Prevalence of exercise-induced oxygen desaturation after recovery from SARS-CoV-2 pneumonia and use of lung ultrasound to predict need for pulmonary rehabilitation

BACKGROUND

Persistence of breathlessness after recovery from SARS-CoV-2 pneumonia is frequent. Recovery from acute respiratory failure (ARF) is usually determined by normalized arterial blood gases (ABGs), but the prevalence of persistent exercise-induced desaturation (EID) and dyspnea is still unknown.

METHODS

We investigated the prevalence of EID in 70 patients with normal arterial oxygen at rest after recovery from ARF due to COVID-19 pneumonia. Patients underwent a 6-min walking test (6MWT) before discharge from hospital. We recorded dyspnea score and heart rate during 6MWT. We also investigated the possible role of lung ultrasound (LU) in predicting EID. Patients underwent a LU scan and scores for each explored area were summed to give a total LU score.

RESULTS

In 30 patients (43%), oxygen desaturation was >4% during 6MWT. These patients had significantly higher dyspnea and heart rate compared to non-desaturators. LU score >8.5 was significantly able to discriminate patients with EID.

CONCLUSION

In SARS-CoV-2 pneumonia, ABGs at discharge cannot predict the persistence of EID, which is frequent. LU may be useful to identify patients at risk who could benefit from a rehabilitation program.

Performance of helmet CPAP using different configurations: Turbine-driven ventilators vs Venturi devices

BACKGROUND

Traditionally, Venturi-based flow generators have been preferred over mechanical ventilators to provide continuous positive airway pressure (CPAP) through the helmet (h-CPAP). Recently, modern turbine-driven ventilators (TDVs) showed to be safe and effective in delivering h-CPAP. We aimed to compare the pressure stability during h-CPAP delivered by Venturi devices and TDVs and assess the impact of High Efficiency Particulate Air (HEPA) filters on their performance.

METHODS

We performed a bench study using an artificial lung simulator set in a restrictive respiratory condition, simulating two different levels of patient effort (high and low) with and without the interposition of the HEPA filter. We calculated the average of minimal (Pmin), maximal (Pmax) and mean (Pmean) airway pressure and the time product measured on the airway pressure curve (PTPinsp). We defined the pressure swing (Pswing) as Pmax - Pmin and pressure drop (Pdrop) as End Expiratory Pressure - Pmin.

RESULTS

Pswing across CPAP levels varied widely among all the tested devices. During "low effort", no difference in Pswing and Pdrop was found between Venturi devices and TDVs; during high effort, Pswing (p<0.001) and Pdrop (p<0.001) were significantly higher in TDVs compared to Venturi devices, but the PTPinsp was lower (1.50 SD 0.54 vs 1.67 SD 0.55, p<0.001). HEPA filter addition almost doubled Pswing and PTPinsp (p<0.001) but left unaltered the differences among Venturi and TDVs systems in favor of the latter (p<0.001).

CONCLUSIONS

TDVs performed better than Venturi systems in delivering a stable positive pressure level during h-CPAP in a bench setting.

Ten important articles on noninvasive ventilation in critically ill patients and insights for the future: A report of expert opinions

Background

Noninvasive ventilation is used worldwide in many settings. Its effectiveness has been proven for common clinical conditions in critical care such as cardiogenic pulmonary edema and chronic obstructive pulmonary disease exacerbations.

Since the first pioneering studies of noninvasive ventilation in critical care in the late 1980s, thousands of studies and articles have been published on this topic. Interestingly, some aspects remain controversial (e.g. its use in de-novo hypoxemic respiratory failure, role of sedation, self-induced lung injury). Moreover, the role of NIV has recently been questioned and reconsidered in light of the recent reports of new techniques such as high-flow oxygen nasal therapy.

Methods

We conducted a survey among leading experts on NIV aiming to 1) identify a selection of 10 important articles on NIV in the critical care setting 2) summarize the reasons for the selection of each study 3) offer insights on the future for both clinical application and research on NIV.

Results

The experts selected articles over a span of 26 years, more clustered in the last 15 years. The most voted article studied the role of NIV in acute exacerbation chronic pulmonary disease. Concerning the future of clinical applications for and research on NIV, most of the experts forecast the development of innovative new interfaces more adaptable to patients characteristics, the need for good well-designed large randomized controlled trials of NIV in acute “de novo” hypoxemic respiratory failure (including its comparison with high-flow oxygen nasal therapy) and the development of software-based NIV settings to enhance patient-ventilator synchrony.

Conclusions

The selection made by the experts suggests that some applications of NIV in critical care are supported by solid data (e.g. COPD exacerbation) while others are still waiting for confirmation. Moreover, the identified insights for the future would lead to improved clinical effectiveness, new comparisons and evaluation of its role in still “lack of full evidence” clinical settings.

Electronic supplementary material

The online version of this article (10.1186/s12871-017-0409-0) contains supplementary material, which is available to authorized users.

Metabolic fate of milk glycosaminoglycans in breastfed and formula fed newborns

In this study, the content, structure and residual percentages of glycosaminoglycans (GAGs) in the feces of seven breastfed newborns after ingesting a known amount of milk were studied. A comparison was made with five newborns fed with formula milk. Characterization of GAGs from milk and feces samples was performed according to previous methodology. Compared to the ingested GAGs present in milk, residual feces GAGs of breastfed newborns were <0.4 %, contrary to formula milk fed children, where the residues were ~4 %. As a consequence, >99 % of human milk GAGs are utilized as opposed to ~96 % of formula milk. Hyaluronic acid utilization was found to be fairly similar contrary to chondroitin sulfate/dermatan sulfate and heparan sulfate, which were found to be ~10-18 times lower in formula milk fed children. Our new results further demonstrate that the elevated content of human milk GAGs passes undigested through the entire digestive system of newborns, possibly protecting the infant from infections. In the distal gastrointestinal tract, these complex macromolecules are catabolized by a cohort of bacterial enzymes and constituent monosaccharides/oligosaccharides utilized for further metabolic purposes potentially useful for bacteria metabolism or internalized by intestinal cells. Thanks to their elevated structural heterogeneity, milk GAGs are used differently depending on their distinct primary structure. Finally, a different utilization and availability was observed for human milk GAGs compared to formula milk due to their various composition and structural heterogeneity.

Changes of swallowing function after tracheostomy: a videofluoroscopy study

BACKGROUND

Patients after tracheostomy often present swallowing dysfunctions but little is known about the mechanism underlying dysphagia and its reversibility. The aims of this study were: 1) to characterize swallowing dysfunctions in patients with dysphagia and tracheostomy; 2) to evaluate the reversibility of these changes; 3) to evaluate the possible influence of the underlying disease.

