Acidification and solar drying of manure-based digestate to produce improved fertilizing products

The increase in energy and fertilizer consumption makes it necessary to develop sustainable alternatives for agriculture. Anaerobic digestion and digestates appeared to be suitable options. However, untreated digestates still have high water content and can increase greenhouse gas emissions during storage and land application. In this study, manure-derived digestate and solid fraction of digestate after separation were treated with a novel solar drying technology to reduce their water content, combined with acidification to reduce the gaseous emissions. The acidified digestate and acidified solid fraction of digestate recovered more nitrogen and ammonia nitrogen than their respective non-acidified products (1.5-1.3 times for TN; 14 times for TAN). Ammonia and methane emissions were reduced up to 94% and 72% respectively, compared to the non-acidified ones, while N₂O increased more than 3 times. Dried digestate and dried acidified digestate can be labeled as NPK organic fertilizer regarding the European regulation, and the dried solid fraction and the improved dried acidified solid fraction can be labeled as N or P organic fertilizer. Moreover, plant tests showed that N concentrations in fresh lettuce leaves were within the EU limit with all products in all the cases. However, zinc concentration appeared to be a limitation in some of the products as their concentration exceeded the European legal limits.

Lung ultrasound protocol decreases radiation in newborn population without side effects: A quality improvement project

OBJECTIVE

To reduce radiation exposure in newborns admitted due respiratory distress based on the implementation of lung ultrasound (LUS).

DESIGN

Quality improvement (QI), prospective, before-after, pilot study.

SETTING

Third level neonatal intensive care unit (NICU) level with 25-bed and 1800 deliveries/year.

PATIENTS

Inclusion criteria were neonates admitted with respiratory distress.

INTERVENTIONS

After a theoretical and practical LUS training a new protocol was approved and introduced to the unit were LUS was the first-line image. To study the effect of the intervention we compare two 6-month periods: group 1, with the previous chest X-ray (CXR)-protocol (CXR as the first diagnostic technique) vs. group 2, once LUS-protocol had been implemented.

MAIN VARIABLES OF INTEREST

The main QI measures were the total exposure to radiation. Secondary QI were to evaluate if the LUS protocol modified the clinical evolution as well as the frequency of complications.

RESULTS

122 patients were included. The number of CXR was inferior in group 2 (group 1: 2 CXR (IQR 1-3) vs. Group 2: 0 (IQR 0-1), p<0.001), as well as had lower median radiation per baby which received at least one CXR: 56 iGy (IQR 32-90) vs. 30 iGy (IQR 30-32), p<0.001. Respiratory support was similar in both groups, with lower duration of non-invasive mechanical ventilation and oxygen duration the second group (p<0.05). No differences regarding respiratory development complications, length of stay and mortality were found.

CONCLUSIONS

The introduction of LUS protocol in unit decreases the exposure radiation in infants without side effects.

Neonatal alloimmune thrombocytopenia due to anti-HPA 5a in a HPA-5a homozygous neonate

The most frequently involved antigen in severe fetal and neonatal alloimmune thrombocytopenia (FNAIT) is the human platelet antigen 1a. Cases of FNAIT caused by HPA-5a antigen are extremely rare, and usually not severe. We report a case of FNAIT caused by anti-HPA antibodies directed to the HPA-5a antigen. The thrombocytopenia was moderate with a minimal platelet count of 36 × 10⁹/L by day 3, and spontaneously resolved by day 10. The pregnancy had been obtained by in vitro fertilization using embryo donation, creating a complete genetic disparity between the HPA 5b5b mother and the HPA 5a5a homozygous neonate. The use of ART with gamete donation can increase the risk and the severity of alloimmune thrombocytopenia and must be considered in new and subsequent pregnancies.

Theory of mind in binge eating disorder: an exploratory study

Introduction

to date, studies on the relationship between Theory of Mind (ToM) and eating disorders (ED) have never considered binge eating disorder (BED).

Aims a) to assess ToM abilities in a sample of patients suffering from BED comparing them with healthy controls; b) to evaluate the influence of several variables (demographic, clinical and neuropsychological dimensions, attachment styles, traumatic events, comorbid Axis I and II disorders) on ToM abilities.

Methods

we assessed ToM in a sample of 20 BED patients and 22 women from the general population using the Reading the Mind in the Eyes Test (RMET) and the Faux Pas Test (FPT).

Results

regarding the first aim, the comparison between groups showed that the clinical group scored significantly lower than the control group on the RMET as well as on FPT. Regarding the second aim, two different multiple regression models were performed: one for the RMET and one for the FPT. Both of them led to significant results. When modeling RMET score, it emerged that age and Binge Eating Scale significantly reduce the score, while vocabulary and drive for thinness have a positive effect (r2 = 0.62). When modeling FPT score, we found that central coherence and binge eating significantly reduce the total score (r2 = 0.33).

Conclusions

our study begins to shed light on the relationship between ToM and BED; in particular, it suggests that BED patients have lower mentalization skills than healthy controls and ToM abilities are partially influenced by clinical variables related to eating pathology.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Two biomarker-directed randomized trials in European and Chinese patients with nonsmall-cell lung cancer: the BRCA1-RAP80 Expression Customization (BREC) studies

BACKGROUND

In a Spanish Lung Cancer Group (SLCG) phase II trial, the combination of BRCA1 and receptor-associated protein 80 (RAP80) expression was significantly associated with outcome in Caucasian patients with nonsmall-cell lung cancer (NSCLC). The SLCG therefore undertook an industry-independent collaborative randomized phase III trial comparing nonselected cisplatin-based chemotherapy with therapy customized according to BRCA1/RAP80 expression. An analogous randomized phase II trial was carried out in China under the auspices of the SLCG to evaluate the effect of BRCA1/RAP80 expression in Asian patients.

