Zusammenfassung Hintergrund Auch für ältere Patienten (> 70 Jahre) ist der Nutzen einer palliativen Chemotherapie beim NSCLC durch Studien gut belegt. Wir haben eine multizentrische, prospektive Datensammlung über die Therapieentscheidungen bei Patienten älter als 70 Jahre durchgeführt, um die klinische Versorgungsrealität in Hinblick auf Überlebensdaten und Komorbiditäten in Deutschland zu analysieren. Material und Methoden Eingeschlossen wurden Patienten die 70 Jahre oder älter waren und ein Lungenkarzinom im Stadium IIIB oder IV hatten. Die Zentren durften jeweils 20 konsekutive Patienten einschließen. Es wurden die Komorbiditäten dokumentiert und mittels des Charlson-Comorbidity-Scores bewertet sowie die Überlebensdaten erfasst. Ergebnisse 253 Patienten wurden dokumentiert. Das mediane Alter betrug 75,5 Jahre (Bereich 70 – 92 Jahre) und 75 % der Patienten waren männlich. 2 % der Patienten wiesen keinerlei Komorbiditäten auf, 5 % eine, 15 % zwei, 24 % drei und 55 % mehr als drei. 237 Patienten (94 %) erhielten eine systemische Chemotherapie: 172 (73 %) als Kombinationstherapie und 58 (24 %) als Monotherapie, von sieben Patienten gibt es keine Angaben bezüglich der Therapie. Von den Kombinationstherapien beinhalteten 66 % Carboplatin und 30 % Cisplatin. Die am häufigsten gegebene Monotherapie war Vinorelbin in 50 % der Fälle. In der Gruppe der über Achtzigjährigen (n = 38) erhielten 53 % eine Monotherapie, 29 % eine Carboplatin-haltige Kombinationstherapie und 16 % keine systemische Therapie. Cisplatin wurde in dieser Gruppe nicht verabreicht. Das mediane Überleben im Gesamtkollektiv betrug 16,9 Monate. Patienten mit einem Charlson-Score von ≤ 6 erreichten 17,9 Monate, solche mit einem von > 6 erreichten 12,0 Monate. In der Gruppe der Patienten, welche eine Kombinationstherapie erhielten, war das Gesamtüberleben median 23,5 Monate. Patienten, die älter als 80 Jahre waren, erreichten hier nur 5,7 Monate. Schlussfolgerung Patienten älter als 70 Jahre erhielten zu einem hohen Anteil eine systemische Therapie. Das Überleben hing stärker von den Komorbiditäten als von dem Alter der Patienten ab.

Background: The aim of the study was to investigate in terms of noninferiority the efficacy and safety of a monochemotherapy regimen of pemetrexed plus bevacizumab (BevPem) versus carboplatin/pemetrexed plus bevacizumab (BevCPem) in elderly patients as first-line treatment for advanced metastatic or recurrent nonsquamous non-small-cell lung cancer (NSCLC). Materials and methods: 65Plus was a Phase III, randomized, open-label study. In total, 253 patients received BevPem (n=119) or BevCPem (n=134). The primary outcome measure was progression-free survival. Secondary end points were overall survival, tumor response, and safety outcomes. Evaluations were performed for the whole study population and stratified according to Eastern Cooperative Oncology Group (ECOG) performance status (PS). Results: Noninferiority of BevPem in comparison to BevCPem could not be demonstrated for the overall population (P=0.7864). Significant superiority of the combined treatment BevCPem was seen in patients of ECOG PS 0-1 (median PFS 5.1 vs 6.9 months, HR 1.353, 95% CI 1.03-1.777), while the opposite tendency was observed in patients with ECOG PS 2 (median PFS 2.9 vs 1.5 months, HR 0.628, 95% CI 0.195-2.025). Overall, better tolerability was found for the BevPem group, irrespective of ECOG PS. Conclusion: Results from the 65plus study give evidence that BevPem and BevCPem treatments may exert differential effects on PFS, depending on the patients ECOG PS. It appears that patients with better ECOG PS (0-1) benefited more from the combined treatment with carboplatin, while the group comprising more severely impaired patients (ECOG PS 2) benefited more from the monochemotherapy.

