Use of protracted CPAP as supportive treatment for COVID-19 pneumonitis and associated outcomes: a national cohort study

BACKGROUND

Continuous positive airway pressure (CPAP) has been increasingly deployed to manage patients with COVID-19 and acute respiratory failure, often for protracted periods. However, concerns about protracted CPAP have been raised. This study aimed to examine the use of CPAP for patients with COVID-19 and the outcomes after protracted use.

METHODS

This was a national cohort study of all adults admitted to Scottish critical care units with COVID-19 from March 1, 2020 to December 25, 2021 who received CPAP. Protracted CPAP was defined as ≥ 5 continuous days of CPAP. Outcomes included CPAP failure rate (institution of invasive mechanical ventilation [IMV] or death), mortality, and outcomes after institution of IMV. Multivariable logistic regression was performed to assess the impact of protracted CPAP on mortality after IMV.

RESULTS

A total of 1961 patients with COVID-19 received CPAP for COVID-19 pneumonitis, with 733 patients (37.4%) receiving protracted CPAP. CPAP failure occurred in 891 (45.4%): 544 patients (27.7%) received IMV and 347 patients (17.7%) died in critical care without IMV. Hospital mortality rate was 41.3% for the population. For patients who subsequently commenced IMV, hospital mortality was 58.7% for the standard duration CPAP group and 73.9% for the protracted duration CPAP group (P=0.003); however, there was no statistical difference in hospital mortality after adjustment for confounders (odds ratio 1.4, 95% confidence interval 0.84-2.33, P=0.195).

CONCLUSIONS

Protracted CPAP was used frequently for managing patients with COVID-19. Whilst it was not associated with worse outcomes for those patients who subsequently required IMV, this might be due to residual confounding and differences in processes of care.

Extubation in neurocritical care patients: the ENIO international prospective study

PURPOSE

Neurocritical care patients receive prolonged invasive mechanical ventilation (IMV), but there is poor specific information in this high-risk population about the liberation strategies of invasive mechanical ventilation.

METHODS

ENIO (NCT03400904) is an international, prospective observational study, in 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Neurocritical care patients with a Glasgow Coma Score (GCS) ≤ 12, receiving IMV ≥ 24 h, undergoing extubation attempt or tracheostomy were included. The primary endpoint was extubation failure by day 5. An extubation success prediction score was created, with 2/3 of patients randomly allocated to the training cohort and 1/3 to the validation cohort. Secondary endpoints were the duration of IMV and in-ICU mortality.

RESULTS

1512 patients were included. Among the 1193 (78.9%) patients who underwent an extubation attempt, 231 (19.4%) failures were recorded. The score for successful extubation prediction retained 20 variables as independent predictors. The area under the curve (AUC) in the training cohort was 0.79 95% confidence interval (CI₉₅) [0.71-0.87] and 0.71 CI₉₅ [0.61-0.81] in the validation cohort. Patients with extubation failure displayed a longer IMV duration (14 [7-21] vs 6 [3-11] days) and a higher in-ICU mortality rate (8.7% vs 2.4%). Three hundred and nineteen (21.1%) patients underwent tracheostomy without extubation attempt. Patients with direct tracheostomy displayed a longer duration of IMV and higher in-ICU mortality than patients with an extubation attempt (success and failure).

CONCLUSIONS

In neurocritical care patients, extubation failure is high and is associated with unfavourable outcomes. A score could predict extubation success in multiple settings. However, it will be mandatory to validate our findings in another prospective independent cohort.

Biomarkers for assessing acute kidney injury for people who are being considered for admission to critical care: a systematic review and cost-effectiveness analysis

BACKGROUND

Acute kidney injury is a serious complication that occurs in the context of an acute critical illness or during a postoperative period. Earlier detection of acute kidney injury may facilitate strategies to preserve renal function, prevent further disease progression and reduce mortality. Acute kidney injury diagnosis relies on a rise in serum creatinine levels and/or fall in urine output; however, creatinine is an imperfect marker of kidney function. There is interest in the performance of novel biomarkers used in conjunction with existing clinical assessment, such as NephroCheck^® (Astute Medical, Inc., San Diego, CA, USA), ARCHITECT^® urine neutrophil gelatinase-associated lipocalin (NGAL) (Abbott Laboratories, Abbott Park, IL, USA), and urine and plasma BioPorto NGAL (BioPorto Diagnostics A/S, Hellerup, Denmark) immunoassays. If reliable, these biomarkers may enable earlier identification of acute kidney injury and enhance management of those with a modifiable disease course.