PATIENTS AND METHODS

Eligibility criteria included stage IIIB-IV NSCLC and sufficient tumor specimen for molecular analysis. Randomization to the control or experimental arm was 1 : 1 in the SLCG trial and 1 : 3 in the Chinese trial. In both trials, patients in the control arm received docetaxel/cisplatin; in the experimental arm, patients with low RAP80 expression received gemcitabine/cisplatin, those with intermediate/high RAP80 expression and low/intermediate BRCA1 expression received docetaxel/cisplatin, and those with intermediate/high RAP80 expression and high BRCA1 expression received docetaxel alone. The primary end point was progression-free survival (PFS).

RESULTS

Two hundred and seventy-nine patients in the SLCG trial and 124 in the Chinese trial were assessable for PFS. PFS in the control and experimental arms in the SLCG trial was 5.49 and 4.38 months, respectively [log rank P = 0.07; hazard ratio (HR) 1.28; P = 0.03]. In the Chinese trial, PFS was 4.74 and 3.78 months, respectively (log rank P = 0.82; HR 0.95; P = 0.82).

CONCLUSION

Accrual was prematurely closed on the SLCG trial due to the absence of clinical benefit in the experimental over the control arm. However, the BREC studies provide proof of concept that an international, nonindustry, biomarker-directed trial is feasible. Thanks to the groundwork laid by these studies, we expect that ongoing further research on alternative biomarkers to elucidate DNA repair mechanisms will help define novel therapeutic approaches.

TRIAL REGISTRATION

NCT00617656/GECP-BREC and ChiCTR-TRC-12001860/BREC-CHINA.

Abstract P4-09-10: Prospective Analysis of Fatty Acid Synthase (FASN) in Breast Cancer Tissue of Early-Stage Breast Cancer Patients

Background: Cancer cells require nutrients to survive in the unfavorable microenvironment of primary solid tumors or metastases before angiogenesis development. Fatty acid synthase (FASN) is a multi-enzyme protein that catalyzes fatty acid synthesis. Expression levels of FASN are low or undetectable in normal human tissues except for the liver and the adipose tissue. In contrast, high levels of FASN expression have been detected in breast cancer tumors and other human carcinomas. Several reports highlight that FASN overexpression in tumor samples correlates with progression, aggressiveness and metastatic potential of the disease. In adition, some studies have suggested the same correlation with serum levels of FASN. Our aim was to analyze the association between the expression of tumor and serum levels of FASN with clinical and pathological prognostic factors in early-stage breast cancer patients.

Methods: Fifty-five patients with early-stage breast cancer treated with surgery and post-operative chemotherapy were included in the study. We prospectively measured the levels of FASN in tumor and serum samples. Clinical data included demographic characteristics, menarche, pregnancy, breast feeding, menopausal status and body mass index (BMI). Pathological and molecular data included: pathological state, histological grade, estrogen and progesterone receptors, HER2 status, p53 mutation and Ki 67 levels. FASN tissue expression levels were determined by IHC and circulating FASN levels were determined by ELISA. FASN expression was graded from 0 to 3+, meaning 0–1+ normal amounts of FASN protein compared to non-tumor breast tissue, 2+ moderate amounts and 3+ the highest levels of FASN expression. Baseline characteristics were summarized descriptively. Categorical variables were compared by c2 or Fisher's exact. For continuous variables, if the data are approximately normal, the two groups were compared using ANOVA. If the normality assumption is not warranted, then the Kruskall-Wallis test has been used.

Results: Median age was 49 (rage 33–77). 51% of the patients were menopausal and median BMI was 24,75. Thirty-four percent of the patients had stage I, 51% stage II and 15% stage III. We observed a statistically significant association between FASN over expression and the lack of progesterone receptors (p = 0.027) in tumor samples. In contrast, we found no relation between FASN and estrogen receptor nor between FASN and HER2 tumor expression in this setting. Menopause and age were strongly related to higher levels of FASN tumor expression (p &lt; 0.001). Patients with higher BMI had higher levels of FASN in tumor tissue although this association was not statistically significant (p = 0.07). Finally, we observed a positive relation between breast cancer stage and the levels of FASN tumor (p = 0.05). In contrast, circulating FASN levels were not associated with any pathological or clinical prognostic factor.

Conclusions: Our study suggests that FASN overexpression is significantly related to age, menopausal status, more advanced stages and lack of progesterone receptor expression in early-stage breast cancer patients. However, no relation between serum levels of FASN and the clinical or molecular prognostic factors have been observed.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-09-10.

