Continuous noninvasive ventilatory support outcomes for patients with neuromuscular disease: a multicenter data collaboration.

BACKGROUND: Typically, patients with progressive neuromuscular disorders (NMDs) develop acute respiratory failure (ARF), are intubated, and when failing spontaneous breathing trials (SBTs) undergo a tracheotomy and receive tracheostomy mechanical ventilation (TMV). However, increasing numbers of patients use nasal noninvasive ventilation (NIV), initially for sleep and this is extended to continuous dependence (CNVS). This can be used as a strategy to assist in successful extubation . We retrospectively reviewed 19 centers offering CNVS and mechanical insufflation-exsufflation (MI-E) as an alternative to TMV. METHODS: Centers with publications or presentations concerning CNVS outcomes data were pooled for amyotrophic lateral sclerosis (ALS), Duchenne muscular dystrophy (DMD), and spinal muscular atrophy type 1 (SMA1). Progression to CNVS dependence without hospitalization, duration of dependence, and extubations and decannulations to CNVS were recorded. Prolongation of life was defined by duration of CNVS dependence without ventilator free breathing ability (VFBA). RESULTS: There were 1623 part time (<23 h/day) NVS users with ALS, DMD, and SMA1 from 19 centers in 16 countries of whom 761 (47%) were CNVS dependent for 2218 patient-years. This included: 335 ALS patients for a mean 1.2 ± 1.0 (range to 8) years each; 385 DMD patients for 5.4 ± 1.6 (range to 29) years; and 41 SMA1 patients for 5.9 ± 1.8 (range to 20) years. Thirty-five DMD and ALS TMV users were decannulated to CNVS and MI-E. At data collection 494 (65%) patients were CNVS dependent but 110 (74 of whom with bulbar ALS), had undergone tracheotomies. CONCLUSIONS: ALS, DMD, and SMA1 patients can become CNVS dependent without requiring hospitalization but CNVS cannot be used indefinitely for many patients with advanced upper motor neuron diseases.

Quantitation of oxygen-induced hypercapnia in respiratory pump failure.

PURPOSE: To determine the likelihood that clinicians know carbon dioxide levels before administering supplemental oxygen to patients with neuromuscular disorders, to quantitate the effect of oxygen therapy on carbon dioxide retention, and to explore hypercapnia contributing to the need to intubate and use of continuous noninvasive ventilatory support to avert it. BASIC PROCEDURES: A retrospective chart review for patients with neuromuscular disorders intubated or having intubation averted by using continuous noninvasive ventilatory support with carbon dioxide known pre- and during oxygen administration. MAIN FINDINGS: For only 2 of 316 patients who were intubated did clinicians know carbon dioxide levels prior to administering oxygen. For four cases, intubation was averted by continuous noninvasive ventilatory support and mechanical insufflation-exsufflation despite severe hypercapnia and acidosis. After initiating oxygen therapy, patients' carbon dioxide partial pressures increased 52.1±42.0mmHg in over as little as 20min. PRINCIPAL CONCLUSIONS: Clinicians should attempt to use continuous noninvasive ventilatory support and mechanical insufflation-exsufflation rather than supplemental oxygen to normalize blood gases for neuromuscular ventilatory failure and should be prepared to intubate hypercapnic patients for whom oxygen is administered.

Introduction and prolonged circulation of G12 rotaviruses in Sicily.

Genotype G12 strains are now considered to be the sixth most prevalent human rotaviruses worldwide. In two Sicilian cities, Palermo and Messina, surveillance of rotavirus circulation performed since 1985 and 2009, respectively, did not detect G12 strains until 2012. From 2012 to 2014 rotavirus infection was detected in 29·7% of 1647 stool samples collected from children admitted for acute gastroenteritis to three Sicilian hospitals in Palermo, Messina and Ragusa. In 2012, G12P[8] was first detected in Palermo and then in Messina where it represented the second most frequent genotype (20% prevalence) after G1P[8]. Thereafter, G12 strains continued to circulate in Sicily, showing a marked prevalence in Ragusa (27·8%) in 2013 and in Palermo (21%) and Messina (16·6%) in 2014. All but one of the Sicilian G12 strains carried a P[8] VP4 genotype, whereas the single non-P[8] rotavirus strain was genotyped as G12P[9]. Phylogenetic analysis of the VP7 and VP4 sequences allowed distinction of several genetic lineages and separation of the G12P[8] strains into three cluster combinations. These findings indicate independent introductions of G12 rotavirus strains in Sicily in recent years.

