Pulmonary rehabilitation for chronic obstructive pulmonary disease

BACKGROUND

The widespread application pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function attributable to the programs. This review updates that reported by Lacasse et al Lancet 1996; 748:1115-1119.

OBJECTIVES

To determine the impact of rehabilitation on health-related quality of life (QoL) and exercise capacity in patients with COPD.

SEARCH STRATEGY

The 14 randomized controlled trials (RCTs) included in the original meta-analysis were included. Additional RCTs were identified from the Cochrane Airways Group's registry of COPD RCTs using the strategy: [exp, lung diseases, obstructive] and [exp, rehabilitation or exp, exercise therapy] and [research design or longitudinal studies or evaluation study or randomized controlled trial]. Abstracts presented at American Thoracic Society 1980-2000, American College of Chest Physicians 1980-2000 and European Respiratory Society 1987-2000 were also searched.

SELECTION CRITERIA

RCTs of rehabilitation in patients with COPD in which quality of life (QoL) and/or functional (FEC) or maximal (MEC) exercise capacity were measured. Rehabilitation was defined as exercise training for at least 4 weeks with or without education and/or psychological support. Control groups received conventional community care without rehabilitation.

DATA COLLECTION AND ANALYSIS

Weighted mean differences (WMD) were calculated using a random-effects model. Missing data from the primary study reports were requested from the authors.

MAIN RESULTS

23 RCTs met the inclusion criteria. Statistically significant improvements were found for all the outcomes. In three important domains of QoL (Chronic Respiratory Questionnaire scores for Dyspnea, Fatigue and Mastery), the effect was larger than the minimal clinically important difference of 0.5 units using this instrument. For example Dyspnoea score: WMD 0.98 units, 95% Confidence Interval (95% CI) 0.74 - 1.22 units; n=9 trials. For FEC and MEC, the effect was small and a little below the threshold of clinical significance for the 6- minute walking distance: WMD 49 m, 95% CI: 26 - 72 m; n=10 trials.

REVIEWER'S CONCLUSIONS

Rehabilitation relieves dyspnea and fatigue and enhances patients' sense of control over their condition. These improvements are moderately large and clinically significant. The average improvement in exercise capacity was modest. Rehabilitation forms an important component of the management of COPD.

[Evaluation of the impact of individual antibiotic order forms on consumption of antibiotics]

The aim of the study was to assess the impact of an individual patient order form which concerned the 21 most costly antibiotics in a university hospital. Antibiotics expenditures were monitored from 1995 to 1999 and were expressed in 1999 French Francs per 100 patient days (p.d.). The time series were analyzed by auto-regressive models. The trend of antibiotics expenditures which were concerned by the individual patient order form was a yearly increase of 50 FF/100 p.d. (p < 0.01). The individual patient order form had no significant impact on global antibiotics expenditures but there were some differences across departments: antibiotics costs decreased 1.293 FF/100 p.d. (p = 0.02) in intensive care departments. Monitoring antibiotics consumption should be continued in order to increase power of analysis and to assess the impact of the implementation of guidelines.

Effects of agent strain and host genotype on PrP accumulation in the brain of sheep naturally and experimentally affected with scrapie

Different cellular and neuroanatomical types of disease-specific prion protein (PrP(d)) accumulation in the brain were identified in sheep of different breeds and PrP genotypes exposed to experimental or natural scrapie infection. Immunohistochemical examination of the brains of 43 sheep with clinical signs compatible with scrapie revealed 12 different PrP(d)types, which were subjectively quantified in eight different brain regions. The PrP(d)types were grouped into four PrP(d)patterns, the relative magnitude of which provided the PrP(d)profile of each sheep examined. The analysis of the differences in magnitude and relative proportion of each of these PrP(d)types and patterns indicated (1) an effect of the scrapie strain on the PrP(d)profile, and (2) a possible effect of the host genotype on the magnitude of PrP(d)accumulation in the brain, apparently related to the incubation period. Furthermore, intraneuronal deposition of PrP(d)was the type most closely associated with the development of clinical disease. We conclude that different scrapie strains can be distinguished by PrP immunohistochemical examination of brains of affected animals.

