Otto D. Schoch

S2k-Leitlinie: Tuberkulose im Erwachsenenalter

Since 2015 a significant increase in tuberculosis cases is notified in Germany, mostly due to rising numbers of migrants connected to the recent refugee crisis. Because of the low incidence in previous years, knowledge on tuberculosis is more and more limited to specialized centers. However, lung specialist and healthcare workers of other fields have contact to an increasing number of tuberculosis patients. In this situation, guidance for the management of standard therapy and especially for uncommon situations will be essential. This new guideline on tuberculosis in adults gives recommendations on diagnosis, treatment, prevention and prophylaxis. It provides a comprehensive overview over the current knowledge, adapted to the specific situation in Germany. The German Central Committee against Tuberculosis (DZK e.u200aV.) realized this guideline on behalf of the German Respiratory Society (DGP). A specific guideline for tuberculosis in the pediatrics field will be published separately. Compared to the former recommendations of the year 2012, microbiological diagnostics and therapeutic drug management were given own sections. Chapters about the treatment of drug-resistant tuberculosis, tuberculosis in people living with HIV and pharmacological management were extended. This revised guideline aims to be a useful tool for practitioners and other health care providers to deal with the recent challenges of tuberculosis treatment in Germany.

Continuous positive airway pressure improves exercise capacity and heart rate recovery in obstructive sleep apnea

BACKGROUNDnThere is a relationship between obstructive sleep apnea (OSA) and heart failure (HF). Peak oxygen consumption (peak VO(2)), heart rate recovery, and N-terminal-pro-BNP (NT-proBNP) are strong prognostic predictors in HF. The effects of nasal continuous positive airway pressure (nCPAP) on these parameters in OSA patients are not well defined.nnnMETHODSnForty patients with newly diagnosed OSA [apnea-hypopnea index (AHI) 37 (20-65) h(-1)] underwent cardiopulmonary exercise testing for assessment of peak VO(2) and heart rate recovery at one (HRR-1) and two (HRR-2) minutes after exercise termination as well as NT-proBNP measurement at baseline and after 7.9+/-1.4 months of effective nCPAP (nightly usage>3.5 h). The effects of nCPAP were compared in patients with mild-to-moderate (AHI<30 h(-1); n=16) vs. severe (AHI>or=30 h(-1); n=24) OSA.nnnRESULTSnIn the group as a whole, peak VO(2) (baseline: 31.9+/-9.3 vs. follow-up: 33.7+/-9.0 ml/kg/min; p=0.02) and HRR-2 [38 (32-43) vs. 42 (32-47) bpm; p=0.01] but not HRR-1 [22 (15-26) vs. 22 (16-27) bpm; p=0.16] improved from baseline to follow-up. The effect on peak VO(2) was mainly driven by a trend towards an increase in patients with mild-to-moderate OSA (31.8+/-10.7 vs. 33.9+/-10.2 ml/kg/min; p=0.08), whereas an effect on HRR-1 [20 (15-23) vs. 21 (16-26) bpm; p=0.03] and HRR-2 [38 (29-42) vs. 42 (33-47) bpm; p=0.004] was observed only in those with severe OSA. NT-proBNP levels remained unchanged [21 (11-45) vs. 26 (5-52) pg/ml; p=0.6].nnnCONCLUSIONSnTreatment with nCPAP is associated with an improvement in peak VO(2) and heart rate recovery in patients with OSA.

Determinants of Postexercise Heart Rate Recovery in Patients With the Obstructive Sleep Apnea Syndrome

BACKGROUNDnYoung patients with obstructive sleep apnea syndrome (OSAS) display an attenuated heart rate recovery (HRR) during the first minute (HRR-1) and the first 2 min (HRR-2) postexercise. We sought to compare determinants of HRR-1 and HRR-2 in OSAS and to assess whether these associations depend on age.nnnMETHODSnExercise testing with measurements of HRR-1 and HRR-2 was performed in 54 patients with untreated OSAS (median [interquartile range] apnea-hypopnea index 27.5 [12.0-42.4] h(-1), desaturation index [DSI] 10.6 [5.1-25.0] h(-1)).nnnRESULTSnOverall, higher DSI (P < .001) and higher total cholesterol ([TC] P = .02) were independent predictors of lower HRR-1, whereas lower peak heart rate (P < .001), higher resting heart rate (P = .006), and higher DSI (P = .01) were independently associated with lower HRR-2. In the below-median age group (age <or= 48 years; n = 27), higher DSI (P = .002) was the only independent predictor of lower HRR-1, and lower peak heart rate (P < .001) and higher DSI (P = .003) were independently associated with lower HRR-2. In contrast, in the above-median age group (age > 48 years; n = 27) higher TC (P = .006), higher insulin resistance (P = .009), and higher resting heart rate (P = .048) were independently associated with lower HRR-1, and lower estimated glomerular filtration rate (P = .001), higher resting heart rate (P = .002), higher TC (P = .005), and lower peak heart rate (P = .01) were independently associated with HRR-2.nnnCONCLUSIONSnAssessment of HRR-2 provides additional information on different aspects of OSAS compared with HRR-1. Markers of OSAS severity, such as DSI, are independently associated with HRR in younger patients only, whereas in older patients, HRR reflects OSAS-related metabolic and renal dysfunction.

