Quality of life improvement with allergen immunotherapy treatment in patients with rhinoconjunctivitis in real life conditions. Results of an observational prospective study (ÍCARA)

Summary

Objectives. Evaluate the changes in quality of life of patients with allergic rhinoconjunctivitis (AR), with or without asthma, after one-year treatment with allergen immunotherapy. Methods. This was an observational prospective multicenter study. RQLQ questionnaire and VAS scale to assess treatment satisfaction were used. Impact on AR and asthma was also analyzed. Any adverse reaction was recorded. Results. 127 patients were recruited. Mean values in RQLQ decreased from 2.61 to 1.34 points, reflecting a statistically and clinically significant improvement (p minor 0.01). The percentage of asthmatic patients decreased significantly (p minor 0.01). Mean value of patients' satisfaction was 7.24 (SD = 1.90). Only 11 patients presented systemic reactions (9.17%), none of them serious. Conclusions. One-year AIT treatment significantly increases QoL in patients with AR. Moreover, high patients' satisfaction values were reported, together with an adequate safety profile.

Atmospheric carbon tetrachloride in rural background and industry surrounded urban areas in Northern Iberian Peninsula: Mixing ratios, trends, and potential sources

Latest investigations on atmospheric carbon tetrachloride (CTC) are focused on its ozone depleting potential, adverse effects on the human health, and radiative efficiency and Global Warming Potential as a greenhouse gas. CTC mixing ratios have been thoroughly studied since its restriction under the Montreal Protocol, mostly in remote areas with the aim of reporting long-term trends after its banning. The observed decrease of the CTC background mixing ratio, however, was not as strong as expected. In order to explain this behavior CTC lifetime should be adjusted by estimating the relative significance of its sinks and by identifying ongoing potential sources. Looking for possible sources, CTC was measured with high-time resolution in two sites in Northern Spain, using auto-GC systems and specifically developed acquisition and processing methodologies. The first site, Bilbao, is an urban area influenced by the surrounding industry, where measurements were performed with GC-MSD for a one-year period (2007-2008). The second site, at Valderejo Natural Park (VNP), is a rural background area where measurements were carried out with GC-FID and covering CTC data a nonsuccessive five-year period (2003-2005, 2010-2011, and 2014-2015years). Median yearly CTC mixing ratios were slightly higher in the urban area (120pptv) than in VNP (80-100pptv). CTC was reported to be well mixed in the atmosphere and no sources were noticed to impact the rural site. The observed long-term trend in VNP was in agreement with the estimated global CTC emissions. In the urban site, apart from industrial and commercial CTC sources, chlorine-bleach products used as cleaning agents were reported as promotors of indoor sources.

Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled trial

Background:

Chronic obstructive pulmonary disease (COPD) generates a high burden on health care, and hospital admissions represent a substantial proportion of the overall costs of the disease. Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level. Deployment strategies for IC services require assessment of effectiveness at the health care system level.

Aims:

The aim of this study was to explore the effectiveness of a community-based IC service in preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients.

Methods:

From April to December 2005, 155 frail community-dwelling COPD patients were randomly allocated either to IC (n=76, age 73 (8) years, forced expiratory volume during the first second, FEV₁ 41(19) % predicted) or usual care (n=84, age 75(9) years, FEV₁ 44 (20) % predicted) and followed up for 12 months. The IC intervention consisted of the following: (a) patient’s empowerment for self-management; (b) an individualised care plan; (c) access to a call centre; and (d) coordination between the levels of care. Thereafter, hospital admissions, ED visits and mortality were monitored for 6 years.

Results:

IC enhanced self-management (P=0.02), reduced anxiety–depression (P=0.001) and improved health-related quality of life (P=0.02). IC reduced both ED visits (P=0.02) and mortality (P=0.03) but not hospital admission. No differences between the two groups were seen after 6 years.

Conclusion:

The intervention improved clinical outcomes including survival and decreased the ED visits, but it did not reduce hospital admissions. The study facilitated the identification of two key requirements for adoption of IC services in the community: appropriate risk stratification of patients, and preparation of the community-based work force.

Platelet-rich plasma in the conservative treatment of painful tendinopathy: a systematic review and meta-analysis of controlled studies

BACKGROUND

Platelet-rich plasma (PRP) seeks to meet the multifaceted demand of degenerated tendons providing several molecules capable of boosting healing.

AREAS TIMELY FOR DEVELOPING RESEARCH

PRP is used for managing tendinopathy, but its efficacy is controversial.