Localized lymphadenopathy due to leishmanial infection

A 25-year-old female patient presented with an isolated cervical lymph node enlargement several months after having returned from Spain and Latin America. She had no other signs or symptoms of disease. Leishmania infantum/chagasi was identified as the causative agent. With extended travel activities localized lymph node enlargement due to leishmanial infection should be included in the differential diagnosis of lymphadenopathy of unknown origin.

Differential diagnosis of infections with the bovine spongiform encephalopathy (BSE) and scrapie agents in sheep

Scrapie, bovine spongiform encephalopathy (BSE), and variant Creutzfeldt-Jakob disease belong to the group of disorders called transmissible spongiform encephalopathies or prion diseases. The possibility that some sheep may be infected with the BSE agent is of human and animal health concern. Immunohistochemical methods were used to identify specific prion protein (PrP) peptide sequences in specific cell types of the brain and lymphoreticular system (LRS) of sheep with natural scrapie and Suffolk and Romney sheep infected experimentally with the BSE agent. Clinically affected and some pre-clinical cases of BSE infection could be distinguished from scrapie cases by the lesser amount of labelling of PrP containing the 84-102 amino-acid peptide sequences in phagocytic cells of the LRS and brain. Additionally, BSE-infected sheep had higher degrees of intra-neuronal PrP accumulation in the brain, as detected by labelling for a range of PrP peptide sequences. These results suggest that there is strain-dependent processing of PrP in specific cell types within the nervous system and LRS which can be used to distinguish BSE- and scrapie-infected sheep.

[Moderate alcohol consumption and cardiovascular diseases]

While excessive ethanol consumption can result in higher rate of morbidity and mortality resulting from several diseases including cancer and cirrhosis, epidemiological studies suggest that moderate alcohol ingestion reduces the risk of cardiovascular diseases. However, the precise mechanisms by which moderate alcohol consumption protects against coronary heart disease (CHD) is not fully understood. Epidemiological studies suggest that alcohol consumption influences several risk factors for CHD including blood pressure, plasma cholesterol levels, platelet function, and fibrinolytic parameters, preventing both vascular thrombosis and occlusion. Turning to molecular and cellular levels, ethanol has been shown to act on several signal transduction mechanisms involve in the inhibition of smooth muscle cells proliferation and migration and in the activation of the release of vasoactive factors from vascular cells such as nitric oxide (NO). The latter is of importance since NO has been shown to possess antioxidant, antiaggregant properties, to regulate vascular tone and to inhibit both proliferation of smooth muscle cells and adhesion of leukocytes. Altogether, the above mentioned beneficial properties of moderate concentration of ethanol might help to explain the cardio- and vascular protection induced by ethanol. This review compels several bibliographic data concerning the cardiovascular effect of moderate alcohol consumption.

Deposition of the NG2 proteoglycan at nodes of Ranvier in the peripheral nervous system

The node of Ranvier is a complex macromolecular assembly of ion channels and other proteins that is specialized for the rapid propagation of the action potential. A full understanding of the processes responsible for the assembly and maintenance of the node requires first the identification and characterization of the proteins found there. Here we show that NG2, a structurally unique chondroitin sulfate proteoglycan, is a molecular component of the node of Ranvier in the peripheral nervous system. In adult sciatic nerve, NG2 is (1) associated with thin, elongated fibroblast-like cells, (2) on some but not all basal laminae, and (3) at nodes of Ranvier. At the nodes, NG2 is restricted to the nodal gap and is absent from the paranodal or juxtaparanodal region. In dissociated cell cultures of adult sciatic nerve, perineurial fibroblasts but not Schwann cells express NG2 on their surfaces. Approximately 45% of the total NG2 in peripheral nerves is in a soluble, rather than particulate, subcellular compartment. NG2 is also present in membrane fractions that also contain high levels of voltage-dependent sodium channels, caspr, and neuron-glia related cell adhesion molecule. These medium-density membranes likely correspond to the nodal and paranodal region of the axon-Schwann cell unit. These results suggest a model in which perineurial fibroblasts secrete or shed NG2, which subsequently associates with nodes of Ranvier. The growth-inhibitory and anti-adhesive properties of NG2 may limit the lateral extension of myelinating Schwann cells as nodes mature. NG2 may also participate in the barrier functions of the perineurial linings of the nerve.

