POS0890 NINTEDANIB REAL-LIFE EFFICACY AND SAFETY IN SYSTEMIC SCLEROSIS (SSc)-INTERTISTIAL LUNG DISEASE (ILD): AN ITALIAN MULTICENTRE PRELIMINARY STUDY

Background

Nintedanib (NTD) has been approved for Systemic Sclerosis (SSc)-Interstitial Lung Disease (ILD) following the positive results of the SENSCIS trial.

Objectives

to describe the efficacy and safety of NTD in SSc-ILD in a real-life setting.

Methods

The clinical data of SSc-ILD patients treated with NTD from 10 Italian SSc centres were retrospectively evaluated at baseline, 6 and 12 months: SSc clinical features, NTD tolerability, pulmonary function tests (PFTs) and modified Rodnan skin score (mRSS) were recorded.

Results

69 SSc-ILD patients (22 males [32%], mean age 60±12 years, disease onset 50±13 years, 4 [6%] anti-centromere, 53 [77%] anti-topoisomerase I, 3 [4%] anti-RNA-polimerase III) were identified. The vast majority (84%) was previously treated with immunosuppressants: 27 (39%) cyclophosphamide, 45 (65%) mycophenolate mofetil, 6 (9%) methotrexate, 9 (13%) azathioprine, 6 (9%) tocilizumab and 22 (32%) rituximab. In 11 (16%) patients, NTD was the first treatment for SSc-ILD. At baseline, 57 patients (83%) were on corticosteroids (mean daily prednisone dose 6±5 mg), 58 (84%) on immunosuppressants, 47 (68%) on mycophenolate mofetil, 14 (20%) on rituximab, 3 (4%) on tocilizumab, 2 on methotrexate (3%) and 1 (1%) on azathioprine. At baseline HRCT showed UIP pattern in 27 (39%) and NSIP pattern in 42 (61%) patients. The modifications of PFTs and mRSS over time are shown in Table 1. Since NTD introduction, gastro-intestinal (GI) side effects were recorded in 34 (49%) patients, with diarrhoea being the most common complaint (35%), followed by nausea/vomiting (23%) and weight loss (16%). In 21 (30%) patients, after a mean time of 2.6±3.4 months, NTD was maintained after dose adjustment. In 5 (7%) patients NTD was stopped after a median time of 5 (1-6) months due to subocclusion and persistent diarrhoea in 3 patients, untreatable nausea and vomiting in one patient and liver toxicity in 1 patient. During the follow-up after a median time of 10 (6 – 33) months, 4 patients died.

Table 1.

Pulmonary function tests and mRSS at baseline, 6 and 12 months in SSc-ILD on NTD.

Baseline6 monthsP valueBaseline12 monthsP valueFVC (% predicted)64 ± 1865 ± 18 (33 pts)0.63870 ± 1969 ± 18 (20 pts)0.586TLC (% predicted)64 ± 1561 ± 14 (27 pts)0.15464 ± 1465 ± 18 (16 pts)0.944DLCO (% predicted)40 ± 1741 ± 18 (29 pts)0.66040 ± 1838 ± 18 (20 pts)0.304mRSS9 ± 68 ± 6 (26 pts)0.0027 ± 48 ± 6 (15 pts)0.334

pts= patients

Conclusion

Our preliminary data confirm that in a real-life clinical scenario NTD, in combination with immunosuppressants, may stabilize PFT. However, despite the fact that GI side effects are frequent, they may be controlled with NTD dose adjustment thus retaining the drug in SSc-ILD patients. The NTD efficacy on skin involvement needs to be thoroughly evaluated on a larger SSc population.

Disclosure of Interests

Corrado Campochiaro Speakers bureau: Boeboehringer ingelheim, Giacomo De Luca Speakers bureau: boehringer ingelheim, Maria Grazia Lazzaroni Grant/research support from: boehringer ingelheim, Giuseppe Armentaro: None declared, Amelia Spinella: None declared, Barbara Vigone: None declared, Barbara Ruaro: None declared, Anna Stanziola: None declared, Devis Benfaremo: None declared, Enrico De Lorenzis: None declared, Francesco Benvenuti: None declared, Silvia Laura Bosello Speakers bureau: boehringer ingelheim, Gianluca Moroncini: None declared, Giovanna Cuomo: None declared, Marco Confalonieri: None declared, Lorenzo Beretta: None declared, Elisabetta Zanatta: None declared, Dilia Giuggioli: None declared, Nicoletta Del Papa: None declared, Paolo Airò: None declared, Lorenzo Dagna: None declared, Marco Matucci-Cerinic Speakers bureau: boehringer ingelheim

AB1297 EVALUATION OF POSSIBLE RISK FACTOR OF PULMONARY EMBOLISM IN SARCOIDOSIS PATIENTS

Background

Some studies reported a correlation between sarcoidosis and an increased risk of pulmonary embolism (PE) 1,2.

Objectives

To assess possible risk factors of PE in sarcoidosis patients.

Methods

We enrolled 260 sarcoidosis patients (170 females and 90 males; mean age at diagnosis 46 ± 9), after giving written informed consent. We perform clinical evaluations, laboratory tests and radiology features.

Results

Our study population included 20 sarcoidosis patients with PE (14 females and 6 males; mean age at diagnosis 45 ± 10), diagnosed by lung scintigraphy and 240 sarcoidosis patients without PE (170 females and 70 males; mean age at diagnosis 46 ± 11). There was a significant increase of the presence of antiphospholipid antibodies in the sarcoidosis group with pulmonary embolism (55%) than in group without PE (9%) (p-value<0.01). There was no statistically significant difference between the two groups on smoking habit, obesity, treatments and hereditary thrombophilia frequency (p > 0.05, respectively).

Conclusion

This study demonstrated an increased of antiphospholipid antibodies positivity in sarcoidosis patients with pulmonary embolism. Furthermore, we propose screening for these antibodies

in all sarcoidosis patients.

References

[1]Turetz M, et al. Semin Intervent Radiol 2018;35:92–98

[2]Larsson J, et al. Sarcoidosis Vasc Diffuse Lung Dis 2020; 37: 104-135

Disclosure of Interests

None declared

POS1435 CLINICAL CHARACTERIZATION AND PREDICTIVE FACTORS FOR PROGRESSION IN A COHORT OF ILD PATIENTS WITH FEATURES OF AUTOIMMUNITY: ARE IPAF CRITERIA SUFFICIENT?

Background:

It is unknown whether patients with interstitial lung disease (ILD) and only some features of autoimmunity have a different natural history from those with a defined connective tissue disease (CTD-ILD). The classification criteria for “ILD with autoimmune features” (IPAF) may not be able to characterize all these patients, especially those with a usual interstitial pneumonia (UIP) pattern [1].

Objectives:

To determine clinical characteristics and predictive factors for progression in a cohort of ILD patients with features of autoimmunity, through the application of classification criteria for IPAF and specific CTD, whenever possible.

Methods:

We retrospectively selected a cohort of consecutive patients with ILD as onset manifestation and features of autoimmunity (at least 1 autoantibody and/or 1 clinical sign/symptom), evaluated by our multidisciplinary unit from March 2009 to March 2020. All the final diagnoses were revised according to the latest CTD and IPAF criteria. Patients were followed up for 33 (16.5-69.5) months.

Results:

Of the 101 patients enrolled (67.4±10.9 yrs, F/M ratio 65/36), 53 (52.5%) and 37 (36.6%) respectively satisfied the CTD and IPAF criteria. Eleven patients (10.9%) did not satisfy IPAF criteria because of only 1 item (clinical or serologic) within the IPAF domains and a UIP pattern; we defined this group as “autoimmune” UIP (AI-UIP). All the 8 patients initially classified as undifferentiated CTD had sufficient IPAF criteria. Among the IPAF patients (68.2±10.1 years, F/M ratio 20/17), the most common findings were: Nonspecific interstitial pneumonia pattern (56.8%), antinuclear antibodies positivity (43.2%) and arthritis (24.3%). The combination of a positive morphologic and serologic domain was the most common to reach the diagnosis (48.6%). Some IPAF patients had features not included in IPAF criteria, such as non-anti-synthetase myositis-specific antibodies (21.6%), objective sicca syndrome (13.5%) and anti-myeloperoxidase antibodies (2.7%). Over a median of 17 months, 2 IPAF patients (5.4%) developed a definite UIP pattern, while 4 (10.8%) a specific CTD. Comparing the IPAF, CTD-ILD and AI-UIP groups, no statistically significant differences were found in the mean age, sex distribution, smoking habits and mean duration of the disease. However, IPAF patients had a significantly higher prevalence of arterial hypertension and left-sided heart failure and a lower predominance of UIP pattern as expected (10.8% vs. 32.1% vs. 100%, p<0.01). Although no differences were found at the diagnosis, at 1 year the proportion of IPAF patients with radiological progression of the fibrosis and/or functional deterioration (defined by a decline in FVC of ≥ 10% and/or DLCO of ≥ 15% predicted) was lower to that of CTD-ILD and AI-UIP (17.1% vs. 31.4% vs. 63.6%, p 0.01). Fewer IPAF patients needed oxygen support (8.6% vs. 31.4% vs. 36.4, p 0.02). Considering the overall 101 patients, having an IPAF and a UIP pattern respectively predicted a slower (OR: 0.37, p 0.04) and a faster (OR: 3.56, p 0.01) ILD progression at the multivariate analysis.