OBJECTIVE

The objective was to evaluate the role of biomarkers for assessing acute kidney injury in critically ill patients who are considered for admission to critical care.

DATA SOURCES

Major electronic databases, conference abstracts and ongoing studies were searched up to June 2019, with no date restrictions. MEDLINE, EMBASE, Health Technology Assessment Database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Web of Science, World Health Organization Global Index Medicus, EU Clinical Trials Register, International Clinical Trials Registry Platform and ClinicalTrials.gov were searched.

REVIEW METHODS

A systematic review and meta-analysis were conducted to evaluate the performance of novel biomarkers for the detection of acute kidney injury and prediction of other relevant clinical outcomes. Random-effects models were adopted to combine evidence. A decision tree was developed to evaluate costs and quality-adjusted life-years accrued as a result of changes in short-term outcomes (up to 90 days), and a Markov model was used to extrapolate results over a lifetime time horizon.

RESULTS

A total of 56 studies (17,967 participants), mainly prospective cohort studies, were selected for inclusion. No studies addressing the clinical impact of the use of biomarkers on patient outcomes, compared with standard care, were identified. The main sources of bias across studies were a lack of information on blinding and the optimal threshold for NGAL. For prediction studies, the reporting of statistical details was limited. Although the meta-analyses results showed the potential ability of these biomarkers to detect and predict acute kidney injury, there were limited data to establish any causal link with longer-term health outcomes and there were considerable clinical differences across studies. Cost-effectiveness results were highly uncertain, largely speculative and should be interpreted with caution in the light of the limited evidence base. To illustrate the current uncertainty, 15 scenario analyses were undertaken. Incremental quality-adjusted life-years were very low across all scenarios, ranging from positive to negative increments. Incremental costs were also small, in general, with some scenarios generating cost savings with tests dominant over standard care (cost savings with quality-adjusted life-year gains). However, other scenarios generated results whereby the candidate tests were more costly with fewer quality-adjusted life-years, and were thus dominated by standard care. Therefore, it was not possible to determine a plausible base-case incremental cost-effectiveness ratio for the tests, compared with standard care.

LIMITATIONS

Clinical effectiveness and cost-effectiveness results were hampered by the considerable heterogeneity across identified studies. Economic model predictions should also be interpreted cautiously because of the unknown impact of NGAL-guided treatment, and uncertain causal links between changes in acute kidney injury status and changes in health outcomes.

CONCLUSIONS

Current evidence is insufficient to make a full appraisal of the role and economic value of these biomarkers and to determine whether or not they provide cost-effective improvements in the clinical outcomes of acute kidney injury patients.

FUTURE WORK

Future studies should evaluate the targeted use of biomarkers among specific patient populations and the clinical impact of their routine use on patient outcomes and management.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019147039.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 7. See the NIHR Journals Library website for further project information.

Cost-effectiveness and value of information analysis of NephroCheck and NGAL tests compared to standard care for the diagnosis of acute kidney injury

BACKGROUND

Early and accurate acute kidney injury (AKI) detection may improve patient outcomes and reduce health service costs. This study evaluates the diagnostic accuracy and cost-effectiveness of NephroCheck and NGAL (urine and plasma) biomarker tests used alongside standard care, compared with standard care to detect AKI in hospitalised UK adults.

METHODS

A 90-day decision tree and lifetime Markov cohort model predicted costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) from a UK NHS perspective. Test accuracy was informed by a meta-analysis of diagnostic accuracy studies. Clinical trial and observational data informed the link between AKI and health outcomes, health state probabilities, costs and utilities. Value of information (VOI) analysis informed future research priorities.

