The acute wheezy adult with airways disease in the emergency department: a retrospective case-note review of exacerbations of COPD

Introduction: There has been an increase in interest in the peripheral blood eosinophil count as a biomarker in COPD. Few studies have examined the eosinophil count in patients attending the emergency department (ED) with acute exacerbations of COPD (AECOPD). We investigated the relationship between the blood eosinophil and other variables collected routinely at ED presentation and outcomes.

Methods: Retrospective case note review of patients attending the ED with an AECOPD over 18 months. Demographic, clinical and pharmacological data were analyzed at the time of presentation, and clinical outcomes relating to hospital admission, length of hospital stay and mortality were investigated.

Results: There were 743 AECOPD index events in 537 patients. Over half (57%) of all attendees were admitted to hospital. They were older, reported an increased number of exacerbations and higher levels of total leukocytes and neutrophils. Length of stay was shorter in patients with a blood eosinophil count ≥2% compared to <2% (median (IQR) 3 days (1–7) vs 4 days (2–8) respectively, p<0.05). Length of stay correlated with peripheral blood neutrophils (r=0.12, p=0.021), peripheral blood absolute and relative eosinophils (r=−0.12, p=0.024 and r=−0.11, p=0.035, respectively) and CRP (r=0.16, p=0.027). Non-eosinophilic AECOPD were associated with an increased risk of mortality during an exacerbation (χ² 5.9, OR 3.08, 95% CI 1.19–7.96, p=0.015).

Conclusion: In exacerbations of COPD presenting to ED, a higher blood eosinophil count is associated with a shorter length of stay and reduced mortality.

Characterizations of the normal distribution by suitable transformations

Yu. V. Linnik showed that certain transformations, given by Formulae (1.1), (1.6) and (1.7) transform a normal sample into itself. The transformations (1.1) and (1.7) apply to samples of size 2 while (1.6) admits an arbitrary sample size. It is also assumed that the population mean is zero.

In the present paper the converse theorems are proven so that characterizations of the normal distribution are obtained. The problem leads to the functional equations (2.3) and (2.13) whose solution yields the desired results.

Early cryoprecipitate for major haemorrhage in trauma: a randomised controlled feasibility trial

BACKGROUND

Low fibrinogen (Fg) concentrations in trauma haemorrhage are associated with poorer outcomes. Cryoprecipitate is the standard source for Fg administration in the UK and USA and is often given in the later stages of transfusion therapy. It is not known whether early cryoprecipitate therapy improves clinical outcomes. The primary aim of this feasibility study was to determine whether it was possible to administer cryoprecipitate, within 90 min of admission to hospital. Secondary aims were to evaluate laboratory measures of Fg and clinical outcomes including thrombotic events, organ failure, length of hospital stay and mortality.

METHODS

This was an unblinded RCT, conducted at two civilian UK major trauma centres of adult trauma patients (age ≥16 yrs), with active bleeding and requiring activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy (STANDARD) (n=22), or to standard haemorrhage therapy plus two early pools of cryoprecipitate (CRYO) (n=21).

RESULTS

85% (95% CI: 69-100%) CRYO participants received cryoprecipitate within 90 min, median time 60 min (IQR: 57-76) compared with 108 min (67-147), CRYO and STANDARD arms respectively (P=0.002). Fg concentrations were higher in the CRYO arm and were maintained above 1.8 g litre(-1) at all time-points during active haemorrhage. All-cause mortality at 28 days was not significantly different (P=0.14).

CONCLUSIONS

Early Fg supplementation using cryoprecipitate is feasible in trauma patients. This study supports the need for a definitive RCT to determine the effect of early Fg supplementation on mortality and other clinical outcomes.

TRIAL REGISTRY NUMBER

ISRCTN55509212.