Brain metastases from lung cancer responding to erlotinib: the importance of EGFR mutation

Median survival of patients with brain metastases from nonsmall cell lung cancer (NSCLC) is poor and more effective treatments are urgently needed. We have evaluated the efficacy of erlotinib in this setting and its association with activating mutations in the epidermal growth factor receptor (EGFR) gene. We retrospectively identified patients with NSCLC and brain metastases treated with erlotinib. EGFR mutations in exons 19 and 21 were analysed by direct sequencing. Efficacy and tolerability were compared according to EGFR mutational status. 69 NSCLC patients with brain metastases were identified, 17 of whom harboured EGFR mutations. Objective response rate in patients with EGFR mutations was 82.4%; no responses were observed in unselected patients (p<0.001). Median (95% CI) time to progression within the brain for patients harbouring EGFR mutations was 11.7 (7.9-15.5) months, compared to 5.8 (5.2-6.4) months for control patients whose EGFR mutational status had not been assessed (p<0.05). Overall survival was 12.9 (6.2-19.7) months and 3.1 (2.5-3.9) months (p<0.001), respectively. The toxicity of erlotinib was as expected and no differences between cohorts were observed. Erlotinib is active in brain metastases from NSCLC; this clinical benefit is related to the presence of activating mutations in exons 19 or 21 of the EGFR gene.

Characteristics and outcomes of non-small cell lung cancer (NSCLC) patients (pts) carrying epidermal growth factor receptor (EGFR) mutations who progress after initial erlotinib (E) response

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Background: Most NSCLC pts with EGFR mutations respond to E; however, resistance to this tyrosine kinase inhibitor (TKI) can be acquired. The resistant T790M mutation has been identified in 50% of progressing pts. We assessed pt characteristics and outcome to additional treatment in 55 EGFR mutated pts after progression to E. Results: Pts mean age was 59±12.5 years; 65% females; 94% never-smokers; 54 adenocarcinoma. 35 pts (63%) were PS ≤2; main metastasis sites were lung (39/71%), bone (21/38%) and liver (10/18%). 22 and 25 pts received E as first- or second-line treatment, respectively. Mutations in tumor were: 65% DelE19 (Δ746–750), 35% L858R mutation; with 31% and 20% serum detection respectively. For the complete cohort, overall response rate (ORR) with E was 78% and time to progression (TTP) was 11.2 months (m) (range, 4–29 m). After progressing to E, 8 pts were re-biopsied, of whom 2 had the T790M mutation; 9 had the T790M mutation in serum (16%). 49% received platinum-based chemotherapy, 14.5% E plus another agent (bevacizumab, fulvestrant, vorinostat), 25.5% single-agent chemotherapy and 11% a non-reversible TKI (HKI-272). ORR for first-line post-E treatments was 33% (CR 1/PR 9) and median TTP was 8 m (range, 4.1–11.8 m). There were no differences in TTP according to gender (p = 0.10), type of mutation (p = 0.63) or severity of skin toxicity (p = 0.16). 11 pts received a second-line post-E treatment with E plus chemotherapy, achieving an ORR of 40%. Median survival was 27 m for all 55 pts (range, 22.9–31.1 m). Conclusions: Pts with EGFR mutations present a biologically different disease which continued to be sensitive to other treatments after progressing to E.

No significant financial relationships to disclose.

Multicenter prospective trial of customized erlotinib for advanced non-small cell lung cancer (NSCLC) patients (p) with epidermal growth factor receptor (EGFR) mutations: Final results of the Spanish Lung Cancer Group (SLCG) trial

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Background: The purpose of the study was to evaluate the efficacy of erlotinib and the feasibility of screening for EGFR mutations in advanced NSCLC p (chemonaive or relapsed after 2 prior chemotherapy regimens). Methods: Exon 19 deletions and L858R mutations in tumor and paired serum DNA were assessed in one central laboratory, using three different techniques. Results: From April 2005 to December 2008, 2507 p were screened. EGFR mutations were detected in 358 p; 217 were entered on the trial: 158 (72.8%) female; 148 (68.2%) never-smokers; 176 (81.1%) adenocarcinoma; 134 (62.3%) exon 19 deletion, 83 (37.7%) L858R mutation; 112 (51.6%) first-line, 104 (48.4%) second-line. Response in 139/197 evaluable p (70.6%); complete response (CR) in 24 p (12.2%). Odds ratio for response: 3 for p with exon 19 deletion (P=0.001). Time to progression (TTP): 14 months (m). Median survival (MS): 27 m. MS according to response shown in table. Cox model for TTP showed that male gender (hazard ratio [HR], 2.3; P=0.001), L858R mutation (HR, 1.8; P=0.008), and mutated EGFR in serum (HR,1.6; P=0.03) had a negative impact. Conclusions: A multicenter study of customized erlotinib, using a central screening laboratory, is feasible and shows the outstanding benefit to p for selecting erlotinib treatment based on EGFR mutation status. The SLCG has initiated a randomized trial of first-line erlotinib vs chemotherapy.

[Table: see text]

No significant financial relationships to disclose.

Fennel waste-based films suitable for protecting cultivations

Biodegradable, flexible, and moisture-resistant films were obtained by recycling fennel waste and adding to fennel homogenates the bean protein phaseolin that was modified or not modified by the enzyme transglutaminase. All films were analyzed for their morphology, mechanical properties, water vapor permeability, and susceptibility to biodegradation under soil-like conditions. Our experiments showed that transglutaminase treatment of the phaseolin-containing fennel waste homogenates allowed us to obtain films comparable in their mechanical properties and water vapor permeability to the commercial films Ecoflex and Mater-Bi. Furthermore, biodegradability tests demonstrated that the presence of the enzyme in the film-casting sample significantly influences the integrity of such a product that lasts longer than films obtained either with fennel waste alone or with a mixture of fennel waste and phaseolin. These findings indicate the fennel-phaseolin film prepared in the presence of transglutaminase to be a promising candidate for a new environmentally friendly mulching bioplastic.