RESULTS

Under base case assumptions, the biomarker tests were not cost-effective with ICERs of £105,965 (NephroCheck), £539,041 (NGAL urine BioPorto), £633,846 (NGAL plasma BioPorto) and £725,061 (NGAL urine ARCHITECT) per QALY gained compared to standard care. Results were uncertain, due to limited trial data, with probabilities of cost-effectiveness at £20,000 per QALY ranging from 0 to 99% and 0 to 56% for NephroCheck and NGAL tests respectively. The expected value of perfect information (EVPI) was £66 M, which demonstrated that additional research to resolve decision uncertainty is worthwhile.

CONCLUSIONS

Current evidence is inadequate to support the cost-effectiveness of general use of biomarker tests. Future research evaluating the clinical and cost-effectiveness of test guided implementation of protective care bundles is necessary. Improving the evidence base around the impact of tests on AKI staging, and of AKI staging on clinical outcomes would have the greatest impact on reducing decision uncertainty.

Vasoactive agents in acute mesenteric ischaemia in critical care. A systematic review

Background: Acute mesenteric ischaemia (AMI) is a surgical emergency which has an associated high mortality.  The mainstay of active treatment includes early surgical intervention, with resection of non-viable bowel, and revascularisation of the ischaemic bowel where possible. Due to the physiological insult of AMI however, perioperative care often involves critical care and the use of vasoactive agents to optimise end organ perfusion. A number of these vasoactive agents are currently available with varied mechanism of action and effects on splanchnic blood flow. However, specific guidance on which is the optimal vasoactive drug to use in these settings is limited. This systematic review aimed to evaluate the current evidence comparing vasoactive drugs in AMI. Methods: A systematic search of Ovid Medline, Ovid Embase, Cochrane CENTRAL and the Cochrane Database of Systematic Review was performed on the 5th of November 2020 to identify randomised clinical trials comparing different vasoactive agents in AMI on outcomes including mortality. The search was performed through the Royal College of Surgeons of England (RCSEng) search support library. Results were analysed using the Rayyan platform, and independently screened by four investigators. Results: 614 distinct papers were identified. After screening, there were no randomised clinical trials meeting the inclusion criteria. Conclusions: This review identifies a gap in literature, and therefore recommends an investigation into current practice and clinician preference in relation to vasoactive agents in AMI. Multicentre randomised controlled trials comparing these medications on clinical outcomes will therefore be required to address this question.

Vasoactive agents in acute mesenteric ischaemia in critical care. A systematic review

Background: Acute mesenteric ischaemia (AMI) is a surgical emergency which has an associated high mortality.  The mainstay of active treatment includes early surgical intervention, with resection of non-viable bowel, and revascularisation of the ischaemic bowel where possible. Due to the physiological insult of AMI however, perioperative care often involves critical care and the use of vasoactive agents to optimise end organ perfusion. A number of these vasoactive agents are currently available with varied mechanism of action and effects on splanchnic blood flow. However, specific guidance on which is the optimal vasoactive drug to use in these settings is limited. This systematic review aimed to evaluate the current evidence comparing vasoactive drugs in AMI. Methods: A systematic search of Ovid Medline, Ovid Embase, Cochrane CENTRAL and the Cochrane Database of Systematic Review was performed on the 5th of November 2020 to identify randomised clinical trials comparing different vasoactive agents in AMI on outcomes including mortality. The search was performed through the Royal College of Surgeons of England (RCSEng) search support library. Results were analysed using the Rayyan platform, and independently screened by four investigators. Results: 614 distinct papers were identified. After screening, there were no randomised clinical trials meeting the inclusion criteria. Conclusions: This review identifies a gap in literature, and therefore recommends an investigation into current practice and clinician preference in relation to vasoactive agents in AMI. Multicentre randomised controlled trials comparing these medications on clinical outcomes will therefore be required to address this question.

Extubation strategies in neuro-intensive care unit patients and associations with outcomes: the ENIO multicentre international observational study

Background

Prolonged invasive ventilation is common in patients with severe brain injury. Information on optimal management of extubation and on the use of tracheostomy in these patients is scarce. International guidelines regarding the ventilator liberation and tracheostomy are currently lacking.