METHODS

Prospective, observational, single-center study enrolling patients with tracheostomy admitted to a rehabilitation center over a period of 36 months. All patients who were found to be dysphagic underwent a swallowing study with videofluoroscopy (VF) at the beginning of hospital stay and a second VF study was repeated after approximately 4 weeks.

RESULTS

A total of 557 patients with tracheostomy were admitted to the rehabilitation center during the considered period. 187 patients fulfilled the enrolling criteria and were studied with VF soon after admission. They had been tracheostomized for respiratory failure secondary to cerebrovascular accident (N.=106) or to acute-on chronic respiratory failure (N.=81). Incomplete backward epiglottis folding, pharyngeal retention, penetration and aspiration were the most frequent swallowing dysfunctions, observed with a frequency of 48%, 32%, 33% and 28%, respectively. Eighty-one patients underwent a second VF study, where these four swallowing phases again turned out to be the most compromised, with a frequency of 41%, 19%, 27% and 17%, respectively. The improvement was less evident in patients with chronic respiratory disease.

CONCLUSION

The swallowing function is impaired in patients with dysphagia and tracheostomy, but most swallowing abnormalities appear to be partially reversible. Patients with chronic respiratory disease exhibit a worse swallowing function.

Clinical applications of diaphragm ultrasound: moving forward

Establishing the correct time of weaning from mechanical ventilation is a crucial issue in the clinical practice. The difficult process of weaning can be due to pathological conditions that result in an imbalance between respiratory-muscle strength and respiratory load. Recently it has been suggested that ultrasound measurements of diaphragm muscle thickening in inspiration during weaning could provide an estimation of extubation success. Bedside ultrasonography, particularly sonographic evaluation of the diaphragm by measuring the percentage variation of diaphragm thickness (tdi) between end-inspiration and end-expiration (Δtdi%), has become a valuable tool in the management of intensive care unit patients. This non-invasive, low-cost and fast to perform technique seems to predict with a good accuracy the extubation failure. Some limitations derive from the difficulty to determine the maximum (end inspiratory) and minimum (end expiratory) tdi observing a dynamic image in B-mode, in particular in non-collaborating patients. In addition, some dynamic situations causing extubation failure could not be predicted by an ultrasound measure performed at the beginning of the weaning trial. Nowadays the technique proposed remains a useful tool for helping the prediction of extubation failure. It would be useful in the future to set up multicentric studies with a standardised description of the procedure and serial measurements in different timing during the weaning trial. Furthermore, randomized controlled trials to evaluate the efficiency of Δtdi% versus other indexes in predicting extubation failure are needed.

Lung abscess in a child secondary to Mycoplasma pneumoniae infection

We present a case of a lung abscess in a child 6-year-old admitted with a history of right hemithorax pain lasting for 15 days and the onset of mild fever in the last two days. Etiological research showed positivity of IgM antibodies to Mycoplasma pneumoniae after seven days of admission. The child has been successfully treated with antibiotic therapy, without the use of macrolides, for a duration of 4 weeks. Our study suggests that the Mycoplasma pneumoniae infection may predispose to severe infections, such as lung abscess, caused by typical respiratory pathogens. The reported case of lung abscess is one of the few reported in the literature in the modern antibiotic era and is the first preceded by Mycoplasma pneumoniae infection.

Orthofile®: a new approach for mechanical interproximal reduction : a scanning electron microscopic enamel evaluation

PURPOSE

The aim of this in vitro study was to evaluate the stripping achieved on different teeth (incisors, canines, and premolars) by two grades of abrasive strips used for the first and tenth time. Our second aim was to test the efficacy of these strips by calculating the time necessary to perform interproximal reductions of 0.10, 0.20, and 0.30 mm.

METHODS

Four models were constructed using extracted teeth affixed in wax. The upper and lower arches were set on plaster bases and fixed in wax, carefully creating contact points. All model mouths were treated with artificial saliva (Oral Balance®) in order to simulate the biological conditions in the oral cavity. We then tested specific air-rotor strips of different grades and degrees of wear (15-µm-grain and 25-µm-grain Orthofile® strips). Afterwards the teeth from all samples were cut lengthwise in half, and each mesial and distal portion was gold-plated and observed under SEM at incremental magnification (30, 60, and 100 µm).

RESULTS

The 25-µm-grain strip was more effective than the 15-µm-grain strip, irrespective of the tooth involved. Second, the finishing phase with specific polishing strips after interproximal reduction was fundamental in reducing the number of abrasions and irregularities created by stripping, in particular after using the 25-µm-grain strip. To achieve the best result, the entire abraded area must be polished.

CONCLUSION

This system permits a rapid and effective stripping procedure in direct proportion to the strip's grain and in inverse proportion to the wear from its use. Further research will enable us to compare this system with similar procedures.

Two cases of neonatal adrenal hemorrhage presenting with persistent jaundice

The adrenal hemorrhage is a relatively rare event in newborns but must be considered in the presence of a persistent unexplained jaundice, especially in presence of predisposing factors. Serial ultrasonography is the modality of choice for initial diagnosis and follow-up of neonatal adrenal hemorrhage. We report two cases of neonatal adrenal hemorrhage presenting with persistent jaundice. The causes of the neonatal adrenal hemorrhages were a difficult vaginal delivery in macrosomic infant and a neonatal infection.

Pollen-induced allergic rhinitis in 1360 Italian children: comorbidities and determinants of severity

BACKGROUND

Pollen-induced allergic rhinoconjunctivitis (AR) is highly prevalent and rapidly evolving during childhood. General practitioners may not be fully aware of the nature and severity of symptoms experienced by patients and might underestimate the prevalence of moderate or severe disease. Thus, the relevance of early diagnosis and intervention may be overlooked.

OBJECTIVES

To investigate the severity of pollen-induced AR and its determinants in Italian children referred to allergy specialists and who had never received specific immunotherapy (SIT).

METHODS

Children (age 4-18 yr) affected by pollen-induced AR who had never undergone SIT were recruited between May 2009 and June 2011 in 16 pediatric outpatient clinics in 14 Italian cities. Recruited children's parents answered standardized questionnaires on atopic diseases (International Study of Allergy and Asthma in Childhood, Allergic Rhinitis and its Impact on Asthma, Global Initiative for Asthma). The children underwent skin-prick test (SPT) with several airborne allergens and six food allergens. Information on socio-demographic factors, parental history of allergic diseases, education, perinatal events, breastfeeding, nutrition and environmental exposure in early life was collected through an informatics platform shared by the whole network of clinical centers (AllergyCARD™).

