Overview of reviews: Mechanical interventions for the treatment and management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterized by a progressive and non‐reversible airflow limitation and symptoms of breathlessness, sputum production and cough. COPD is the fourth most common cause of mortality worldwide and represents a significant social and economic burden. As such, effective strategies that might be employed to treat COPD and manage symptoms need to be investigated. This overview aimed to summarize the existing evidence available in the Cochrane Library regarding the use of mechanical interventions used for the treatment and management of COPD. Systematic reviews that included adult participants with diagnosed COPD who received a mechanical intervention were included. Five reviews were included, and due to the heterogeneity of these reviews, direct and indirect comparisons of the effects of the intervention were not possible. Instead, data of the effectiveness of each intervention were extracted and summarized in tables and discussed as a narrative summary. Interventions included non‐invasive positive pressure ventilation (NPPV), positive airway pressure (PEP) devices and neuromuscular electrical stimulation (NMES). Evidence regarding the effectiveness of NPPV was limited, and available data do not support the use of NPPV for patients with stable COPD. NPPV might, however, be of benefit as a weaning strategy for intubated patients and for patients experiencing respiratory failure; however, more research is required. Although PEP devices are considered as a safe airway clearance technique, data do not reveal a clear clinical benefit to their use. NMES is also regarded as safe for patients with COPD, and might also be beneficial in improving exercise tolerance and improving quality of life for patients with COPD.     

Sarcopenia in COPD: relationship with COPD severity and prognosis

Objective:

To evaluate the prevalence of sarcopenia in COPD patients, as well as to determine whether sarcopenia correlates with the severity and prognosis of COPD.

Methods:

A cross-sectional study with COPD patients followed at the pulmonary outpatient clinic of our institution. The patients underwent dual-energy X-ray absorptiometry. The diagnosis of sarcopenia was made on the basis of the skeletal muscle index, defined as appendicular lean mass/height² only for low-weight subjects and adjusted for fat mass in normal/overweight subjects. Disease severity (COPD stage) was evaluated with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The degree of obstruction and prognosis were determined by the Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity (BODE) index.

Results:

We recruited 91 patients (50 females), with a mean age of 67.4 ± 8.7 years and a mean BMI of 25.8 ± 6.1 kg/m². Sarcopenia was observed in 36 (39.6%) of the patients, with no differences related to gender, age, or smoking status. Sarcopenia was not associated with the GOLD stage or with FEV₁ (used as an indicator of the degree of obstruction). The BMI, percentage of body fat, and total lean mass were lower in the patients with sarcopenia than in those without (p < 0.001). Sarcopenia was more prevalent among the patients in BODE quartile 3 or 4 than among those in BODE quartile 1 or 2 (p = 0.009). The multivariate analysis showed that the BODE quartile was significantly associated with sarcopenia, regardless of age, gender, smoking status, and GOLD stage.

Conclusions:

In COPD patients, sarcopenia appears to be associated with unfavorable changes in body composition and with a poor prognosis.     

CLINICAL PROGNOSTIC FACTORS FOR PATIENTS WITH ANTERIOR KNEE PAIN IN PHYSICAL THERAPY; A SYSTEMATIC REVIEW

Background

Although many authors have studied the prognostic factors that may contribute to anterior knee pain, synthesis of the existing evidence has not been performed.

Purpose

The purpose of this systematic review is to summarize and examine existing prognostic models in patients with anterior knee pain that first present to physical therapists (primary care setting).

Design

Systematic review

Method

For this review Pubmed, Embase and Cinahl databases were searched and published papers that reported prognostic models for patients with anterior knee pain that first present to physical therapists (primary care setting) were selected. The authors extracted and summarized the univariate and multivariate predictors and evaluated which predictors consistently appeared to be relevant to pain, function, or recovery.

Results

Nine studies were included. The quality scores of these studies ranged from 9 to 17 positive items out of 21 items included in the assessment for quality. None of the prognostic models were validated internally or externally. Four studies were considered to be of sufficient quality. The authors of these four studies found 14 different predictors significantly related to pain intensity of which seven with limited evidence. Fifteen different predictors were found that were related to function of which seven with limited evidence. Furthermore, strong evidence was found that baseline pain intensity, pain coping and kinesiophobia are of no predictive value for pain, and activity related pain, pain coping and kinesiophobia are of no predictive value for function at follow up.