Interstitial pneumonitis after treatment with bevacizumab and pegylated liposomal doxorubicin in a patient with metastatic breast cancer.

of respiratory symptoms. All antineoplas-tic drugs were discontinued. With predni-sone 50 mg daily, tapered off over 6 weeks, symptoms resolved promptly, and lung function tests and CT scan after 6 weeks documented improvement ( table 1 ). We assumed bevacizumab more likely caus-ative for drug-induced pneumonitis than PLD as there are much more safety data available for PLD without clear evidence of interstitial pneumonitis related to PLD [1] . Thus, we decided to reinitiate PLD alone after a 3-month treatment holiday. No pul-monary side effects were noted, suggesting bevacizumab being the cause of interstitial pneumonitis. Pulmonary complications observed so far with bevacizumab are hemorrhage and hemoptysis, mainly ob-served in lung cancer patients and more commonly seen in patients with squamous cell carcinoma of the lung than in those with nonsquamous histology [2] . Only lately, a first description of interstitial pneumonitis in a patient treated with the [3] .drug-induced lung injury is poorly under-stood. Direct injury to pneumocytes or the alveolar capillary endothelium (chemical We report on a patient with metastatic breast cancer in whom interstitial pneu-monitis developed after treatment with bevacizumab in combination with pe-gylated liposomal doxorubicin (PLD). Re-exposure to PLD after recovery was with-out any pulmonary side effects. A 53-year-old woman presented with symptomatic histologically proven diffuse metastatic infiltration of the stomach as the only site of disease 5 years after pri-mary diagnosis of lobular breast cancer. Treatment with PLD (Caelyx ) 20 mg/m

Eight months of continuous positive airway pressure (CPAP) decrease tumor necrosis factor alpha (TNFA) in men with obstructive sleep apnea syndrome.

ObjectivesThe aim of this study was to assess serum tumor necrosis factor alpha (TNFA) concentrations 8xa0months of continuous positive airway pressure (CPAP) therapy.DesignThis study used prospective, observational clinical trial.PatientsSixty-six patients with newly diagnosed sleep apnea syndrome (12 women, 54 men), age 52.3u2009±u20099.8 (meanu2009±u2009SD) with a body mass index of 29.7u2009±u20094.4 and an apnea-hypopnea index of 39.7u2009±u200926.8, were studied.InterventionCPAP was administered for a mean of 7.8u2009±u20091.3xa0months.Measurements and resultsTNFA concentrations using an ultrasensitive ELISA assay at baseline and follow-up. TNFA decreased in men with high (5.2u2009±u20091.7xa0h/night, −0.46u2009±u20091.1xa0ng/l, pu2009=u20090.001) and with low (2.5u2009±u20091.0xa0h/night −0.63u2009±u20090.77xa0ng/l, pu2009=u20090.001) adherence but not in women. Average number of hours of CPAP use correlated positively with delta TNFA (R2 0.08, pu2009=u20090.04)ConclusionLong-term CPAP positively affects TNFA even in men with poor adherence to CPAP.

Monetary value of undisturbed sleep

STUDY OBJECTIVESnTo design a national antinoise policy, we need to know the monetary value that people attach to the reduction of sleep disturbance due to road traffic noise.nnnPRINCIPLESnPatients with obstructive sleep apnea syndrome (OSAS) controlled by nasal continuous positive airway pressure (nCPAP) underwent one-to-one structured interviews to determine the monetary value of their resultant undisturbed sleep. This was then converted into a value for sleep undisturbed by noise, using a severity ratio.nnnSETTINGnOutpatient interviews in 67 OSAS patients (54 males, 28 to 73 years old) managed by the Center for Sleep Medicine, Kantonsspital, St. Gallen, Switzerland.nnnMATERIALS AND METHODSnThe interview questions addressed the outcome and difficulties of nCPAP therapy, the self-rated severity of pretreatment sleep disturbance and self-rated monetary value of sleep improvement. Thirteen OSAS patients who had also experienced noise-related sleep disturbance rated its severity on a visual analogue scale (VAS).nnnRESULTSnThe mean monetary value of nCPAP-controlled sleep disturbance was Swiss francs (CHF) 70/night (CHF1 = US

