Three-dimensional echocardiography and 2D-3D speckle tracking imaging in chronic pulmonary hypertension. diagnostic accuracy in detecting hemodynamic signs of RV failure

Background and objective. Our aim was to compare three-dimensional (3D) and 2D and 3D speckle tracking (2D-STE, 3D-STE) echocardiographic parameters with conventional right ventricular (RV) indexes in patients with chronic pulmonary hypertension (PH), and investigate whether these techniques could result in better correlation with hemodynamic variables indicative of heart failure. Methods. Seventy-three adult patients (mean age, 53±13 years; 44% male) with chronic PH of different etiologies were studied by echocardiography and cardiac catheterization (25 precapillary PH from pulmonary arterial hypertension, 23 obstructive pulmonary heart disease, and 23 postcapillary PH from mitral regurgitation). Thirty healthy subjects (mean age, 54±15 years; 43% male) served as controls. Standard 2D measurements (RV-FAC -fractional area change-, TAPSE -tricuspid annular plane systolic excursion-) and mitral and tricuspid tissue Doppler annular velocities were obtained. RV 3D volumes, and global and regional ejection fraction (3D-RVEF) were determined. RV strains were calculated by 2D-STE and 3D-STE. Results. RV 3D global-free-wall longitudinal strain (3DGFW-RVLS), 2D global-free-wall longitudinal strain (GFW-RVLS), apical-free-wall longitudinal strain (AFW-RVLS), basal-free-wall longitudinal strain (BFW-RVLS), and 3D-RVEF were lower in patients with pre-capillary PH (p<0.0001) and post-capillary PH (p<0.01) compared to controls. 3DGFW-RVLS (HR 4.6, 95% CI 2.79-8.38, p=0.004) and 3D-RVEF (HR 5.3, 95% CI 2.85-9.89, p=0.002) were independent predictors of mortality. ROC curves showed that the thresholds offering an adequate compromise between sensitivity and specificity for detecting hemodynamic signs of RV failure were 39% for 3D-RVEF (AUC 0.89), -17% for 3DGFW-RVLS (AUC 0.88), -18% for GFW-RVLS (AUC 0.88), -16% for AFW-RVLS (AUC 0.85), 16mm for TAPSE (AUC 0.67), and 38% for RV-FAC (AUC 0.62). Conclusions. In chronic PH, 3D, 2D-STE and 3D-STE parameters indicate global and regional RV dysfunction that is associated with RV failure hemodynamics better than conventional echo indices

The fertilising potential of manure-based biogas fermentation residues: pelleted vs. liquid digestate

Spreading of manure on agricultural soils is a main source of ammonia emissions and/or nitrate leaching. It has been addressed by the European Union with the Directives 2001/81/EC and 91/676/EEC to protect the environment and the human health. The disposal of manure has therefore become an economic and environmental challenge for farmers. Thus, the conversion of manure via anaerobic digestion in a biogas plant could be a sustainable solution, having the byproducts (solid and liquid digestates) the potential to be used as fertilizers for crops. This work aimed at characterizing and assessing the effect of digestates obtained from a local biogas plant (Biogas Wipptal, Gmbh), either in the form of liquid fraction or as a solid pellet on: (i) the fertility of the soils during an incubation experiment; (ii) the plant growth and nutritional status of different species (maize and cucumber). Moreover, an extensive characterization of the pellet was performed via X-ray microanalytical techniques. The data obtained showed that both digestates exhibit a fertilizing potential for crops, depending on the plant species and the fertilizer dose: the liquid fraction increases the shoot fresh weight at low dose in cucumber, conversely, the solid pellet increases the shoot fresh weight at high dose in maize. The liquid digestate may have the advantage to release nutrients (i.e. nitrogen) more rapidly to plants, but its storage represents the main constraint (i.e. ammonia volatilization). Indeed, pelleting the digestates could improve the storability of the fertilizer besides enhancing plant nutrient availability (i.e. phosphate and potassium), plant biomass and soil biochemical quality (i.e. microbial biomass and activity). The physical structure and chemical composition of pellet digestates allow nutrients to be easily mobilized over time, representing a possible source of mineral nutrients also in long-term applications

