Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management

OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilator-dependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov:NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results.

Eugenol attenuates pulmonary damage induced by diesel exhaust particles

Zin WA, Silva AG, Magalhaes CB, Carvalho GM, Riva DR, Lima CC, Leal-Cardoso JH, Takiya CM, Valen a SS, Saldiva PH, Faffe DS. Eugenol attenuates pulmonary damage induced by diesel exhaust particles. J Appl Physiol 112: 911-917, 2012. First published December 22, 2011; doi: 10.1152/japplphysiol.00764.2011.-Environmentally relevant doses of inhaled diesel particles elicit pulmonary inflammation and impair lung mechanics. Eugenol, a methoxyphenol component of clove oil, presents in vitro and in vivo anti-inflammatory and antioxidant properties. Our aim was to examine a possible protective role of eugenol against lung injuries induced by diesel particles. Male BALB/c mice were divided into four groups. Mice received saline (10 mu l in; CTRL group) or 15 mu g of diesel particles DEP (15 mu g in; DIE and DEUG groups). After 1 h, mice received saline (10 mu l; CTRL and DIE groups) or eugenol (164 mg/kg; EUG and DEUG group) by gavage. Twenty-four hours after gavage, pulmonary resistive (Delta P1), viscoelastic (Delta P2) and total (Delta Ptot) pressures, static elastance (Est), and viscoelastic component of elastance (Delta E) were measured. We also determined the fraction areas of normal and collapsed alveoli, amounts of polymorpho- (PMN) and mononuclear cells in lung parenchyma, apoptosis, and oxidative stress. Est, Delta P2, Delta Ptot, and Delta E were significantly higher in the DIE than in the other groups. DIE also showed significantly more PMN, airspace collapse, and apoptosis than the other groups. However, no beneficial effect on lipid peroxidation was observed in DEUG group. In conclusion, eugenol avoided changes in lung mechanics, pulmonary inflammation, and alveolar collapse elicited by diesel particles. It attenuated the activation signal of caspase-3 by DEP, but apoptosis evaluated by TUNEL was avoided. Finally, it could not avoid oxidative stress as indicated by malondialdehyde.

Temporal Trends of Asthma Mortality Rates in Brazil from 1980 to 2010

Objective. Mortality from asthma has varied among countries during the last several decades. This study aimed to identify temporal trends of asthma mortality in Brazil from 1980 to 2010. Method. We analyzed 6840 deaths of patients aged 5-34 years that occurred in Brazil with the underlying cause of asthma. We applied a log-linear model using Poisson regression to verify peaks and trends. We also calculated the point estimation and 95% confidence interval (CI 95%) of the annual percent change (APC) of the mortality rates, and the average annual percent change (AAPC) for 2001-2010. Results. A decline was observed from 1980 to 1992 [APC = -3.4 (-5.0 to -1.8)], followed by a nonsignificant rise until 1996 [APC = 6.8 (-1.4 to 15.6)], and a new downward trend from 1997 to 2010 [APC = -2.7 (-3.9 to -1.6)]. The APCs varied according to age strata: 5-14 years from 1980 to 2010 [-0.3 (-1.1 to 0.5)]; 15-24 years from 1980 to 1991 [-2.1 (-5.0 to 0.9)], from 1992 to 1996 [6.8 (-6.7 to 22.2)], and from 1997 to 2010 [-3.9 (-5.7 to -2.0)]; 24-25 years from 1980 to 1992 [-2.5 (-4.6 to -0.3)], from 1993 to 1995 [12.0 (-21.1 to 59.1)], and from 1996-2010 [-1.7 (-3.0 to -0.4)]. AAPC from 2001 to 2010 was -1.7 (-3.0 to -0.4); the decline for this period was significant for patients over 15 years old, women, and those living in the Southeast region. Conclusion. Asthma mortality rates in Brazil have been declining since the late 1990s.

