 7.1% of the cases tested whereas non-atopics showed an antibody prevalence of 14.3%. A comparison of Toxocara seroprevalence assessed within the recent study and in an earlier study among healthy pregnant women in Vienna did not show significant differences. The results of this study carried out in Vienna indicate that patients with bronchial hyper-reactivity or atopy show no higher seroprevalence than the normal population.

We studied the retinal effects of 1.25 GHz high peak power microwaves in Rhesus monkeys. Preexposure fundus photographs, retinal angiograms, and electroretinograms (ERG) were obtained to screen for normal ocular structure and function and, after exposure, as endpoints of the study. Histopathology of the retina was an additional endpoint. Seventeen monkeys were randomly assigned to receive sham exposure or pulsed microwave exposures. Microwaves were delivered anteriorly to the face at 0, 4.3, 8.4, or 20.2 W/kg spatially and temporally averaged retinal specific absorption rates (R-SAR). The pulse characteristics were 1.04 MW ( approximately 1.30 MW/kg temporal peak R-SAR), 5.59 micros pulse length at 0, 0.59, 1. 18, and 2.79 Hz pulse repetition rates. Exposure was 4 h per day and 3 days per week for 3 weeks, for a total of nine exposures. The preexposure and postexposure fundus pictures and angiograms were all within normal limits. The response of cone photoreceptors to light flash was enhanced in monkeys exposed at 8.4 or 20.2 W/kg R-SAR, but not in monkeys exposed at 4.3 W/kg R-SAR. Scotopic (rod) response, maximum (combined cone and rod) response, and Naka-Rushton R(max) and log K of scotopic b-waves were all within normal range. Retinal histopathology revealed the presence of enhanced glycogen storage in photoreceptors among sham (2/5), 8.4 W/kg (3/3), and 20.2 W/kg (2/5) exposed monkeys, while enhanced glycogen storage was not observed in the 4.3 W/kg (0/4) exposed group. Supranormal cone photoreceptor b-wave was R-SAR dependent and may be an early indicator of mild injury. However no evidence of degenerative changes and ERG depression was seen. We concluded that retinal injury is very unlikely at 4 W/kg. Functional changes that occur at higher R-SAR are probably reversible since we saw no evidence of histopathologic correlation with ERG changes. Bioelectromagnetics 21:439-454, 2000. Published 2000 Wiley-Liss, Inc.

With the easy attainability of hand-held laser devices and the burgeoning light emitting diode (LED) technology, safety standards for long-term viewing of continuous light sources are being scrutinized. One concern is with quantifying the effect of head and eye movements on the distribution of energy over the retina. This experiment describes target motion over the retina as a result of head and eye movements during a deliberate fixation task. Volunteers deliberately fixated, with (fettered) and without (unfettered) head and chin rest support, on LEDs that subtended a 0.1 min of arc visual angle. A Dual Purkinje Image Eyetracker measured eye position during each 100-s fixation trial. The data showed an elliptical retinal energy distribution, oriented on the temporal/ nasal retinal axis, with a major axis 1.5 times greater than the minor. The average half-maximum diameter for the major axis was 40 microm for the fettered and 107 microm for the unfettered condition. The retinal area illuminated from head and eye movements showed a positive linear relationship with time. Peak retinal radiant exposure at 100 s was reduced by a factor of 10 as a result of eye movements and by a factor of 30 as a result of head and eye movements. Although the net result was a reduction in radiant exposure from a "no-movement" baseline, the distribution of energy over the retina was well within the 200 microm foveal boundary. The data suggest that the laser permissible exposure limits for long term viewing of a small continuous wave source include a factor that adjusts for this reduction in retinal radiant exposure with time.

Recent investigation demonstrate that ocular motility in eyes with retinal pathology may show a lower propensity to visit such areas of the retina as compared to non-pathological retinal sites. While current ophthalmic instruments with the ability to image both the retina and visual function test target placement on the retina have provided this observation, the ability to quantify in real time these images as an eye movement measurement is presently lacking and the objective of this paper. A Rodenstock confocal scanning ophthalmoscope (CSLO) was used to image the retina during the performance of a visual fixation task. Direct observation of acuity target placement at the retina under continuous viewing conditions was possible with this apparatus. Target fixation eye movement images of the retina were rapidly digitized from video tape records and registered using a specialized rapid retinal image tracking algorithm. Fixational eye movement pattern densities at the retina were derived from these data. Preliminary data obtained demonstrate the utility of this technique in quantifying fixation eye movement patterns observed in three human patients with vocation-related laser retinal injury. In all patients, areas of severe retinal damage was generally avoided. The density of ocular eye movement tends to reflect regions of retinal normality and avoidance of retinal regions with severe pathology. Variation in eye movement density may exist where pathology is less severe.

