In Vitro Evaluation of an Active Heat-and-Moisture Exchanger: The Hygrovent Gold

BACKGROUND: To improve the heat and humidification that can be achieved with aheat-and-moisture exchanger (HME),a hybrid active (ie,adds heat and water) HME,the Hygrovent Gold,was developed. We evaluated in vitro the performance of theHygrovent Gold. METHODS: We tested the Hygrovent Gold (with and without its supplemental heat andmoisture options activated),the Hygrobac,and the Hygrovent S. We measured theabsolute humidity,using a test lung ventilated at minute volumes of 5,10,and15 L/min,in normothermic (expired temperature 34 degrees C) and hypothermic(expired temperature 28 degrees C) conditions. We also measured the HMEs' flowresistance and weight after 24 h and 48 h. RESULTS: In its active mode the Hygrovent Gold provided the highest absolutehumidity,independent of minute volume,in both normothermia and hypothermia. Therespective normothermia and hypothermia absolute humidity values at 10 L/min were36.3 + 1.3 mg/L and 27.1 + 1.0 mg/L with the active Hygrovent Gold,33.9 + 0.5mg/L and 24.2 + 0.8 mg/L with the passive Hygrovent Gold,33.8 + 0.56 mg/L and24.4 + 0.4 mg/L with the Hygrobac,and 33.9 + 0.8 mg/L and 24.6 + 0.6 mg/L withthe Hygrovent S. The efficiency of the tested HMEs did not change over time. At24 h and 48 h the increase in weight and flow resistance was highest in theactive Hygrovent Gold. CONCLUSIONS: The passive Hygrovent Gold provided adequate heat and moisture innormothermia,but the active Hygrovent Gold provided the highest humidity,inboth normothermia and hypothermia

Exercise Intervention to Improve Functional Capacity in Older Adults After Acute Coronary Syndrome

More than one-half of patients admitted for acute coronary syndrome (ACS) are age $70 years. Mobility limitations and sedentary behavior are common in older ACS patients and contribute to high risk of recurrence and mortality (1). Although older ACS patients may benefit the most from participation in exercise-based cardiac rehabilitation/secondary prevention programs (CR/SP), they are less likely to participate in such programs (2). Whether an early, individualized, and low-cost physical activity (PA) intervention including a few supervised sessions and a home-based program might be feasible and effective for improving functional capacity in this high-risk and undertreated population is unknown. The HULK (Physical Activity Intervention for Patients With Reduced Physical Performance After Acute Coronary Syndrome; NCT03021044) trial is a multicenter, randomized clinical trial. A detailed study outline and statistical plan have been previously published (3). Inclusion criteria were age$70 years, hospitalization for ACS, and Short Physical Performance Battery (SPPB) score between 4 and 9 at the inclusion visit (30 5 days after hospital discharge). The SPPB is a scale that combines gait speed, chair stand, and balance tests. It ranges from 0 (worst) to 12 (best) and has predictive validity for mortality (4). Participants were randomized to usual care and health education (control group) or usual care and PA intervention (intervention group). The control group received a 20-min session and a detailed brochure stressing the importance of PA in cardiovascular health. The PA intervention consisted of four supervised sessions (1, 2, 3, and 4 months after hospital discharge), combined with an individualized home-based PA program. Centerbased sessions included a moderate standardized treadmill-walk, strength, and balance exercises (3). After the practice sessions, patients received a tailored PA home program (3). Weekly energy expenditure from PA was determined by a selfreported 7-day physical activity recall (kcal/week), and objectively measured by wearing an accelerometer (min/week). The primary endpoint was the 6- month SPPB. Secondary endpoints were 1-year SPPB and time engaged in PA. From January 2017 to April 2018, 235 patients were randomized (n ¼ 117, control group; n ¼ 118, intervention group). The median age was 76 (interquartile range [IQR]: 73 to 81) years, and 23% were female. Before the hospitalization, light and moderateintensive PA was performed by 66% and 14% of patients, respectively. Baseline characteristics, as well as baseline SPPB value (Figure 1), did not differ between groups. The adherence rates of the PA intervention group to the 1-, 2-, 3-, and 4-month scheduled supervised sessions were 100%, 89%, 85%, and 72%, respectively. The time engaged in PA progressively and significantly increased in the intervention group (Figure 1). At 6 months, the SPPB score was significantly higher in the intervention group (median: 9 [IQR: 8 to 11] vs. 7 [IQR: 5 to 8]; p < 0.001) (Figure 1). This improvement was supported by a significant increase in SPPB components of walking and chair rise (balance remained unchanged). The number of patients showing an increase of at least 1 point in SPPB score was 86 (74%) in the intervention group versus 46 (40%) in the control group (p < 0.001). The SPPB increase was maintained at the 1-year visit (Figure 1) and independent of sex and educational status. Typical CR/SP includes 3 weekly supervised exercise and educational sessions for 12 weeks. Despite the health benefits associated with these interventions, few eligible patients are referred or complete such programs (1). Our novel PA intervention was designed to address this issue. The attendance rate was high (72% [95% confidence interval: 64% to 80%]). The average weekly energy expenditure from PA in the intervention group increased 3.4 times, and SPPB score showed a mean increment of 2.0 points. This finding is notable given that an SPPB improvement of 1.0 point is generally considered a substantial clinically meaningful change (2). In addition, despite the absence of supervised sessions after the sixth month, the achievements were maintained until 1-year visit. If confirmed in future studies, our PA intervention model might help to mitigate the challenges related to limited health care resources and might increase the number of older adults receiving CR/SP