Analysis of early strains of the norovirus pandemic variant GII.4 Sydney 2012 identifies mutations in adaptive sites of the capsid protein.

Global surveillance for norovirus identified in 2012 the emergence of a novel pandemic GII.4 variant, termed Sydney 2012. In Italy, the novel pandemic variant was identified as early as November 2011 but became predominant only in the winter season 2012-2013. Upon sequencing and comparison with strains of global origin, the early Sydney 2012 strains were found to differ from those spreading in 2012-2013 in the capsid (ORF2) putative epitopes B, C and D, segregating into a distinct phylogenetic clade. At least three residues (333, 340 and 393, in epitopes B, C and D, respectively) of the VP1 varied among Sydney 2012 strains of different clades. These findings suggest that the spread of the pandemic variant in Italy during the winter season 2012-2013 was due to the introduction of strains distinct from those circulating at low frequency in the former winter season and that similar strains were also circulating elsewhere worldwide.

tst1-positive ST22-MRSA-IVa in healthy Italian preschool children.

A survey was performed in May 2013 to assess methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization in healthy children attending 26 municipal daycare centres in Palermo, Italy. Of the 500 children, ten (2 %) tested positive. Eight MRSA isolates were tst1-positive ST22-MRSA-IVa, spa t223; the other two isolates were identified as ST1-IVa and ST398-V, respectively. tst1-positive ST22-MRSA, spa t223 has been previously identified only in the Middle Eastern area.

Successful control of an outbreak of colonization by Klebsiella pneumoniae carbapenemase-producing K. pneumoniae sequence type 258 in a neonatal intensive care unit, Italy.

This article reports an outbreak of colonization by Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-Kp) sequence type (ST) 258 in a neonatal intensive care unit (NICU) in Palermo, Italy. KPC-Kp ST258 was detected by an active surveillance culture programme. Between 18th September and 14th November 2012, KPC-Kp was isolated from 10 out of 54 neonates admitted in the outbreak period. No cases of infection were recorded. Male sex was associated with colonization, whereas administration of ampicillin- sulbactam plus gentamicin was protective. Infection control interventions interrupted the spread of KPC-Kp without the need to close the NICU to new admissions.

Evidence for recombination between pandemic GII.4 norovirus strains New Orleans 2009 and Sydney 2012.

During 2012, a novel pandemic GII.4 norovirus variant, Sydney 2012, emerged worldwide. A signature of the variant was a GII.Pe ORF1, in association with GII.4 Apeldoorn 2008-like ORF2-ORF3 genes. We report the detection of recombinant GII.4 Sydney 2012 strains, possessing the ORF1 gene of the former pandemic variant New Orleans 2009.

Subsurface application of poultry litter in pasture and no-till soils.

Poultry litter provides a rich nutrient source for crops, but the usual practice of surface-applying litter can degrade water quality by allowing nutrients to be transported from fields in surface runoff while much of the ammonia (NH3)-N escapes into the atmosphere. Our goal was to improve on conventional titter application methods to decrease associated nutrient losses to air and water while increasing soil productivity. We developed and tested a knifing technique to directly apply dry poultry litter beneath the surface of pastures. Results showed that subsurface litter application decreased NH3-N volatilization and nutrient losses in runoff more than 90% (compared with surface-applied litter) to levels statistically as low as those from control (no litter) plots. Given this success, two advanced tractor-drawn prototypes were developed to subsurface apply poultry litter in field research. The two prototypes have been tested in pasture and no-till experiments and are both effective in improving nutrient-use efficiency compared with surface-applied litter, increasing crop yields (possibly by retaining more nitrogen in the soil), and decreasing nutrient losses, often to near background (control plot) levels. A paired-watershed study showed that cumulative phosphorus losses in runoff from continuously grazed perennial pastures were decreased by 55% over a 3-yr period if the annual poultry litter applications were subsurface applied rather than surface broadcast. Results highlight opportunities and challenges for commercial adoption of subsurface poultry litter application in pasture and no-till systems.

[Mediterranean spotted fever in paediatric and adult patients: two clinical aspects of the same disease]. / La febbre bottonosa del Mediterraneo in età pediatricae in età adulta: due realtà cliniche differenti nella stessamalattia.

