The administration of aerosolised medications in bronchiectasis: the rediscovery of an old method

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Fringe jump analysis and implementation of polarimetry on the ASDEX Upgrade DCN interferometer

The ASDEX Upgrade tokamak is equipped with a 5-channel DCN interferometer with a probing wavelength of 195 μm. Up to now, phase measurement and density calculation have been accomplished by hard-wired phase counting electronics. Meanwhile, a fast digitizer has been installed which acquires the raw signals. That way, the various causes of counting errors by integer multiples of 2π, so-called fringe jumps, can be analyzed, and phase reconstruction schemes based on digital signal processing can be developed. In addition, a prototype polarimeter setup has been installed on one channel and allows for measurement of the Faraday rotation experienced by the probing beam.

Trends and challenges in tuberculosis in a medium-sized southern European setting

Trends in tuberculosis (TB) admissions over 40 years at the Infectious Diseases Clinic of Perugia University Hospital, Perugia, Italy, show that in the last decade non-Italian TB case admissions outweighed those of Italians, with a large number of cases from Eastern Europe (25.2%) and Africa (23.4%). Non-Italians tended to be younger and were generally new pulmonary TB cases, and drug resistance was also more common. Overall, the number of multidrug-resistant cases increased. Only one case occurred in a native-born Italian, and five of seven cases had newly diagnosed TB. In low TB incidence settings such as Perugia, Italy, TB prevention and control programmes for the foreign-born need to be reinforced.

Laparoscopic lymphatic roadmapping with blue dye and radioisotope in colon cancer

Lymphatic mapping (LM) and sentinel lymph node (SLN) identification by blue dye in colon cancer is a procedure feasible during minimally invasive surgery, with good specificity, but still a low sensitivity (78% in our series). These results are in accordance with the literature and have limited more widespread diffusion of the method, both as a tool for upstaging and more controversially, as a potential roadmap to a tailored lymphadenectomy. It is possible to improve the results of LM with careful selection of patients and by the use of an intraoperative gamma camera. The preliminary results of intra-operative lymphoscintigraphy are promising in a well-selected small group of patients, with high levels of sensitivity and specificity. If these results are confirmed in further prospective analyses, it may be possible to undertake selected, tailored lymphadenectomy.

Trends in the prevalence of asthma and allergic rhinitis in Italy between 1991 and 2010

The prevalence of asthma increased worldwide until the 1990s, but since then there has been no clear temporal pattern. The present study aimed to assess time trends in the prevalence of current asthma, asthma-like symptoms and allergic rhinitis in Italian adults from 1990 to 2010. The same screening questionnaire was administered by mail or phone to random samples of the general population (age 20-44 yrs) in Italy, in the frame of three multicentre studies: the European Community Respiratory Health Survey (ECRHS) (1991-1993; n = 6,031); the Italian Study on Asthma in Young Adults (ISAYA) (1998-2000; n = 18,873); and the Gene Environment Interactions in Respiratory Diseases (GEIRD) study (2007-2010; n = 10,494). Time trends in prevalence were estimated using Poisson regression models in the centres that repeated the survey at different points in time. From 1991 to 2010, the median prevalence of current asthma, wheezing and allergic rhinitis increased from 4.1% to 6.6%, from 10.1% to 13.9% and from 16.8% to 25.8%, respectively. The prevalence of current asthma was stable during the 1990s and increased (relative risk 1.38, 95% CI 1.19-1.59) from 1998-2000 to 2007-2010, mainly in subjects who did not report allergic rhinitis. The prevalence of allergic rhinitis has increased continuously since 1991. The asthma epidemic is not over in Italy. During the past 20 yrs, asthma prevalence has increased by 38%, in parallel with a similar increase in asthma-like symptoms and allergic rhinitis.

The Gene-Environment Interactions in Respiratory Diseases (GEIRD) Project

The role of genetic and environmental factors, as well as their interaction, in the natural history of asthma, allergic rhinitis and chronic obstructive pulmonary disease (COPD) is largely unknown. This is mainly due to the lack of large-scale analytical epidemiological/genetic studies aimed at investigating these 3 respiratory conditions simultaneously. The GEIRD project is a collaborative initiative designed to collect information on biomarkers of inflammation and oxidative stress, individual and ecological exposures, diet, early-life factors, smoking habits, genetic traits and medication use in large and accurately defined series of asthma, allergic rhinitis and COPD phenotypes. It is a population-based multicase-control design, where cases and controls are identified through a 2-stage screening process (postal questionnaire and clinical examination) in pre-existing cohorts or new samples of subjects. It is aimed at elucidating the role that modifiable and genetic factors play in the occurrence, persistence, severity and control of inflammatory airway diseases, by way of the establishment of a historical multicentre standardized databank of phenotypes, contributed by and openly available to international epidemiologists. Researchers conducting population-based surveys with standardized methods may contribute to the public-domain case-control database, and use the resulting increased power to answer their own scientific questions.

Interferon-γ-Release Assays Detect Recent Tuberculosis Re-Infection in Elderly Contacts

The tuberculin skin test (TST) does not discriminate between recent and remote latent tuberculosis infection (LTBI). This study was carried out to test two interferon-γ (IFN-γ)-based blood assays in recent contacts with high prevalence of remote LTBI. We performed a contact tracing investigation in a nursing home for the elderly, where elderly patients were exposed to a case of pulmonary tuberculosis. TST, QuantiFERON-TB Gold (QFT-G) and T-SPOT.TB (TS.TB) were performed 8 weeks after the end of potential exposure. IFN-γ measurements were recorded and correlation with exposure was evaluated. Twenty-seven (37.5%), 32 (44.4%) and 16 (22.2%) subjects were TST, TS.TB and QFT-G positive, respectively; agreement between TS.TB and QFT-G was good among exposed subjects only (κ=0.915, 0.218 in unexposed, p<0.001). When amounts of IFN-γ were corrected for the number of producing T cells, specific IFN-γ production was significantly different between exposed and unexposed individuals (16.75±5.40 vs 2.33±0.71 IFN-γ IU/1000 SFC, p=0.0001). QFT-G and TS.TB provided discordant results among elderly contacts. Unlike TST, the specific IFN-γ response might discriminate between recent and long-lasting tuberculosis infection.

