IA PULMONARY VEIN ATLAS FOR RADIOTHERAPY PLANNING

BACKGROUND AND PURPOSE

Cardiac arrhythmia is a recognised potential complication of thoracic radiotherapy, but the responsible cardiac substructures for arrhythmogenesis have not been identified. Arrhythmogenic tissue is commonly located in the pulmonary veins (PVs) of cardiology patients with arrhythmia, however these structures are not currently considered organs-at-risk during radiotherapy planning. A standardised approach to their delineation was developed and evaluated.

MATERIALS AND METHODS

The gross and radiological anatomy relevant to atrial fibrillation was derived from cardiology and radiology literature by a multidisciplinary team. A region of interest and contouring instructions for radiotherapy computed tomography scans were iteratively developed and subsequently evaluated. Radiation oncologists (n=5) and radiation technologists (n=2) contoured the PVs on the four-dimensional planning datasets of five patients with locally advanced lung cancer treated with 1.8-2.75 Gy fractions. Contours were compared to reference contours agreed by the researchers using geometric and dosimetric parameters.

RESULTS

The mean dose to the PVs was 35% prescription dose. Geometric and dosimetric similarity of the observer contours with reference contours was fair, with an overall mean Dice of 0.80 ± 0.02. The right superior PV (mean DSC 0.83 ± 0.02) had better overlap than the left (mean DSC 0.80 ± 0.03), but the inferior PVs were equivalent (mean DSC of 0.78). The mean difference in mean dose was 0.79 Gy ± 0.71 (1.46% ± 1.25).

CONCLUSION

A PV atlas with multidisciplinary approval led to reproducible delineation for radiotherapy planning, supporting the utility of the atlas in future clinical radiotherapy cardiotoxicity research encompassing arrhythmia endpoints.

Buried RF Sensors for Smart Road Infrastructure: Empirical Communication Range Testing, Propagation by Line of Sight, Diffraction and Reflection Model and Technology Comparison for 868 MHz-2.4 GHz

Updating the road infrastructure requires the potential mass adoption of the road studs currently used in car detection, speed monitoring, and path marking. Road studs commonly include RF transceivers connecting the buried sensors to an offsite base station for centralized data management. Since traffic monitoring experiments through buried sensors are resource expensive and difficult, the literature detailing it is insufficient and inaccessible due to various strategic reasons. Moreover, as the main RF frequencies adopted for stud communication are either 868/915 MHz or 2.4 GHz, the radio coverage differs, and it is not readily predictable due to the low-power communication in the near proximity of the ground. This work delivers a reference study on low-power RF communication ranging for the two above frequencies up to 60 m. The experimental setup employs successive measurements and repositioning of a base station at three different heights of 0.5, 1 and 1.5 m, and is accompanied by an extensive theoretical analysis of propagation, including line of sight, diffraction, and wall reflection. Enhancing the tutorial value of this work, a correlation analysis using Pearson's coefficient and root mean square error is performed between the field test and simulation results.

Concomitant use of Sapien 3 transcatheter valve for severe MAC with Intuity Elite rapid deployment valve for aortic stenosis

Background

Concomitant double valve pathology in the presence of severe MAC poses significant technical challenges when planning surgical intervention. With continued evolution of valve prosthesis, innovative techniques can be considered with the potential for additional therapeutic benefit.

Case presentation

We present a novel technique of using a rapid deployment surgical aortic valve in combination with open surgical transcatheter mitral valve implantation (TMVI) for severe Mitral Annular Calcification (MAC). The Intuity Elite rapid deployment prosthesis (Edwards Lifesciences, Irvine, CA) was used concomitantly with the Sapien 3 (Edwards Lifesciences, Irvine, CA) transcatheter prosthesis trans-atrially on cardiopulmonary bypass in a patient with critical aortic stenosis and moderate-severe mixed mitral valve disease in the setting of severe MAC (off-label use).

Conclusions

We demonstrate how both technologies can, not only be accommodated, but indeed complement each other achieving an excellent outcome in a high-risk patient.

Open transcatheter valve implantation for mitral annular calcification: One-year outcomes

Background

Transcatheter mitral valve implantation (TMVI) for native mitral valve pathology with severe mitral annular calcification has emerged as an alternative treatment option to conventional mitral valve surgery. The objective of this study was to evaluate patients who were referred for TMVI with severe mitral annular calcification and their procedural outcomes.

Methods

Retrospective analysis of patients from 2017 to 2020 referred for TMVI was carried out. Demographic characteristic details; surgical strategy; perioperative complications; and hospital stay, including 30-day and 1-year mortality, were analyzed.

Results

Eleven patients were referred for consideration of TMVI. The 8 patients who underwent TMVI had a median age of 74 years (range, 57-80 years), the median Society of Thoracic Surgeons score was 4.6 (range, 2.4-10.9), and European System for Cardiac Operative Risk Evaluation II score was 5.2% (2%-10.1%). The median cardiopulmonary bypass time and crossclamp times were 170 minutes (range, 150-248 minutes) and 152 minutes (range, 118-214 minutes), respectively. The median hospital stay was 29 days (range, 2-40 days). Thirty-day in hospital mortality was 12%, whereas 1-year mortality was 25%. There was symptomatic improvement with downgrade of New York Heart Association functional class from III or IV to I or II. The 3 patients who were turned down had a median age of 73 years, median Society of Thoracic Surgeons score was 13.4, and median European System for Cardiac Operative Risk Evaluation II score was 5.72%. They were alive at 12 months follow-up from the date of surgical assessment; however, all with New York Heart Association functional class III or IV symptoms.

Conclusions

We describe a series demonstrating the technical consideration and capability of transatrial TMVI to treat mitral annular calcification and native mitral valve disease. Our results are favorable when compared with TMVI global registry data for transseptal or transapical approach.

Correction to: Health-related qualify of life, angina type and coronary artery disease in patients with stable chest pain

An amendment to this paper has been published and can be accessed via the original article.

Health-related qualify of life, angina type and coronary artery disease in patients with stable chest pain

BACKGROUND

Health-related quality of life (HRQoL) is impaired in patients with stable angina but patients often present with other forms of chest pain. The aim of this study was to compare the pre-diagnostic HRQoL in patients with suspected coronary artery disease (CAD) according to angina type, gender, and presence of obstructive CAD.