SOURCES OF DATA

Electronic databases were searched for clinical studies assessing PRP efficacy. Methodological quality was evaluated using the methods described in the Cochrane Handbook for systematic reviews.

AREAS OF AGREEMENT

Thirteen prospective controlled studies, comprising 886 patients and diverse tendons were included; 53.8% of studies used identical PRP protocol.

AREAS OF CONTROVERSY

Sources of heterogeneity included different comparators, outcome scores, follow-up periods and diverse injection protocols, but not PRP formulation per se.

GROWING POINTS

Pooling pain outcomes over time and across different tendons showed that L-PRP injections ameliorated pain in the intermediate-long term compared with control interventions, weighted mean difference (95% CI): 3 months, -0.61 (-0.97, -0.25); 1 year, -1.56 (-2.27, -0.83). However, these findings cannot be applied to the management of individual patients given low power and precision.

RESEARCH

Further studies circumventing heterogeneity are needed to reach firm conclusions. Available evidence can help to overcome hurdles to future clinical research and bring forward PRP therapies.

A protocol with adjuvant chemotherapy (CT) and radiotherapy (RT) for endometrial cancer: Results

e16549

Background: The classic adjuvant treatment for high-risk endometrial cancer is RT. Several phase III trials explored the role of CT, as single treatment or added to RT sequentially (ST) or concurrently (CR), but design heterogeneity hampers conclusions. We report the results of a single-institution protocol with adjuvant CT + RT for advanced stages or type II histologies. Key points: (1) ST and CR permitted. (2) CT used pre-, post- and/or during RT: carboplatin AUC 5 + paclitaxel 175 mg/m2 (150 during RT) Q3W, 4-6 cycles (“carbotaxol”). (3) since 2010, cisplatin 50 mg/m2 was used for CR (on day 1 and 28 of RT). CR was preceded/followed by carbotaxol. Methods: All patients (PT) included in the protocol between 1/2005 and 9/2011 were retrospectively revised. Endpoints were survival and toxicity grade 3-4. Kaplan Meier and Fisher test were used. Conclusions: CR-carbotaxol showed a longer progression-free and overall survival than ST without reaching statistical significance (log rank, p= 0.14 and p=0.33). Median survivals with CR-cisplatin were not reached because of shorter follow-up. Statistical differences in toxicities were not found. In the CR-carbotaxol arm, 5 PT had grade 3-4 acute diarrhoea vs none in the others. [Table: see text]

Simultaneous indoor and outdoor on-line hourly monitoring of atmospheric volatile organic compounds in an urban building. The role of inside and outside sources

Indoor air quality (IAQ) has become a very important issue in recent years. As in developed countries people spend more than 90% of their time indoors, besides outdoor pollution assessment, the indoor one is also required. IAQ is not only affected by indoor sources linked to indoor activities, outdoor sources such as road or street traffic and industrial and commercial activities have their role too. Volatile organic compounds (VOCs) frequently show higher indoor mixing ratios with respect to the outdoor ones, and monitoring is required to report their indoor mixing ratios. Many studies have reported average indoor VOCs' mixing ratios in different environments, but their temporal variability has not been well documented. The main objective of this work was to simultaneously measure VOCs' indoor and outdoor mixing ratios with high time-resolution in order to assess the effect of sources inside and outside the building upon indoor mixing ratios of individual VOCs. Simultaneous hourly, continuous, and on-line measurements of C(2)-C(11) VOCs were performed inside and outside the School of Engineering of Bilbao (ETSI) building, located in the city center of Bilbao, an urban area in Northern Spain. The analysis of simultaneous data allowed the classification of VOCs based on their main sources. Some VOCs were mainly emitted by indoor sources (1-pentene, 2-methylpentane, n-hexane, methylcyclopentane, benzene, 1-heptene+2,2,4-trimethylbenzene, and tetrachloroethylene) or by outdoor sources (n-heptane, C(8) alkanes except trimethylpentanes and C(9) aromatics). Other VOCs, such as toluene, were emitted by both indoor and outdoor sources. The isoprene indoor pattern indicated that its main indoor source could be the air exhaled by people occupying the building. Some halocarbons, such as trichloroethylene, tetrachloroethylene, and carbon tetrachloride may be generated from the use inside the building of chlorine bleach containing products.