Doping and respiratory system

Historically many different drugs have been used to enhance sporting performances. The magic elixir is still elusive and the drugs are still used despite the heavy adverse effects. The respiratory system is regularly involved in this research probably because of its central location in the body with several connections to the cardiovascular system. Moreover people are aware that O2 consumption and its delivery to mitochondria firstly depend on ventilation and on the respiratory exchanges. The second step consists in the tendency to increase V'O2 max and to prolong its availability with the aim of improving the endurance time and to relieve the fatigue. Many methods and substances had been used in order to gain an artificial success. Additional oxygen, autologous and homologous transfusion and erythropoietin, mainly the synthetic type, have been administered with the aim of increasing the amount of oxygen being delivered to the tissues. Some compounds like stimulants and caffeine are endowed of excitatory activity on the CNS and stimulate pulmonary ventilation. They did not prove to have any real activity in supporting the athletic performances. Beta-adrenergic drugs, particularly clenbuterol, when administered orally or parenterally develop a clear illicit activity on the myosin fibres and on the muscles as a whole. Salbutamol, terbutaline, salmeterol and formoterol are legally admitted when administrated by MDI in the treatment of asthma. The prevalence of asthma and bronchial hyperactivity is higher in athletes than amongst the general population. This implies that clear rules must be provided to set a correct diagnosis of asthma in the athletes and a correct therapy to align with the actual guidelines according to the same rights of the "other" asthmatic patients.

Management of multidrug-resistant tuberculosis in Italy

SETTING

SMIRA (Italian Study on Anti-Tuberculosis Drug Resistance) network, 46 major clinical units and 22 laboratories nationwide in Italy.

OBJECTIVES

To determine the main features, adherence to WHO guidelines and the outcomes of multidrug-resistant tuberculosis (MDR-TB) patients enrolled from January 1995 to December 1999.

DESIGN

Observational study, preceded by proficiency testing, according to WHO recommendations. Results were stratified by appropriate and inappropriate regimens (< three active drugs). Analysis of the outcomes was performed according to adequacy of treatment. Analysis of risk factors and factors predicting treatment outcomes was performed using univariate and multivariate analysis (level of significance P < 0.05).

RESULTS

One hundred and twenty-seven MDR patients were diagnosed. The overall success rate was low (39%). Seventy per cent of cases were treated with at least three active drugs. Factors predicting treatment success were new MDR-TB cases (OR 3.45; 95% CI 1.22-9.78; P < 0.05) and treatment for > or = 12 months (OR 5.03; 95% CI 1.65-15. 31; P < 0.05). Immigration and HIV infection were the main risk factors among new MDR-TB cases.

CONCLUSION

The best available treatment should be provided to all newly diagnosed MDR-TB patients, avoiding the use of poorly modified regimens. MDR-TB patients should be referred to highly specialised centres.

[Evaluation of dairy production in the alpine regions of Valcamonica and Sondrio, and the adherence to hygienic practice guidelines]

The Regional Veterinary Service of Lombardy (northern Italian region) developed guideline on good hygienic practices to improve the safety of milk production and transformation in the mountain pastures and to grant the European acknowledgment (EU seal). Therefore we carried out 26 inspections in Valcamonica (Province of Brescia) and 30 in the Sondrio's province (26% and 16% respectively) in mountain pastures that had required the acknowledgment. The data analysis has shown that in Valcamonica 26.9% of the mountains pastures was conform to the regulations, in Sondrio's province instead 6.6% was conform; the frequency of acceptable conformity level increases respectively to 46% and to 33%, if we also consider the mountains pastures in restructuring phase and with very low level of non conformity. Our study emphasizes the need of structural adjustments of these traditional setting and of education of workers in order to improve the food safety and operator's life quality, and also to promote the maintenance of mountain pastures in the Alpine region.

The role of climate on the geographic variability of asthma, allergic rhinitis and respiratory symptoms: results from the Italian study of asthma in young adults

BACKGROUND

Variations in the prevalence of respiratory symptoms according to geo-climatic factors could provide important clues to the knowledge of the aetiology of asthma.

METHODS

Geo-climatic variations in the prevalence of current asthma, allergic rhinitis and chronic cough, and phlegm were assessed on a random sample of 18 873 subjects (response rate = 72.7%) from different climatic regions of Italy. An ecological analysis, supported by robust statistical methods, was employed to investigate potential trends.

RESULTS

The prevalence of all symptoms was significantly heterogeneous throughout the peninsula. Only asthma-like symptoms showed a north-south trend: the prevalence increased at a decreasing latitude [odds ratio (OR) varies from 0.92 to 0.96, P < 0.05], at a decreasing distance from the sea (OR: 0.90-0.93 for 30 km distance, P < 0.05), at higher annual mean temperatures (OR: 1.11-1.14, P < 0.05) and at smaller annual temperature ranges (OR: 0.94-0.95, P < 0.05). Of the geo-climatic variables considered, temperature range had the greatest influence on most asthma-like symptoms. No association was found between geo-climatic variables and allergic rhinitis or chronic cough and phlegm.

CONCLUSIONS

Asthma prevalence seems to be significantly affected by climate as asthma-like symptoms were more common in central-southern Italy, with a Mediterranean climate, than in areas with a continental climate (northern Italy).

