RhoA downregulation in the murine intestinal epithelium results in chronic Wnt activation and increased tumorigenesis

Rho GTPases are molecular switches regulating multiple cellular processes. To investigate the role of RhoA in normal intestinal physiology, we used a conditional mouse model overexpressing a dominant negative RhoA mutant (RhoAT19N) in the intestinal epithelium. Although RhoA inhibition did not cause an overt phenotype, increased levels of nuclear β-catenin were observed in the small intestinal epithelium of RhoAT19N mice, and the overexpression of multiple Wnt target genes revealed a chronic activation of Wnt signaling. Elevated Wnt signaling in RhoAT19N mice and intestinal organoids did not affect the proliferation of intestinal epithelial cells but significantly interfered with their differentiation. Importantly, 17-month-old RhoAT19N mice showed a significant increase in the number of spontaneous intestinal tumors. Altogether, our results indicate that RhoA regulates the differentiation of intestinal epithelial cells and inhibits tumor initiation, likely through the control of Wnt signaling, a key regulator of proliferation and differentiation in the intestine.

Biomechanical characteristics of the ovarian cortex in POI patients and functional outcomes after drug-free IVA

PURPOSE

There is increasing evidence that the ovarian extracellular matrix (ECM) plays a critical role in follicle development. The rigidity of the cortical ECM limits expansion of the follicle and consequently oocyte maturation, maintaining the follicle in its quiescent state. Quiescent primordial, primary, and secondary follicles still exist in primary ovarian insufficiency (POI) patients, and techniques as in vitro activation (IVA) and drug-free IVA have recently been developed aiming to activate these follicles based on the Hippo signaling disruption that is essential in mechanotransduction. In this context, we analyze the effect of drug-free IVA in POI patients, comparing the relationship between possible resumption ovarian function and biomechanical properties of ovarian tissue.

METHODS

Nineteen POI patients according to ESHRE criteria who underwent drug-free IVA by laparoscopy between January 2018 and December 2019 and were followed up for a year after the intervention. A sample of ovarian cortex taken during the intervention was analyzed by atomic force microscopy (AFM) in order to quantitatively measure tissue stiffness (Young's elastic modulus, E) at the micrometer scale. Functional outcomes after drug-free were analyzed.

RESULTS

Resumption of ovarian function was observed in 10 patients (52.6%) and two of them became pregnant with live births. There were no differences in clinical characteristics (age and duration of amenorrhea) and basal hormone parameters (FSH and AMH) depending on whether or not there was activation after surgery. However, ovarian cortex stiffness was significantly greater in patients with ovarian activity after drug-free IVA: median E = 5519 Pa (2260-11,296) vs 1501 (999-3474); p-value < 0.001.

CONCLUSIONS

Biomechanical properties of ovarian cortex in POI patients have a great variability, and higher ovarian tissue stiffness entails a more favorable status when drug-free IVA is applied in their treatment. This status is probably related to an ovary with more residual follicles, which would explain a greater possibility of ovarian follicular reactivations after treatment.

The Role of Intestinal Permeability in Gastrointestinal Disorders and Current Methods of Evaluation

An increased intestinal permeability has been described in various gastrointestinal and non-gastrointestinal disorders. Nevertheless, the concept and definition of intestinal permeability is relatively broad and includes not only an altered paracellular route, regulated by tight junction proteins, but also the transcellular route involving membrane transporters and channels, and endocytic mechanisms. Paracellular intestinal permeability can be assessed in vivo by using different molecules (e.g., sugars, polyethylene glycols, ⁵¹Cr-EDTA) and ex vivo in Ussing chambers combining electrophysiology and probes of different molecular sizes. The latter is still the gold standard technique for assessing the epithelial barrier function, whereas in vivo techniques, including putative blood biomarkers such as intestinal fatty acid-binding protein and zonulin, are broadly used despite limitations. In the second part of the review, the current evidence of the role of impaired barrier function in the pathophysiology of selected gastrointestinal and liver diseases is discussed. Celiac disease is one of the conditions with the best evidence for impaired barrier function playing a crucial role with zonulin as its proposed regulator. Increased permeability is clearly present in inflammatory bowel disease, but the question of whether this is a primary event or a consequence of inflammation remains unsolved. The gut-liver axis with a crucial role in impaired intestinal barrier function is increasingly recognized in chronic alcoholic and metabolic liver disease. Finally, the current evidence does not support an important role for increased permeability in bile acid diarrhea.