A moderate 500-m treadmill walk for estimating peak oxygen uptake in men with NYHA class I-II heart failure and reduced left ventricular ejection fraction

Background: Maximal cardiopulmonary exercise testing (CPX) is the gold-standard for cardiorespiratory fitness assessment in chronic heart failure (CHF) patients. However, high costs, required medical supervision, and safety concerns make maximal exercise testing impractical for evaluating mobility-impaired adults. Thus, several submaximal walking protocols have been developed and currently used to estimate peak oxygen consumption (VO(2)peak)in CHF patients. However, these tests have to be performed at close to maximum exercise intensity. The aim of this study was to examine the validity of a 500-m treadmill-walking test carried out at moderate intensity for estimating VO(2)peak in community-dwelling adult and elderly patients with CHF and reduced left ventricular ejection fraction (HFrEF).Methods: Forty-three clinically stable men with HFrEF (age 67.7 +/- 9.2 years, and left ventricular ejection fraction, LVEF 38% +/- 6%) underwent exercise testing during an outpatient cardiac rehabilitation/secondary prevention program. Each patients completed a CPX, and a moderate and self-paced (11-13/20 on the Borg scale) 500-m treadmill-walking test. Age, weight, height, walk time, and heart rate during the 500-m test were entered into prediction equations previously validated for VO(2)peak estimation from a 1000-m walking test in patients with cardiovascular disease and preserved LVEF.Results: Directly measured and estimated VO(2)peak values were not different (21.6 +/- 4.9 vs 21.7 +/- 4.6 mL/kg/min). The comparison between measured and estimated VO(2)peak values yielded a correlation of R = 0.97 (SEE = 0.7 mL/kg/min, P < 0.0001). The slope and the intercept coincided with the line of identity (Passing and Bablock analysis, P = 0.50). Residuals were normally distributed, and the examination of the Bland-Altman analysis do not show systematic or proportional error.Conclusions: A moderate and self-regulated 500-m treadmill-walking test is a valid tool for VO(2)peak estimation in patients with HFrEF. These findings may have practical implications in the context of transitioning from clinically based programs to fitness facilities or self-guided exercise programs in adults and elderly men with HFrEF

In vitro and in vivo evaluation of a new active heat moisture exchanger.