Conclusion:

In our cohort, IPAF criteria were useful to identify a subset of patients with a slower ILD progression and a possible evolution to CTD (10-15% of cases) [2]. These criteria do not characterize all the patients with a UIP pattern and limited features of autoimmunity, which seem to have a worse prognosis, independently from the final diagnosis. Further studies are needed to clarify if the prognosis of AI-UIP is different from that of idiopathic pulmonary fibrosis.

References:

[1]Graney, et al. Ann Am Thorac Soc 2019;16(5):525-33.

[2]Sebastiani, et al. Biomedicines 2021,9,17.

Disclosure of Interests:None declared

POS1228 THE ROLE OF CHEST CT IN UNDERSTANDING INTERSTITIAL LUNG DISEASE (ILD): SYSTEMIC SCLEROSIS (SSc). VERSUS COVID-19

Background:

COVID-19 pandemic is a global emergency which may overlap on the clinical and radiological scenario of ILD in SSc. In clinical practice, the striking similarities observed at computed tomography (CT) between the diseases make it difficult to distinguish a COVID-19 superinfection from a progression of SSc-ILD.

Objectives:

The aim of our study was to identify the main CT features that may help distinguishing SSc-ILD from COVID-19 pneumonia.

Methods:

22 international readers were included and divided in the radiologist group (RAD) and non-radiologist group (nRAD). The RAD group included non-chest RAD and chest-RAD. A total of 99 patients, 52 with COVID-19 and 47 with SSc-ILD, were included in the study.

Results:

Fibrosis inside focal ground glass opacities (GGO) in the upper lobes; fibrosis in the lower lobe GGO; reticulations in lower lobes (especially if bilateral and symmetrical or associated with signs of fibrosis) were the CT parameters most frequently associated with SSc-ILD. The CT parameters most frequently associated with COVID- 19 pneumonia were: consolidation (CONS) in the lower lobes, CONS with peripheral (both central/peripheral or patchy distributions), anterior and posterior CONS and rounded-shaped GGOs in the lower lobes. After multivariate analysis, the presence of CONS in the lower lobes (p <0.0001) and signs of fibrosis in GGO in the lower lobes (p <0.0001) remained independently associated with COVID-19 pneumonia or SSc-ILD, respectively. These two variables were combined in a predictive score which resulted positively associated with the COVID-19 diagnosis, with 96.1% sensitivity and 83.3% specificity: 3 different risk class for COVID-19 pneumonia may be identified: high risk for COVID-19 pneumonia (5-9 points); probable overlap COVID-19 pneumonia in SSc-ILD (4 points); low risk for COVID-19 pneumonia (0-3 points).

Conclusion:

The CT differential diagnosis between COVID-19 Pneumonia and SSc-ILD is possible and may be fostered in practice by the use of a radiological score. In the case where an overlap of both diseases is suspected, the presence of consolidation in the lower lobes may suggest a COVID-19 pneumonia while the presence of fibrosis inside GGO may indicate a SSc-ILD.

References:

[1]Orlandi M, Landini N, Bruni C, et al. Infection or autoimmunity? The clinical challenge of interstitial lung disease in systemic sclerosis during COVID 19 pandemic. J Rheumatol. 2020 Dec 1: jrheum.200832

[2]Simpson S, Kay FU, Abbara S, et al. Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA [published online ahead of print, 2020 Apr 28]. J Thorac Imaging. 2020;10.1097/RTI.0000000000000524.

[3]Cheng C, Li C, Zhao T, et al. COVID-19 with rheumatic diseases: a report of 5 cases. Clin Rheumatol. 2020;39(7):2025-2029.

[4]Mariano RZ, Rio APTD, Reis F. Covid-19 overlapping with systemic sclerosis. Rev Soc Bras Med Trop. 2020 Sep 21;53:e20200450.

Disclosure of Interests:

None declared

FRI0641-HPR INTERSTITIAL LUNG DISEASE AS INITIAL MANIFESTATION OF SYSTEMIC AUTOIMMUNE RHEUMATIC DISEASES IN A MONOCENTRIC COHORT: THE IMPORTANCE OF A MULTIDISCIPLINARY APPROACH

Background:

Interstitial lung disease (ILD) can be the first manifestation of connective tissue disease (CTD) and rheumatoid arthritis (RA). Pulmonologists are usually the first referral in these patients.

Objectives:

To determine: 1) the prevalence of ILD as initial manifestation of CTD or RA 2) clinical characteristics of such patients.

Methods:

From a database of consecutive patients with CTD or RA referred to our academic hospital from 2009 and 2017, we selected all the patients with ILD as initial manifestation of the disease. Periodic multidisciplinary evaluations were performed during a median follow-up of 48 (35-50) months.

Results:

1) Fifty-four of the 427 patients with CTD or RA (12.6%) had ILD as initial manifestation (mean age: 63.9±12.9 yrs, F/M ratio: 20/34). Autoimmune myositis was diagnosed in 16/54 patients (29.6%), systemic sclerosis in 11 patients (20.4%), RA in 9 patients (16.7%), Sjogren syndrome in 9 patients (16.7%) and SLE in 3 patients (5.5%). Six patients remained classified as IPAF (11.1%). Among the Rheumatology patients we followed-up in the same period, autoimmune myositis had the highest prevalence of ILD as initial manifestation (63.6%), followed by Sjogren syndrome (20.5%), systemic sclerosis (20.0%), RA (3.4%), and SLE (3.3%). 2) Patients with initial ILD were all firstly evaluated by the Pulmonologist and the main reasons for Rheumatology referral were positivity for one or more autoantibodies (57.4%), mainly ANA≥1:320, and joint pain (29.6%). Thirty-six patients (66.7%) received steroid and/or immunosuppressive therapy in the six months before the first Rheumatology visit to relieve respiratory symptoms. Twenty of these patients (58.8%) had rheumatic manifestations during steroid tapering. ILD CT patterns were NSIP (25 patients, 52.1%), UIP (18 patients, 33.4%), and organizing pneumonia (5 patients, 9.3%). In four patients (4.5%), autoantibodies became positive during the follow-up. The final diagnosis of CTD- or RA-ILD was made after a median period of 16.5 (6-39) months from the clinical onset. At the time of diagnosis, average FVC was 90.4±18.7% of predicted, DLCO 55.4±20.2% and the median GAP index was 3 (2-3). During the median follow-up of 48 months, eight patients (14.8%) had a decline in DLCO of ≥ 15% predicted and/or a decline in FVC of ≥ 10% despite immunosuppressive drugs. Nine patients (17%) died and six of these patients (11.1%) for causes related to ILD.

Conclusion:

In our study population, the prevalence of ILD as initial manifestation of CTD or RA was 12.6%. Autoimmune myositis, systemic sclerosis and Sjogren syndrome were the most frequent diagnosis. As our data confirmed, ILD is a major cause of death in patients with systemic autoimmune diseases and can progress despite immunosuppression [1]. Furthermore, clinical features may become evident even months after the disease onset. A multidisciplinary evaluation is therefore essential, not only at the time of diagnosis but also during the follow-up [2].