Establishing research strategies, methodologies and technologies to link genomics and proteomics to seagrass productivity, community metabolism, and ecosystem carbon fluxes

A complete understanding of the mechanistic basis of marine ecosystem functioning is only possible through integrative and interdisciplinary research. This enables the prediction of change and possibly the mitigation of the consequences of anthropogenic impacts. One major aim of the European Cooperation in Science and Technology (COST) Action ES0609 "Seagrasses productivity. From genes to ecosystem management," is the calibration and synthesis of various methods and the development of innovative techniques and protocols for studying seagrass ecosystems. During 10 days, 20 researchers representing a range of disciplines (molecular biology, physiology, botany, ecology, oceanography, and underwater acoustics) gathered at The Station de Recherches Sous-marines et Océanographiques (STARESO, Corsica) to study together the nearby Posidonia oceanica meadow. STARESO is located in an oligotrophic area classified as "pristine site" where environmental disturbances caused by anthropogenic pressure are exceptionally low. The healthy P. oceanica meadow, which grows in front of the research station, colonizes the sea bottom from the surface to 37 m depth. During the study, genomic and proteomic approaches were integrated with ecophysiological and physical approaches with the aim of understanding changes in seagrass productivity and metabolism at different depths and along daily cycles. In this paper we report details on the approaches utilized and we forecast the potential of the data that will come from this synergistic approach not only for P. oceanica but for seagrasses in general.

Beam position stabilization for a confocal multiphoton microscope

The influence of beam-pointing on scanning confocal microscopy is investigated. The beam displacement is measured using a quadrant photodiode, and the apparent movement of a sub-micron-sized particle observed by second-harmonic microscopy is linked to the beam displacement. A simple beam-pointing stabilization is implemented, and improvement of beam stability by three orders of magnitude on long time scales is achieved.

Low bone mineral density is not associated with angiographically determined coronary atherosclerosis in men

This study for the first time investigates the association of bone mineral density (BMD) with angiographically determined coronary atherosclerosis in men. Our data show that the prevalence of low BMD is very high in men undergoing coronary angiography. However, neither osteopenia nor osteoporosis is associated with an increased prevalence of angiographically determined coronary atherosclerosis.

INTRODUCTION

The association of low BMD with angiographically determined coronary atherosclerosis in men is unknown.

METHODS

We enrolled 623 consecutive men undergoing coronary angiography for the evaluation of established or suspected coronary artery disease (CAD). BMD was assessed by dual X-ray absorptiometry. CAD was diagnosed in the presence of any coronary artery lumen narrowing at angiography; coronary stenoses with lumen narrowing > or =50% were considered significant.

RESULTS

From the total study cohort (mean age of 64 +/- 11 years), 207 patients (33.2%) had osteopenia and 65 (10.4%) had osteoporosis; at angiography, CAD was diagnosed in 558 patients (89.6%) and 403 (64.7%) had significant coronary stenoses. In multivariate logistic regression analysis neither osteopenia nor osteoporosis was associated with an increased prevalence of CAD (adjusted odds ratios (ORs) = 0.71 [95% confidence interval 0.40-1.23]; p = 0.222 and 1.03 [0.38-2.80]; p = 0.955, respectively) or with significant coronary stenoses (OR 0.74 [0.52-1.07], p = 0.112 and 0.72 [0.41-1.26]; p = 0.251, respectively). Also, as a continuous variable, BMD was not associated with angiographically diagnosed CAD.

CONCLUSIONS

The prevalence of low BMD is very high in men undergoing coronary angiography. However, low BMD is not associated with angiographically determined coronary atherosclerosis in men.

