Biomarkers in acute respiratory failure

Acute respiratory failure (ARF) is the most common type of organ failure leading to the need for intensive care. It is often secondary to acute lung injury (ALI) and its more severe form, acute respiratory distress syndrome (ARDS). ARF, and especially ALI and ARDS, cause increased morbidity, and mortality rates remain high (up to 40%). These disorders are characterised by inflammatory reaction and tissue damage. In some cases, inflammation continues and leads to an overwhelming repair process with ongoing fibrosis, accompanied by organ dysfunction and eventually a loss of function. Measuring the magnitude of the inflammation, and the repair process, would theoretically offer information concerning outcome. Early identification of patients whose disease process is likely to proceed unfavourably, would help clinicians to optimise their treatment. The aim of this study was to evaluate the epidemiology of ARF, its treatment, and outcome in Finland, with special interest in biomarkers, and their value in the prediction of mortality. Altogether, 958 adult patients treated with ventilatory support were prospectively included in this study during an eight week period in 2007 in 25 intensive care units. Plasma aminoterminal pro-brain natriuretic peptide (NT-pro-BNP) was assessed in 602 patients, and plasma cell-free DNA in 580 patients, to evaluate their prognostic value in ARF. Markers of collagen metabolism were studied in longitudinal serum samples in 68 patients in order to evaluate their evolution in ARF and the association to multiple organ dysfunction (MOD). Ventilatory support was used in 39% of all ICU patients. The estimated incidence of ARF was 149.5/100 000 per year. Median tidal volumes used were higher than recommended. Overall mortality at 90 days was 31%. Plasma NT-pro-BNP and cell-free DNA were highly increased in the majority of patients. Both markers were independent predictors of 90-day mortality, but their discriminative power was at most moderate when used separately. The mortality was highest in those patients, in whom both biomarkers were over their separate cut-off values. Thus, combined use of these biomarkers may increase their clinical value in the mortality prediction. The markers of collagen metabolism changed significantly over time in surviving patients. None of these markers did associate with MOD in these patients.

Nonlinear measures of respiration: Respiratory irregularity and increased chaos of respiration in patients with panic disorder

Background. Respiratory irregularity has been previously reported in patients with panic disorder using time domain measures. However, the respiratory signal is not entirely linear and a few previous studies used approximate entropy (APEN), a measure of regularity of time series. We have been studying APEN and other nonlinear measures including a measure of chaos, the largest Lyapunov exponent (LLE) of heart rate time series, in some detail. In this study, we used these measures of respiration to compare normal controls (n = 18) and patients with panic disorder (n = 22) in addition to the traditional time domain measures of respiratory rate and tidal volume. Methods: Respiratory signal was obtained by the Respitrace system using a thoracic and an abdominal belt, which was digitized at 500 Hz. Later, the time series were constructed at 4 Hz, as the highest frequency in this signal is limited to 0.5 Hz. We used 256 s of data (1,024 points) during supine and standing postures under normal breathing and controlled breathing at 12 breaths/min. Results: APEN was significantly higher in patients in standing posture during normal as well as controlled breathing (p = 0.002 and 0.02, respectively). LLE was also significantly higher in standing posture during normal breathing (p = 0.009). Similarly, the time domain measures of standard deviations and the coefficient of variation (COV) of tidal volume (TV) were significantly higher in the patient group (p = 0.02 and 0.004, respectively). The frequency of sighs was also higher in the patient group in standing posture (p = 0.02). In standing posture, LLE (p < 0.05) as well as APEN (p < 0.01) contributed significantly toward the separation of the two groups over and beyond the linear measure, i.e. the COV of TV. Conclusion: These findings support the previously described respiratory irregularity in patients with panic disorder and also illustrate the utility of nonlinear measures such as APEN and LLE as additional measures toward a better understanding of the abnormalities of respiratory physiology in similar patient populations as the correlation between LLE, APEN and some of the time domain measures only explained up to 50-60% of the variation. Copyright (C) 2002 S. Karger AG, Basel.

