Amino acid digestibility and metabolizable energy of soybean meal of different origins in cecectomized laying hens

This study investigated the variation in amino acid (AA) digestibility and MEn of 18 samples of solvent-extracted soybean meal (SBM; 6 European, 7 Brazilian, 2 Argentinian, 2 North American, 1 Indian) in cecectomized laying hens. The experimental diets contained either 300 g/kg of cornstarch or one of the SBM samples. Pelleted diets were fed to 10 hens in two 5 × 10 row-column designs so that 5 replicates were obtained from each diet during 5 periods. A regression approach and the difference method were used to determine AA digestibility and MEn, respectively. The variation in the digestibility of SBM differed among AA with ranges in digestibility of 6 to 12%-units for most AA. Among the first-limiting AA, the digestibility was 87 to 93%, 63 to 86%, 85 to 92%, 79 to 89%, and 84 to 95% for Met, Cys, Lys, Thr, and Val, respectively. The range of MEn for the SBM samples was 7.5 to 10.5 MJ/kg DM. Indicators of SBM quality (including trypsin inhibitor activity, KOH solubility, urease activity, and in vitro N solubility) and analyzed SBM constituents were significantly correlated (P ≤ 0.05) with AA digestibility or MEn only in a few cases. No differences were observed in AA digestibility and MEn between countries of origins, except low digestibility of some AA and MEn for the 2 Argentinian SBM samples. These results suggest that the precision of feed formulation benefits from considering the variations in AA digestibility and MEn. Often used indicators for SBM quality and analyzed constituents were not suitable to explain variations in AA digestibility and MEn, suggesting that AA digestibility and MEn are determined by other factors.

Effects of gradual differences in trypsin inhibitor activity on the estimation of digestible amino acids in soybean expellers for broiler chickens

The present study investigated the effect of varying trypsin inhibitor activity (TIA) in differently processed soybean expellers on apparent prececal amino acid (AA) digestibility in male broiler chickens. Two different raw soybean batches were treated using varying processing techniques and intensities. In this way, 45 expeller extracted soybean meal (ESBM) variants were created. The processed soybean variants were then merged into a basal diet (160 g/kg crude protein [CP]) at 2 inclusion levels (15%, 30%) resulting in 90 different diets plus one basal diet (0.4 mg/g-8.5 mg/g TIA). All diets contained 0.5% titanium dioxide. A total of 5,460-day-old male broilers (Ross 308) were allocated on d 14 to 546 pens (10 birds/pen) after a starter phase (CP 215 g/kg, 14 g/kg Lysine, 12.5 MJ ME/kg). The 91 experimental diets were fed ad libitum until d 22. Subsequently, birds were euthanized and digesta of the terminal ileum was collected for determination of AA digestibility. TIA depressed the prececal digestibility of every single AA significantly in a straight linear fashion (P < 0.001). Sulfur-containing AA expressed the strongest suppression by TIA with cystine showing the lowest apparent prececal digestibility measured (10.6% at 23.6 mg/g TIA in raw ESBM). The present data demonstrate that TIA severely depresses digestibility of essential and nonessential AA in a straight linear fashion. On the one hand, this questions the usefulness of defined upper limits of TIA in soy products whereas on the other hand, TIA must be considered when testing raw components for their feed protein value in vivo.

Effects of supplementing a CP-reduced diet with rumen-protected methionine on Fleckvieh bull fattening

The objective of this study was to evaluate the effect of supplementing a CP-reduced diet with rumen-protected methionine on growth performance of Fleckvieh bulls. A total of 69 bulls (367 ± 25 kg BW) were assigned to three feeding groups (n = 23 per group). The control (CON) diet contained 13.7% CP and 2.11 g methionine/kg diet (both DM basis) and was set as positive control. The diet reduced in CP (nitrogen) (RED) diet as negative control and the experimental RED + rumen-protected methionine (MET) diet were characterised by deficient CP concentrations (both 9.04% CP). The RED + MET diet differed from the RED diet in methionine concentration (2.54 g/kg DM vs. 1.56 g/kg DM, respectively) due to supplementation of rumen-protected methionine. Rumen-protected lysine was added to both RED and RED + MET at 2.7 g/kg DM to ensure a sufficient lysine supply relative to total and metabolisable protein intake. Metabolisable energy (ME) and nutrient composition were similar for CON, RED, and RED + MET. Bulls were fed for 105 days (d) on average. Individual feed intake was recorded daily; individual BW was recorded at the beginning of the experiment, once per month, and directly before slaughter. At slaughter, blood samples were collected and carcass traits were assessed. Reduction in dietary CP concentration reduced feed intake, and in combination with lower dietary CP concentration, daily intake of CP for RED and RED + MET was lower compared with CON (P < 0.01). Daily ME intake was reduced in RED and RED + MET compared with CON (P < 0.01). Consequently growth performance and carcass weights were reduced (both P < 0.01) in both RED and RED + MET compared with CON. Supplemental rumen-protected methionine was reflected in increased serum methionine concentration in RED + MET (P < 0.05) as compared to RED but it did not affect growth performance, carcass traits and serum amino acid (AA) concentrations, except for lysine which was reduced (P < 0.01) compared to CON and RED. In conclusion, bulls fed RED or RED + MET diets were exposed to a ruminal CP deficit and subsequently a deficit of prececal digestible protein, but methionine did not appear to be the first-limiting essential AA for growth under the respective experimental conditions.

