Peak oxygen consumption is associated with the inotropic reserve in patients with heart failure with reduced ejection fraction undergoing cardiopulmonary testing

Background

The role of cardiopulmonary exercise testing (CPET) in the prognostic evaluation of heart failure with reduced ejection fraction (HFrEF) is powerful and well-established. Nevertheless, the value of CPET in predicting left ventricular inotropic reserve in HFrEF remains unknown.

Purpose

The investigation of possible associations between CPET variables and left ventricular contractile reserve in patients with HFrEF.

Methods

Consecutive patients aged ≥18 years old with a diagnosis of heart failure and a left ventricular ejection fraction ≤40%, as assessed by echocardiography, were prospectively enrolled. Demographic and clinical data were recorded. All subject underwent CPET with either a Bruce or a modified Bruce protocol. Peak oxygen consumption (VO2), carbondioxide production (VCO2), minute ventilation to carbon dioxide production (VE/VCO2) slope, minute ventilation (VE), and VO2/heart rate (HR) values were calculated, while hemodynamic parameters during the test were also measured.

Results

In total, 191 patients with HFrEF were included in the analysis. The mean age was 58.8±11.8 years and 30 (15.7%) patients were women. Ischemic heart disease was the etiology of HFrEF in 101 (52.9%) patients, whereas 90 (47.1%) patients had a history of dilated cardiomyopathy. The mean exercise time was 7.6±.3 minutes. Mean peak VO2 and VE/VCO2 slope values were calculated at 19.1±6.1 ml kg–1 min–1 and 43.7±10.1, respectively. According to peak VO2 values, 70 patients (37.2%) were in Weber class A, 57 (29.8%) in class B, 48 (25.1%) in class C and 15 (7.9%) in class D. In univariate analysis, the change between rest and peak systolic blood pressure (ΔSBP), which is considered to reflect the left ventricular inotropic reserve, was positively correlated to the peak VO2 (p<0.001), the total pulmonary ventilation (VE) (p<0.001) and the peak heart rate during exercise (p=0.02). In multivariable analysis, peak VO2 was independently, linearly associated with the ΔSBP during CPET (Figure 1) (β=0.661, p=0.022). In Roc analysis, it was found that a cut-off value for peak VO2 of 16 ml kg–1 min–1 exhibits 64% sensitivity and 60% specificity in predicting a ΔSBP>40mmHg during exercise (area under the curve: 0.657, p<0.001 – Figure 2).

Conclusion

The peak oxygen consumption during cardiopulmonary testing represents an acceptable predictor of inotropic reserve in patients with HFrEF.

Funding Acknowledgement

Type of funding sources: None.

Optimization of biventricular cardiac resynchronization improves cardiac power and atrial kinetics in patients with systolic heart failure with often hospitalizations for decompensation

 

Cardiac resynchronization therapy (CRT) reduces symptoms and improves left ventricular function in patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. In this work the biochemical, clinical and echocardiographic outcome of optimizing CRT (optCRT) function by the optimal VTI value of left ventricular outflow track.

Methods

80 NYHA III patients (68±10 years; 75% men; 53% ischemic cardiomyopathy-ICM), under optimal tolerated medical therapy, with standard BVP indication, having been implanted with a CRT system. Echocardiographic measurements, including aortoventricular coupling (VAC) calculation, 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months on optCRT. Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451.

Results

End-systolic volume of left ventricle was reduced (p=0.001) in both ischemic and non-ICM; while max left atrial volume was reduced only in non-ICM patients (72.1±32 to 65.8±30, p=0.04). Global longitudinal strain was improved in non ICM patients (p=0.015). Systolic strain of right ventricle was improved in non-ICM (9.4±2.2 to 10.7±2.3 vs. 8.7±3 to 8.9±3.2, p=0.03 for non-ICM); while left atrial function and the ratio E to E TDI of mitral annulus were not improved in either group. Non-ICM patients improved VAC (baseline: 1,36±0,3; CRT: 1.11±0.2; p=0.01) and CP (baseline 660±160 to 782±260, p=0.001); while no significant improvement was detected to ICM patients. 6-min-walk test was improved up to 30% (p=0.05). NtproBNP levels were decreased only in non-ICM patients (1759±1060.9 to 1015±650 vs. 2063,8±1800 to 1950.7±2342, p=0.001). MLHFQ improved in non-ICM patients (p=0.015); while non-significant improvement was detected in ICM patients.