METHODS

From the pilot study for the European DISCHARGE trial, we analysed data from 24 sites including 1263 patients (45.9% women, 61.1 ± 11.3 years) who were clinically referred for invasive coronary angiography (ICA; 617 patients) or coronary computed tomography angiography (CTA; 646 patients). Prior to the procedures, patients completed HRQoL questionnaires: the Short Form (SF)-12v2, the EuroQoL (EQ-5D-3 L) and the Hospital Anxiety and Depression Scale.

RESULTS

Fifty-five percent of ICA and 35% of CTA patients had typical angina, 23 and 33% had atypical angina, 18 and 28% had non-anginal chest discomfort and 5 and 5% had other chest discomfort, respectively. Patients with typical angina had the poorest physical functioning compared to the other angina groups (SF-12 physical component score; 41.2 ± 8.8, 43.3 ± 9.1, 46.2 ± 9.0, 46.4 ± 11.4, respectively, all age and gender-adjusted p < 0.01), and highest anxiety levels (8.3 ± 4.1, 7.5 ± 4.1, 6.5 ± 4.0, 4.7 ± 4.5, respectively, all adjusted p < 0.01). On all other measures, patients with typical or atypical angina had lower HRQoL compared to the two other groups (all adjusted p < 0.05). HRQoL did not differ between patients with and without obstructive CAD while women had worse HRQoL compared with men, irrespective of age and angina type.

CONCLUSIONS

Prior to a diagnostic procedure for stable chest pain, HRQoL is associated with chest pain characteristics, but not with obstructive CAD, and is significantly lower in women.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02400229.

Pilot study of the multicentre DISCHARGE Trial: image quality and protocol adherence results of computed tomography and invasive coronary angiography

OBJECTIVE

To implement detailed EU cardiac computed tomography angiography (CCTA) quality criteria in the multicentre DISCHARGE trial (FP72007-2013, EC-GA 603266), we reviewed image quality and adherence to CCTA protocol and to the recommendations of invasive coronary angiography (ICA) in a pilot study.

MATERIALS AND METHODS

From every clinical centre, imaging datasets of three patients per arm were assessed for adherence to the inclusion/exclusion criteria of the pilot study, predefined standards for the CCTA protocol and ICA recommendations, image quality and non-diagnostic (NDX) rate. These parameters were compared via multinomial regression and ANOVA. If a site did not reach the minimum quality level, additional datasets had to be sent before entering into the final accepted database (FADB).

RESULTS

We analysed 226 cases (150 CCTA/76 ICA). The inclusion/exclusion criteria were not met by 6 of the 226 (2.7%) datasets. The predefined standard was not met by 13 of 76 ICA datasets (17.1%). This percentage decreased between the initial CCTA database and the FADB (multinomial regression, 53 of 70 vs 17 of 75 [76%] vs [23%]). The signal-to-noise ratio and contrast-to-noise ratio of the FADB did not improve significantly (ANOVA, p = 0.20; p = 0.09). The CTA NDX rate was reduced, but not significantly (initial CCTA database 15 of 70 [21.4%]) and FADB 9 of 75 [12%]; p = 0.13).

CONCLUSION

We were able to increase conformity to the inclusion/exclusion criteria and CCTA protocol, improve image quality and decrease the CCTA NDX rate by implementing EU CCTA quality criteria and ICA recommendations.

KEY POINTS

• Failure to meet protocol adherence in cardiac CTA was high in the pilot study (77.6%). • Image quality varies between sites and can be improved by feedback given by the core lab. • Conformance with new EU cardiac CT quality criteria might render cardiac CTA findings more consistent and comparable.

Local food supply chain resilience to constitutional change: the Brexit effect

Purpose

The purpose of this paper is to investigate how local supply chains prepare for and respond to the threats and opportunities presented by constitutional change, thereby building resilience.

Design/methodology/approach

Multiple case study analysis of 14 firms in the food sector is presented in the context of the UK’s impending exit from the European Union (Brexit). Organisations studied include farmers, processors, retailers and non-government organisations (NGOs). Data from interviews and roundtable discussions has been interpreted using the dynamic capabilities perspective, covering the sensing, seizing, and transforming stages.

Findings

The data highlights the importance of both vertical and horizontal collaboration between supply chain actors as they seek to anticipate the impact of the disruption and influence the future shape of the constitution. There is also evidence to suggest firms in possession of dynamic capabilities can innovate to build resilience and enhance their competitive position. Characteristics of the disruption posed by constitutional change are identified and contrast with those of many other threats more typically described in the literature. As a result, the process of building resilience is different.

Research limitations/implications

The study could be extended to include post-Brexit interviews to further understand the seizing and transforming stages whilst the impact of Brexit on actors that remain within the EU could also be considered.

Practical implications

Practitioners need to work together to influence the future shape of the constitution; and they need to reconfigure their operations and supply chains where necessary to become more resilient to the threat posed by Brexit, such as by reducing their reliance on EU funding streams and trade. The study also has policy implications.

Originality/value

The first study of supply chain resilience to constitutional change and a rare empirical study of resilience across multiple supply chain tiers.

Serum- and HDL3-serum amyloid A and HDL3-LCAT activity are influenced by increased CVD-burden

BACKGROUND

High density lipoproteins (HDL) protect against cardiovascular disease (CVD). However, increased serum amyloid-A (SAA) related inflammation may negate this property. This study investigated if SAA was related to CVD-burden.

METHODS

Subjects referred to the rapid chest pain clinic (n = 240) had atherosclerotic burden assessed by cardiac computerised tomography angiography. Subjects were classified as: no-CVD (n = 106), non-obstructive-CVD, stenosis<50% (n = 58) or moderate/significant-CVD, stenosis ≥50% (n = 76). HDL was subfractionated into HDL2 and HDL3 by rapid-ultracentrifugation. SAA-concentration was measured by ELISA and lecithin cholesterol acyltransferase (LCAT) activity measured by a fluorimetric assay.

RESULTS

We illustrated that serum-SAA and HDL3-SAA-concentration were higher and HDL3-LCAT-activity lower in the moderate/significant-CVD-group, compared to the no-CVD and non-obstructive-CVD-groups (percent differences: serum-SAA, +33% & +30%: HDL3-SAA, +65% and +39%: HDL3-LCAT, -6% & -3%; p < 0.05 for all comparisons). We also identified a positive correlation between serum-SAA and HDL3-SAA (r = 0.698; p < 0.001) and a negative correlation between HDL3-SAA and HDL3-LCAT-activity (r = -0.295; p = 0.003), while CVD-burden positively correlated with serum-SAA (r = 0.150; p < 0.05) and HDL3-SAA (r = 0.252; p < 0.001) and negatively correlated with HDL3-LCAT-activity (r = -0.182; p = 0.006). Additionally, multivariate regression analysis adjusted for age, gender, CRP and serum-SAA illustrated that HDL3-SAA was significantly associated with modifying CVD-risk of moderate/significant CVD-risk (p < 0.05).