Local immune response to food antigens drives meal-induced abdominal pain

Up to 20% of people worldwide develop gastrointestinal symptoms following a meal¹, leading to decreased quality of life, substantial morbidity and high medical costs. Although the interest of both the scientific and lay communities in this issue has increased markedly in recent years, with the worldwide introduction of gluten-free and other diets, the underlying mechanisms of food-induced abdominal complaints remain largely unknown. Here we show that a bacterial infection and bacterial toxins can trigger an immune response that leads to the production of dietary-antigen-specific IgE antibodies in mice, which are limited to the intestine. Following subsequent oral ingestion of the respective dietary antigen, an IgE- and mast-cell-dependent mechanism induced increased visceral pain. This aberrant pain signalling resulted from histamine receptor H₁-mediated sensitization of visceral afferents. Moreover, injection of food antigens (gluten, wheat, soy and milk) into the rectosigmoid mucosa of patients with irritable bowel syndrome induced local oedema and mast cell activation. Our results identify and characterize a peripheral mechanism that underlies food-induced abdominal pain, thereby creating new possibilities for the treatment of irritable bowel syndrome and related abdominal pain disorders.

Lactoferrin and Its Possible Role in Iron Enrichment of Infant Formulas

The properties and functions of lactoferrin in relation to its use in the supplementation of infant formulas are discussed. Special attention is paid to lactoferrin functions directly related to its ability to bind iron, that is, its effect on iron absorption and bacteriostatic and antioxidant activities. From the results obtained by different authors, it can be concluded that the addition of lactoferrin, usually bovine, to infant formulas, does not affect iron absorption. However, given its ability to bind iron, its use in infant formulas could be useful for protecting the gut of infants against infections from microbial-requiring iron, its ability to reduce interelemental interactions and especially to protect infant formulas supplemented with iron and ascorbic acid against free radical formation. Although bovine lactoferrin is at the moment the most easily available, today it is possible to have human recombinant lactoferrin. The possibility of adding it to infant formulas should be considered, if and when the toxicological evaluation proves favorable, because of the possible additional improvement of iron bioavailability.

The FXR agonist obeticholic acid prevents gut barrier dysfunction and bacterial translocation in cholestatic rats

Bacterial translocation (BTL) drives pathogenesis and complications of cirrhosis. Farnesoid X-activated receptor (FXR) is a key transcription regulator in hepatic and intestinal bile metabolism. We studied potential intestinal FXR dysfunction in a rat model of cholestatic liver injury and evaluated effects of obeticholic acid (INT-747), an FXR agonist, on gut permeability, inflammation, and BTL. Rats were gavaged with INT-747 or vehicle during 10 days after bile-duct ligation and then were assessed for changes in gut permeability, BTL, and tight-junction protein expression, immune cell recruitment, and cytokine expression in ileum, mesenteric lymph nodes, and spleen. Auxiliary in vitro BTL-mimicking experiments were performed with Transwell supports. Vehicle-treated bile duct-ligated rats exhibited decreased FXR pathway expression in both jejunum and ileum, in association with increased gut permeability through increased claudin-2 expression and related to local and systemic recruitment of natural killer cells resulting in increased interferon-γ expression and BTL. After INT-747 treatment, natural killer cells and interferon-γ expression markedly decreased, in association with normalized permeability selectively in ileum (up-regulated claudin-1 and occludin) and a significant reduction in BTL. In vitro, interferon-γ induced increased Escherichia coli translocation, which remained unaffected by INT-747. In experimental cholestasis, FXR agonism improved ileal barrier function by attenuating intestinal inflammation, leading to reduced BTL and thus demonstrating a crucial protective role for FXR in the gut-liver axis.

Obeticholic acid, a farnesoid X receptor agonist, improves portal hypertension by two distinct pathways in cirrhotic rats

The farnesoid X receptor (FXR) is a nuclear bile acid receptor involved in bile acid homeostasis, hepatic and intestinal inflammation, liver fibrosis, and cardiovascular disease. We studied the effect of short-term treatment with obeticholic acid (INT-747), a potent selective FXR agonist, on intrahepatic hemodynamic dysfunction and signaling pathways in different rat models of cirrhotic portal hypertension (PHT). For this, thioacetamide (TAA)-intoxicated and bile-duct-ligated (BDL) rats were used as models. After gavage of two doses of 30 mg/kg of INT-747 or vehicle within 24 hours, in vivo hemodynamics were assessed. Additionally, we evaluated the direct effect of INT-747 on total intrahepatic vascular resistance (IHVR) and intrahepatic vascular tone (endothelial dysfunction and hyperresponsiveness to methoxamine) by means of an in situ liver perfusion system and on hepatic stellate cell contraction in vitro. FXR expression and involved intrahepatic vasoactive pathways (e.g., endothelial nitric oxide synthase [eNOS], Rho-kinase, and dimethylarginine dimethylaminohydrolase [DDAH]) were analyzed by immunohistochemistry, reverse-transcriptase polymerase chain reaction, or western blotting. In both cirrhotic models, FXR expression was decreased. Treatment with INT-747 in TAA and BDL reactivated the FXR downstream signaling pathway and decreased portal pressure by lowering total IHVR without deleterious systemic hypotension. In the perfused TAA and BDL cirrhotic liver, INT-747 improved endothelial vasorelaxation capacity, but not hyperresponsiveness. In both groups, this was associated with an increased eNOS activity, which, in TAA, related to down-regulation of Rho-kinase and in BDL to up-regulation of DDAH-2.