Standards of care and clinical predictors in patients hospitalised for a COPD exacerbation - The Italian SOS (Stratification Observational Study)

Background and aims. Hospitalisations for chronic obstructive pulmonary disease (COPD) exacerbations are major events in the natural history of the disease in terms of survival, quality of life and risk of further episodes of exacerbation. The aims of study were to evaluate: 1. adherence to recommended standards of care; and 2. clinical factors influencing major outcomes during hospitalisation for an episode of COPD exacerbation and within a 6-month follow-up. Methods. An observational, prospective study was conducted in 68 centres. Assessment of standards of care included diagnostic procedures (such as pulmonary function tests and microbiology) and management options (such as drug therapies, vaccinations and rehabilitation). Outcome measures relevant to the hospitalisation were: survival, need for mechanical ventilation, and length of stay (LOS). Outcomes at 6-months were: survival, exacerbations and hospitalisations for an exacerbation. Multivariate logistic regression was applied to evaluate the relation between clinical factors and outcomes. Results. 931 patients were enrolled. Only 556 patients (59.7%) were diagnosed COPD and stratified for severity with the support of spirometry (FEV1/VC ≤0.7) and were considered for outcome analysis. Among treatments, pulmonary rehabilitation and anti-smoking counselling were applied infrequently (14.5 and 8.1% of patients, respectively). Within six months 63 COPD patients (17.7%) had at least one episode of exacerbation prompting a further hospitalisation and 19 died (5.3%). Predictor of mortality was the co-morbidity Charlson index (odds ratio, OR 10.3, p=0.03 CI:1.25-84.96). A further hospitalisation was predicted by hospitalisation for an exacerbation in the previous 12 months (OR 3.59, p=0.003 CI:1.54-8.39). Conclusions. Standards of care were far lower than recommended, in particular 40% of patients were labelled as COPD without spirometry. COPD patients with a second hospitalisation in 12 months for an exacerbation had about 3 times the risk of suffering a new episode and hospitalisation in the following six months

Roflumilast in moderate-to-severe chronic obstructive pulmonary disease treated with longacting bronchodilators: two randomised clinical trials

Background Patients with chronic obstructive pulmonary disease (COPD) have few options for treatment. The efficacy and safety of the phosphodiesterase-4 inhibitor roflumilast have been investigated in studies of patients with moderate-to-severe COPD, but not in those concomitantly treated with longacting inhaled bronchodilators. The effect of roflumilast on lung function in patients with COPD that is moderate to severe who are already being treated with salmeterol or tiotropium was investigated. Methods In two double-blind, multicentre studies done in an outpatient setting, after a 4-week run-in, patients older than 40 years with moderate-to-severe COPD were randomly assigned to oral roflumilast 500 mu g or placebo once a day for 24 weeks, in addition to salmeterol (M2-127 study) or tiotropium (M2-128 study). The primary endpoint was change in prebronchodilator forced expiratory volume in 1s (FEV(1)). Analysis was by intention to treat. The studies are registered with ClinicalTrials.gov, number NCT00313209 for M2-127, and NCT00424268 for M2-128. Findings In the salmeterol plus roflumilast trial, 466 patients were assigned to and treated with roflumilast and 467 with placebo; in the tiotropium plus roflumilast trial, 371 patients were assigned to and treated with roflumilast and 372 with placebo. Compared with placebo, roflumilast consistently improved mean prebronchodilator FEV(1) by 49 mL (p<0.0001) in patients treated with salmeterol, and 80 mL (p<0.0001) in those treated with tiotropium. Similar improvement in postbronchodilator FEV(1) was noted in both groups. Furthermore, roflumilast had beneficial effects on other lung function measurements and on selected patient-reported outcomes in both groups. Nausea, diarrhoea, weight loss, and, to a lesser extent, headache were more frequent in patients in the roflumilast groups. These adverse events were associated with increased patient withdrawal. Interpretation Roflumilast improves lung function in patients with COPD treated with salmeterol or tiotropium, and could become an important treatment for these patients