In vitro embryo production and embryo transfer in domestic and non-domestic cats

Over a 5-year interval, multiple laparoscopic oocyte retrievals were done in fishing cats (Prionailurus viverrinus), caracals (Caracal caracal) and domestic cats after ovarian stimulation with gonadotropins. From 21 retrievals in five fishing cats, 579 preovulatory oocytes (mean = 27.6) were recovered and 348 embryos were produced in vitro (mean = 16.6). A total of 452 preovulatory oocytes (mean = 25.1) were recovered from 18 of 24 retrievals in six caracals and 297 (mean = 16.6) embryos were produced. An additional 16 caracal embryos (19%) were produced after in vitro maturation of 83 oocytes, 59 of which came from six retrievals producing only immature oocytes. The presence of corpora lutea at oocyte retrieval occurred in each species (1) at a similar frequency (33%) and (2) more frequently during January through May (11 of 15 retrievals) than during the latter half of the year (4 of 30 retrievals). Of the 12 embryo transfer procedures done in fishing cats, one pregnancy (8%) was obtained and one live kitten born after the auto-transfer of 10 Day-6 embryos. In caracals, a total of 46 Day-4 or Day-5 embryos were auto-transferred to six recipients, one of which delivered two live kittens. Then, 109 caracal embryos were cryopreserved before thawing and transferring to nine recipients (mean = 12.1) on Days 5 or 6. From three pregnancies established (33%), a total of three kittens were born. Two to six gonadotropin treatments/oocyte retrievals were done in domestic cats during 1999 through 2003; an average of 24.9, 23.5, 22.0, 23.1, 23.5 and 40.9 oocytes (P > 0.05) were recovered at the first through the sixth treatment cycles from 138, 138, 97, 49, 22, and seven retrievals, respectively.

A genetic map of candidate genes and QTLs involved in tomato fruit size and composition

In order to screen for putative candidate genes linked to tomato fruit weight and to sugar or acid content, genes and QTLs involved in fruit size and composition were mapped. Genes were selected among EST clones in the TIGR tomato EST database (http://www.tigr.org/tdb/tgi/lgi/) or corresponded to genes preferentially expressed in the early stages of fruit development. These clones were located on the tomato map using a population of introgression lines (ILs) having one segment of Lycopersicon pennellii (LA716) in a L. esculentum (M82) background. The 75 ILs allowed the genome to be segmented into 107 bins. Sixty-three genes involved in carbon metabolism revealed 79 loci. They represented enzymes involved in the Calvin cycle, glycolysis, the TCA cycle, sugar and starch metabolism, transport, and a few other functions. In addition, seven cell-cycle-specific genes mapped into nine loci. Fourteen genes, primarily expressed during the cell division stage, and 23 genes primarily expressed during the cell expansion stage, revealed 24 and 26 loci, respectively. The fruit weight, sugars, and organic acids content of each IL was measured and several QTLs controlling these traits were mapped. Comparison between map location of QTLs and candidate gene loci indicated a few candidate genes that may influence the variation of sugar or acid contents. Furthermore, the gene/QTL locations could be compared with the loci mapped in other tomato populations.

Fatal cardiovascular complications in a patient with Ehlers-Danlos syndrome type IV and dextrocardia

A report is presented of a 31 year female patient with Ehlers-Danlos syndrome type IV who presented a bilateral renal artery dissection and a hematoma of the ascending aorta simultaneously. She had had an uneventful delivery six months before. We also discovered a situs solitus with dextrocardia in this patient. These complications were managed conservatively. Unfortunately the patient died of a pulmonary infection and a multi-organ failure syndrome several days after her admission.

[Cardiogenic shock complicating extensive infarction with ventricular septal defect. Circulatory assistance and heart transplantation]

A 47 year old man had a massive anterior myocardial infarction with cardiogenic shock with a left parasternal murmur. Coronary angiography showed occlusion of the left anterior descending artery for which angioplasty resulted in failure. There was antero-lateral-apical akinesia and a ventricular septal defect (VSD) with a left-right shunt (Qp/Qs = 1.54). Persistence and aggravation of haemodynamic instability led to intra-aortic balloon pumping with inotropic pharmacological support followed by biventricular assistance with a MEDOS device. Under transoesophageal echocardiographic monitoring, the outcome was marked over 7 days by the progressive increase in the shunt volume of the VSD, a decrease of drainage and injection flow, progressive increase in spontaneous contrast echos followed by the presence of fibrin in the cardiac chambers and canulae, the presence of thrombus in the external ventricles, blockage of the right external valve which only opened after increasing the degree of anticoagulation, and, finally, cardiac tamponade which required drainage before the patient's state improved. On the 8th day, the patient being stable with a normal neurological status, the availability of a donor heart led to the decision to transplant, which was carried out without complications. This case poses the problem of cardiac assist devices and their daily monitoring, and then that of cardiac transplantation in this indication.