CONCLUSION

This study has demonstrated increased SAA-related inflammation in subjects with moderate/significant CVD-burden, which appeared to impact on the antiatherogenic potential of HDL. We suggest that SAA may be a useful biomarker to illustrate increased CVD-burden, although this requires further investigation.

Factory eco-efficiency modelling

Purpose

– This paper reports on the experimentation of an integrated manufacturing and building model to improve energy efficiency. Traditionally, manufacturing and building-facilities engineers work independently, with their own performance objectives, methods and software support. However, with progresses in resource reduction, advances have become more challenging. Further opportunities for energy efficiency require an expansion of scope across the functional boundaries of facility, utility and manufacturing assets.

Design/methodology/approach

– The design of methods that provide guidance on factory modelling is inductive. The literature review outlines techniques for the simulation of energy efficiency in manufacturing, utility and facility assets. It demonstrates that detailed guidance for modelling across these domains is sparse. Therefore, five experiments are undertaken in an integrated manufacturing, utility and facility simulation software IES < VE > . These evaluate the impact of time-step granularity on the modelling of a paint shop process.

Findings

– Experimentation demonstrates that time-step granularity can have a significant impact on simulation model results quality. Linear deterioration in results can be assumed from time intervals of 10 minutes and beyond. Therefore, an appropriate logging interval, and time-step granularity should be chosen during the data composition process. Time-step granularity is vital factor in the modelling process, impacting the quality of simulation results produced.

Practical implications

– This work supports progress towards sustainable factories by understanding the impact of time-step granularity on data composition, modelling, and on the quality of simulation results. Better understanding of this granularity factor will guide engineers to use an appropriate level of data and understand the impact of the choices they are making.

Originality/value

– This paper reports on the use of simulation modelling tool that links manufacturing, utilities and facilities domains, enabling their joint analysis to reduce factory resource consumption. Currently, there are few available tools to link these areas together; hence, there is little or no understanding of how such combined factory analysis should be conducted to assess and reduce factory resource consumption.

Phylogeny, biogeography and ecological diversification of Sarcocornia (Salicornioideae, Amaranthaceae)

BACKGROUND AND AIMS

Sarcocornia comprises about 28 species of perennial succulent halophytes distributed worldwide, mainly in saline environments of warm-temperate and subtropical regions. The genus is characterized by strongly reduced leaves and flowers, which cause taxonomic difficulties; however, species in the genus show high diversity in growth form, with a mat-forming habit found in coastal salt marshes of all continents. Sarcocornia forms a monophyletic lineage with Salicornia whose species are all annual, yet the relationship between the two genera is poorly understood. This study is aimed at clarifying the phylogenetic relationship between Sarcocornia and Salicornia, interpreting biogeographical and ecological patterns in Sarcocornia, and gaining insights into putative parallel evolution of habit as an adaptation to environmental factors.

METHODS

A comprehensively sampled and dated phylogeny of Sarcocornia is presented based on nuclear ribosomal DNA (external transcribed spacer) and chloroplast DNA (atpB-rbcL, rpl32-trnL) sequences; representative samples of Salicornia were also included in the analyses. To infer biogeographical patterns, an ancestral area reconstruction was conducted.

KEY RESULTS

The Sarcocornia/Salicornia lineage arose during the Mid-Miocene from Eurasian ancestors and diversified into four subclades: the Salicornia clade, the American Sarcocornia clade, the Eurasian Sarcocornia clade and the South African/Australian Sarcocornia clade. Sarcocornia is supported as paraphyletic, with Salicornia nested within Sarcocornia being sister to the American/Eurasian Sarcocornia clade. The American and the South African/Australian Sarcocornia clade as well as the Salicornia clade were reconstructed to be of Eurasian origin. The prostrate, mat-forming habit arose multiple times in Sarcocornia.

CONCLUSIONS

Sarcocornia diversified in salt-laden environments worldwide, repeatedly evolving superficially similar prostrate, mat-forming habits that seem advantageous in stressed environments with prolonged flooding, high tidal movement and frost. Some of these prostrate-habit types might be considered as ecotypes (e.g. S. pacifica or S. pillansii) while others represent good ecospecies (e.g. S. perennis, S. decumbens, S. capensis), hence representing different stages of speciation.

Barriers to industrial energy efficiency

Purpose

– The purpose of this research is to capture organisational barriers that can inhibit energy reduction in manufacturing. Energy consumption is a significant contributor to the economic and environmental components of industrial sustainability, and there is a significant body of knowledge emerging on the technical steps necessary to reduce that consumption. Achieving technical success requires organisational alignment, without which barriers to energy efficiency can be experienced.

Design/methodology/approach

– The research uses a theory building–theory testing cycle to propose and then verify existence of barriers to industrial energy efficiency. Literature review is used to build potential organisational barriers that can arise. The existence of barriers is then verified in industrial energy reduction projects using interview, observation and document analysis. Findings are validated by company staff.

Findings

– From the literature barriers that can be related to energy reduction, projects are uncovered. The generic and energy reduction-specific barriers are confirmed and two new barriers are identified. A cognitive map linking the relationships between all the barriers is proposed.

Research limitations/implications

– The research is built on detailed examination of a number of projects in a single company and work is needed to verify the findings in companies of different size and different industrial sector.

Practical implications

– The list of barriers created can support industry in preparing for and undertaking energy efficiency projects. The cognitive map proposed will help industry and academia understand why removing current prominent barriers can lead to surfacing of new barriers.

Originality/value

– The novelty of this research is in both the creation of a list of organisational barriers for energy efficiency as well as identifying the relationships between them. The work brings generic change management barriers to enhance the specific energy reduction barriers together into a broader collation of barriers as well as uncovering new barriers. The work proposes a cognitive map of industrial energy efficiency barriers to demonstrate their interrelationships.

Efficacy and safety of levofloxacin in the context of other contemporary fluoroquinolones: a review

BACKGROUND

In recent years, fluoroquinolone research has focused on achieving several goals, including (1) enhanced potency against gram-positive cocci, notably Streptococcus pneumoniae, and anaerobes, while (2) maintaining potency against gram-negative pathogens, (3) optimizing pharmacokinetics and pharmacodynamics (PK/PD), and (4) minimizing potential adverse drug reactions through recognition and avoidance of structural configurations that have characterized earlier, reactive compounds.