Study Objectives: The aim of this study was to investigate prospectively the changes in neural drive to the diaphragm in the first year after lung volume reduction surgery (LVRS) in patients with COPD., Patients and Methods: In 14 patients with severe emphysema (mean +/- SD; age, 53.7 +/- 8.3 years; FEV(1), 0.64 +/- 0. 18 L; residual volume [RV], 5.33 +/- 1.25 L; PaO(2), 62.3 +/- 9.0 mm Hg; PaCO(2), 39.0 +/- 6.0 mm Hg), we assessed lung function, arterial blood gases, maximal exercise capacity (Wmax), and oxygen uptake (f1.gif" BORDER="0">O(2)max); intrinsic positive end-expiratory pressure (PEEPi); diaphragmatic strength (transdiaphragmatic pressure, Pdisniff) and endurance capacity (tlim); central diaphragmatic drive assessed by root mean square analysis of the esophageal electromyogram (rmsdia); and isotime dyspnea during loaded breathing tests (BS)., Results: Despite a significant increase (expressed as a percentage of baseline) in FEV(1) (40.6%) and a decrease in RV (30.0%) and PEEPi (75.7%) 1 month after LVRS, the improvements in Wmax (31.2%) and f1.gif" BORDER="0">O(2)max (13.7%); Pdisniff (25.4%) and tlim (64.9%); rmsdia (34.6%); and BS (21.7%) did not reach statistical significance (p < 0.05) until 6 months after LVRS. Arterial blood gases did not change significantly. Significant correlations were found between decrease in rmsdia and changes in PEEPi (r = 0.69), Wmax (r = -0.56), Pdisniff (r = -0.65), tlim (r = -0.59), and BS (r = 0.71) 6 months after LVRS., Conclusions: Our results show that LVRS is able to increase the efficacy of the respiratory pump and by this way reduce ventilatory drive and respiratory effort sensation.

Several studies note that bronchial hyperresponsiveness has increased in the past years. There is a connection between allergen exposition during childhood and the development of asthma bronchiale. 1988 a questionnaire was sent to the parents of 281 Viennese school children. The children were tested for bronchial hyperresponsiveness as well as for sensitization to airborne allergens like Alternaria alternata (A. alternat) and Dermatophagoides pteronyssinus (D. pter.). The same test with the same methodology was repeated in 390 children at the same school in 1997. In the period from 1988 to 1997 the number of children with bronchial hyperresponsiveness increased significantly from 20 to 27 percent. The prevalence of sensitization increased from 24 to 34 percent. The report of asthmatic symptoms and allergic reactions is increasing as well.

Objective: To evaluate cell block preparations as a tool for the diagnosis of pulmonary malignancy and to correlate the findings with those from brush cytology and histology from forceps biopsy., Study Design: One hundred twenty consecutive samples from patients with primary or metastatic lung cancer were routinely processed and stained for cytologic and histologic examination. In addition to smears, a cell block was prepared from each brushing sample. Brush smears, cell blocks and biopsy specimens were compared and evaluated for their diagnostic accuracy., Results: Brush cytology samples were interpreted as positive for malignancy in all 120 cases. In 42 cases immunohistochemistry performed on cell blocks led to the final precise type diagnosis. Owing to technical problems (stenosis, bleeding, peripheral location), forceps biopsy specimens were obtained from only 51 patients., Conclusion: In addition to lower patient risk, cell block preparation yields high diagnostic accuracy and may thus be considered an improvement in quality assurance.