[Risk Assessment of Acute Exacerbation in COPD Patients in the Context of Pulmonary Follow-Up Rehabilitation Based on the Prevalence and Severity of Comorbidities]

INTRODUCTION

 Acute COPD exacerbations (AECOPD) in the context of pulmonary rehabilitation (PR) are frequent and dangerous complications and, in addition to impairing quality of life, lead to an interruption of PR and jeopardize PR success. In this study, a correlation between the health status and an increased risk of AECOPD is described. The question arises whether the Charlson Comorbidity Index (CCI) or the Cumulative Illness Rating Scale (CIRS) are suitable for the preventive detection of COPD patients at risk for exacerbation in PR.

PATIENTS AND METHODS

 In a retrospective study, data of COPD patients who underwent PR in 2018 were analyzed with the CCI as the primary endpoint. All data were taken from the Phoenix Clinical Information System, and COPD exacerbations were recorded. The 44 patients (22 with and 22 without exacerbation during PR) required according to the sample size planning were randomly recruited from this pool of patients (using a random list for each group). CCI and CIRS were determined for all the cases included in the two groups. The primary endpoint (CCI) was evaluated by group comparison of the arithmetic means and Welch test. This was supported by further statistical measures of position and dispersion (median, quartile, standard deviation).In addition, the optimal cut-off point for discrimination in AECOPD and non-AECOPD patients was obtained via Receiver Operating Characteristic (ROC) analysis for both the CCI and the CIRS.

RESULTS

 Out of 244 COPD patients who underwent PR for an average of 21 days, 59 (24 %) suffered AECOPD that required treatment during PR. The 22 patients with AECOPD had a mean CCI of 6.77 (SD: 1.97) and the 22 patients without AECOPD had a mean CCI of 4.32 (SD: 1.17). This difference of -2.45 was statistically significant at a level of significance of 5 % (p < 0.001; 95 % CI: [-3.45; -1.46]). The ROC analysis led to 6 as the optimal cut-off point for the CCI, with 81.8 % sensitivity for determining an AECOPD and 86.4 % specificity with an area under the curve (AUC) value of 0.87. The optimal cut-off point for CIRS was 19 with a sensitivity of 50 %, a specificity of 77.2 % and an AUC of 0.65.

CONCLUSION

 COPD patients with acute exacerbation during PR have a higher CCI. The CCI allows the risk of AECOPD to be assessed with high sensitivity and specificity in participants with COPD in an inpatient PR program.

Portuguese adaptation of the S3-non-invasive ventilation (S3-NIV) questionnaire for home mechanically ventilated patients

Short, valid and easy to use tools are needed to monitor non-invasive ventilation in clinical practice and for organization of home mechanical ventilation services. The aim of this study was to develop a professional translation and cultural adaptation of the Portuguese S³ non-invasive ventilation questionnaire. 234 stable patients (128 male patients, 53.8%) with a mean age of 69.3 years under long-term home non-invasive ventilation were recruited from a single-center outpatient clinic. The most frequent diagnostic groups were obesity hypoventilation syndrome, chronic obstructive pulmonary disease and restrictive chest wall disorders. The Portuguese version of the questionnaire was obtained using translation back-translation process with two professional translators. Internal consistency for the total score was good (Cronbach's α coefficient of 0.76) as well as for the "respiratory symptoms" and the "sleep and side effects" domains (Cronbach's α coefficient=0.68 and Cronbach's α coefficient=0.72, respectively). An exploratory factor analysis was performed leading to an explained variance of 54.6%, and resulted in 3 components. The Portuguese version of the S3-NIV questionnaire is a simple and valid tool for the routine clinical assessment of patients receiving home NIV.

[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]

Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.

[Day/Night Variability of Coughing Events in Interstitial Lung Disease]

INTRODUCTION

 Besides dyspnea a dry cough is one of the main symptoms in patients with pulmonary fibrosis. Little is known about the 24-hour-variability of this symptom. Moreover, it is unclear if other auscultation phenomena occur.

METHODS

 A long-term auscultation for 24-hours was performed in patients with fibrotic lung diseases (LEOSound, Löwenstein Medical GmbH & Co. KG, Medical-Electronics, Bad Ems, Germany). Coughing and wheezing sounds were recorded. For the following analysis the 24-hour period was divided into two intervals of 12 hours each (daytime and nighttime). Events were registered in epochs (at least one event in 30 seconds).

RESULTS

 20 patients were included (6 with nonspecific interstitial pneumonia and 14 with idiopathic pulmonary fibrosis). On average 166 coughing epochs were recorded in a 24-hour-period (day/night 116/50; P < 0.001). Moreover, 203 wheezing epochs were registered (day/night 84/119; P = 0.273). Auscultation phenomena did not correlate with spirometric and bodyplethymographic data, nor with data of diffusion capacity.