14–3-3 σ and checkpoint with forkhead and ring finger (CHFR) methylation in serum in erlotinib-treated non-small-cell lung cancer (NSCLC) patients (p) with EGFR mutations

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Background: 14–3-3 proteins have 130 potential binding partners, including Cbl. 14–3-3 expression can prevent mutant EGFR binding to Cbl, impairing ubiquitination and endocytosis. 14–3-3s is frequently methylated in NSCLC; we hypothesized that in the presence of EGFR mutations, methylated 14–3-3s could permit the formation of the EGFR-Cbl complex. CHFR is a checkpoint that delays entry into metaphase in response to mitotic stress. Methods: 73 stage IV NSCLC p with EGFR exon 19 deletion or exon 21 L858R mutation received first- or second-line erlotinib single therapy. 14–3-3s and CHFR methylation was examined in the baseline serum of these p. Results: Median age, 63 (range, 26–83); females, 48 p (65.8%); Caucasian, 72 p, Asian, 1 p; never-smokers, 45 p, ex-smokers, 21 p, smokers, 7 p; adenocarcinoma, 64 p, large cell carcinoma, 9. PS: 0, 19 p, 1, 42 p, 2–3, 12 p. 14–3-3s was methylated in 39.7% and CHFR in 42.5% of p. No differences in p characteristics were observed according to methylation status. Complete response was observed in 11.1% of p, and partial response in 75.4%. Overall response was 86.5%. There was a trend toward a higher response rate in p with unmethylated CHFR (94.4% vs 76.6%; P=ns). Overall median time to progression (TTP) and survival (MS) have not been reached either in first- or second-line. However, when split according to methylation status, there was a trend toward better TTP and MS in both first- and second-line in p with methylated 14–3-3s. TTP in second-line in p with methylated 14–3-3s has not been reached, while it was 10.8 months (m) for p with unmethylated 14–3-3s (P=ns). TTP in second-line in p with methylated CHFR was 5.2 m but was not reached for p with unmethylated CHFR (P=0.05). Conclusions: Methylated 14–3-3s can permit Cbl binding to mutant EGFR and predict longer-lasting response to erlotinib in p with EGFR mutations. The precise role of CHFR warrants further research. Complete data will be presented.

No significant financial relationships to disclose.

Viral Genotyping of Infectious Bursal Disease Viruses Isolated from the 2002 Acute Outbreak in Spain and Comparison with Previous Isolates

An infectious bursal disease (IBD) outbreak occurred in the east region of Spain in the spring of 2002 and rapidly spread thorough the whole country, although proper vaccination programs were applied. In this report, 33 infectious bursal disease viruses (IBDVs) isolated from this outbreak were characterized by nucleotide sequencing of the VP2 gene hypervariable region and were compared with reference IBD strains and the 1990s Spanish IBDVs in order to determine possible emergence of IBDV isolates with modified antigenic or virulent properties. Moreover, histopathologic and immunohistochemical studies of those cases where bursal tissues were available were carried out. Of the 33 isolates, 23 were identified as very virulent IBDVs (vvIBDVs), whereas the other 10 isolates were classified as attenuated or intermediate virulence classical strains and could possibly be IBDV live vaccine strains used in the immunization of these chickens. Results of this study indicate that wIBDV isolates from the 2002 Spanish outbreak are closely related with those from the 1990s outbreak. However, acute IBD cases have not been reported in Spain during these 10 yr. Genetic, management, and environmental factors likely related with IBD reemergence in Spain are discussed. Moreover, our results indicate that good correlation exists between the IBDV subtype present in the field and the degree of lesions in bursa tissue, as well as the immunohistochemistry staining.

Recombinant human tissue transglutaminase produced into tobacco suspension cell cultures is active and recognizes autoantibodies in the serum of coeliac patients

Human tissue transglutaminase (htTG) is one of the most important member within the transglutaminase family, enzymes that for their capacity of catalyzing post-translational modifications of proteins and peptides, rise an high interest for industrial applications. More recently, for its implication as the major autoantigen in the coeliac disease, availability of human tissue transglutaminase as recombinant form is required for accurate diagnostic tests. The aim of this study was to find an alternative and inexpensive source to produce human tissue transglutaminase. To date, plant systems are proposed as heterologous hosts to produce recombinant proteins for use in disease diagnosis and therapy. Here, we describe the stable expression of human tissue transglutaminase into Nicotiana tabacum cultured cells (cultivar Bright Yellow 2 (BY-2)). The recombinant enzyme was successfully expressed in different plant cell compartments and both apoplast (apo) and chloroplast (chl) purified proteins were shown to be catalytically active and able to bind GTP, a property possessed by the natural counterpart. Importantly, plant produced human tissue transglutaminase recognized autoantibodies in the serum of coeliac patients, suggesting possible applications in the diagnosis of coeliac disease.