OBJECTIVE

This review examines the efficacy and safety of fluoroquinolones and the specific clinical evidence regarding levofloxacin.

METHODS

Using published literature collected over time by the author, a review was conducted, focusing on the efficacy and safety profile of levofloxacin and other fluoroquinolones.

RESULTS

The newer fluoroquinolones have fulfilled many of the research goals described above. Levofloxacin has improved anti-gram-positive potency, PK/PD properties, a proven clinical trial record (particularly for communityacquired pneumonia [CAP]), and an excellent safety profile-in the context of the treatment of >250 million patients worldwide in the past decade. It is licensed for management of drug-resistant S pneumoniae infections in the United States and has gained widespread formulary acceptance and guideline inclusion. Studies assessing levofloxacin for CAP therapy show significant advantages over standard therapy, such as trends toward reduced IV therapy and length of hospitalization, reduced mortality, and significant associated cost reduction. In addition, levofloxacin has proved highly effective in acute exacerbations of chronic bronchitis (AECB), with excellent clinical and bacteriologic results, typical of the class, and significant advantages-in terms of clinical response, overall pathogen eradication, extension of the symptom-free period, and trends toward a reduction in the number of consultation visits and hospitalizations-over standard agents, such as the oral cephalosporins.

CONCLUSIONS

Levofloxacin offers a combination of documented efficacy and tolerability, and provides an important option for the treatment of bacterial infections, including CAP and AECB, compared with standard agents used in the management of lower respiratory tract infections.

Abstract 461: Compositional Changes to High-Density Lipoproteins That Are Related to Increased Cardiocascular Disease Burden

Atherosclerosis is a vascular disease characterized by the build up of lipid derived plaques, and an individual’s risk of acute coronary syndrome is related to plaque burden and composition. Multiple risk markers for atherosclerosis and CVD act in a synergistic way through inflammatory pathways. One such inflammatory marker is serum amyloid A (SAA), which associates with HDL, negating its antiatherogeinc properties, which may have a causal role in atherosclerosis development.

This study examined if SAA was related to CVD burden, and if this influenced the antiatherogenic properties of HDL.

Subjects (n=240) referred to the rapid chest pain clinic at the Ulster Hospital UK, had atherosclerotic burden assessed by cardiac computerised tomography (CCT) and were classified as no CVD; mild CVD stenosis <50% and moderate/severe CVD stenosis >50%. HDL 2 and HDL 3 were isolated from serum by rapid ultracentrifugation. SAA was measured by an ELISA procedure, lipids by a colorimetric method and CETP activity by a fluorimetric assay.

Results: Although lipids were similar in HDL 2 across the groups, lipids decreased in HDL 3 with increasing CVD burden. In addition, the concentration of SAA and the activity of CETP increased with increasing CVD burden (see table). Additionally, ordinal regression analysis illustrated that HDL 3 -SAA and HDL 2 -CETP where independently related to CVD burden (p=0.001).

Conclusions: This study has shown that SAA was associated with increased CVD burden and that HDL had altered lipid composition and increased CETP activity. Thus, SAA and CETP may be useful biomarkers for the detection and assessment of CVD.

Funded by Heart-Research UK

Common Respiratory Tract Infections as Psychological Entities: A Review of the Mood and Performance Effects of Being Ill

The clinical manifestations associated with colds and influenza overshadow the equally important mood and performance impairments. While decreased alertness and increased anxiety can be considered side effects of symptomatology, symptoms alone may not be responsible for the psychomotor and attention deficits of colds and influenza, respectively. An alternative hypothesis, as proposed in this review, suggests that the immune response, in the form of a cytokine cascade, may be responsible for both the physical and psychological symptoms. In particular, patterns of cytokine production for each infection will dictate the symptoms and performance deficits both within and between viruses. This hypothesis can be extended to incorporate infectious mononucleosis, as well as colds and influenza. The efficacy of symptom‐based overthe‐counter medications is then called into question.

Conclusions: the future of antimicrobial therapy - Augmentin and beyond

Since most infectious microorganisms inevitably develop resistance to any agents used to combat them, there has been a constant need to produce improved, more potent, antimicrobials. At least in part, the emergence and spread of resistant organisms has been provoked by inappropriate over-use of antibacterials. In the last decade, many fewer new antibacterials have been developed but overall prescribing has continued to increase. Consensus prescribing principles have now been defined with the aim of optimising therapy and preventing further increases in, or even to prompt a reduction in, the prevalence of resistance to antibacterial agents. Whilst it is important to encourage continued development of new classes of antibacterials, it is also vital to make the best use of available agents. The development of new dosages and formulations of amoxicillin/clavulanate allows this agent to continue to fill the important role in therapy which it has occupied, and continues to occupy, 25 years after it was launched.

Effect of textured foot orthotics on static and dynamic postural stability in middle-aged females

Foot orthotics (FO) may be prescribed for a range of lower limb and foot conditions. Prior studies report use of FO in enhancing postural stability in healthy younger adults, and do not control for footwear type. Currently, interest in the effects of FO on postural stability in older adults has increased. Limited reports exist of the effects on postural stability of FO made of combinations of materials, thicknesses and surface textures. In this study 40 healthy females (51.1+/-5.8 years) recruited into a within subject test-retest randomised clinical trial were provided with identical footwear and randomised into four FO conditions (control, grid, dimple and plain, n=10 for each condition). Participants wore the footwear for 4 weeks, a minimum of 6h/day. A Kistler force plate was used to determine postural stability variables (anterior-posterior displacements and medial-lateral displacements) for each participant in a static position, with eyes open and eyes closed. Base of support was evaluated using the GAITRite system. Each outcome measure was measured at baseline and 4 weeks. Postural stability variables demonstrated no significant differences between the four FO conditions. No significant differences were observed with base of support between the four conditions. We have demonstrated no detrimental effects on postural stability in older females after 4 weeks. This is regardless of orthotic texture and is independent of footwear. Biomechanical or sensory effects of FO on postural stability are still to be determined. These may be dependent on the geometry and texture of the orthotic.