Modelling and classification of respiratory volume wavefourms

A technique is proposed for classifying respiratory volume waveforms(RVW) into normal and abnormal categories of respiratory pathways. The proposed method transforms the temporal sequence into frequency domain by using an orthogonal transform, namely discrete cosine transform (DCT) and the transformed signal is pole-zero modelled. A Bayes classifier using model pole angles as the feature vector performed satisfactorily when a limited number of RVWs recorded under deep and rapid (DR) manoeuvre are classified.

Hypoxia-Mediated Impairment of the Mitochondrial Respiratory Chain Inhibits the Bactericidal Activity of Macrophages

In infected tissues oxygen tensions are low. As innate immune cells have to operate under these conditions, we analyzed the ability of macrophages (M phi) to kill Escherichia coli or Staphylococcus aureus in a hypoxic microenvironment. Oxygen restriction did not promote intracellular bacterial growth but did impair the bactericidal activity of the host cells against both pathogens. This correlated with a decreased production of reactive oxygen intermediates (ROI) and reactive nitrogen intermediates. Experiments with phagocyte NADPH oxidase (PHOX) and inducible NO synthase (NOS2) double-deficient M phi revealed that in E. coli- or S. aureus-infected cells the reduced antibacterial activity during hypoxia was either entirely or partially independent of the diminished PHOX and NOS2 activity. Hypoxia impaired the mitochondrial activity of infected M phi. Inhibition of the mitochondrial respiratory chain activity during normoxia (using rotenone or antimycin A) completely or partially mimicked the defective antibacterial activity observed in hypoxic E. coli-or S. aureus-infected wild-type M phi, respectively. Accordingly, inhibition of the respiratory chain of S. aureus-infected, normoxic PHOX-/- NOS2(-/-) M phi further raised the bacterial burden of the cells, which reached the level measured in hypoxic PHOX-/- NOS2(-/-) M phi cultures. Our data demonstrate that the reduced killing of S. aureus or E. coli during hypoxia is not simply due to a lack of PHOX and NOS2 activity but partially or completely results from an impaired mitochondrial antibacterial effector function. Since pharmacological inhibition of the respiratory chain raised the generation of ROI but nevertheless phenocopied the effect of hypoxia, ROI can be excluded as the mechanism underlying the antimicrobial activity of mitochondria.

Control dynamics of severe acute respiratory syndrome transmission

Severe acute respiratory syndrome (SARS) is a serious disease with many puzzling features. We present a simple, dynamic model to assess the epidemic potential of SARS and the effectiveness of control measures. With this model, we analysed the SARS epidemic data in Beijing. The data fitting gives the basic case reproduction number of 2.16 leading to the outbreak, and the variation of the effective reproduction number reflecting the control effect. Noticeably, our study shows that the response time and the strength of control measures have significant effects on the scale of the outbreak and the lasting time of the epidemic.

Comparative investigations on the respiratory physiology of euryhaline gammarids with special reference to salinity adaptation. [Translation from: Helgolaender Wissenschaftliche Meeresuntersuchungen 23(4) 485-534, 1972.]

Members of the family Gammaridae are very closely interrelated. There arises the question as to how far they also differ amongst themselves through physiological characteristics. Comparative respiratory and physiological experiments were made on the five euryhaline species Gammarus locusta, G. oceanicus, G. salinus, G. zaddachi and G. duebeni. The respiratory measurements carried out within the framework of this experiment were occupied with the relationships between oxygen consumption and body size depending on salinity. They also had the object of determing the variations in metabolic intensity after an abrupt change in the salt content of the external medium, and to establish the period of time for the process of adaptation. As the experiments were carried out polarographically in a testing plant with continuous flow-through, and the method which was applied permitted continuous recording over prolonged intervals, there could also be carried out comparisons between metabolism at rest and under activity, and the alterations of oxygen consumption during the process of moulting could be measured.