INTRODUCTION: In order to improve the efficiency of heat moisture exchangers (HMEs), new hybrid humidifiers (active HMEs) that add water and heat to HMEs have been developed. In this study we evaluated the efficiency, both in vitro and in vivo, of a new active HME (the Performer; StarMed, Mirandola, Italy) as compared with that of existing HMEs (Hygroster and Hygrobac; Mallinckrodt, Mirandola, Italy). METHODS: We tested the efficiency by measuring the temperature and absolute humidity (AH) in vitro using a test lung ventilated at three levels of minute ventilation (5, 10 and 15 l/min) and at two tidal volumes (0.5 and 1 l), and in vivo in 42 patients with acute lung injury (arterial oxygen tension/fractional inspired oxygen ratio 283 +/- 72 mmHg). We also evaluated the efficiency in vivo after 12 hours. RESULTS: In vitro, passive Performer and Hygrobac had higher airway temperature and AH (29.2 +/- 0.7 degrees C and 29.2 +/- 0.5 degrees C, [P < 0.05]; AH: 28.9 +/- 1.6 mgH2O/l and 28.1 +/- 0.8 mgH2O/l, [P < 0.05]) than did Hygroster (airway temperature: 28.1 +/- 0.3 degrees C [P < 0.05]; AH: 27 +/- 1.2 mgH2O/l [P < 0.05]). Both devices suffered a loss of efficiency at the highest minute ventilation and tidal volume, and at the lowest minute ventilation. Active Performer had higher airway temperature and AH (31.9 +/- 0.3 degrees C and 34.3 +/- 0.6 mgH2O/l; [P < 0.05]) than did Hygrobac and Hygroster, and was not influenced by minute ventilation or tidal volume. In vivo, the efficiency of passive Performer was similar to that of Hygrobac but better than Hygroster, whereas Active Performer was better than both. The active Performer exhibited good efficiency when used for up to 12 hours in vivo. CONCLUSION: This study showed that active Performer may provide adequate conditioning of inspired gases, both as a passive and as an active device

Physical activity intervention for elderly patients with reduced physical performance after acute coronary syndrome (HULK study): Rationale and design of a randomized clinical trial

Background: Reduced physical performance and impaired mobility are common in elderly patients after acute coronary syndrome (ACS) and they represent independent risk factors for disability, morbidity, hospital readmission and mortality. Regular physical exercise represents a means for improving functional capacity. Nevertheless, its clinical benefit has been less investigated in elderly patients in the early phase after ACS. The HULK trial aims to investigate the clinical benefit of an early, tailored low-cost physical activity intervention in comparison to standard of care in elderly ACS patients with reduced physical performance. Design: HULK is an investigator-initiated, prospective multicenter randomized controlled trial (NCT03021044). After successful management of the ACS acute phase and uneventful first 1 month, elderly (≥70 years) patients showing reduced physical performance are randomized (1:1 ratio) to either standard of care or physical activity intervention. Reduced physical performance is defined as a short physical performance battery (SPPB) score of 4-9. The early, tailored, low-cost physical intervention includes 4 sessions of physical activity with a supervisor and an home-based program of physical exercise. The chosen primary endpoint is the 6-month SPPB value. Secondary endpoints briefly include quality of life, on-treatment platelet reactivity, some laboratory data and clinical adverse events. To demonstrate an increase of at least one SPPB point in the experimental arm, a sample size of 226 patients is needed. Conclusions: The HULK study will test the hypothesis that an early, tailored low-cost physical activity intervention improves physical performance, quality of life, frailty status and outcome in elderly ACS patients with reduced physical performance

Protective Mechanical Ventilation during General Anesthesia for Open Abdominal Surgery Improves Postoperative Pulmonary Function

BACKGROUND:: The impact of intraoperative ventilation on postoperative pulmonary complications is not defined. The authors aimed at determining the effectiveness of protective mechanical ventilation during open abdominal surgery on a modified Clinical Pulmonary Infection Score as primary outcome and postoperative pulmonary function. METHODS:: Prospective randomized, open-label, clinical trial performed in 56 patients scheduled to undergo elective open abdominal surgery lasting more than 2 h. Patients were assigned by envelopes to mechanical ventilation with tidal volume of 9 ml/kg ideal body weight and zero-positive end-expiratory pressure (standard ventilation strategy) or tidal volumes of 7 ml/kg ideal body weight, 10 cm H2O positive end-expiratory pressure, and recruitment maneuvers (protective ventilation strategy). Modified Clinical Pulmonary Infection Score, gas exchange, and pulmonary functional tests were measured preoperatively, as well as at days 1, 3, and 5 after surgery. RESULTS:: Patients ventilated protectively showed better pulmonary functional tests up to day 5, fewer alterations on chest x-ray up to day 3 and higher arterial oxygenation in air at days 1, 3, and 5 (mmHg; mean \ub1 SD): 77.1 \ub1 13.0 versus 64.9 \ub1 11.3 (P = 0.0006), 80.5 \ub1 10.1 versus 69.7 \ub1 9.3 (P = 0.0002), and 82.1 \ub1 10.7 versus 78.5 \ub1 21.7 (P = 0.44) respectively. The modified Clinical Pulmonary Infection Score was lower in the protective ventilation strategy at days 1 and 3. The percentage of patients in hospital at day 28 after surgery was not different between groups (7 vs. 15% respectively, P = 0.42). CONCLUSION:: A protective ventilation strategy during abdominal surgery lasting more than 2 h improved respiratory function and reduced the modified Clinical Pulmonary Infection Score without affecting length of hospital stay