DISCUSSION

 The study is showing the clinical potential of long-term auscultation in patients with fibrotic lung diseases. Especially the findings concerning the coughing symptoms were remarkable. It could be shown that there was a decrease of coughing during nighttime in comparison to daytime. In contrast to this, wheezing sounds were increasing at nighttime. The clinical relevance of this finding is yet to be assessed. Finally, there was no correlation between the severity of the disease measured by functional diagnostics and the amount of coughing.

[Position Paper for the State of the Art Application of Respiratory Support in Patients with COVID-19 - German Respiratory Society]

Against the background of the pandemic caused by infection with the SARS-CoV-2, the German Society for Pneumology and Respiratory Medicine (DGP e.V.), in cooperation with other associations, has designated a team of experts in order to answer the currently pressing questions about therapy strategies in dealing with COVID-19 patients suffering from acute respiratory insufficiency (ARI).The position paper is based on the current knowledge that is evolving daily. Many of the published and cited studies require further review, also because many of them did not undergo standard review processes.Therefore, this position paper is also subject to a continuous review process and will be further developed in cooperation with the other professional societies.This position paper is structured into the following five topics:1. Pathophysiology of acute respiratory insufficiency in patients without immunity infected with SARS-CoV-22. Temporal course and prognosis of acute respiratory insufficiency during the course of the disease3. Oxygen insufflation, high-flow oxygen, non-invasive ventilation and invasive ventilation with special consideration of infectious aerosol formation4. Non-invasive ventilation in ARI5. Supply continuum for the treatment of ARIKey points have been highlighted as core statements and significant observations. Regarding the pathophysiological aspects of acute respiratory insufficiency (ARI), the pulmonary infection with SARS-CoV-2 COVID-19 runs through three phases: early infection, pulmonary manifestation and severe hyperinflammatory phase.There are differences between advanced COVID-19-induced lung damage and those changes seen in Acute Respiratory Distress Syndromes (ARDS) as defined by the Berlin criteria. In a pathophysiologically plausible - but currently not yet histopathologically substantiated - model, two types (L-type and H-type) are distinguished, which correspond to an early and late phase. This distinction can be taken into consideration in the differential instrumentation in the therapy of ARI.The assessment of the extent of ARI should be carried out by an arterial or capillary blood gas analysis under room air conditions and must include the calculation of the oxygen supply (measured from the variables of oxygen saturation, the Hb value, the corrected values of the Hüfner number and the cardiac output). In principle, aerosols can cause transmission of infectious viral particles. Open systems or leakage systems (so-called vented masks) can prevent the release of respirable particles. Procedures in which the invasive ventilation system must be opened, and endotracheal intubation must be carried out are associated with an increased risk of infection.The protection of personnel with personal protective equipment should have very high priority because fear of contagion must not be a primary reason for intubation. If the specifications for protective equipment (eye protection, FFP2 or FFP-3 mask, gown) are adhered to, inhalation therapy, nasal high-flow (NHF) therapy, CPAP therapy or NIV can be carried out according to the current state of knowledge without increased risk of infection to the staff. A significant proportion of patients with respiratory failure presents with relevant hypoxemia, often also caused by a high inspiratory oxygen fraction (FiO2) including NHF, and this hypoxemia cannot be not completely corrected. In this situation, CPAP/NIV therapy can be administered under use of a mouth and nose mask or a respiratory helmet as therapy escalation, as long as the criteria for endotracheal intubation are not fulfilled.In acute hypoxemic respiratory insufficiency, NIV should be performed in an intensive care unit or in a comparable unit by personnel with appropriate expertise. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring with readiness to carry out intubation must be ensured at all times. If CPAP/NIV leads to further progression of ARI, intubation and subsequent invasive ventilation should be carried out without delay if no DNI order is in place.In the case of patients in whom invasive ventilation, after exhausting all guideline-based measures, is not sufficient, extracorporeal membrane oxygenation procedure (ECMO) should be considered to ensure sufficient oxygen supply and to remove CO2.

Zehn Jahre Rauchverbot − Auswirkungen des Nichtraucherschutzgesetzes am Beispiel des traditionellen Kneipenviertels der Kölner Südstadt

Hintergrund Seit September 2007 regelt das Bundesnichtraucherschutzgesetz ein gesetzliches Rauchverbot. Dieses regelt ein generelles Rauchverbot in Einrichtungen des Bundes, in Verkehrsmitteln des öffentlichen Personenverkehrs sowie in Personenbahnhöfen. Weitere Rauchverbote sind uneinheitlich geregelt und unterscheiden sich innerhalb der einzelnen Bundesländer. Neben Plätzen öffentlichen Interesses, Sportstätten und dem Arbeitsplatz galt immer auch besonderes Augenmerk auf Diskotheken und Gaststätten, wo seit jeher vermehrt geraucht wurde. Für die in dieser Arbeit betrachtete Situation der Kneipen der Südstadt in Köln gilt das erweiternde Gesetz zum Schutz von NichtraucherInnen in NRW vom 20. Dezember 2007.

Methodik Eine Befragung mittels gesondert erstelltem, 24-Items umfassendem Fragebogen wurde durchgeführt. Befragt wurden BesucherInnen ausgewählter Kneipen über 26 Jahre, damit sichergestellt war, dass bei Einführung des Nichtraucherschutzgesetzes die Teilnehmenden das damalige legale Alter zum Rauchen erreicht hatten.