RESULTS

Among the 1360 recruited patients (68% males, age 10.5 ± 3.4 yr), 695 (51%) had moderate-to-severe AR, 533 (39%) asthma, and 325 (23.9%) oral allergy syndrome (OAS). Reported onset of pollen-induced AR was on average at 5.3 ± 2.8 yr, and its mean duration from onset was 5.2 ± 3.3 yr. Only 6.2% of the patients were pollen-monosensitized, and 84.9% were sensitized to ≥3 pollens. A longer AR duration was significantly associated with moderate-to-severe AR symptoms (p 0.004), asthma (p 0.030), and OAS comorbidities (p < 0.001).

CONCLUSIONS

This nationwide study may raise awareness of the severity of pollen-induced AR among Italian children who have never received pollen SIT. The strong association between pollen-induced AR duration and several markers of disease severity needs replication in longitudinal studies, while suggesting that countrywide initiatives for earlier diagnosis and intervention should be planned.

First Report of Stem Wilt and Root Rot of Schlumbergera truncata Caused by Fusarium oxysporum f. sp. Opuntiarum in Southern Italy

Schlumbergera truncata (Haw.) Moran, belonging to the Cactaceae, is a very common ornamental cactus in southern Italy. In November 2011, sudden stem wilt and root rot was observed in about 45% of vegetatively propagated plants cultivated as potted ornamental plants in a commercial greenhouse in Cerignola (Foggia Province, Apulia, Italy). The roots and collars of the plants showed brown rot. Yellow sunken lesions that were similar to cortical cankers were detected at basal level of the stem. Ten plants with these symptoms were analyzed by fungal isolation techniques. Small (0.5 cm) tissue portions from root, collar, and basal stem were plated on potato dextrose agar (PDA) after disinfection with 75% ethanol for 1 to 2 min, 0.2% NaOCl for 1 to 2 min, and a wash with sterile distilled water. A fungal isolate that was morphologically similar to Fusarium sp. was isolated from 85% of these tissue samples. It had nucleotide sequences of the internal transcribed spacer region (ITS1-5.8S-ITS2) of ribosomal DNA (GenBank Accession No. KC196121) 100% identical to those of the comparable sequences of Fusarium oxysporum (HQ651161). The nucleotide sequences of its translation elongation factor 1-α (EF-1α) gene (KC196120) showed 100% identity to sequences of F. oxysporum f. sp. opuntiarum (DQ837689, AF246881) retrieved from GenBank. Pathogenicity tests were performed at 22 ± 3°C on 18 45-day-old plants of S. truncate by adding of a 5-ml aliquot of conidial suspension adjusted to 5 × 10⁶ conidia/ml to soil of each plant. Six non-inoculated plants were used for a control treatment and sprayed with 5 ml of sterilized water. Plants were maintained in greenhouse at 22 ± 3°C. After 10 days, nine of the inoculated plants showed wilting, and after 45 days, all of them were dead, with root and collar rot and lesions on the basal stem. Control plants were symptomless. Koch's postulates were fulfilled as the pathogen was reisolated from all of the symptomatic tissues and identified as Fusarium sp. On the basis of 3-septate macroconidia (mean 31.75 × 3.21 μm; range, 26 to 35 μm long, 3.0 to 4.2 μm wide), aseptate microconidia, single chlamydospores, and monophialide conidiophores on carnation leaf agar, and molecular analyses, the fungus was identified as F. oxysporum f. sp. opuntiarum (Speg) (1,2,3). In Italy, F. oxysporum f. sp. opuntiarum was reported as basal stem rot of Echinocactus grusoni (4). To our knowledge, this is the first report of stem wilt and root rot of S. truncata caused by F. oxysporum f. sp. opuntiarum in Italy. References: (1) W. Gerlach. Phytopathol. Z. 74:197, 1972. (2) W. L. Gordon. Can. J. Bot. 43:1309, 1965. (3) P. E. Nelson et al. Fusarium Species: An Illustrated Manual for Identification. Pennsylvania State University Press, University Park, 1983. (4) G. Polizzi et al. Plant Dis. 88:85, 2004.

Chronic massive fetomaternal hemorrhage in a newborn from immigrants. Clinical and organizational implications

Fetomaternal hemorrhage (FMH) refers to the entry of fetal blood into the maternal bloodstream before or during delivery. FMH of more than 30 mL occurs with the frequency of about 1/300. Fetal outcomes may be compromised by still births, hydrops fetalis, cardiac complications, and increased rates of postpartum infant death. In most cases, the cause is not identified. Clinical manifestations of FMH depend on the volume of blood lost and the rate that it occurred. We report a case of chronic massive FMH in a newborn of an immigrant mother with a favorable outcome. Medical visits and tests during pregnancy, including ultrasound scans, were not performed. The baby was hemodynamically stable after birth, manifesting only pallor. The complete blood count revealed severe hypochromic anemia (hemoglobin 3,8 g/dl, hematocrit 14,4%) and reticulocytosis (reticulocyte 25,2%). There was no ABO blood type incompatibility and the result of direct Coomb's test was negative. The Kleihauer-Betke test revealed 5% of fetal erythrocytes in the maternal bloodstream equivalent to 180 mL. The fact that FMH can occur without prior risk factors, and the diagnosis is often postnatal, underscores the importance of heightened of medical suspicion particularly in infants born to immigrants where there is often the lack of prenatal visits.

Interfaces for noninvasive mechanical ventilation: technical aspects and efficiency

Noninvasive mechanical ventilation (NIV) has become a standard of care in select patients with both hypercapnic and non-hypercapnic acute respiratory failure (ARF). Consequent to the increasing use of NIV, new interfaces of different designs, shapes, sizes, and materials have been proposed for clinical use in recent years. The aim of this report is to examine the most relevant physiological aspects related to the choice of interface with particular emphasis on the problems related to dead space and air leaks that may affect the synchrony between the patient and the machine, ultimately determining the patient's compliance and therefore NIV success.

Plectosphaerella species associated with root and collar rots of horticultural crops in southern Italy

Plectosphaerella cucumerina, most frequently encountered in its Plectosporium state, is well known as a pathogen of several plant species causing fruit, root and collar rot, and collapse. It is considered to pose a serious threat to melon (Cucumis melo) production in Italy. In the present study, an intensive sampling of diseased cucurbits as well as tomato and bell pepper was done and the fungal pathogens present on them were isolated. Phylogenetic relationships of the isolates were determined through a study of ribosomal RNA gene sequences (ITS cluster and D1/D2 domain of the 28S rRNA gene). Combining morphological, culture and molecular data, six species were distinguished. One of these (Pa. cucumerina) is already known. Four new species are described as Plectosphaerella citrullae, Pa. pauciseptata, Pa. plurivora and Pa. ramiseptata. Acremonium cucurbitacearum is shown to be a synonym of Nodulisporium melonis and is transferred to Plectosphaerella as Plectosphaerella melonis comb. nov. A further three known species of Plectosporium are recombined in Plectosphaerella.