Incidence of thyroid cancer in Italian contaminated sites

Some human literature suggests a possible role of endocrine disruptors (EDs) exposure in thyroid cancer (TC) development. We investigated TC incidence in selected Italian National Priority Contaminated Sites (NPCS) with documented presence of EDs considered thyroid carcinogens. Adjusted Standardized Incidence Ratios (SIRs), with their 90% confidence intervals, were computed by gender, and age-specific groups (aged 15-39 years, and 40 years or over) for each NPCS in the period 2006 to 2013. In the age group of 15-39 years, a significant excess of TC risk was found in two NPCSs in males; non-significant excess risks were observed in four NPCSs in males, and in five in females. In the age group of 40 years and over, significant excess risks were found in six NPCSs in males and in seven NPCSs in females; non-significant excess risks were identified in two NPCSs in males and females. The findings of several excesses in incidence, mainly observed in adults aged 40 years or over, are suggestive of a possible adverse effect associated with residence in NPCSs, even if a role of other factors cannot be excluded, due to the adoption of an ecological study design. Future analytical studies are needed to clarify if EDs are a TC risk factor for individuals living in NPCSs

Worldwide trends in population-based survival for children, adolescents, and young adults diagnosed with leukaemia, by subtype, during 2000–14 (CONCORD-3) : analysis of individual data from 258 cancer registries in 61 countries

Background Leukaemias comprise a heterogenous group of haematological malignancies. In CONCORD-3, we analysed data for children (aged 0–14 years) and adults (aged 15–99 years) diagnosed with a haematological malignancy during 2000–14 in 61 countries. Here, we aimed to examine worldwide trends in survival from leukaemia, by age and morphology, in young patients (aged 0–24 years). Methods We analysed data from 258 population-based cancer registries in 61 countries participating in CONCORD-3 that submitted data on patients diagnosed with leukaemia. We grouped patients by age as children (0–14 years), adolescents (15–19 years), and young adults (20–24 years). We categorised leukaemia subtypes according to the International Classification of Childhood Cancer (ICCC-3), updated with International Classification of Diseases for Oncology, third edition (ICD-O-3) codes. We estimated 5-year net survival by age and morphology, with 95% CIs, using the non-parametric Pohar-Perme estimator. To control for background mortality, we used life tables by country or region, single year of age, single calendar year and sex, and, where possible, by race or ethnicity. All-age survival estimates were standardised to the marginal distribution of young people with leukaemia included in the analysis. Findings 164563 young people were included in this analysis: 121328 (73·7%) children, 22963 (14·0%) adolescents, and 20272 (12·3%) young adults. In 2010–14, the most common subtypes were lymphoid leukaemia (28205 [68·2%] patients) and acute myeloid leukaemia (7863 [19·0%] patients). Age-standardised 5-year net survival in children, adolescents, and young adults for all leukaemias combined during 2010–14 varied widely, ranging from 46% in Mexico to more than 85% in Canada, Cyprus, Belgium, Denmark, Finland, and Australia. Individuals with lymphoid leukaemia had better age-standardised survival (from 43% in Ecuador to ≥80% in parts of Europe, North America, Oceania, and Asia) than those with acute myeloid leukaemia (from 32% in Peru to ≥70% in most high-income countries in Europe, North America, and Oceania). Throughout 2000–14, survival from all leukaemias combined remained consistently higher for children than adolescents and young adults, and minimal improvement was seen for adolescents and young adults in most countries. Interpretation This study offers the first worldwide picture of population-based survival from leukaemia in children, adolescents, and young adults. Adolescents and young adults diagnosed with leukaemia continue to have lower survival than children. Trends in survival from leukaemia for adolescents and young adults are important indicators of the quality of cancer management in this age group.peer-reviewe