Die Datenakquirierung erfolgte sowohl in Direktbefragungen von Teilnehmenden in ausgewählten Lokalen der Kölner Südstadt als auch mittels Online-Umfragen, auf welche in Presse, Fernsehen und über soziale Medien aufmerksam gemacht wurde.

Ergebnisse Insgesamt wurden 1318 vollständig ausgefüllte Fragebögen evaluiert. Die Teilnehmenden waren im Durchschnitt 49 Jahre alt (± 12,1). Aus den 1318 auswertbaren Fragebögen ergab sich, dass im Jahr 2007 von den Befragten 726 aktiv rauchten (55,1 %). 2018 gaben noch 518 (39,3 %) (p: < 0,001) Befragte an, aktiv zu rauchen. Von den aktiven RaucherInnen konsumierten 2007 insgesamt 289 von 726 (39,8 %) mehr als 20 Zigaretten am Tag. 2018 waren es 179 von 518 (34,6 %) (p: < 0,001). In die Gruppe der mittelschweren RaucherInnen mit 10 – 19 Zigaretten pro Tag fielen 2007 303 Personen (41,7 % der Rauchenden), 2018 waren es noch 227 (43,8 %) (p: < 0,001). Der Gruppe der Wenigrauchenden mit 1 – 9 Zigaretten am Tag zugehörig waren 2007 insgesamt 134 Personen (18,5 %), 2018 noch 112 Personen (21,6 %) (p: < 0,001). Unter den aktiven RaucherInnen stellte in dieser Befragung das Rauchverbot die relevanteste Ursache für eine Veränderung des Rauchverhaltens dar. Bei Nicht- oder ehemals Rauchenden waren gesundheitliche Aspekte sowie Familie und Freunde die entscheidenden Faktoren, Tabakprodukte abzulehnen.

Zusammenfassung Durch die Untersuchung konnte anhand der 1318 TeilnehmerInnen umfassenden Stichprobe unter Kneipenbesuchenden gezeigt werden, dass die Anzahl an aktiven RaucherInnen seit Einführung des Nichtraucherschutzgesetzes 2007 signifikant und deutlich zurückgegangen ist. Weiterhin konnte festgestellt werden, dass in der heutigen Zeit die Zahl von Menschen mit eher geringem Zigarettenkonsum signifikant zunimmt.

[Update and Comment on the German S3 "Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation: Evidence-Based Recommendations"]

In 2017 the German Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation: Evidence-Based Recommendations were released. This article highlights emerging data and new concepts which were introduced since 2017. Among others it summarizes the current progress made in evidence-based recommendations of mechanical ventilation and extracorporeal membrane oxygenation (ECMO). In detail, the new evidence for treating severe ARDS with ECMO, phenotyping of ARDS, early neuromuscular blockade and the application of non-invasive ventilation and high-flow oxygen therapy are discussed.

[Prolonged Weaning - S2k-Guideline Published by the German Respiratory Society]

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by insufficiency of respiratory muscles and/or lung parenchymal disease when/after other treatments, (i. e. medication, oxygen, secretion management, continuous positive airway pressure or nasal highflow) have failed.MV is required to maintain gas exchange and to buy time for curative therapy of the underlying cause of respiratory failure. In the majority of patients weaning from MV is routine and causes no special problems. However, about 20 % of patients need ongoing MV despite resolution of the conditions which precipitated the need for MV. Approximately 40 - 50 % of time spent on MV is required to liberate the patient from the ventilator, a process called "weaning."There are numberous factors besides the acute respiratory failure that have an impact on duration and success rate of the weaning process such as age, comorbidities and conditions and complications acquired in the ICU. According to an international consensus conference "prolonged weaning" is defined as weaning process of patients who have failed at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Prolonged weaning is a challenge, therefore, an inter- and multi-disciplinary approach is essential for a weaning success.In specialised weaning centers about 50 % of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, heterogeneity of patients with prolonged weaning precludes direct comparisons of individual centers. Patients with persistant weaning failure either die during the weaning process or are discharged home or to a long term care facility with ongoing MV.Urged by the growing importance of prolonged weaning, this Sk2-guideline was first published in 2014 on the initiative of the German Respiratory Society (DGP) together with other scientific societies involved in prolonged weaning. Current research and study results, registry data and experience in daily practice made the revision of this guideline necessary.The following topics are dealt with in the guideline: Definitions, epidemiology, weaning categories, the underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV and recommendations for end of life decisions.Special emphasis in the revision of the guideline was laid on the following topics:- A new classification of subgroups of patients in prolonged weaning- Important aspects of pneumological rehabilitation and neurorehabilitation in prolonged weaning- Infrastructure and process organization in the care of patients in prolonged weaning in the sense of a continuous treatment concept- Therapeutic goal change and communication with relativesAspects of pediatric weaning are given separately within the individual chapters.The main aim of the revised guideline is to summarize current evidence and also expert based- knowledge on the topic of "prolonged weaning" and, based on the evidence and the experience of experts, make recommendations with regard to "prolonged weaning" not only in the field of acute medicine but also for chronic critical care.Important addressees of this guideline are Intensivists, Pneumologists, Anesthesiologists, Internists, Cardiologists, Surgeons, Neurologists, Pediatricians, Geriatricians, Palliative care clinicians, Rehabilitation physicians, Nurses in intensive and chronic care, Physiotherapists, Respiratory therapists, Speech therapists, Medical service of health insurance and associated ventilator manufacturers.