Conclusion

Optimization of cardiac resynchronization therapy based on stroke volume maximization benefits quality of life and exercise tolerance, mainly in non-ICM. GLPS and aorto-ventricular coupling was improved in non-ischemic patients, reflecting the better adaptation of CRT in this population. Thus, CRT optimization by echocardiographic evaluation may be useful in improve clinical status and quality of life in CRT non-responder patients.

Funding Acknowledgement

Type of funding sources: None.

Multipoint left ventricular pacing effects on hemodynamic parameters and functional status: HUMVEE single-arm clinical trial

Objectives

The aim of this study was to assess the capacity of optimized multipoint pacing (MPP) over optimized cardiac resynchronization therapy (CRT), in terms of clinical, functional, and echocardiographic parameters among dyssynchronous heart failure patients.

Methods

Eighty patients (Caucasian, 77.5% male, 68.4±10.1 years, 53.8% ischemic cardiomyopathy) sequentially received optimized CRT and optimized MPP over 6 and 12-month periods, in a single-arm clinical trial. Clinical, laboratory and echocardiographic assessment was conducted at baseline and following completion of each step.

Results

Significant additive effects of optimized MPP over optimized CRT were noted regarding 6-minute walking distance (baseline/optCRT/optMPP: 293±120m vs 367±94m vs 405±129m, p<0.001), NYHA class (2.36 vs 2.19 vs 1.45, p<0.001), VTIlvot (14.25±3.2cm vs 16.2±4cm vs 17.5±3.4cm, p<0.001), stroke volume (48±13.5ml vs 55±15ml vs 59±15ml, p<0.001), LVEF (29%±7.1% vs 33%±7.3% vs 37%±7.7%, p<0.001), maximal left atrial volume (77.2±34.2ml vs 74.2±39.5ml vs 67.7±32ml, p=0.02), pulmonary artery systolic pressure (35.9mmHg vs 33.5mmHg vs 31mmHg, p<0.001), and right ventricular strain (−8.3%±6.9% vs −8.8%±6.6% vs −11.8%±6.1%, p=0.022). Regarding VAC SW and CP as percentages of maximal, there was significant difference detected compared to baseline for both CRT and MPP. Additive effects persisted only if suitable MPP dipoles were present. Exploratory analysis revealed that ischemic cardiomyopathy continued to exhibit significant differences favoring MPP, whereas nonischemic cardiomyopathy had similar findings regarding total left atrial strain and quality of life.

Conclusions

Optimized MPP showed significant improvements on hemodynamic parameters and ventricular function, in heart failure patients over optimized CRT. The beneficial effect was more prominent in men and in those with rather reduced LVEF, consistent with findings suggesting a beneficial trend in VAC and CP with the more homogenous depolarization offered by optimized MPP

Funding Acknowledgement

Type of funding sources: None.

Melt-quenched and as-deposited structures of amorphous selenium: a density functional/ molecular dynamics comparison

Molecular dynamics simulations using a density functional description of energies and forces have been carried out for a model of an as-deposited (AD) surface of amorphous selenium. The deposition model assumed the annealing (at 400 K) of layers of randomly located single atoms, followed by compression to the density used in earlier melt-quenched (MQ) simulations of amorphous Se, and by further annealing. The AD and MQ structures are predominantly twofold coordinated and similar, for example in the pair distribution functions, with notable differences: the AD structures have more defects (atoms with one and three neighbours), and the ring distributions differ. These differences are also reflected in the electronic structures of the AD and MQ samples, where the increased presence of defects in the former influences the Bader charges and the edge states of the band gap. The dominance of rings found in a previous simulation of AD structures is not found.

Optimization in cardiac resynchronization therapy with quadripolar leads offer improvement in cardiac energetics in heart failure patients compared with bipolar leads: HUMVEE Clinical Trial

Background

Cardiac resynchronization therapy (CRT) is a well-established technique for symptomatic heart failure (HF) patients, producing significant clinical benefits. Recent studies have revealed the potential role of multipoint pacing (MPP) in improving response and clinical outcomes. The aim of this work from the Heart failUre study of Multisite pacing effects on VEntriculoartErial coupling (HUMVEE) trial was to evaluate the association between MPP of the left ventricle vs those of optimized biventricular pacing (optBVP) on: a) ventriculoarterial coupling (VAC) and energy efficiency of the failing heart. Both BVP and MPP mode were optimized according to the optimal VTI value of left ventricular outflow track.