Mediterranean Spotted Fever is an acute febrile disease caused by Rickettsia conorii and transmitted to humans by the brown dog tick Rhipicephalus sanguineus. Nearly 400 cases are reported every year in Sicily, mainly from June to September. The aim of this study is to compare the clinical and laboratory features of two different groups of patients , one of adults and one of children. The analysis included all adult patients with MSF diagnosed at the Institute of Infectious Diseases, Paolo Giaccone University Polyclinic in Palermo, during the period January 2007- August 2010 and all the children diagnosed with MSF at the G. Di Cristina Children Hospital in Palermo during the period January 1997- December 2004. On admission, a complete physical and laboratory examination was carried out on every patient. An indirect immunofluorescence assay for Rickettsia conorii was performed in every case, a PCR assay was performed with blood samples from some adult patients. Analysis of the results confirms that MSF is a benign, and self-limiting disease in children, while severe complications can often arise in adults.

A comparison of phosphorus speciation and potential bioavailability in feed and feces of different dairy herds using 31p nuclear magnetic resonance spectroscopy.

An experiment was conducted to examine how potential phosphorus (P) bioavailability (inferred from speciation) differs in feed and feces collected in spring from four dairy herds representing different management systems: (i) total confinement with cows fed total mixed ration (TMR), (ii) total confinement with TMR plus P mineral supplement, (iii) a hybrid of confinement with TMR and pastoral grazing, and (iv) predominantly grazing with supplemental grains. A treatment was included that air dried feces to simulate conditions after dung deposition. Wet chemical techniques and solution (31)P nuclear magnetic resonance spectroscopy ((31)P-NMR) were used to identify P concentrations and compounds present in water (a surrogate for P in overland flow), dilute acid (0.012 M HCl, an estimate of P utilization by cattle), or NaOH-EDTA (a solution that maximizes the organic P extraction) extracts of feed and feces. In general, P concentration in feces paralleled P in feed. Air drying feces decreased water-extractable P by 13 to 61% largely due to a decrease in orthophosphate, whereas NaOH-EDTA-extractable P increased by 18 to 48%. Analysis of dilute HCl was unsuccessful due to orthophosphate precipitation when pH was adjusted to 12 for (31)P-NMR. In water extracts, more P was in bioavailable diester-P forms, undetectable by colorimetry, than in NaOH-EDTA extracts. In feed, orthophosphate dominated (46-70%), but myo-IHP varied with feed (<10% in forage samples but 43% in a TMR sample). The proportion of myo-IHP decreased in feces compared with feed via mineralization but decreased less in systems with a greater proportion of available P input (e.g., orthophosphate and phospholipids). Feed and drying effect the concentrations and forms of P in feces and their potential impact on soil and water quality. Although bioavailable P in feces from pasture-based and confined systems can be similar in spring, dung-P is distributed on a lower kg P ha(-1) rate in grazing systems. The best method to mitigate P loss from feces is to decrease P in feed.

Viral gastroenteritis in children hospitalised in Sicily, Italy.

The aim of the present study was to describe the epidemiologic and clinical characteristics of acute viral gastroenteritis in hospitalised Italian children. A total of 215 stool specimens were collected from January to December 2003 from patients hospitalised in Palermo for acute diarrhoea. Samples were tested for group A rotavirus, astrovirus, adenovirus, norovirus, enteropathogenic bacteria, and parasites. Rotaviruses, mostly belonging to types G1-G4, were detected in 25.1% of samples, astrovirus in 7%, adenovirus in 6%, norovirus in 18.6%, and bacterial agents in 17.2%. No parasitic infections were diagnosed. Mixed infections represented 9.8% of all cases. The mean and median ages of children with rotavirus gastroenteritis were lower than those of children with other viruses (p = 0.029), with the highest median ages being found in astrovirus-infected patients. Vomiting and dehydration were more frequent among patients with viral infection (p < 0.01), and the severity score was significantly higher for children infected with astrovirus or group A rotavirus (p = 0.008). Rotavirus was the leading cause of prolonged hospitalisation (p = 0.005). In conclusion, viruses were confirmed in Italy as the most common cause of severe enteric illness in childhood, with rotavirus types G1-G4, which correspond to those included in the rotavirus vaccines being developed, playing the main role. Routine testing should be introduced for noroviruses, since they seem to represent an important cause of sporadic paediatric gastroenteritis.