Background: Data on incidence, risk factors and outcome of community-acquired pneumonia (CAP) including outpatients is sparse.Methods: We conducted a cohort study on 1.837.080 adults insured by a German statutory health insurance in 2010-2011. CAP was identified via ICD-10-GM codes, ambulatory cases were validated by antibiotic prescription within 7 days. Primary outcomes were incidence, hospitalisation and 30-day all-cause mortality. Evaluated risk factors included age, sex and comorbidities. Evaluation was done by multivariate regression analysis adjusting for these factors and health care utilization.Results: CAP incidence was 9.7 per 1000 person years, hospitalisation rate 46.5%, and 30-day mortality 12.9%. 30-day mortality of ambulatory cases was 5% (with 27% subsequently hospitalized for another diagnosis before death). 30-day mortality of hospitalized patients was 21.9%, but in-hospital mortality 17.2%. Risk factors for CAP included age, male sex and all evaluated comorbidities with highest risk for neurologic (OR 2.4), lung (OR 2.3) or immunosuppressive (OR 2.1) disease. Mortality risk was highest for neurologic (OR 2.3) and malignant (OR 2.0) disease.Conclusions: CAP constitutes a major burden in terms of incidence, morbidity and all-cause mortality in hospitalized and ambulatory patients. Interventions to raise awareness for disease impact also in ambulatory patients with risk factors are warranted. (C) 2016 Elsevier Ltd. All rights reserved.

Introduction: Pirfenidone, an oral anti-fibrotic agent for idiopathic pulmonary fibrosis (IPF), has shown its efficacy in 3 multinational, randomised placebo-controlled trials and was approved in the EU for the treatment of adults with mild to moderate IPF. Objectives: To report on clinical experiences including safety and efficacy data in patients with IPF started with pirfenidone in a tertiary care hospital. Methods: We conducted a retrospective review of patients with mild-to-moderate IPF treated with pirfenidone between November 2011 and October 2014. Baseline clinical characteristics, physiological parameters, side effects and therapy adherence were documented at clinical visits. Results: 59 patients were treated for a mean duration of 14 ± 11 months. The mean physiological parameters at treatment start were for FVC (% pred.) 74 ± 15, for DLCO (% pred.) 35 ± 10, for PaO2 (kPa) 9,3 ± 1,2 and for 6MWD (m) 390 ± 101. Side effects were reported on 53 % of the patients, mostly gastrointestinal symptoms (41%) and skin symptoms (20%). In 32% of the patients treatment was discontinued, 17% due to side effects. Patients discontinued pirfenidone treatment had initial lower physiological parameters than patients still on pirfenidone. Treatment discontinuation was seen more frequently in patients with concomitant corticosteroid treatment. Conclusions: In real life pirfenidone treatment for IPF is generally well tolerated. It might be that an earlier treatment start is associated with a better therapy adherence and therefore with a better clinical course of the disease.

Introduction: Bird keeper9s lung (BKL) is a common form of hypersensitivity pneumonitis (HP). In patients with acute HP a positive antigen-specific IgG antibody is one of the most significant predictors for the clinical diagnosis. The differentiation of patients with chronic HP from those with idiopathic pulmonary fibrosis (IPF) can be challenging. Objectives: To compare antigen-specific IgG antibodies in patients with acute or chronic BKL and with IPF analysed with an automated quantitative fluorimetric enzyme immunoassay (FEIA). Methods: Retrospective review of patients with BKL treated in a tertiary care hospital between 2005 and 2013. Baseline clinical characteristics, the clinical course and specific IgG antibodies were analysed and compared with IPF patients. Results: 155 patients were diagnosed with BKL (90 with chronic and 65 with acute HP) and were compared with a control group of 52 IPF patients. Specific IgG antibodies to avian antigens were significantly higher in acute BKL comparing to chronic BKL (budgerigar antigens: 144 ± 58 vs. 54 ± 44 mg/l, goose feathers: 82 ± 46 vs. 41 ± 32 mg/l, pigeon antigens: 114 ± 55 vs. 57 ± 40 mg/l, parrot antigens: 125 ± 55 vs. 58 ± 37 mg/l; all p < 0.0001). Specific IgG antibodies to avian antigens in chronic BFL were significantly higher comparing to IPF patients (budgerigar antigens: 54 ± 44 vs. 7 ± 7 mg/l, goose feathers: 41 ± 32 vs. 6 ± 4 mg/l, pigeon antigens: 57 ± 40 vs. 13 ± 7 mg/l, parrot antigens: 58 ± 37 vs. 16 ± 7 mg/l; all p < 0.0001). Conclusions: This study demonstrates that specific IgG antibodies to avian antigens in patients with chronic BKL are lower comparing to acute BKL but are still higher comparing to patients with IPF.