[Evolving Epidemiology of Home Mechanical Ventilation: A Rapidly Growing Challenge for Patient Care]

BACKGROUND

 Home mechanical ventilation is dramatically evolving in Germany. Patients with non-invasive and invasive ventilation are increasingly treated at home. In-hospital treatment of these patients is also necessary either for control visits or the management of acute medical problems. However, the development of in-hospital patient care, morbidity and mortality of these patients is unknown.

METHODS

 All patients with long-term dependence on mechanical ventilation for more than three months requiring hospitalisation between 2006 and 2016 were analysed (data obtained from the Federal Statistical Office of Germany).

RESULTS

 There was an exponential increase in the number of in-patients with long-term dependence of mechanical ventilation. While 24 845 patients were treated in-hospital in 2006, 86 117 patients were treated in 2016. Correspondingly, mortality decreased from 13.2 % (2006) to 5.7 % (2016). In addition, in 2016 47 % of all patients were treated on the intensive care or high dependency care unit. Overall, patients had been severely ill, as there were plenty of medical and neurological co-morbidities. The most common diagnosis was COPD with 58 % of all cases, followed by several cardiology diagnosis. A high number of patients had an impairment of renal function (24 %), in part requiring dialysis.

CONCLUSIONS

 The rapid development of home mechanical ventilation substantially impacts on the development of the hospital landscape in Germany. The exponential increase of these care-intensive patients is challenging for the health care system and requires a discussion about its limits.

Chickens' growth performance and pancreas development exposed to soy cake varying in trypsin inhibitor activity, heat-degraded lysine concentration, and protein solubility in potassium hydroxide

This study focused on the effect of varying trypsin inhibitor activity (TIA), heat-degraded lysine concentration and protein solubility in potassium hydroxide on broiler performance and pancreas weight. Two soybean breeds were subject to varying thermal, hydrothermal, pressure, and kilning processing. This resulted in a total of 34 soy cake variants, widely varying in TIA (0.25 to 23.6 mg/g), heat-degraded lysine (1.40 to 8.60 g/kg), and potassium hydroxide (65.5 to 97.6%), respectively. These soy cake variants as well as a commercial soybean meal extract were included into a common grower and finisher diet for broiler chicks at fixed amounts (grower: 35%; finisher: 25%) and tested in a 35 d fattening experiment with 1680 broiler chicks (grower phase: day 11 to 24; finisher phase day 25 to 35). TIA was the dominant factor affecting zootechnical performance and pancreas weight at slaughter (day 35), depressing liveweight at day 24 (P < 0.006), and day 35 (0.026), weight gain (grower: P < 0.006) and feed: gain ratio during grower phase (P < 0.005) and increasing pancreas weight (P < 0.010) at the time of slaughter. Negative effects of TIA were also visible in soy cake variants below recommended thresholds. This highlights the necessity of complete elimination of TIA in broiler diets as far as technically possible.

Effects of supplementing rumen-protected niacin on fiber composition and metabolism of skeletal muscle in dairy cows during early lactation

Nicotinic acid (NA) has been shown to induce muscle fiber switching toward oxidative type I fibers and a muscle metabolic phenotype that favors fatty acid (FA) utilization in growing rats, pigs, and lambs. The hypothesis of the present study was that supplementation of NA in cows during the periparturient phase also induces muscle fiber switching from type II to type I fibers in skeletal muscle and increases the capacity of the muscle to use free FA, which may help to reduce nonesterified fatty acid (NEFA) flow to the liver, liver triglyceride (TG) accumulation, and ketogenesis. Thirty multiparous Holstein dairy cows were allocated to 2 groups and fed a total mixed ration without (control group) or with ∼55 g of rumen-protected NA per cow per day (NA group) from 21 d before expected calving until 3 wk postpartum (p.p.). Blood samples were collected on d -21, -14, -7, 7, 14, 21, 35, and 63 relative to parturition for analysis of TG, NEFA, and β-hydroxybutyrate. Muscle and liver biopsies were collected on d 7 and 21 for gene expression analysis and to determine muscle fiber composition in the musculus semitendinosus, semimembranosus, and longissimus lumborum by immunohistochemistry, and liver TG concentrations. Supplementation of NA did not affect the proportions of type I (oxidative) or the type II:type I ratio in the 3 muscles considered. A slight shift from glycolytic IIx fibers toward oxidative-glycolytic fast-twitch IIa fibers was found in the semitendinosus, and a tendency in the longissimus lumborum, but not in the semimembranosus. The transcript levels of the genes encoding the muscle fiber type isoforms and involved in FA uptake and oxidation, carnitine transport, tricarboxylic acid cycle, oxidative phosphorylation, and glucose utilization were largely unaffected by NA supplementation in all 3 muscles. Supplementation of NA had no effect on plasma TG and NEFA concentrations, liver TG concentrations, and hepatic expression of genes involved in hepatic FA utilization and lipogenesis. However, it reduced plasma β-hydroxybutyrate concentrations in wk 2 and 3 p.p. by 18 and 26% and reduced hepatic gene expression of fibroblast growth factor 21, a stress hormone involved in the regulation of ketogenesis, by 74 and 56%. In conclusion, a high dosage of rumen-protected NA reduced plasma β-hydroxybutyrate concentrations in cows during early lactation, but failed to cause an alteration in muscle fiber composition and muscle metabolic phenotype.

