Pandemic 2009 H1N1 influenza virus (H1N1) infection is considered harmful to lung transplant recipients (LTRs). Vaccination against this virus is recommended for LTRs, but little is known about ...associated benefits and risks. Our aim in this study is to document the safety and clinical effectiveness of the H1N1 vaccine in LTRs.
All LTRs received an informational letter on the H1N1 pandemic that included hygiene and vaccination recommendations. After completing a questionnaire, volunteering LTRs received Pandemrix (H1N1 2009 Monovalent AS03-Adjuvanted Vaccine; GSK). Adverse events (AEs) were documented at short-term follow-up visits and by telephone. Any flu-like symptoms were reported and a low threshold for performing nasal/pharyngeal swabs for virus detection was maintained.
Of 168 eligible LTRs (107 already vaccinated for 2009 seasonal influenza), 148 (88%) received at least one vaccination with the H1N1 vaccine and 115 received a second dose. After the first vaccination, 44% had no AEs. Six self-limiting, severe AEs occurred, and the remainder were minor to moderate, predominantly injection-site reactions. After the second vaccination, AEs were clearly less frequent. All AEs resolved completely. Documented H1N1 infection occurred in 2 of 148 vaccinated LTRs, in contrast to 5 infections in 20 non-vaccinated LTRs.
H1N1 vaccination is generally well tolerated with mild to moderate, predominantly local AEs in most LTRs and few self-limiting severe events. Clinical effectiveness is good.
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a severe, chronic multisystemic disease which, depending on its severity, can lead to considerable physical and cognitive impairment, ...loss of ability to work and the need for nursing care including artificial nutrition and, in very severe cases, even death.The aim of this D-A-CH (Germany, Austria, Switzerland) consensus statement is 1) to summarize the current state of knowledge on ME/CFS, 2) to highlight the Canadian Consensus Criteria (CCC) as clinical criteria for diagnostics with a focus on the leading symptom post-exertional malaise (PEM) and 3) to provide an overview of current options and possible future developments, particularly with regard to diagnostics and therapy. The D-A-CH consensus statement is intended to support physicians, therapists and valuer in diagnosing patients with suspected ME/CFS by means of adequate anamnesis and clinical-physical examinations as well as the recommended clinical CCC, using the questionnaires and other examination methods presented. The overview of the two pillars of therapy for ME/CFS, pacing and symptom-relieving therapy options, is intended not only to provide orientation for physicians and therapists, but also to support decision-makers from healthcare policy and insurance companies in determining which therapy options should already be reimbursable by them at this point in time for the indication ME/CFS.
Zusammenfassung
Myalgische Enzephalomyelitis/Chronisches Fatigue-Syndrom (ME/CFS) ist eine schwere, chronische Multisystemerkrankung, die je nach Ausprägung zu erheblichen körperlichen und kognitiven ...Einschränkungen, zum Verlust der Arbeitsfähigkeit bis hin zur Pflegebedürftigkeit einschließlich künstlicher Ernährung und in sehr schweren Fällen sogar zum Tod führen kann. Das Ziel dieses D-A-CH-Konsensusstatements ist es, 1) den aktuellen Wissensstand zu ME/CFS zusammenzufassen, 2) in der Diagnostik die kanadischen Konsensuskriterien (CCC) als klinische Kriterien mit Fokus auf das Leitsymptom post-exertionelle Malaise (PEM) hervorzuheben und 3) vor allem im Hinblick auf Diagnostik und Therapie einen Überblick über aktuelle Optionen und mögliche zukünftige Entwicklungen aufzuzeigen. Das D-A-CH-Konsensusstatement soll Ärzt:innen, Therapeut:innen und Gutachter:innen dabei unterstützen, Patient:innen mit Verdacht auf ME/CFS mittels adäquater Anamnese und klinisch-physikalischen Untersuchungen sowie der empfohlenen klinischen CCC zu diagnostizieren und dabei die präsentierten Fragebögen sowie die weiteren Untersuchungsmethoden zu nutzen. Der Überblick über die zwei Säulen der Therapie bei ME/CFS, Pacing und die symptomlindernden Therapieoptionen sollen nicht nur Ärzt:innen und Therapeut:innen zur Orientierung dienen, sondern auch Entscheidungsträger:innen aus der Gesundheitspolitik und den Versicherungen darin unterstützen, welche Therapieoptionen bereits zu diesem Zeitpunkt bei der Indikation „ME/CFS“ von diesen erstattbar sein sollten.