CONCLUSION

FXR agonist INT-747 improves PHT in two different rat models of cirrhosis by decreasing IHVR. This hemodynamic effect relates to increased intrahepatic eNOS activity by pathways that differ depending on the etiology of cirrhosis.

IL-4 induces columnar-like differentiation of esophageal squamous epithelium through JAK/PI3K pathway: possible role in pathogenesis of Barrett's esophagus

Barrett's esophagus is characterized by a distinct Th2-predominant cytokine profile (IL-4) from in vivo or ex vivo evidence. The detailed role of cytokines in Barrett's esophagus, particularly whether Th2 cytokines are causative factors driving metaplastic processes, remains unknown. In this study, air-liquid interface-cultured human esophageal epithelial cells were stimulated by a Th2 cytokine, IL-4, and Th1 cytokines, TNF-α and IL-1β, continuously for 10 days. Barrier function was determined by transepithelial electrical resistance. Morphological changes were investigated by hematoxylin and eosin staining. Keratin profile (keratin 7, 8, 13, and 14) and squamous differentiation markers (involucrin) were investigated by RT-quantitative PCR, Western blotting, and immunohistochemical staining. Pharmacological inhibitors were used to identify the underlying cellular signaling. We report that IL-4, TNF-α, and IL-1β decrease barrier function, but only IL-4 significantly increases cell layers and changes cell morphology. IL-4 time dependently downregulates the expression levels of the squamous cell markers involucrin and keratin 13 and upregulates the expression levels of the columnar cell markers keratin 7 and 8. Neither TNF-α nor IL-1β shows any effect on these indexes. JAK inhibitor I and PI3K inhibitors significantly block the IL-4-induced changes in the levels of keratin 8 and 13. In conclusion, IL-4 inhibits squamous differentiation program of esophageal epithelial cells and induces differentiation toward columnar cells through the JAK/PI3K pathway. Thus IL-4 may be involved in the early stages of Barrett's esophagus development.

The effect of gastric juice on interleukin-8 production by cystic fibrosis primary bronchial epithelial cells

CF patients are often treated with proton pump inhibitors (PPIs) to reduce acidic gastro-esophageal reflux (GER) and bronchial aspiration of duodeno-gastric contents is common in CF. We have previously demonstrated that gastric juice (GJ) from patients "on" PPI can induce interleukin-8 (IL-8) production by bronchial epithelial cells in culture. We hypothesized that such effect would be more pronounced in CF patients known to have high inflammatory susceptibility. We aimed to evaluate the effect of GJ on IL-8 production by primary bronchial epithelial cells (PBEC), derived from a CF patient and a healthy subject.

METHODS

PBEC obtained from one donor (normal PBEC) and one receptor (CF-PBEC) for lung transplantation were stimulated with GJ from patients "off" and "on" PPI. IL-8 levels were measured in the supernatant.

RESULTS

GJ from patients "on" PPI provoked a significant higher IL-8 production compared to GJ from patients "off" PPI, both in normal PBEC [462 (200-1468) vs. 11 (4-28) pg/ml, p=0.0001] as in CF-PBEC [1468 (841-2449) vs. 85 (26-131) pg/ml, p<0.0001]. Exposure of the cells to GJ "off" PPI and "on" PPI provoked significantly higher IL-8 production in the CF-PBEC compared to the normal PBEC ["off" PPI 85 (26-131) vs. 11 (4-28) pg/ml, p=0.01; "on" PPI 1468 (841-2449) vs. 462 (200-1468) pg/ml, p=0.01]. Filtration (0.20 μm) of the GJ "on" PPI, to eliminate large particles and bacterial sub-products, resulted in a significant decrease of IL-8 production.

CONCLUSION

Patients with CF, treated with PPIs, have GJ with high pH and high endotoxin levels. These patients often have GER and bronchial aspiration. The aspirated material (GJ "on" PPI) has a significantly enhanced inflammatory effect on CF bronchial epithelial cells in culture. As chronic PPI treatment in CF may result in a paradoxically increased inflammatory effect in the airways, alternative anti-reflux therapies should be considered in CF.

Bile acids in sputum and increased airway inflammation in patients with cystic fibrosis

BACKGROUND

Up to 80% of patients with cystic fibrosis (CF) may have increased gastroesophageal reflux and aspiration of duodenogastric contents into the lungs. We aimed to assess aspiration in patients with CF by measuring duodenogastric components in induced sputum and to investigate whether the presence of bile acids (BAs) in sputum was correlated with disease severity and markers of inflammation.