Conclusions

Because of the low quality of a number of studies and the heterogeneity of the examined variables and outcome measures of most of the studies, only limited evidence for seven predictors related to pain and seven predictors related to function in patients with anterior knee pain in a primary care setting was found.

Level of Evidence

1b     

Purification of eosinophil peroxidase and studies of biosynthesis and processing in human marrow cells

Human eosinophil peroxidase (EPO) was purified from leukocytes obtained from a patient with hypereosinophilia. EPO was extracted from the granule fraction using 0.2 mol/L sodium acetate pH 4.0, and the extract was subjected to gel chromatography on Sephadex G-75 and ion exchange chromatography on Biorex 70. The mol wt calculated from gel chromatography was approximately 50,000. However, under reducing and denaturing conditions, polyacrylamide gel electrophoresis revealed two subunits with mol wt of 50,000 and 15,000. The biosynthesis of EPO was studied in marrow cells from patients with eosinophilia using labeling with (14C)-leucine, followed by immunoprecipitation with anti-EPO, sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and fluorography for visualization of labeled EPO. Biosynthesis of an Mr 53,000 subunit was demonstrated. Biosynthetic labeling of the Mr 15,000 subunit was not demonstrated. A labeled Mr 25,000 chain was detected and may represent a degradation product or a chain that, after further modification, produces the Mr 15,000 subunit. Labeling was also detected in two polypeptides with mol wt of 78,000 and 72,000. These forms of EPO seem to represent precursor polypeptides subjected to proteolytic processing in a similar manner as has been reported for myeloperoxidase (MPO). However, Monensin, a proton ionophore, which blocks the processing of MPO, did not inhibit processing of EPO, indicating separate mechanisms by which MPO and EPO are directed to granules.     

Intratubular disinfection with tri-antibiotic and calcium hydroxide pastes

Objective: The aim of this study was to compare the in vitro intradentinal antimicrobial ability of the calcium hydroxide and tri-antibiotic pastes.

Materials and methods: Standard bovine dentin tubes were sterilized and then infected with Enterococcus faecalis by a new contamination protocol of great depths of dentin. The specimens were filled with the medications, divided into two test-groups: calcium hydroxide (Group 1) and tri-antibiotic (Group 2) pastes. After 15 days, the teeth were evaluated by microbiological culture and confocal laser scanning microscopy (CLSM) with viability dye assay LIVE/DEAD inside dentinal tubules. In experiment of culture, the bacterial collection of the dentin fragments was done for counting the colony-forming units.

Results: The tri-antibiotic paste had a slightly greater antimicrobial effect; however, there was no statistical difference between the groups.

Conclusions: It was concluded that the tri-antibiotic paste and the calcium hydroxide paste exercise the same effect on intra-tubular decontamination against E. faecalis. So, due the multiples advantages, the calcium hydroxide paste can be the choice for dentinal decontamination in regenerative procedures.     

Rhinoscleroma: a detailed histopathological diagnostic insight

Rhinoscleroma (RS) is a chronic specific disease of nose and upper respiratory passages caused by Klebsiella rhinoscleromatis bacilli. It is endemic in Egypt and in sporadic areas worldwide. Diagnosis of RS depends on identification of the pathognomonic Mickulicz cells (MCs) which is most prominent during granulomatous phase but spares or absent during catarrhal or sclerotic phases of the disease. This study aimed to identify the potential diagnostic features of nasal RS when MCs are absent. Nasal biopsies from 125 patients complaining of chronic nasal symptoms were retrieved for this study; including 72 chronic non specific inflammatory lesions and 53 RS diagnosed by PAS and Geimsa stains. The detailed histological differences among the two groups were measured statistically. RS was frequently a bilateral disease (P < 0.05) of young age (P < 0.001) with a female predominance (P < 0.05) and usually associated with nasal crustations (P < 0.001). Five strong histological indicators of RS were specified by univariate binary logistic regression analyses including squamous metaplasia (OR 27.2, P < 0.0001), dominance of plasma cells (OR 12.75, P < 0.0001), Russell bodies (OR 8.83, P < 0.0001), neutrophiles (OR 3.7, P < 0.001) and absence of oesinophiles (OR 12.0, P < 0.0001). According to Multivariate analysis, the diagnostic features of RS in absence of MCs can be classified into major criteria including dominance of plasma cells infiltration and absence of oesinophiles and minor criteria including young age, female gender, bilateral nasal involvement, nasal crustation, squamous metaplasia, Russell bodies, and neutrophiles. The diagnostic model using the two major criteria confirmed or excluded RS in 84.3% of the investigated cases.     