[Long-term hemodynamic function of the transplanted heart]

The aim of this study was to identify the long-term haemodynamic changes of the transplanted heart. Between 1987 and 1997, 136 patients required cardiac transplantation at Dijon hospital. During follow-up, 76 patients aged 51.2 +/- 9.46 years underwent catheter studies (12 women, 15.8%; and 64 men, 84.2%). Right and left heart catheterisation was performed at 3 months, 1, 2, 3 and 5 years after transplantation. Right heart catheterisation included measurement of mean pulmonary artery and pulmonary capillary pressures and pulmonary arteriolar resistances. During left heart catheterisation, cardiac output, mean aortic pressure, the ejection fraction, the dp/dt max of the left ventricular wall, systemic arterial resistances and left ventricular end diastolic pressures were measured. At each catheter study, the indexed myocardial mass, indexed end systolic and end diastolic left ventricular volumes, the mass/volume ratio, the residual serum cyclosporine concentrations and the serum creatinine were analysed. In addition, an endomyocardial biopsy was also performed. Initially raised, the mean pulmonary artery and pulmonary capillary pressures decrease from the 3rd month to the 2nd year. From the 3rd year onwards, they readjust to the upper limits of normal. The pulmonary artery resistances underwent the same changes. The left heart parameters remained constant over the period of follow-up but with a heart rate, mean aortic pressure and left ventricular end diastolic pressure higher than normal. The indexed myocardial mass was increased at all periods. The indexed left ventricular end systolic and diastolic volumes decreased with a M/V ratio which increased. Cyclosporine concentrations decreased whereas serum creatinine increased. The frequency of severe rejection and of coronary atherosclerosis was low. Significant correlations were observed between different parameters at different periods. In the long-term, the function of the transplanted heart is not normal in the strict sense of the term. The apparent normality is obtained by anti-hypertensive treatment. The transplanted heart adapts to the increase in cyclosporine-induced afterload by permanent myocardial hypertrophy, and increased diastolic pressure probably relates to diastolic dysfunction without noticeable intracardiac fibrosis.

Extra-virgin olive oil increases the resistance of LDL to oxidation more than refined olive oil in free-living men with peripheral vascular disease

Patients with peripheral vascular disease (Fontaine stage II) are characterized by ischemia of the lower extremities, atherosclerosis and alteration of blood coagulation and fibrinolysis. A randomized, two-period, crossover design was used to compare the effects of extra-virgin (VO) and refined olive (RO) oils on plasma lipids and lipoprotein composition and LDL oxidation susceptibility in free-living men with peripheral vascular disease. The oils differed in their antioxidant profile (alpha-tocopherol: 300 vs. 200 mg/kg; phenolic compounds 800 vs. 60) and concentration but not in their fatty acid composition. Subjects were randomly assigned to two groups. The first group (n = 12) received VO with which to freely cook all meals for 3 mo, followed by a 3-mo wash-out period; they then received RO for the final 3 mo. The second group (n = 12) consumed the oils in the opposite order. Energy, fat, polyunsaturated fatty acids (PUFA) and alpha-tocopherol intakes were not different when patients consumed the two oils. Profiles of the major fatty acids in plasma and LDL were not different after consumption of VO and RO. The slope of the line for LDL oxidation vs. the line for copper concentration was significantly higher after the intake of RO than after the intake of VO. Total LDL taken up by macrophages was significantly greater when the men consumed RO rather than VO. We suggest that antioxidants present in VO may protect LDL against oxidation more than does RO in men with peripheral vascular disease.

Lifestyle changes in free-living patients with peripheral vascular disease (Fontaine stage II) related to plasma and LDL lipid composition: a 15 month follow-up study