Gap-filling methods for 3D PlanTIS data

The range of positron emitters and their labeled compounds have led to high-resolution PET scanners becoming widely used, not only in clinical and pre-clinical studies but also in plant studies. A high-resolution PET scanner, plant tomographic imaging system (PlanTIS), was designed to study metabolic and physiological functions of plants noninvasively. The gantry of the PlanTIS scanner has detector-free regions. Even when the gantry of the PlanTIS is rotated during the scan, these regions result in missing sinogram bins in the acquired data. Missing data need to be estimated prior to the analytical image reconstructions in order to avoid artifacts in the final reconstructed images. In this study, we propose three gap-filling methods for estimation of the unique gaps existing in the 3D PlanTIS sinogram data. The 3D sinogram data were gap-filled either by linear interpolation in the transaxial planes or by the bicubic interpolation method (proposed for the ECAT high-resolution research tomograph) in the transradial planes or by the inpainting method in the transangular planes. Each gap-filling method independently compensates for slices in one of three orthogonal sinogram planes (transaxial, transradial and transangular planes). A 3D numerical Shepp-Logan phantom and the NEMA image quality phantom were used to evaluate the methods. The gap-filled sinograms were reconstructed using the analytical 3D reprojection (3DRP) method. The NEMA phantom sinograms were also reconstructed by the iterative reconstruction method, ordered subsets maximum a posteriori one step late (OSMAPOSL), to compare the results of gap filling followed by 3DRP with the results of OSMAPOSL reconstruction without gap filling. The three methods were evaluated quantitatively (by mean square error and coefficients of variation) over the selected regions of the 3D numerical Shepp-Logan phantom at eight different Poisson noise levels. Moreover, the NEMA phantom scan data were used in visual assessments of the methods. We observed that all methods improved the reconstructed images both quantitatively and visually. Therefore, the proposed gap-filling methods followed by the analytical 3DRP are alternative for the reconstructions of not only the 3D PlanTIS data, but also other PET scanner data of the ClearPET family.

Factors influencing the health related quality of life in patients with systemic lupus erythematosus: long-term results (2001—2005) of patients in the German Lupus Erythematosus Self-Help Organization (LULA Study)

The aim of this longitudinal study was to determine disease-specific and individual factors associated with health-related quality of life (HRQOL) in a cohort of patients with systemic lupus erythematosus (SLE) organized in the German Lupus Erythematosus Self-Help Organization. Three hundred and seventeen patients aged between 11 and 77 years participated annually in five surveys carried out between 2001 and 2005. Regression analyses were carried out for physical and mental HRQOL as dependent variables. Factors influencing HRQOL were the respective HRQOL scores of the previous year, SLE activity as measured by the Systemic Lupus Activity Questionnaire (SLAQ), and impairments in everyday life. Social support indicated by living in marriage or in a marriage-like partnership had a positive influence on both mental and physical HRQOL, whereas individual factors such as education seemed to be of minor importance.

Design and initial performance of PlanTIS: a high-resolution positron emission tomograph for plants

Positron emitters such as (11)C, (13)N and (18)F and their labelled compounds are widely used in clinical diagnosis and animal studies, but can also be used to study metabolic and physiological functions in plants dynamically and in vivo. A very particular tracer molecule is (11)CO(2) since it can be applied to a leaf as a gas. We have developed a Plant Tomographic Imaging System (PlanTIS), a high-resolution PET scanner for plant studies. Detectors, front-end electronics and data acquisition architecture of the scanner are based on the ClearPET system. The detectors consist of LSO and LuYAP crystals in phoswich configuration which are coupled to position-sensitive photomultiplier tubes. Signals are continuously sampled by free running ADCs, and data are stored in a list mode format. The detectors are arranged in a horizontal plane to allow the plants to be measured in the natural upright position. Two groups of four detector modules stand face-to-face and rotate around the field-of-view. This special system geometry requires dedicated image reconstruction and normalization procedures. We present the initial performance of the detector system and first phantom and plant measurements.

Robot-assisted gait training in multiple sclerosis: a pilot randomized trial

Objective To evaluate feasibility and perform an explanatory analysis of the efficacy of robot-assisted gait training (RAGT) in MS patients with severe walking disabilities (Expanded Disability Status Scale [EDSS] 6.0—7.5) in a pilot trial.

Methods Prospective, randomized, controlled clinical trial comparing RAGT with conventional walking training (CWT) in a group of stable MS patients ( n = 35) during an inpatient rehabilitation stay, 15 sessions over three weeks. All patients participated additionally in a multimodal rehabilitation program. The primary outcome measure was walking velocity and secondary measures were 6-minwalking distance, stride length and knee-extensor strength. All tests were performed by an external blinded assessor at baseline after three weeks and at follow-up after six months. Additionally, Extended Barthel Index (EBI) at entry and discharge was assessed (not blinded), and acceptance/convenience of RAGT rated by patients (Visual Analogue Scale [VAS]) was recorded.