e19052 Background: In various trials designed especially for elderly patients with NSCLC stage IIIB/IV (≥ 70 years) survival and QoL benefit from single or combination chemotherapy could be demonstrated. Treatment decision concerning single or combination chemotherapy should be based on performance status and co-morbidities. We prospectively evaluated treatment behaviours for elderly patients in Germany in clinical practice. Methods: Between November 2009 and October 2013 a total of 253 patients were included. Participating centres were limited to 20 patients and had to enroll consecutive NSCLC patients ≥ 70 years with stage IIIB or IV. Co-morbidities accrued prospectively in questionnaire and weighted according to Charlson Score. Results: Median age was 75.5 years ranging from 70 through 92 years. 75% of all patients were male. Co-morbidities: 2% none, 5% one, 15% two, 24% three and 55% with more than three concomitant diseases. Most common co-morbidities were hypertension (69%), COPD (42%) and diabetes (22%). In total 237 patients (94%) received a systemic cancer treatment. Of those, 172 patients (73%) received combination and 58 patients (24%) single-agent therapy. Combination was mainly based on platinum therapy (Carboplatin 66%, Cisplatin 30%), whereas Vinorelbine was the most frequent single-agent therapy seen in 50% of cases. A total of 38 patients were aged > 80 years. Of these 20 patients (53%) received single-agent therapy, 11 patients (29%) a platinum doublet (Carboplatin) and 6 patients (16%) no systemic treatment. No patient > 80 years received Cisplatin. Median survival of all patients was 16.9 months. Patients with a Charlson Score of ≤ 6 achieved a median survival of 17.9 months, whereas patients with a score of > 6 reached 12.0 months, respectively. In comparison, in the selected group of patients receiving combination therapy median survival was 23.5 months. Patients aged > 80 years showed a median survival of 5.7 months. Conclusions: Nearly all patients elder 70 years received systemic chemotherapy. Similar to younger patients elderly patients receive a platinum doublet in clinical practice. In patients elder 80 years single agent therapy is the most frequent treatment.

ObjectivesFirst-line pemetrexed-cisplatin (Pem-Cis) induction therapy followed by Pem maintenance, and first-line bevacizumab- (Bev-) based therapy are treatment options for patients with advanced non-squamous NSCLC. This study explored efficacy and safety of first-line induction Pem-Cis+Bev followed by maintenance Pem+Bev.Materials and methodsPatients with ECOG performance status (PS) 0–1 were scheduled to receive four cycles Pem 500mg/m2, Cis 75mg/m2, and Bev 7.5mg/kg, given every 21 days. In absence of progressive disease (PD) and if ECOG-PS ≤1, patients could continue Pem+Bev maintenance until PD or unacceptable toxicity. All patients received vitamin supplementation as per Pem label. Primary endpoint was progression-free survival (PFS); secondary endpoints included overall survival (OS), response rate, and toxicity.Results109 patients received induction therapy (median age 61 yrs, ECOG-PS 0/1 54/46%, stage IIIB/IV 9/91%, adenocarcinoma 91%), 72 patients (66.1%) started maintenance therapy. Median (maximum) numbers of cycles were 4 (4) for Cis and 8 (34) for Pem+Bev. Overall, median PFS and OS were 6.9 (90%CI 5.7–8.3) and 14.7 (95%CI 11.5–19.7) months. For patients starting maintenance therapy, median (95%CI) PFS and OS were 9.4 (7.2–11.5) and 19.7 (14.9–25.9) months. Overall response and disease control rates were 42.2% and 67.9%, respectively. Two patients died from study-treatment related toxicity (gastrointestinal hemorrhage, aspiration pneumonia; both during induction therapy). Most common G3/4 toxicities were neutropenia (25.7%) and fatigue (14.7%); hypertension was less common (5.5%).ConclusionPatients with advanced NS-NSCLC eligible for Bev-treatment may derive clinical benefit at acceptable toxicity from the addition of Bev to both Pem-Cis induction and Pem maintenance therapy; however, this is not an approved combination regimen.