Purpose: This study was performed to examine the causes, triggers and therapy of bronchial asthma in a statistically relevant group of teachers at primary schools in Vienna. Furthermore, it was intended to investigate the correlation between their knowledge and their approach in respect of the management of asthmatic pupils., Methods: 1054 (80.4%) of 1311 questionnaires were returned and evaluated. Five items were investigated: "general knowledge", "symptoms and triggers"; "exercise", "treatment" and "individual experience". Statistical analysis was performed by using counting statistics. For the correlation of items, Spearman correlation coefficients and Wilcoxon's test were used., Results: The teachers in primary schools showed a good basic knowledge of asthma and its symptoms. Poor understanding was found with regard to the medical treatment and trigger factors of asthma; only 34% of the teachers knew that playing games in cold wind may provoke an exacerbation of asthma; less than half of the teachers (45%) were aware of the fact that an asthma attack can be prevented by prophylactic treatment. A significantly positive correlation was found between previous instruction on asthma and its management, the degree of individual experience, and the correct belief that asthmatic children should be encouraged to fully participate in school sports and activities (p = 0.001). Most of the teachers (94%) felt the lack of sufficient information. Only 2% had received proper instruction on asthma and revealed a significantly better knowledge of all items (p = 0.0001)., Conclusion: We suggest that teachers at primary school receive further instruction on asthma, especially regarding its practical aspects.

The sensitivity and specificity of Cyfra 21-1 as marker for lung cancer was evaluated in comparison with carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC) and neuron-specific enolase (NSE). Patients with histologically verified lung cancer and different groups without lung cancer were investigated. Sensitivity of Cyfra 21-1 (cut-off level 2.9 micrograms/l) was 40% for non-small cell lung cancer (NSCLC), 60% for rare histological types and 21% for small cell lung cancer (SCLC). In NSCLC sensitivity of Cyfra 21-1 was 35% for squamous cell carcinoma and 41% for adenomous carcinoma. The highest sensitivity for CEA was 45% in NSCLC, with 57% in the subtype of adenomous cell carcinoma; for SCC 30% was achieved in squamous cell carcinoma and for NSE 66% sensitivity was reached in SCLC. In our patients Cyfra 21-1 and CEA appeared equally useful for evaluating patients with NSCLC.

The objective of the present study was to investigate nasal function by active anterior rhinomanometry with respect to spirometric data and bronchial hyperresponsiveness to methacholine in 9-year-old children. The study population consisted of 300 children (ages 8 to 11 years; mean, 9.3 years; 161 male, 139 female), who underwent basal rhinomanometry followed by a decongestion test and a lung function test consisting of spirometry and a methacholine provocation test. The flow values of the basal rhinomanometry showed a significant correlation with height and bronchial hyperresponsiveness. The consecutive decongestion test showed a marked increase in flow rates at each level, which was found to be significantly higher in children with bronchial hyperresponsiveness (p < 0.01). The spirometric data showed no influence on rhinomanometric values. These results suggest that nasal dysfunction and reactivity in terms of the decongestion test may be associated with bronchial hyperresponsiveness in children.

The feasibility of nasal continuous positive airway pressure (CPAP) for heavy snoring associated with daytime sleepiness was studied in 118 consecutive patients with an apnea hypopnea index below 5. Fifty-nine of them reported daytime sleepiness in a questionnaire and were offered treatment with nasal CPAP. Whereas 48 patients refused it, the remaining 11 (19%) accepted nasal CPAP for home therapy. Acceptors and refusers did not differ in sleep structure, but acceptors had slightly more sleep-disordered breathing events per hour of sleep than refusers. The pressure needed to abolish snoring in these 11 patients was 7.3 +/- 1.6 cm H2O. Six months after prescription, the built-in time counters of the patients' devices were read. By dividing the hours of operation by the days since initiation of treatment, we found a mean daily use time of only 2.8 +/- 1.5 h. Nevertheless, eight patients (73%) reported that their sleepiness had improved with therapy. We conclude that only a minority of nonapneic snorers accept treatment with nasal CPAP on a long-term basis and that this subgroup is not predictable from polysomnography.