Tumour necrosis factor family genes in a phenotype of COPD associated with emphysema

Genetic factors are believed to play a role in the individual susceptibility to chronic obstructive pulmonary disease (COPD). Tumour necrosis factor (TNF) family genes have been widely investigated but inconsistent results may lie either in the genetic heterogeneity of populations or in the poor phenotype definition. A genetic study was performed using a narrower phenotype of COPD. The authors studied 86 healthy smokers and 63 COPD subjects who were enrolled based on irreversible airflow obstruction (forced expiratory volume in one second/forced vital capacity <70% predicted) and a diffusing capacity for carbon monoxide <50% predicted (moderate-to-severe COPD associated with pulmonary emphysema). The following polymorphisms were investigated: TNF-308, the biallelic polymorphism located in the first intron of the lymphotoxin-alpha gene, and exon 1 and exon 6 of the TNF receptor 1 and 2 genes, respectively. No significant deviations were found concerning the four polymorphisms studied between the two populations. The authors confirm that the tumour necrosis factor family genes, at least for the polymorphisms investigated, are not major genetic risk factors for chronic obstructive pulmonary disease in Caucasians, either defined in terms of emphysema (this study) or airflow obstruction (previous studies). Nevertheless, the authors would like to emphasise the importance of narrowing the phenotype in the search for genetic risk factors in chronic obstructive pulmonary disease.

Anti-tissue transglutaminase antibodies from coeliac patients inhibit transglutaminase activity both in vitro and in situ

BACKGROUND AND AIMS

Coeliac disease (CD) is a multifactorial disorder which has an autoimmune component characterised by the occurrence of disease specific autoreactive antibodies against the enzyme tissue transglutaminase (tTG). The aim of this study was to investigate whether binding of antibodies to the enzyme influences tTG activity.

METHODS

tTG activity was assayed in the presence of immunoglobulin A (IgA) and immunoglobulin G (IgG) purified from the serum of coeliac patients, CUB 7402 (an anti-tTG mouse monoclonal antibody), and human anti-tTG monoclonal antibodies derived from both intestinal lymphocytes from three patients with CD and from peripheral blood lymphocytes from healthy subjects. For our studies we used calcium treated and untreated recombinant human tTG. Furthermore, the effects of antibodies were determined by immunohistochemical detection of tTG activity in sections of human umbilical cord.

RESULTS

IgG and IgA from CD patients inhibited tTG activity in vitro in a dose dependent manner, with a different rate of inhibition among patients. The monoclonal antibody CUB 7402 and human monoclonal antibodies displayed a dose dependent inhibitory effect towards the catalytic activity of the enzyme, both in vitro and in situ. Preincubation of tTG with CaCl(2) caused loss of the inhibitory effect due to CUB 7402 but not that caused by human monoclonal antibodies.

CONCLUSIONS

Purified CD IgA, IgG, as well as human anti-tTG monoclonal antibodies inhibited the enzymatic activity of human tTG both in vitro and in situ.

Lack of additional effect of adjunct of assisted ventilation to pulmonary rehabilitation in mild COPD patients

Different modalities of assisted ventilation improve breathlessness and exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate the effects of the addition of assisted ventilation during exercise training on the outcome of a structured pulmonary rehabilitation programme (PRP) in COPD patients. Thirty-three male patients with stable COPD (mean (SD) forced expiratory volume in 1 s (FEV1) 44 (16) % pred), without chronic ventilatory failure, undergoing a 6-week multidisciplinary outpatient PRP including exercise training, were randomised to training during either mask proportional assist ventilation (PAV: 18 patients) or spontaneous breathing (SB: 15 patients). Assessment included exercise tolerance, dyspnoea, leg fatigue, and health-related quality of life (HRQL). Five out of 18 patients (28%) in the PAV group dropped out due to lack of compliance with the equipment. Both groups showed significant post-PRP improvements in exercise tolerance (peak work rate difference: 20 (95% Cl 2.4-37.6) and 14 (3.8% CI to 24.2) W in PAV and SB group, respectively), dyspnoea and leg fatigue, but not in HRQL, without any significant difference between groups. It is concluded that with the modality and in the patients assessed in this study assisted ventilation during training sessions included in a multidisciplinary PRP was not well tolerated by all patients and gave no additional physiological benefit in comparison with exercise training alone.

In-hospital short-term training program for patients with chronic airway obstruction

OBJECTIVE

To compare the functional benefits and relative costs of administering an intense short-term inpatient vs a longer outpatient pulmonary rehabilitation program (PRP) for patients with chronic airway obstruction (CAO).

DESIGN

Retrospective case-control study.

SETTING

Pulmonary ward and outpatient clinic of a rehabilitation center.

PATIENTS

Forty-three patients (case subjects) selected on the basis of selection criteria were compared with control subjects matched to them for age, sex, FEV(1), and diagnosis of either COPD or asthma. Case subjects performed 10 to 12 daily sessions (5 sessions a week) of inpatient PRP; control subjects performed 20 to 24 sessions (3 sessions a week) of outpatient PRP.

MEASUREMENTS

At baseline and after the PRP, an incremental exercise test was performed, including evaluation of dyspnea and leg fatigue by Borg scale (D and F, respectively) at each workload step. The cost of PRP was also evaluated.

RESULTS

Both PRPs resulted in similar significant improvements in cycloergometry peak workload (from 68 +/- 18 to 82 +/- 22 and from 75 +/- 17 to 87 +/- 27 W in case subjects and control subjects, respectively), isoload D (from 6.4 +/- 1.6 to 4.2 +/- 1.8 for case subjects and from 8.5 +/- 1.9 to 6.3 +/- 2.4 for control subjects) and isoload F (from 6.6 +/- 1.8 to 4.2 +/- 1.8 for case subjects and from 8.9 +/- 1.9 to 7.0 +/- 1.8 for control subjects). Although the single daily session was less expensive, the outpatient PRP total costs were greater because of the higher number of sessions and the cost of daily transportation.