References:

[1] A. Fischeret al.Progressive fibrosing interstitial lung disease associated with systemic autoimmune diseases.Clin Rheum(2019); 38:2673-81

[2] F. Furini,et al. The role of the Multidisciplinary Evaluation of Interstitial Lung Diseases: Systematic Literature Review of the Current Evidence and Future Perspectives.Front Med(2019); 6:246

Disclosure of Interests:

None declared

Tuberculosis screening in outpatient healthcare workers: lessons from a high-income, low TB burden country

SETTING: Early diagnosis of latent tuberculous infection (LTBI) should be pursued in healthcare workers (HCWs). While HCWs in hospitals are screened for LTBI, HCWs in outpatient settings are usually not. In 2017, in Italy, a tuberculosis (TB) infected paediatrician working in an outpatient vaccination service infected 15 adults and nine children. The investigation involved 2490 children and 151 adults. Among children, nine were tuberculin skin test-positive, and four developed active TB. Among 123 adult contacts with longer exposure, seven were interferon-gamma release assay (IGRA) positive and none had active TB. Among 28 close contacts, eight had a positive IGRA, and three had pulmonary TB. The total outbreak cost €1 017 903.OBJECTIVE: To compare the outbreak cost with those of potential screening programme strategies.RESULTS: Regular screening of paediatric outpatient HCWs would have cost between €2592 and €11 373. Extending the screening to all outpatient HCWs (caring for adults and children) would have cost between €66 384 and €155 043. Investigating only close contacts would have cost €42 857.CONCLUSION: Each of these screening strategies would have been cost-effective compared with the outbreak investigation occurring in real life with a cut-off of 474 for the maximum number of tested outpatient HCWs needed for the screening strategy to be cost-saving.

Tumour infiltrating lymphocytes and PD-L1 expression as potential predictors of outcome in patients with malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a rare and aggressive form of tumour. Some mesotheliomas have been proven to be highly immunogenic. Here, we investigated the correlation between tumour infiltrating lymphocytes (TILs) or programmed cell death ligand 1 (PD-L1) expression with overall survival (OS) in patients with MPM. 62 Paraffin-embedded formalin fixed (PEFF) samples were analysed for TILs and PD-L1 expression. Patients were divided in 4 groups according to a cut-off of the percentage of TILs found per sample as measured by immunohistichemistry: "0" or absent (between 0 and 5%), "1" or low (between 6 and 25%), "2" or moderate (between 26 and 50%) and "3" or high (between 51 and 75%). OS was then correlated with different TILs' expression patterns. Moreover, PD-L1 expression was assessed within the tumour as well as in the adjacent stroma on the same samples. Higher expression of peritumoral TILs (Group 2 + 3) versus Group 0 and 1 correlated with improved OS (p-value = 0.02). On the contrary PD-L1 expression seemed to be inversely correlated with clinical outcomes, even in the absence of statistical significance (HR 1.76; p = 0.083 95% IC 0.92-3.36 in areas within the tumour; HR 1.60; p = 0.176 95%; IC 0.80-3.19 in areas within the stroma). No relationship between TILs and PD-L1 expression was identified. Our research supports the use of TILs and PD-L1 expression as potential outcome predictors in patients with MPM. The use of TILs and PD-L1 as biomarkers for checkpoint inhibitors' efficacy warrants future investigation.

To use or not to use corticosteroids for pneumonia? A clinician's perspective

The use of corticosteroids in the management of pneumonia is still a controversial issue. The physicians in daily clinical practice often use corticosteroids in patients with pneumonia for different reasons all over the world. As an example of real life is the frequent use of corticosteroids to treat patients with pneumonia due to H1N1 pandemic influenza in spite of WHO' statements that clearly discouraged this therapy. In fact, the literature up to august 2012 reported a total of 6,650 patients with pneumonia due to H1N1 virus infection (of whom 2,515 were ICU patients): corticosteroids were used with various dose regimen in 2404 patients (37.8%). The attitude of international guidelines on pneumonia in using steroids do not help the clinician to clearly choice when and how to treat pneumonia with steroids. However, stress doses of corticosteroids are suggested by some major guidelines on community-acquired pneumonia in case of severe episodes with sepsis. To date, there are 10 randomised controlled trials assessing the effectiveness of corticosteroids for community-acquired pneumonia globally involving 1090 participants. Most of the trials adopted stress doses of glucorticoids for 4-7 days. The evidence from these trials taken separately is weak due to limitations of the studies themselves, but a Cochrane review and a systematic review found benefit using prolonged low doses of glucocorticoids in severe community-acquired pneumonia. Moreover, such a strategy decreases vasopressor dependency and appears to be safe. Nevertheless, larger trials with more patients and clinically important end-points were claimed to provide robust evidence. Finally, infection surveillance is critical in patients treated with corticosteroids, and to prevent the rebound phenomenon, the drug should be weaned slowly.

Prolonged hospitalisation for immigrants and high risk patients with positive smear pulmonary tuberculosis

BACKGROUND AND OBJECTIVE

Tuberculosis (TB) occurring in immigrants and resistance to drugs are major problems for TB control in Western countries. Directly observed therapy (DOT) reduces disease transmission, but this approach may have poor results among illegal immigrants. Our aim was to evaluate a prolonged hospitalisation programme to improve early outcome of TB treatment in high risk patients.

METHODS

All the consecutive adult patients with sputum smear-positive pulmonary TB admitted to 2 Italian referral TB Centres were evaluated. Hospital-based DOT was provided to high risk patients up-to smear conversion. Demographic, microbiological and clinical conditions, as potential factors associated with confirmed smear conversion at 60 and 90 days of anti-tuberculous therapy were evaluated.

RESULTS

122 patients were studied, 45.9% of them were immigrants (20% illegal) from high-prevalence TB countries. HIV testing was negative in all cases. Twelve patients had M. tuberculosis resistant to > or = 1 first-line anti-tuberculous agents. The rate of defaulting from TB treatment was 73%. Sputum smear became negative in 84.4% cases after 60 days and 933% cases after 90 days. At such time, smear conversion rates were similar among different high risk subgroups such as illegal immigrants (95.9%), legal foreign-born (92.5%) and Italian persons (94.8%). Persistent sputum smear positivity was independently correlated with the extent of pulmonary lesions at 60 (p < 0.0001) and 90 days (p = 0.038) of hospital-based DOT.

CONCLUSIONS

These findings suggest that prolonged hospitalisation for illegal immigrants and high risk TB patients, may positively influence the early outcome of TB treatment despite of drug resistance and legal status.

Out-of-hospital helmet CPAP in acute respiratory failure reduces mortality: a study led by nurses

BACKGROUND AND AIM

Acute respiratory failure (ARF) is a condition that must be treated as quickly as possible. Continuous Positive Airway Pressure (CPAP) is a common method used to treat ARF in hospital. The main objective of our study was to investigate the effect of CPAP prior to admission to the emergency room, on the reduction of endotracheal intubation, in-hospital mortality and on the length of stay in hospital (HLOS).

METHODS

A prospective, observational (non-randomised) study with a historical control group. Data from 3 groups of patients with ARF, irrespective of cause, was collected: pre-hospital CPAP (PHCPAP) group, i.e., 35 patients treated with a helmet CPAP in the ambulance, by trained nurses (mean age, years 80.1 +/- 7.9 SD; 14 males); hospital CPAP (HCPAP) group, i.e., 46 patients treated with helmet CPAP in the hospital emergency room (mean age 78.6 +/- 6.9 SD; 27 males), and a historical control group of 125 patients treated with medical therapy only (mean age 76.7 +/- 5.5 SD; 52 males). CPAP was delivered via a helmet interface.

RESULTS

Compared with standard medical therapy, helmet CPAP (pre and in-hospital) reduced mortality by 77% (p = 0.005), while pre-hospital helmet CPAP reduced it by 94% (p = 0.011), after adjustment for age, sex, severity of clinical conditions at entry and diagnosis upon admission. HLOS was reduced, compared with standard medical therapy, by 63.5% and by 66% (adjusting for age, sex, severity of clinical conditions at entry and diagnosis at admission) with helmet CPAP (pre and in-hospital) and with helmet CPAP in the ambulance, respectively (p < 0.0001).

CONCLUSIONS

Treating patients with ARF of any cause, with CPAP by trained nurses, before hospital admission, is safe, reduces mortality and the length of stay needed in hospital.