Haemoptysis is a potentially life-threatening condition with the need for prompt diagnosis. In about 10-20% of all cases the bleeding source remains unexplained with the standard diagnostic approach. The aim of this article is to show the necessity of widening the diagnostic approach to haemoptysis with consideration of pulmonary venous stenosis as a possible cause of even severe haemoptysis and haemoptoe.A review of the literature was performed using the Medline/ PubMed database with the terms: "pulmonary venous stenosis'', "pulmonary venous infarction'' and "haemoptysis''. Further references from the case reports were considered.58 case reports and case collections about patients with haemoptysis due to pulmonary venous stenosis were detected. This review gives an overview about the case reports and discusses the underlying pathophysiology and the pros and cons of different imaging techniques for the detection of pulmonary venous stenosis.Several conditions predispose to the obstruction of the mediastinal pulmonary veins. Clinical findings are unspecific and may be misleading. Pulmonary venous stenosis can be detected using several imaging techniques, yet three-dimensional magnetic resonance-angiography and three-dimensional contrastenhanced computed tomography are the most appropriate. Pulmonary venous stenosis should be considered in patients with haemoptysis.

8013 Background: Pemetrexed (P) and bevacizumab (B) are efficacious drugs for treatment of non-squamous NSCLC. In this trial the benefit of combining PB with carboplatin (C) was investigated in elderly patients (pts) ≥ 65 years with NSCLC. Methods: In this German multicenter (27 centers), open-label phase III trial pts with stage IIIb/IV non-squamous NSCLC were recruited. Pts were randomized 1:1 to P (500 mg/m 2 ) + B (7.5 mg/kg) or P+B+C (AUC5) d1 q3 wks for 4 to 6 cycles followed by maintenance therapy with B or P+B. The primary endpoint was progression-free survival (PFS), while secondary endpoints included overall survival (OS), 1-year survival rate, overall response rate (ORR) as well as tolerability (AEs/SAEs). Results: 271 pts were enrolled from Sep 2009 to Jan 2012, the ITT population consists of 251 evaluable pts, less than 10 pts are still receiving maintenance therapy. Baseline characteristics were balanced between both treatment groups (PB 118 pts, PBC 133 pts). Median age was 71 years in PB and 72 in PBC. Median PFS time was 4.8 mo in PB and 6.8 mo in PBC. Treatment comparison for ECOG performance status (PS) 0-1 subgroup (PB 112 pts, PBC 126 pts): p=0.0426 (Wilcoxon test), hazard ratio (HR) = 1.31 (95% CI 0.99-1.73). ORR was 31.4% in PB vs. 44.4% in PBC (p=0.0343). Median OS time was 11.6 mo in PB vs. 15.2 mo in PBC. Treatment comparison ECOG PS 0-1: p=0.2050, HR = 1.20 (95% CI 0.85-1.70). 1-year survival rates were 48.2% and 58.8%, respectively. Compared to this the median OS time in the small group of pts with ECOG PS 2 was 11.5 mo in PB vs. 3.8 mo in PBC. AE grade 3/4 and SAE profiles were comparable in both treatment arms, 76 pts (64.4%) with AEs grade 3/4 in PB and 87 pts (65.4%) in PBC, 58 pts (49.2%) with SAEs in PB and 64 pts (48.1%) in PBC. 46 pts (39.0%) in PB vs. 69 pts (51.9%) in PBC received maintenance therapy. Conclusions: Combination of PBC demonstrates with a median OS of 15.2 mo a strong efficacy with acceptable toxicity profile for elderly patients. Addition of carboplatin is recommended for eligible patients. However, in patients with ECOG PS 2 the administration of carboplatin must be carefully reviewed. Clinical trial information: NCT00976456.