Methods

The aim of ‘Extubation strategies in Neuro-Intensive care unit patients and associations with Outcomes’ (ENIO) study is to describe current management of weaning from invasive ventilation, focusing on decisions on timing of tracheal extubation and tracheostomy in intensive care unit (ICU) patients with brain injury. We conducted a prospective, international, multi-centre observational study enrolling patients with various types of brain injury, including trauma, stroke, and subarachnoid haemorrhage, with an initial Glasgow Coma Score equal or less than 12, and a duration of invasive ventilation longer than 24 hours from ICU admission. ENIO is expected to include at least 1,500 patients worldwide. The primary endpoint of the ENIO study is extubation success in the 48 hours following endotracheal tube removal. The primary objective is to validate a score predictive of extubation success. To accomplish this, the study population will be randomly divided to a development cohort (2/3 of the included patients) and a validation cohort (the remaining 1/3). Secondary objectives are: to determine the incidence of extubation success rate according to various time-frames (within 96 hours, >96 hours after extubation); to validate (existing) prediction scores for successful extubation according to various time-frames and definitions (i.e., tracheostomy as extubation failure); and to describe the current practices of extubation and tracheostomy, and their associations.

Discussion

ENIO will be the largest prospective observational study of ventilator liberation and tracheostomy practices in patients with severe brain injury undergoing invasive mechanical ventilation, providing a validated predictive score of successful extubation.

Trial registration

The ENIO study is registered in the Clinical Trials database: NCT 03400904.

Bleeding during percutaneous dilatational tracheostomy - What to do while waiting for the surgeon?

A patient suffered significant bleeding during an attempt at percutaneous dilatational tracheostomy due to an aberrant anterior jugular vein. Bleeding was controlled with pressure temporarily, but quickly returned necessitating conversion to an open technique. We present an algorithm for the management of significant peri-procedural bleeding during this procedure.

Post-admission outcomes of participants in the PARAMEDIC trial: A cluster randomised trial of mechanical or manual chest compressions

BACKGROUND

The PARAMEDIC cluster randomised trial evaluated the LUCAS mechanical chest compression device, and did not find evidence that use of mechanical chest compression led to an improvement in survival at 30 days. This paper reports patient outcomes from admission to hospital to 12 months after randomisation.

METHODS

Information about hospital length of stay and intensive care management was obtained through linkage with Hospital Episode Statistics and the Intensive Care National Audit and Research Centre. Patients surviving to hospital discharge were approached to complete questionnaires (SF-12v2, EQ-5D, MMSE, HADS and PTSD-CL) at 90days and 12 months. The study is registered with Current Controlled Trials, number ISRCTN08233942.

RESULTS

377 patients in the LUCAS arm and 658 patients in the manual chest compression were admitted to hospital. Hospital and intensive care length of stay were similar. Long term follow-up assessments were limited by poor response rates (53.7% at 3 months and 55.6% at 12 months). Follow-up rates were lower in those with worse neurological function. Among respondents, long term health related quality of life outcomes and emotional well-being was similar between groups. Cognitive function, measured by MMSE, was marginally lower in the LUCAS arm mean 26.9 (SD 3.7) compared to control mean 28.0 (SD 2.3), adjusted mean difference -1.5 (95% CI -2.6 to -0.4).

CONCLUSION

There were no clinically important differences identified in outcomes at long term follow-up between those allocated to the mechanical chest compression compared to those receiving manual chest compression.

Adenosine triphosphate bioluminescence to validate decontamination of endoscopes

The reports of outbreaks involving carbapenemase-resistant Enterobacteriaceae (CRE) associated with gastrointestinal endoscopy prompted a review and study of a novel method of assessing cleaning. This study assessed adenosine triphosphate (ATP) bioluminescence to demonstrate cleanliness prior to endoscopy. ATP testing was compared with microbiological monitoring for 127 endoscopes. Samples were taken after cleaning, reprocessing and storage, but immediately before the endoscopy procedure. We recommend implementing ATP testing prior to endoscopy procedures as an alternative to microbiological testing at periodic intervals. ATP testing provides a convenient assessment of endoscopy hygiene to demonstrate safety and quality assurance.

Do we know if our Patients are Delirious?