Production of transgenic barrel medic (Medicago truncatula Gaernt.) using the ipt-type MAT vector system and impairment of Recombinase-mediated excision events

Expression of the uidA reporter gene was tested in transformation experiments of barrel medic (Medicago truncatula Gaertn.) with the ipt-type control vectors pIPT5, pIPT10 and pIPT20 and distinct in vitro culture conditions. The highest GUS expression levels were obtained with the pIPT10 construct carrying the ipt gene under the control of the native ipt promoter and using kanamycin as selective agent. The ipt-shooty transformants, characterized by the absence of both rooting ability and apical dominance associated with vitrification, were easily identified by visual selection. Using only the ipt gene as selectable marker, we obtained a stable transformation frequency of 9.8% with pIPT10 construct. The ipt-type MAT vector pEXM2 was then used to monitor the excision events mediated by the yeast Recombinase and the consequent production of ipt marker-free transgenic plants. Transgenic ipt-shooty lines were recovered at a frequency of 7.9% in the absence of kanamycin-based selection. The ipt-shooty phenotype was maintained in all the transgenic lines and no reversion to the normal phenotype occurred. PCR analysis revealed the presence of the 'hit and run' cassette in the genome of all the regenerated ipt-shooty lines while RT-PCR experiments confirmed the expression of the R gene, encoding the yeast Recombinase. A detailed molecular investigation, carried out to verify the integrity of the RS sites, revealed that these regions were intact in most cases. Our results with barrel medic suggest that the MAT system must be carefully evaluated and discussed on a case by case basis.

Efficacy and safety of azithromycin 1 g once daily for 3 days in the treatment of community-acquired pneumonia: an open-label randomised comparison with amoxicillin-clavulanate 875/125 mg twice daily for 7 days

This randomised, open-label, non-inferiority study was designed to demonstrate that a 3-day course of oral azithromycin 1 g once daily was at least as effective as a standard 7-day course of oral amoxicillin-clavulanate 875/125 mg twice daily in the treatment of outpatients with community-acquired pneumonia (Fine class I and II). In total, 267 patients with clinically and radiologically confirmed community-acquired pneumonia were randomly assigned to receive either the azithromycin (n=136) or the amoxicillin-clavulanate (n=131) regimen. At screening, 60/136 (58.8%) and 61/131 (62.9%) respectively had at least one pathogen identified by sputum culture, PCR, or serology. The primary endpoint was the clinical response in the intent-to-treat population at the end of therapy (day 8 to 12). Clinical success rates were 126/136 (92.6%) for azithromycin and 122/131 (93.1%) for amoxicillin-clavulanate (treatment difference: - 0.48%; 95% confidence interval: - 5.66%; 4.69%). Clinical and radiological success rates at follow-up (day 22-26) were consistent with the end of therapy results, no patient reporting clinical relapse. Bacteriological success rates at the end of therapy were 32/35 (91.4%) for azithromycin and 30/33 (90.9%) for amoxicillin-clavulanate (treatment difference: 0.52%; 95% confidence interval - 10.81%; 11.85%). Both treatment regimens were well tolerated: the overall incidence of adverse events was 34/136 (25.0%) for azithromycin and 22/132 (16.7%) for amoxicillin-clavulanate. In both treatment groups, the most commonly reported events were gastrointestinal symptoms. Azithromycin 1g once daily for 3 days is at least as effective as amoxicillin-clavulanate 875/125 mg twice daily for 7 days in the treatment of adult patients with community-acquired pneumonia.

Out-patient high-dose-rate endobronchial brachytherapy for palliation of lung cancer: an observational study

BACKGROUND AND AIM

Out-patient high-dose-rate endobronchial brachytherapy (HDREB) is a possible option in the palliation of symptoms in patients with advanced lung cancer, but literature data is limited and the technique is still under development in Italy. Our aim was to evaluate safety and effectiveness of out-patient HDREB for palliation of malignant endobronchial tumours in the context of a multidisciplinary approach.

METHODS

Out-patient HDREB sessions were scheduled at weekly intervals (500-1000 cGy per session) with prior Diodi-laser resection in some cases. Response was assessed bronchoscopically, clinically and functionally at the end of treatment and one month after the last HDREB session. Inclusion criteria was: histological evidence of malignant tumour not susceptible to surgical treatment for extension or co-morbidity.

RESULTS

150 outpatient HDREB sessions were carried out on consecutive 35 patients (mean age 69 yrs, M/F 29/6) with symptoms due to central airway obstruction. A shortterm endoscopic response was observed in 15/28 patients. After delivering 2000 cGy dyspnoea decreased significantly. After one month cough decreased and haemoptysis disappeared. Palliation was obtained in all patients except one during. Lung function tests did not significantly improve after HDREB. No fatal complication occurred. A temporary radiation bronchitis was observed in six patients.

CONCLUSIONS

This non-comparative, prospective observational study showed a palliative response of HDREB in most of patients with advanced endoluminal lung cancer. The safety of the procedure was good and the rate of non-fatal serious complications was very low.

A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation

Knowing the likelihood of failure of noninvasive positive pressure ventilation (NPPV) in patients with exacerbation of chronic obstructive pulmonary disease (COPD) could indicate the best choice between NPPV and endotracheal intubation instituted earlier. For this purpose, two risk charts were designed (at admission and after 2 h of NPPV) that included all relevant measurable clinical prognostic indicators derived from a population representing the patients seen routinely in clinical practice. Risk stratification of NPPV failure was assessed in 1,033 consecutive patients admitted to experienced hospital units, including two intensive care units, six respiratory intermediate care units, and five general wards. NPPV was successful in 797 patients. Patients with a Glasgow Coma Score <11, acute physiology and chronic health evaluation (APACHE) II > or =29, respiratory rate > or =30 breaths x min(-1) and pH at admission <7.25 have a predicted risk of failure >70%. A pH <7.25 after 2 h greatly increases the risk (>90%). The risk charts were validated on an independent group of 145 consecutive COPD patients treated with NPPV due to an acute ventilatory failure episode. To identify patients with a probability of failure >50%, the sensitivity and specificity were 33% and 96.7% on admission and 52.9% and 94.1% after 2 h of NPPV, respectively. The prediction chart, based on data from the current study, can function as a simple tool to predict the risk of failure of noninvasive positive pressure ventilation and thus improve clinical management of patients tailoring medical intervention.

Quality of generated diagnosis related groups in Italian Respiratory Intermediate Care Units

BACKGROUND

To date we lack official data on tipology of Diagnosis Related Groups (DRGs) and their quality in Italian Respiratory Intermediate Care Units (RICUs).

AIM

The objective of the study was to collect data on the activity of 26 Italian RICUs and to evaluate the quality of the DRGs generated.

METHODS

The primary and secondary diseases, the procedures carried out and their coding using the ICD9 system (valid Italy until 2000) were collected from the discharge forms of patients admitted to RICUs. To obtain the DRG, these codes were automatically recoded in the ICD9-CM classification system by Grouper 10. Afterwards, the same diseases and procedures were directly processed by the ICD9-CM classification system. Finally, in order to evaluate the quality of care, the DRGs generated by the ICD9 classification system were compared to DRGs generated by the ICD9-CM classification system.

RESULTS

The average weight of the patients cared for in an Italian RICU was 2.05 using the ICD9 classification system and 2.53 using the ICD9-CM classification system. Some non-complicated DRGs (80-97) or non specific DRGs (101-102) were set to zero; others, like DRG 87 appear due to the ability of the ICD9-CM classification system to recognise and accept the fifth digit of the Respiratory Failure code (518.81). The difference in terms of DRG scores generated by the two codification systems was 360.5 DRG points in favour of ICD9-CM. More than 1 million Euro of reimbursements have been lost, as the average national reimbursement for each DRG score is Euro 2,943.80.

CONCLUSION

Severe pulmonary diseases determined the case mix of patients cared for in the Italian RICUs during the observed period. The Italian RICUs offer high quality assistance and are characterised by high mean weight per treated patient. However, the activity has been under-estimated due to the low sensitivity of the ICD9 classification system used in the recognition of the real disease and in the correct generation of relative DRG. The ICD9 classification system penalised the recognition of respiratory failure in particular.

Where to perform noninvasive ventilation?

Noninvasive positive-pressure ventilation (NPPV) has been shown to be a means of reducing the need for endotracheal intubation, which when effective reduces the complication rate and improves outcome. Because paralysis and sedation are not needed and because the patient is not necessarily dependent upon a machine for respiration, ventilation outside the intensive care unit (ICU) is an option. A number of studies have shown that NPPV for acute exacerbations of chronic obstructive pulmonary disease (COPD) can be effective in the non-ICU environment, though usually in patients with less severe exacerbations. However, there have been no direct comparisons of the application of NPPV in different locations. The likelihood of success of the technique is an important factor in deciding there NPPV should be performed. Ready access to invasive ventilation is important when NPPV is not indicated from the outset or fails after an initial trial. In acute exacerbations of COPD, NPPV is less likely to be successful the more severe the exacerbation, as measured by the severity of acidosis. Good tolerance of NPPV, which translates into an improvement in pH and a fall in respiratory rate, predicts a successful outcome and is a useful way of monitoring progress. NPPV has been shown to be cost effective both in the ICU and when performed on general wards. A dedicated intermediate care unit with particular expertise in noninvasive modes of ventilation may provide the best environment, both in terms of outcome, but also cost effectiveness. The ideal location for noninvasive positive-pressure ventilation will vary from country to country and indeed from hospital to hospital, depending upon local factors. However, the most important factor is that staff be adequately trained in the technique and be available throughout the 24-h period.

Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study

CONTEXT

In patients with hypoxemic acute respiratory failure (ARF), randomized studies have shown noninvasive positive pressure ventilation (NPPV) to be associated with lower rates of endotracheal intubation. In these patients, predictors of NPPV failure are not well characterized.

OBJECTIVE

To investigate variables predictive of NPPV failure in patients with hypoxemic ARF.

DESIGN

Prospective, multicenter cohort study.

SETTING

Eight Intensive Care Units (ICU) in Europe and USA.

PATIENTS

Of 5,847 patients admitted between October 1996 and December 1998, 2,770 met criteria for hypoxemic ARF. Of these, 2,416 were already intubated and 354 were eligible for the study.

RESULTS

NPPV failed in 30% (108/354) of patients. The highest intubation rate was observed in patients with ARDS (51%) or community-acquired pneumonia (50%). The lowest intubation rate was observed in patients with cardiogenic pulmonary edema (10%) and pulmonary contusion (18%). Multivariate analysis identified age > 40 years (OR 1.72, 95% CI 0.92-3.23), a simplified acute physiologic score (SAPS II) > or = 35 (OR 1.81, 95% CI 1.07-3.06), the presence of ARDS or community-acquired pneumonia (OR 3.75, 95% CI 2.25-6.24), and a PaO2:FiO2 < or = 146 after 1 h of NPPV (OR 2.51, 95% CI 1.45-4.35) as factors independently associated with failure of NPPV. Patients requiring intubation had a longer duration of ICU stay ( P < 0.001), higher rates of ventilator-associated pneumonia and septic complications ( P < 0.001), and a higher ICU mortality ( P < 0.001).

CONCLUSIONS

In hypoxemic ARF, NPPV can be successful in selected populations. When patients have a higher severity score, an older age, ARDS or pneumonia, or fail to improve after 1 h of treatment, the risk of failure is higher.

Respiratory intensive care units in Italy: a national census and prospective cohort study

BACKGROUND

In Italy, respiratory intensive care units (RICUs) provide an intermediate level of care between the intensive care unit (ICU) and the general ward for patients with single organ respiratory failure. Because of the lack of official epidemiological data in these units, a two phase study was performed with the aim of describing the work profile in Italian RICUs.

METHODS

A national survey of RICUs was conducted from January to March 1997 using a questionnaire which comprised over 30 items regarding location, models of service provision, staff, and equipment. The following criteria were necessary for inclusion of a unit in the survey: (1) a nurse to patient ratio ranging from 1:2.5 to 1:4 per shift; (2) availability of adequate continuous non-invasive monitoring; (3) expertise for non-invasive ventilation (NIV) and for intubation in case of NIV failure; (4) physician availability 24 hours a day. Between November 1997 and January 1998 a 3 month prospective cohort study was performed to survey the patient population admitted to the RICUs.

RESULTS

Twenty six RICUs were included in the study: four were located in rehabilitation centres and 22 in general hospitals. In most, the reported nurse to patient ratio ranged from 1:2 to 1:3, with 36% of units reporting a ratio of 1:4 per shift. During the study period 756 consecutive patients of mean (SD) age 68 (12) years were admitted to the 26 RICUs. The highest proportion (47%) were admitted from emergency departments, 19% from other medical wards, 18% were transferred from the ICU, 13% from specialist respiratory wards, and 2% were transferred following surgery. All but 32 had respiratory failure on admission. The reasons for admission to the RICU were: monitoring for expected clinical instability (n=221), mechanical ventilation (n=473), and weaning (n=59); 586 patients needed mechanical ventilation during their stay in the RICU, 425 were treated with non-invasive techniques as a first line of treatment (374 by non-invasive positive pressure, 51 by iron lung), and 161 underwent invasive mechanical ventilation (63 intubated, 98 tracheostomies). All but 48 patients had chronic respiratory disease, mainly chronic obstructive pulmonary disease (COPD; n=451). More than 70% of patients (n=228) had comorbidity, mainly consisting of heart disorders. The median APACHE II score was 18 (range 1--43). The predicted inpatient mortality risk rate according to the APACHE II equation was 22.1% while the actual inpatient mortality rate was 16%. The mean length of stay in the RICU was 12 (11) days. The outcome in most patients (79.2%) admitted to RICUs was favourable.

CONCLUSIONS

Italian RICUs are specialised units mainly devoted to the monitoring and treatment of acute on chronic respiratory failure by non-invasive ventilation, but also to weaning from invasive mechanical ventilation. The results of this study provide a useful insight into an increasingly important field of respiratory medicine.

Microbiological confirmation of tuberculosis cases at diagnosis and at the end of treatment in Italy

Microbiological findings at diagnosis and at the end of treatment are relevant for evaluating tuberculosis (TB) treatment programmes. The objectives of this study were to describe the microbiological findings at diagnosis and at the end of treatment in pulmonary and extrapulmonary TB patients treated under programme conditions in Italy. The study was a prospective monitoring activity based on the collection of standard recording and reporting forms from a representative sample of Italian TB Units. The forms with individual data were reviewed and analysed on a quarterly basis, 9 months after enrolment. The complete bacteriological profile of patients was analysed at diagnosis and at the completion of treatment. Individual data on 992 patients were analysed. At diagnosis 320 (32.2%) of cases were pulmonary sputum smear positive, 361 (36.4%) pulmonary smear negative or not done and 311 (33.4%) extrapulmonary; 424 (42.7%) of all TB cases were culture confirmed at diagnosis (368, 50.2%, of pulmonary cases); 575 (84.4%) of pulmonary cases had a culture done at diagnosis and 156 (22.9%) at the end of treatment (p < 0.001); 572 (84%) had a sputum smear done at diagnosis and 164 (24.1%) at the end of treatment (p < 0.001). Although the rate of bacteriologically confirmed cases is similar to that of other European countries, the bacteriological confirmation at diagnosis and, particularly, at the end of treatment, is sub-optimal. The importance of further disseminating national guidelines among physicians managing TB is emphasized, in order to achieve a higher proportion of TB cases bacteriologically confirmed at diagnosis and monitored at the end of treatment.

Clinical relevance of monitoring respiratory mechanics in the ventilator-supported patient: an update (1995–2000)

The introduction of mechanical ventilation in the intensive care unit environment had the merit of putting a potent life-saving tool in the physicians' hands in a number of situations; however, like most sophisticated technologies, it can cause severe side effects and eventually increase mortality if improperly applied. Assessment of respiratory mechanics serves as an aid in understanding the patient-ventilator interactions with the aim to obtain a better performance of the existing ventilator modalities. It has also provided a better understanding of patients' pathophysiology. Thanks to it, new ventilatory strategies and modalities have been developed. Finally, on-line monitoring of respiratory mechanics parameters is going to be more than a future perspective.

The appropriate setting of noninvasive pressure support ventilation in stable COPD patients

STUDY OBJECTIVE

To evaluate the short-term physiologic effects of two settings of nasal pressure-support ventilation (NPSV) in stable COPD patients with chronic hypercapnia.

DESIGN

Randomized controlled physiologic study.

SETTING

Lung function units and outpatient clinic of two affiliated pulmonary rehabilitation centers.

PATIENTS

Twenty-three patients receiving domiciliary nocturnal NPSV for a mean (+/- SD) duration of 31 +/- 20 months.

METHODS

Evaluation of arterial blood gases, breathing pattern, respiratory muscles, and dynamic intrinsic positive end-expiratory pressure (PEEPi,dyn) during both unassisted and assisted ventilation. Two settings of NPSV were randomly applied for 30 min each: (1) usual setting (U), the setting of NPSV actually used by the individual patient at home; and (2) physiologic setting (PHY), the level of inspiratory pressure support (IPS) and external positive end-expiratory pressure (PEEPe) tailored to patient according to invasive evaluation of respiratory muscular function and mechanics.