Community-acquired pneumonia (CAP) represents a major life-threatening infection, but disease course and outcome is highly variable. Major drivers of prognosis are respiratory failure, sepsis-related organ dysfunction and unstable comorbidities. Current risk stratification tools have been primarily designed to predict mortality and identify low risk patients potentially suitable for ambulatory management. Detection of patients at high risk for clinical deterioration by current scores remains suboptimal. Therefore, management-related risk stratification tools designed to predict benefit from early intensified monitoring and treatment strategies in hospitalised CAP are advocated. An approach including early and repeatedly evaluated clinical markers of respiratory failure, sepsis-related organ dysfunction or decompensating comorbidity combined with individual definition of treatment goals is suggested. Inflammatory biomarkers can add prognostic information. New cardiovascular or stress-related biomarkers like copeptin, midregional proadrenomedullin and cortisol have been repeatedly linked with outcome and disease course in CAP and improved clinical scoring in observational studies. Thus they represent promising tools for individualised risk stratification. A major task in future CAP research will be the evaluation of their additional value in large interventional trials with control groups incorporating strict management guidance by clinical criteria.

e19148 Background: 1st line PEM+CIS induction CT followed by PEM maintenance and 1st line BEV-based CT followed by BEV maintenance offer clinical benefit (PFS, OS) in NS-NSCLC. This study explored efficacy and safety of 1st line induction PEM+CIS+BEV followed by maintenance PEM+BEV. Methods: Pts with advanced NS-NSCLC and ECOG 0-1 were planned to receive 4 cycles PEM 500 mg/m2, CIS 75 mg/m2, BEV 7.5 mg/kg, q3w. In absence of PD and with ECOG 0-1, pts could continue on PEM+BEV until PD or unacceptable toxicity. All pts received vitamin supplementation as per PEM label. Primary endpoint was PFS; secondary were OS, response rate, toxicity. Results: 109 pts were enrolled in 5 countries. Characteristics: median age 61 yrs, males/females 59/41%, ECOG 0/1 54/46%, IIIB/IV 9/91%, adenocarcinoma 91%. 72 pts (66%) had maintenance CT. Overall median (max) no of cycles were 6 (34) for PEM+BEV and 2 (4) for CIS. Median PFS was 6.9 m (90% CI 5.7, 8.3). The table gives efficacy and G3/4 AE data. 2 pts died from study-drug related toxicity (GI hemorrhage, pneumonia aspiration; during induction). Conclusions: In this study of PEM+CIS+BEV induction followed by PEM+BEV maintenance median PFS was 6.9 m. Main G3/4 toxicities included neutropenia and fatigue, hypertension was less common. Clinical trial information: NCT01004250. [Table: see text]

We sought to determine whether patients with precapillary pulmonary hypertension show elevated serum levels of prolactin (PRL) and its 16-kDa N-terminal fragment (16-kDa PRL) and whether there is any correlation to measures of prognosis.Twenty-eight patients with idiopathic pulmonary artery hypertension, 15 with peripheral chronic thromboembolic pulmonary hypertension, and 4 with portopulmonary hypertension Child-Pugh class A were included. Our control subjects were 56 blood donors. Total prolactin was measured with an immunoluminometric assay. Antibodies against epitope C detected only the intact prolactin before it was split. The 16-kDa PRL was calculated from the difference between total and intact prolactin.Prolactin was significantly (P=0.009) higher in the study group (median, 190 mU/L; interquartile range, 162 mU/L) than in the control group (median, 140 mU/L; interquartile range, 91 mU/L). The 16-kDa PRL was significantly elevated in the study group (P=0.046). Prolactin and 16-kDa PRL correlated inversely with the 6-minute-walk distance (P <0.01) and with peak oxygen uptake during exercise (P <0.005).Serum levels of prolactin and 16-kDa PRL were significantly higher in patients with precapillary pulmonary hypertension and were inversely correlated with 6-minute-walk distance and peak oxygen uptake.These results indicate that prolactin and 16-kDa PRL might play a role in the pathophysiology of precapillary pulmonary hypertension.