Occurrence of asthma symptoms and of airflow obstruction in amateur swimmers between 8 and 17 years of age

Objective: To determine the prevalence of asthma symptoms and of airflow obstruction in amateur swimmers between 8 and 17 years of age, as well as to assess the awareness of asthma and asthma management among these swimmers, their parents, and their coaches. Methods: Our sample comprised 1,116 amateur swimmers who completed a modified version of the International Study of Asthma and Allergies in Childhood written questionnaire, to which questions regarding the reasons to initiate swimming and regarding asthma management had been added. In addition, the participants underwent spirometry prior to a swimming competition. Results: The prevalence of asthma symptoms in the last 12 months was 11.5%, and 327 (29.4%) of the participants reported "wheezing or whistling" in the past. Of the 223 swimmers who reported "asthma ever" or "bronchitis ever", only 102 (45.7%) reported having ever been treated: the most common "treatment" was swimming (in 37.3%), and only 12.7% used inhaled corticosteroids. Of the 254 participants (22.7%) with airflow obstruction, only 52 (20.5%) reported having asthma symptoms. Conclusions: Asthma symptoms are present in amateur swimmers, and a considerable number of such swimmers have airflow obstruction without symptoms. It is therefore likely that the prevalence of asthma is underestimated in this population. It is worrisome that, in our study sample, the swimmers previously diagnosed with asthma were not using the recommended treatments for asthma. The clinical implications of these findings underscore the importance of implementing educational measures for amateur swimmers, as well as for their parents and coaches, to help them recognize asthma symptoms and the consequent risks in the sports environment, in order to allow prompt diagnosis and early clinical intervention.

Chronic Pain after Cesarean Section. Influence of Anesthetic/Surgical Technique and Postoperative Analgesia

Cancado TO, Omais M, Ashmawi HA, Torres MLA - Chronic Pain after Cesarean Section. Influence of Anesthetic/Surgical Technique and Postoperative Analgesia. Background and objectives: Brazil ranks second among countries with the highest rates of cesarean section in the world. Little is known about the future consequences of this procedure on maternal health. This study investigated the influence of anesthetic/surgical technique and postoperative analgesia on the onset of chronic pain after three months of cesarean section. Method: This is a prospective randomized study of 443 patients undergoing cesarean section (elective and emergency), with different doses of hyperbaric bupivacaine 0.5% and opioids in spinal anesthesia. Patients were alocated into five groups as follow: G1 received hyperbaric bupivacaine (8 mg), sufentanil (2.5 mu g), and morphine (100 mu g); G2 received hyperbaric bupivacaine (10 mg), sufentanil (2.5 mu g), and morphine (100 mu g); G3 received hyperbaric bupivacaine (12.5 mg) and morphine (100 mu g); G4 received hyperbaric bupivacaine (15 mg) and morphine (100 mu g); G5 received hyperbaric bupivacaine (12.5 mg) and morphine (100 mu g), without perioperative anti-inflammatory. Pain at rest and in movement were evaluated in the immediate postoperative period. Phone contact was made after three months of surgery for identification of patients with chronic pain. Results: The incidence of chronic pain in the groups was G1 = 20%; G2 = 13%; G3 = 7.1%; G4 = 2.2%, and G5 = 20.3%. Patients who reported higher pain scores in the postoperative period had a higher incidence of chronic pain (p < 0.05). Conclusion: The incidence of chronic pain decreases with higher doses of local anesthetics and use of anti-inflammatory drugs. The higher pain scores in the postoperative period were associated with chronic pain development after three months of cesarean section.

Percutaneous sciatic nerve block with tramadol induces analgesia and motor blockade in two animal pain models

Local anesthetic efficacy of tramadol has been reported following intradermal application. Our aim was to investigate the effect of perineural tramadol as the sole analgesic in two pain models. Male Wistar rats (280-380 g; N = 5/group) were used in these experiments. A neurostimulation-guided sciatic nerve block was performed and 2% lidocaine or tramadol (1.25 and 5 mg) was perineurally injected in two different animal pain models. In the flinching behavior test, the number of flinches was evaluated and in the plantar incision model, mechanical and heat thresholds were measured. Motor effects of lidocaine and tramadol were quantified and a motor block score elaborated. Tramadol, 1.25 mg, completely blocked the first and reduced the second phase of the flinching behavior test. In the plantar incision model, tramadol (1.25 mg) increased both paw withdrawal latency in response to radiant heat (8.3 +/- 1.1, 12.7 +/- 1.8, 8.4 +/- 0.8, and 11.1 +/- 3.3 s) and mechanical threshold in response to von Frey filaments (459 +/- 82.8, 447.5 +/- 91.7, 320.1 +/- 120, 126.43 +/- 92.8 mN) at 5, 15, 30, and 60 min, respectively. Sham block or contralateral sciatic nerve block did not differ from perineural saline injection throughout the study in either model. The effect of tramadol was not antagonized by intraperitoneal naloxone. High dose tramadol (5 mg) blocked motor function as well as 2% lidocaine. In conclusion, tramadol blocks nociception and motor function in vivo similar to local anesthetics.

