Clusters of individuals recovering from an exacerbation of chronic obstructive pulmonary disease and response to in-hospital pulmonary rehabilitation.

INTRODUCTION AND OBJECTIVES: Due to the present low availability of pulmonary rehabilitation (PR) for individuals recovering from a COPD exacerbation (ECOPD), we need admission priority criteria. We tested the hypothesis that these individuals might be clustered according to baseline characteristics to identify subpopulations with different responses to PR. METHODS: Multicentric retrospective analysis of individuals undergone in-hospital PR. Baseline characteristics and outcome measures (six-minute walking test - 6MWT, Medical Research Council scale for dyspnoea -MRC, COPD assessment test -CAT) were used for clustering analysis. RESULTS: Data analysis of 1159 individuals showed that after program, the proportion of individuals reaching the minimal clinically important difference (MCID) was 85.0%, 86.3%, and 65.6% for CAT, MRC, and 6MWT respectively. Three clusters were found (C1-severe: 10.9%; C2-intermediate: 74.4%; C3-mild: 14.7% of cases respectively). Cluster C1-severe showed the worst conditions with the largest post PR improvements in outcome measures; C3-mild showed the least severe baseline conditions, but the smallest improvements. The proportion of participants reaching the MCID in ALL three outcome measures was significantly different among clusters, with C1-severe having the highest proportion of full success (69.0%) as compared to C2-intermediate (48.3%) and C3-mild (37.4%). Participants in C2-intermediate and C1-severe had 1.7- and 4.6-fold increases in the probability to reach the MCID in all three outcomes as compared to those in C3-mild (OR = 1.72, 95% confidence interval [95% CI] = 1.2 - 2.49, p = 0.0035 and OR = 4.57, 95% CI = 2.68 - 7.91, p < 0.0001 respectively). CONCLUSIONS: Clustering analysis can identify subpopulations of individuals recovering from ECOPD associated with different responses to PR. Our results may help in defining priority criteria based on the probability of success of PR.

Induction of cystic forms by different stress conditions in Borrelia burgdorferi.

Cystic forms of Borrelia burgdorferi might represent a low metabolic activity state or phase of B. burgdorferi cells that allows the spirochete to survive in a hostile environment until conditions are favourable to multiply again. In this study we evaluated the rate of cyst formation induced by oxidative stress, pH variations, and heating, reconversion of cysts to vegetative forms, and some aspects of their metabolic activity. We observed cyst formation in the presence of extreme pH values, and at high temperature, but the best production of cystic forms was observed in the presence of H2O2. When transferred to BSK II medium, the cystic forms reconverted to spirochetes in relation to their age and type of induction treatment. Furthermore, we demonstrated a low metabolic activity of cystic forms by measuring amino acid incorporation. Overall, these data suggest that the phenomenon of conversion to cysts by B. burgdorferi provides a limited survival potential. This short-term survival, however, gives borreliae an additional chance to overcome unfavourable environmental conditions.

Conversion of Borrelia garinii cystic forms to motile spirochetes in vivo.

Cystic forms (also called spheroplasts or starvation forms) and their ability to reconvert into normal motile spirochetes have already been demonstrated in the Borrelia burgdorferi sensu lato complex. The aim of this study was to determine whether motile B. garinii could develop from cystic forms, not only in vitro but also in vivo, in cyst-inoculated mice. The cysts prepared in distilled water were able to reconvert into normal motile spirochetes at any time during in vitro experiments, lasting one month, even after freeze-thawing of the cysts. Motile spirochetes were successfully isolated from 2 out of 15 mice inoculated intraperitoneally with cystic forms, showing the infectivity of the cysts. The demonstrated capacity of the cysts to reconvert into motile spirochetes in vivo and their surprising resistance to adverse environmental conditions should lead to further studies on the role and function of these forms in Lyme disease.

Simultaneous measurement by flow cytometry of phagocytosis and metabolic burst induced in phagocytic cells in whole blood by Borrelia burgdorferi.