CONCLUSIONS

In patients with CAO, a shorter inpatient PRP may result in improvement in exercise tolerance similar to a longer outpatient PRP but with lower costs. Whether a shorter outpatient PRP may get physiologic and clinical benefits, while further reducing costs, must be evaluated by future controlled, randomized, prospective studies.

Substance P and its transglutaminase-synthesized spermine derivative elicit yawning behavior via nitric oxide in rats

Previously, we showed that intranigrostriatal injection of substance P (SP) cause behavioral changes in rats. Those effects, such as locomotion and food intake, resulted related to catecholamines release modulated by nitric oxide [18]. Here we report that intranigrostriatal injection of SP elicited yawning in rats. Moreover, since in previous studies we demonstrated that transglutaminase-synthesized gamma-(glutamyl5)spermine derivative of SP (Spm-SP) could be a useful tool in differentiating NK1 receptors [5,19,26], we reports the effects of injecting the selective septide-sensitive NK1 receptor agonist Spm-SP into the nigrostriatal region of the rat brain on yawning. The administration of L-N(omega)-nitroarginine methyl ester, a NO-synthase inhibitor, stereospecifically reduced in a dose related manner both SP and Spm-SP-induced yawning. In contrast, L-arginine pretreatment prevented the effect of NO-synthase inhibitor. Moreover, the NK1 antagonist RP,67580 blocked yawning behavior induced by both SP and Spm-SP, whereas the pretreatment with systemic reserpine determined its increase. The administration of NO-synthase inhibitor resulted ineffective in reducing SP and Spm-SP-induced yawns in reserpinized rats. Finally, yawns elicited by SP or Spm-SP were blocked when rats were treated with scopolamine but not with methylscopolamine. These results indicate that yawning induced in rats by SP injection is dependent upon endogenous dopamine levels in brain nigrostriatal area. Moreover, we demonstrate, by using Spm-SP, that septide-sensitive NK1 receptor are specifically involved in yawning behavior.

Physiological response to pressure support ventilation delivered before and after extubation in patients not capable of totally spontaneous autonomous breathing

We designed a prospective, physiological study in 12 patients affected by chronic respiratory disorders. The study was aimed at assessing the diaphragm energy expenditure (PTPdi), lung resistance (RL) and elastance (EL), arterial blood gases (ABG), breathing pattern, and dyspnea measured by a visual analog scale during invasive pressure support ventilation (i-PSV) and noninvasive PSV (n-PSV). The ventilator settings were kept the same. Both i-PSV and n-PSV significantly reduced the PTPdi per minute, compared with that during a T-piece trial (204.4 +/- 93.8 cm H(2)O x s/min [i-PSV]; 197.5 +/- 119.8 [n-PSV]; 393.8 +/- 129.0 [T-piece]). Expired tidal volume (VTe) was significantly higher (p < 0.05) during n-PSV (615 +/- 166 ml) than during i-PSV (519 +/- 140 ml). The respiratory pump (PTPdi/VTe) was more effective (p < 0.05) with noninvasive ventilation (22.3 +/- 2.3 cm H(2)O x s/L for i-PSV versus 17.2 +/- 3.3 for n-PSV). RL and EL were similar with the two modes of ventilation. Overall dyspnea was significantly (p < 0.05) better during n-PSV than i-PSV, whereas ABG were similar. We have shown, in patients affected by stable chronic respiratory disorders not ready to sustain totally spontaneous breathing, that i-PSV and n-PSV are equally effective in reducing the PTPdi and in improving ABG, but that n-PSV seems to be better tolerated.

Comparison of two methods for weaning patients with chronic obstructive pulmonary disease requiring mechanical ventilation for more than 15 days

We designed a prospective multicenter randomized controlled study in three long-term weaning units (LWU) to evaluate which protocol, inspiratory pressure support ventilation (PSV) or spontaneous breathing trials (SB), is more effective in weaning patients with chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation for more than 15 d. Fifty-two of 75 patients, failing an initial T-piece trial at admission, were randomly assigned to PSV or SB (26 in both groups). No significant difference was found in weaning success rate (73% versus 77% in the PSV and SB group, respectively), mortality rate (11.5% versus 7.6%), duration of ventilatory assistance (181 +/- 161 versus 130 +/- 106 h), LWU (33 +/- 12 versus 35 +/- 19 d), or total hospital stay. The results of these defined protocols were retrospectively compared with an "uncontrolled clinical practice" in weaning historical control patients. The overall 30-d weaning success rate was significantly greater (87% versus 70%) and the time spent under mechanical ventilation by survived and weaned patients was shorter in the patients in the study than in historical control patients (103 +/- 144 versus 170 +/- 127 h). The LWU and hospital stays were also significantly shorter (27 +/- 12 versus 38 +/- 18 and 38 +/- 17 versus 47 +/- 18 d). Spontaneous breathing trials and decreasing levels of PSV are equally effective in difficult-to-wean patients with COPD. The application of a well-defined protocol, independent of the mode used, may result in better outcomes than uncontrolled clinical practice.

