Inhaler technique knowledge and skills before and after an educational program in obstructive respiratory disease patients: A real-life pilot study.

INTRODUCTION AND OBJECTIVE: Patients present poor knowledge and skills about their respiratory disease and inhaler device. We aimed to: (1) evaluate COPD and asthmatic patients... ability to manage inhaled drugs (2) identify differences among devices and (3) correlate clinical data with patient ability. MATERIAL AND METHODS: Patients (n=134) admitted for pulmonary rehabilitation (PR) were given an ad-hoc questionnaire covering 0% as the worst and 100% the best value of global ability (indicating the sum of knowledge and skills in managing inhaled drugs) at baseline (T0) and discharge (T1). Educational program was provided during PR. Setting of rehabilitation, age, sex, diagnosis, spirometry, CIRS score, level of autonomy to use medications, if na..ve about PR, educational level, and number/type of prescribed inhaled drugs were recorded. RESULTS: Most patients used 1 drug while 37% used 2 drugs. DPIs were the main device prescribed. At baseline, patients... mean level of knowledge and skills were 73% and 58%, respectively. There was a significant difference in level of skills (p=0.046) among device families, DPIs resulting worst and pMDIs best. Global ability, skills and knowledge improved after educational support (p<0.001) but did not reach the optimal level, 88%, 87% and 89%, respectively. Baseline global ability was positively correlated to female gender, younger age, previous PR access, outpatient status, higher education level and GOLD D class. CONCLUSIONS: At hospital admission, global ability was not optimal. Education may improve this, irrespective of the type of device used, in particular in male, elderly, na..ve to PR, low educational level patients.

Is it possible a new definition of metabolic syndrome in childhood?

OBJECTIVE: To investigate whether a group of Italian children and adolescents who were diagnosed to have metabolic syndrome (MS) according to a new ethnic age and gender specific definition had, in comparison with a control group, other signs and metabolic risk factors which are commonly associated with MS. PATIENTS AND METHODS: The cross-sectional study population included 300 subjects (51% boys, age range 6-14 years), who were divided into 2 groups according to the presence of MS, diagnosed on the basis of 3/5 factors derived from the age and gender specific quantile distribution of MS components in a large regional Italian population survey (Calabrian Sierras Community Study, CSCS). In all subjects the following data were collected: anthropometric measures, blood pressure, liver function, C-reactive protein (hsCRP), uric acid blood levels, lipid and glucose profile. Triglycerides/HDL-cholesterol (TG/HDL-C) ratio was calculated. RESULTS: There were 38 subjects (13%) with MS, who had higher indices of growth and fat distribution and higher blood levels of uric acid, alanine aminotransferase and gamma-glutamyltransferase. TG/HDL ratio was higher (median 3.11 vs. 1.14, p = 0.00001) in MS subjects who had lower apolipoprotein A and higher apolipoprotein B and non-HDL-C levels. hsCRP was not different between groups. CONCLUSIONS: Our ethnic age and gender specific definition of MS in Italian children and adolescents was able to identify in a youth group different cardiometabolic risk factors related to insulin resistance, endothelial damage and nonalcoholic fatty liver disease, which are commonly associated with MS diagnosis.

Assessment of venous thrombus time of progression by gray-scale median analysis.

AIM: To determine if gray-scale median (GSM) analysis could differentiate acute and recent deep venous thrombosis (DVT). METHODS: Patients submitted to vascular ultrasound examination of lower extremities due to suspected DVT were evaluated. Patients with acute or recent femoropopliteal DVT were included, whereas those without DVT, with chronic or isolated calf DVT were excluded. Time of onset of DVT symptoms was recorded. A transverse image of the thrombosed vein and adjacent artery was obtained. Two sonographers determined a subjective impression of thrombus time of progression and classified it as acute or recent. Thrombus GSM was calculated with a software. ROC curve was used to determine GSM cut-off points. Fischer's exact and Student´s t tests were also used. P<0.05 indicated statistical significance. RESULTS: 128 veins of 63 extremities were studied. Thrombus GSM correlated with time of onset of DVT symptoms (P=0.005) and with subjective evaluation of thrombus time of progression (P<0.001). When DVT symptoms had begun up to two weeks before and thrombus was classified as acute, GSM was lower. Area under ROC curve for thrombus GSM was 0.76 (P<0.001). GSM 17.90, 23.03, and 40.02 cut-off points differentiated between acute and recent thrombi with 35.59% sensitivity and 91.30% specificity, 59.32% sensitivity and 84.06% specificity, 91.53% sensitivity and 31.88% specificity, respectively. CONCLUSION: GSM was a reliable tool for objectively differentiating acute and recent DVT in most thrombus images. GSM 17.90 and 40.02 cut-off points showed high specificity and high sensitivity, respectively, for acute and recent DVT differentiation. In 17.90 to 40.02 interval, GSM cut-off point that best distinguished acute from recent DVT was 23.03.