The present study investigated the sensitization to inhalatory allergens in a randomized cross-section of the population of Vienna (altogether 3000 men and women). A representative sample of 600 persons was invited to an examination consisting of a skin prick test and determination of serum total IgE and allergen-specific IgE. In addition, the same tests were performed in persons with asthma or allergic rhinitis on the basis of a history of these conditions in the replies to a screening questionnaire. Our results showed comparatively high sensitization rates to grass pollen (28%), house dust mite (25%) and cat dander (20%) in the randomized group A. In the symptom-free "healthy" subgroup of the randomized population sample (Group B) there were remarkably high sensitization rates to house dust mite (21%), grass pollen (17%) and cat dander (12%). For the group with allergic rhinitis (Group D) sensitization to grass pollen exceeded 60%, followed by cat dander (44%), birch pollen (36%) and house dust mite (35%). In the asthmatic persons (Group C) the leading allergens were cat dander (40%) and the house dust mite (37%), followed by grass pollen (33%) and birch pollen (20%). Regarding the overall sensitization to inhalatory allergens 61% of the asthmatic group showed a positive prick test. Increased serum levels of total IgE or specific IgE were found in 76% of cases, which underlines the allergic origin of this disease. In the randomized group 51% were sensitized to inhalatory allergens, whilst 39% were subclinically sensitized without ever having had any allergic complaints.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of our study was to evaluate the effect of aminophylline on the contractile function of the human diaphragm during varying muscle fiber length. Ten healthy subjects were studied during maximal sniff maneuvers and bilateral phrenic nerve twitch stimulations, with and without intravenous infusion of aminophylline in a randomized fashion. The transdiaphragmatic pressures generated at various baseline lung volumes, from residual volume to 90% of total lung capacity, were recorded before and after the induction of diaphragm exhaustion. At all levels of lung volume, aminophylline did not have an effect on the contractility of the fresh diaphragm. In the exhausted diaphragm, however, the pressure values, induced by sniffs and twitch stimulations, were significantly improved by aminophylline. This positive effect on diaphragm contractility was also impressive at 60, 75, and 90% of total lung capacity. This indicates that aminophylline significantly improves the contractile function of the exhausted human diaphragm, even if the muscle fibers are shorter than optimal. This effect occurs regardless of the neuronal firing rate, whether it is low (twitch stimulation) or high (sniff maneuver).

Using a stepwise logistic regression analysis, we investigated clinical data, allergologic findings, spirometric data, and the cellular and humoral immune system in order to gain new insights into the role these parameters play in bronchial hyperresponsiveness to methacholine in children and to create a model for the prediction thereof. Bronchial hyperresponsiveness, which was found in 124 of 462 children (26.8%), was observed to have been influenced by an increased level of eosinophils, the positivity of the skin prick test for any of the allergens tested, a decreased baseline forced expiratory volume in 1 second (FEV1) (percent predicted), a decreased maximum expiratory flow at 50% expiration as a percent of forced vital capacity, and a decreased level of kappa-chain-assembled immunoglobulins. Logit analysis disclosed that the influence of all other parameters on the occurrence of bronchial hyperresponsiveness was of no further statistical significance. The degree of bronchial hyperresponsiveness (provocative dose causing a 20% fall in FEV1) showed a statistically significant correlation with the eosinophil count (Spearman's r = -0.198) and FEV1 (percent predicted) (Spearman's r= 0.203). Our findings suggest that allergic sensitization and eosinophilic reaction in children are major factors in contributing to the occurrence of bronchial hyperresponsiveness to methacholine.

Purpose: The aim of this study was to assess the usefulness of a specific inspiratory muscle training in Duchenne muscular dystrophy (DMD)., Patients and Methods: Fifteen patients with DMD started 6 months of training the inspiratory muscles and 15 patients served as a control group. Pulmonary and inspiratory muscle function parameters were assessed 3 months before and at the beginning of training, in the first and third month of training, at the end, and 6 months after its cessation. Maximal sniff assessed esophageal and transdiaphragmatic pressure values served as indices for global inspiratory muscle strength and diaphragmatic strength, respectively. Inspiratory muscle endurance was assessed by the length of time a certain inspiratory task could be maintained., Results: In 10 of the 15 patients, respiratory muscle function parameters improved significantly after 1 month of training. Further improvements were to be seen after 3 and after 6 months. Even 6 months after the end of training, those effects remained to a large extent. In the other five patients, there was no such improvement after 1 month of training, which was therefore discontinued. All these five patients had vital capacity values of less than 25 percent predicted and/or PaCO2 values of more than 45 mm Hg. The 15 control patients had no significant change in their respiratory muscle function parameters., Conclusion: We conclude that a specific inspiratory muscle training is useful in the early stage of DMD.