Developing sustainable models of rural health care: a community development approach

Globally, small rural communities frequently are demographically similar to their neighbours and are consistently found to have a number of problems linked to the international phenomenon of rural decline and urban drift. For example, it is widely noted that rural populations have poor health status and aging populations. In Australia, multiple state and national policies and programs have been instigated to redress this situation. Yet few rural residents would agree that their town is the same as an apparently similar sized one nearby or across the country. This article reports a project that investigated the way government policies, health and community services, population characteristics and local peculiarities combined for residents in two small rural towns in New South Wales. Interviews and focus groups with policy makers, health and community service workers and community members identified the felt, expressed, normative and comparative needs of residents in the case-study towns. Key findings include substantial variation in service provision between towns because of historical funding allocations, workforce composition, natural disasters and distance from the nearest regional centre. Health and community services were more likely to be provided because of available funding, rather than identified community needs. While some services, such as mental illness intervention and GPs, are clearly in demand in rural areas, in these examples, more health services were not needed. Rather, flexibility in the services provided and work practices, role diversity for health and community workers and community profiling would be more effective to target services. The impact of industry, employment and recreation on health status cannot be ignored in local development.

Meeting report: Fourth Forum on Respiratory Tract Infections, Sitges, Spain, 8–11 February 2007

Over 420 delegates participated in this, the fourth of a biennial series of scientific meetings, drawing from 30 or more nations and encompassing the specialties of infectious diseases, clinical microbiology, pulmonary and general medicine and Industry inter alia. The 2007 Forum was chaired by Professors Antoni Torres Marti, Giuliana Gialdroni Grassi and Dr Peter Ball and received academic endorsement from the British Society for Antimicrobial Chemotherapy (BSAC), Italian Society for Chemotherapy, Spanish Pulmonology Society, Paul Ehrlich Society and the Société de Pneumologie de Langue Français. The Scientific Programme was scientifically and financially supported by the BSAC and a consortium of pharmaceutical companies. Discussion focused on key contemporary issues in respiratory tract infection (RTI), including the impact of antibiotic resistance on clinical outcomes and the continuing need for antibiotic conservation via evolving guidelines, the challenges of avian influenza, nosocomial RTIs and the emergence of new pathogens, e.g. community-acquired methicillin-resistant Staphylococcus aureus, novel antimicrobial agents, disease definitions (e.g. healthcare-associated pneumonia) and therapeutic assessment criteria, such as patient-reported outcome measures, in improving RTI management. The entire meeting was granted CME recognition (18 sessions) by the European Accreditation Council for continuing medical education.

Circadian function in patients with advanced non-small-cell lung cancer

This study aimed to evaluate whether patients with advanced non-small-cell lung cancer experience disrupted rest–activity daily rhythms, poor sleep quality, weakness, and maintain attributes that are linked to circadian function such as fatigue. This report describes the rest–activity patterns of 33 non-small-cell lung cancer patients who participated in a randomised clinical trial evaluating the benefits of melatonin. Data are reported on circadian function, health-related quality of life (QoL), subjective sleep quality, and anxiety/depression levels prior to randomisation and treatment. Actigraphy data, an objective measure of circadian function, demonstrated that patients' rest–activity circadian function differs significantly from control subjects. Our patients reported poor sleep quality and high levels of fatigue. Ferrans and Powers QoL Index instrument found a high level of dissatisfaction with health-related QoL. Data from the European Organization for Research and Treatment for Cancer reported poor capacity to fulfil the activities of daily living. Patients studied in the hospital during or near chemotherapy had significantly more abnormal circadian function than those studied in the ambulatory setting. Our data indicate that measurement of circadian sleep/activity dynamics should be accomplished in the outpatient/home setting for a minimum of 4–7 circadian cycles to assure that they are most representative of the patients' true condition. We conclude that the daily sleep/activity patterns of patients with advanced lung cancer are disturbed. These are accompanied by marked disruption of QoL and function. These data argue for investigating how much of this poor functioning and QoL are actually caused by this circadian disruption, and, whether behavioural, light-based, and or pharmacologic strategies to correct the circadian/sleep activity patterns can improve function and QoL.

Therapeutic advances of new fluoroquinolones

Fluoroquinolone antimicrobials have been available for over 10 years. Recent modifications to nuclear side-chains have enhanced both the antimicrobial and pharmacokinetic profiles of this class. Rapidly increasing antimicrobial resistance among community and hospital bacterial pathogens has diminished therapeutic options. Infections caused by such pathogens, including drug-resistant Streptococcus pneumoniae and multi-resistant Enterobacteriaceae are now treatable by few classes of antibacterials, one of these being the fluoroquinolones. Ciprofloxacin was one of the first effective agents available in both iv. and oral formulations for the treatment of Gram-negative infection, resistant to other antibiotics. More recent developments, such as sparfloxacin and grepafloxacin, are more effective in vitro against Gram-positive pathogens, although their safety profile may be less promising. Fluoroquinolones not yet in widespread clinical use, including trovafloxacin, clinafloxacin and moxifloxacin, hold considerable promise as community 'respiratory antimicrobials' and the results of clinical trials are awaited with anticipation. In this review, the three generations of fluoroquinolone development are examined and the relative antimicrobial, pharmacokinetic, clinical and safety profiles of available and developmental quinolones are compared.

217. Interaction of cdyl (chromodomain y-chromosome like) with the nuclear transport protein importin α2

Spermatogenesis is a unique, ordered process governed by the precise expression of a specific set of genes at each stage. Progression through successive stages requires the shuttling of proteins and transcription factors into and out of the nucleus to implement changes in gene transcription. Major factors that mediate nucleocytoplasmic transport are members of the importin superfamily, of which there are five and 20 different importin α and β genes, respectively, in mouse. We have previously demonstrated that several importins display distinct mRNA and protein expression patterns in adult mouse testis1 indicating that specific importins carry a specific cargo at discrete stages of spermatogenesis. Identification of importin cargoes in the testis should help describe the potential developmental switches critical to the spermatogenic process. We performed a yeast two-hybrid screen using full length importin α2 as bait and an adult mouse testis library, identifying nine target proteins. Some of these proteins include nuclear components that may be important in eliciting changes in the nuclear structure during spermatogenesis, as well as those involved in cell cycle regulation, homologous chromosome pairing and recombination, transcriptional regulation and guanine nucleotide biosynthesis. One key candidate is CDYL, which has been implicated in male infertility. It is a chromodomain-containing protein that is predominantly expressed during spermiogenesis and has been previously described to participate in hyperacetylation of histone H4, which is believed to facilitate protamine replacement of histones during spermiogenesis. Verification of CDYL-importin α2 interaction was demonstrated using co-immunoprecipation and co-transfection, while immunohistochemical staining of testis sections indicated colocalisation in the same cell types (mainly elongating spermatids). Importantly, preliminary experiments indicated that increasing CDYL nuclear accumulation by over-expressing importin α2 can increase histone H4 acetylation. Our hypothesis is that importin α2 is central in nuclear targeting of CDYL to facilitate its hyperacetylation role during protamine-histone exchange. (1)Hogarth et al. (2005). Dev. Dynamics (submitted).