METHODS

In 41 patients with CF, 15 healthy volunteers, 29 patients with asthma, and 28 patients with chronic cough, sputum was obtained after inhalation of hypertonic saline. Sputum supernatant was tested for BA and neutrophil elastase. Spirometry and BMI were assessed on the day of sputum collection.

RESULTS

Two of 15 healthy patients (13%), eight of 29 patients (28%) with asthma, four of 28 patients (14%) with chronic cough, and 23 of 41 patients (56%) with CF had BA in sputum. BA concentrations were similar in patients who are positive for BA with genotype F508del homozygote, F508del heterozygote, and other CF mutations and were not related with BMI and age. Patients with CF with BA in sputum had a higher concentration of neutrophil elastase compared with patients without BA in sputum (31.25 [20.33-54.78] μg/mL vs 14.45 [7.11-27.88] μg/mL, P < .05). There was a significant correlation between BA concentrations and dynamic lung volumes (FEV(1) % predicted [r = -0.53, P < .01], FVC% [r = -0.59, P < .01]) as well as with number of days of antibiotic IV treatment (r = 0.58, P < .01).

CONCLUSIONS

BAs are present in the sputum of more than one-half of patients with CF, suggesting aspiration of duodenogastric contents. Aspiration of BA was associated with increased airway inflammation. In patients with BA aspiration, the levels of BA were clearly associated with the degree of lung function impairment as well as the need for IV antibiotic treatment.

Gastric emptying and different types of reflux in adult patients with cystic fibrosis

BACKGROUND

Increased gastro-oesophageal reflux (GER) is common in patients with cystic fibrosis (CF). Previous studies showed delayed gastric emptying (GE) and a high prevalence of bile acids in saliva suggesting duodenogastro-oesophageal reflux (DGER).

AIM

To assess different types of reflux (acid, weakly acidic and bile) and their relationship with rate of GE in adult CF patients.

METHODS

Gastric emptying was assessed in 33 CF patients using breath tests, reflux was monitored in 42 patients using impedance-pH-metry and 14 CF patients underwent combined impedance-pH-Bilitec monitoring.

RESULTS

Delayed GE was found in 33%, increased GER (predominantly acid) in 67% and pathological DGER in 35% of the CF patients. There was a significant correlation between oesophageal bile and acid exposure (P < 0.0001, r = 0.85). Patients with increased DGER had a higher proximal extent of reflux compared to those without DGER [17 (9-35) vs. 5 (1-12), P = 0.04]. There was no correlation between GE and reflux parameters, however, in a subgroup of 10 patients studied by impedance-pH-Bilitec and GE, there was a strong correlation between GE rate and bile exposure (P = 0.005, r = 0.83).

CONCLUSIONS

Delayed gastric emptying is present in 1/3 of patients with cystic fibrosis. There is a subgroup of these patients with both delayed gastric emptying and increased acidic duodenogastro-oesophageal reflux with high proximal extent and risk of aspiration. Controlled studies should be performed to evaluate the effect of prokinetics or antireflux surgery on the clinical cystic fibrosis evolution in these patients.

The capsaicin receptor TRPV1 is a crucial mediator of the noxious effects of mustard oil

Mustard oil (MO) is a plant-derived irritant that has been extensively used in experimental models to induce pain and inflammation. The noxious effects of MO are currently ascribed to specific activation of the cation channel TRPA1 in nociceptive neurons. In contrast to this view, we show here that the capsaicin receptor TRPV1 has a surprisingly large contribution to aversive and pain responses and visceral irritation induced by MO. Furthermore, we found that this can be explained by previously unknown properties of this compound. First, MO has a bimodal effect on TRPA1, producing current inhibition at millimolar concentrations. Second, it directly and stably activates mouse and human recombinant TRPV1, as well as TRPV1 channels in mouse sensory neurons. Finally, physiological temperatures enhance MO-induced TRPV1 stimulation. Our results refute the dogma that TRPA1 is the sole nocisensor for MO and motivate a revision of the putative roles of these channels in models of MO-induced pain and inflammation. We propose that TRPV1 has a generalized role in the detection of irritant botanical defensive traits and in the coevolution of multiple mammalian and plant species.

Bile acids aspiration reduces survival in lung transplant recipients with BOS despite azithromycin

Azithromycin (AZM) improved bronchiolitis obliterans syndrome (BOS) and reduced aspiration in lung transplant (LTx) recipients. We hypothesize that AZM could improve graft and overall survival more efficiently in LTx patients with BOS who have bile acid (BA) aspiration by protecting against the aspiration-induced progression of BOS. The goal was to compare FEV(1) (% baseline), BOS progression and overall survival in LTx recipients treated with AZM for BOS, both with versus without BA aspiration. Therefore, LTx recipients treated with AZM for BOS were recruited and broncho-alveolar lavage (BAL) samples were analyzed for the presence of BA and neutrophilia before the start of AZM treatment. Short-term effect of AZM on FEV(1) and BAL neutrophilia was assessed, progression of BOS and survival were followed-up for 3 years and results were compared between patients with/without BA aspiration. 19/37 LTx patients had BA in BAL. BA aspiration predisposed to a significantly worse outcome, in terms of decline in FEV(1) , progression of BOS ≥ 1 and survival. AZM does not seem to protect against the long-term allograft dysfunction caused by gastroesophageal reflux (GER) and aspiration and an additional treatment targeting aspiration may be indicated in those LTx patients.