A comparison of enzyme-linked immunoabsorbent assays and flow cytometry techniques for the detection of HLA specific antibodies

LATM, Quikscreen (QS), and B-Screen (QSB) are ELISA-based tests for the detection of HLA specific antibodies. FlowPRA beads are microparticles coated with HLA antigens for the detection of HLA specific antibodies by flow cytometry. The aim of this study was to evaluate the sensitivity and specificity of the LATM, QS, QSB, and FlowPRA screening tests. One hundred sixty-three sera from renal transplant patients were tested using LATM, FlowPRA, QS, and QSB. Discrepant results were further investigated using complement dependent cytotoxicity, QuikID, and PRA-STAT. When QS was compared with LATMI and FlowPRAI for the detection of HLA class I specific antibodies the overall concordance was 82.8% with no particular specificity missed by any one test. Comparing QSB with LATMII and FlowPRAII, for the detection of HLA class II specific antibodies, there was 90.7% concordance. Although the overall concordance was better for class II specific antibodies, QSB failed to detect antibodies to HLA-DQ in a number of samples from different patients. Of the methods tested, flow cytometry using FlowPRA beads appeared to be the most sensitive and specific, missing the least number of specificities. However, the ELISA methods offer the advantage of being more suitable for testing large numbers of samples in a more time- and cost-effective manner.

Profiles of patients who experienced a late acute rejection due to nonadherence with immunosuppressive therapy

The purpose of this study was to determine the significance and patient profiles of nonadherence with immunosuppressive therapy in the etiology of late acute rejections (LARs), more than 1 year after heart transplantation. Nonadherence was assessed in 101 heart transplant recipients (14 females, 87 males) with a median age of 56 (Q1=50; Q3=61) and a median posttransplant status of 3 (range, 1-6) years, using electronic event monitoring and self-report. The influence of depression, perceived self-efficacy, knowledge, perceived health, symptom frequency and distress, perceived social support, and adherence with outpatient appointments on medication nonadherence was examined. Ten LARs occurring in six patients were observed. Nine of the rejections, emerging in five patients, appeared to be caused by medication nonadherence. Nonadherence with immunosuppressive therapy is a major risk factor in the etiology of LAR. Patient profiles allow the identification of patients at risk.

Effects of dehydration and rehydration on EMG changes during fatiguing contractions

PURPOSE

This study measured the effects of sauna-induced dehydration (Dhy) and the effectiveness of rapid rehydration on muscle performance and EMG frequency spectrum changes associated with fatigue during isometric contractions.

METHODS

Knee extensor muscle strength during isometric maximal voluntary contraction (MVC) and endurance time at 25% and 70% of MVC (ET25 and ET70, respectively) were measured three times in 11 healthy male subjects, under euhydration conditions (Eu), after Dhy, and after rehydration following Dhy (Rhy).

RESULTS

Dhy led to a decrease in body weight by 2.95 +/- 0.05%. No significant effect of the hydration status was shown on MVC values. A 23% decrease in ET25 was recorded during Dhy (P < 0.01), whereas ET70 only tended to decrease (-13%, P = 0.06). ET25 was higher during Rhy than Dhy (8%, P < 0.05) but remained lower than during Eu (-17%, P < 0.05). The EMG root mean square (RMS) increased earlier during Dhy than Eu. Opposite changes were shown for the mean power frequency (MPF) of EMG, and Dhy resulted in an accelerated fall in MPF. However, because ET25 decreased with dehydration, RMS and MPF changes were similar during Eu and Dhy when reported to normalized contraction time, exhaustion was thus associated with similar values of RMS and MPF for all conditions. RMS and MPF changes during Rhy showed an intermediate pattern between Eu and Dhy.

CONCLUSIONS

Dhy induced an increase in muscle fatigue, associated with early changes in EMG spectral parameters. It is not clear whether these alterations could be attributed to biochemical modifications, and the role of increased perception of effort when subjects were dehydrated should be clarified.