Tissue transglutaminase expression in quail epiphyseal chondrocytes

Tissue transglutaminase (tTGase) is a GTP-binding Ca(2+)-dependent enzyme which catalyses the post-translational modification via epsilon(gamma-glutamyl)lysine bridges. The physiological role of tTGase is not fully understood. It has been shown that in cartilage the expression of tTGase correlates with terminal differentiation of chondrocytes. Recent evidence suggests that the GTP-binding activity of tTGase may play a role in the control of cell cycle progression thus explaining some of the suggested roles for the enzyme.tTGase activity is present in primary cultures of epiphyseal chondrocytes and increases transiently upon retinoic acid (RA) treatment. Increase in enzyme activity occurs upon RA addition and is accompanied by a parallel increase in protein and mRNA levels. Stimulation of tTGase expression by RA correlates with suppression of cell growth and occurs independently of cell adhesion and cell differentiation.tTGase expression is not observed in MC2, a permanent chondrocyte cell line derived from retrovirus infected chondrocytes. RA treatment fails to activate tTGase expression in MC2 cells and to completely suppress cell proliferation. Our findings lend support to the idea that tTGase might play a role in non-dividing cultured chondrocytes.

Effect of pulmonary rehabilitation on exhaled nitric oxide in patients with chronic obstructive pulmonary disease

BACKGROUND

In patients with mild to moderate chronic obstructive pulmonary disease (COPD) the exercise induced increase in exhaled nitric oxide (eNO) parallels that observed in normal untrained subjects. There is no information on the effects of the level of exercise tolerance on eNO in these patients. The aim of this study was to evaluate the effect of a pulmonary rehabilitation programme including exercise training on eNO in patients with COPD.

METHODS

In 14 consecutive male patients with stable COPD of mean (SD) age 64 (9) years and forced expiratory volume in one second (FEV1) 55 (14)% predicted, fractional eNO concentration (FeNO), peak work rate (Wpeak) and oxygen uptake (VO2peak) were assessed at baseline (T-1), at the end of a 1 month run in period (T0), and after an 8 week outpatient multidisciplinary pulmonary rehabilitation programme (T1) including cycloergometer training.

RESULTS

FeNO did not significantly differ at T-1 and T0 (mean (SE) 4.3 (0.6) and 4.4 (0.6) ppb, respectively), whereas it rose significantly at T1 to 6.4 (0.7) ppb (p<0.02). Compared with T0, both Wpeak and VO2 were significantly (p<0.05) increased at T1 (mean (SE) Wpeak from 89 (5.6) W to 109 (6.9) W); VO2peak from 1.27 (0.1) l/min to 1.48 (0.1) l/min). A significant correlation was found between baseline FEV1 and the change in FeNO following the rehabilitation programme (r=-0.71; p<0.05) and between changes in FeNO and Wpeak from T0 to T1(r=0.60; p<0.05).

CONCLUSIONS

Pulmonary rehabilitation in patients with mild to moderate COPD is associated with an increase in exhaled nitric oxide.

Effect of pulmonary rehabilitation on exhaled nitric oxide in patients with chronic obstructive pulmonary disease

BACKGROUND

In patients with mild to moderate chronic obstructive pulmonary disease (COPD) the exercise induced increase in exhaled nitric oxide (eNO) parallels that observed in normal untrained subjects. There is no information on the effects of the level of exercise tolerance on eNO in these patients. The aim of this study was to evaluate the effect of a pulmonary rehabilitation programme including exercise training on eNO in patients with COPD.

METHODS

In 14 consecutive male patients with stable COPD of mean (SD) age 64 (9) years and forced expiratory volume in one second (FEV1) 55 (14)% predicted, fractional eNO concentration (Feno), peak work rate (Wpeak) and oxygen uptake (V˙o2peak) were assessed at baseline (T–1), at the end of a 1 month run in period (T0), and after an 8 week outpatient multidisciplinary pulmonary rehabilitation programme (T1) including cycloergometer training.

RESULTS

Fenodid not significantly differ at T–1 and T0 (mean (SE) 4.3 (0.6) and 4.4 (0.6) ppb, respectively), whereas it rose significantly at T1 to 6.4 (0.7) ppb (p<0.02). Compared with T0, both Wpeak andV˙o2 were significantly (p<0.05) increased at T1 (mean (SE) Wpeak from 89 (5.6) W to 109 (6.9) W);V˙o2peak from 1.27 (0.1) l/min to 1.48 (0.1) l/min). A significant correlation was found between baseline FEV1 and the change in Feno following the rehabilitation programme (r=–0.71; p<0.05) and between changes in Feno and Wpeak from T0 to T1(r=0.60; p<0.05).

CONCLUSIONS

Pulmonary rehabilitation in patients with mild to moderate COPD is associated with an increase in exhaled nitric oxide.

Antithrombin activity of an algal polysaccharide

In an effort to reduce the risks of a possible iatrogenic transmission of bovine spongiform encephalitis (BSE) through the use of bovine-derived medicinal products, we patented in the USA in 1999 a polysaccharide from brown algae, endowed with interesting pharmacological activities: (a) concentration-dependent inhibition of thromboplastin or cephalin-kaolin-induced thrombin generation from platelets, (b) concentration-dependent inhibition of thrombin-induced platelet aggregation, (c) thrombin has hypotensive effect, which was blunted and zeroed by our fucansulfate in a dose-dependent way, (d) when aortae are stimulated with thrombin, they become stickier for polymorphonucleated leukocytes (PMNs); our fucansulfate decreased concentration-dependently, PMNs sticking to autologous rabbit aortae, (e) dose-dependent inhibition of thrombin-induced thrombosis. All the above data suggest that our fucansulfate could be a heparin substitute endowed with antithrombotic and anti-inflammatory activities, devoid or the problems caused to heparin by its animal origin, i.e., possible prion protein contamination.