Rosaceae-associated exercise-induced anaphylaxis with positive SPT and negative IgE reactivity to Pru p 3

BACKGROUND

Food-dependent-exercise-induced anaphylaxis (FDEIA) is characterized by anaphylactic symptoms after exercise following ingestion of food. We present a case of FDEIA induced by Rosacee fruits showing some diagnostic problems.

MATERIAL AND METHODS

A 12 years-old boy with seasonal allergy to olive and cypressus pollens, experienced two distinct episodes of FDEIA, grade 4 and 3 of the Sampson Scale respectively, during intense exercise, about 30 minutes after eating a peach with peel or some cherries. SPT with commercial peach extract and fresh Rosacee fruits scored positive while SPT with a date palm profilin-enriched extract was negative. On in vitro tests total IgE were 44 kU/l and IgE for peach, cherry, Prup 3, Prup 1, Bet v 1, Bet v 2, Bet v 4 were negative. SPT with Prup 3 UniCAP device (cellulose polymer in a plastic reserve highly binding allergen protein) was negative. An oral food challenge, performed at rest using a commercial peach juice, scored negative. An immunoblot analysis performed with peach extract was negative.

DISCUSSION

The main peculiarity of this case of FDEIA is the discrepancy between positive SPT and negative in-vitro findings. The positive SPT with the commercial peach extract suggested hypersensitivity to lipid transfer protein; however, no IgE reactivity to rPrup 3 was found in-vitro. The negative immunoblot analysis, possibly caused by the low levels of specific IgE, did not allow us to investigate the nature of the relevant allergen protein further. It is possible that this patient reacted to a different peach allergen or, alternatively, that he recognized an isoform of LTP that is different fr-om that in Uni-CAP.

CONCLUSION

This case emphasizes once more the diagnostic relevance of SPT with extracts and fresh material to be performed before investigating IgE reactivity to single allergen components in-vitro.

IL-22 mRNA in peripheral blood mononuclear cells from allergic rhinitic and asthmatic pediatric patients

T helper (T(H) )-17 lymphocytes are characterized by the expression of many regulatory cytokines, including IL-17A and IL-22, but at present no clinical data are available on the expression of these cytokines in peripheral blood mononuclear cells (PBMC) from allergic asthmatic and rhinitic (AR) children. The aim of this study was to investigate a possible relationship between IL-22 and IL-17A mRNAs and clinical parameters in seroatopic, AR, and asthmatic children. The study, conducted during the pollen season, included 18 healthy and 18 allergic (n=9 asthmatic and n=9 rhinitic) children. Serum total and specific IgE, eosinophil count, and skin prick test were performed; in addition, IL-22 and IL-17A mRNA levels were detected in PBMC from healthy and allergic subjects by quantitative real-time PCR. Despite the absence of the mRNA for the IL-17A cytokine, IL-22 expression was found in PBMC from asthmatic patients, with increased IL-22 mRNA levels in patients with chronic severe respect to those with moderate asthma. A positive correlation between IL-22 mRNA and serum total IgE levels was found in asthmatic children. In addition, higher IL-22 and IL-17A mRNA levels were detected in both AR and asymptomatic seroatopic children, compared to healthy individuals, and a correlation between IL-22 and IL17A mRNA and serum total IgE levels was demonstrated. Moreover, the mRNA level of retinoic acid-related orphan receptor C, the T(H) 17 transcription factor, was found to be increased in AR but not in asthmatic patients. This study provides the first evidence that IL-22 mRNA might be expressed in chronic severe asthmatic and AR children. The expression of IL-22 and IL-17A mRNAs in asymptomatic monosensitized seroatopic children suggests a role of these cytokines in the early events involved in the development of these allergic diseases.

Autoimmune hepatitis type 2 following anti-papillomavirus vaccination in a 11-year-old girl

In the last years numerous reports describing a possible association between administration of vaccines and development of autoimmune phenomena and overt autoimmune disease were published. Possible mechanisms of induction of autoimmune phenomena by vaccines and their excipients are probably similar to those implicated in induction by infectious agents. Here we report the case of an 11-year-old girl who developed autoimmune hepatitis type II after four weeks from vaccination against human papillomavirus. The possible relationships between the use of adjuvated vaccine against papillomavirus and autoimmune hepatitis are discussed. Although we do not provide evidence for a causal link, we suggest that the occurrence of the autoimmune hepatitis may be related to the stimulation of immune system by adjuvated-vaccine, that could have triggered the disease in a genetically predisposed individual. Therefore a monitoring of liver function test following administration of vaccine against papillomavirus may be useful in adolescent girl with signs of hepatopathy, as jaundice, dark urine or hepatomegaly, to early identify and to promptly treat autoimmune liver disorders.

Changes in nutritional status and body composition during enzyme replacement therapy in adult-onset type II glycogenosis

BACKGROUND

In adult glycogen storage disease type II (GSDII), a single-gene mutation causes reduction of the lysosomal enzyme acid alpha-glucosidse. This produces a chronic proximal myopathy with respiratory involvement. Enzyme replacement treatment (ERT) has recently become available and is expected to improve muscle strength. This should result in increased lean body mass. In this study we evaluate body composition and nutritional status in GSDII, and assess whether these parameters changed during treatment.

METHODS

Seventeen patients with late-onset GSDII, aged 52.6 +/- 16.8 years, received ERT for >18 months. Dietary habits and metabolic profiles of glucids, lipids, and proteins were assessed. Body composition was calculated using anthropometry and bioelectrical impedence analysis.

RESULTS

On inclusion, we found increased fat mass (FM) in five patients in severe disease stage; all had normal body mass index (BMI). FM correlated inversely, and lean mass (LM) directly, with creatine kinase, prealbumin and albumin levels. After treatment, BMI and FM significantly increased, while LM only showed a trend toward increase. Prealbumin and albumin levels increased as early as after the first months of ERT.

DISCUSSION

Body mass index value may underestimate FM in patients in severe stage of disease, due to altered body composition. In severely affected patients, laboratory parameters revealed a relative protein malnutrition, that was reversed by ERT, this reflecting restoration of normal muscle metabolic pathways. Increased BMI may indicate a reduction in energy consumption during exercise or respiration, along with clinical improvement.