Point mutation in the stalk of angiotensin-converting enzyme causes a dramatic increase in serum angiotensin-converting enzyme but no cardiovascular disease

BACKGROUND

Angiotensin-converting enzyme (ACE) metabolizes many small peptides and plays a key role in blood pressure regulation. Elevated serum ACE is claimed to be associated with an increased risk for cardiovascular disease. Previously, two families with dramatically increased serum ACE were described, but no systematic survey of affected individuals was performed, and the molecular background of this trait is unknown.

METHODS AND RESULTS

Eight families were identified with autosomal dominant inheritance of a dramatic (5-fold) increase of serum ACE activity. Strikingly, no clinical abnormalities were apparent in the affected subjects. Isolated blood cells were used for genetic and biochemical analysis. The level of ACE expression on the blood leukocytes and dendritic cells and total cell-associated ACE of the affected individuals was similar to that in nonaffected relatives; however membrane-bound mutant ACE was much more efficiently clipped from the cell surface compared with its wild-type counterpart. A point mutation causing Pro1199Leu in the stalk region of the ACE molecule cosegregates with the increase in serum ACE (LOD score, 6.63).

CONCLUSIONS

A point mutation in the stalk region of the ACE protein causes increased shedding, leading to increased serum ACE, whereas cell-bound ACE is unaltered, and affected individuals exhibit no clinical abnormalities. These findings qualify the importance of serum ACE and establish a new determinant of ACE solubilization.

Methodology for identifying patients at high risk for osteoporotic fracture

BACKGROUND

Osteoporotic fractures are associated with significant morbidity, mortality, and health care costs.

OBJECTIVE

The purpose of this paper is to present and validate a mathematical model that managed care organizations can apply to administrative claims data to help locate members at risk for osteoporotic fracture and estimate future fracture rates.

METHODS

Using known risk factors from previous clinical studies, 92,000 members of a large Midwest health plan were placed in 1 of 4 risk categories based on historical claims markers: demographic/lifestyle (age, sex, smoking, alcoholism); steroid use; medical history (previous osteoporotic fracture, ordinary bone fracture, osteoporosis diagnosis, bone mineral density test); or steroid use with medical history. Logistic regression was used to assign a probability of fracture for the 4 groups over the next 2 years. These predictions were compared with actual fracture rates, and refined models were produced. The models were then validated by applying them to current data and comparing the predicted fracture rate for each group to known results.

RESULTS

The model predicted that 1.26% of the study members would experience osteoporotic fracture over the next 2 years; the actual result was 1.27%. Within the 4 risk groups, the predicted fracture rates were lower than the actual rates for the demographic risk group (0.87% predicted vs 0.97% actual) and higher than the actual rates for the steroid use (1.78% predicted vs 1.58% actual), medical history (5.90% predicted vs 4.94% actual), and the steroid use with medical history groups (7.80% predicted vs 6.42% actual).

CONCLUSION

The application of this risk model to an administrative claims database successfully identified plan members at risk for osteoporotic fracture.

Dominant role of intercellular adhesion molecule-1 in the pathogenesis of autoimmune diabetes in non-obese diabetic mice

Intercellular adhesion molecule (ICAM)-1 is involved in forming the immunological synapse. The contribution of ICAM-1 to immune responses is not critical because mice with a disrupted ICAM-1 gene do not have grossly abnormal immune reactivity. Here we report on the surprising finding that diabetes-prone NOD mice with a disrupted ICAM-1 gene (ICAM-1(-/-)) are completely protected from disease development. While 64% of ICAM-1(+/+) and 44% of ICAM-1(+/-) female NOD mice developed overt diabetes until 310 days old, no ICAM-1(-/-) NOD mice became hyperglycaemic. Histological examinations revealed minor infiltration around pancreatic islets of ICAM1(-/-) NOD mice. Administration of cyclophosphamide caused a progression to severe islet destruction in ICAM-1(+/+) NOD mice within 10 days. In contrast, ICAM-1(-/-) mice showed only mild insulitis. Furthermore, ICAM-1(+/+) NOD mice showed an increase of IFN-gamma, interleukin (IL)-12p40 and IL-12p35 pancreatic mRNA levels, leading to an increased ratio of IFN-gamma: IL-4 and IL-12p40: IL-12p35 expression. In contrast, ICAM-1(-/-) NOD mice did not upregulate IFN-gamma or IL-12p40 gene expression but maintained IL-4 and increased IL-12p35 gene expression. These results identify a dominant and non-redundant role of ICAM-1 in the development of autoimmune diabetes.