[Guideline for the Diagnosis and Treatment of COPD Patients - Issued by the German Respiratory Society and the German Atemwegsliga in Cooperation with the Austrian Society of Pneumology]

This document is a revision of the guideline for diagnosis and treatment of COPD that replaces the version from 2007. A multitude of recent reports regarding risk factors, diagnosis, assessment, prevention and pharmacological as well as non-pharmacological treatment options made a major revision mandatory. The new guideline is based on the GOLD document taking into account specifics in Germany and Austria.

[Guidelines for Non-Invasive and Invasive Home Mechanical Ventilation for Treatment of Chronic Respiratory Failure - Update 2017]

Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010 the German Society of Pneumology and Mechanical Ventilation (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure". However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines.For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning.In the current guidelines different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.The currently updated guidelines are valid for the next three years, following their first online publication on the home page of the Association of the Scientific Medical Societies in German (AWMF) in the beginning of July 2017. A subsequent revision of the guidelines remains the aim for the future.

[Biomarkers in Diagnosis, Treatment and Prognosis of Infectious Lung Diseases]

Biomarkers play an important role in the management of infectious pulmonary diseases, even though there is only limited evidence that biomarker-guided therapies are superior to clinical strategies.Well-established indications for the use of biomarkers are the guidance of the duration of antibiotic therapy in community-acquired pneumonia (CAP) by PCT, the decision against the use of antibiotics by CRP or PCT in ambulatory settings, and the evaluation of CAP treatment by CRP or PCT kinetics.In the prognostic assessment of CAP, the standard biomarkers of acute organ dysfunction should be given priority, e. g. leukocyte and platelet counts, creatinine/urea and lactate, in combination with clinical signs and symptoms.MR-pro-ADM could enrich diagnostics in the future. Genetic transcriptome analysis is a completely new and promising concept.

Validation of the Greek version of the Severe Respiratory Insufficiency questionnaire

BACKGROUND

The Severe Respiratory Insufficiency (SRI) questionnaire is a multidimensional, well-validated tool for the assessment of health-related quality of life (HRQL) in patients with severe chronic respiratory failure (CRF), due to a variety of underlying disorders. The aim of this study was to validate the SRI questionnaire in the Greek language (Gr-SRI).

METHODS

Reliability and validity analyses were performed for the Gr-SRI using data of 136 consecutive patients with CRF, due to chronic obstructive pulmonary disease (COPD) or non-COPD respiratory diseases (kyphoscoliosis, obesity-hypoventilation, and post-tuberculosis sequelae). Sixty-three patients (46.3 %) were under long-term oxygen therapy (LTOT), while 73 (53.7 %) under long-term non-invasive mechanical ventilation at home (HMV), either with or without LTOT.

RESULTS

Cronbach's alpha was high for the Summary Score of the SRI (0.86) showing high internal consistency, comparable to that of the original German version. The results of the principal component analysis on the SRI Summary Score produced a one-factor construct with a variance of 54 %, which confirmed a single Summary Score for the Greek SRI also. The highest and the lowest scores were detected in Respiratory Complaints and Physical Functioning subscales, respectively. The SRI was capable of discriminating COPD patients and non-COPD patients, with COPD patients having lower mean SRI scores, but no difference was observed between COPD patients under HMV or LTOT.

CONCLUSIONS

Greek SRI has high psychometric properties qualifying its use for HRQL assessment in patients with CRF. HIPPOKRATIA 2017, 21(4): 186-190.

[Exacerbation of COPD]

Acute worsenings of chronic obstructive pulmonary disease (COPD) were for a long time regarded as transient deteriorations, although occasionally life-threatening. No connection to disease progression was recognized. Data emerging during the last decade showed that patients had a considerably worse survival outcome after severe exacerbations. This insight was consolidated in 2012 by a large population-based cohort analysis. At present, severe exacerbations are regarded as key risk factors for COPD disease progression. The present article summarises the current knowledge on exacerbations of COPD, as delineated during an expert workshop in February 2017. It comprises pathogenic mechanisms, exacerbation triggers, the characteristics of frequent exacerbators, and the predictors of worse survival outcome. The role of comorbidities is considered more closely. The presentation of the pharmacotherapy of acute exacerbation is supplemented by an overview of ventilatory support. Finally, pharmacological and nonpharmacological preventive measures are summarised.