RESULTS

All patients tolerated NPSV well throughout the procedure. Mean U was IPS, 16 +/- 3 cm H(2)O and PEEPe, 3.6 +/- 1.4 cm H(2)O; mean PHY was IPS, 15 +/- 3 cm H(2)O and PEEPe, 3.1 +/- 1.6 cm H(2)O. NPSV was able to significantly (p < 0.01) improve arterial blood gases independent of the setting applied. When compared with spontaneous breathing, both settings induced a significant increase in minute ventilation (p < 0.01). Both settings were able to reduce the diaphragmatic pressure-time product, but the reduction was significantly greater with PHY (by 64%; p < 0.01) than with U (56%; p < 0.05). Eleven of 23 patients (48%) with U and 7 of 23 patients (30%) with PHY showed ineffective efforts (IE); the prevalence of IE (20 +/- 39% vs 6 +/- 11% of their respiratory rate with U and PHY, respectively) was statistically different (p < 0.05).

CONCLUSION

In COPD patients with chronic hypercapnia, NPSV is effective in improving arterial blood gases and in unloading inspiratory muscles independent of whether it is set on the basis of patient comfort and improvement in arterial blood gases or tailored to a patient's respiratory muscle effort and mechanics. However, setting of inspiratory assistance and PEEPe by the invasive evaluation of lung mechanics and respiratory muscle function may result in reduction in ineffective inspiratory efforts. These short-term results must be confirmed in the long-term clinical setting.

[Surgical treatment of varicocele with inguinal microligation technique. 6-year experience]

BACKGROUND

Varicocele is found approximately in 15% of the male population and is considered a major cause of infertility. Varicocele management include surgical (traditional or laparoscopic) or conservative techniques (sclerotherapy). The authors present their experience on microsurgical inguinal varicocelectomy. This technique has been adopted since 1992 to decrease the incidence of recidives of high spermatic vein ligation; it also permitted to use local or loco-regional anesthesia, reducing time of hospitalization and realizing a minimally invasive approach.

METHODS

From 1992 to 1997, 433 microsurgical inguinal varicocelectomy with artery and lymphatic sparing have been performed at the Militar Hospital of Milan in 409 young men with idiopathic varicocele. All patients were discharged 24 hours after operation. Only those who lived particularly far from the hospital remained for 48 hours.

RESULTS

Clinical controls were performed I, III, VI months after operation. At the third control (VI month), a new semen analysis was performed, and 65% of patients had an improvement of seminal characteristics. In 394 patients, a complete resolution of varicocele was observed; 4 patients had a recurrence of the pathology and 11 had a recidive. Seventy-three patients who presented a concomitant homolateral inguinal hernia were treated at the same time.

CONCLUSIONS

The conclusion is drawn that microsurgical ligation of spermatic veins represents a good surgical option in the treatment of varicocele. It is a quite simple technique that guarantees a low risk of recidives, permits using local or loco-regional anesthesia and can be performed in day-surgery with good results, few complications and good short and long term results.

Transformation of elite white poplar (Populus alba L.) cv. ' Villafranca' and evaluation of herbicide resistance

 Transgenic white poplar plants (Populus alba L.) expressing the nptII gene and the bar gene from Streptomyces hygroscopicus have been produced using Agrobacterium tumefaciens-mediated gene transfer. Eleven kanamycin-resistant plant lines were obtained with a transformation frequency of 7%. Successful genetic transformation was confirmed by Southern and northern analyses. The level of resistance to the commercial preparation of phosphinothricin (Basta; Roussel-Hoechst Agrovet) was evaluated by in vitro and in vivo assays. Using in vitro selective conditions for phosphinothricin, only plantlets from four kanamycin-resistant independent lines remained green and continued to grow and root. After transfer to the growth chamber, all selected transgenic lines were shown to be completely resistant to the herbicide Basta with doses equivalent to 6 l ha^-1 (normal field dosage) and were tolerant at concentration of 12 l ha^-1. This is the first report describing the genetic transformation of a P. alba clonal cultivar of commercial interest with a gene of agronomic value.

Induced sputum cellularity. Reference values and distribution in normal volunteers

Sputum induction has recently been proposed as the only direct noninvasive method for measuring airway inflammatory indices. The reference values and the distribution of cells in induced sputum in a control population have not yet been well defined. We therefore evaluated data from a large number of healthy volunteers. One hundred fourteen healthy, nonatopic, nonsmoking volunteers without airway hyperreactivity were enrolled (age: 38 +/- 13 yr [mean +/- SD]; FEV(1): 105 +/- 10% predicted; provocative dose of methacholine inducing a 20% decrease FEV(1) > 3,200 microgram). Ninety-six subjects (84%) produced adequate analysis samples. The subjects had a normal age distribution. Their induced sputum was rich in macrophages (69.2 +/- 13%) and neutrophils (27.3 +/- 13%), and poor in eosinophils (0.6 +/- 0.8%), lymphocytes (1.0 +/- 1.2%), and epithelial cells (1.5 +/- 1.8%). Only macrophages and neutrophils showed a normal distribution; total and differential counts of other cells did not. We propose that these data be used in comparison of the induced sputum cells of normal subjects and those of patients with airway inflammation.

Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation

In uncontrolled studies, noninvasive positive pressure ventilation (NPPV) was found useful in avoiding endotracheal intubation in patients with acute respiratory failure (ARF) caused by severe community-acquired pneumonia (CAP). We conducted a prospective, randomized study comparing standard treatment plus NPPV delivered through a face mask to standard treatment alone in patients with severe CAP and ARF. Patients fitting the American Thoracic Society criteria for severe CAP were included in presence of ARF (refractory hypoxemia and/or hypercapnia with acidosis). Exclusion criteria were: severe hemodynamic instability, requirement for emergent cardiopulmonary resuscitation, home mechanical ventilation or oxygen long-term supplementation, concomitant severe disease with a low expectation of life, inability to expectorate or contraindications to the use of the mask. Fifty-six consecutive patients (28 in each arm) were enrolled, and the two groups were similar at study entry. The use of NPPV was well tolerated, safe, and associated with a significant reduction in respiratory rate, need for endotracheal intubation (21% versus 50%; p = 0.03), and duration of intensive care unit (ICU) stay (1.8 +/- 0.7 d versus 6 +/- 1.8 d; p = 0.04). The two groups had a similar intensity of nursing care workload, time interval from study entry to endotracheal intubation, duration of hospitalization, and hospital mortality. Among patients with chronic obstructive pulmonary disease (COPD), those randomized to NPPV had a lower intensity of nursing care workload (p = 0.04) and improved 2-mo survival (88.9% versus 37.5%; p = 0.05). We conclude that in selected patients with ARF caused by severe CAP, NPPV was associated with a significant reduction in the rate of endotracheal intubation and duration of ICU stay. A 2-mo survival advantage was seen in patients with COPD.

Patient-ventilator asynchrony during noninvasive ventilation: the role of expiratory trigger

OBJECTIVE

Air leaks around the mask are very likely to occur during noninvasive ventilation, in particular when prolonged ventilatory treatment is required. It has been suggested that leaks from the mask may impair the expiratory trigger cycling mechanism when inspiratory pressure support ventilation (PSV) is used. The aim of this study was to compare the short-term effect of two different expiratory cycling mechanisms (time-cycled vs flow-cycled) during noninvasive inspiratory pressure support ventilation (NIPSV) on patient-ventilator synchronisation in severe hypoxemic respiratory failure.

STUDY POPULATION

Six patients with acute lung injury (ALI) due to acquired immunodeficiency syndrome (AIDS)-related opportunistic pneumonia were enrolled in the protocol.

INTERVENTION

Each subject was first studied during spontaneous breathing with a Venturi oxygen mask (SB) and successively submitted to a randomly assigned 20' conventional flow-cycling (NIPSVfc) or time-cycling inspiratory pressure support ventilation (NIPSVtc). The pre-set parameters were: inspiratory pressure of 10 cm H2O, PEEP of 5 cm H2O for the same inspired oxygen fraction as during SB. A tight fit of the mask was avoided in order to facilitate air leaks around the mask. The esophageal pressure time product (PTPes) and tidal swings (delta Pes) were measured to evaluate the patient's respiratory effort. A subjective "comfort score" and the difference between patient and machine respiratory rate [delta RR(p-v)], calculated on esophageal and airway pressure curves, were used as indices of patient-machine interaction.