Delirium in the intensive care unit (ICU) setting is a significant cause of morbidity, mortality and increases ICU, as well as hospital length of stay1,2. Furthermore, with so many of the risk factors being present in the critically ill patient in the ICU environment, it's not surprising that other studies have found that up to 80% of patients will be delirious at some point during admission3,4.

We performed a small study in a Toronto Medical-Surgical ICU using the Confusion Assessment Method for the ICU (CAM-ICU)5 to determine the prevalence of delirium in this unit. We concurrently reviewed medical and nursing notes to identify documentation of symptoms and signs that could indicate possible delirium during routine clinical assessment of the patient.

[Enterococcal bacteremia at Nîmes university hospital]

PURPOSE OF THE STUDY

The aim of this study was the description of enterococcal bacteremia and the evaluation of their resistance evolution to antibiotics and the virulence profile of these isolates.

PATIENTS AND METHODS

We have studied all the bacteremia caused by Enterococcus spp. from the 1st of July 2003 until the 30th of June 2004 at Nîmes university hospital. For each isolate, population, clinical and microbiological data were collected. Multiplex PCR allowed for the identification of glycoprotein resistant phenotypes and furthermore, to identify the main virulence genes found in the enterococci.

RESULTS

Thirty-three strains were identified from 33 patients (60.6% male) with a median age of 68 years (median: 3-96). The vital prognostic was calculated in 63.6% of the cases (MacCabe > or =1); seven patients died during their hospitalization (21.2%). The infections were nosocomial in 60.6% of the cases. No epidemic was observed. The principal comorbidities were cardiovascular and digestive pathologies. In addition, 54.5% of patients had had a surgical intervention. Enterococcus faecalis (87.9%) was the cause of infection in the majority of cases followed by Enterococcus faecium. Most of the infections were monomicrobial (75.8%). E. faecalis was sensitive to amoxicillin and to glycopeptides but was resistant to norfloxacin, erythromycin and pristinamycin. The same observations were made for the E. faecium with the exception of amoxicillin. E. faecalis had the maximum number of virulence genes and E. faecium the least.

CONCLUSION

The enterococcal bacteremia had mainly a nosocomial origin. The isolates came from digestive tract flora but also from catheters. The mortality rate was 21.2%. A developing sensitivity to erythromycin and pristinamycin was observed in comparison to the data of the ONERBA (2002-2003). Only one isolate was resistant to glycopeptide. This was the first European E. faecium containing the vanD allele. This isolate proved fatal to the patient. The dark evolution of enterococcal bacteremia and their frequent nosocomial origin induce to promote studies intended for better knowing the risk factors of such infections.

Targeted mapping of a sugarcane rust resistance gene (Bru1) using bulked segregant analysis and AFLP markers

The presence of a major resistance gene (Bru1) for brown rust in the sugarcane cultivar R570 (2n about 115) was confirmed by analyzing segregation of rust resistance in a large population of 658 individuals, derived from selfing of clone R570. A subset of this population was analyzed with AFLP and bulked segregant analysis (BSA) to develop a detailed genetic map around the resistance gene. Four hundred and forty three primer pairs were used resulting in the identification of eight AFLP markers surrounding the resistance gene in an interval of 10 cM, with the closest markers located at 1.9 and 2.2 cM on each side of the gene. Efficiency of the AFLP/BSA applied to the complex polyploid genome of sugarcane is discussed, as well as the potential of the newly identified AFLP markers for developing a map-based cloning approach exploiting, synteny conservation with sorghum.

Special hospitals. About the size of it

Special hospitals are facing their third major upheaval in a decade with their proposed assimilation into mental health trusts. Their size is likely to continue to decrease. But the need for them remains. Patients' needs would be best served by smaller hospitals offering more specialised care, closely integrated with other forensic services.