We present a case of farmer's lung (FL) with the primary presenting feature of a large bulla in the lung. A 70-year-old nonsmoking woman with dyspnea on exercise was referred for surgical resection of a large bulla in the lung. The postoperative evaluation of the lung tissue revealed a follicular lymphocytic alveolitis and loosely formed granulomas suspicious for hypersensitivity pneumonitis (HP). The patient had worked in farming since her youth. Dyspnea on exercise was the only symptom, but it was related to the large bulla. No other radiologic features of HP were shown in a high-resolution CT of the lung. Specific IgG antibodies against typical antigens of FL were detected, bronchoalveolar lavage demonstrated no lymphocytic alveolitis but an inhalative challenge with own hay was positive. A diagnosis of chronic FL was made. Despite lung emphysema being a possible reaction in FL, giant bullae as primary and single manifestation of this disease have not been reported before.

Background: Up to now, only few data existed evaluating quality of life in patients with PAH and/or CTEPH. Question: To describe the association between anxiety, depression, cardiopulmonary hemodynamics, and exercise parameters with physical quality of life (QoL). Methods: Patients with PAH and/or CTEPH performed a 6 minute walk test, cardiopulmonary exercise testing (CPET) and right heart catheterization and completed 3 QoL questionnaires (SF36, SRGQ and MacNew). Hospital Anxiety and Depression Scale (HADS) was used to assess psychological constructs like anxiety and depression. Results: 63 PAH und 22 CTEPH patients were prospectively included. Peak oxygen uptake (VO2 peak) during CPET was 13±4 ml/min/kg and 6 minute walk distance (6MWD) was 325±127 m. After multivariate analysis anxiety showed an independent association with activity, impact, and total scores in SGRQ and with emotional, physical, social and total scores in MacNew and with mental score in SF36. There was an independent correlation between depression and physical, mental and symptom scores in SF-36. Peak VO2 showed an independent association with all above mentioned subscales in SGRQ and with physical and mental QoL in SF36, whereas 6MWD was associated with all above mentioned scores of the MacNew and the symptom score of SF36. Conclusion: Peak VO2 and 6MWD reflect quality of life in patients with PAH and/or CTEPH. In addition, anxiety and depression showed a strong association with mental and physical QoL underlining the need for awareness of these disorders.

RATIONALE:Optimal risk prediction of early clinical deterioration in community-acquired pneumonia (CAP) remains unresolved. We prospectively examined the predictive value of the new biomarkers copeptin and proadrenomedullin (MR-proADM) in comparison to clinical scores and inflammatory markers to predict early high risk prognosis in CAP.METHODS:51 consecutive hospitalised adult patients were enrolled. We measured CRB-65- and PSI-scores, the ATS/IDSA 2007 minor criteria to predict ICU-admission and the biomarkers CRP, procalcitonin, copeptin and MR-proADM on admission. Predefined outcome parameters were combined mortality or ICU-admission after 7 days and clinical instability after 72 h.RESULTS:Copeptin was the only biomarker significantly elevated in patients with either adverse short term outcome (p = 0.003). According to ROC-curve analysis, copeptin predicted ICU admission or death within 7 days (AUC 0.81, cut-off 35 pmol/l: sensitivity 78%, specificity 79%) and persistent clinical instability after 72 h (AUC 0.74). In Kaplan-Meier-analysis patients with high copeptin showed lower ICU-free survival within 7 days (p = 0.001). The diagnostic accuracy of copeptin was superior to the CRB-65 score and comparable to the PSI-score and the ATS/IDSA minor criteria. If copeptin was included as additional minor criterion for combined 7-day mortality or ICU-admission, the diagnostic accuracy of the minor criteria was significantly improved (p = 0.045).CONCLUSION:Copeptin predicts early deterioration and persistent clinical instability in hospitalised CAP and improves the predictive properties of existing clinical scores. It should be evaluated within a biomarker guided strategy for early identification of high risk CAP patients who most likely benefit from early intensified management strategies.