Oesophageal shortening: in vivo validation of high-frequency ultrasound measurements of oesophageal muscle wall thickness

BACKGROUND AND AIMS

Assessment of oesophageal muscle wall thickness with high-frequency intraluminal ultrasound (HFIUS) is proposed as a method to evaluate longitudinal muscle contraction and oesophageal shortening in patients with oesophageal symptoms. Studies using this technique suggested that prolonged oesophageal wall thickening can be associated with chest pain and heartburn. Validation studies comparing HFIUS measurements against fluoroscopic investigations of oesophageal shortening are not available. The aim of this study was to evaluate the relationship between oesophageal muscle wall thickening and oesophageal shortening in vivo.

METHODS

Oesophageal shortening and muscle wall thickness were assessed simultaneously in lightly sedated cats, using fluoroscopic tracking of endoscopically attached metal clips and HFIUS, respectively. Oesophageal shortening was studied during secondary peristalsis and oesophageal mucosal acidification. Video fluoroscopy and HFIUS images were recorded simultaneously and the magnitude and timing of changes in distance between clips and muscle wall thickness were compared.

RESULTS

During peristalsis, the distance between the clips was maximally reduced to 33% and the muscle wall thickness was increased to 218% above baseline. Maximal shortening and wall thickening correlated significantly and occurred simultaneously. Likewise, mucosal acidification provoked simultaneous oesophageal shortening (20%) and increased basal muscle wall thickness (40%). Secondary peristalsis during mucosal acidification was associated with strong and prolonged oesophageal shortening.

CONCLUSIONS

Oesophageal muscle wall thickening, measured with HFIUS is a good predictor of oesophageal shortening and longitudinal muscle contraction during swallowing and oesophageal mucosal acidification.

Respiratory impedance during weaning from mechanical ventilation in a mixed population of critically ill patients

BACKGROUND

Worsening of respiratory mechanics during a spontaneous breathing trial (SBT) has been traditionally associated with weaning failure, although this finding is based on studies with chronic obstructive pulmonary disease patients only. The aim of our study was to assess the course of respiratory impedance non-invasively measured by forced oscillation technique (FOT) during a successful and failed SBT in a mixed population.

METHODS

Thirty-four weaning trials were reported in 29 consecutive mechanically ventilated patients with different causes of initiation of ventilation. During the SBT, the patient was breathing through a conventional T-piece connected to the tracheal tube. FOT (5 Hz, +/- 1 cm H(2)O, 30 s) was applied at 5, 10, 15, 20, 25, and 30 min. Respiratory resistance (Rrs) and reactance (Xrs) were computed from pressure and flow measurements. The frequency to tidal volume ratio f/V(t) was obtained from the flow signal. At the end of the trial, patients were divided into two groups: SBT success and failure.

RESULTS

Mixed model analysis showed no significant differences in Rrs and Xrs over the course of the SBT, or between the success (n=16) and the failure (n=18) groups. In contrast, f/V(t) was significantly (P<0.001) higher in the failure group.

CONCLUSIONS

Worsening of respiratory impedance measured by FOT is not a common finding during a failed SBT in a typically heterogeneous intensive care unit population of mechanically ventilated patients.

Azithromycin reduces gastroesophageal reflux and aspiration in lung transplant recipients

Azithromycin (AZI) is a macrolide antibiotic that improves lung function in lung transplant recipients (LTx). Gastroesophageal reflux (GER) has been implicated in the pathogenesis of chronic rejection after LTx. Macrolide antibiotics may affect GER by modifying esophageal and gastric motility. The purpose of this study was to evaluate the effect of AZI on GER and gastric aspiration after LTx. Acid and weakly acidic GER was measured with 24-h pH-impedance monitoring in 47 LTx patients (12 patients "on" AZI). Gastric aspiration was assessed in a separate group of 30 LTx patients before and after AZI by measurements of pepsin and bile acid in bronchoalveolar lavage fluid (BALF). Patients "on" AZI had a significant lower total number of reflux events [41 (30-61) vs. 22.5 (7-37.5)], number of acid reflux events [24 (16-41) vs. 8 (4-18)], esophageal acid exposure [2.9% (0.7-7.3) vs. 0.2% (0.1-2.0)], bolus exposure [0.73% (0.5-1.4) vs. 0.21% (0.12-0.92)], and proximal extent of reflux [14 (9-24) vs. 5 (2-7)]. AZI reduced the concentration of bile acids in BALF without affecting levels of pepsin. LTx patients "on" AZI have less GER and bile acids aspiration. This effect might be due to enhanced esophageal motility and accelerated gastric emptying.