Home oxygen therapy: evidence versus reality

INTRODUCTION

LTOT is a well-established treatment option for hypoxemic patients. Scientific evidence for its benefits of LTOT dates back to the 1980s, when two randomized controlled trials showed prolonged survival in COPD-patients undergoing LTOT for at least 15 hours/day. In contrast, the potential benefits of LTOT in non-COPD-patients has not been well researched and the recommendations for its application are primarily extrapolated from trials on COPD-patients. Recently, a large trial confirmed that COPD-patients who don't meet classic indication criteria, and have moderate desaturation at rest or during exercise, do not benefit from oxygen therapy. Also the significant technical evolution of LTOT devices has improved its application. Areas covered: A literature research was performed in pubmed regarding home oxygen therapy (terms: LTOT, ambulatory oxygen therapy, short burst oxygen therapy, nocturnal oxygen therapy). Expert commentary: LTOT proved a survival benefit for COPD patients about 30 years ago. Whether the results of these trials are still valid for patients under modern treatment guidelines remains unknown. Nevertheless, the classic indication criteria for LTOT still persist in guidelines, since there is a lack of updated evidence for the effects of LTOT in more severe hypoxemic patients.

[Extracorporeal CO2 Elimination (ECCO2R) for Hypercapnic Respiratory Failure: From Pathophysiology to Clinical Application]

Extracorporeal CO₂ removal (ECCO₂R) is becoming an increasingly established treatment option for patients with acute severe hypercapnic respiratory failure. Technically, pumpless arterio-venous systems using the natural arterio-venous pressure gradient and also pump-driven veno-venous systems are available. Here, veno-venous ECCO₂R has become the preferred technique, as settings for arterio-venous ECCO₂R are restricted and side effects are more common with arterio-venous ECCO₂R. Using veno-venous ECCO₂R with blood flow rates up to 450 ml/min 60 to 80 ml CO₂ can be removed per minute corresponding to 20 to 30 % of the total amount of CO₂ production. However, in case of very severe hypercapnic respiratory failure with severe respiratory acidosis (pH 7.1 or less) blood flow rates of around 1000 ml/min are required for compensating severe respiratory acidosis corresponding to the elimination of 50 to 60 % of the total amount of CO₂ production. Relevant side effects include the activation of blood coagulation and associated bleeding complications. Two recent case-control studies in severely exacerbated COPD patients could demonstrate that intubation rates can be reduced by the application of ECCO₂R, but this was associated with non-ignorable side effects. Therefore, randomized controlled trials are urgently needed to more precisely establish the risks and benefits of ECCO₂R when aimed at avoiding intubation.

Validation of the Portuguese Severe Respiratory Insufficiency Questionnaire for home mechanically ventilated patients

The aim of this study was to develop and validate the professional translation and cultural adaptation of the Portuguese Severe Respiratory Insufficiency (SRI) Questionnaire. The sample was composed of 93 patients (50 male patients, 53.8%) with a mean age of 66.3 years. The most frequent diagnostic groups were chronic obstructive pulmonary disease, obesity hypoventilation syndrome and restrictive chest wall disorders. The patients were asked to fill in both the SRI and SF-36 questionnaires. Factor analysis of the SRI questionnaire was performed leading to an explained variance of 73%, and resulted in 13 components. When analyzing the reliability, we obtained values for Cronbach's alpha above 0.70 for most subscales with the reliability of the summary scale being even higher (0.84). This professional translation and cultural adaptation of the Portuguese SRI Questionnaire has good psychometric properties which are similar, not only to the original, but also to other translations. These characteristics make this questionnaire applicable to the Portuguese population receiving home mechanical ventilation for severe respiratory insufficiency.

[Impact of a Senso-Motoric Intervention in COPD-Patients Participating in an Outpatient Pulmonary Rehabilitation Program: A Randomized Controlled Trial]

Objective Exercise training provides a cornerstone of pulmonary rehabilitation (PR) in COPD-patients. However, the components of the training are not yet fully investigated. We conducted a randomized controlled trial to investigate the effectiveness of a sensory-motoric training (SMT) in comparison to a conventional strength training (KT) according to the physical performance. Patients and Methods: 43 COPD patients were randomized and participated either in the intervention group (SMT = 30 minutes SMT per day) or in the control group (KT = 30 minutes KT per day). The SMT was performed as circuit training with five stations. The primary endpoint was the difference between T1 (start of the PR) and T2 (end of the PR) in 5-Times Sit-to-stand test (5-STST) in the intergroup comparison. Secondary endpoints were the intra- and intergroup comparisons of T1 and T2 in the 6-Minute Walk Test (6-MWT), COPD Assessment Test (CAT), St. George Respiratory Questionnaire (SGRQ), Hospital Anxiety- and Depression Scale (HADS) and in lung function. Results No significant differences were seen in the results of the 5-STST between the groups. Likewise, in the 6-MWT, SGRQ, CAT, HADS and lung function. The intragroup comparison between T1 and T2 showed significant differences in 5-STST, 6-MWT, SGRQ, CAT and HADS in both groups. The differences in lung function were not significantly, neither in the inter- nor in the intragroup comparison. Conclusion Similarly to a conventional strength training improvements in exercise capacity could be achieved with a SMT during PR in COPD patients. Further studies are necessary to define the role of the SMT in regards to postural control.

