Recovery of body composition improves long-term outcomes after lung volume reduction surgery for emphysema.

Nutritional status deteriorates along with progression of emphysema, with the decline of body composition correlating with risk of disease-related events. Lung volume reduction surgery (LVRS), by improving respiratory function and recovering body composition, may influence long-term disease-related morbidity and mortality when compared to respiratory rehabilitation (RR). In this non-randomised study, 44 male patients with moderate-to-severe emphysema underwent LVRS, while 35 received RR. Respiratory parameters, body composition, number and time-to-occurrence of disease-related events were evaluated for 5 yrs. After LVRS, respiratory and nutritional parameters had significantly greater and longer lasting improvements than after RR. Disease-related events occurred later and less frequently after surgery than after rehabilitation, with better morbidity and mortality survival curves (p<0.01 and p<0.03, respectively). Body mass index (BMI) > or =23kg x m(-2), BODE (BMI, airflow obstruction, dyspnoea, exercise capacity) index < or =2 and fat-free mass index (FFMI) > or =16kg x m(-2) at 1 yr were the best positive predictors of post-operative outcomes (p<0.03, p<0.04 and p<0.005, respectively). Reduction in residual volume at 36 months after surgery was significantly correlated with the increase of BMI (rho = -0.56, p = 0.009) and FFMI (rho = -0.64, p = 0.001). LVRS significantly and durably improved respiratory function and body composition over RR. Relationships among residual volume, BMI, FFMI and disease-related events suggest that recovery in respiratory dynamics improves nutritional status, thus significantly reducing long-term disease-related morbidity and mortality.

The role of Humphrey Matrix testing in the early diagnosis of retinopathy in type 1 diabetes.

AIM: The aim of the study was to investigate the role of Humphrey Matrix threshold testing in the detection of early functional retinal impairment in subjects with type 1 diabetes mellitus (DM1) without any signs of retinal vasculopathy, and to investigate the relationship between both functional and structural retinal parameters and metabolic control. METHODS: Thirty eyes of 30 subjects with DM1, with no sign of retinal vasculopathy, and 30 eyes of 30 age- and sex-matched healthy subjects were enrolled in this cross-sectional clinical study. Functional testing included Humphrey Matrix perimetry and white-on-white Humphrey visual field perimetry (HFA), while retinal nerve fibre layer (RNFL) thickness was measured by scanning laser polarimetry with variable corneal birefringence compensator (GDx VCC). RESULTS: Matrix mean deviation (MD) was found to be significantly reduced in subjects with DM1 compared with controls (-1.10 (SD 2.98; 95% CI -2.21 to 0.01) vs 1.37 (SD 2.11; 95% CI 0.58 to 2.16), p = 0.0005). HFA MD and pattern standard deviation (PSD) were significantly worse in subjects with DM1 compared with controls (p = 0.010 and p = 0.013 respectively). Among structural parameters, average peripapillary RNFL thickness was reduced in DM1 subjects (p = 0.006). Matrix MD and HFA MD and PSD, and average peripapillary and superior RNFL, were significantly reduced in subjects with DM1 with HbA(1c) > or = 7% compared with controls. CONCLUSIONS: Functional and structural retinal testing by Humphrey Matrix and GDx VCC could be useful for the identification of early retinal impairment in people with DM1 with no sign of retinal vasculopathy.

Combined islet and hematopoietic stem cell allotransplantation: a clinical pilot trial to induce chimerism and graft tolerance.

To prevent graft rejection and avoid immunosuppression-related side-effects, we attempted to induce recipient chimerism and graft tolerance in islet transplantation by donor CD34+hematopoietic stem cell (HSC) infusion. Six patients with brittle type 1 Diabetes Mellitus received a single-donor allogeneic islet transplant (8611 +/- 2113 IEQ/kg) followed by high doses of donor HSC (4.3 +/- 1.9 x 10(6) HSC/kg), at days 5 and 11 posttransplant, without ablative conditioning. An 'Edmonton-like' immunosuppression was administered, with a single dose of anti-TNFalpha antibody (Infliximab) added to induction. Immunosuppression was weaned per protocol starting 12 months posttransplant. After transplantation, glucose control significantly improved, with 3 recipients achieving insulin-independence for a short time (24 +/- 23 days). No severe hypoglycemia or protocol-related adverse events occurred. Graft function was maximal at 3 months then declined. Two recipients rejected within 6 months due to low immunosuppressive trough levels, whereas 4 completed 1-year follow-up with functioning grafts. Graft failure occurred within 4 months from weaning (478 +/- 25 days posttransplant). Peripheral chimerism, as donor leukocytes, was maximal at 1-month (5.92 +/- 0.48%), highly reduced at 1-year (0.20 +/- 0.08%), and was undetectable at graft failure. CD25+T-lymphocytes significantly decreased at 3 months, but partially recovered thereafter. Combined islet and HSC allotransplantation using an 'Edmonton-like' immunosuppression, without ablative conditioning, did not lead to stable chimerism and graft tolerance.

Impact of lung volume reduction surgery versus rehabilitation on quality of life.

This study aims at evaluating the effects of lung volume reduction versus respiratory rehabilitation on quality of life, assessed by three different questionnaires. Sixty emphysematous patients were randomised by computer to receive either surgery (n = 30) or rehabilitation (n = 30). Life quality was evaluated by the Nottingham Health Profile, the Short Form (SF)-36 item and the St George's questionnaires. As reported previously, dyspnoea index, forced expiratory volume in one second, residual volume, 6-min walk test and arterial oxygen tension improved after surgery more than after rehabilitation. Quality of life was significantly improved after surgery as follows Nottingham Health Profile physical mobility; SF-36 physical and social functioning, mental and general health, emotional role; St George's general, activity. At multivariate analysis 6- and 12-month changes after surgery of Short Form-36 physical functioning, general health, and St George's activity domains were significantly correlated with forced expiratory volume in one second, while Short Form-36 social functioning and Nottingham Health Profile isolation correlated with residual volume. Functional and especially symptomatic improvements persisted: dyspnoea index, residual volume, and Short Form-36 and St Georges's physical scores were still significant at 4 yrs. Surgery produces greater and longer effects than rehabilitation on quality of life by improving both physical and psychosocial domains. Symptomatic improvements persisted at 4 yrs.