Efficacy and safety of short course (5-day) moxifloxacin vs 7-day ceftriaxone in the treatment of acute exacerbations of chronic bronchitis (AECB)

The aim of this multicenter, open, randomized study was to compare the efficacy and tolerability of a 5-day treatment course with oral moxifloxacin (MXF) vs a 7-day course with i.m. ceftriaxone (CRO) in 476 patients with acute exacerbations of chronic bronchitis (AECB), and to conduct a cost minimization analysis of the two treatments from the perspectives of both the Italian National Health Service (INHS) and society. The study was conducted in Italy. Clinical success rates at test-of-cure in the 423 patients of the PP (Per Protocol) population (primary efficacy parameter) were 90.6% and 89.0% for MXF and CRO, respectively. Statistical non-inferiority of MXF vs CRO was confirmed. Similar results were found between study drugs on the secondary efficacy parameters, including success at end-of-treatment (95.3% for MXF vs 92.9% for CRO), success at test-of-cure in bacteriologically-positive patients (94.1% vs 90.7%) and eradication/presumed eradication rates (91.7% vs 93.3%). ITT (Intention-to-Treat) analysis confirmed these data. There was a low incidence of adverse events (10.8% vs 9.1%). During a 6-month follow-up period, relapse rates were lower for MXF vs CRO (23.3% vs 28.3%; p > .05). Compared with CRO, MXF was associated with cost savings per patient ranging from Euro226.57 (INHS perspective) to Euro448.23 (societal perspective), with lower hospitalization rate the major variable contributing to reduced costs. MXF appears to be an ideal candidate for AECB treatment.

Virulence of Mycobacterium tuberculosis affects interleukin-8, monocyte chemoattractant protein-1 and interleukin-10 production by human mononuclear phagocytes

Microbial virulence and cytokine-mediated immune responses to Mycobacterium tuberculosis infection are important determinants of the pathogenesis of human tuberculosis. To determine the interrelationship between mycobacterial virulence and cytokine induction, human monocytes and monocyte-derived macrophages were infected with attenuated (H37Ra) and virulent (H37Rv and CH306) strains of M. tuberculosis and the amount of proinflammatory [interleukin (IL)-8 and monocyte chemoattractant protein (MCP)- 1] and inhibitory (IL- 10) cytokines was measured in the culture supernatants by enzyme-linked immunosorbent assay (ELISA). Infection with live bacilli induced de novo synthesis of IL-8, MCP-1 and IL-10, since cytokine release was abolished when cells were preincubated with the protein synthesis inhibitor cycloheximide. A differential production of antiinflammatory and inhibitory cytokines was observed. The amount of IL-8 and MCP-1 release was inversely related to strain virulence, the attenuated H37Ra strain being more prone than virulent strains to induce secretion of chemokines. In contrast, virulent strains induced greater amounts of the inhibitory cytokine IL-10. Efficient upregulation of IL-10 synthesis, but not of chemokines, required infection of cells with live bacilli, since heat killing of organisms or challenge with soluble mycobacterial products completely abrogated the effect. Moreover, cells infected with virulent strains produced IL-10 even at a very low bacillus-to-cell ratio and secreted IL-10 continuously during the 96 h that followed infection. The results suggest that the degree of virulence affects host cell responses to M. tuberculosis infection. Continued production of IL-10 may be one of the means by which M. tuberculosis downregulates acute local inflammatory reactions, favoring the development of tuberculosis.

A 10-year survey of Mycobacterium tuberculosis isolates in Pavia and their drug resistance: a comparison with other Italian reports

A retrospective review was made of the bacteriological and medical records of patients with culture-confirmed pulmonary tuberculosis who attended the IRCCS San Matteo Polyclinic of Pavia, between 1990 and 2000. Altogether, 279 patients were included in the survey: 220 new cases and 59 prior treatment cases. Resistance to at least one drug, and resistance to both isoniazid and rifampicin (MDR) were more common among previously treated patients than among new cases (86.4% vs. 34.1%, and 44% vs. 5.9%, respectively). While the frequency of resistance to any drug showed no variation in the period examined, a trend toward a progressive decrease in the frequency of primary MDR-TB was observed (from 11.9% in 1990-1992 to 1.3% in 1998-2000). The level of resistance observed in our study suggests that all isolates of Mycobacterium tuberculosis should be tested for drug susceptibility, especially when obtained from patients who report a previous episode of the disease.

Prevalence of resistance to anti-tuberculosis drugs: results of the 1998/99 national survey in Italy

OBJECTIVE

To determine the prevalence of resistance to the main anti-tuberculosis drugs in newly and previously treated tuberculosis patients in Italy and to evaluate the contribution of foreign-born and human immunodeficiency virus (HIV) positive cases to drug resistance.

METHODS

Methods and definitions were derived from the WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. Univariate and multivariate analysis was used to study prevalence rates of drug resistance in risk groups.

RESULTS

In a national survey in Italy, 810 initial isolates of Mycobacterium tuberculosis (683 from new cases, 115 from retreatment cases and 12 from patients whose treatment history was unknown/dubious) were analysed. Low prevalence of drug and multidrug resistance was found in the new cases (isoniazid 2.9%; rifampicin 0.8%; multidrug resistance 1.2%; any drug resistance 12.3%). The prevalence of resistance to isoniazid and rifampicin was significantly higher in immigrants and HIV-positive subjects, respectively. A high prevalence of drug resistance was found in cases with previous treatment failure or default (isoniazid 5.2%; rifampicin 4.3%; multidrug resistance 36.5%; any drug resistance 61.7%).

RECOMMENDATIONS

Special efforts are necessary to monitor trends in drug resistance and to ensure favourable treatment outcomes among immigrants and HIV-positive tuberculosis cases.

Lung cancer resection: the prediction of postsurgical outcomes should include long-term functional results

STUDY OBJECTIVES

To assess (1) the possibility of predicting long-term postoperative lung function, and (2) the usefulness of maximal oxygen consumption (O(2)max) as a criterion for operability and as a predictor of long-term disability.

DESIGN

Prospective study.

SETTING

Outpatients and inpatients of a university hospital.

PARTICIPANTS

Sixty-two consecutive patients (mean +/- SD age, 62 +/- 8 years; 51 male and 11 female patients) were preoperatively evaluated for lung cancer resection (pneumonectomy or bilobectomy [n = 14] and lobectomy [n = 48]).