This paper describes the interactions between a strain of Borrelia burgdorferi and phagocytic cells, measured in whole blood, by a two-color flow cytometric method, which allowed the simultaneous quantification of both the phagocytosis rate and the oxidative burst activation. The data obtained indicated that: a) phagocytosis and metabolic activation increased as a function of spirochete concentration; b) the number of ingesting cells peaked within 10 min but activation followed later, and did not involve all the phagocytosing cells; c) opsonization of borreliae with a patient's serum enhanced the two cellular activities, mostly phagocytosis. The intensity of such functions was lower than those found for Staphylococcus aureus. The flow cytometric assay of phagocytes interactions with Borrelia burgdorferi assessed in whole blood represents an experimental approach which simulates the physiological conditions in nature.

Oligonucleotides specific for pathogenic and saprophytic leptospira occurring in water.

Sets of primers specific for both pathogenic (SPL) and saprophytic (SSL) Leptospira were designed from ribosomal 16S genes (rrs) available in databases. They were used as two sets of primer pairs for the PCR amplification of known pathogenic and saprophytic strains. It was possible to identify pathogenic strains by the use of SPL primers and saprophytic ones by SSL primers. Serovars from L. meyeri, of controversial pathogenicity status, confirmed the heterogeneity of the species representatives in this respect. Serovars ranarum, sofia and perameles were amplified by SPL and not SSL. Conversely, serovar semaranga was amplified by SSL and not SPL. In order to use SPL primers for the detection of pathogenic leptospires from a natural water environment, we set up an additional semi-nested PCR by employing a second internal primer which succeeded in detecting as few as 5 pathogenic leptospires per ml of water.

Leptospira interrogans and Leptospira peptidoglycans induce the release of tumor necrosis factor alpha from human monocytes.

Elevated plasma concentrations of the cytokine tumor necrosis factor alpha (TNF alpha) have been observed in patients affected by leptospirosis. In this study we found that a preparation of peptidoglycan of Leptospira interrogans, serovar copenhageni, was able to induce the release of TNF alpha from peripheral blood mononuclear cells. TNF alpha induction occurred in a dose dependent manner and was not affected by the endotoxin inhibitor polymixin B. This is the first report on induction of TNF alpha release by a peptidoglycan of spirochetes. Our findings are consistent with existing clinical data and provide a potential mechanism for TNF alpha production.

Prevalence of IgG reactivity in Lyme borreliosis patients versus Borrelia garinii and Borrelia afzelii in a restricted area of Northern Italy.

This survey evaluates the antibody band patterns of sera taken from clinically defined cases of Lyme borreliosis, towards three locally isolated strains of Borrelia burgdorferi, belonging to the three species: Borrelia sensu stricto, Borrelia garinii and Borrelia afzelii, by means of Western blot. The sera were taken from patients resident in a limited area of Friuli Venezia Giulia (FVG) region. The data indicated that, besides a different feature of the band reactivity which correlated to the different stages of Lyme borreliosis, there was a preferential reactivity to the species Borrelia afzelii and Borrelia garinii. An immunodominant band at 51 kDa, corresponding to a protein visible in the electrophoretic profile of strain BL3 (B. afzelii), behaved like a marker of an early infection, because it was present exclusively in the sera of patient with ECM. The overall findings would indicate that B. afzelii and B. garinii are the prevalent genospecies in the FVG area, even if strains belonging to B. sensu stricto have been also isolated in this area. Consequently strains representative of these two species must be used as antigens in Western blot.

IgM and IgG significant reactivity to Borrelia burgdorferi sensu stricto, Borrelia garinii and Borrelia afzelii among Italian patients affected by Lyme arthritis or neuroborreliosis.