Dicubane-like tetrameric cobalt(II)-pseudohalide ferromagnetic clusters

Three tetrameric cobalt(II)-pseudohalide complexes have been structurally and magnetically characterized. Compounds 1 and 2 are isomorphous and exhibit the general formula [Co2(dpk-OH)(dpk-CH3O)(L)(H2O)]2A2-4H2O where dpk = di-2-pyridyl ketone, L = N3(-) and A = BF4(-) for 1, and L = NCO(-) and A = ClO4(-) for 2. The ligands dpk-OH(-) and dpk-CH3O(-) result from solvolysis and ulterior deprotonation of dpk in water and methanol, respectively. Both compounds exhibit cationic tetramers consisting of a dicubane-like core with two missing vertexes where the Co(II) ions are connected through end-on pseudohalide and oxo-bridges. A similar tetranuclear core has been found for 3 whose formula is [Co2(dpk-OH)(dpk-CH3O)(NCO)2]2. In this case, the tetramers are neutral and exhibit a terminal cyanate in place of the coordinated molecule of water for 1 and 2. The tetrameric units for 2 and 3 represent the first examples of any kind of cubanes exhibiting cyanate bridges as well as the first Co(II) compounds exhibiting intermetallic bridges through these pseudohalide groups. Measurements of the magnetic susceptibility indicated the presence of ferromagnetic Co(II)-Co(II) interactions in the three compounds.

IgG antibody subclass responses determined by immunoblot in infants' sera following vaccination with a meningococcal recombinant hexavalent PorA OMV vaccine

The introduction of meningococcal serogroup C conjugate vaccines into the UK immunisation schedule has led to the decline of serogroup C disease in those vaccinated but there is no imminent vaccine solution for serogroup B disease. The PorA outer membrane protein (OMP) is a potential serogroup B vaccine candidate and an outer membrane vesicle (OMV) vaccine containing six different PorA OMPs (each representing a different serosubtype) has been evaluated in phase II trials with encouraging results. Little is known about the IgG subclass response to the various antigens contained within this vaccine. These responses are important due to the different half-lives and complement fixing abilities of these antibodies. In this study, immunoblotting was undertaken with infants' sera following either three or four doses of vaccine, and OMVs from six isogenic meningococcal strains differing only in their PorA serosubtype. Following either three or four doses of the vaccine, IgG(3) and IgG(1) subclass antibodies were induced to all six of the isogenic strains, although sera collected after four doses of vaccine showed stronger antibody levels. IgG(3) was found in more sera than IgG(1). For both sets of sera, the two isogenic strains expressing P1.5,2 and P1.5(c),10 induced stronger IgG subclass antibody responses than the other four meningococcal strains. The recombinant hexavalent PorA OMV vaccine stimulates both IgG(1) and IgG(3) subclass antibodies, the subclasses that are most effective in activating the complement system.

Low-density lipoprotein particle size, triglyceride-rich lipoproteins, and glucose tolerance in non-diabetic men with essential hypertension