MEASUREMENTS

Clinical examination and recorded respiratory symptoms and spirometry results before surgery and 6 months after surgery. If predicted postoperative FEV(1) (ppoFEV(1)) was < 40%, patients underwent exercise testing; if O(2)max was between 10 mL/kg/min and 20 mL/kg/min, patients underwent a split-function study.

RESULTS

All the patients with ppoFEV(1) > or = 40%-even those patients (26%) with FEV(1) < 80%-underwent thoracotomy without further tests. Seven patients with ppoFEV(1) < 40% underwent exercise testing, and three of them underwent a split-function study. Nine patients (15%; including six patients with COPD and one patient with asthma) had immediate postoperative complications (pneumonia [n = 5] and respiratory failure [n = 4]); seven of these patients had ppoFEV(1) > or = 40%. ppoFEV(1) significantly underestimated the actual postoperative FEV(1) (poFEV(1); p < 0.001) 6 months after pneumonectomy or bilobectomy but was reliable for actual poFEV(1) after lobectomy. Two patients with predicted postoperative O(2)max > 10 mL/kg/min became oxygen dependent and had marked limitation of daily living.

CONCLUSIONS

ppoFEV(1) > or = 40% reliably identifies patients not requiring further tests and not at long-term risk of respiratory disability. O(2)max, effective for defining the immediate surgical risk, is not useful in predicting long-term disability.

Variations in the prevalence across countries of chronic bronchitis and smoking habits in young adults

The present work aims to assess the international variation in the prevalence of chronic bronchitis and its main risk factor, smoking habits, in young adults of 35 centres from 16 countries. Respiratory symptoms and pulmonary function were assessed in 17,966 subjects (20-44 yrs), randomly selected from the general population, in the frame of the European Community Respiratory Health Survey. The median prevalence of chronic bronchitis was 2.6%, with wide variations across countries (p<0.001; 0.7-9.7%). The prevalence of current smokers ranged 20.1-56.9%, (p<0.001) with a median value of 40%. Current smoking was the major risk factor for chronic bronchitis, especially in males. Its effect increased according to number of pack-yrs: in males, the odds ratio of chronic bronchitis was 3.51 (95% confidence interval (CI) 2.31-5.32) in 1-14 pack-yrs smokers and increased to 17.32 (9.97-30.11) in > or = 45 pack-yrs smokers with respect to nonsmokers. Only 30% of the geographical variability in prevalence could be explained by differences in smoking habits, suggesting that other environmental and/or genetic factors may play an important role. In conclusion, chronic bronchitis is a substantial health problem even in young adults. The impressive prevalence in current smokers in most countries highlights the need to improve the quality of prevention.

Variations in serum levels of interleukin (IL)-1beta, IL-2, IL-6, and tumor necrosis factor-alpha during specific immunotherapy

BACKGROUND

Cytokine production by T helper cells is essential for the induction and maintenance of allergic inflammation in the bronchial mucosa. According to recent views, specific immunotherapy (SIT) favors the differentiation of T lymphocytes into cells of the Th1 rather than those of the Th2 subset.

OBJECTIVE

To determine whether or not SIT induces a decrease in the inflammatory reaction by studying eventual variations in the serum levels of IL-1beta, IL-2, IL-6, and TNF-alpha in allergic subjects during SIT.

METHODS

Serum levels of IL-1beta, IL-2, IL-6, and TNF-alpha were determined before and after 3, 6, and 9 months of SIT by an immunoradiometric assay (IRMA) in 11 adults with perennial allergic asthma and/or rhinitis caused by house dust mites and in 6 nonatopic healthy volunteers.

RESULTS

Median serum IL-1beta and TNF-alpha levels of the patients were significantly higher at baseline than those of the controls and decreased during SIT to values similar to or lower (P < .01) after 6 months of SIT for TNF-alpha than those of the controls. Median serum IL-2, significantly lower at baseline than in the controls, increased during SIT to a level similar to that of the controls. Although the median values of IL-1beta and TNF-alpha in the patients tended to decrease and those of IL-2 to increase during SIT, the differences were not significant; the correlation coefficients (r) of the serum levels of IL-1beta IL-6, and TNF-alpha versus duration of SIT were negative, while that of IL-2 was positive.

CONCLUSIONS

Decreases in median serum IL-1beta and TNF-alpha levels during SIT, together with the increases in serum IL-2 and IL-6, compared with those of the controls furnish evidence supporting a reduction in the inflammatory response in the course of SIT.

Genetic aspects in sarcoidosis

Sarcoidosis is an immune-mediated, multiorgan, granulomatous disorder thought to be triggered by an intricate combination of environmental and genetic factors. Two robust lines of evidence support the hypothesis of a genetic component in the pathogenesis of sarcoidosis: racial variation in its epidemiology and familial clustering of cases. The relationship between epidemiology and environmental factors affecting variations in sarcoidosis incidence/prevalence and presentation are reviewed, as well as strategies to be pursued in the search for susceptibility genes for the disorder. Pathogenic processes leading to sarcoid granuloma formation and maintenance have prompted investigators interested in the genetics of sarcoidosis to focus mainly on major histocompatibility complex genes, and indeed a remarkable amount of data has been accumulated during the last two decades. Whilst in contrast with some autoimmune disorders a clear association between human leukocyte antigen (HLA) and sarcoidosis is still a controversial issue, there is, however, a general agreement that some HLA genes are related to phenotypic variations of the disease. Some genetic investigators have focused on T-cell receptor genes, immunoglobulin genes, angiotensin converting enzyme gene, chemokine genes and others. From a review of studies performed in different racial and ethnic groups, a reasonable suggestion arises that genetic factors are the major determinant in the racial variations in the epidemiology of the disorder. This assumption is, however, so far limited by lack of studies considering both genetic and environmental factors simultaneously.