Runoff transport of faecal coliforms and phosphorus released from manure in grass buffer conditions.

AIMS: To test the hypothesis that faecal coliform (FC) and phosphorus (P) are transported similarly in surface runoff through the vegetative filter strip after being released from land-applied manure. METHODS AND RESULTS: The Hagerstown soil was packed into boxes that were 10 cm deep, 30 cm wide and 100, 200 or 300 cm long. Grass was grown in boxes prior experiments. Same-length boxes were placed under rainfall simulator and tilted to have with either 2% or 4% slopes. Dairy manure was broadcast on the upper 30-cm section. Rainfall was simulated and runoff samples were collected and analysed for Cl, FC and total phosphorus (TP). Mass recovery, the concentration decrease rate k, and the ratio FC : TP showed that there was a consistent relationship between FC and TP in runoff. CONCLUSION: The FC and TP transport through simulated vegetated buffer strips were highly correlated. SIGNIFICANCE AND IMPACT OF THE STUDY: As a knowledge base on the effect of the environmental parameters on P transport in vegetated buffer strips is substantially larger than for manure-borne bacteria, the observed similarity may enhance ability to assess the efficiency of the vegetated buffer strips in retention of FC currently used as indicator organisms for manure-borne pathogens.

Evaluating nitrogen management options for reducing nitrate leaching from northeast U.S. pastures.

Substantial amounts of nitrate nitrogen NO3-N can leach from intensively grazed pasture in the northeast U.S. where there is about 30 cm of groundwater recharge, annually. Management options for reducing NO3-N leaching were evaluated for this environment using the Cornell Net Carbohydrate and Protein System Model and a recently developed nitrogen leaching index. Management options utilizing energy supplementation of grazing dairy cows could improve nitrogen efficiency within the cow, but would not necessarily reduce NO3-N leaching at the pasture scale if stocking rate was not controlled. The management option of using white clover to supply nitrogen to the pasture decreased NO3-N leaching, but produced less dry matter yield, which in turn reduced stocking rate. The economic returns of reducing NO3-N with these options need to be evaluated in light of milk prices and commodity and fertilizer nitrogen costs. At current prices and costs, the economic benefit from the energy supplementation options is substantial.

Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure. A different approach to weaning.

The purpose of this study was to prospectively compare parameters that might predict successful translaryngeal extubation and tracheostomy tube decannulation. Irrespective of ventilatory function, 62 extubation/decannulation attempts were made on 49 consecutive patients with primarily neuromuscular ventilatory insufficiency who satisfied criteria. Thirty-four patients required 24-h ventilatory support. Noninvasive intermittent positive pressure ventilation (IPPV) was substituted as needed for IPPV via translaryngeal or tracheostomy tubes. Successful decannulation was defined as extubation or decannulation and site closure with no consequent respiratory symptoms or blood gas deterioration for at least 2 weeks. Failure was defined by the appearance of respiratory distress and decreases in vital capacity and oxyhemoglobin saturation despite use of noninvasive IPPV and assisted coughing. The independent variables of age, extent of predecannulation ventilator use, vital capacity, and peak cough flows (PCF) were studied to determine their utility in predicting successful extubation and decannulation. Only the ability to generate PCF greater than 160 L/min predicted success, whereas inability to generate 160 L/min predicted the need to replace the tube. All 43 attempts on patients with PCF greater than 160 L/min succeeded; all 15 attempts on patients with PCF below 160 L/min failed; and of 4 patients with PCF of 160 L/min, 2 succeeded and 2 failed. We conclude that the ability to generate PCF of at least 160 L/min is necessary for the successful extubation or tracheostomy tube decannulation of patients with neuromuscular disease irrespective of ability to breathe.

Adhesion of follicular lymphoma cells to lymphoid germinal centers--a potential mechanism of tumor cell homing following autologous transplantation.