Methods

HUMVEE is a single-center, prospective (13 months) trial (clinicaltrials.gov identifier NCT03189368), of 80 NYHA III patients (68±10 years; 75% men; 53% ischemic cardiomyopathy), under optimal tolerated therapy, with standard BVP indication, having being implanted with a CRT system able to deliver both modes of pacing. Echocardiographic measurements, including VAC calculation, 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months post BVP optimization (right before MPP activation) and at the end of follow-up (6 months post MPP optimization). Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451.

Results

23 patients (30%), due to inability to deliver MPP, remained in optBVP. Those in MPP had 45% ischemic cardiomyopathy vs. 65% in optBVP patients, (p=0.056); ejection fraction 26.5%, vs. 29.5%, p=0.05; while there was no significant difference in gender, age and baseline NYHA class. Both optBVP and MPP patients improved VAC (baseline: 1,26±0,3; CRT: 1.18±0.4; MPP: 1.07±0.06, p=0.07); but only MPP patients significant improved from baseline to 12-months (p=0.02); CP was improved in both groups (p=0.02 in optBVD and p=0.01 in MPP), with MPP patients showing improvement in CP by 30% vs 12% in optBVP (p=0.001); 6-min-walk test was improved in MPP patients by 42% from baseline (p=0.0001), compared to optBVP patients who showed improvement up to 30% (p=0.05) and during the first 6 months only. NtproBNP levels were decreased in all patients (p=0.05 for MPP and p=0.07 for optBVP). Only patients who achieved MPP showed improvement in the Quality of life score (baseline: 31.6±23; optBVD:20.1±17; MPP:15.8±12, p=0.002; while those remained in optBVP showed no significant improvement.

Conclusions

MPP is a new, promising biventricular pacing modality offering additive effects on myocardial energy balance, cardiac power, systolic and diastolic ventricular function and aortoventricular coupling. HUMVEE trial illustrates those clinical, imaging and biochemical divergences of MPP from even opt BVP that confer significant improvement in quality of life reflecting better myocardial energy handling in patients with advanced HF and cardiac dysychronization.

Funding Acknowledgement

Type of funding source: None

P4534The Mediterranean diet benefit in chronic heart failure by decoding central and peripheral vessel rheology, atheroma formation and serum prolactin levels

Background

Central hemodynamics and especially wave reflection amplification exhibit a vital parameter of chronic heart failure (CHF) physiology. Erectile dysfunction (ED) displays a poor peripheral vessel rheology and serum prolactin role is still debated in CHF mechanisms. The Mediterranean diet (Med-diet) is famous for its vasoprotective and wellbeing properties.

Purpose

To investigate the effect of the Med-diet in central hemodynamics, erectile status, atheroma formation and serum prolactin levels in male patients with chronic heart failure.

Methods

123 CHF male patients under optimal medical therapy enrolled the study (mean age: 65±8 yo, NYHA class II, ejection fraction <40%). All underwent evaluation of the carotid – femoral pulse wave velocity (PWV), estimation of central pressures and augmentation index (AIx) as parameter of wave reflection amplification (sphygmocor device). Ejection fraction (EF) of the left ventricle was estimated by using 2D echocardiography (Simpson method). ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values point to better erectile function and a great Med-diet compliance respectively. Detection of atheroma was based on the intima- media thickness (IMT) of the common carotid artery. Prolactin levels were assessed in morning blood samples taken before 09:00 am.

Results

The SHIM −5 score (mean: 12±4) was associated to the AIx (p=0,03, r=0,75) and both positively and strongly related to the Med-diet score (p=0,01, r=0,8 and p=0,01, r=0,75 respectively). Med-diet compliance was negatively associated to IMT (p=0,02, r=−0,8) and serum prolactin levels (p=0,03, r=−0,6).Moreover, we notice a positive association between prolactin and the IMT (p=0,04, r=0,7). By multiple linear regression analysis the relation of SHIM-5 and Med-diet score remained significant (p=0,04) after adjustment for BMI, central pulse and mean arterial pressures. We further subdivide our population according to the mean Med-diet value (28) into high and low Med-diet adherence groups. Only in the group with the greater Med-diet adherence (n=73, 60%) AIx was strongly associated to the SHIM-5 score (p=0,02) even after adjustment for PWV, age and BMI. Prolactin levels there were still related to IMT (p=0,04) after adjustment for PWV, AIx, BMI and central pulse pressure. All statistics remained significant when adjusting for ejection fraction of the left ventricle.