A new respiratory fluoroquinolone, oral gemifloxacin: a safety profile in context

Gemifloxacin is a broad-spectrum quinolone antibacterial with enhanced potency against Gram-positive bacteria, including multi-drug resistant Streptococcus pneumoniae, and retained potency against Gram-negative bacilli and bacterial strains resistant to other antibiotics. It has proven particularly effective in respiratory and urinary tract infection. This review presents safety data from 6775 patients included in clinical trials, receiving either the recommended 320 mg once daily oral dose of gemifloxacin, or standard dose of other quinolones, macrolides or beta-lactams (n = 5248). Studies in healthy volunteer and special populations are also reported. Adverse experiences (AEs) were observed in 44.7% of gemifloxacin-treated patients and 47.5% of those who received comparator drugs. Mild gastro-intestinal adverse drug reactions (ADRs) (diarrhoea 5.1%, nausea 3.9%) predominated. Rash, usually maculo-papular and in no case proceeding to more severe eruptions, was observed in 3.6% of those receiving gemifloxacin. A higher incidence of rash (>20%) was observed in young women and was the subject of further study. Adverse drug reactions suspected or probably related to treatment occurred in 17.4% of patients receiving gemifloxacin and in 20% of those receiving comparator antibiotics. Diarrhoea and nausea were experienced by 3.6 and 2.7%, respectively, of gemifloxacin-treated patients (4.6 and 3.2% of comparators), rash by 2.8% (0.6% of comparators) and headache by 1.2% (1.5% of comparators). Gemifloxacin-related vomiting (0.9%), dizziness (0.8%) and taste perversion (0.3%) were uncommon. Treatment discontinuation followed one or more adverse drug reactions in 2.2% of gemifloxacin-treated patients (0.9% due to rash) and 2.1% of comparator-treated patients. A total of 63 deaths (33 receiving gemifloxacin) occurred in the trial population: none were considered related to treatment. A slight prolongation in QT interval (2.56 ms (S.D. +/-24.5)) was observed in gemifloxacin-treated patients: no cardiac arrhythmias were reported. There was a low incidence of liver function tests (LFTs) classified as of potential clinical concern: gemifloxacin (0.4-1.2%), comparators (0.2-1.3%). Serious adverse events (SAEs), occurring during but not necessarily related to therapy, occurred in 3.6% of gemifloxacin-treated patients (4.3% of comparators). SAEs related to treatment agents were rare (0.4% in each group) and included rash (0.1%) and elevated liver enzymes (<0.1%). Gemifloxacin was well tolerated by the elderly, those with renal or hepatic impairment and when co-administered with omeprazole, digoxin, theophylline, warfarin (with which there were no significant interactions) and Maalox. In conclusion, gemifloxacin 320 mg once daily demonstrated a favourable safety and tolerability profile similar to that of comparator antibiotics, including other quinolones.

Safety profile of oral and intravenous moxifloxacin: Cumulative data from clinical trials and postmarketing studies

BACKGROUND

The established safety profile of the fluoroquinolones has been disrupted in the past decade by the detection of low-frequency but potentially serious adverse events that have led to the license suspension, voluntary withdrawal, or restricted use of specific members of the class. Moxifloxacin is a broad-spectrum, advanced-generation fluoroquinolone that has potent activity against respiratory tract infections in adults in both oral and IV formulations.

OBJECTIVE

The goal of this article was to provide an overview of the cumulative safety data on both oral and IV moxifloxacin, including data from the most recent clinical trials and postmarketing studies.

METHODS

Data from clinical trials of moxifloxacin were captured from an electronic database maintained by the manufacturer. Safety data for oral moxifloxacin were obtained from 30 Phase II/III comparator studies (n = 7,368 moxifloxacin, n = 5,687 comparators), 1 Phase IV study (n = 18,374), and 4 postmarketing observational studies (n = 27,756). Safety data for IV moxifloxacin were obtained from 2 Phase III comparator studies (n = 550 maxifloxacin, n = 579 comparators). In addition, pharmacokinetic data were reviewed.

RESULTS

In Phase II/III comparator studies, gastrointestinal complaints were the most common adverse drug reactions (ADRs) associated with both formulations of moxifloxacin, with nausea occurring in 7.1% and 3.1% of patients receiving oral and IV moxifloxacin, respectively, and diarrhea occurring in 5.2% and 6.2% of patients. Discontinuation rates due to ADRs with oral and IV moxifloxacin were 2.7% and 6.0%, and mortality rates were 0.3% and 4.0%. Similar rates of withdrawal and mortality were observed in the comparator groups. There was no evidence that moxifloxacin caused disturbances in glucose metabolism in patients with or without diabetes mellitus, and there was no evidence of an increased risk for cardiovascular adverse events. Pharmacokinetic analyses indicated that dose adjustment of moxifloxacin does not appear to be necessary in elderly patients, those with renal dysfunction, or those with mild to moderate hepatic impairment. The pharmacokinetics of moxifloxacin have not been studied in patients with severe hepatic insufficiency. Moxifloxacin does not interact with a number of commonly prescribed drugs, although its absorption is decreased by concomitant administration of iron and cationic antacids.

CONCLUSIONS

Based on evidence from >7000 patients in clinical trials and >46,000 patients in postmarketing studies, moxifloxacin is generally well tolerated. Its lack of significant drug interactions in target groups makes it an option in diabetic patients or the elderly, as well as in those with renal impairment.

Adverse drug reactions: implications for the development of fluoroquinolones

Quinolone antibacterials, originally derived from anti-malarial compounds, have been developed through side-chain and nuclear manipulation, notably by piperazine and other mono- or bi-cyclic substitutions at the 7 position (giving anti-pseudomonal activity and greater anti-Gram-negative activity) and fluorination at various sites (giving increased anti-Gram-positive activity). The class has now been in clinical use for 40 years. Increased activity has not been without cost: for example, specific idiosyncratic reactions have consigned agents such as the 1-(2,4)-difluorophenyl compounds, such as temafloxacin (haemolytic uraemic syndrome) and trovafloxacin (hepatotoxic reactions), to restriction, suspension or withdrawal. Class adverse drug reactions (ADRs), variable in frequency and severity within the group, have significantly affected individual groups of compounds, such as the 8-chloro derivatives (Bay y 3118, clinafloxacin and sitafloxacin), which, whilst extremely potent, are also highly phototoxic and have largely been discarded.