The aim of the study is to investigate serum lipoproteins abnormalities including low-density lipoprotein (LDL) particle size, and their relationship with other cardiovascular risk factors in men with essential hypertension. Plasma glucose and serum insulin levels during oral glucose tolerance test (OGTT), serum lipoprotein(a), apolipoprotein (apo) A-I. apo B. cholesterol and triglycerides in serum and in lipoproteins, and LDL particle diameter were measured in thirty-eight consecutive newly-diagnosed non-diabetic untreated hypertensive men and 38 healthy male controls. Plasma glucose at baseline, 60 and 120 min during OGTT was significantly higher in patients than controls whereas serum insulin levels did not differ between patients and controls. Serum apo B and triglycerides were significantly raised in patients compared with controls (1.08 +/- 0.17 g/L [mean +/- SD] vs 0.97 +/- 0.22 g/L. p < 0.05, and 1.56 +/- 0.90 mmol/L vs 1.15 +/- 0.57 mmol/L, p < 0.05, respectively). Very-low-density lipoprotein (VLDL) triglycerides and LDL-cholesterol were increased in patients compared with controls (0.89 +/- 0.79 mmol/L and 0.54 +/- 0.35 mmol/L, p < 0.05, and 4.08 +/- 0.85 mmol/L and 3.60 +/- 0.92 mmol/L, p < 0.05, respectively) whereas high-density lipoprotein (HDL) cholesterol was lower in patients compared with controls 0.95 +/- 0.22 mmol/L and 1.07 +/- 0.20 mmol/L, p < 0.05). Adjustment for body mass index, abdominal/hip perimeter ratio and area under the glucose curve did not attenuate the relationship between hypertension and VLDL-triglycerides. Six patients and two controls had a mean LDL diameter < or = 25.5 nm and in the former serum triglycerides ranged from 1.86 mmol/L to 2.37 mmol/L. Mean LDL particle diameter in both patients and controls showed an inverse relationship with log-transformed serum triglycerides (r = - 0.51, p < 0.001 and r = - 0.47, p < 0.005, respectively). Among patients, those with serum triglycerides > or = [corrected] 1.58 mmol/L had a lesser mean LDL diameter than those with triglycerides above this threshold (25.78 +/- 0.47 nm vs 26.30 +/- 0.35 nm, p < 0.001). Higher plasma glucose, serum apo B and LDL-cholesterol as well as the decrease in serum HDL-cholesterol in patients with hypertension are consistent with high coronary heart disease risk. Not only mild hypertriglyceridemia but also high-normal serum triglycerides in themselves or as a surrogate of a predominance of small dense LDL particles in plasma convey an additional risk for cardiovascular disease in hypertensive patients even though routine plasma lipids are within or near normal range.

Long-term low-dose IL-2 enhances immune function in common variable immunodeficiency

Common variable immunodeficiency (CVID) is a primary immunodeficiency disease characterized by hypogammaglobulinemia and lack of antibody production. Numerous T cell defects have been described, including reduced gene expression and production of IL-2. Since some of the T cell defects could be explained by lack of IL-2, we have been investigating the effects of in vivo IL-2 treatment. Here, a long-acting form of IL-2, PEG-IL-2, was given for 12-18 months to 15 randomly chosen CVID subjects, in comparison to 39 CVID subjects who served as controls. After 6 to 12 months of treatment, T cell proliferative responses to mitogens and to IL-2 were significantly enhanced; proliferative responses to tetanus and candida antigens increased up to 50-fold. Four of eight subjects immunized with the neoantigen bacteriophage &phi;X 174 displayed increased antibody responses after treatment. Treated subjects recorded reduced, but not overall statistically significant, days of bronchitis, diarrhea, and joint pain. These data indicate that IL-2 might serve as an adjuvant to therapy in some subjects with CVID, enhancing T cell functions and reversing T cell anergy in most.

Horizontal gene transfer and host specificity of beta-haemolytic streptococci: the role of a putative composite transposon containing scpB and lmb

Beta-haemolytic streptococci are important human and animal pathogens: their genetic traits that are associated with the ability to infect human hosts remain, however, unclear. The surface protein, Lmb, mediates the adherence of Streptococcus agalactiae to human laminin. For further analysis of the corresponding gene, the adjacent genomic regions were sequenced. Lmb is localized on a putative composite transposon of 16 kb and is flanked by two copies of a novel insertion sequence element (ISSag2). It harbours the genes scpB and lmb, which are 98% identical with the respective genes of Streptococcus pyogenes. Analysis of the distribution of these genes and ISSag2 among 131 streptococcal strains revealed that all of the human isolates, but only 20% (12 of 61) of the animal isolates, contained scpB and lmb or their homologues. To investigate if the putative transposon can be mobilized, an erythromycin resistance marker was incorporated into the lmb gene of S. agalactiae. Screening for mutant strains with a regained susceptibility for erythromycin identified strains with a deletion of scpB, lmb, and one copy of ISSag2. We hypothesize that a horizontal gene transfer caused the exchange of scpB and lmb and that the ability of S. pyogenes, S. agalactiae and group C and G streptococcal strains to colonize or infect human hosts is dependent on their presence.