Conclusion

High adherence to the Med-diet benefits CHF hemodynamics by enforcing wave reflection amplification, thus generating a stronger pulse signal to peripheral vasculature. Moreover suppresses serum prolactin levels that relates to atheroma formation. Both actions enhance erectile performance independently of the EF of the left ventricle. It is important to advise CHF patients to adopt this dietary pattern in order to improve hemodynamic status and the sense of wellbeing.

P4529Atrioventricular optimization in cardiac resynchronization therapy with quadripolarleads, improves energy handling and quality of life in heart failure patients: HUMVEE Trial

Background

Cardiac resynchronization therapy (CRT) is a well-established technique for symptomatic heart failure (HF) patients, producing significant clinical benefits. Recent studies have revealed the potential role of multipoint pacing (MPP) in improving response and clinical outcomes. The aim of Heart failUre study of Multisite pacing effects on VEntriculoartErial coupling (HUMVEE) trial was to evaluate the association between MPP of the left ventricle vs those of standard biventricular pacing (BVP) on: a) ventriculoarterial coupling (VAC) and energy efficiency of the failing heart, b) diastolic function, c) quality of life, and d) NT-proBNP levels.

Methods

HUMVEE is a single-center, prospective (13 months) trial (clinicaltrials.gov identifier NCT03189368), of 54 NYHA III patients (69±9 years; 79% men; 50% dilated cardiomyopathy), under optimal tolerated medical therapy, with standard BVP indication, having being implanted with a CRT system able to deliver both modes of pacing. Creatinine and NT-proBNP levels and echocardiographic measurements (VAC calculation, strain rate, diastolic function assessment), as well as 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months post BVP optimization (right before MPP activation) and at the end of follow-up (6 months post MPP optimization). Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451.

Results

Both CRT and MPP improved 6-min-walk (differences at baseline/6 mo/end of FU: 277±27 vs. 345±27 vs 363±27 m, p=0.07); left ventricular ejection fraction (24,2% vs 30,6%vs, 32%, p=0.05); end -diastolic diameters of left ventricle (65±1,4 vs. 63±1.7 vs. 61±1.1, p=0.03); end-systolic volume (150±15 vs. 140±10 vs. 131±13, p=0.08); stroke volume (41.6±9 vs. 53.6±14 vs. 62±9, p=0.0001 for MPP); left atrial volume (76±5 vs. 74±10 vs 61±6, p=0.001 for MPP), E/Emv (14±5 vs. 12±4 vs. 11±3, p=0.05 for MPP); NtproBNP (2782±1000 vs. 2080±2500 vs. 2000±1000, p=0.05 for MPP). VAC was reduced from 1.14±0.27 to 1.1±0.17 (p=0.1) while CP increased from 564.2±142 to 768±103 (p=0.009). Quality of life score (the lower the better) improved from 23.75±17 at baseline to 17.25±10 at end of FU (p=0.05).

Conclusions

MPP is a new, promising pacing modality with the potential to improve HF patients' outcome, offering additive effects on myocardial energy balance, cardiac power, systolic and diastolic ventricular function and aortoventricular coupling, especially in ischemic patients. HUMVEE trial illustrates those clinical, imaging and biochemical divergences of MPP from standard BVP that reflect significant improvement in quality of life in patients with advanced HF and cardiac dysychronization.

P6221Salt consumption as a predictor of cardiovascular events among hypertensive patients: a 5-year follow-up study

Background/Introduction

Salt intake is linked to hypertension but data on its association with incident cardiovascular events, especially among hypertensives, is limited.

Purpose

To examine the prospective association of different salt consumption levels with cardiovascular morbidity in a hypertensive population.

Methods

We followed 2130 hypertensive patients (age 57±12 years, 11.2% untreated) without a history of cardiovascular disease for a mean period of 5.3±3.3 years. At the baseline examination, salt intake was evaluated by a structured validated questionnaire. Accordingly, the study population was divided into three groups: hypertensives with a low (1079 patients, 51% of the population), a moderate (895 patients, 42%) and a high salt consumption (146 patients, 7%). During follow-up, patients underwent clinic visits at least yearly for management of hypertension and risk factors. The outcome studied was the composite of non-fatal cardiovascular events.