Patterns of home mechanical ventilation use in Europe: results from the Eurovent survey

The study was designed to assess the patterns of use of home mechanical ventilation (HMV) for patients with chronic respiratory failure across Europe. A detailed questionnaire of centre details, HMV user characteristics and equipment choices was sent to carefully identified HMV centres in 16 European countries. A total of 483 centres treating 27,118 HMV users were identified. Of these, 329 centres completed surveys between July 2001 and June 2002, representing up to 21,526 HMV users and a response rate of between 62% and 79%. The estimated prevalence of HMV in Europe was 6.6 per 100,000 people. The variation in prevalence between countries was only partially related to the median year of starting HMV services. In addition, there were marked differences between countries in the relative proportions of lung and neuromuscular patients using HMV, and the use of tracheostomies in lung and neuromuscular HMV users. Lung users were linked to a HMV duration of <1 yr, thoracic cage users with 6-10 yrs of ventilation and neuromuscular users with a duration of > or =6 yrs. In conclusion, wide variations exist in the patterns of home mechanical ventilation provision throughout Europe. Further work is needed to monitor its use and ensure equality of provision and access.

Quality control of equipment in home mechanical ventilation: a European survey

Quality control of the equipment used in home mechanical ventilation is necessary in order to ensure that patients safely and accurately receive the prescribed ventilatory support. The aim of this study was to carry out a survey on the quality-control procedures in different centres and countries. The survey was carried out in the context of a European Commission Concerted Action covering 16 European countries. The study was extensive and detailed, involving 326 centres, which provided home ventilation to >20,000 patients. The survey showed that: 1) ventilator servicing was mainly carried out by external companies (62% of centres), with a servicing frequency ranging 3-12 months; 2) interaction between servicing companies and prescribers was limited (only 61% of centres were always informed of major incidents); 3) participation of centres in equipment quality control was poor (only 56% of centres assessed that patients/caregivers correctly cleaned/maintained the ventilator); and 4) centres were insufficiently aware of vigilance systems (only 23% of centres). Moreover, the data showed considerable inter- and intra-country differences. The size of the centre was an important determinant of many of these quality-control aspects. This survey provides information that will enable the European Commission Concerted Action to formulate recommendations on procedures for home-ventilator quality control.

Dialyzability of iron, zinc, and copper of different types of infant formulas marketed in Spain

The bioavailability of trace elements in infant formulas is affected by different physiological and dietetic factors. In vitro methods based on element dialyzability have been proposed to estimate the bioavailability. Infant formulas of the same type but from different manufacturers can differ in the salt used for supplementation and in the contents of other components that can affect mineral bioavailability. The aim of our study is to estimate the dialyzability of iron, zinc, and copper of formulas marketed in Spain, in order to detect possible differences in formulas of the same type coming from different manufacturers. At the same time, the effects of the type of formula, the composition of the protein fraction, and the mineral content on the element dialyzability are also studied. Differences are found in the dialysis percentages of the elements studied in formulas of the same type but from different manufacturers. The formulas giving the highest dialysis percentages for the three considered elements are the hypoallergenic ones based on protein hydrolysates. No differences are observed in formulas having whey or casein as the main protein fraction. Significant correlations are obtained between the element contents and the dialyzability of the elements.

Gas compression artefacts when testing peak expiratory flow meters with mechanically-driven syringes

Mechanically-driven syringes used to test peak expiratory flow (PEF) meters must produce the American Thoracic Society (ATS) standard waveforms with PEF accuracy of 2%. However, gas compression within the syringe could result in significant PEF inaccuracy when testing high resistance meters. The gas compression artefact was investigated in a mechanical syringe (PWG; MH Custom Design & Mfg L.C., Midvale, Ut, USA) of 13.6 L connected to a standard range mini-Wright PEF meter (Clement Clarke International, Harlow, UK). Scaled versions of the ATS standard waveform No. 24, with peak flows of 750 and 450 L x min(-1), were discharged through the PEF meter from different starting piston positions to vary syringe volume (Vsyr). The PEF recorded by the meter decreased linearly with increasing Vsyr. PEF decreased by 0.31 and 0.27% per litre for the ATS standard waveforms with PEF of 750 and 450 L x min(-1), respectively. The target PEF computed from piston displacement overread the actual PEF delivered into the PEF meter by approximately 4% when Vsyr = 13.6 L. Overreading fell to approximately 1% when Vsyr was reduced to 3.62 L. Therefore, gas compression error in commercially available large mechanical syringes can exceed the 2% inaccuracy limit when testing high resistance portable PEF meters. Measurements can be corrected for gas compression by linearly extrapolating PEF recordings to zero volume.