Increased frequency of CFTR gene mutations in sarcoidosis: a case/control association study

A complete screening of the CFTR gene by DGGE and DNA sequencing was performed in patients with sarcoidosis. In 8/26 cases, missense and splicing CFTR gene mutations were found, a significant difference over controls (9/89) from the same population (P = 0.014). The odds ratio for a person with a CFTR gene mutation to develop the disease is 3.95 (1.18 < OR < 13.26). Seven different CFTR gene mutations were observed: R75Q, R347P, 621 + 3 A/G, 1898 + 3 A/G, L997F, G1069R, and a novel mutation which was detected in this study, I991V. R75Q mutation was present in 3/26 patients, a significant increase (P = 0. 01) in cases over controls, indicating its preferential association with sarcoidosis. A trend towards disease progression was observed in patients with CFTR gene mutations compared to patients without mutations. These data suggest that CFTR gene mutations predispose to the development of sarcoidosis.

HLA-Gm/kappam interaction in sarcoidosis. Suggestions for a complex genetic structure

The aetiology of sarcoidosis is still unknown. Environmental exposures are believed to interact with genetic factors in determining the pattern of sarcoidosis presentation, progression and prognosis. The frequency of serological polymorphism of immunoglobulin G heavy chain (Gm) and kappa light chain (kappam) markers in 107 patients with biopsy-proven sarcoidosis and in 227 controls, and their interactions with histocompatibility leukocyte antigen (HLA) class I, II, and III markers, were studied. A "protective" effect of the Gm(3 5*) phenotype in the sarcoid group versus controls (p-value for number of specificities tested (p(c))=0.05, odds ratio 0.15) and a reduced frequency of Gm(3 23 5*) in patients with advanced chest radiographic stage (Chi-squared (two degrees of freedom)(chi2(2df) 17.61, p(c)=0.0058) were observed. With reference to epistatic interactions, the combination Gm(3 23 5*)/BfS had a "protective" effect towards stage II (chi2(2dt) 13.86, p(c)=0.043). Finally, correspondence analysis defined two clusters: HLA-DR4, C4BQ0, Gm(1, 3, 17 23 5*, 21, 28) and BfF associated with stage II, and HLA-DR3, C4AQ0, kappam(1) and Gm(3 23 5*) associated with stage I. These data further support the hypothesis that sarcoidosis results from an interplay of environmental factors and genes, each contributing to the susceptibility/resistance to and/or the clinical heterogeneity of the disease. In addition, these data provide the first evidence of an interaction between immunoglobulin G heavy chain/kappa light chain markers and histocompatibility leukocyte antigen class III genes in a disease.

Hospital admission policy for tuberculosis in pulmonary centres in Italy: a national survey. AIPO Tuberculosis Study Group. Italian Association of Hospital Pulmonologists

SETTING

A national survey including 203 pulmonary centres (PCs) (144 hospital PCs with beds dedicated to TB patients and 59 out-patient PCs) managing tuberculosis cases in Italy during 1995.

OBJECTIVES

To evaluate: 1) hospitalisation practices (criteria for admission/discharge; duration of hospitalisation) as primary end-points; and 2) as secondary end-points the availability of beds, the preventive measures adopted to reduce the spread of infection, the sources of referral for hospitalisation and the procedures adopted to follow up TB patients after discharge.

DESIGN

A 26-point questionnaire mailed to 203 PCs.

RESULTS

Of 167 PCs that responded to the questionnaire (82.3%), 159 questionnaires were considered valid for the analysis (110 from hospitals PCs and 49 from out-patient PCs). The criteria adopted by PCs to admit TB patients were: all TB cases 47%, only smear-positive pulmonary TB 14%, TB cases with clinical problems 39%. Hospital PCs hospitalised significantly more cases of smear-negative, extra-pulmonary TB. On average 71.6% of all cases were hospitalised (88.2% by hospital and 28% by out-patient PCs). The median hospital stay was 34 days for sputum smear-positive, 20 for sputum smear-negative and 21.5 for extra-pulmonary TB cases. Sputum conversion was considered the mandatory criterion to allow discharge from 61% of hospital PCs.

CONCLUSION

A switch from the present policy (majority of cases hospitalised for a long period) to an outpatient oriented policy needs the co-ordinated educational effort of scientific societies and health authorities.

The Italian AIPO study on tuberculosis treatment results, report 1997. National AIPO "Tuberculosis" Study Group

In Italy no national data have been available on tuberculosis (TB) treatment results. In 1995 the AIPO (Italian Association of Hospital Pneumologists) TB Study Group, in collaboration with the Istituto Superiore di Sanità (technical branch of the Ministry of Health) started a prospective monitoring activity based on the recommendations of the World Health Organization and the International Union Against Tuberculosis and Lung Disease. The aim of this study was to analyse the case findings and treatment results during 1997. Data were collected from a representative network of TB units nation-wide, managing a significant proportion of all TB cases notified in Italy each year. A total of 715 TB cases were reported (56% males; 24% immigrants), of which 635 (89%) were new cases. Of these cases 493 (69%) were pulmonary, 187 (26%) extra-pulmonary cases and 35 (5%) both pulmonary and extrapulmonary. The main risk factors for TB were history of recent contact and diabetes among native Italians, human immunodeficiency virus-seropositive status and a history of recent contact among immigrants. The majority of immigrants came from Africa and Central and South America, and stayed in Italy for more than 24 months before the diagnosis of TB was made. Thirty-six per cent of patients had a positive direct sputum smear examination for alcohol acid-fast bacilli and 27% were resistant to any drug (monoresistance to isoniazid: 2.4%; multi-drug resistance: 7.5%). In 97% of cases the duration of treatment was < 12 months. The overall success rate (cured plus treatment completed) was 78.1%. A significantly higher percentage of deaths, which was age related, was found in native Italians, while immigrants had a higher default rate. In conclusion, case finding and treatment results in Italy in 1997 are similar to those described in 1995 and 1996.