No evidence of selenosis from a selenium-rich diet in the Brazilian Amazon

Selenium (Se) is an essential element and a well-known anti-oxidant. In the Lower Tapajos River region of the Brazilian Amazon, biomarkers of Se range from normal to very high. The local traditional diet includes important Se sources such as Brazil nuts, chicken, game meat and certain fish species. Some studies have reported alterations in keratin structure, gastrointestinal problems and paresthesia in populations with high Se intake. The objective of the present study was to evaluate cutaneous and garlic odor of the breath signs and sentinel symptoms of Se toxicity (selenosis) in relation to Se status in communities along the Tapajos River. Participants (N = 448), aged 15-87 years, were recruited from 12 communities. Se concentrations were measured in blood (B-Se) and plasma (P-Se) by ICP-MS. A nurse performed an examination of the hair, nails, skin and breath for signs of Se toxicity. Interview-administered questionnaires were used to collect information on socio-demographics, medical history and possible symptoms of Se toxicity. In this population, the median levels of B-Se and P-Se were 228.4 mu g/L (range 103.3-1500.2 mu g/L) and 134.8 mu g/L (range 53.6-913.2 mu g/L) respectively. Although B-Se and P-Se surpassed concentrations considered toxic (B-Se: 1000 mu g/L (U.S. EPA, 2002)), no dermal or breath signs or symptoms of Se toxicity were associated with the biomarkers of Se status. In the present study population, where Se intake is mostly from traditional diet, there is no evidence of selenosis. These findings support the need to re-assess Se toxicity considering factors such as the chemical form of Se exposure, route of exposure (inhaled versus ingested), co-exposures to toxic elements such as mercury. Considering the current food transition towards a western diet in the Amazon, further studies should address the possible association between high Se status and cardiometabolic health in this study population. (C) 2011 Elsevier Ltd. All rights reserved.

Effect of the ketamine/xylazine anesthetic on the auditory brainstem response of adult gerbils

The auditory brainstem response (ABR) is a test widely used to assess the integrity of the brain stem. Although it is considered to be an auditory-evoked potential that is influenced by the physical characteristics of the stimulus, such as rate, polarity and type of stimulus, it may also be influenced by the change in several parameters. The use of anesthetics may adversely influence the value of the ABR wave latency. One of the anesthetics used for e ABR assessment, especially in animal research, is the ketamine/xylazine combination. Our objective was to determine the influence of the ketamine/xylazine anesthetic on the ABR latency values in adult gerbils. The ABRs of 12 adult gerbils injected with the anesthetic were collected on three consecutive days, or a total of six collections, namely: pre-collection and A, B, C, D, and E collections. Before each collection the gerbil was injected with a dose of ketamine (100 mg/kg)/xylazine (4 mg/kg). For the capture of the ABR, 2000 click stimuli were used with rarefaction polarity and 13 stimuli per second, 80 dBnHL intensity and in-ear phones. A statistically significant difference was observed in the latency of the V wave in the ABR of gerbils in the C and D collections compared to the pre-, A and E collections, and no difference was observed between the pre-, A, B, and E collections. We conclude that the use of ketamine/xylazine increases the latency of the V wave of the ABR after several doses injected into adult gerbils; thus clinicians should consider the use of this substance in the assessment of ABR.