First Report of Wilt Caused by Verticillium dahliae on Cosmos (Cosmos bipinnatus) in Italy

Cosmos (Cosmos bipinnatus Cav., Asteraceae) is an herbaceous plant that is grown for landscape use. During August and September of 2008 in five public and three private gardens located in Monopoli (Apulia, southern Italy), 3 to 8% of the plants showed severe symptoms of vine decline, stunting, gradual yellowing and wilting of the leaves, and final collapse of the whole plant. External symptoms were associated with brown or black streaking of the vascular tissue of roots, collar, and stem. Dead plants had numerous microsclerotia embedded in the xylem of plant tissues. Stem, collar, and root sections (0.5 cm long) from symptomatic plants collected in five gardens were surface disinfested in 5% NaOCl for 1 min and transferred to petri dishes containing potato dextrose agar (PDA) amended with 100 μg ml^-1 of streptomycin sulfate and 10 μg ml^-1 of neomycin. After 10 days of incubation, at 25°C in the dark, hyaline hyphae with dark microsclerotia (37 to 112 μm) and verticillate conidiophores were produced. Conidia were single celled and hyaline with dimensions of 3.3 to 7.8 × 1.8 to 3.3 μm (mean dimensions 4.2 × 2.5 μm). According to morphological characteristics, the fungus was identified as Verticillium dahliae Kleb. (1) (isolates no. Vd1818, Vd1819, and Vd1820 stored in a collection at the Department DiSACD, University of Foggia). Molecular analyses were performed on the basis of nucleotide sequences of the internal transcribed spacer region (ITS1-5.8S-ITS2) of ribosomal DNA. ITS sequences of this fungus, compared with sequences found in GenBank and attributed to V. dahliae (no. GQ130129, GQ130130, GQ130131), showed 98 to 99% sequence similarity. Healthy 40-day-old plants of C. bipinnatus (garden cosmos) cv. Sonata Pink Blusk and C. sulphurous (yellow cosmos) cv. Bilbo, obtained from seeds previously disinfested for 1 min in 3% NaOCl and ascertained to be healthy by isolation on PDA medium, were used for pathogenicity tests. Plants were grown in 3-liter pots in a steam-disinfested peat, sand, and soil mixture (2:1:1) in the greenhouse at 23 to 26°C. Ten plants of each cultivar were inoculated by root dipping into a conidial suspension of each fungal isolate (1.5 × 10⁶ CFU ml^-1). Six noninoculated cosmos plants of each cultivar served as controls. The experiment was repeated three times. First symptoms of wilting were observed on all inoculated plants of each cultivar 20 days after the inoculation; at 40 days, symptom severity ratings on plants were taken, in which 1 = asymptomatic, 2 = stunted, 3 = wilting, and 4 = dead. All three isolates caused vascular discoloration, stunting, wilting, and plant death. The mean disease rating was 3.2 and did not differ significantly among isolates. The pathogen was consistently reisolated from infected plants, fulfilling Koch's postulates. Noninoculated plants remained healthy. To our knowledge, this is the first report of Verticillium wilt on cosmos in Italy. The finding is important since other ornamental plants that are susceptible to Verticillium wilt are also grown in landscapes in the region. The disease was previously reported in Turkey (2). References: (1) G. F. Pegg and B. L. Brandy. Verticillium Wilts. CABI Publishing, Wallingford, UK, 2002. (2) E. Sezgin et al. Turk. Phytopathol. 14:43, 1985.

Non-invasive ventilation

Non-invasive ventilation (NIV) is an effective technique that can avert side effects and complications associated with endotracheal intubation. NIV is primarily used to avert the need for endotracheal intubation in patients with early stage acute respiratory failure (ARF), and to prevent postextubation respiratory failure in patients considered to be at risk. It can also be used as an alternative to invasive ventilation at a more advanced stage of ARF or to facilitate the process of weaning from mechanical ventilation. The success of NIV relies on several factors including the type and severity of ARF, the underlying disease, the timing, the location of treatment, and the experience of the team. In this review article, we analyze, compare, and discuss the results of studies in which NIV was applied in different pathologies and with different timing during the evolution of ARF.

Urinary tract infection caused by Kluyvera ascorbata in a child: case report and review of the kluyvera infections in children

Kluyvera species are described infrequently in association with clinically significant infections, and infections caused by these gram negative rods are rare in children. The spectrum of disease due to Kluyvera infection in children includes urinary tract infections, enteritis, soft tissue infections, sepsis, central venous catheter infections and peritonitis. The authors report a case of Kluyvera ascorbata urinary tract infection in a 3-month-old female baby, and they review the literature on Kluyvera infections in children.

Comparison of two humidification systems for long-term noninvasive mechanical ventilation

There is no consensus concerning the best system of humidification during long-term noninvasive mechanical ventilation (NIMV). In a technical pilot randomised crossover 12-month study, 16 patients with stable chronic hypercapnic respiratory failure received either heated humidification or heat and moisture exchanger. Compliance with long-term NIMV, airway symptoms, side-effects and number of severe acute pulmonary exacerbations requiring hospitalisation were recorded. Two patients died. Intention-to-treat statistical analysis was performed on 14 patients. No significant differences were observed in compliance with long-term NIMV, but 10 out of 14 patients decided to continue long-term NIMV with heated humidification at the end of the trial. The incidence of side-effects, except for dry throat (significantly more often present using heat and moisture exchanger), hospitalisations and pneumonia were not significantly different. In the present pilot study, the use heated humidification and heat and moisture exchanger showed similar tolerance and side-effects, but a higher number of patients decided to continue long-term noninvasive mechanical ventilation with heated humidification. Further larger studies are required in order to confirm these findings.

Hepatic hydatid cysts: intraperitoneal perforation in a pediatric patient

We report a rare case of intraperitoneal hepatic hydatid cyst perforation in a 7 years-old boy. Diagnosis was performed by ultrasounds, computerized tomography scan, and serology. Surgical treatment was followed by pharmacologic treatment with the aim of avoiding a relapse. A brief review of the diagnostic and therapeutic management of the disease is provided.