Fluticasone furoate/Vilanterol 92/22 μg once-a-day vs Beclomethasone dipropionate/Formoterol 100/6 μg b.i.d. in asthma patients: a 12-week pilot study

Two of the most recent LABA/ICS combinations for treatment of persistent asthma are Fluticasone furoate/Vilanterol 92/22 &micro;g (Ellipta) and Beclomethasone dipropionate/Formoterol 100/6 &micro;g (Nexthaler). Objective: To compare once-daily Fluticasone/ Vilanterol combination with twice daily Beclomethasone/ Formoterol association in moderate asthma, in terms of quality of life and lung function. Methods: Fourty patients with moderate asthma treated with Beclomethasone/Formoterol 100/6 &micro;g or Fluticasone/Vilanterol 92/22 &micro;g. We revalued patients in terms of lung function and Asthma Control Test, at 4, 8 and 12 weeks to assess any differences between the two groups. After 4 weeks, thirty-one of the fourty patients were evaluated in terms of respiratory function at predetermined time intervals. Result: In patients treated with beclomethasone/formoterol FEV1 presented a mean value of 78% at the third visit and of 79.1% during the final check, compared with 74.5% and to 75.8% in patients in treatment with fluticasone/vilanterol (p 0.01). Mean values of IC and MMEF25-75% were higher in patients treated with beclomethasone/formoterol compared with fluticasone/vilanterol. For the dyspnea it was a difference at the third observation. For the nocturnal symptoms and the use of rescue drug there was a significant difference, except at the beginning. For the perception of control by patients, there was a difference in the two groups at the beginning, after 4 and 8 weeks. Total ACT score showed a significant difference after 4, 8 and 12 weeks. In the group treated with beclomethasone/formoterol FEV1 value was significantly higher at a distance of four hours after drug administration (p 0.04) and after the second dose (p 0.02) compared with the group treated with fluticasone/vilanterol. Discussion: Patients in treatment with beclomethasone/formoterol showed improved asthma control and nocturnal symptoms and more stable respiratory function compared with patients receiving fluticasone/vilanterol

Do we have two hearts? New insights in right ventricular function supported by myocardial imaging echocardiography

RV performance is difficult to evaluate, given its geometry, interrelationship with the left ventricle, and sensitivity to alterations in pulmonary pressure. This article focuses on some of the challenges related to the assessment of RV function in the setting of the RV's unique anatomic, physiologic, conventional and newer echocardiographic aspects, and therapeutic implications. The majority of proposed methods of echocardiographic assessment of RV function are based on volumetric approximations of the RV. Such approaches have inherent limitations, first as volume-related measures such as EF are load dependent, second because of the complex geometry of the RV. The issue of RV geometry is usually overcome using geometry-independent parameters such as tricuspid annular excursion and the Tei index. The recent introduction of real-time three-dimensional echocardiography and myocardial imaging echocardiography (tissue Doppler imaging, 1D-strain and 2D-strain echocardiography) implied a great progress in echocardiography. Tissue Doppler imaging allows the quantitative assessment of RV systolic and diastolic function by means of measurement of myocardial velocities. Strain measurements have been shown to correlate well with sonomicrometry segment length measurements both in the inflow and outflow tract of the RV and under different loading conditions. Other findings have been reported in chronic and acute clinical settings. Standard and novel echocardiographic methods of assessment of RV size and performance can help clinicians in the treatment of acute and chronic RV failure and contribute to a better understanding of the peculiar chamber-related functional mechanisms in the context of ventricular interdependent independency