Although no data exist on the effect of altitude exposure on coronary flow reserve (CFR), patients with coronary artery disease (CAD) are advised not to exceed moderate altitudes of approximately ...2500 m above sea level. We studied the influence of altitude on myocardial blood flow (MBF) in controls and CAD patients.
In 10 healthy controls and 8 patients with CAD, MBF was measured by positron emission tomography and 15O-labeled water at rest, during adenosine stress, and after supine bicycle exercise. This protocol was repeated during inhalation of a hypoxic gas mixture corresponding to an altitude of 4500 m (controls) and 2500 m (CAD). Workload was targeted to comparable heart rate-blood pressure products at normoxia and hypoxia. Resting MBF increased significantly in controls at 4500 m (+24%, P<0.01) and in CAD patients at 2500 m (+24%, P<0.05). Altitude had no influence on adenosine-induced hyperemia and CFR. Exercise-induced hyperemia increased significantly in controls (+38%, P<0.01) at 4500 m (despite a reduction in workload, -28%, P<0.0001) but not in CAD patients at 2500 m (moderate decrease in workload, -11%, P<0.05). Exercise-induced reserve was preserved in controls (+10%, P=NS) but decreased in CAD patients (-18%, P<0.005).
At 2500 m altitude, there is a significant decrease in exercise-induced reserve in CAD patients, indicating that compensatory mechanisms might be exhausted even at moderate altitudes, whereas healthy controls have preserved reserve up to 4500 m. Thus, patients with CAD and impaired CFR should be cautious when performing physical exercise even at moderate altitude.
There is a lack of data regarding use of ECMO in children undergoing lung transplantation. We evaluated our experience of ECMO in pediatric lung transplant recipients. All patients (<18 yr) who ...underwent lung transplants between 1997 and 2011 were included (17 children; nine males; median age 16 yr), and the use of intra‐operative ECMO evaluated. Transplant procedures were carried out with intra‐operative ECMO in seven children (all bilateral lung transplants). Demographics of ECMO and non‐ECMO patients were comparable. One child was already on ECMO pre‐operative. Lung graft size reduction was undertaken in five ECMO and four non‐ECMO cases, respectively. Five patients were taken off ECMO intra‐operatively; the other patients were weaned off ECMO within 48 h post‐operatively. Three‐months survival was 100%. By 12 months post‐transplantation, one patient each died in the ECMO and in the non‐ECMO group. At the end of the study, six of seven ECMO cases were still alive (median survival 48.5 months); one patient required a retransplant at 53 months. Our small case series suggests that lung transplant procedures can be safely carried out in selected children on intra‐operative ECMO support; however, our pediatric experience regarding this scenario is very limited but probably almost unique.
The City of Phoenix has received a lot of attention for its efficiencies, particularly those achieved through contracting. In this revealing article, two senior managers with responsibility for ...labor-management relations and human resources describe the city's evolution from an aggressive labor relations posture, to a much more satisfying and productive relationship that relies more on cooperation. They tell us that, contrary to popular opinion about Phoenix and contracting, much of this city's success is attributable to the contributions coming from the cooperative, service-focused relationship between management and labor. The combination of a focus on service efficiencies with a productive labor relations environment, including employment security, they tell us, is far more powerful than simply focusing on efficiencies that can be produced in the private sector. In fact, as they have shifted their approach to integrate cooperation, participation and service quality, the city has been more cost effective than private competitors. As this article tells us, the city, working with its employees, has taken back the significant work it once contracted out. For those intrigued by management competition, the message conveyed in this article should be closely read.
Chronic lymphocytic leukaemia (CLL) is a common disorder. Patients typically present with lymphadenopathy, splenomegaly and marked lymphocytosis (often >100 000/μl). Although pulmonary involvement ...from CLL can be found in more than one third of patients on autopsy, respiratory symptoms caused by the disease itself are not often reported. Pulmonary involvement mainly includes parenchymal infiltrates, peribronchial and perivascular infiltration, recurrent bacterial pneumonia, oedema or infarction, pleural effusions, and lymphadenopathy. Occasionally, patients may present with dry cough and progressive dyspnoea, even with low peripheral white blood cell count. We report a case of CLL and dyspnoea at rest, predominant “tree-in-bud” sign on chest computed tomography scan, and biopsy proven bronchiolar infiltration with monoclonal lymphocytes. With bronchoalveolar lavage alone, the diagnosis would have been missed. Chemotherapy with rituximab, cyclophosphamide, and fludarabinphosphate led to a prompt clinical and radiological improvement with a gain in 6 min walking distance from 60 to 210 m.
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