The ecological impact of different mechanisms of chronic sub-lethal toxicity on feeding and respiratory physiology

Sub-lethal toxicity tests, such as the scope-for-growth test, reveal simple relationships between measures of contaminant concentration and effect on respiratory and feeding physiology. Simple models are presented to investigate the potential impact of different mechanisms of chronic sub-lethal toxicity on these physiological processes. Since environmental quality is variable, even in unimpacted environments, toxicants may have differentially greater impacts in poor compared to higher quality environments. The models illustrate the implications of different degrees and mechanisms of toxicity in response to variability in the quality of the feeding environment, and variability in standard metabolic rate. The models suggest that the relationships between measured degrees of toxic stress, and the maintenance ration required to maintain zero scope-for-growth, may be highly nonlinear. In addition it may be possible to define critical levels of sub-lethal toxic effect above which no environment is of sufficient quality to permit prolonged survival.

Social, economic, and health impact of the respiratory syncytial virus: a systematic search

Background: Bronchiolitis caused by the respiratory syncytial virus (RSV) and its related complications are common in infants born prematurely, with severe congenital heart disease, or bronchopulmonary dysplasia, as well as in immunosuppressed infants. There is a rich literature on the different aspects of RSV infection with a focus, for the most part, on specific risk populations. However, there is a need for a systematic global analysis of the impact of RSV infection in terms of use of resources and health impact on both children and adults. With this aim, we performed a systematic search of scientific evidence on the social, economic, and health impact of RSV infection. Methods: A systematic search of the following databases was performed: MEDLINE, EMBASE, Spanish Medical Index, MEDES-MEDicina in Spanish, Cochrane Plus Library, and Google without time limits. We selected 421 abstracts based on the 6,598 articles identified. From these abstracts, 4 RSV experts selected the most relevant articles. They selected 65 articles. After reading the full articles, 23 of their references were also selected. Finally, one more article found through a literature information alert system was included. Results: The information collected was summarized and organized into the following topics: 1. Impact on health (infections and respiratory complications, mid-to long-term lung function decline, recurrent wheezing, asthma, other complications such as otitis and rhino-conjunctivitis, and mortality; 2. Impact on resources (visits to primary care and specialists offices, emergency room visits, hospital admissions, ICU admissions, diagnostic tests, and treatments); 3. Impact on costs (direct and indirect costs); 4. Impact on quality of life; and 5. Strategies to reduce the impact (interventions on social and hygienic factors and prophylactic treatments). Conclusions: We concluded that 1. The health impact of RSV infection is relevant and goes beyond the acute episode phase; 2. The health impact of RSV infection on children is much better documented than the impact on adults; 3. Further research is needed on mid-and long-term impact of RSV infection on the adult population, especially those at high-risk; 4. There is a need for interventions aimed at reducing the impact of RSV infection by targeting health education, information, and prophylaxis in high-risk populations.

Tipagem das células do infiltrado inflamatório peritumoral em carcinoma de células escamosas da mucosa bucal: correlação com expressão de Ki67

O emprego de técnicas imunoistoquímicas, utilizando marcadores biológicos como o Ki67, que permite a avaliação do índice de proliferação celular em neoplasias malignas, vem sendo preconizado como um importante caminho de investigação do comportamento biológico das neoplasias malignas, tendo como consequências contribuições para o estabelecimento do prognóstico e desenvolvimento de novos protocolos terapêuticos. Neste trabalho, utiliza-se o método imunoistoquímico da avidina-biotina-peroxidase avaliada a expressão de Ki67 no parênquima de amostras de carcinomas de células escamosas da mucosa bucal com diferentes graus de diferenciação histológica. Além disso, a quantificação da área de infiltrado inflamatório foi avaliada. Os resultados demonstraram que a resposta imunológica celular é o principal mecanismo de defesa no carcinoma de células escamosas da mucosa bucal, expressada pelo grande número de linfócitos T e macrófagos e a expressão de Ki67 está relacionado ao índice mitótico e, consequentemente, à proliferação celular e, também, à diferenciação da neoplasia.