First Report of Pitch Canker Caused by Fusarium circinatum on Pinus halepensis and P. pinea in Apulia (Southern Italy)

Since 2005, pitch canker symptoms have been observed in Apulia (southern Italy, 41°27'42.84″N, 15°33'0.36″E) on numerous trees of Pinus halepensis and P. pinea in urban parks and gardens. Trees showed crown decline as a consequence of dieback of twigs and branches and withering of needles. Bleeding cankers with abundant resin were visible on twigs and branches. The needles of affected twigs and branches wilted, faded, turned yellow, then red, and were discarded. Isolations from symptomatic needles, twigs, and branches were performed on water agar, potato dextrose agar (PDA), and pentachloronitrobenzene medium. A species of Fusarium was consistently isolated from all infected tissues, and pure cultures were obtained by single hyphal tip transfers on PDA and synthetic nutrient agar medium (2). Colonies were incubated at 22 ± 3°C for 7 to 10 days. They produced white aerial mycelia, violet pigment, typically 3-septate macroconidia with slightly curved walls, single-celled microconidia, and characteristic sterile hyphal coils. Microconidia were ovoid or allantoid and born in false heads on aerial polyphialides. The species was identified as Fusarium circinatum Nirenberg & O'Donnell (= F. subglutinans Wollenweb & Reinking) on the basis of morphological and cultural characteristics (3). The identification was confirmed by PCR with specific primers CIRC1A/CIRC4A. The specific primer pair amplified a 360-bp DNA fragment of the two nuclear ribosomal IGS region (4). The pathogenicity of three Italian isolates of F. circinatum from Pinus spp. (Fc1640, Fc1642, and Fc1643 stored in the collection of Dipartimento Scienze Agroambientali, Chimica and Difesa Vegetale, University of Foggia) was evaluated by artificial inoculations on 2-year-old potted seedlings of P. halepensis, P. pinea, P. nigra, P. sylvestris, P. domestica, P. pinaster, P. excelsa, P. radiate, and Pseudotsuga menziesii (10 seedlings for each species and fungal isolate). Small PDA plugs from actively growing colonies of F. circinatum were introduced into a U-shaped cut on the stem of the seedlings and wrapped with moist sterile cottonwool. An equal number of control plants of each Pinus spp. was inoculated with sterile agar. All plants were grown in a nursery at ambient temperature (20 to 28°C). Within 30 days after inoculation, resinous cankers appeared on the stem of the seedlings of P. halepensis, P. pinea, P. domestica, P. pinaster, and P. radiata. Basal needles began to wilt, turn yellow, then red, and were discarded. F. circinatum was reisolated from stems of symptomatic seedlings. No symptoms were observed on seedlings of Pseudotsuga menziesii, P. sylvestris, P. excelsa, and P. nigra or on control seedlings. In Europe, pitch canker caused by F. circinatum previously has been reported only in Spain on P. radiata and P. pinaster (1). There was an unconfirmed report of this disease in Italy ( http://www.eppo.org ), but to our knowledge, this is the first definite conclusive evidence of the presence of pitch canker of pine in Italy. References: (1) E. Landeras et al. Plant Dis. 89:1015, 2005. (2) H. I. Niremberg. Mitt. Biol. Bundesanst. Land-Forstwirtsch. Berl.-Dahl, 169:1, 1976. (3) H. I. Niremberg and K. O'Donnell. Mycologia 90:434, 1998. (4) W. Schweigkofler et al. Appl. Environ. Microbiol. 70:3512, 2004.

Effect of varying the pressurisation rate during noninvasive pressure support ventilation

The aim of the study was to assess the effects of varying the pressurisation rate during noninvasive pressure support ventilation on patients' breathing pattern, inspiratory effort, arterial blood gases, tolerance to ventilation and amount of air leakage. A total of 15 chronic obstructive pulmonary disease patients recovering from an acute episode of hypercapnic acute respiratory failure were studied during four randomised trials with different levels of pressurisation rate. No significant changes were observed in breathing pattern and arterial blood gases between the different runs. The pressure time product of the diaphragm, an estimate of its metabolic consumption, was significantly lower with all pressurisation rates than with spontaneous breathing, but was significantly lowest with the fastest rate. However, air leak, assessed by the ratio between expired and inspired tidal volumes, increased and the patients' tolerance of ventilation, measured using a standardised scale, was significantly poorer with the fastest pressurisation rate. In chronic obstructive pulmonary disease patients recovering from an episode of acute hypercapnic respiratory failure and ventilated with noninvasive pressure support ventilation, different pressurisation rates resulted in different reductions in the pressure time product of the diaphragm; this reduction was greater with the fastest rate, but was accompanied by significant air leaks and poor tolerance.

O/W microemulsions for oral drug delivery

Quaternary microemulsion compositions for oral administration using isopropyl myristate, polysorbate 80 and ethanol 96 degrees were developed and three ratio of polysorbate to ethanol were selected. Isotropic single-phase compositions were considered as microemulsions and were registered on a Pseudo-Ternary Phase Diagram. The objective was to formulate a therapeutic dose for lorazepam and loperamide in a drop liquid form. Another aim was to obtain a liquid oral formula for nifedipine taking advantage of its insured fast absorption to be used in hypertensive crises. The physical stability of the compositions was evaluated by normal aging, centrifugal resistance time and by cycling as well. The selected formulation characterization included density, pH and conductivity measurements. The particle size distribution was determined by a light scattering method and, finally the carried drugs concentration was valued. The versatility showed by this type of systems allows both to carry drugs of different physico-chemical properties and to deal with a number of pharmacotherapeutic objectives.

Delayed presentation of congenital diaphragmatic Bochdalek hernia. Case report

The authors describe the case of a 1-month-old patient admitted for crisis of paleness, accompanied by hyporeactivity, tachycardia and polypnea; the symptoms, attenuated after detension of the abdomen, grew worse, with compromise of general conditions and respiratory failure. Chest X-ray shows the herniation of intestinal loops in the thoracic cavity. After the first emergency care, it became necessary to submit the baby to HFO and cardiovascular drugs for some hours before getting oxygenation index (OI) and circulation stabilization. Late presenting congenital diaphragmatic hernia (LCDH) is a condition that can occur during first or second infancy with respiratory or abdominal symptoms, quickly worsening or intermittent. The prognosis is good if diagnosis is timely. Patient stabilization before surgical intervention must be valued not only by O.I. but also by circulation conditions.

Bench testing of pressure support ventilation with three different generations of ventilators

OBJECTIVE

The new generations of intensive care ventilators tend to be more innovative and sophisticated than previous ones, but little is known about their respective performance for delivering pressure support ventilation (PSV) and how they compare to previous generations.

DESIGN

Active lung model bench test.

APPARATUS

Twenty-two commercially available ventilators classified into three categories: new generation ventilators (after 1993, n=7), previous generation (before 1993, n=6), and recent piston or turbine-based ventilators ( n=9).