Background: Heart-type fatty acid-binding protein (H-FABP) is a promising novel biomarker for risk stratification of patients with chronic thromboembolic pulmonary hypertension (CTEPH). Whether disease severity in a group of patients with pre capillary pulmonary hypertension (PH) can be predicted by determination of plasma H-FABP levels remains unknown. Methods: 41 consecutive patients with a mean (±SD) age of 60.6 ± 2.1 years and severe PH were studied with a mean follow up to 541 days (95% CI: 420; 661 days). H-FABP, but also the biomarkers NT-Pro-BNP and big-endothelin (Big-ET1), were correlated to parameters derived from right sided cardiac catheterization and cardio-pulmonary exercise test. Results: At baseline H-FABP levels ranged from 620 to 15200 pg/ml (3648 ± 502 pg/ml) and were weakly but significantly correlated to VO2AT (r = –0.37, p = 0.04) and VO2 peak (r =–0.38, p = 0.03). However, invasively measured hemodynamic parameters of PH and right ventricular dysfunction did not correlate with H-FABP levels. In- terestingly, moderate to high correlations between H-FABP and NT-Pro-BNP (r = 0.51, p = 0.01) and Big-ET1 (r = 0.65, p = 0.01) and between Big-ET1 and NT-Pro-BNP (r = 0.5, p = 0.01) could be observed. In contrast to H-FABP, NT-Pro-BNP, and even more Big-ET1, showed significant correlations to different invasively measured hemodynamic parameters of the disease indicating severity and consequently prognosis of severe pre-capillary pulmonary hypertension. However, in a multivariate Cox regression analysis, PVR, mixed venous oxygen saturation and the VE/VCO2 slope (>60) as well as the heart rate recovery within one minute (HRR) but none of the biomarkers were identified as independent factors of poor prognosis. In con- trast, peak workload and mixed venous saturation were identified as risk markers in the idiopathic pulmonary arterial hypertension subgroup. Conclusions: In contrast to the predictive value of H-FABP in CTEPH H-FABP fails to be a reliable marker in PH or to be a novel predictor of mid and long term outcome. The data suggest that an increased slope of VE/VCO2 and a decreased extent of HRR within one minute represent more promising diagnostic non invasive parameters.

Transbronchial lung biopsy with forceps is a standard procedure in bronchoscopic tissue sampling. Suction catheter aspiration is another technique, but it is not widely known and almost no data exist regarding its diagnostic efficiency. 272 patients were included in a prospective and randomised study between February 2007 and October 2009. All were referred for bronchoscopic evaluation of pulmonary nodules/masses or infiltrates. We compared the diagnostic yield of forceps biopsy and suction catheter aspiration for a definite diagnosis and looked at whether such a diagnosis depends on the underlying pulmonary change. All patients underwent bronchoscopy with forceps biopsy and catheter aspiration. A definitive diagnosis was reached in a total of 183 (67.3%) patients, with catheter aspiration in 140 (51.5%) patients and with forceps biopsy in 136 (50.0%) patients. In 90 (33.1%) patients, a definite diagnosis could only be reached with the combination of both techniques. The diagnostic yield of forceps biopsy was better than catheter aspiration in infiltrates (p=0.027), but was no different in nodules or masses (p=0.09). Suction catheter aspiration is a useful technique of bronchoscopic tissue sampling. The combination of catheter aspiration and forceps biopsy results in a higher diagnostic yield than either method used alone.

BACKGROUND:Patients with chronic hypersensitivity pneumonitis (HP) can present with an insidious onset of their disease without typical fluctuating flu-like symptoms, and there are only signs of chronic respiratory failure caused by the progressive fibrotic lung disease.CASE REPORT:A 45-year-old man with a pneumomediastinum and interstitial lung disease was referred for further investigations and therapy. No traumatic event or interventional procedure had occurred prior to referral. The patient had been working in farming for almost 20 years and was exposed in childhood by his father to pigeon breeding from childhood until 20 years ago. He reported dyspnea on exercise for the previous 2 years. High-resolution CT of the lung showed a pneumomediastinum and a fibrotic interstitial lung disease without dominating ground-glass opacities. Specific IgG antibodies were markedly elevated against molds and avian antigens. Bronchoalveolar lavage demonstrated a slightly lymphocytic and neutrophilic alveolitis. After recovering from the pneumomediastinum, an open lung biopsy was performed and a UIP-pattern was detected. An inhalative challenge with hay from the work-place was positive. A diagnosis of chronic farmer's lung was made.CONCLUSIONS:Pneumomediastinum has been described in other fibrotic lung diseases, but until now it has not been described as a primary manifestation of chronic fibrotic HP. Particularly in cases of concurrent antigen sources, an inhalative challenge could be done, even in a chronic course of HP.