Avaliação do potencial leishmanicida e antibacteriano de Annona mucosa (Jacq.) - Annonaceae cultivada in vitro e in vivo

A biodiversidade brasileira abrange plantas de importância medicinal que podem ser utilizadas na formulação de novos fármacos. Contudo, tem sido reduzida em velocidade alarmante, em função de diferentes ações antrópicas. A cultura de tecidos vegetais propicia a conservação e uso do germoplasma permitindo a obtenção de substâncias de importância medicinal. As leishmanioses são consideradas um problema de saúde pública mundial sendo a espécie Leishmania braziliensis de maior importância epidemiológica no Brasil. Recentemente tem-se registrado aumento da resistência à linha de tratamento usual. Do mesmo modo, o uso indiscriminado de antibióticos levou ao aumento de bactérias multirresistentes, que representam sério risco de infecção. A espécie Annona mucosa (Jacq.) possui substâncias, como acetogeninas e alcaloides, que apresentam atividades antiparasitária e antimicrobiana. Nesse sentido, o objetivo do trabalho foi avaliar o potencial leishmanicida e antibacteriano de extratos de A. mucosa de material produzido in vitro e in vivo. Foi proposto um protocolo de germinação in vitro, ainda não reportada para a espécie, com vistas à obtenção de plântulas axênicas. Em meio WPM foram cultivados explantes hipocotiledonares e foliares em meio MS, suplementados com PIC e diferentes concentrações de KIN, BAP ou TDZ. Os calos obtidos foram cultivados em meio líquido de mesma composição para a produção de suspensões celulares. Os materiais foram submetidos à extração metanólica e posterior fracionamento em hexano e diclorometano. Para a avaliação da atividade dos extratos sobre L. braziliensis foi usado o modelo in vitro, com a forma promastigota, e in vivo na forma amastigota, a partir do tratamento de macrófagos peritoneais de camundongos infectados com o parasito. Ambas as formas foram tratadas com os extratos por 96 e 48h, respectivamente. A atividade antimicrobiana foi avaliada por macrodiluição do extrato em Mueller-Hinton, sendo avaliado o crescimento das cepas após 16h de incubação a 48C. A germinação in vitro da espécie foi alcançada em substrato vermiculita estéril umedecido com solução de sais do meio MS, com taxa média de 85%. A maior produção de calos friáveis foi obtida em meios contendo KIN, com potencial uso para cultivo em suspensões celulares. Os extratos do material in situ e in vitro apresentaram atividade leishmanicida, apesar da toxicidade para macrófagos. Culturas de células em suspensão apresentaram potencial leishmanicida in vitro e redução da infecção em macrófagos. Os extratos do material avaliado apresentaram atividade antimicrobiana seletiva, com inibição do crescimento de Streptococcus pyogenes e Bacillus thurigiensis em diferentes concentrações avaliadas. Os métodos biotecnológicos empregados permitiram a obtenção de materiais com propriedades medicinais para as atividades leishmanicida e antibacteriana, assim como o material in vivo, constituindo este estudo o primeiro relato para as atividades propostas em A. mucosa.

Influência do refluxo duodenogástrico nas alterações histológicas da mucosa gástrica em ratos infectados por Helicobacter pylori: modelo experimental

O Helicobacter pylori, é tido como o principal fator de risco para o carcinoma gástrico. Diferentes estudos experimentais em animais procuram relacionar essa carcinogênese a outros fatores carcinógenos sem sucesso. Neste estudo, procurou-se avaliar-se em ratos, se há correlação entre o refluxo duodenogástrico, o Helicobacter pylori e o desenvolvimento do câncer gástrico ou de seus precursores. Para tal, realizou-se nos três grupos de ratos (n de dez por grupo) as técnicas de: piloroplastia precedida de infecção, gastrectomia subtotal precedida de infecção e um grupo no qual foi praticada apenas a infecção. Apois seis meses, analisou-se as alterações da mucosa, comparando-se os três grupos. As alterações da mucosa pesquisadas foram as seguintes: gastrites, metaplasias, displasias e neoplasias epiteliais. Ao término do estudo, foi encontrado, no grupo submetido a piloroplastia precedida de infecção um alto percentual de alterações epiteliais. Conclui-se que, no rato, a operação de piloroplastia, levou ao maior desenvolvimento da população do Helicobacter pylori, que se relaciona com as lesões pré- malignas e o adenocarcinoma gástrico.