Results

The composite endpoint (19 strokes and 65 cases of coronary artery disease) occurred in 84 patients (3.9%). At baseline, increasing salt consumption was significantly associated with age, body mass index, office blood pressure and renal function. Unadjusted Cox regression analysis showed that, compared to the reference group, the risk for cardiovascular morbidity was similar in patients with moderate salt consumption (HR: 1.1, 95% CI: 0.71–1.77) but significantly higher in patients with high salt consumption (HR: 2.12, 95% CI: 1.09–4.38). This pattern was clearly sustained after adjusting for multiple risk factors including baseline blood pressure levels.

Conclusions

Among hypertensive patients, heavy salt consumption is associated with an increased cardiovascular risk, while moderate consumption does not affect patient outcome.

P5468Systolic versus diastolic blood pressure as predictors of cardiovascular events among treated hypertensive patients: a 6-year prospective study

Background/Introduction

There has been a long debate regarding the association of systolic versus diastolic blood pressure with cardiovascular outcome and data regarding hypertensive patients under treatment have been conflicting.

Purpose

To investigate the association of different patterns of uncontrolled blood pressure (BP) among treated hypertensive patients.

Methods

We prospectively studied 1507 treated hypertensive patients (age 59±11 years) that are followed in the setting of a single-center, clinic-based registry. During follow-up, patients underwent regular visits for hypertension and risk factor management. Based on the cut-off limits for uncontrolled hypertension of office systolic BP≥140mmHg and diastolic BP≥90mmHg, study participants were divided into four groups: those with controlled hypertension (796 patients, 53% of the population), uncontrolled systolic BP (257 patients, 17%), uncontrolled diastolic BP (135 patients, 9%) and uncontrolled systolic and diastolic BP (319 patients, 21%). The outcome studied was the composite of cardiovascular morbidity set as coronary artery disease and stroke, and the controlled hypertension group served as reference.

Results

The median follow-up period was 6.4±3.0 years and the composite endpoint (13 strokes and 41 cases of coronary artery disease) occurred in 54 patients (3.6%). Unadjusted Cox regression analysis showed that, compared to the reference group of controlled hypertensives, the risk for cardiovascular morbidity was similar in patients with uncontrolled diastolic BP (HR: 0.88, 95% CI: 0.26–2.97) but significantly higher in patients with uncontrolled systolic BP (HR: 2.17, 95% CI: 1.08–4.36), while patients with both uncontrolled systolic and diastolic BP showed the worse prognosis (HR: 2.35, 95% CI: 1.24–4.43). This pattern of risk was overall sustained after adjusting for different sets of confounders.

Conclusions

Among treated hypertensive patients, uncontrolled systolic BP is associated with a greater risk for cardiovascular events compared to uncontrolled diastolic BP while uncontrolled systolodiastolic hypertension presents with the worse prognosis.

Ab initio computer simulations of non-equilibrium radiation-induced cascades in amorphous Ge2Sb2Te5

Ion irradiation corresponds to a process that involves the production of non-equilibrium cascades in the host material, and the atomistic modelling of such events in glasses is challenging. Here, non-equilibrium cascades in amorphous Ge₂Sb₂Te₅ phase-change memory material have been investigated by means of first-principles molecular-dynamics simulations. A stochastic boundary-conditions approach is employed to treat the thermal nature of the cascades and drive the modelled system back to equilibrium in a natural way, while four different initial thermal-spike energies are considered. A comprehensive analysis of the cascade evolution is presented with respect to the kinetic profile and the dynamics of the cascade inside the glass structure. The modelling results show that the instantaneous maximum kinetic energy decays rapidly with time, and that the time-scale of the ballistic phase of the cascade inside the glass model is very short. The quality of the implemented approach is validated through a comparison of the calculated structure factor for the modelled glasses with experimental data from the literature. Analysis of the bonding for all the species in the glass structure highlights particular structural modifications in the connectivity of the amorphous network due to the simulated cascade.

Patterns of drug resistance among patients with tuberculous pleural effusion in Greece

SETTING

Data on the relationship between pleural tuberculosis (TB) and anti-tuberculosis drug resistance are scarce.

OBJECTIVE

To determine the patterns of drug resistance among pleural Mycobacterium tuberculosis isolates in Greece and the incidence of tuberculous pleural effusion (TPE) among patients with multidrug-resistant (MDR) or extensively drug-resistant (XDR) pulmonary TB.