Estimation of random errors in respiratory resistance and reactance measured by the forced oscillation technique

The forced oscillation technique (FOT) allows the measurement of respiratory resistance (Rrs) and reactance (Xrs) and their associated coherence (gamma2). To avoid unreliable data, it is usual to reject Rrs and Xrs measurements with a gamma2 <0.95. This procedure makes it difficult to obtain acceptable data at the lowest frequencies of interest. The aim of this study was to derive expressions to compute the random error of Rrs and Xrs from gamma2 and the number (N) of data blocks involved in a FOT measurement. To this end, we developed theoretical equations for the variances and covariances of the pressure and flow auto- and cross-spectra used to compute Rrs and Xrs. Random errors of Rrs and Xrs were found to depend on the values of Rrs and Xrs, and to be proportional to ((1-gamma2)/(2 x N x gamma2))1/2. Reliable Rrs and Xrs data can be obtained in measurements with low gamma2 by enlarging the data recording (i.e. N). Therefore, the error equations derived may be useful to extend the frequency band of the forced oscillation technique to frequencies lower than usual, characterized by low coherence.

Active inspiratory impedance and neuromuscular respiratory output during halothane anaesthesia in humans

The aim of this study was to measure, in 11 patients with healthy lungs, active inspiratory impedance during anaesthesia. In addition, we recorded changes in inspiratory occlusion pressure at 100 ms (P0.1) and ventilatory pattern while awake and during anaesthesia with a mean inspiratory fraction (FI) of 0.017 halothane in O2. The total active inspiratory resistance and elastance values were 5.4 +/- 3.3 hPa.l.1.s and 29.9 +/- 6.2 hPa.l.1, respectively. P0.1 and the ratio between P0.1 and mean inspiratory flow (P0.1/(VT/TI)) increased 124% (p less than 0.001) and 68% (p less than 0.001), respectively, during anaesthesia. Respiratory frequency rose significantly from 12.2 +/- 1.5 (mean +/- SD) to 24.6 +/- 4.6 cycles.min-1, while tidal volume and inspiratory duty cycle lowered significantly from 0.599 +/- 0.195 l and 0.44 +/- 0.04 to 0.372 +/- 0.088 l (p less than 0.001) and 0.40 +/- 0.04 (p less than 0.05), respectively. Minute ventilation (VE) and VT/TI did not change significantly. During halothane anaesthesia with an FI:0.017, the increase in neuromuscular respiratory output appears to compensate for the increased mechanical load, thus resulting in maintenance of VE at levels similar to those of an awake state.

Determination of Cd, Co, Cu, Fe, Pb, Mn, Ni and Zn in diets: development of a method

A method useful for the determination of cadmium, cobalt, copper, iron, lead, manganese, nickel and zinc in diets is described. Organic matter is destroyed applying a wet procedure, and element content is measured by flame atomic absorption spectroscopy (FAAS) in the case of copper, iron, manganese, nickel and zinc, and by graphite furnace (GF-AAS) in the case of cadmium, cobalt and lead. The matrix interference study is carried out. Values found for linearity, detection and quantitation limits as well as accuracy show that the described method is useful to determine the elements taken into account at usual levels in diets.

Respiratory impedance to ambient pressure changes at low frequencies

Respiratory impedance may be studied by measuring airway flow (Vaw) when pressure is varied at the mouth (input impedance) or around the chest (transfer impedance). A third possibility, which had not been investigated so far, is to apply pressure variations simultaneously at the two places, that is to vary ambient pressure (Pam). This provides respiratory impedance to ambient pressure changes (Zapc = Vaw/Pam). In that situation airway impedance (Zaw) and tissue impedance (Zt) are mechanically in parallel, and both are in series with alveolar gas impedance (Zg): Zapc = Zaw + Zg + Zaw.Zg/Zt. We assessed the frequency dependence of Zapc from 0.05 to 2 Hz in nine normal subjects submitted to sinusoidal Pam changes of 2-4 kPa peak to peak. The real part of Zapc (Rapc) was of 6.2 kPa.1(-1).s at 0.05 Hz and decreased to 1.9 kPa.1(-1).s at 2 Hz. Similarly the effective compliance (Capc), computed from the imaginary part of Zapc, decreased from 0.045 1.kPa-1 at 0.05 Hz to 0.027 1.kPa-1 at 2 Hz. Breathing against an added resistance of 0.46 kPa.1(-1).s exaggerated the negative frequency dependence of both Rapc and Capc. When values of airway resistance and inertance derived from transfer impedance data were introduced, Zapc was used to compute effective tissue resistance (Rt) and compliance (Ct). Rt was found to decrease from 0.32 to 0.15 kPa.1(-1).s and Ct from 1.11 to 0.64 1.kPa-1 between 0.25 and 2 Hz. Ct was slightly lower with the added resistance. These results are in good agreement with the data obtained by other approaches.