Rat coagulating gland secretion contains a kinesin heavy chain-like protein acting as a type IV transglutaminase substrate

By a proteomic approach, we demonstrated in rat coagulating gland secretion the presence of a 120 kDa protein which shares at least 80% identity at the amino acid level with the most closely related kinesin heavy chain codified by the kinesin superfamily protein Kif5c gene. In addition, we identified 30 and 66 kDa proteolytic fragments of such a kinesin heavy chain-like protein, corresponding to the 73-299 N-terminal and 300-860 C-terminal regions, respectively. Finally, we demonstrated the occurrence in coagulating gland secretion of a 200 kDa protein probably derived by cross-linking reaction of the kinesin heavy chain-like protein with type IV transglutaminase. In fact, kinesin heavy chain-like protein and its 66 kDa proteolytic fragment were also found to act as effective acyl donor substrates for the enzyme in vitro.

Measurement of dyspnoea

Dyspnoea is the term generally applied to unpleasant or uncomfortable respiratory sensations. The measurement of dyspnoea is a critical aspect of patient evaluation and management. Both psychophysical methods and clinical scales have been used to assess breathlessness. Because of dyspnoeic patient is frequently unable to perform the daily activities of life due to discomfort associated with breathing, the clinical methods used to measure dyspnoea have depended primarily on the magnitude of the exertional task that evokes breathlessness. The visual analogue scale is one method that has been used. To improve the clinical rating, two more indices (baseline dyspnoea index and transition dyspnoea index) that include the components of functional impairment and magnitude of effort, in addition to the magnitude of the task, were developed. The category-ratio-10 scale developed by Borg consists of verbal descriptors adjacent to specific numbers, providing a category scale with ratio properties. Measurement instruments may involve a cost for use, may be self-administered or require an interviewer, and will vary in the time required for completion and scoring.

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.

Preliminary results on nursing workload in a dedicated weaning center

OBJECTIVE

To evaluate the nursing time required for difficult-to-wean patients in a dedicated weaning center (WC) and to examine the correlation of the nursing time with nursing workload (NW) scores and with clinical severity and dependency.

SETTING

Four-bed WC of a pulmonary rehabilitation department.

INTERVENTION

None.

DESIGN AND MEASUREMENT

Prospective, observational study of 46 consecutive patients admitted to a long-term WC. Time required by items of the Time Oriented Score System (TOSS) and other tasks specific to respiratory intermediate intensive care units were evaluated for all the activities performed on each patient in the first 2 days after admission. Patient dependency and level of nursing care at admission were measured using the Dependence Nursing Scale (DNS) and the Intermediate Therapeutic Intervention Score System (TISS-int). The Acute Physiology and Chronic Health Evaluation (APACHE) II score was also recorded at admission.

RESULTS

On the first day each patient needed 45 +/- 15% (63 +/- 23%, 45 +/- 22%, and 29 +/- 14% for the three nursing shifts) of allocated single nursing time. On the TOSS on the first day patients required a daily mean 28 +/- 10% of total available nursing time; on the second day the results did not change. Time of care in the first 24 h was only weakly related to DNS, APACHE II score, and TISS-int; only DNS was able (although weakly; r = 0.45) to predict minutes of nursing care.

CONCLUSIONS

In difficult-to-wean patients from mechanical ventilation the nursing time in the first 2 days after admission is high. The use of TOSS may underestimate NW by about 38%. Although only DNS showed the ability to predict minutes of care, the weak relationship limits its value in clinical practice.

Endogenous nitric oxide in patients with chronic heart failure (CHF): relation to functional impairment and nitrate-containing therapies

We assessed the levels of exhaled nitric oxide (eNO) in patients with chronic heart failure (CHF) according to the functional impairment and the use of nitrate-containing agents. Forty patients (age 55+/-9 years) were classified according to the NYHA classes I-II (n=18, group 1) and classes III-IV (n=22, group 2), and to the use of nitrate-containing drugs (Nitrate+, Nitrate-). Twenty-two healthy age-related subjects served as controls (group 3). Respiratory function, symptom-limited incremental cycloergometry and resting eNO concentration at peak (FENOp) or plateau (FENOpl) of the single-breath exhalation curve were assessed in all subjects. FENOpl was significantly lower in patients than in controls (7.8+/-2.7 and 10.6+/-2.8 ppb, respectively, P<0.005) and lower in most severe CHF patients (7.1+/-2.6 and 8.8+/-2.7 ppb in group 2 and group 1, respectively, P<0.05). A significant correlation between peak V'O(2), Watts and FENOpl (r=0.42, P<0.013 and r=0.46, P=0.008, respectively) was found. Independent of NYHA class, Nitrate+ showed higher FENOp levels than Nitrate- patients (36.9+/-15.7 vs. 28. 1+/-15.1 ppb, P<0.05). Resting eNO was lower in the most compromised CHF patients and was significantly related to exercise capacity. Nitrate-containing agents might influence the levels of eNO in these patients.