[Development of minimal requirements for site assessment and monitoring to estimate exposure in environmental medicine--the Hamburg approach]

As a further step towards quality management in environmental medicine the Hamburg Association of Panel Physicians and the Hamburg Department of Labour, Health and Welfare developed a consensus paper concerning the handling of indoor related problems. It focuses on the cooperation between environmental physicians and engineers. A critical point in the process of environmental health risk assessment is the selection of either human biomonitoring or environmental monitoring. Further well-known problems are quality of measures and process documentation. Accurate, reliable measures of individual exposure are an essential need for physicians who have to judge the potential impact of environmental contaminants on human health. The approach proposed in this paper was chosen to enable the patient and the physician to benefit from the special knowledge of environmental engineers on indoor related problems. The procedure and criteria might help to reduce misclassifications of diseases and the amount of measures with no medical relevance and to establish scientifically valid associations between health outcomes and exposures to environmental contaminants.

Impaired coronary vasodilator responsiveness as a cause of lactate production during pacing-induced ischemia in patients with angina pectoris and normal coronary arteries

Subgroups of patients with angina pectoris and normal coronary arteries are known to have pacing-induced lactate production and, therefore, myocardial ischemia. To examine the mechanism of this pacing-induced ischemia, the effect of incremental atrial pacing on coronary blood flow and metabolism was studied in 27 patients with angina and normal coronary arteries. Seventeen patients continued to exhibit normal lactate extraction even at heart rates up to 160 beats/min (Group 1), whereas in 10 patients (Group 2) lactate extraction changed to production at the highest pacing rate. Coronary blood flow increased in Group 1 patients by 18, 41 and 75%, respectively, as heart rate was increased by 20 beat/min increments from 100 to 160 beats/min. In contrast, coronary blood flow increased by only 8, 7 and 14%, at the three respective pacing rates in Group 2. Between the heart rates of 100 and 160 beats/min, coronary vascular resistance decreased 32% in Group 1 patients but was unchanged in Group 2 patients. There was no significant change in the ratio of myocardial O2 consumption/rate-pressure product in Group 1 patients, but this ratio decreased from 0.91 +/- 0.26 ml O2 X min-1 X (mm Hg X beats/min)-1 to 0.53 +/- 0.11 (p less than 0.05) in Group 2 patients as heart rate increased from baseline to 160 beats/min. Thus, patients with angina and normal coronary arteries who develop ischemia with pacing have a decreased coronary vasodilator response that interferes with their ability to increase myocardial oxygen supply to match the higher demand.

Transit time analysis of the forced expiratory vital capacity in cystic fibrosis

Transit time analysis of the forced expiratory vital capacity maneuver was applied to 37 patients with cystic fibrosis 8 to 22 years of age. This analysis divides the vital capacity into segments of air and assigns a transit time to each segment. The characteristics of the distribution of these transit times are used as measurements of pulmonary function. The quantities were compared with the forced vital capacity, 1-sec forced expiratory volume, ratio of 1-sec forced expiratory volume to vital capacity, peak flow, forced expiratory flow during the middle half of the forced vital capacity, maximal expiratory flow at 25 per cent of the vital capacity, specific airway conductance, and arterial PO2 of these patients. The standard deviation of the transit times was the most frequently abnormal. The mean transit time had the largest range of values in terms of its own standard deviation, and it was the best single estimate of over-all lung function because it correlated almost equally with large and small airway function. The coefficient of cariance of transit times was specific in detecting abnormality of small airways and was as sensitive in the detection of minimal lung disease as the standard deviation of transit times.

The ventilatory response to carbon dioxide in asthmatic children, measured by the mouth-occlusion method (Pm100)

Ventilatory responses to carbon dioxide vary widely in patients with bronchial asthma; some have a high response despite increased airway resistance. This paradoxical response was studied in 31 asthmatic children and 22 age-matched healthy children. Measurement of the ventilatory response to carbon dioxide with a conventional rebreathing method showed wide variation in the patients, paralleling the degree of their airway obstruction as measured by the one-second forced expiratory volume and maximal midexpiratory flow rate, but their mean response was similar to that in the control subjects. The ventilatory response was then determined with a new index (Pm100), which rises linearly with increasing carbon dioxide concentration. Despite wide variation in the slope of Pm100 in the patients, their mean response significantly exceeded normal, confirming that the neurochemical drive is increased in bronchial asthma.

Transit time analysis of the forced expiratory spirogram in growth

In the search for more sensitive indicators of airway obstruction Fish et al. (Am. Rev. Respirat. Diseases 109: 700, 1974) have proposed a transit time analysis of the forced expiratory spirogram. In this method the forced vital capacity (FVC) is divided into volumes of air and each volume is assigned a transit time; the nature of the FVC can be described by the transit times' mean, standard deviation, and index of skewness. In a group of 48 healthy nonsmoking subjects between the ages of 9 and 22 yr we found that all three quantities decreased with increasing age. This demonstrates an improvement in the function of the peripheral airways with lung growth. In contrast to the increase in flow rates with lung growth, none of this improved function can be attributed to increased lung volume.