DESIGN

Drug susceptibility testing (DST) results recorded in the database of the National Reference Centre for Tuberculosis in Athens, Greece, over a 9-year period (2003-2011) were reviewed. Chest X-rays from hospitalised patients with pulmonary MDR/XDR-TB during the same period were also reviewed for the presence of TPE.

RESULTS

Resistance to at least one first-line drug was observed in 11% of the cases (MDR-TB 3%, XDR-TB 1%), while 29% of the patients with pulmonary MDR/XDR-TB presented with TPE during the course of their disease, the majority ipsilateral to the lung lesions, which responded to guided anti-tuberculosis treatment.

CONCLUSION

The prevalence of drug resistance among pleural M. tuberculosis isolates in Greece highlights the importance of DST prior to treatment selection in TPE patients. In our study population, TPE that developed in one third of the patients with pulmonary MDR/XDR-TB usually resolved with DST-guided anti-tuberculosis treatment.

Early detection of subclinical HIV sensory polyneuropathy using intraepidermal nerve fibre density quantification: association with HIV stage and surrogate markers

The linear intraepidermal nerve fibre density (IENFD) and secondary branching were evaluated from skin biopsy of both the distal calf and the proximal thigh after staining with protein gene product 9.5 in 94 individuals of an HIV outpatient cohort. Possible correlations with clinical and electrophysiological evidence of distal sensory polyneuropathy (DSP), patients' demographics, antiretroviral history and HIV surrogate markers were analysed. Reduced IENFD was recognized in the majority of this population (mean ± standard deviation [SD] IENFD in the calf and the thigh was 3.19 ± 1.91 and 7.07 ± 3.5 fibres/mm, respectively). One-third of the patients with low IENFD had no clinical or electrophysiological evidence of DSP. The level of prior immunosuppression as expressed by lower nadir CD4 count, more advanced HIV stage and prior exposure to combinations of neurotoxic antiretrovirals was associated with more decreased IENFD. Increased SB was associated with symptomatic DSP.

The Bcl-2/Bax system and apoptosis in ulcerative colitis

BACKGROUND/AIMS

Ulcerative colitis (UC) constitutes a chronic inflammatory process of the colon of unknown etiology. Current data support a pivotal role of apoptosis in the evolution of pathogenesis of UC. We performed a prospective study in order to determine the role of Bcl-2, Bax and Bcl-x in the apoptotic pathway in UC.

METHODOLOGY

We included 23 patients with UC and 11 controls. Histological severity of the disease was assessed according to the Sidney classification system. Patients in the UC group were divided in 2 groups according to histological severity of the disease. The TUNEL method was used for the in situ evaluation of apoptosis. Immunohistochemical staining was used for the detection of Bax, Bcl-2, Bcl-x. For the assessment of cellular proliferation we used the monoclonal antibody Ki67. Appropriate statistical methods were applied.

RESULTS

Overall 77 specimens were assessed; 57 from UC patients and 20 from controls. Bcl-2, Bax and Bcl-x were upregulated in the group of patients with UC compared to controls. Nevertheless, Bax in epithelial cells and Bcl-x in lymphocytes were downregulated in patients with moderate/severe disease (p = 0.029 and 0.04 respectively). A weak correlation between epithelial apoptosis and Bcl-x expression in lymphocytes (r = 0.31, p = 0.02) was found. An even weaker correlation was also noticed between the epithelial component apoptosis and Bax in lymphocytes (r = 0.02, p = 0.07).

CONCLUSIONS

Bcl-2/Bax system does not appear to be involved in the induction of apoptosis in UC. Activation of intraepithelial lymphocytes may be associated with epithelial apoptosis or simply represent epiphenomena related to the inflammatory process.

Distal sensory polyneuropathy in HIV-positive patients in the HAART era: an entity underestimated by clinical examination

The aim of this study was to determine the prevalence of distal sensory polyneuropathy (DSP) in our HIV-positive patients under highly active antiretroviral therapy (HAART) and to investigate correlations with clinical, laboratory and demographic factors. One hundred consecutive HIV-positive patients underwent clinical and electrophysiological evaluation for DSP. Correlations with HIV stage, CD4 count, nadir CD4 count, viral load (VL), disease duration, age, sex and type of antiretrovirals were examined. Thirty-six percent of the patients had DSP (13% clinical, 23% subclinical diagnosed by electrophysiology). The prevalence of DSP was affected in a statistically significant manner by the diagnosis of AIDS (P = 0.00033), age (P = 0.0102), nadir CD4 count (P = 0.0087) and exposure to two neurotoxic antiretrovirals (P = 0.0189). Advanced HIV stage, sex, time from diagnosis, current CD4 count and VL did not seem to affect the prevalence of DSP. Clinical examination plus electrophysiology reveals that DSP affects 36% of patients under HAART, although subclinical in 2/3 of cases. Age, severe prior immunosuppression and the combined use of zalcitabine (ddC), stavudine (d4T) and didanosine (ddI) are important risk factors.