Human respiratory impedance from 8 to 256 Hz corrected for upper airway shunt

Respiratory input impedance (Zrs) was measured from 8 to 256 Hz in 10 healthy subjects by a method that eliminated the shunt impedance of extrathoracic airway walls. It consisted of combining the data obtained with a pressure input at the mouth (standard method, Zst) and with a pressure input around the head (Zhg) Zrs = Zst.(Zp + Zhg)/(Zp + Zst) where Zp is the impedance of the mouthpiece and pneumotachograph. Large quantitative differences were observed between Zrs and Zst, demonstrating that the standard method is unreliable at such frequencies. The real part of Zrs increased from 2.6 +/- 0.8 cmH2O.l-1.s at 8 Hz to a maximum of 38 +/- 19 cmH2O.l-1.s at 158 +/- 49 Hz. The imaginary part exhibited a maximum of 19 +/- 8 cmH2O.l-1.s at 126 +/- 38 Hz, a resonance at 157 +/- 43 Hz, and a minimum of lambda 19 +/- 16 cmH2O.l-1.s at 185 +/- 45 Hz. The data were analyzed with five models featuring alveolar gas compressibility; tissue resistance, inertance, and compliance; and different representations of the airways with lumped and distributed parameters. All except the simplest (lumped frequency-dependent resistance) fitted the data equally well, but none provided reliable estimates of gas compliance. Three models gave a consistent description of the airway in terms of equivalent rigid tubes (cross-sectional area 3.5-3.7 cm2, length 47-51 cm). We conclude that high-frequency input impedance could prove useful in exploring the airways but not the peripheral lung.

[Pesticide determination in water after separation on reverse-phase minicolumns]

The lindane, methoxichlor, parathion and methylparathion content of water is measured in a gas-chromatography fitted with a capture electron detector. Prior extraction and concentration are done by using Sep-Pak C18 cartridges with ethyl acetate as eluent, which is offers certain advantages over hexane and methanol. With solutions of 0.5 ppb recovery values of 102.7% (lindane), 85% (methoxychlor), 94.7% (parathion) and 93.1% (methylparathion) are obtained. The method proposed is less time-consuming and less expensive than the usual consisting of extraction with dichloromethane: hexane (15:75 v/V) and concentration in a Kuderna-Danish.

Recording pressure at the distal end of the endotracheal tube to measure respiratory impedance

To minimize the flow-dependent effects caused by an endotracheal tube during impedance measurements, we recorded pressure inside the tube at its distal end. We used a commercial endotracheal tube with a lumen built into its wall with the opening located near the outlet of the tube. We characterized the effect of the tube by means of an effective transfer function (H). We measured H from 0.25-32 Hz on a mechanical analogue by using pseudorandom excitation with different peak-to-peak flow amplitudes (Vpp). For an 8 mm internal diameter (ID) endotracheal tube the modulus of H measured with Vpp 0.2 l.s-1 was 1.00 at 0.25 Hz and increased with the frequency to 1.40 at 32 Hz. The phase factor was close to zero (less than 5 degrees) over the whole frequency band. The modulus of H changed less than 5% and the phase factor less than 3 degrees when Vpp was increased from 0.2 to 0.8 l.s-1. We evaluated the method on five mechanical analogues with increased resistance or elastance and with a different tracheal area. The mean normalized distance in the complex plane over the whole frequency band (dz) between the analogue impedance and the estimated value from intubation was always less than 5%. Finally, the method was tested on an active analogue which superimposed a high-amplitude (up to 1.4 l.s-1 peak-to-peak) low-frequency (0.25 or 0.33 Hz) sinusoidal flow onto excitation: dz was always less than 4.3%.

Effect of body posture on respiratory impedance

The effects of posture on the mechanics of the respiratory system are not well known, particularly in terms of total respiratory resistance. We have measured respiratory impedance (Zrs) by the forced random noise excitation technique in the sitting and the supine position in 24 healthy subjects. Spirometry and lung volumes (He-dilution technique) were also measured in both postures. The equivalent resistance (Rrs), compliance (Crs), and inertance (Irs) were also calculated by fitting each measured Zrs to a linear series model. When subjects changed from sitting to the supine position, the real part of Zrs increased over the whole frequency band. The associated equivalent resistance, Rrs, increased by 28.2%. The reactance decreased for frequencies lower than 18 Hz and increased for higher frequencies. Consequently, Crs decreased by 38.7% and Irs increased by 15.6%. All of these parameter differences were significant (P less than 0.001). A covariance analysis showed that a significant amount of the postural change in Rrs and Crs can be explained by the reduction of functional residual capacity (FRC). This indicates that the observed differences on Zrs can in part be explained be a shift of the operating point of the respiratory system induced by the decrease in the FRC.