RESULTS

Air leaks through the mask occurred in five out of six patients. The values of PEEPi (< 1.9 cm H2O) excluded significant expiratory muscle activity. NIPSVtc significantly reduced PTPes, delta Pes, and delta RR(p-v) when compared to NIPS-Vfc [230 +/- 41 (SE) vs 376 +/- 72 cm H2O.s.min-1; 8 +/- 2 vs 13 +/- 2 cm H2O; 1 +/- 1 vs 9 +/- 2 br.min-1; respectively] with a concomitant significant improvement of the "comfort score".

CONCLUSIONS

In the presence of air leaks a time-cycled expiratory trigger provides a better patient-machine interaction than a flow-cycled expiratory trigger during NIPSV.

Gas exchange response to exercise in patients with chronic heart failure

The objective of the study was investigate the pulmonary gas exchange response to exercise in 16 male patients with chronic heart failure (CHF) due to previous myocardial infarction and left ventricular dysfunction (ejection fraction < 45%). All patients underwent a symptom-limited exercise test during which cardiac frequency (fC), tidal volume (VT), respiratory frequency (fR), minute ventilation (V'E), oxygen consumption (V'O2) and carbon dioxide production (V'CO2) were measured on a breath-by-breath basis. Ventilatory equivalent for carbon dioxide (V'E/V'CO2) and lactate threshold (LT) were calculated. Arterial blood gas levels were measured at rest and at peak exercise. The dead space (VD) to tidal volume ratio (VD/VT) and alveolar-arterial oxygen gradient (PA-a,O2) were computed. Two subgroups of patients were identified according to peak V'O2 (V'O2,peak), group A (n = 7), V'O2,peak > 14 mL.kg-1.min-1 (17.2 +/- 2.5 SEM, range 14.5-20.8), and group B (n = 9), V'O2,peak < 14 mL.kg-1.min-1 (11.9 +/- 1.8, range 9.2-13.6). Arterial oxygen tension (Pa,O2) increased from rest to peak exercise in both groups (group A: 12.2 +/- 0.94 to 13.4 +/- 0.82 kPa (91.4 +/- 7.1 to 100.4 +/- 6.2 mmHg), p < 0.05; group B: 11.7 +/- 1.0 to 13.4 +/- 1.1 kPa (88.0 +/- 7.8 to 100.9 +/- 8.2 mmHg), p < 0.01), while a significant reduction in arterial carbon dioxide tension (Pa,CO2), from rest to peak exercise, was observed in group B only (4.64 +/- 0.39 to 4.08 +/- 0.36 kPa (34.9 +/- 2.8 to 30.7 +/- 2.7 mmHg), p < 0.005). Maximal V'E and maximal power (Powermax) were significantly lower in group B compared to group A (V'E 37.6 +/- 8.4 versus 52.1 +/- 13.8 L.min-1, p < 0.05; Powermax 64.4 +/- 12 versus 82.8 +/- 14.1 W, p < 0.01). fC was not significantly different at peak exercise, although the work load was significantly higher in group A. VD/VT failed to decrease significantly at maximal exercise in both groups. In group B, V'E/V'CO2 tended to be higher than in group A. In chronic heart failure patients, measurements of arterial blood gas levels during exercise might help to identify those subjects with a more pronounced depression of left ventricular function. At peak exercise, high ventilatory demand and respiratory alkalosis were observed in group B patients, suggesting an increased responsiveness of the respiratory centre that might be one major factor contributing to this excessive ventilatory response to exercise; vice versa, a combination of ventilation-perfusion mismatch, wasted ventilation and unpaired peripheral blood circulation seem to play only a minor role.

Effect of methacholine challenge on cellular composition of sputum induction

BACKGROUND

Induced sputum and methacholine inhalation challenge are routinely used for the assessment of airway inflammation and airway hyperresponsiveness, respectively. This study investigates whether a methacholine challenge performed one hour before sputum induction alters the cellular and biochemical constituents of sputum.

METHODS

Sixteen stable asthmatic patients with lung function within the normal range underwent two sputum inductions within one week. One hour before one of the sputum inductions a methacholine challenge was performed.

RESULTS

There were no significant differences in total cell count, macrophages, neutrophils, eosinophils, lymphocytes, epithelial cells, ECP, and albumin between the two challenges. The repeatability of cell counts was good for all cells, ECP and albumin, but poor for total cells.

CONCLUSIONS

In patients with stable asthma a methacholine challenge carried out one hour before sputum induction does not significantly alter the cellular and biochemical constituents of sputum.

Study of release of eosinophil cationic proteins (ECP and EPX) in the hypereosinophilic syndrome (HES) and other hypereosinophilic conditions

BACKGROUND

Up to date, the etiology and the pathogenesis of HES are still unknown and particularly it is unclear why eosinophils in HES are more aggressive towards tissues than in other eosinophilic conditions.

METHODS

We assessed the cationic proteins ECP and EPX serum concentrations, their in vitro release from polymorphonuclear cell culture, and the monoclonal antibodies EG1 and EG2 in 3 patients with HES, 6 patients with other hypereosinophilic conditions and 20 healthy control subjects.

RESULTS

Serum ECP and EPX concentrations were higher in eosinophilic patients than in healthy subjects. Hypereosinophilic patients had more EG2+ cells than healthy subjects, but EG2+ rate failed to differentiate HES from other hypereosinophilic conditions (p = 0.074). Moreover, the release in vitro of ECP and EPX was significantly higher in HES patients (p < 0.05).

CONCLUSIONS

Our preliminary results seem to suggest the importance of functional data, such as ECP and EPX release, in differentiating HES from other hypereosinophilic diseases. Particularly, ECP and EPX release in vitro is higher in cell cultures from HES patients than from patients with other hypereosinophilic conditions.

Inhaled corticosteroids reduce neutrophilic bronchial inflammation in patients with chronic obstructive pulmonary disease

BACKGROUND

Airways inflammation is a feature of chronic obstructive pulmonary disease (COPD), but the role of corticosteroids in the management of clinically stable patients has yet to be established. A randomised controlled study was carried out to investigate the effect of high dose inhaled beclomethasone dipropionate (BDP) administered for two months to patients with stable, smoking related COPD. Sputum induction was used to evaluate bronchial inflammation response.

METHODS

34 patients (20 men and 14 women) were examined on three separate occasions. At the initial clinical assessment (visit 0), spirometry and blood gas analysis were performed. On visit 1 (within one week of visit 0) sputum induction was performed and each patient was randomised to receive either BDP 500 micrograms three times daily (treated group) or nothing (control group). After two months (visit 2), all patients underwent repeat clinical assessment, spirometry, and sputum induction.

RESULTS

There were no differences in sputum cell counts between the groups at baseline. After two months of treatment, induced sputum samples from patients in the treated group showed a reduction in both neutrophils (-27%) and total cells (-42%) with respect to baseline, while the control group did not (neutrophils +9%, total cells +7%). Macrophages increased in the treated group but not in the control group. The mean final value of sputum neutrophils was 52% in the treated group and 73.3% in the control group (95% confidence interval (CI) -27.2 to -15.4). The mean final value of sputum macrophages was 35.8% in treated group and 19.3% in control group (95% CI 10.3 to 22.8). The differences between the treated and control groups for neutrophils (-21.3%), macrophages (+16.5%), and total cells (-65%) were significant. Spirometry and blood gas data did not change from baseline in either patient group.

CONCLUSIONS

A two month course of treatment with high dose inhaled BDP reduces significantly neutrophil cell counts in patients with clinically stable, smoking related COPD. Further studies on the effectiveness of inhaled steroids in COPD are needed to confirm the clinical importance of this observation.

Haemodynamic response during initiation of non-invasive positive pressure ventilation in COPD patients with acute ventilatory failure

The aim of this study was to check non-invasively the acute haemodynamic effects of non-invasive positive pressure ventilation (NPPV) initiation in patients with chronic obstructive pulmonary disease (COPD) and acute ventilatory failure (AVF). Nineteen consecutive COPD patients with AVF were evaluated clinically and echocardiographically during spontaneous breathing with O2 supplementation and during NPPV plus O2. NPPV was administered with a scheduled inspiratory pressure of 15 cmH2O and an expiratory pressure of 4 cmH2O, via facial mask. Arterial blood gas improved significantly (pH and PaCO2; P < 0.001) during NPPV administration in all patients; none had hypotension or acute arrhythmia. Doppler echocardiographic evaluation was feasible in most of the patients (16/18). With reference to baseline values, no significant changes in pulmonary artery pressures and cardiac output (CO) were observed by Doppler echocardiography in most patients. Only four patients (21%) showed a significant reduction (> 15%) of CO during NPPV. No correlation was found between decreased CO and baseline data, but three patients showing CO reduction had poor tolerance to mask ventilation and did not improve respiratory rate during NPPV. It was concluded that the initiation of NPPV by facial mask does not alter haemodynamics acutely in most COPD patients with AVF, but individual patients may experience reduction in CO in spite of adequate oxygen saturation levels. This suggests that caution should be used when applying pre-determined and fixed pressures during NPPV. Monitoring haemodynamics by Doppler echocardiography may be useful for early detection of haemodynamic alterations due to NPPV application in patients with AVF.