Checklists for the Assessment of Correct Inhalation Therapy

Introduction For the long-term treatment of obstructive lung diseases inhalation therapy with drugs being delivered directly to the lungs as an aerosol has become the method of choice. However, patient-related mistakes in inhalation techniques are frequent and recognized to be associated with reduced disease control. Since the assessment of patient-mistakes in inhalation has yet not been standardized, the present study was aimed at developing checklists for the assessment of correct inhalation. Methods Checklists were developed in German by an expert panel of pneumologists and professionally translated into English following back-translation procedures. The checklists comparably assessed three major steps of inhalation: 1) inhalation preparation, 2) inhalation routine, and 3) closure of inhalation. Results Checklists for eight frequently used inhalers were developed: Aerolizer, Breezhaler, Diskus (Accuhaler), metered-dose inhaler, Handihaler, Novolizer, Respimat, Turbohaler. Each checklist consists of ten items: three for inhalation preparation, six for inhalation routine, and one for closure of inhalation. Discussion Standardized checklists for frequently used inhalers are available in German and English. These checklists can be used for clinical routines or for clinical trials. All checklists can be downloaded free of charge for non-profit application from the homepage of the German Airway League (Deutsche Atemwegsliga e. V.): www.atemwegsliga.de.

[Outcome predictors for COPD patients hospitalized for acute exacerbation]

BACKGROUND

Prognostic factors for clinical failure of acute exacerbation in patients with COPD (AECOPD) are of special importance in order to choose an adequate therapy and resources during inpatient treatment. Our database was analyzed to identify predictors for a negative outcome.

MATERIALS AND METHODS

In a retrospective analysis medical records of 616 patients (299 women; 317 men) hospitalized for AECOPD between January 2011 and January 2016 were analyzed in order to evaluate demographic and clinical parameters leading to adverse events. Only the first admission was considered. Logistic regression analysis was performed to determine the relative risk (odds ratio (OR) leading to severe adverse events such as intensive care unit (ICU) admission, mechanical ventilation (invasive or noninvasive), early readmission to ICU and hospital and death).

RESULTS

An increased risk of an ICU admission was found for patients with a coronary heart disease (OR = 5.734; p = 0.009) and for patients requiring an antibiotic therapy (OR = 11.721; p = 0.003). An increased risk for rehospitalisation and mortality was found for age (OR = 1.034; p = 0.028) and a longer duration of the hospital stay (OR = 1.063; p = 0.042). A lower C‑reactive protein (CRP) level was associated with a lower risk of readmission to the hospital (OR = 0.991; p = 0.03). An increased risk of ventilator therapy was found for patients with chronic heart failure (OR = 6.166; p = 0.02) and sleep apnea syndrome (OR = 6.698; p = 0.003), diabetes (OR = 3.754; p = 0.041) and a long stay in the ICU (OR = 2.018; p = 0.000).

CONCLUSIONS

Comorbidities in patients with AECOPD were found to be a major risk factor for ICU admission and mechanical ventilation. Elderly patients and patients with prolonged hospital stay showed a higher risk for readmission and mortality. Patients with a low CRP blood level seemed to have a lower risk for rehospitalisation.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

[Diagnosis and Treatment of Diaphragmatic Dysfunction]

There are many reasons for an impairment of the diaphragmatic function potentially affecting all components of the respiratory pump. Particularly, diagnosis and treatment of unilateral and bilateral phrenic nerve paralysis are challenging. Neuromuscular disorders, trauma, iatrogenic conditions, tumor compression, but also infectious and inflammatory conditions in addition to neuralgic amyotrophy and idiopathic phrenic nerve paralysis are reasons for phrenic nerve paralysis. Primarily, diagnostic procedures include the anamnesis, physical examination, blood gas analysis, lung function testing and the diagnosis of the underlying disease. In addition, specific respiratory muscle testing and respiratory imaging are available today. Current established treatment options include respiratory muscle training, long-term non-invasive ventilation and surgical diaphragm plication in selected patients.

Effects on pulmonary rehabilitation in patients with COPD or ILD: A retrospective analysis of clinical and functional predictors with particular emphasis on gender

BACKGROUND

The response of patients in a pulmonary rehabilitation (PR) is essentially good. However, not all patients benefit from PR to the same extent. In this analysis we wanted to identify the impact of gender and other factors on PR outcomes in patients with chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD).

METHODS

Patients suffering from COPD (n = 1492) or ILD (n = 599), treated during an inpatient PR between 1997 and 2015, were analysed according to the effects of PR on exercise capacity and quality of life with regard to the impact of gender or other predictors by univariate and multivariate analyzes.

RESULTS

In the group of COPD patients, 30% did not achieve the expected physical performance during the 6-min walk test (28% of female and 32% of male patients). However, the non-responders initially have had a higher 6-min walking distance (6-MWD) (p < 0.001) and both male and female showed a significant lower BODE index (p = 0.025) in the multivariate analysis. In the ILD-group, 37% females and 43% males were classified as non-responders with regard to the 6-MWD. Also in this group, the non-responders initially have had a higher 6-MWD (p < 0.001). All other variables (age, BMI, lung function, blood gases, C-reactive Protein, Haemoglobin or rehabilitation duration) had no influence on the outcome.

CONCLUSION

Our study supports the positive effects of PR in COPD and ILD patients. In both groups, patients with the biggest limitations benefit most from PR. However, relevant gender differences or other predictors could not be found.