Oral gemifloxacin once daily for 5 days compared with sequential therapy with i.v. ceftriaxone/oral cefuroxime (maximum of 10 days) in the treatment of hospitalized patients with acute exacerbations of chronic bronchitis

In a randomized, open-label, controlled, multicentre study, the clinical and bacteriological efficacy, safety and tolerability of oral gemifloxacin (320 mg once daily, 5 days) was compared with sequential intravenous (i.v.) ceftriaxone (1 g once daily, maximum 3 days) followed by oral cefuroxime axetil (500 mg twice daily, maximum 7 days) in adult hospitalized patients with acute exacerbations of chronic bronchitis (AECB) (n = 274). The clinical success rates at follow-up (21-28 days post-therapy) in the clinical per-protocol population (the primary endpoint) were 86.8% (105/121) for gemifloxacin vs. 81.3% (91/112) for ceftriaxone/cefuroxime (treatment difference = 5.5,95% CI -3.9,14.9). The corresponding clinical results in the clinical intention-to-treat (ITT) population were 82.6% (114/138) vs. 72.1% (98/136), respectively (treatment difference = 10.5,95% CI 0.7, 20.4).Thus, gemifloxacin had significantly higher clinical success rates than ceftriaxone/cefuroxime. The median time to discharge was 9 days in the gemifloxacin group vs. 11 days in the ceftriaxone/cefuroxime group (P = 0.04, Wilcoxon test). At follow-up, 120/138 (87.0%) gemifloxacin-treated patients had been discharged from hospital, compared with 111/136 (81.6%) ceftriaxone/cefuroxime-treated patients in the clinical ITT population. Both treatments were generally well tolerated and there was no significant difference between the treatment groups in the incidence or type of adverse events reported. A 5-day course of oral gemifloxacin was shown by this study to be at least equivalent to sequential i.v. ceftriaxone/cefuroxime axetil (for up to 10 days) in patients with AECB who require hospital treatment.

Oral gemifloxacin versus sequential therapy with intravenous ceftriaxone/oral cefuroxime with or without a macrolide in the treatment of patients hospitalized with community-acquired pneumonia: a randomized, open-label, multicenter study of clinical efficacy and tolerability

OBJECTIVE

This study aimed to compare the efficacy and safety of oral gemifloxacin, an enhanced-affinity quinolone, with sequential therapy with IV ceftriaxone followed by oral cefuroxime (with or without a macrolide) in patients hospitalized for community-acquired pneumonia (CAP).

METHODS

A randomized, open-label, multicenter study comprised adults hospitalized with a clinical and radiologic diagnosis of CAP. Patients were randomized 1:1 to receive either (1) oral gemifloxacin 320 mg once daily (7-14 days); or (2) IV ceftriaxone 2 g once daily (1-7 days) followed by oral cefuroxime 500 mg twice daily (1-13 days) for a total of < or = 14 days. Patients receiving ceftriaxone/cefuroxime were allowed concomitant macrolide treatment.

RESULTS

A total of 345 patients were randomized, of whom 341 received at least 1 dose of study medication (gemifloxacin, 169/172; ceftriaxone/cefuroxime, 172/173). Clinical success rates in the clinically evaluable (CE) population at follow-up (day 21-28 post-therapy), the primary end point, were 92.2% (107/116) for gemifloxacin and 93.4% (113/121) for ceftriaxone/cefuroxime (treatment difference, -1.15; 95% CI, -7.73 to 5.43). In patients in Fine risk classes IV and V, the clinical success rate was 87.0% (20/23) for gemifloxacin versus 83.3% (20/24) for ceftriaxone/cefuroxime. No difference in clinical response at follow-up was noted based on macrolide use. Bacteriologic success rates at follow-up in the bacteriologically evaluable (BE) population were 90.6% (58/64) for gemifloxacin and 87.3% (55/63) for ceftriaxone/cefuroxime (treatment difference 3.32; 95% CI, -7.57 to 14.21). The clinical success rate in bacteremic patients at follow-up (BE population) was 100.0%. Both treatments were generally well tolerated. The frequency and types of adverse events were similar between the 2 groups. The most common treatment-related adverse events with gemifloxacin were diarrhea, liver-function adverse events, and rash; with ceftriaxone/cefuroxime, they were diarrhea, elevated hepatic-enzyme activity, and moniliasis.

CONCLUSION

The clinical efficacy and tolerability of oral gemifloxacin 320 mg once daily were similar to those of IV ceftriaxone followed by oral cefuroxime (with or without a macrolide) in the treatment of adult patients hospitalized with moderate to severe CAP. Both treatments were effective in bacteremic patients and those at increased risk of mortality.

Calcium diglutamate improves taste characteristics of lower-salt soup

OBJECTIVE

: To ascertain (1) whether the taste characteristics of a conventionally-salted (150 mM NaCl) soup can be reproduced in soups of substantially lower NaCl level with the help of added glutamate, and (2) whether calcium diglutamate (CDG) is equivalent to monosodium glutamate (MSG) in its effect on the taste of soup.

DESIGN

: Cross-sectional, with multiple measurements on each subject.

SETTING

: Healthy university students.

SUBJECTS

: A total of 107 volunteers, recruited by on-campus advertising.

METHODS

: Subjects tasted 32 soups, with all possible combinations of four NaCl concentrations (0-150 mM), four glutamate levels (0-43 mM), and two glutamate types (MSG, CDG).

MAIN OUTCOME MEASURES

: Ratings of each soup on six scales (liking, flavour-intensity, familiarity, naturalness of taste, richness of taste, saltiness).

RESULTS

: A 50 or 85 mM NaCl soup with added CDG or MSG is rated as high as, or higher than, a 150 mM NaCl soup free of added glutamate on five of the six scales (the exception being saltiness). CDG and MSG have equivalent effects.

CONCLUSIONS

: Addition of glutamate allows substantial reductions in Na content of soup, without significant deterioration of taste. CDG and MSG have equivalent effects, but use of CDG permits a greater reduction in Na intake.