Differing effects of exogenous and endogenous hydrogen sulphide in carrageenan-induced knee joint synovitis in the rat.

BACKGROUND AND PURPOSE: Recent findings suggest that the noxious gas H(2)S is produced endogenously, and that physiological concentrations of H(2)S are able to modulate pain and inflammation in rodents. This study was undertaken to evaluate the ability of endogenous and exogenous H(2)S to modulate carrageenan-induced synovitis in the rat knee. EXPERIMENTAL APPROACH: Synovitis was induced in Wistar rats by intra-articular injection of carrageenan into the knee joint. Sixty minutes prior to carrageenan injection, the rats were pretreated with indomethacin, an inhibitor of H(2)S formation (DL-propargylglycine) or an H(2)S donor [Lawesson's reagent (LR)]. KEY RESULTS: Injection of carrageenan evoked knee inflammation, pain as characterized by impaired gait, secondary tactile allodynia of the ipsilateral hindpaw, joint swelling, histological changes, inflammatory cell infiltration, increased synovial myeloperoxidase, protein nitrotyrosine residues, inducible NOS (iNOS) activity and NO production. Pretreatment with LR or indomethacin significantly attenuated the pain responses, and all the inflammatory and biochemical changes, except for the increased iNOS activity, NO production and 3-NT. Propargylglycine pretreatment potentiated synovial iNOS activity (and NO production), and enhanced macrophage infiltration, but had no effect on other inflammatory parameters. CONCLUSIONS AND IMPLICATIONS: Whereas exogenous H(2)S delivered to the knee joint can produce a significant anti-inflammatory and anti-nociceptive effect, locally produced H(2)S exerts little immunomodulatory effect. These data further support the development and use of H(2)S donors as potential alternatives (or complementary therapies) to the available anti-inflammatory compounds used for treatment of joint inflammation or relief of its symptoms.

Endogenous cannabinoids induce fever through the activation of CB1 receptors.

BACKGROUND AND PURPOSE: The effects of centrally administered cannabinoids on body core temperature (Tc) and the contribution of endogenous cannabinoids to thermoregulation and fever induced by lipopolysaccharide (LPS) (Sigma Chem. Co., St. Louis, MO, USA) were investigated. EXPERIMENTAL APPROACH: Drug-induced changes in Tc of male Wistar rats were recorded over 6 h using a thermistor probe (Yellow Springs Instruments 402, Dayton, OH, USA) inserted into the rectum. KEY RESULTS: Injection of anandamide [(arachidonoylethanolamide (AEA); Tocris, Ellisville, MO, USA], 0.01-1 microg i.c.v. or 0.1-100 ng intra-hypothalamic (i.h.), induced graded increases in Tc (peaks 1.5 and 1.6 degrees C at 4 h after 1 microg i.c.v. or 10 ng i.h.). The effect of AEA (1 microg, i.c.v.) was preceded by decreases in tail skin temperature and heat loss index (values at 1.5 h: vehicle 0.62, AEA 0.48). Bell-shaped curves were obtained for the increase in Tc induced by the fatty acid amide hydrolase inhibitor [3-(3-carbamoylphenyl)phenyl] N-cyclohexylcarbamate (Cayman Chemical Co., Ann Arbor, MI, USA) (0.001-1 ng i.c.v.; peak 1.9 degrees C at 5 h after 0.1 ng) and arachidonyl-2-chloroethylamide (ACEA; Tocris) (selective CB(1) agonist; 0.001-1 microg i.c.v.; peak 1.4 degrees C 5 h after 0.01 microg), but (R,S)-(+)-(2-Iodo-5-nitrobenzoyl)-[1-(1-methyl-piperidin-2-ylmethyl)-1H-indole-3-yl] methanone (Tocris) (selective CB(2) agonist) had no effect on Tc. AEA-induced fever was unaffected by i.c.v. pretreatment with 6-Iodo-2-methyl-1-[2-(4-morpholinyl)ethyl]-1H-indole-3-yl](4-methoxyphenyl) methanone (Tocris) (selective CB(2) antagonist), but reduced by i.c.v. pretreatment with N-(piperidin-1-yl)-5-(4-iodophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1H-pyrazole-3-carboxamide (AM251; Tocris) (selective CB(1) antagonist). AM251 also reduced the fever induced by ACEA or LPS. CONCLUSIONS AND IMPLICATIONS: The endogenous cannabinoid AEA induces an integrated febrile response through activation of CB(1) receptors. Endocannabinoids participate in the development of the febrile response to LPS constituting a target for antipyretic therapy.