We investigated 8 patients undergoing continuous ambulatory peritoneal dialysis (CAPD) for diaphragmatic strength and the neuromechanical efficiency of the diaphragm while the abdomen was filled with dialysate and while it was empty. Maximum transdiaphragmatic pressure (Pdimax) served as parameter for diaphragmatic strength; diaphragmatic efficiency was assessed by simultaneously monitoring transdiaphragmatic pressure (Pdi) and diaphragmatic electromyogram (EMGdi) during room-air breathing and hyperoxic CO2-rebreathing. After instilling dialysate, Pdimax increased from 76.7 +/- 12.1 cmH2O to 92.2 +/- 16.3 cmH2O (P < 0.05). While the slopes of the regression lines relating minute ventilation (VE) to arterial CO2 tension, and the change in VE for a given change in Pdi during hypercapnic rebreathing were similar in both states, the slope of EMGdi vs Pdi was significantly steeper when the abdomen was filled (P < 0.05). The increase in Pdimax observed in the filled state may suggest an adaptive rightward shift in the diaphragm's force-length relationship in CAPD patients, although this mechanism is insufficient to prevent a reduction of neuromechanical efficiency of the diaphragm.

The diagnostic value of chest X-ray following the ILO standards was compared with bronchoalveolar lavage (BAL) and the histology of transbronchial forceps biopsy in 83 patients with collagen vascular diseases. BAL in the middle lobe was considered abnormal in case of increased cell count per milliliter and/or lymphocytosis and/or neutrophil granulocytosis and this was found in 32 out of 42 cases (76.2%) with, and in 33 of out 41 cases (80.5%) without abnormal radiological finding. Pathological changes in the histology were found in 14 out of 20 cases (70.0%) with and in 40 out of 63 cases (63.5%) without abnormal chest X-ray in the upper lobe from which the transbronchial forceps biopsy specimens were obtained. In histological specimens obtained from transbronchial forceps biopsy, only fibrosis correlated with abnormal radiological findings in this region. Other inflammatory processes defied prediction by chest X-ray. This suggests that, regardless of chest X-ray findings, BAL should be performed together with transbronchial forceps biopsy for the histological examination of patients with collagen vascular diseases in which interstitial lung involvement is suspected.

To investigate the activity of the endogenous opioid system in patients with insulin-dependent diabetes mellitus during ventilatory stress situations, we measured plasma beta-endorphin levels in six male and five female diabetic patients breathing against fatiguing inspiratory resistive loads. The patients had to generate with each inspiration an esophageal pressure (Pes) 80% of maximum until they were exhausted and could no longer develop target Pes. The loaded breathing run was repeated three times with a 1-min interval between each run. Duty cycle, tidal volume, and breathing frequency were constant in all tasks. For each run plasma beta-endorphin levels were measured, inspiratory effort sensation assessed using a modified Borg scale, and inspiratory muscle endurance evaluated by the length of time the task could be maintained (Tlim). A group of 11 sex-, age-, height-, and weight-matched healthy individuals served as control subjects. Tlim was significantly lower in the diabetic patients. Evaluating respiratory effort during the three test runs in control subjects at a time corresponding to the break point of loaded breathing in patients showed significantly lower Borg ratings in the control group than in the patient group. Baseline plasma beta-endorphin was significantly lower in the diabetic patients (10.6 +/- 2.1 versus 27.0 +/- 4.2 pg/ml, p < 0.01). Additionally, whereas resistive loaded breathing caused a further increase in plasma beta-endorphin concentration in the control group (p < 0.005), absolutely no increase was found in the diabetic patients. We conclude that the endogenous opioid system in insulin-dependent diabetic patients does not respond to stress caused by breathing against fatiguing inspiratory resistive loads.