Virtual bronchoscopy versus thin section computed tomography in evaluation of moderate and low grade stenoses: receiver operating characteristic curve analysis

PURPOSE

To evaluate the impact of virtual bronchoscopy, under proper threshold settings, on observer level of confidence in the assessment of bronchial abnormalities producing stenoses < or = 75% compared to interpretation of thin section computed tomography (CT) images.

MATERIAL AND METHODS

Sixty-five patients with fiberoptic bronchoscopy positive for tracheobronchial abnormalities were evaluated in a blinded observer study using a commercially available virtual endoscopy software package. The findings of virtual endoscopy were compared with those of fiberoptic bronchoscopy using receiver operating characteristic curves (ROCs) and other statistical tools.

RESULTS

A total of 102 lesions were identified by fiberoptic bronchoscopy, with 44 of these producing bronchial stenoses < or = 75%. Concerning the latter lesions, for virtual bronchoscopy the areas under the ROCs were 0.93 and 0.96 for the two observers, respectively, while for thin section CT the corresponding values were 0.86 and 0.88; the differences observed were statistically significant. Contrary to thin section CT, virtual bronchoscopy did not show statistically significant differences from fiberoptic bronchoscopy regarding estimation of degree of stenosis.

CONCLUSION

Virtual bronchoscopy under proper threshold settings has a statistically significant impact on observer performance where moderate and low-grade bronchial stenoses are concerned and gives an estimate of the degree of stenosis more precisely than thin section CT.

Cefepime versus ceftazidime for treatment of pneumonia

Consecutive patients with pneumonia, treated with cefepime (n = 66) or ceftazidime (n = 132), were evaluated in a retrospective, observational study. There was no significant difference between the two treatment groups with respect to age, underlying diseases, acute physical and chronic health evaluation score, intensive care unit admission, presence of sepsis, community or hospital acquisition, causative organism, duration of therapy, death, cure or improvement in infection, adverse events, superinfections, presence of vancomycin-resistant enterococcus (VRE) and resistance to therapy. Post-therapy hospitalization (days) and vancomycin co-administration were significantly lower, and time to vancomycin initiation significantly higher, in the cefepime compared with the ceftazidime group. The results suggest a trend towards less resistance on therapy, less VRE, reduced vancomycin use and shorter post-therapy hospitalization in patients treated with cefepime compared with ceftazidime. The clinical outcomes for hospitalized patients treated for serious pneumonia were similar between the two groups.

The use and reported effects of mobilization with movement techniques in low back pain management; a cross-sectional descriptive survey of physiotherapists in Britain

Manual therapy is the most commonly used approach in the management of low back pain (LBP) and encompasses a wide range of techniques. The aims of this study were to investigate the current use of mobilizations with movement (MWM) for LBP management in Britain and to inform future clinical research exploring their effects.A postal survey of a random sample of 3295 practising physiotherapists in Britain was conducted. A response rate of 72.1% (n=2357) was obtained. Of these, 48.2% (n=1136) reported treating LBP, of whom 41.1% (n=467) reported using MWMs in LBP management. Therefore, the sample applicable for analysis consisted of these 467 therapists currently treating LBP and using MWMs. Most respondents (51.4%) worked in a national health service setting. Over half of the respondents used MWMs on at least a weekly basis, with 61.9% using MWMs primarily for mechanical LBP. The most commonly reported changes seen immediately after the application of MWMs were increases in range of movement (ROM) (54.4%) and pain relief (27.5%). This was also reflected in the outcomes chosen to evaluate improvement. On average, two spinal levels were mobilized using 2-3 sets of 4-5 repetitions. The lower lumbar levels were treated more often. Most therapists indicated using a combination of other treatment approaches together with MWMs when treating LBP patients. In conclusion, this study is the first to describe the current practice of MWMs by physiotherapists in Britain, and the results will be used to inform the design of a clinical trial exploring the effects of MWMs for LBP.