A COCAÍNA E O CRACK: As Drogas da Morte

Diante da relevância mundial do desafio no enfrentamento do tema concernente ao uso de drogas, o presente artigo tem por escopo principal abordar alguns aspectos sobre a cocaína em suas diversas formas de consumo, isto é, como chá, em pó (inalada), como injeção (diluída) e fumo – neste caso denominado crack (“pedra”) ou merla (“pasta”). Nesse contexto, no primeiro tópico, explana-se um breve histórico sobre as drogas, com enfoque nas espécies do tipo estimulantes, no qual se ressalta os efeitos tóxicos que causam ao organismo dos usuários. A seguir, há relevo sobre os problemas sociais e psicológicos acarretados pelo uso da cocaína em qualquer de suas formas, bem como expõe apontamentos sobre métodos de tratamento

Untersuchung zur Bestimmung quantitativer Parameter der Lungenventilation mittels CT und MRT

Die zuverlässige Berechnung von quantitativen Parametern der Lungenventilation ist für ein Verständnis des Verhaltens der Lunge und insbesondere für die Diagnostik von Lungenerkrankungen von großer Bedeutung. Nur durch quantitative Parameter sind verlässliche und reproduzierbare diagnostische Aussagen über den Gesundheitszustand der Lunge möglich. Im Rahmen dieser Arbeit wurden neue quantitative Verfahren zur Erfassung der Lungenventilation basierend auf der dynamischen Computer- (CT) und Magnetresonanztomographie (MRT) entwickelt. Im ersten Teil dieser Arbeit wurde die Frage untersucht, ob das Aufblähen der Lunge in gesunden Schweinelungen und Lungen mit Akutem Lungenversagen (ARDS) durch einzelne, diskrete Zeitkonstanten beschrieben werden kann, oder ob kontinuierliche Verteilungen von Zeitkonstanten die Realität besser beschreiben. Hierzu wurden Serien dynamischer CT-Aufnahmen während definierter Beatmungsmanöver (Drucksprünge) aufgenommen und anschließend aus den Messdaten mittels inverser Laplace-Transformation die zugehörigen Verteilungen der Zeitkonstanten berechnet. Um die Qualität der Ergebnisse zu analysieren, wurde der Algorithmus im Rahmen von Simulationsrechnungen systematisch untersucht und anschließend in-vivo an gesunden und ARDS-Schweinelungen eingesetzt. Während in den gesunden Lungen mono- und biexponentielle Verteilungen bestimmt wurden, waren in den ARDS-Lungen Verteilungen um zwei dominante Zeitkonstanten notwendig, um die gemessenen Daten auf der Basis des verwendeten Modells verlässlich zu beschreiben. Es wurden sowohl diskrete als auch kontinuierliche Verteilungen gefunden. Die CT liefert Informationen über das solide Lungengewebe, während die MRT von hyperpolarisiertem 3He in der Lage ist, direkt das eingeatmete Gas abzubilden. Im zweiten Teil der Arbeit wurde zeitlich hochaufgelöst das Einströmen eines 3He-Bolus in die Lunge erfasst. Über eine Entfaltungsanalyse wurde anschließend das Einströmverhalten unter Idealbedingungen (unendlich kurzer 3He-Bolus), also die Gewebeantwortfunktion, berechnet und so eine Messtechnik-unabhängige Erfassung des Einströmens von 3He in die Lunge ermöglicht. Zentrale Fragestellung war hier, wie schnell das Gas in die Lunge einströmt. Im Rahmen von Simulationsrechnungen wurde das Verhalten eines Entfaltungsalgorithmus (basierend auf B-Spline Repräsentationen) systematisch analysiert. Zusätzlich wurde ein iteratives Entfaltungsverfahren eingesetzt. Aus zeitlich hochaufgelösten Messungen (7ms) an einer gesunden und einer ARDS-Schweinelunge konnte erstmals nachgewiesen werden, dass das Einströmen in-vivo in weniger als 0,1s geschieht. Die Ergebnisse zeigen Zeitkonstanten im Bereich von 4ms–50ms, wobei zwischen der gesunden Lungen und der ARDS-Lunge deutliche Unterschiede beobachtet wurden. Zusammenfassend ermöglichen daher die in dieser Arbeit vorgestellten Algorithmen eine objektivere Bestimmung quantitativer Parameter der Lungenventilation. Dies ist für die eindeutige Beschreibung ventilatorischer Vorgänge in der Lunge und somit für die Lungendiagnostik unerlässlich. Damit stehen quantitative Methoden für die Lungenfunktionsdiagnostik zur Verfügung, deren diagnostische Relevanz im Rahmen wissenschaftlicher und klinischer Studien untersucht werden kann.