The Italian AIPO study on tuberculosis treatment results, report 1996. National AIPO "Tuberculosis" Study Group. Associazione Italiana Pneumologi Ospedalieri

In Italy, no national data on tuberculosis (TB) treatment results were available. In 1995, the AIPO (Italian Association of Hospital Pneumologists) TB Study Group, in collaboration with the Istituto Superiore di Sanità (technical branch of the Ministry of Health), started a prospective monitoring activity based on World Health Organization (WHO) and International Union against Tuberculosis and Lung Disease (IUATLD) recommendations. Data were collected from a nationwide network of 41 TB units, managing a significant proportion of all the TB cases notified in Italy each year. The aim of this study was to analyse the case findings and treatment results for the year 1996. Eight hundred and thirty eight TB cases were reported (56% males; 26% immigrants), 708 (84%) being new cases. Of these cases, 565 (67%) were pulmonary, 235 (28%) extrapulmonary and 38 (5%) both pulmonary and extrapulmonary. The main risk factors for TB were a history of recent contact and diabetes among native Italians and recent contact and human immunodeficiency virus-seropositive status among immigrants. The majority of immigrants were from Africa and Asia, and had been in Italy > 24 months before diagnosis of TB. Thirty-six per cent of patients had a positive direct sputum smear examination for alcohol acid-fast bacilli; 37% were resistant to any drug (monoresistance to isoniazid 4.4%; multidrug resistance 10.4%). In 96% of cases, the duration of treatment was < 12 months. The overall success rate (cured plus treatment completed) was 84.1%. A significantly higher percentage of deaths was found in native Italians (being age-related), whereas immigrants had a higher default rate.

Micellar electrokinetic chromatography for analyzing active site specificity of Pseudomonas aeruginosa elastase

The geometry of the catalytic site of Pseudomonas aeruginosa elastase was reexamined, exploiting the specific feature of micellar electrokinetic chromatography (MEKC), i.e., its ability to detect a decrease of intact substrate and simultaneous formation of reaction products. We carried out a detailed investigation using two tri- and six tetra-peptide 4-nitroanilides (NA) differing from each other by only one or more amino acids as stable substrates. The kinetic cleavage parameters Km and k(cat) determined by MEKC and the catalytic efficiency Km/k(cat) values calculated allowed us to better define the substrate specificity of this proteinase.

Prospective multicentre study on the evaluation of antituberculosis treatment results in Italy: comparison of the culture- versus the smear-based methods. National AIPO Tuberculosis Study Group

Cohort analysis of treatment outcomes is the most informative technique to evaluate the tuberculosis (TB) control programme. The aim of the study was to assess treatment outcomes comparing the smear- versus the culture-based methods, using data on TB patients treated under programme conditions in Italy. This was a prospective monitoring study based on the standardized collection of forms from a representative sample of Italian TB Units. The forms, with individual data, were reviewed and analysed on a quarterly basis according to the principles of cohort analysis, using both the smear- and culture-based methods. The complete bacteriological profile of patients was analysed at diagnosis and at completion of treatment. Nine hundred and ninety-two TB cases were notified. Among 681 pulmonary cases, 368 cases were culture-confirmed at diagnosis (333 new and 35 retreatment cases, 293 being sputum smear positive, 79.6%). At the end of treatment, out of the 333 new culture-confirmed cases, 136 (40.8%) were defined "cured" using the culture-based method and 108 (32.4%) using the smear-based method (p<0.05, chi2 test). The culture-based method is the recommended tool to evaluate pulmonary tuberculosis treatment results. Culture allows a more precise definition of a "cured" patient in both sputum smear positive and negative tuberculosis cases.

Late pulmonary sequelae after childhood bone marrow transplantation

BACKGROUND

Respiratory function in transplanted children is important because of the long life expectancy of bone marrow transplant recipients, particularly children. Attention is now being focused on the late sequelae of treatment on organ system function. A few papers have been published but available data are somewhat conflicting.

METHODS

A cross sectional study aimed at evaluating the late effects of transplantation on lung function was performed in a group of 52 young patients who were given autologous or allogeneic bone marrow transplants during childhood for haematological malignancies.

RESULTS

No patients reported chronic respiratory symptoms. The distribution of respiratory function patterns showed that only 62% of patients had respiratory function within the normal limits; 23% had a restrictive pattern and 15% had isolated transfer factor impairment. The percentage of patients with lung function abnormalities was higher in those who (1) received a bone marrow transplant after two or three complete remissions compared with those who were transplanted immediately after the first remission (54% vs 21%; p < 0.02), (2) underwent allogeneic bone marrow transplantation rather than an autologous transplantation (45% vs 26%; p = 0.06), and (3) had a pulmonary infection compared with those without (56% vs 26%; p = 0.07).

CONCLUSIONS

In spite of the absence of chronic respiratory symptoms there is a high prevalence of children with late pulmonary sequelae after bone marrow transplantation. Regular testing is recommended after transplantation, in particular in subjects at higher risk of lung injuries, such as those receiving transplants after more than one remission, those receiving allogeneic transplants, and those having suffered from pulmonary infections. When lung function abnormalities become apparent, long term follow up is necessary to see whether they become clinically relevant. All patients should remain non-smokers after transplantation and should have active early and aggressive treatment for respiratory illnesses.