Myeloperoxidase overexpression in children with hypercholesterolemia.

BACKGROUND: Studies conducted in healthy children showed that biomarkers of oxidative stress decreased with increasing age from 1 to 11 years. No data have been reported concerning the behavior of age-related oxidative stress in hypercholesterolemic children. OBJECTIVE: Aim of this study was to test if children with hypercholesterolemia have prolonged exposure to enhanced oxidative stress and to study the underlying mechanism. METHODS: We performed a cross-sectional study comparing 8-hydroxy-2'deoxyguanosine, oxidized-LDL and myeloperoxidase plasma levels in 95 normocholesterolemic and 95 hypercholesterolemic children. RESULTS: Compared to normocholesterolemic children, those with hypercholesterolemia had higher 8-hydroxy-2'deoxyguanosine, oxidized-LDL and myeloperoxidase plasma levels. A correlation analysis of the overall population showed that total cholesterol was directly correlated with 8-hydroxy-2'deoxyguanosine, oxidized-LDL and myeloperoxidase. Stepwise linear regression showed that only total cholesterol, 8-hydroxy-2'deoxyguanosine and myeloperoxidase levels predicted oxidized-LDL plasma levels. In normocholesterolemic children oxidized-LDL and myeloperoxidase plasma levels significantly decreased from first (1-5 years) to second (6-9 years) quartile of age. In hypercholesterolemic children 8-hydroxy-2'deoxyguanosine, oxidized-LDL and myeloperoxidase plasma levels did not show significant differences among quartiles of age. CONCLUSION: This study shows that an early and persistent oxidative stress is detected in hypercholesterolemic children and that myeloperoxidase up-regulation might play a role.

[Translaryngeal tracheostomy. A new era?]. / Tracheostomia translaringea. Nuova era?

OBJECTIVE: Presentation of a new technique of dilation tracheostomy projected to offer a minimum risk of complication and tissue trauma. DESIGN: Prospective study carried out between July 1993 and December 1995, to evaluate the feasibility of the procedure, its possible advantages over other methods, and possible complications. SETTING: General ICU with a Paediatrics Section. PATIENTS: Uninterrupted series of 84 adults and 12 children with multifactorial respiratory insufficiency. INTERVENTION: Through a needle inserted in the trachea, a guide wire is retrogradely pushed out of the mouth and attached to a special device formed by a flexible plastic cone with pointed metal tip joined to an armoured tracheal cannula. This device is then pulled back through the oral cavity, larynx, trachea-hence the definition: TransLaryngeal Tracheostomy (TLT)- and outwards across the neck wall by applying traction on the wire with one hand and counterpressure on the neck wall with the fingers of the operator's other hand. When the cone and part of the cannula have emerged, the cone is separated from the cannula. The cannula is further extracted until its inside portion can be turned downwards to its final placement. RESULTS: A precise localisation of the stoma placement and the needle introduction are facilitated by the rigid tracheoscope and protrusion. Thanks to the very pointed cone, the piercing resistances are lowered. At the same time, every degree of traction power is allowed through the counterpressure practised by the fingers. The channel is very regular with a strong adherence to the cannula that secures a virtual lack of bleeding and local inflammation. We observed this in the fifty cases, in which the final version of our technique was applied. Trachea CT scan and endoscopic control did not show late lesions of the airway. CONCLUSIONS: TLT is characterised by highest inherent safety and lowest tissue traumatism, that it can also be performed in patients who would risk complications from any other tracheostomy techniques.

[Pulmonary involvement in scleroderma assessed with high-resolution computerized tomography and functional tests]. / Danno polmonare nella sclerodermia valutato con Tomografia Computerizzata con alta risoluzione e prove funzionali.