Chirurgia dermatologica pediatrica

Le caratteristiche istologiche, immunologiche e fisiologiche della cute in età pediatrica sono responsabili di quadri dermatologici differenti nel bambino rispetto all’adulto, per cui la dermatologia pediatrica sta acquisendo sempre maggiore importanza come branca specifica nell’ambito sia della dermatologia generale che della pediatria. Il problema cruciale che si incontra nel management delle dermatosi pediatriche è legato alle difficoltà diagnostiche incontrate, che comportano spesso la necessità di eseguire una biopsia cutanea. Mentre gli studi epidemiologici relativi alla frequenza delle patologie dermatologiche pediatriche siano ampiamente riportati in letteratura, i dati e le revisioni relative alla chirurgia pediatrica dermatologica, nell’ambito dei servizi di Dermatologia Pediatrica, sono ridotti. Nell’arco dei tre anni di dottorato, la mia attività è stata finalizzata a valutare la possibilità di organizzare un servizio ambulatoriale per i prelievi bioptici in età pediatrica, con il solo ausilio di anestetici topici e locali. Durante i tre anni di Dottorato di Ricerca sono stati eseguiti 296 prelievi. Le biopsie eseguite sono state suddivise in 3 gruppi: biopsie diagnostiche su patologie dermatologiche (108 pz, 36%), biopsie su neoformazioni cutanee (174 pz, 59 %) e biopsie su lesioni follicolari ( 14 pz, 5%). Di ciascun gruppo sono state valutate le patologie riscontrate, l’età, il sesso, l’impiego di anestetico topico associato ad anestetico locale. In 180 (61%) pazienti dopo la biopsia si è proceduto all’applicazione di punti di sutura. Si sono valutati inoltre i vantaggi e gli svantaggi di tale attività ambulatoriale rispetto ai prelievi eseguiti avvalendosi di una sedazione profonda.

Biomarkers in chronic obstructive pulmonary diseases. Clinical and functional correlations.

Asthma and chronic obstructive pulmonary disease (COPD) are two distinct lung diseases with distinctive clinical and inflammatory features. A proportion of asthmatic patients experience a fixed airflow obstruction that persists despite optimal pharmacologic treatment for reasons that are still largely unknown. We found that patients with asthma and COPD sharing a similar fixed airflow obstruction have an increased lung function decline and frequency of exacerbations. Nevertheless, the decline in lung function is associated with specific features of the underlying inflammation. Airway inflammation increases during asthma exacerbation and disease severity. Less is known about the correlations between symptoms and airway inflammation in COPD patients. We found that there is no correlation between symptoms and lung function in COPD patients. Nevertheless symptoms changes are associated with specific inflammatory changes: cough is associated with an increase of sputum neutrophils in COPD, dyspnoea is associated with an increase of eosinophils. The mechanisms of this correlation remain unknown. Neutrophils inflammation is associated with bacterial colonization in stable COPD. Is not known whether inhaled corticosteroids might facilitate bacterial colonization in COPD patients. We found that the use of inhaled corticosteroids in COPD patients is associated with an increase of airway bacterial load and with an increase of airway pathogen detection. Bacterial and viral infections are the main causes of COPD and asthma exacerbations. Impaired innate immune responses to rhinovirus infections have been described in adult patients with atopic asthma. Whether this impaired immune condition is present early in life and whether is modulated by a concomitant atopic condition is currently unknown. We found that deficient innate immune responses to rhinovirus infection are already present early in life in atopic patients without asthma and in asthmatic subjects. These findings generalize the scenario of increased susceptibility to viral infections to other Th2 oriented conditions.