Long-Term Burden and Respiratory Effects of Respiratory Syncytial Virus Hospitalization in Preterm Infants — The SPRING Study

The health status of premature infants born 32(1)-35(0) weeks' gestational age (wGA) hospitalized for RSV infection in the first year of life (cases; n = 125) was compared to that of premature infants not hospitalized for RSV (controls; n = 362) through 6 years. The primary endpoints were the percentage of children with wheezing between 2-6 years and lung function at 6 years of age. Secondary endpoints included quality of life, healthcare resource use, and allergic sensitization. A significantly higher proportion of cases than controls experienced recurrent wheezing through 6 years of age (46.7% vs. 27.4%; p = 0.001). The vast majority of lung function tests appeared normal at 6 years of age in both cohorts. In children with pulmonary function in the lower limit of normality (FEV1 Z-score [-2; -1]), wheezing was increased, particularly for cases vs. controls (72.7% vs. 18.9%, p = 0.002). Multivariate analysis revealed the most important factor for wheezing was RSV hospitalization. Quality of life on the respiratory subscale of the TAPQOL was significantly lower (p = 0.001) and healthcare resource utilization was significantly higher (p<0.001) in cases than controls. This study confirms RSV disease is associated with wheezing in 32-35 wGA infants through 6 years of age.

Eficácia de um protocolo de higiene bucal com utilização de solução de clorexidina a 0,12% na prevenção de pneumonias associadas à ventilação mecânica (PAVM) e os efeitos sobre a microbiota da mucosa bucal de pacientes internados em unidades de terapia intensiva

A presente investigação teve como objetivo avaliar a prática de cirurgiões dentistas em uma unidade de terapia intensiva (UTI) de um hospital militar, o estabelecimento de um protocolo de higiene oral e os seus efeitos sobre a redução de pneumonias associadas à ventilação mecânica (PAVM). As percepções da equipe da UTI sobre as atividades dos cirurgiões dentistas também foram avaliadas por meio de um questionário. O perfil de colonização microbiana da mucosa oral antes e depois do estabelecimento das medidas de higiene oral também foi avaliado tanto por diluição e plaqueamento em meios de cultura microbiológicos seletivos e enriquecidos e através da amplificação pelo método de PCR e eletroforese em gel desnaturante em gradiente (DGGE), subsequente ao sequenciamento dos amplicons. A carga microbiana foi avaliada após a contagem de placas de agar e através da amplificação por PCR em tempo real (qPCR) do gene rrs nas amostras. O protocolo de higiene oral, realizado pelos cirurgiões dentistas, foi capaz de reduzir a incidência de PAVM (p <0,05). O questionário revelou que a modificação da halitose foi percebida por 93,33% dos participantes. A redução da ocorrência das úlceras orais e dos lábios durante a internação dos pacientes foi observada por 80% da equipe da UTI. Foi observada a redução da produção das secreções nasais e bucais por 70% da equipe dos profissionais da UTI. Para 86,66% dos participantes a assistência aos pacientes tornou-se mais agradável após a instituição dos cuidados bucais. O protocolo, realizado com a utilização de solução 0,12% de clorexidina, não foi capaz de evitar a colonização da mucosa oral por patógenos microbianos usualmente encontrados no ambiente hospitalar tais como os bastonetes Gram-negativos entéricos e não fermentadores, nem foi capaz de eliminá-los quando tais micro-organismos já se encontravam presentes antes dos procedimentos de higiene bucal. Alguns Bastonetes Gram-positivos (Lactobacillus sp e corinebactérias) e Staphylococcus epidermidis permaneceram após a realização dos procedimentos. O protocolo de higiene oral permitiu a redução da carga microbiana na mucosa oral de 50% dos pacientes considerando-se o método de contagem microbiana e para 35% dos pacientes pela avaliação dos números de cópias de genes rrs através de qPCR. Em conclusão, o protocolo de higiene oral desenvolvido pelos cirurgiões dentistas foi capaz de reduzir a incidência de PAV na UTI, embora não tenha sido capaz de prevenir a colonização da mucosa oral por supostos patógenos microbianos. O protocolo de higiene oral com a participação ativa dos cirurgiões dentistas foi bem aceito pelos profissionais da UTI e foi capaz de melhorar a qualidade da assistência aos pacientes críticos.