Follicular non-Hodgkin's lymphomas (NHL) generally present as disseminated diseases with infiltration of lymphoid organs, bone marrow (BM), as well as peripheral blood (PB). These lymphoma cells may recapitulate the behavior of normal germinal center (GC) B cells, some of which remain in follicles and others which have the capacity to migrate. Normal activated B cells and follicular lymphoma cells bind to GCs in vitro and this interaction is mediated by VLA-4 on the lymphoid cell and VCAM-1 on follicular dendritic cells. Since the disseminated nature of follicular NHLs may be related to the ability of PB and BM cells to recirculate through lymphoid tissues, we examined the adhesive characteristics of follicular lymphoma cells isolated from these site. Cells from 10 of 14 cases of follicular NHL involving PB or BM bound to normal GCs. Neoplastic GCs could similarly support the binding of PB or BM derived follicular NHL cells. This interaction was inhibited by monoclonal antibodies directed against VLA-4 and VCAM-1. These studies may provide insight into the clinical behavior of these diseases. More importantly the homing and adhesion of lymphoma cells is likely to be relevant to the use of PB and BM as a source of hematopoietic stem cells following high dose ablative therapy.

Detection by polymerase chain reaction of residual cells with the bcl-2 translocation is associated with increased risk of relapse after autologous bone marrow transplantation for B-cell lymphoma.

Although molecular biologic techniques can now detect minimal numbers of residual cancer cells in patients in complete clinical remission, the clinical significance of minimal residual disease has never been conclusively established. If the detection of minimal residual disease predicts which patients will relapse, then therapy could be altered based upon the detection of these cells. The t(14;18) can be detected by polymerase chain reaction (PCR) amplification in 50% of patients with B-cell non-Hodgkin's lymphoma and allows detection of one lymphoma cell in up to 1 million normal cells. To determine the clinical significance of the detection of minimal residual lymphoma cells in the bone marrow (BM) PCR amplification was used to detect the presence of residual lymphoma cells after autologous BM transplantation (ABMT) in serial BM samples from 134 patients with B-cell lymphoma in whom a bcl-2 translocation could be detected. PCR analysis was performed on a total of 542 BM samples obtained while these patients were in complete remission. Disease-free survival was markedly increased in patients with no PCR-detectable lymphoma cells in the marrow compared with those in whom residual lymphoma cells were detected (P < .00001), and the presence of detectable lymphoma cells was associated with a 48-fold increase in the risk of relapse. Of the 77 patients (57%) with no PCR-detectable lymphoma cells in their most recent BM sample, none have relapsed. In contrast, all 33 patients (25%) who have relapsed had PCR-detectable lymphoma cells detected in their BM before clinical relapse occurred. In 19 patients (14%), residual lymphoma cells in the BM were detected early following transplantation and subsequently were no longer detectable, although these patients received no further therapy. In these patients, residual lymphoma cells may already have been irreversibly damaged by the high-dose therapy or an endogenous immune mechanism may be capable of eliminating residual lymphoma cells in some patients. Therefore, although the detection of minimal residual disease by PCR following ABMT in patients with lymphoma identifies those patients at high risk of relapse, the presence of residual minimal disease early after transplantation may not be associated with poor prognosis in a small subset of patients. Confirmatory studies will be required to determine more definitively the role of minimal disease detection to identify which patients require additional therapy.

Airway secretion clearance by mechanical exsufflation for post-poliomyelitis ventilator-assisted individuals.

Pulmonary complications from impaired airway secretion clearance mechanisms are major causes of morbidity and mortality for post-poliomyelitis individuals. The purpose of this study was to review the long-term use of manually assisted coughing and mechanical insufflation-exsufflation (MI-E) by post-poliomyelitis ventilator-assisted individuals (PVAIs) and to compare the peak cough expiratory flows (PCEF) created during unassisted and assisted coughing. Twenty-four PVAIs who have used noninvasive methods of ventilatory support for an average of 27 years, relied on methods of manually assisted coughing and/or MI-E without complications during intercurrent respiratory tract infections (RTIs). Nine of the 24 individuals were studied for PCEF. They had a mean forced vital capacity (FVC) of 0.54 +/- 0.47L and a mean maximum insufflation capacity achieved by air stacking of ventilator insufflations and glossopharyngeal breathing of 1.7L. The PCEF were as follows: unassisted, 1.78 +/- 1.16L/sec; following a maximum assisted insufflation, 3.75 +/- 0.73L/sec; with manual assistance by abdominal compression following a maximum assisted insufflation, 4.64 +/- 1.42L/sec; and with MI-E, 6.97 +/- 0.89L/sec. We conclude that manually assisted coughing and MI-E are effective and safe methods of airway secretion clearance for PVAIs with impaired expiratory muscle function who would otherwise be managed by endotracheal suctioning. Severely decreased maximum insufflation capacity but not vital capacity indicate need for a tracheostomy.