The Italian AIPO study on tuberculosis treatment results, report 1995. National AIPO "Tuberculosis" Study Group

In Italy, no national data on tuberculosis (TB) treatment results were available. In 1995, the AIPO (Italian Association of Hospital Pneumologists) TB Study Group, in collaboration with the Istituto Superiore di Sanità (technical branch of the Ministry of Health), started a prospective monitoring activity based on World Health Organization (WHO) and International Union against Tuberculosis and Lung Disease (IUATLD) recommendations. Data were collected from a nationwide network of 41 TB units, managing a significant proportion of all TB cases notified in Italy each year. The aim of this study was to analyse the case findings and treatment results for the year 1995. Seven hundred and seventy eight TB cases were reported (59% males; 21% immigrants), 640 (82%) being new cases. Of these cases, 517 (66%) were pulmonary, 239 (31%) extrapulmonary and 22 (3%) both pulmonary and extrapulmonary. The main risk factors for TB were a history of recent contact and alcohol abuse among native Italians and human immunodeficiency virus-seropositive status among immigrants. The majority of immigrants were from Africa and South America, and had been in Italy > 24 months before diagnosis of TB. Thirty-seven per cent of patients had a positive direct sputum smear examination for alcohol acid-fast bacilli; 20% were resistant to any drug (monoresistance to isoniazid 3.5%; multidrug resistance 5.2%). In 95% of cases, the duration of treatment was < 12 months. The overall success rate (cured plus treatment completed) was 81.1%. A significantly higher percentage of deaths was found in native Italians (being age-related), whereas immigrants had a higher default rate.

Cost-comparison of different management policies for tuberculosis patients in Italy. AIPO TB Study Group

Although in developing countries the treatment of tuberculosis (TB) cases is among the most cost-effective health interventions, few studies have evaluated the cost-effectiveness of TB control in low-prevalence countries. The aim of the present study was to carry out an economic analysis in Italy that takes into account both the perspective of the resource-allocating authority (i.e. the Ministry of Health) and the broader social perspective, including a cost description based on current outcomes applied to a representative sample of TB patients nationwide (admission and directly observed treatment (DOT) during the initial intensive phase of treatment); a cost-comparison analysis of two alternative programmes: current policy based on available data (scenario 1) and an hypothetical policy oriented more towards outpatient care (scenario 2) (both scenarios included the option of including or not including DOT outside hospital admission, and incentives) were compared in terms of cost per case treated successfully. Indirect costs (such as loss of productivity) were included in considerations of the broader social perspective. The study was designed as a prospective monitoring activity based on the supervised collection of forms from a representative sample of Italian TB units. Individual data were collected and analysed to obtain a complete economic profile of the patients enrolled and to evaluate the effectiveness of the intervention. A separate analysis was done for each scenario to determine the end-point at different levels of cure rate (50-90%). The mean length of treatment was 6.6 months (i.e. patients hospitalized during the intensive phase; length of stay was significantly higher in smear-positive patients and in human immunodeficiency virus (HIV) seropositive patients). Roughly six direct smear and culture examinations were performed during hospital admission and three during ambulatory treatment. The cost of a single bed day was US$186.90, whereas that of a single outpatient visit ranged, according to the different options, from US$2.50 to US$11. Scenario 2 was consistently less costly than scenario 1. The cost per case cured for smear-positive cases was US$16,703 in scenario 1 and US$5946 in scenario 2. The difference in cost between the cheapest option (no DOT) and the more expensive option (DOT, additional staff, incentives) ranged from US$1407 (scenario 1, smear-negative and extrapulmonary cases) to US$1814 (scenario 2, smear-positive cases). The additional cost to society including indirect costs ranged from US$1800 to US$4200. The possible savings at the national level were in the order of US$50 million per year. In conclusion, cost-comparison analysis showed that a relatively minor change in policy can result in significant savings and that the adoption of DOT will represent a relatively modest economic burden, although the real gain in effectiveness resulting from DOT in Italy requires further evaluation.

Inadequate antiasthma drug use in the north of Italy

A multicentre survey of prevalence, determinants and management of asthma (the European Community Respiratory Health Survey (ECRHS)) has shown that the ratio of subjects declaring current use of antiasthmatic drugs to those reporting asthma attacks in the previous 12 months was particularly low (0.54) in the north of Italy. In this study, we used a standardized clinical interview to gather a more detailed insight into the issue of asthma undertreatment in the north of Italy. A total of 1,104 subjects were interviewed, 116 of whom had been defined as asthmatic by the family doctor. Fifty subjects had current asthma and 66 had a history of previous asthma. A considerable percentage (26%) of subjects with current asthma were not being treated with antiasthmatic therapy. Even when only patients with severe asthma were considered, the percentage of untreated patients was still high (21%). Forty two per cent of subjects used inhaled beta2-agonists alone, 28% inhaled steroids plus beta2-agonists, 2% inhaled steroids alone and 2% other drugs. Only 19% of the asthmatics on treatment, 85% of whom had more severe asthma, received daily treatment. Only 65% of the subjects who had received antiasthmatic drug prescriptions declared they had taken all the drugs prescribed; this percentage was 74% when respiratory symptoms were worsening. Of the patients with past asthma, 18% had taken antiasthmatic drugs. Most of these patients were those who had had more severe asthma. In conclusion, antiasthmatic drugs are underused in the north of Italy, at least in part due to low compliance.

Evaluation of the impact of guidelines on tuberculosis control in Italy. National AIPO "Tuberculosis" Study Group. Associazione Italiana Pneumologi Ospedalieri

This study was performed in Italy, where a central tuberculosis (TB) unit and national guidelines on TB control are lacking. The objectives of the study were: 1) to design comprehensive guidelines on TB control; 2) to discuss them within the scientific community and to present them to administrators and politicians: and 3) to evaluate their impact from a public health perspective. The ultimate goal was to improve TB control nationwide through a consensus-based initiative. The steps taken in planning were as follows: 1) an assessment of control activities operating in the country was made by means of three surveys: 2) guidelines on TB control were designed, presented, discussed and approved during three Consensus Conferences involving representatives of organizations operating in TB control and services; and 3) their impact was evaluated by means of objectively verifiable indicators (availability of TB case definition, regional control programmes, surveillance reports, guidelines on treatment, staff training). Regional TB control programmes were implemented in three major regions (30% of the national population), and are in advanced process in other four regions (29% of the national population). The protocol approved during the three Consensus Conferences benefited from the co-ordinated action of governmental and nongovernmental organizations. Its impact on tuberculosis control was positive, particularly at the regional level.