Inspiratory muscle performance, ventilation, and gas exchange were studied during exercise in healthy subjects to look for typical changes of pattern of contraction at the ventilatory threshold (VT). The steepening of the slope of carbon dioxide output (VCO2) vs oxygen uptake (VO2) at the VT was accompanied by a nonlinear increase of the mean rate of esophageal pressure development (Pes/TI) vs the esophageal pressure time index (PTIes) reflecting both the relative force (Pbreath/Pesmax) and duration (TI/TTOT) required for inspiration. The esophageal pressure time integral within one breath (Pbreath.dTI) was one of the best single predictors of the ventilatory equivalent for oxygen (VE/VO2) at the VT. Moreover, we presented inspiratory muscle load indices as a mirror image of breathing pattern, with the obvious advantage that the ventilation component can be compared with better established methods of presenting ventilatory output. Inspiratory muscle performance during exercise should link the increased metabolic rate to ventilatory output. We conclude that 1) there exists an inspiratory muscle threshold that is well correlated to commonly used gas exchange thresholds, and 2) the efficiency of ventilation and gas exchange during exercise could be linked to pressure and timing of inspiratory muscle contraction.

We used size-exclusion high-performance liquid chromatography (HPLC) to investigate the properties of the 2 isoforms of Vitamin A-containing (holo) retinol-binding protein (RBP) in animals: the form that is bound to transthyretin (holo-TTR-RBP), and the form that does not bind to TTR (holo-free RBP). We also used radial immunodiffusion to measure immunologically active RBP (apo + holo RBP). We compared the isoforms of RBP in animals with those of human beings to determine which animal is the best model of human RBP. Size-exclusion HPLC detected holo-free and holo-TTR-RBP in every animal species studied. Apparent concentration of holo-TTR-RBP varied among species: that of rabbits and dogs >> that of apes, sheep, goats, monkeys, rhinoceroses, felids, rats, human beings, and deer > that of pigs, zebra, and bison > that of penguins. Dogs have unusual RBP chromatograms; they have high concentration of RBP, but also appear to transport much of their vitamin A on protein other than RBP. Human RBP antibody preparations could detect apo + holo RBP immunologic activity only in apes, monkeys, and felids. Apes and monkeys appeared to have complete cross-reactivity to human RBP antibodies. Felids may have substantial, but partial, cross-reactivity. Apes and monkeys appear to be the most relevant animal models for study of human RBP transport. However, there is a need for less-expensive models. Further research is needed, but in the interim, rats or sheep may be satisfactory for some purposes.

To estimate reliability of self-reported compliance with nasal continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA), we studied 63 OSA patients aged 53.7 +/- 1.2 years (mean +/- SEM) with an apnea hypopnea index (AHI) of 50.8 +/- 2.9 and lowest sleep SaO2 of 65.6 +/- 2.3 percent receiving nasal CPAP for 539 +/- 44 days. During a follow-up polysomnography (PSG) on the pressure prescribed for home therapy (10.3 +/- 0.3 cm H2O), the hours of operation shown on the built-in time counter of the patients' devices were read to determine objective compliance by dividing the run time by the days since initiation of therapy. This parameter was compared with subjective compliance reported in a self-administered questionnaire. Mean measured use time was 4.9 +/- 0.3 h per night, whereas reported daily use time calculated from reported nights a week and hours a night was 6.1 +/- 0.3 h per night. As predominantly patients with poor compliance misestimated daily use time, we conclude that self-reports are unable to distinguish between compliant and noncompliant patients.

In the present study the incidence of bronchial asthma, airway complaints, and allergic rhinitis was investigated in a randomized population section including 3000 male and female inhabitants of Vienna (sex ratio 1:1), aged 20-44. Data on complaints in the respiratory tract were obtained from a total of 71% of the study population. Our results suggest that 14.7% of the entire population was suffering from allergic rhinitis (16.4% male versus 13.0% female; p < 0.05). Airway complaints such as wheezing, whistling, and feeling of tightness in the chest, awakening because of shortness of breath or cough were frequently reported, with no major differences between male and female subjects. The overall percentage of study subjects stating that they had suffered from airway complaints in the year before, i.e., the percentage of those giving affirmative answers to one of the questions, was 29%. Bronchial asthma was calculated to be present in 5.1% of the entire population (5.9 male versus 4.4 female). Attacks of asthma were reported by only 2.2% of the subjects, which gives an indication of the discrepancy between identified and unidentified bronchial asthma. Allergic rhinitis is correlated to, and constitutes a risk factor for the occurrence of complaints in the respiratory tract; public health policy should therefore be aimed at the prevention or early treatment of allergic rhinitis, and at reducing the proportion of cases suffering from unidentified bronchial asthma.