Characterization of a gene for spinach CAP160 and expression of two spinach cold-acclimation proteins in tobacco

The cDNA sequence for CAP160, an acidic protein previously linked with cold acclimation in spinach (Spinacia oleracea L.), was characterized and found to encode a novel acidic protein of 780 amino acids having very limited homology to a pair of Arabidopsis thaliana stress-regulated proteins, rd29A and rd29B. The lack of similarity in the structural organization of the spinach and Arabidopsis genes highlights the absence of a high degree of conservation of this cold-stress gene across taxonomic boundaries. The protein has several unique motifs that may relate to its function during cold stress. Expression of the CAP160 mRNA was increased by low-temperature exposure and water stress in a manner consistent with a probable function during stresses that involve dehydration. The coding sequences for CAP160 and CAP85, another spinach cold-stress protein, were introduced into tobacco (Nicotiana tabacum) under the control of the 35S promoter using Agrobacterium tumefaciens-based transformation. Tobacco plants expressing the proteins individually or coexpressing both proteins were evaluated for relative freezing-stress tolerance. The killing temperature for 50% of the cells of the transgenic plants was not different from that of the wild-type plants. As determined by a more sensitive time/temperature kinetic study, plants expressing the spinach proteins had slightly lower levels of electrolyte leakage than wild-type plants, indicative of a small reduction of freezing-stress injury. Clearly, the heterologous expression of two cold-stress proteins had no profound influence on stress tolerance, a result that is consistent with the quantitative nature of cold-stress-tolerance traits.

Constitutive non-inducible expression of the Arabidopsis thaliana Nia 2 gene in two nitrate reductase mutants of Nicotiana plumbaginifolia

We have isolated a haploid cell line of N. plumbaginifolia, hNP 588, that is constitutive and not inducible for nitrate reductase. Nitrate reductase mutants were isolated from hNP 588 protoplasts upon UV irradiation. Two of these nitrate reductase-deficient cell lines, nia 3 and nia 25, neither of which contained any detectable nitrate reductase activity, were selected for complementation studies. A cloned Arabidopsis thaliana nitrate reductase gene Nia 2 was introduced into each of the two mutants resulting in 56 independent kanamycin-resistant cell lines. Thirty of the 56 kanamycin-resistant cell lines were able to grow on nitrate as the sole nitrogen source. Eight of these were further analyzed for nitrate reductase enzyme activity and nitrate reductase mRNA production. All eight lines had detectable nitrate reductase activity ranging from 7% to 150% of wild-type hNP 588 callus. The enzyme activity levels were not influenced by the nitrogen source in the medium. The eight lines examined expressed a constitutive, non-inducible 3.2 kb mRNA species that was not present in untransformed controls.

Effect of theophylline on exercise performance in patients with severe chronic obstructive pulmonary disease

BACKGROUND

Theophylline is a well known bronchodilator which has been used for more than 50 years in the treatment of obstructive pulmonary diseases. In patients with severe chronic obstructive pulmonary disease whose cardiopulmonary performance is limited by their ventilatory capacity the administration of theophylline may improve exercise performance.

METHODS

A randomised, placebo controlled, double blind, crossover trial was conducted in 22 patients with severe but stable disease. The patients (mean age 68 years) were studied before and after one month of placebo and one month of treatment with a sustained release preparation of theophylline administered orally. The theophylline dose was adjusted until a blood level above 55.5 mumol/l was achieved. The two treatments were administered in random order and separated by a two week washout period. After theophylline was administered for one month a mean level of 68.2 mumol/l was achieved. Pulmonary function tests, arterial blood gas measurements, maximal voluntary ventilation (MVV), and an incremental exercise test were performed before (baseline) and at the end of the first and second month of treatment.

RESULTS

Pulmonary function tests showed no improvement in the flow parameters but showed an improvement in MVV after treatment with theophylline. Pulmonary gas exchange was improved after theophylline (resting arterial PO2 8.91 v 8.59 kPa, PCO2 5.38 v 5.56 kPa). The incremental exercise study showed improvement in maximal work rate (86.5 v 75.0 watts) and maximal ventilation (VEmax) (46.7 v 43.01/min). The dyspnoea index on maximal effort (VEmax/MVV), anaerobic threshold, and oxygen pulse remained unchanged. Resting and exercise heart rate were higher after theophylline.

CONCLUSIONS

Theophylline improved cardiorespiratory performance in these patients with severe chronic obstructive pulmonary disease mainly by increasing the ventilatory capacity.