Chronic respiratory symptoms, bronchial responsiveness and dietary sodium and potassium: a population-based study

A possible relationship between Na+ intake and increased prevalence and mortality from asthma and chronic obstructive pulmonary disease (COPD) has been suggested but not clearly proven for several reasons (difficulty in assessing Na+ and K+ both by 24 h excretion and dietary recall, too small an effect of these ions on the pathology, and the role of potential confounders). We wanted to determine the relationship of Na+ and K+ intake, assessed by means of a 7 day recall, with chronic respiratory symptoms and bronchial responsiveness in a sample of the general population. Two hundred and five subjects were studied, with complete dietary and respiratory questionnaires, and baseline respiratory function tests, together with a subsample of 146 subjects who underwent histamine challenge. The 7 day recall consisted of two parts: the first assessed discretionary Na+; and the second assessed Na+ and K+ contained in food. The whole sample was split into two groups based on the levels of consumption, and the statistical analysis was performed contrasting the three lower quartiles vs the highest. Smoking habit, social economic status, age and body mass index (BMI) were not confounders for Na+ and K+ intake. The prevalence of symptomatic subjects and baseline respiratory function values were not significantly different in the two groups of quartiles for Na+ and K+. Baseline respiratory values and dose-response slope of the subsample were also not significantly different. We did not prove a relationship between these dietary factors and either bronchial responsiveness or chronic respiratory symptoms. Although we consider that our questionnaire is more reliable than other methods for Na+ and K+ assessment, several potential biases still remain.(ABSTRACT TRUNCATED AT 250 WORDS)

Reference values of maximal respiratory mouth pressures: a population-based study

The aim of our study was to measure values of maximal inspiratory (MIP) and expiratory (MEP) mouth pressures in 625 (266 male, 359 female) clinically and functionally normal subjects drawn out of a sample representative of the general population. MEP (near TLC and FRC) was found to be significantly higher when compared with MIP (near RV and FRC), and pressures in male subjects were significantly higher than those in female subjects. MEP values at TLC and FRC were found to be closely related, as were values of MIP near RV and near FRC. Among the tested body-size variables, body surface area (BSA) for all parameters had the highest degree of correlation. Stepwise linear regression analysis was performed to define the equation of normality for all four parameters, employing BSA, sex, age, and relative interaction terms. R2 values, although the variables employed for the equations were highly significant, were relatively low and didn't fully explain the source of variability. The influence of age was smaller than the influence of BSA, although age did reduce the unexplained variance in MEP and MIP. These results confirm that the most useful employment of MIP and MEP is to monitor their changes in each patient, but they point out, however, the usefulness of reliable reference equations.

Cefaclor advanced formulation versus cefaclor in the treatment of pneumonia

The use of cefaclor advanced formulation (cefaclor AF) in the treatment of pneumonia caused by susceptible organisms was investigated in a multi-center trial conducted in the United Kingdom and the United States. A total of 266 patients were enrolled in this double-blind, double-dummy, randomized, parallel study; 132 patients were treated with cefaclor AF and 134 patients received the reference drug cefaclor. Inclusion criteria were a diagnosis of lobar pneumonia or bronchopneumonia, with a positive sputum culture and an infiltrate on chest roentgenogram. Patients received either cefaclor AF (750 mg twice daily) or cefaclor (500 mg three times daily) for 10 to 14 days. Forty patients in the cefaclor AF group and 45 in the cefaclor group were evaluable for efficacy, with 37 (92.5%) and 43 (95.6%), respectively, showing a favorable posttherapy clinical response. Proven or presumed pathogen elimination was achieved in 87.5% and 86.7% of cases, respectively. Both study drugs demonstrated high levels of activity against Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase-producing strains), and Moraxella catarrhalis (including beta-lactamase-producing strains). There were no statistically significant differences between drugs in efficacy results. One or more side effects were reported by 42.4% of the patients treated with cefaclor AF and by 44.0% of those treated with cefaclor; diarrhea, nausea, headache, and respiratory disorders were the most common adverse events. No drug-related side effects were seen with a frequency or severity that would be unexpected with the use of oral cephalosporins. Cefaclor AF and cefaclor performed equally well with respect to clinical and bacteriologic response rates in the treatment of pneumonia.

[Therapeutic efficacy and general tolerability of 4-carbomethoxythiazolidine chlorohydrate in combination with antibiotic and bronchoactive therapy in adult patients with acute and chronic bronchopneumopathy with prevalent exudative component]

20 patients, aged between 31 and 71, have been treated. All were hospitalized because of acute or chronic broncho-pneumopathy and have been administered 4-carbomethoxythiazolidine at a dosage of 300 mg/d. in association with the common antibiotic or chemiotherapic treatments. Every day all symptoms have been registered (asthenia, cephalea, sibiluses, rhoncuses, rales, inspiratory and expiratory dyspnea). Before and after the treatment some respiratory functioning tests have been performed, including the VEMS and VEMS/CV determination. A further study on the distribution of the inhaled air has been carried out, as well as on the ventilation/perfusion ratio by means of He and CO2 curves. At the beginning and at the end of the TMC treatment some hematiobiologic tests have been carried out, including: haemochromo with leukocytic formula, blood platelets counting, VES, glycemia, azotemia, transaminase, alkaline phosphatase, total bilirubinaemia, prothrombinic activity and determination of urine's specific weight. The pulmonary symptomatology (cough, sibiluses, rhoncuses, rates, inspiratory and expiratory dyspnea), was markedly reduced. Even if, as for the preliminary character of the experiment, we can state that 4-carbomethoxythiazolidine is a drug with an outstanding level of tolerance.

Effects of celiprolol on the bronchial reactivity in asthma

In 10 patients with bronchial asthma but normal ventilatory function, celiprolol, a cardioselective beta-adrenoreceptor antagonist, did not significantly affect forced expiratory volume in 1 second (FEV1) or airways resistance (Raw). In contrast, metoprolol substantially reduced FEV1 and increased Raw. In addition, compared with metoprolol, celiprolol induced a greater recovery of FEV1 and Raw after methacholine-induced bronchoconstriction.