A comparison of gemifloxacin and clarithromycin in acute exacerbations of chronic bronchitis and long-term clinical outcomes

BACKGROUND

Gemifloxacin is an enhanced-affinity quinolone with potent activity against lower respiratory tract pathogens.

OBJECTIVE

The efficacy and safety of a 5-day course of gemifloxacin were compared with those of a standard 7-day regimen of clarithromycin in patients with an acute exacerbation of chronic bronchitis (AECB). The impact of treatment on the long-term (26 weeks) clinical outcome was also assessed.

METHODS

The acute phase of this randomized, double-blind study was performed in 93 centers in 7 countries. Adult patients (age >40 years) with a history of chronic bronchitis and an Anthonisen type 1 acute exacerbation (increased dyspnea, cough, and sputum purulence) were eligible. Patients receiving systemic steroids at a dose of >10 mg prednisone or the equivalent were excluded. Patients were randomized to receive gemifloxacin 320 mg once daily for 5 days or clarithromycin 500 mg twice daily for 7 days. Clinical and bacteriologic response rates were assessed at the end-of-therapy visit (days 8-12), the week 2-3 follow-up visit (days 13-24), and the week 4-5 follow-up visit (days 25-38). The long-term phase (26 weeks), which included US and Canadian participants only, evaluated the proportion of patients who remained free of a recurrence of AECB requiring additional antimicrobial therapy after resolution of the initial episode.

RESULTS

Seven hundred twelve patients were randomized to treatment, 351 to gemifloxacin and 361 to clarithromycin. The long-term study included 438 patients, 214 receiving gemifloxacin and 224 receiving clarithromycin. Clinical success rates at the 2-3 week follow-up visit were 85.4% for gemifloxacin and 84.6% for clarithromycin. Bacteriologic success rates were 86.7% for gemifloxacin and 73.1% for clarithromycin. Significantly more patients receiving gemifloxacin than clarithromycin remained free of AECB recurrences (71.0% vs 58.5%, respectively; P = 0.016). Both treatments were well tolerated.

CONCLUSIONS

In the acute treatment of Anthonisen type 1 AECB, a 5-day course of gemifloxacin was at least as effective as a 7-day regimen of clarithromycin. In this population, significantly more patients receiving gemifloxacin remained free of AECB recurrence after 26 weeks compared with those receiving clarithromycin.

Antibiotic therapy of community respiratory tract infections: strategies for optimal outcomes and minimized resistance emergence

Widespread, increasing antibiotic resistance amongst the major respiratory pathogens has compromised traditional therapy of the major infective respiratory syndromes, including bacterial pneumonia and acute exacerbations of chronic bronchitis. Guidelines for antibiotic prescribing dating from the 1980s to 1990s, which attempted to address such problems, were commonly too prescriptive and difficult to apply, and took little account of end-user practice or locally prevalent resistance levels. Further confusion was caused by conflicting recommendations emanating from differing specialty groups. The evidence that such guidelines benefited either clinical outcomes or treatment costs has been disputed. They have probably had little effect on resistance emergence. We report the recommendations of an independent, multi-national, inter-disciplinary group, which met to identify principles underlying prescribing and guideline formulation in an age of increasing bacterial resistance. Unnecessary prescribing was recognized as the major factor in influencing resistance and costs. Antibiotic therapy must be limited to syndromes in which bacterial infection is the predominant cause and should attempt maximal reduction in bacterial load, with the ultimate aim of bacterial eradication. It should be appropriate in type and context of local resistance prevalence, and optimal in dosage for the pathogen(s) involved. Prescribing should be based on pharmacodynamic principles that predict efficacy, bacterial eradication and prevention of resistance emergence. Pharmacoeconomic analyses confirm that bacteriologically more effective antibiotics can reduce overall management costs, particularly with respect to consequential morbidity and hospital admission. Application of these principles should positively benefit therapeutic outcomes, resistance avoidance and management costs and will more accurately guide antibiotic choices by both individuals and formulary/guideline committees.

Future of the quinolones

New fluoroquinolones and fluoronaphthyridones continue to provide the mainstay of antibiotic development, despite recent events associated with unexpected or uncharacteristically severe adverse drug reactions. These have included hepatotoxicity caused by trovafloxacin (suspended), cardiotoxicity associated with grepafloxacin, and phototoxicity caused by clinafloxacin (both withdrawn). Prolongation of the QT interval appears to be an emergent class effect, the implications of which are not yet fully understood. However, the second-generation agents ciprofloxacin and, latterly, levofloxacin have excellent safety profiles and provide standard optimal choices for therapy of a wide range of gram-negative pathogens. They are also useful for many respiratory infections, though the use of ciprofloxacin in pneumococcal pneumonia has been questioned and continued use of levofloxacin may act as a selection pressure for emergence of quinolone-resistant Streptococcus pneumoniae. Active conservation measures may be required to protect the class from this problem because alternatives, should high-level penicillin-resistance continue to spread, are few. The new 8-methoxy quinolones (moxifloxacin and gatifloxacin) are more highly potent against both penicillin-susceptible and multidrug-resistant S. pneumoniae, while retaining activity against enterobacteria. Clinical Phase III development has shown them to produce very satisfactory clinical and bacteriologic responses in respiratory infections and to be remarkably free of clinically significant adverse effects. Postmarketing surveillance of moxifloxacin in Germany has revealed no additional concerns. These agents are now licensed in many countries, including the United States, and add a further, broad-based respiratory dimension to the future of the class.

Efficacy and safety of gemifloxacin 320 mg once-daily for 7 days in the treatment of adult lower respiratory tract infections

An open-label, non-comparative study assessed the clinical and bacteriological efficacy of gemifloxacin (320 mg, once-daily for 7 days) in lower respiratory tract infections (LRTI). Patients with acute exacerbation of chronic bronchitis (AECB, n=261) or community-acquired pneumonia (CAP, n=216) were enrolled into the study. Clinical success rates at follow-up (days 21-28) in the intent-to-treat (ITT) population were high, 83.1% in AECB patients (95% CI: 77.9, 87.4) and 82.9% in CAP patients (95% CI: 77.0, 87.5). High bacteriological success rates were achieved (bacteriological ITT population), 91.2% (52/57) in AECB patients (95% CI: 80.0, 96.7) and 77.9% (60/77) in CAP patients (95% CI: 66.8, 86.3). Gemifloxacin was well tolerated with a low incidence of adverse events. Gemifloxacin treatment resulted in high clinical and bacteriological success rates and is a well-tolerated therapy for the treatment of LRTIs.