Assessment of exercise capacity in asthmatic children with various degrees of activity

Physical fitness in a group of 49 stable asthmatic children was determined by an incremental exercise test. Thirty-one normal children served as a control group. The asthmatic children were divided into three groups. Group 1 was comprised of 16 children who actively participated in organized sports, Group 2 of 16 children who did not participate in organized sports but who engaged in free-play, and Group 3 of 17 children with a sedentary life-style who avoided even free-play. The results of cardiopulmonary evaluation before and after maximal incremental exercise testing have shown that Groups 1 and 2 behaved like the control group and their physical fitness was similar. Group 3 whose life-style was sedentary had poor physical fitness as compared to the other asthmatics and to the control group. This was the result of poor cardiovascular conditioning and was unrelated to the respiratory limitation. We conclude that poor physical fitness in asthmatic children is the result of a sedentary life-style and can be potentially normalized.

[Cardiopulmonary exercise testing in asthmatic patients]

In order to obtain objective information on physical fitness of asthmatic patients, mainly those with severe chronic airway obstruction, an incremental exercise test was carried out in 50 asthmatics. A control group of 48 healthy subjects had similar anthropometric characteristics. The 2 groups achieved similar maximal heart rates: 96.1 +/- 8 of predicted rate in the asthmatics as compared to 98.4 +/- 4 in the controls. Maximum oxygen consumption (VO2max), anaerobic threshold and oxygen pulse (VO2/hr) were significantly lower in the asthmatics. While in mild and moderate cases performance was limited by the cardiovascular system, in severe asthmatics the limitation was respiratory. There was no correlation between severity of airway obstruction and cardiac parameters such as oxygen pulse, anaerobic threshold and VO2max. On the other hand, there was good correlation between FEV1% and the dyspnea index (Ve/MVV%). The latter was less than 60% in all asthmatics when measured during exercise testing at 75% of maximal predicted heart rate. It is thus possible for an asthmatic to engage in physical activity of the intensity that can potentially improve his physical fitness. We assume that reduction in cardiac parameters is a result of poor physical fitness related to prolonged inactivity, quite common in asthmatics as a result of inappropriate physical education.

Excellence and shopping centre management

Examines what is expected of shopping centre management and the relationship of the centre manager on site and surveyor colleagues in professional matters. Considers community relationship, shopping centre marketing, and the problems of retailers as factors in centre management. Concludes that turnover rents enhance the relative attractiveness of centres, but that the ultimate competition will be for good centre management of facilities, public, tenants and marketing.

Polyamine levels in petunia genotypes with normal and abnormal floral morphologies

We characterized the polyamine pathway in Petunia hybrida genotypes that were either wild type or that had been identified as having altered floral morphology. Analysis of four normal morphology lines revealed two patterns of endogenous levels of putrescine and arginine decarboxylase: two with higher levels of putrescine, two with lower levels of putrescine. Analysis of F1 and backcross progeny between high putrescine and low putrescine strains is consistent with their differences being due to a dominant allele for low putrescine content and arginine decarboxylase activity. Four Petunia mutants with floral morphology changes were also screened. One of these mutants, alf, showed high levels of putrescine and high levels of arginine decarboxylase late in development; these high levels were found whether the alf line was present in either of the two types of normal morphology genetic backgrounds that had been characterized.

Prenatal diagnosis of Weyers syndrome (deficient ulnar and fibular rays with bilateral hydronephrosis)

A fetus with Weyers oligodactyly was studied after a previous sibling had been born with that condition. Prenatal diagnosis was undertaken using ultrasound to visualize the long bones, which were found to be severely affected by the condition at 19 weeks of gestation. Most notable were the ulnae and fibulae, which were very short; the fetus had bilateral hydronephrosis.