Optimierung der Inhalationstherapie bei Kindern und Mukoviszidose-Patienten

Die pulmonale Applikation von Arzneimitteln hat in den vergangenen Jahren zu- rnnehmend an Bedeutung gewonnen und wird vor allem in der lokalen Therapie bei Asthma, COPD und Mukoviszidose genutzt. Als neues innovatives Inhalationsgerät befindet sich der Respimat® seit 2004 auf dem Arzneimittelmarkt und ist bisher nur für Erwachsene zugelassen. Daher wurden im Rahmen dieser Arbeit die Anwendbarkeit und die Modifikation des Respimats® bei Kindern untersucht. Zusammenfassend zeigen die Ergebnisse, dass Kinder ab einem Alter von fünf Jahren fähig sind suffizient mit dem Respimat® zu inhalieren und gute Werte für die estimierte Intrathorakaldosis zu erreichen. Besonders Kinder von 9-12 Jahren und Patienten mit DPI- oder Autohaler®-Inhalationserfahrung erreichten aufgrund eines hohen Atemflusses eine niedrigere estimierte Intrathorakaldosis als es das Potenzial des Respimats® erlaubt hätte. Durch den Einbau eines höheren internen Widerstands in den Orginalrespimat® wurde der Atemfluss signifikant verlangsamt und die Intrathorakaldosis erhöht. Des Weiteren wurden in der vorliegenden Arbeit die physikalisch-chemische Kompatibilität und die aerodynamischen Eigenschaften von Mischinhalationslösung/-suspensionen untersucht. In der Praxis mischen Muko-viszidose-Patienten oftmals mehrere Fertigarzneimittel und inhalieren diese simultan. Dadurch wird der Zeitaufwand der täglichen Inhalation reduziert und die Compliance sowie die Lebensqualität verbessert. Die 4er Kombination aus Colistimethat mit konservierungsmittelfreier Salbutamolsulfat, Ipratropiumbromidinhalationslösungen und Fluticason-17-propionatinhalationssuspension erwies sich als physikalisch-chemisch kompatibel. Die entwickelte mikrobiologische Wertbestimmungsmethode erwies sich als robust, präzise, gut reproduzierbar und erfüllte alle Anforderungen des statistischen Modells. Weiterhin wurden die aerodynamischen Eigenschaften einer praxisrelevanten 3er Mischinhalationssuspension aus Salbutamolsulfat, Ipratropiumbromid und Fluticason-17-propionat im Vergleich zu deren konsekutiven Vernebelung mittels Kaskadenimpaktion betrachtet. Die Charakteristik des erzeugten Aerosols änderte sich für simultan vernebeltes Salbutamolsulfat und Ipratropiumbromid nicht, wohingegen Fluticason-17-propionat bei simultaner Vernebelung eine Reduktion des MMADs, der delivered dose und der recovery aufwies. Dennoch ist die inhalative Glukokortikoiddosis ausreichend hoch um eine effektive antiinflammatorische Wirkung zu gewährleisten. Daher kann die simultane Inhalation der 3er Kombination empfohlen werden und somit die Compliance und die Lebensqualität von Mukoviszidosepatienten erhöht werden.rn

Methodische Untersuchung zur Diagnostik der bronchialen Hyperreagibilität mit Hilfe eines inhalativen Methacholin-Provokationstests