This survey evaluates the specificity of band patterns in immunoblot of sera taken from clinically defined cases of Lyme arthritis and neuroborreliosis, towards three locally isolated strains of Borrelia burgdorferi, belonging to the three species: Borrelia sensu stricto, Borrelia garinii and Borrelia afzelii. To assess specificity, patient sera were statistically (X2, P < or = 0.05) compared with blood donors sera samples. Both IgG and IgM antibodies were considered. The overall reactivity of the three Borrelia strains in IgG immunoblots indicated that ten protein bands were significant, with a different prevalence of some of them in the two groups of patient sera: bands at 60-58, 30-33, 36-37 and 28-27 kDa were markers for neuroborreliosis sera; proteins at 100-83, 72-70 and 18-17 kDa behaved like markers for Lyme arthritis. The IgM Immunoblots revealed significant bands at 100-83, 72-70, 51, 24-21 and 18-17 kDa only with neuroborreliosis sera. Though there were variable band reactivities in each strain, a correlation emerged between the three genospecies and the clinical symptoms: in fact B. afzelii and B. garinii were prevalent in Lyme arthritis sera, (IgG Immunoblots); B. garinii was associated to neuroborreliosis (IgG and IgM Immunoblots); B. sensu stricto was strongly reactive with neuroborreliosis in IgM immunoblots. These data indicate that the three locally strains of Borrelia representing the three genospecies should be used together in immunoblot to detect antibodies elicited in neuroborreliosis and Lyme arthritis.

Comparable effects of flickering and steady patterns of light adaptation on photomechanical responses of cones in amphibian (Xenopus laevis) retina.

The effects of two distinct patterns of light stimulus, steady and flicker, on cone photomechanical movements (PMMs) in the Xenopus laevis retina were investigated. For both patterns studied, the effects on PMMs were assessed by quantitative analysis of the cone positions in the outer retina. Steady light adaptation was found to be equally effective as flicker in causing cone contractions. This was unlike the situation previously found in the cyprinid fish retina, in which flickering light was significantly more effective than steady. This difference could be related to the light-evoked response characteristics and circuitry of dopaminergic retinal neurones in the two vertebrate classes. The role of dopamine and other possible neuromodulator(s) in light adaptive control of vertebrate retinae is discussed.

Sensitivity of Borrelia and Leptospira to Quinupristin-dalfopristin (Synercid) in vitro.

In vitro activity of Quinupristin-dalfopristin (Synercid) against seventeen isolates of Borrelia burgdorferi and two representatives of Leptospira spp. was investigated. MICs ranged from 0.03 to 0.125 for B. burgdorferi and 0.125-0.25 microg/ml for Leptospires. Time killing studies carried out with 2 MIC demonstrated U 3 log(10)-unit killing after 72 h, showing a significant activity against spirochetes, though at a lower level than other antibiotics in use in the therapy of Lyme disease and leptospirosis.

Surface receptors of neutrophils towards B. burgdorferi.

The spirochetal agent of Lyme borreliosis, Borrelia burgdorferi, is able to induce an infection which develops in three stages: an early, localized infection, disseminated infection and a third stage, chronic infection, which probably indicates that a protected niche has been established in one or more tissues, where the spirochetes persist even if a specific immune response has been initiated. During the first stage, immediately after their entry into the host tissue, B. burgdorferi meet the motile phagocytic cells, neutrophils and monocytes; this is followed by consequent phagocytosis and killing. Although the rate and mechanism of this killing is not entirely clear, there is evidence that phagocytosis by both neutrophils and monocytes proceeds even in the absence of specific antibodies. We have demonstrated in both neutrophils and CHO Mac-1 (CR3 integrin) transfected cells, that one phagocyte receptor which is involved in B. burgdorferi adhesion in non osponic phagocytosis is the CR3 complement receptor known as integrin alpha m beta 2. Both recognition domains of the integrin, the iC3b site and the COOH terminal lectin site, bind to B. burgdorferi. Data presented here show that inhibition of adhesion on CR3 Mac-1 transfected cells and neutrophils is induced by mannose as well as by N-acetyl-D-glucosamine, sugars known to be specific inhibitors of the COOH terminal lectin-site of the integrin CR3. The inhibitory effect was serum complement independent. On the contrary, monoclonal antibody VIM12 directed towards the lectin domain not only failed to inhibit but improved adhesion, suggesting that, as a consequence of the binding, the integrin becomes more receptive to B. burgdorferi attachment at the I domain. Pretreatment of the borrelias with NalO4 eliminated adhesion, suggesting that the sugar residue/s recognized by CR3 is located on the bacteria.

Detection of HGE agent-like Ehrlichia in Ixodes ricinus ticks in northern Italy by PCR.