Regulation in the neural plate of Xenopus laevis demonstrated by genetic markers

To follow the subsequent history of grafted tissue in experiments designed to study regulation and commitment in the amphibian neural plate, previous workers have relied on graft scars, vital dyes applied externally to cells, or xenoplastic grafts. Each of these methods has been criticized on the grounds that they do not indicate unambiguously the origins of individual cells within the operated host. To overcome these difficulties, homoplastic, genetically marked embryonic grafts were taken from the prospective spinal neuroectoderm of triploid and tetraploid Xenopus laevis frogs and transplanted to presumptive eye and prosencephalic regions of the neural plate of diploid X. laevis embryos. Orthotopic presumptive eye grafts also were done. Marked cells were scored in section either by nucleolar number or computerized nuclear size analysis. Of 28 heterotopically grafted embryos that survived to stage 41, when the retina has differentiated, prospective spinal cord neuroectoderm in eight animals gave rise to cell types unique to the eye. The remaining 20 survivors appeared to be mosaic. These results substantiate claims of regulation in the neural plate and extend these observations to the level of individual cell types, a level of resolution not previously obtained in other studies.

In vitro metabolic response of articular cartilage segments to low levels of hydrostatic pressure

Bovine and human articular cartilage segments exhibit variable alterations in metabolism following in vitro exposure to hydrostatic pressure. A decrease in incorporation of the labeled substrates 35SO4, 3H-glycine and 3H-uridine to values less than 50% of non-pressurized tissue results from exposure to pressures between 75 and 300 psi. A pressure of 375 psi consistently results in a 10-15% increase in cartilage synthetic activity in the presence or absence of 10% fetal calf serum. Dialyzed fetal calf serum increases the metabolic response at 375 psi from 10% to 55%. The recovery phase following exposure to pressure includes a release (rebound) phenomenon whereby a burst of metabolic activity elevates the metabolic rate to normal levels when the tissues are inhibited (75-300 psi) and accelerates the metabolic rate by 60% in tissues whose metabolism was elevated (375 psi). These data suggest that articular cartilage chondrocytes have the capacity to rapidly and differentially transform mechanical signals derived from application of hydrostatic pressure into metabolic events. The direction of the response is apparently dictated by the magnitude of the applied force and presence of dialyzable components in serum. Although the force applied only partially mimics in vivo forces, the observed responses to pressure support the thesis that pressure modulation of metabolic activity in articular cartilage may be an important factor in its maintenance.

Tolerance maintenance depends on persistence of the tolerizing antigen: evidence from transplantation studies on Xenopus laevis

In order to assess the role of antigen persistence in the tolerant state, tolerance was induced in Xenopus laevis by the embryonic transplantation of whole eyes or tail tissue. Both types of transplants were seen to heal in and persist, with no signs of immunological incompatibility. At metamorphosis, tail resorption occurred and grafted tail tissue was lost. Eye transplants were maintained through metamorphosis in most eye grafted animals. Eye graft recipients which had maintained the transplant were observed to accept challenge skin allografts from donors of the same genotype as the eye donor in all but one case, while recipients which had lost the eye transplant at metamorphosis or had the eye transplant experimentally removed sometimes did not accept the challenge skin graft. Animals tail grafted as embryos did not accept post metamorphic skin grafts from donors of the same genotype as the tail tissue donor, but rejection was not accelerated. It is proposed that tolerance induction is dependent on the presence of appropriately presented antigen at a time when precursor thymocyte cells are migrating to the thymus, prior to their processing into alloreactive cells, and that tolerance maintenance is dependent upon the persistence of the tolerizing antigen.

Allograft rejection in Xenopus laevis following larval thymectomy

Xenopus laevis thymectomized at stages 41 through 49 accept first set allografts, while animals thymectomized at stage 51 or older reject allografts in times similar to intact animals. However, thymectomy at progressively earlier stages results in a greater proportion of animals unable to reject second set grafts. In some animals, the allograft response remains deficient even after multiple challenges. The results indicate that alloreactive cells are thymus dependent, and suggest that the thymus processes precursor thymocytes starting upon its formation at around stage 41. The processed cells, competent to respond to alloantigens, are released to the periphery almost immediately. While an increasing pool of processed T cells accumulates during stages 41-49, the persistent defective allograft response displayed by animals thymectomized during these stages suggests that early thymectomy may leave a population of alloreactive cells qualitatively defective in some subpopulation necessary for normal allograft responses, or that any residual cells processed prior to thymectomy are capable of only limited clonal expansion.