Die unspezifische Provokation mit Methacholin ist die am weitesten verbreitete und akzeptierte Methode zur Diagnose bzw. zum Ausschluss der bronchialen Hyperreagibilität bei Patienten mit Verdacht auf ein Asthma bronchiale und zu dessen Therapiekontrolle. Um die Sicherheit und die Genauigkeit der Methode weiter zu verbessern, wurde daher ein Dosimeterprotokoll entwickelt, das die inhalierte Methacholin-Dosis anstatt durch die Erhöhung, d.h. in der Regel Verdoppelung, der Methacholinkonzentrationen nur durch Erhöhung der Anzahl der Inhalationen bei konstanter, niedriger Konzentration der Methacholinlösung steigert. Dieses neue Protokoll wurde verglichen mit anderen weit verbreiteten Methacholin-Provokationsprotokollen. Die Methacholinchlorid-Lösung (1,75 mg/ml) wurde mit Hilfe des Dosimetersystems ZAN 200 ProvAir II sowie des Verneblertopfes DeVilbiss 646 vernebelt. 15 Asthmapatienten mit einer vor der Provokation normalen Lungenfunktion (FEV1 98 +/- 9 % PN) und 18 Lungengesunde (FEV1 110 +/- 12 % PN) nahmen an der Testreihe teil. Begonnen wurde mit einer Dosis von 20 μg Methacholinchlorid (= eine Inhalation); beendet wurde der Versuch bei einer Kumulativdosis von 2000 μg Methacholinchlorid, wenn nicht vorher ein Kriterium für einen positiven Test und damit für einen Versuchsabbruch erfüllt wurde. Abbruchkriterien waren entweder ein Abfall der FEV1 um 20 % des Ausgangswertes oder ein Anstieg des totalen Atemwegswiderstandes auf ≥ 0,5 kPa*s/l. Mittels linearer Regression wurden die Provokationsdosen PD 20 FEV1 und PD Rtot ≥ 0,5 berechnet. Im Vergleich mit anderen Protokollen zeigte sich, dass auch das neue Protokoll zuverlässig und sicher zwischen gesund und krank unterscheidet. Der Median der PD 20 FEV1 liegt in der Gruppe der Asthmatiker bei 222 μg, bei den Lungengesunden bei 2000 μg; daraus ergibt sich ein p-Wert von < 0,001. In Bezug auf die PD Rtot ≥ 0,5 liegt der Median bei den Asthmatikern bei 122 μg, in der Gruppe der Lungengesunden bei 2000 μg; hieraus errechnet sich ebenfalls ein p-Wert von < 0,001. Sensitivität und Spezifität der Methode wurden mittels ROC-Kurven untersucht. Basierend auf der PD 20 FEV1 liefert die Methode für die Diagnose einer bronchialen Hyperreagibilität bei einer Enddosis von 1000 μg Methacholinchlorid eine Sensitivität von über 93 % und eine Spezifität von 83 %; basierend auf der PD Rtot ≥ 0,5 liegt die Sensitivität bei einer Dosis von 1000 μg bei 90 %, die Spezifität bei 89 %. Für die gemeinsame Betrachtung der parameterspezifischen Provokationsdosen PD 20 FEV1 und PD Rtot ≥ 0,5, der PD Minimal, bei 1000 μg liegt die Sensitivität bei über 93 % und die Spezifität bei 83 %. Daher können 1000 μg als Schwellendosis für den Ausschluss einer bronchialen Hyperreagibilität zum Untersuchungszeitpunkt angesehen werden, und der Test darf an diesem Punkt abgebrochen werden. Grundsätzlich ist festzustellen, dass die Diagnostik der bronchialen Hyperreagibilität sicher und genau mit Hilfe eines Dosimeterprotokolls erfolgen kann, das die Methacholin-Dosis nur durch die Steigerung der Inhalationen bei gleichbleibender Konzentration der Methacholinlösung erhöht. Die Schwellendosis zwischen normaler und pathologischer bronchialer Reaktion, Sensitivität und Spezifität sowie die Trennschärfe der Methode sind sehr gut vergleichbar mit anderen bisher etablierten Protokollen.

Type IV delayed-type hypersensitivity of the respiratory tract due to budesonide use: report of two cases and a literature review

Respiratory type-IV hypersensitivity reactions due to corticosteroids is a rare phenomenon. We describe two such cases. The first is a 37- year-old atopic woman who developed labial angioedema and nasal itching after the use of budesonide nasal spray. A month later, after the first puffs of a formoterol/budesonide spray prescribed for asthma, she noticed symptoms of tongue and oropharyngeal itching and redness with subsequent dysphagia, labial and tongue angioedema, and facial oedema. The second is a 15-year-old non-atopic woman who reported pruritic eruptions around the nostrils after using a budesonide nasal spray. A year later she presented with nasal pruritus with intense congestion and labial and facial oedema after using the same spray. Both patients were evaluated with patch-tests using the commercial T.R.U.E. test, a budesonide solution, and corticosteroid creams. Test evaluation was performed at 48 and 96 hours. In both patients, patch tests were positive to budesonide (++) on the second day. The first patient also had a positive (+) reaction to tixocortol-21-pivalate. All the other patch tests were negative. Clinicians should be aware that hypersensitivity reactions may occur during the use of nasal or inhaled corticosteroids.