Care of Patients with Obstructive Sleep Apnea Syndrome in Switzerland

0.877, year end 2004; 25th and 75th percentiles: CHF 35 and CHF 100). Interviewees maintained this high estimate after learning that the actual treatment costs were only approximately 6 CHF/night. A severity ratio ranging from 2.3:1 to 4.7:1 for sleep disturbance resulting from OSAS or from noise was derived from patients responses and literature. The value of noise-free sleep was CHF 7.45-23.81 per night.nnnCONCLUSIONnSleep undisturbed by noise has a remarkably high monetary value for people, which should be considered in political decision-making.

Tuberculosis screening in immigrants from high-prevalence countries: Interview first or chest radiograph first? A pro/con debate

Background: The obstructive sleep apnea syndrome (OSAS) is the most prevalent sleep-related breathing disorder. In Switzerland, the Swiss Respiratory Society together with the Swiss and the Cantonal Lung Associations have formed a Task Force to survey the current diagnostic and therapeutic state of the art. The present practice guidelines summarize the conclusions and recommendations based on scientific evidence and on the specific setting of the Swiss health care system. Methods: Review of the scientific literature, health care policy and practice, and expert panel discussions. Results: OSAS is diagnosed by typical symptoms together with findings during polysomnography. Pulse oximetry or limited respiratory polygraphy are not appropriate to exclude OSAS. Nasal continuous positive airway pressure (CPAP) is the most effective treatment for OSAS. In Switzerland, OSAS is diagnosed by pulmonary physicians in private practice and in sleep disorder centers. The pulmonologists work closely together with the local lung associations which play an essential role in the long-term care of OSAS patients on CPAP therapy. In particular, the associations provide counseling services, home care and technical support. With this approach, a high compliance with CPAP therapy has been achieved. The costs for CPAP therapy are reimbursed by the health insurance. Weight reduction in obese patients, sleep positional training and avoidance of alcohol and sedatives are adjunctive measures. In habitual snorers and in patients with OSAS unable to tolerate CPAP, removable oral appliances have provided favorable results. Conclusions: OSAS is suggested by a typical history and evaluated by a sleep study as a basis for treatment by nocturnal CPAP. Close cooperation of pulmonary physicians and lung associations provides excellent results in the long-term care of OSAS patients on CPAP.

Effect of telemetric monitoring in the first 30 days of continuous positive airway pressure adaptation for obstructive sleep apnoea syndrome – a controlled pilot study

Immigration from high tuberculosis (TB) prevalence countries has a substantial impact on the epidemiology of TB in receiving countries with low TB incidence. Cross‐border migration offers an ideal opportunity for active case finding that will result in a lower caseload in the host country and a reduced spread of disease to both the indigenous and migrant populations. Screening strategies can start ‘offshore’, thereby indirectly assisting and empowering public health systems in the source countries, or be performed at ports of entry with or without long‐term engagement of ‘onshore’ facilities and systems to provide either preventive therapy or surveillance for reactivation of latent TB. The chest radiograph seems to be playing a key role in this process, but questions remain regarding when, where and in whom radiographs are best done for optimal yield and cost‐effectiveness, and with what other tests they might best be combined to further increase the usefulness of transborder TB control.

Biomarkers of cardiovascular stress in obstructive sleep apnea

Obstructive sleep apnoea syndrome (OSAS) is characterised by repetitive collapse of the upper airway during sleep. Continuous positive airway pressure (CPAP) applied via a mask is the standard treatment for OSAS. CPAP adherence is crucial in therapy to prevent the deleterious consequences of OSAS. We hypothesised that a combination of supervision by telemetry together with targeted telephone support in the first month of CPAP would increase CPAP adherence and treatment success. A total of 113 OSAS patients followed by telemetry-triggered interventions used the device for 5.3u2009h/night on 28/30 nights, significantly more than the 110 OSAS patients in the control group with 4.6u2009h/night and 27/30 nights. Telemetry-triggered interventions have a significant impact on adherence rate in early CPAP treatment. These results can be reached with an acceptable additional effort.