MEASUREMENTS AND RESULTS

During PSV, the unloading efficacy of the assistance depends on the ventilator's ability to meet inspiratory flow demand. Three levels of flow (0.1 l/s, 0.6 l/s, and 1.2 l/s) were used to simulate inspiratory demand and the net area of the inspiratory airway pressure-time trace was calculated over the first 0.3 s, 0.5 s, and 1 s (Area (0.3), Area (0.5), and Area (tot)) with three levels of PSV (5 cmH(2)O, 10 cmH(2)O, and 15 cmH(2)O). To assess the respective role of pressure support delivery and triggering function, triggering sensitivity was assessed independently by measuring the time delay ( TD (tg)) and the pressure fall (Delta Paw (tg)) with two levels of inspiratory drive. All the new generation ventilators exhibited significantly better results than most of the previous generation ventilators regarding Area (0.3) and TD (tg), indicating large improvements in terms of triggering and pressurisation.

CONCLUSION

Regarding PSV and trigger performance, the new generation ventilators - but also some piston and turbine-based ventilators - outperform most of previous generation ventilators.

Muscle retraining in the ICU patients

One of the most common causes of an ICU admission is a severe episode of acute respiratory failure due either to an exacerbation of chronic pulmonary disease or its ex-novo development after a surgical procedure, trauma or medical complications. These patients usually report, at admission to the ICU, a sedentary life before the acute episode, because the evolution of the disease is characterized by a progressive decline not only in respiratory function (e.g. FEV1), but also in the functional status, due to the effects of lack of exercise, drug administration, malnutrition and, later on, gas exchange abnormalities. Together with specific vital organ support, such as mechanical ventilation, patients admitted to an ICU may require other complex and integrated interventions in order to maintain the spared function and to prevent further damage. These interventions include nutritional and psychological support, counselling, nursing, prevention (e.g. to preserve skin integrity) and in particular a complete physiotherapic program, that may range from simple help to maintain a correct posture to complete recovery of walking autonomy.

[It is not so difficult to carry out simple things properly!]

This report is about the results of the experience we did, since 1996, in the nursing unit of a first level mountain hospital in which we work, where we followed a new childbirth and postpartum assistance protocol aimed to humanizing birth and postpartum, promoting exclusive breastfeeding and reducing childbirth risks. The results show that, since the beginning of our experience, we had an evident reduction of preterm childbirth (newborns with less than 36 weeks of gestational age). We also had a reduction of cesarian sections and of neonatal transferrals in second level neonatal units. Furthermore, we had a progressive growth of exclusive breastfeeding. The report also shows that, since 1996, the newborns discharged from our hospital are exclusively breastfed for a time longer than before and that, at 1 year, 11 percent of our children are still breastfed.

[Symptomatic congenital cytomegalovirus infection: report of a clinical case with very severe onset]

This document is about a serious congenital CMV case in a 36 weeks' gestation female newborn with intrauterine growth retardation delivered by cesarean section whose mother was drug addicted. At birth the newborn showed petechiae and bloody blisters all over the body, serious hepatosplenomegaly and microcephaly. Laboratory tests showed thrombocytopeny (platelets count 24.000/mm3) requiring platelets and fresh frozen plasma transfusions during stay in the hospital; echoencephalography showed brain cyst in occipital area, dilated ventricles and calcification in the periventricular area; cardiac echography showed congenital cardiopathy with ventricular and atrial septal defect and patent ductus arteriosus. Urinary presence of CMV-DNA and then CMV-DNA in maternal blood and milk were found. The newborn was given 4 days of endovenous iperimmune immunoglobulin, but the treatment with ganciclovir was impossible for her serious hepatopathy. The newborn was discharged at 45 days and followed monthly with a day hospital program. Now she's 10 months old and she has serious neuromotory problems with left emiparesis and she's following a program of neuromuscular re-education at our hospital.

Helium-oxygen in the postextubation period decreases inspiratory effort

After tracheal extubation, upper and total airway resistances may frequently be increased resulting in an increase in inspiratory effort to breathe. We tested whether breathing a helium-oxygen mixture (HeO(2)) would reduce inspiratory effort in the period after extubation. Eighteen consecutive patients with no chronic obstructive pulmonary disease who had received mechanical ventilation (> 48 h) were successively studied immediately after extubation (N(2)O(2)), 15 min after breathing HeO(2), and after return to N(2)O(2). Effort to breathe, assessed by the transdiaphragmatic pressure swings (DeltaPdi) and the pressure-time index of the diaphragm (PTI), comfort, and gas exchange, were the main end points. The mean reduction of the transdiaphragmatic pressure under HeO(2) was 19 +/- 5%. All but three patients presented a decrease in transdiaphragmatic pressure under HeO(2), ranging from - 4 to - 55%, and a significant reduction in DeltaPdi was observed between HeO(2) and N(2)O(2) (10.2 +/- 0.7 versus 8.6 +/- 1.1 versus 10.0 +/- 0.8 cm H(2)O for the three consecutive periods; p < 0.05). PTI also differed significantly between HeO(2) and N(2)O(2) (197 +/- 19 versus 166 +/- 22 versus 201 +/- 23 cm H(2)O/s/min for the three periods; p < 0.05). Breathing HeO(2) significantly improved comfort, whereas gas exchange was not modified. We conclude that the use of HeO(2) in the immediate postextubation period decreases inspiratory effort and improves comfort.

Noninvasive versus conventional mechanical ventilation. An epidemiologic survey

A prospective survey was performed over a period of 3 wk among 42 intensive care units to assess the incidence of use and effectiveness of noninvasive mechanical ventilation (NIV) in clinical practice. All patients requiring ventilatory support for acute respiratory failure (ARF), either with endotracheal intubation (ETI) or NIV, were included. Ventilatory support was required in 689 patients, 581 with ETI and 108 (16%) with NIV (35% of patients not intubated on admission). Reasons for mechanical ventilation were coma (30%), cardiogenic pulmonary edema (7%), and hypoxemic (48%) and hypercapnic ARF (15%). NIV was never used for patients in coma (who were excluded from further analysis), but was used in 14% of patients with hypoxemic ARF, in 27% of those with pulmonary edema, and in 50% of those with hypercapnic ARF. NIV was followed by ETI in 40% of cases. The incidence of both nosocomial pneumonia (10% versus 19%, p = 0.03), and mortality (22% versus 41%, p < 0.001) was lower in NIV patients than in those with ETI. After adjusting for differences at baseline, Simplified Acute Physiology Score (SAPS) II (odds ratio [OR] = 1.05 per point; confidence interval [CI]: 1.04 to 1.06), McCabe/Jackson score (OR = 2.18; CI: 1.57 to 3.03), and hypoxemic ARF (OR = 2.30; CI: 1.33 to 4.01) were identified as risk factors explaining mortality; success of NIV was associated with a lower risk of pneumonia (OR = 0.06; CI: 0.01 to 0.45) and of death (OR = 0.16; CI: 0.05 to 0.54). In NIV patients, SAPS II and a poor clinical tolerance predicted secondary ETI. Failure of NIV was associated with a longer length of stay. In conclusion, NIV can be successful in selected patients, and is associated with a lower risk of pneumonia and death than is ETI.