Results Nineteen patients were randomly allocated to RAGT and 16 patients to CWT. Groups were comparable at baseline. There were 5 drop-outs (2 related directly to treatment) in the RAGT group and 1 in the CWT group, leaving 14 RAGT patients and 15 CWT patients for final analysis. Acceptance and convenience of RAGT as rated by patients were high. Effect sizes were moderate to large, although not significant, for walking velocity (0.700, 95% CI -0.089 to 1.489), walking distance (0.401, 95% CI - 0.370 to 1.172) and knee-extensor strength (right: 1.105, 95% CI 0.278 to 1.932, left 0.650, 95% CI -0.135 to 1.436) favouring RAGT. Prepost within-group analysis revealed an increase of walking velocity, walking distance and knee-extensor strength in the RAGT group, whereas in CWT group only walking velocity was improved. In both groups outcome values returned to baseline at follow-up after six months ( n = 23).

Conclusions Robot-assisted gait training is feasible and may be an effective therapeutic option in MS patients with severe walking disabilities. Effect size calculation and prepost analysis suggest a higher benefit on walking velocity and knee-extensor strength by RAGT compared to CWT. Due to several limitations, however, our results should be regarded as preliminary. Post hoc power calculation showed that two groups of 106 patients are needed to demonstrate a significant moderate effect size of 0.4 after three weeks of RAGT. Thus, further studies with a larger number of patients are needed to investigate the impact of this new treatment option in MS patients. Multiple Sclerosis 2008; 14: 231—236. http://msj.sagepub.com

[Disability in lupus erythematosus]

Morbidity and co-morbidities in patients with lupus erythematosus (LE) result in an impairment, limiting activities of daily living. We compared the handicap, appraised by the German welfare system in patients with LE and their diagnosis, morbidities and co-morbidities, therapy, functional capacity, psychological status and general health. The data were obtained in an anonymous self-administered questionnaire conducted by the lupus patient association. 892 data sets were available for the trial. The mean age was 46.9y, disease duration was 10.3y. The patients had 3.8 concomitant diseases on average. 39.7% were still working and 35.4% drew a pension. 59.2% made an application for disability, which wasn't assigned in only 2.5% of cases. 82.6% had an average grade of disability of more than 50%. It demonstrated a good correlation to age, disease duration, type of LE and therapy. Predictors for a worse assessment were disease duration, osteoarthritis, cerebral insults and functional capacity. In conclusion the data demonstrate a fair appraisal of disability by the German welfare system in patients with LE. Self-administered questionaires can yield credible results.

High-dose 17beta-estradiol treatment prevents development of heart failure post-myocardial infarction in the rat

OBJECTIVES

Prognosis of heart failure remains poor despite therapeutic advances, such as angiotensin converting enzyme inhibition or beta-receptor blockade. Thus, more effective forms of treatment are urgently needed. Since estrogens have been shown to modulate migration and proliferation of cardiac fibroblasts and to modulate the expression of estrogen receptors of cardiomyocytes we examined whether high-dose estrogen treatment can affect post-myocardial infarction left ventricular remodeling.

METHODS

Female rats were treated with 17beta-estradiol (7.5 mg/90 d) or placebo for ten weeks, starting two weeks prior to experimental myocardial infarction. Eight weeks after infarction, in vivo echocardiographic and hemodynamic measurements as well as isolated heart perfusion were performed.

RESULTS

In vivo, chronic estrogen treatment almost completely prevented the development of all signs of heart failure that occur in untreated infarcted hearts, such as increased left ventricular diameters (dilatation), reduced fractional shortening (systolic dysfunction) or increased left ventricular end-diastolic pressure (diastolic dysfunction). In vitro, the right- (indicating structural dilatation) and downward (indicating left ventricular dysfunction) shift of left ventricular pressure-volume curves occurring in untreated infarcted hearts was completely prevented by estrogen.

CONCLUSIONS

High dose estradiol treatment prevented development of post-MI remodeling, as assessed by in vivo and in vitro parameters of LV dysfunction. Estrogen may hold the potential of becoming a new form of heart failure treatment.However, the mechanisms responsible for this striking and unexpected beneficial action of estrogen in heart failure remain to be elucidated.