This study was aimed at investigating and analyzing lung involvement in scleroderma patients with different imaging methods, toward a rational diagnostic approach. Twenty-four patients with systemic sclerosis were examined with pulmonary function tests (PFT), spirometry and diffusing capacity for carbon monoxide (DLCO), chest radiography and high-resolution Computed Tomography (HRCT). Abnormal findings were present in 42% of cases on X-ray films and in 71% of cases on HRCT images. PFT was abnormal in the spirometries of 42% of cases and in DLCO tests in 50% of cases. The most common findings at HRCT were the small reticular and the ground-glass patterns. HRCT emerged as the most effective method to evaluate lung involvement in systemic sclerosis. In our series, HRCT allowed possibly curable lung lesions to be differentiated from incurable ones. However, HRCT is suggested in the patients with impaired pulmonary function to allow treatment choice; on the contrary, in the patients with no functional impairment, HRCT adds little information to clinical findings, showing only limited focal lesions.

[Dynamic computed tomography in the prognostic assessment of acute pancreatitis]. / Tomografia Computerizzata dinamica nella valutazione prognostica delle pancreatiti acute.

Pancreatic necrosis is a well-known risk factor for infectious complications in the patients affected with acute pancreatitis. Dynamic CT with i.v. administration of a large bolus of contrast medium can establish the diagnosis of necrotizing pancreatitis. A series of 49 cases of severe acute pancreatitis was reviewed, and early CT investigations were seen to fail to detect pancreatic necrosis in 22 instances, versus 27 positive cases. In the group of patients with no necrosis, the clinical course was uneventful or characterized by mild complications which regressed spontaneously or by means of adjuvant medical treatment. On the contrary, 17 patients with necrotizing pancreatitis developed severe complications requiring intensive treatment. These complications occurred in 50% of the patients with < 50% of pancreatic necrosis, while the figure rose to 77% whenever more extensive involvement was observed. Our results show that the presence and extent of pancreatic necrosis must be diagnosed as early as possible for prognostic and therapeutic purposes; this can be done by the routinary use of dynamic CT with the administration of large amounts of contrast media at high flow rates.

Whole-gut lavage for surgery. A case of intraoperative colonic explosion after administration of mannitol.

During the last few years, new forms of bowel preparation before surgery and operative endoscopy have been introduced as whole gut irrigation with saline or mannitol solutions. The use of 10 to 20 per cent mannitol solution is, however, likely to alter the composition and quantity of the colonic gases (methane and hydrogen) and to produce explosive mixtures. Some cases of fatal explosions occurring during endoscopic electroresection have been reported. The authors examine the whole gut lavage methods and report a case of colonic explosion during a left hemicolectomy on a patient prepared with 20 per cent mannitol solution.

[Right partial diaphragmatic eventration. Diagnostic and therapeutic aspects]. / L'eventratio diaframmatica parziale destra. Aspetti diagnostici e terapeutici.

The Authors report a case of asymptomatic right partial diaphragmatic eventration, casually discovered and surgically repaired by imbrication of the hemidiaphragm. They confirm the almost completely asymptomatic and benign character of this disease, and discuss the difficulty of the differential diagnosis with various diseases of the right cardiophrenic angle, particularly the pericardial cysts. Among the diagnostic techniques the Authors advocate the priority of the liver scanning, the echotomography, the C.A.T., the pneumoperitoneography and, in case, the celiac axis arteriography. They consider the plastic repair of the diaphragm performed by a thoracic approach to be indispensable to the confirmation of the diagnosis and, of course, to a radical therapy.

SCLERA: an Astrometric Telescope for Experimental Relativity.

An f/100, 12.2-m focal length photoelectric telescope designed specifically for daytime astrometry of objects near the sun is now operative at its Tucson, Arizona, site. The design goal was to achieve accuracies of order 0.001 sec of arc in field position measurements of stars. To accomplish this, many features reducing systematic and random errors are employed, including Schupmann medial telescope optics, compensation for lateral color aberration, apodization for reduction of diffracted light, and use of an accurately measured solar diameter for calibrating the field.

Measurements of scattered light from mirrors and lenses.

The limitations arising from scattered light from lenses and mirrors in a program of daytime astrometry near the sun are discussed. Measurements were made of the angular distribution of the scattered radiance for (1) a coronagraphic lens, (2) a 2.54-cm thick coronagraph quality window, and (3) flat quartz mirrors. Results are also given for the optical elements after they have been exposed in a vacuum for 48h. The results indicate that the accuracy of a daytime astrometry program would be determined by the shot noise of the scattered light produced by the refracting elements and the sky, each producing equal contributions.