Peripheral vascular disease (PVD) is characterized by arteriosclerosis and lower extremity ischemia which cause intermittent claudication. Patients grouped in the Fontaine stage II have more than 75% organic stenosis in their large coronary arteries and exhibit a number of alterations in blood coagulation and plasma lipids. The aim of this study was to evaluate an intervention program of lifestyle habits including dietary recommendations, moderate exercise and decreased smoking in a population of patients with PVD for a period of 15 months, with respect to plasma-lipid and lipoprotein composition as well as LDL susceptibility to peroxidation. These parameters are well known risk indicators of arteriosclerosis and coronary heart disease. A total 13 subjects diagnosed with PVD (Fontaine stage II) were selected, while a healthy age-matched group (n=20) was used as a reference. This study design was an uncontrolled trial of lifestyle interventions. The group of patients was examined at 0, 3, 6, 9, 12 and 15 months. Patients smoking one or more packets of cigarettes per day at the beginning of the study (54.2%) decreased smoking by as much as 7.7% 15 months later. In addition, physical activity intensified significantly (walking > 1 km: 13.1-77%) and treadmill running increased over the study period while the energy intake decreased by 10%. The percentage of saturated fat in the diet decreased by 10% while the intake of polyunsaturated fat rose, and monounsaturated-fat intake showed a parallel trend to increase; the average intake of cholesterol also fell by 10% and plasma triglycerides and HDL-cholesterol showed a trend to decrease and increase, respectively. No permanent changes in LDL lipid fractions for patients were detected during the follow-up period and no differences between patients and the age-matched reference group were found. The macrophage uptake of plasma-oxidized LDL was significantly higher in patients than in the reference group and no differences due to the intervention period were detected. In conclusion, the education in lifestyle and nutritional habits of patients with PVD led to reduced energy intake parallel with augmented physical activity as well to a fall in plasma triglycerides and a rise in HDL-cholesterol, which are good indicators of a reduced risk of vascular and myocardial complications.

[Ten-year experience with heart transplantation (1987-1997)]

OBJECTIVES

Analyze ten years experience with heart transplantation at the Dijon University Hospital and determine which parameters control mid and long term outcome.

PATIENTS AND METHODS

One hundred thirty six heart transplantations were performed over a 10 year period (1987-1997) in 118 men and 18 women aged 51-87 years. Heart transplantation was indicated on the basis of the following criteria: ejection fraction *20%, pulmonary arteriole resistance < 6 Wood units, peak oxygen uptake < 14 l/kg/min. The Shumway or anatomic technique was used. The triple immunosuppressive protocol combined corticosteroids, azathioprine and cyclosporin. The same team conducted the post-transplantation follow-up with regular programmed consultations in addition to those requested by the general practitioner, the cardiologist or the patient. Follow-up was oriented according to the clinical situation (blood chemistry, cell counts, cyclosporinemia, search for infection, echocardiography, endomyocardial biopsy, coronarography).

RESULTS

Five patients (3.6%) died when still on the waiting list. Absolute emergency transplantation was performed for patients (28.1%) including 8 (5.9%) after circulatory assist. Hospital mortality was 11.7% and late mortality was 16.1%. Actuarial survival was 78% at 1 year, 71% at 5 years and 69% at 10 years. Among the survivors, 94% were taking two, three or even four drugs for hypertension. Cyclosporin levels decreased and creatinine levels increased. Episodes of rejection were minimal: 86.57% of the biopsies were * grade 1 and 4.45% * grade 2. Cytomegalovirus infection was documented and treated in 7.55% of the cases. Incidence of graft coronary artery disease was 3.4% at 1 year, 6.5% at 2 years and 7.9% at 3 years.

CONCLUSION

Our follow-up structure where the same small team conducts regular examinations together with our approach to heart transplantation appears to be the main factor leading to the quality results obtained in this series.

Birth of a male lamb derived from an in vitro matured oocyte fertilised by intracytoplasmic injection of a single presumptive male sperm

The developmental competence of in vitro matured ovine oocytes, cytoplasmically injected with single male or female chromosome-bearing sperm, was investigated. Eighty-five unsorted, 92 'female-sorted' and 74 'male-sorted' ram sperm were injected into in vitro matured sheep oocytes and, two to four hours later, placed into the oviducts of 28 oestrous sheep. The sperm were separated according to sex by analysis of their DNA content with a flow cytometer. One pregnancy was diagnosed by ultrasound after 55 days and a 3 kg male lamb was born after 150 days gestation. This lamb was derived from an oocyte injected with 'male-sorted' sperm.

[Lipomatous septal hypertrophy. Apropos of 3 cases]

Lipomatous hypertrophy of the inter-atrial septum is characterised by fatty accumulation in the inter-atrial septum. Long unrecognised, it has been discovered anew by virtue of the use of transesophageal echocardiography. The authors report three cases, including one presenting as acute ischemia of the right lower limb. After studying the contribution of imaging techniques to its diagnosis, the authors consider the principal differential diagnoses of this condition.