[Gestational diabetes: what follow-up after delivery?]

Women with gestational diabetes have a high risk for dysglycemia and metabolic syndrome. The post-partum screening evaluation allows to establish the "metabolic profile". The components of the SM must be recognized and treated. The life-style modifications are the priority. A follow-up by the general practitioner, assisted by a dietitian when it is indicated must be set up and the objectives regularly evaluated. The difficulty perceiving the long-term benefits and the changes of priority when the child is born represent specific barriers for the preventive interventions and must be identified. Specific preventive strategies to this population at high risk must be created and evaluated.

Increased plasma levels of N-terminal brain natriuretic peptide (NT-proBNP) in type 2 diabetic patients with vascular complications

AIMS

The plasma levels of either brain natriuretic peptide (BNP) or the N-terminal fragment of the prohormone (NT-proBNP) have recently gained extreme importance as markers of myocardial dysfunction. Patients with type 2 diabetes are at high risk of developing cardiovascular complications. This study was aimed to assess whether plasma NT-proBNP levels are at similar levels in type 2 diabetics with or without overt cardiovascular diseases.

METHODS

We assayed plasma NT-proBNP in 54 type 2 diabetics, 27 of whom had no overt macro- and/or microvascular complications, while the remaining ones had either or both. The same assay was carried out in 38 healthy control subjects age and sex matched as a group with the diabetics.

RESULTS

Plasma NT-proBNP was higher in diabetics (median 121 pg/ml, interquartile range 50-240 pg/ml, ) than in those without complications (37 pg/ml, 21-54 pg/ml, P<0.01). Compared with the controls (55 pg/ml, 40-79 pg/ml), only diabetics with vascular complications had significantly increased plasma NT-proBNP levels (P<0.001). In the diabetics, coronary heart disease and nephropathy (defined according to urinary excretion of albumin) were each independently associated with elevated values of plasma NT-proBNP.

CONCLUSIONS

In type 2 diabetes mellitus, patients with macro- and/or micro-vascular complications exhibit an elevation of plasma NT-proBNP levels compared to corresponding patients with no evidence of vascular disease. The excessive secretion of this peptide is independently associated with coronary artery disease and overt nephropathy. The measurement of circulating NT-proBNP concentration may therefore be useful to screen for the presence of macro- and/or microvascular disease.

Barrett's esophagus: a discrepancy between macroscopic and histological diagnosis

BACKGROUND AND STUDY AIMS

The diagnosis of Barrett's esophagus at present requires endoscopic and histological confirmation of specialized intestinal metaplasia. This study prospectively analyzed the endoscopic and histological prevalence of Barrett's esophagus and the risk factors for the presence of Barrett's esophagus among patients being treated in an endoscopy unit.

PATIENTS AND METHODS

A total of 474 unselected patients (58% men; mean age 52 y) were included in the study. Two biopsy specimens each were taken from below and above the squamocolumnar junction and from the antrum and gastric body. Four-quadrant biopsies were taken every 1-2 cm to confirm a macroscopic suspicion of Barrett's esophagus.

RESULTS

Barrett's esophagus was suspected at endoscopy in 109 patients (23%). Of the 109 patients with endoscopically suspected Barrett's esophagus, only 46 (42%) had the finding confirmed histologically. The sensitivity and specificity for the endoscopic diagnosis of Barrett's esophagus were 62% and 84%, respectively. A multivariate logistic regression analysis identified age (P = 0.0001; odds ratio per life-year 1.087; 95% CI, 1.046-1.139), male sex (P = 0.0020; OR 6.346; 95% CI, 2.094-22.314), and the number of biopsies (P = 0.0025; OR 1.661; 95% CI, 1.247-2.392) as factors associated with evidence of intestinal metaplasia on biopsy.

CONCLUSION

The striking discrepancy between the endoscopic findings and the histological diagnosis may be due to the focal distribution of intestinal metaplasia. This emphasizes the importance of an adequate biopsy protocol. In addition, better methods of detecting focal islands of intestinal metaplasia that are not visible at conventional endoscopy are needed.