[Obstructive syndrome caused by trichobezoars: historical disease or disease still current? Description of a case in adolescence]

Trichobezoars are masses of entangled material, found in the stomach and intestines, composed of hair ingested by the patient. When the mass grows, symptoms of intestinal occlusion can appear. Trichobezoars in pediatrics are usually found in adolescent females presenting personality disorders and trichophagia. This work describes a case of trichobezoar diagnosed in a 13 year-old girl, wearing a brace for serious scoliosis but absolutely normal from the emotional and psychical point of view, with normal scholastic and familiar situation. Already hospitalized three months before for pneumonia from mycoplasma, the girl comes to our observation for the appearance of vomiting and constipation. The clinical examination reveal an epigastric mass as big as an orange. General conditions and hematochemical tests are good. Lab tests are performed (abdomen echography and upper abdomen MNR) but is the oesophago-gastroscopy which allows the diagnosis. A big trichobezoar is then surgically removed and the gastroenteric symptoms completely disappear.

Slow compartment features and gas exchange impairment in mild asthma: effects of beta agonist inhalation

Static and dynamic lung volumes, arterial blood gases, alveolar ventilation and ventilation-perfusion (VA/Q) relationships were studied in 14 mild asthmatic patients and in 7 normal subjects (as controls) before and after fenoterol inhalation. Multiple nitrogen washout curves were analyzed by a bicompartmental distribution model, in order to assess the distribution of ventilation and VA/Q mismatch. At baseline, asthmatics showed mild airway obstruction and gas exchange impairment [forced expiratory volume in 1 s (FEV1) = 79% pred; PaO2 = 87.4; alveolar-arterial oxygen tension gradient (AaPO2) = 22.9 mm Hg]. By analysing nitrogen washout curves, an alveolar slow space representing 45.1% of total lung volume (vs. 36.8% in normals; p = 0.044) was identified; its alveolar ventilation per minute per unit lung volume (VA2/L2) was lower than in normals (p = 0.01). beta-Agonist inhalation by the asthmatics, which reversed airway obstruction (FEV1 = 98% pred.; p < 0.001) and improved gas exchange (PaO2 = 92.6 mm Hg, p < 0.001; AaPO2 = 16.8 mm Hg, p = 0.003), led to a highly significant increase in VA2/L2 (p = 0.001). The improvement in PaO2 was associated with the increase in VA2/L2 (r2 = 0.39; p = 0.017), but not with the increase in FEV1. Lastly, the changes in FEV1 and VA2/L2 were not correlated with each other. We conclude that even in mild stable asthma there is substantial unevenness of ventilation, detectable by bicompartmental analysis of nitrogen washout curves, which is responsible for gas exchange impairment and is not related to common spirometric parameters. In addition, the improvement in gas exchange is probably due to the effect of fenoterol on the tributary airways of the alveolar slow compartment. This effect can be assessed by this simple method, which can be used in clinical pharmacology studies and in the follow-up of asthmatic patients.

Effect of a water-soluble fiber (galactomannans)-enriched formula on gastric emptying time of regurgitating infants evaluated using an ultrasound technique

BACKGROUND

Milk formulas enriched with water-soluble fibers are a first-line measure for infants with gastroesophageal reflux. However, it has been reported that these compounds could affect gastric emptying. The aim of this study was to evaluate the effects of these thickeners on gastric emptying time in infants with frequent regurgitation or vomiting.

METHODS

Forty-seven infants, aged 1 to 12 months, with uncomplicated gastroesophageal reflux underwent two ultrasound evaluations of gastric emptying time after receiving either a standard formula or a formula enriched with 0.4 g galactomannan per 100 ml diluted milk. Gastric emptying time was calculated by measuring the antrum area at baseline and at defined intervals over the next 3 hours.

RESULTS

The gastric emptying time (mean +/- SD) for the standard and the thickened formula was 136 +/- 33 and 133 +/- 34 minutes, respectively. There was no significant difference in the gastric emptying patterns of the two formulas. Gastric emptying time was longer after the standard formula in 15 of the 47 subjects, shorter in 15 of the 47, and the same in 17 of the 47.

CONCLUSIONS

The ingestion of a water-soluble fiber-enriched formula does not have any significant influence on the gastric emptying time of infants with frequent regurgitation or vomiting.

[Ovarian cysts diagnosed in utero: Report of 2 clinical cases]

Two cases of ovarian cyst detected antenatally with complications are described. The Authors enphatize the utility of graphic serial investigation for their management.

Noninvasive ventilation with helium-oxygen in acute exacerbations of chronic obstructive pulmonary disease

The use of helium-oxygen (HeO(2)) was tested in combination with noninvasive ventilation (NIV) in 10 patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Effort to breathe as assessed by the respiratory muscle pressure-time index (PTI), work of breathing (WOB), and gas exchange were the main endpoints. Results of NIV-HeO(2) were compared with those obtained with standard NIV (AirO(2)), at two levels of pressure-support ventilation (PSV), 9 +/- 2 cm H(2)O and 18 +/- 3 cm H(2)O. Significant reductions in PTI were observed between HeO(2) and AirO(2) at both the low PSV level (n = 9; 160 +/- 58 versus 198 +/- 78 cm H(2)O/s/ min; p < 0.05) and the high PSV level (n = 10; 100 +/- 45 versus 150 +/- 82 cm H(2)O/s/min; p < 0.01). WOB also differed significantly between HeO(2) and AirO(2) (7.8 +/- 4.1 versus 10.9 +/- 6.1 J/min at the low PSV level, p < 0.05; and 5.7 +/- 3.3 versus 9.2 +/- 5. J/min, p < 0.01 at the high PSV level). HeO(2) reduced Pa(CO(2)) at both the low PSV level (61 +/- 13 versus 64 +/- 15 mm Hg; p < 0.05) and the high PSV level (56 +/- 13 versus 58 +/- 14 mm Hg; p < 0.05), without significantly changing breathing pattern or oxygenation. We conclude that use of HeO(2) during NIV markedly enhances the ability of NIV to reduce patient effort and to improve gas exchange.

Oligosaccharides in human milk during different phases of lactation

Twenty-one oligosaccharides of human milk were quantified by high-performance anion-exchange chromatography. Milk samples were collected from 18 mothers during the first 3 mo of lactation. The data show that the highest amount of all oligosaccharides is present at day 4 postpartum (20 g l(-1)) and then decreases by about 20% at day 30 of lactation. The protective role played by these substances against different infectious agents, in different organs and systems of the breastfed baby, is emphasized.