Physiological effects of flow and pressure triggering during non-invasive mechanical ventilation in patients with chronic obstructive pulmonary disease

BACKGROUND

The effect of the type of trigger system on inspiratory effort has been studied in intubated patients, but no data are available in non-invasive mechanical ventilation where the "trigger variable" may be even more important since assisted modes of ventilation are often employed from the beginning of mechanical ventilation.

METHODS

The effect of flow triggering (1 and 5 1/min) and pressure triggering (-1 cm H2O) on inspiratory effort during pressure support ventilation (PSV) and assisted controlled mode (A/C) delivered non-invasively with a full face mask were compared in patients with chronic obstructive pulmonary disease (COPD) recovering from an acute exacerbation. The patients were studied during randomised 15 minute runs at zero positive end expiratory pressure (ZEEP). The oesophageal pressure time product (PTPoes), dynamic intrinsic PEEP (PEEPi,dyn), fall in maximal airway pressure (delta Paw) during inspiration, and ventilatory variables were measured.

RESULTS

Minute ventilation, respiratory pattern, dynamic lung compliance and resistances, and changes in end expiratory lung volume (delta EELV) were the same with the two triggering systems. The total PTPoes and its pre-triggering phase (PTP due to PEEPi and PTP due to valve opening) were significantly higher during both PSV and A/C with pressure triggering than with flow triggering at both levels of sensitivity. delta Paw was larger during pressure triggering, and PEEPi,dyn was significantly reduced during flow triggering in the A/C mode only.

CONCLUSIONS

In patients with COPD flow triggering reduces the inspiratory effort during both PSV and A/C modes compared with pressure triggering. These findings are likely to be due to a reduction in PEEPi,dyn and in the time of valve opening with a flow trigger.

Noninvasive mechanical ventilation improves the immediate and long-term outcome of COPD patients with acute respiratory failure

Noninvasive positive pressure ventilation (NPPV) has been proposed in COPD patients with acute on chronic respiratory failure (ACRF) in order to avoid endotracheal intubation and to improve immediate outcome, but long-term outcome of this therapeutic approach is still undefined. We evaluated short- and long-term (1 year) outcome of early administration of NPPV in 24 patients with ACRF due to exacerbated COPD (Group A) in comparison with 24 matched historical-control patients treated conventionally (Group B). Patients of Group A were initially treated with NPPV via nasal mask in the presence of pH < or = 7.32, and/or Pa,O2 < 7.98 kPa, and/or Pa,CO2 > 7.18 kPa, plus signs of respiratory distress. In-hospital survival rate was not significantly different in Group A vs Group B, but the patients treated with NPPV showed an earlier improvement in blood gases and a better pH and respiratory rate at discharge. Only 2 patients of Group A needed endotracheal intubation as compared with 9 of Group B. Hospital stay was significantly reduced in survivors of Group A vs Group B. Further severe relapses of ACRF in Group A were treated using NPPV. The number and length of further hospitalizations for pulmonary exacerbations were significantly higher in Group B compared with Group A. The survival rate at 12 months was significantly lower in Group B than in Group A (50% vs 71%). In conclusion, NPPV administration in patients with ACRF due to exacerbated COPD improves not only immediate but also long-term outcome.

International guidelines and educational experiences in an out-patient clinic for asthma

In June 1989, an out-patient clinic for asthma was instituted at Crema Hospital, Italy. Up to November 1994, 430 adult asthmatics were recruited, classified and managed according to the recommendations of the international guidelines. The aims of this study are to verify: 1) whether the organization of the clinic could maintain asthma under control and reduce hospital admissions; and 2) whether the traditional educational approach could be implemented by lessons in the school of asthma to improve the control of asthma symptoms and/or admissions. The data reported refer to the first 360 asthmatics attending the clinic between 1989 and 1994: 53, 45 and 2% of them were suffering from extrinsic, intrinsic and occupational asthma, respectively. On recruitment, forced expiratory volume in one second (FEV1) was < 80% of predicted in 170 patients, and arterial oxygen tension (Pa,O2) 8.0 kPa (< 60 mmHg) in 27 patients. After the admission visit, 190 patients (53%) were classified as mild, 97 (27%) as moderate, and 73 (20%) as severe asthmatics. In May 1993, a school of asthma was organized. Forty four patients were recruited, stratified according to the severity of their asthma and randomized into two groups: 22 patients attended the school, and 22 patients did not. Each group consisted of 5, 10 and 7 patients with mild, moderate and severe asthma, respectively. The school comprised four lessons twice a week. One year after the end of the school, we could find no differences between the two groups (school versus controls) with regard to the number of urgent care visits (9 vs 9), scheduled visits (22 vs 21) and hospital admissions (2 vs 2).

Prevention of delayed emesis with metoclopramide and dexamethasone in patients receiving moderately emetogenic cytotoxic treatment

Forty-three untreated cancer patients receiving moderately emetogenic polychemotherapy entered a phase II trial in order to evaluate the effectiveness of the combination of metoclopramide (40 mg every 6 hrs) and dexamethasone (8 mg every 12 hrs) in the prevention of delayed emesis (days 2-3). For the control of acute emesis all patients received on day 1 ondansetron 8 mg for 3 times. Results of antiemetic treatment were as follows: complete/major protection from acute emesis (day 1) was observed in 72%/88% of patients. Worst day analysis of delayed emesis (days 2 and 3) showed that complete/major protection was obtained in 93%/95% of cases, respectively. Delayed nausea was not as well controlled: complete/major protection was observed in 44%/79% of patients. Extrapyramidal reactions occurred in 3 patients and moderate epigastric pain was reported by 3 patients. Since control of acute emesis could be one of the most important factors influencing delayed emesis, the absence of acute symptoms in 72% of our patients may be partially responsible for the excellent control of delayed emesis. The combination of metoclopramide and dexamethasone is a feasible and effective treatment for delayed emesis in outpatients receiving moderately emetogenic chemotherapy.

Heterozygosity for homocysteinuria: a detectable and reversible risk factor for pulmonary thromboembolism

Heterozygosity for homocysteinuria is a common, inherited autosomal condition that has recently been considered as an independent cardiovascular risk factor. In vitro and in vivo results suggest that this condition, like the homozygous form, is also a risk factor for deep-venous thrombosis and pulmonary thromboembolism. We report a case of recurrent pulmonary thromboembolism in a young woman with familial hyperhomocysteinaemia. The relative frequency of this condition, as well as its simple and harmless cure, make testing for heterozygosity for homocysteinuria useful and profitable in the prevention of pulmonary thromboembolism, above all in younger subjects with a significant case history.

Benign idiopathic hypereosinophilia: a feeble masquerader or a smouldering form of the hypereosinophilic syndrome?

In a patient with long-standing idiopathic hypereosinophilia with no apparent organ damage we measured serum eosinophil cationic protein (ECP) and eosinophil protein X (EPX) titers, activated circulating eosinophil rates (by means of monoclonal antibodies EG1 and EG2), and the release of ECP and EPX in vitro by leukocytes at different cultures stages in order to detect possible functional abnormalities associated with hypereosinophilia. Our patient had elevated serum levels of both ECP and EPX, together with a high EG2 count, which would suggest eosinophil activation. However, serum levels of ECP and EPX were not significantly high in relation to the total number of eosinophil cells, although they were more numerous than in healthy controls. Moreover, the release of intracytoplasmic basic proteins by the patient's eosinophils was poor even after in vitro stimulation. Since hypereosinophilic syndrome (HES) with organ damage can appear as long as 8-9 years after the presence of a hypereosinophilic state, the absolutely benign nature of our patient's condition still cannot be defined. Thus, there is the possibility it could be slow-onset or smoldering HES.