Advantages and Risks of Husbandry and Housing Changes to Improve Animal Wellbeing in a Breeding Colony of Common Marmosets (Callithrix jacchus)

Between 1975 and 2014, housing conditions for laboratory-housed marmosets changed dramatically after the introduction of new guidelines designed to improve their care and wellbeing. According to these guidelines, our facility provided marmosets with outside enclosures, switched to deep litter as bedding material, and discontinued the use of disinfectant agents in animal enclosures. However, both deep litter and access to outside enclosures hypothetically increase the risk of potential exposure to pathogenic microorganisms. We evaluated whether these housing and husbandry modifications constituted an increased veterinary risk for laboratory-housed common marmosets (Callithrix jacchus). After the animals had been exposed to these new housing conditions for 2.5 y, we examined their intestinal bacterial flora and feces, the deep litter, and insects present in the housing. In addition, we assessed the marmosets’ general health and the effect of outdoor housing on, for example, vitamin D levels. Although numerous bacterial strains—from nonpathogenic to potentially pathogenic—were cultured, we noted no increase in illness, mortality, or breeding problems related to this environmental microflora. Housing laboratory marmosets in large enriched cages, with both indoor and outdoor enclosures, providing them with deep litter, and eliminating the use of disinfectants present an increased veterinary risk. However, after evaluating all of the collected data, we estimate that the veterinary risk of the new housing conditions is minimal to none in terms of clinical disease, disease outbreaks, abnormal behavior, and negative effects on reproduction.The Biomedical Primate Research Centre (Rijswijk, The Netherlands) houses a self-sustaining breeding colony of common marmosets (Callithrix jacchus) for the purpose of conducting biomedical research on life-threatening human diseases. The marmoset colony was formed in 1975 and has been used mainly for research on autoimmune diseases, neurodegenerative disorders, and comparative genetics.^{3,5,6,14,21,29}After the introduction of new European and Dutch guidelines regarding animal care and welfare, animal housing conditions changed markedly between 1975 and 2014. Our facility responded promptly to these new guidelines, by providing larger and more complex cages comprising outdoor enclosures, each with an attached heated indoor enclosure, where the animals are housed in family groups to improve animal wellbeing.^22,35 The concept of environmental enrichment continued to be developed and optimized over the years.Potential benefits of outdoor enclosures are exposure to seasonal fluctuations in light and climate and increased sensory stimulation. These enclosures provide opportunities for exploration and manipulation that are considered to contribute positively to the animals’ wellbeing. Furthermore, marmosets housed indoors with no access to UV light are susceptible to metabolic bone diseases. Marmosets cannot synthesize vitamin D3 (cholecalciferol) from the plant form of the vitamin (ergocalciferol, vitamin D2). Without access to UVB radiation, they cannot form vitamin D3 from 7-dehydroxycholesterol in the skin.³¹ In addition to dietary supplementation with vitamin D3, we surmised that access to unfiltered sunlight in outside enclosures would limit or prevent vitamin D deficiency.Another change initiated in response to BPRC''s new housing guidelines was the cleaning of the housing facilities. Scent marking is an important aspect of the natural behavior of marmosets. In laboratory settings, marmosets scent-mark their cages constantly.¹¹ To minimize the removal of scents, disinfectants are no longer used to clean the enclosures. In addition to effects on scent, limiting disinfectant use could have other beneficial effects. For example, the chemical disinfection of their environment was suggested to be one cause of chromosomal disorders in marmosets.¹³A third important housing-related change was the provision of deep litter in the outdoor and indoor enclosures. Deep litter is a floor covering, preferably of organic origin, that promotes activities including locomotion, foraging, and playing. In general, the changes associated with providing deep litter typically involved a shift in the animals’ behavioral profiles toward those that might be observed in their wild counterparts; therefore, the provision of deep litter is seen as environmental enrichment.^{7,9,10,24,30,32}Although some of these changes have been implemented in zoos, primate centers that breed marmosets for research purposes have been more reticent because of potential health issues. To evaluate whether the new housing conditions enhance the animals’ wellbeing, we studied their benefits and potential threats to the animals, the practical consequences for personnel and management, and the influence on experimental results. In particular, the health risks for the marmosets due to increased microbiologic exposure because of the new housing conditions were examined. The aim of the study was to determine whether these changes in their housing constituted not only an improvement in their wellbeing but also a possible increased veterinary risk for laboratory-housed common marmosets.