Little is known about the distribution of Human Granulocytic Ehrlichiosis (HGE) in Europe and even less is known in Italy, where no case of clinically documented HGE has been reported. In a previous study we reported the presence of Ehrlichia DNA in Ixodes ricinus ticks from Central Italy. By the use of an Ehrlichia-specific PCR we found that 24% of the ticks were positive. Furthermore, we demonstrated a simultaneous coinfection of the same tick by both, Borrelia burgdorferi and Ehrlichia phagocytophila. Since the Friuli-Venezia Giulia region (North-east of Italy) is endemic for Lyme borreliosis (LB) and the geographic distribution of HGE usually overlaps that of LB, we decided to carry out a survey concerning the presence of Ehrlichia spp. in a recreational area near Trieste where the presence of Lyme borreliosis and Borrelia burgdorferi sensu lato in ticks is well demonstrated. Ticks were analyzed in pools (because a low infection rate was expected): eleven samples out of 93 were found positive by Ehrlichia-PCR. Subsequent sequence analysis of some of the positive PCR products revealed a high homology with the HGE agent Ehrlichia (only one base substitution in almost 450 bp sequenced). These findings add new and interesting data on the Ehrlichia epidemiology in Italy. By now we have demonstrated the presence of two distinct granulocytic ehrlichiae in Italiyn ticks by the aid of a PCR-based analysis: Ehrlichia phagocytophila in Central Italy and an HGE-like Ehrlichia in the north-eastern Italy, in a region close to Slovenia where the first reported case of HGE in Europe occurred.

[Acromegalic arthropathy]. / L'artropatia acromegalica.

Six acromegalic patients, three males (aged 28 to 48 years) and three females (aged 57 to 75 years), with GH-producing pituitary adenoma, were studied through clinical examination, laboratory and instrumental tests. In all the patients frequent involvement of large joints, with crepitus and provoked pain, was found; while articular mobility was normal especially in the dorso-lumbar spine, a frequent seat of pain. Radiology showed typical features of an osteoarthritic process with characteristic widening of articular spaces, especially in weight-bearing large joints in symptomatic patients. The evolution of this arthropathy lead to anatomo-clinical pictures almost indistinguishable from osteoarthritis; however, in the early stages, the marked cartilaginous hypertrophy is responsible for peculiar anatomo-radiological pictures, principally represented by widening of articular spaces and intervertebral discal spaces, especially in the dorso-lumbar spine. As far as bone metabolism is concerned, neoproduction and reabsorption, both increased, proceed simultaneously; bone mass reduction is described in some segments. In our study, the two patients with active acromegaly showed bone mass reduction in the lumbar spine.

[Results of an airborne spore study in various regions of southern Sardinia]. / Risultati di una indagine aerosporologica in diverse località della Sardegna meridionale.

Fungal air spores can play a significant role in several allergic manifestations. Therefore, the identification of geographic areas of mould distribution could be helpful to the clinician, especially if associated with fungal air spore recording in homes or working environments of sensitized subjects, in determining the real clinical importance of sensitization to fungi. On this basis, we studied the occurrence of airborne fungi at two urban sites and at two rural sites in the South of Sardinia, from May 1987 to April 1988, using the gravity plate method. Our survey has pointed out a significant difference about the occurrence of airborne spores in the areas sampled. Spore concentrations were lower at the urban sites during all the survey period. On the whole 6319 fungal colonies belonging to 28 different genera have been found. Cladosporium, Alternaria, Penicillium and Aspergillus, represented by a range of species, were the most common fungi identified in all sites examined. Remarkable the incidence of Yeasts, represented by the genera Candida, Saccharomyces, Rhodotorula and Sporobolomyces. Aureobasidium, Stemphilium, Botrytis, Chaetomium, Mucor and Rhizopus have been found in all sites but they have not been steadily isolated during the survey. Several other genera have been found only sporadically. Our results seem to confirm that fungal air spores, because of its quantity and variety, can represent a serious problem for human health in Sardinia.

Comparative bacteriostatic and bactericidal activities of cefodizime against Borrelia burgdorferi sensu lato.

The MIC and MSC (minimum spirocheticidal concentration) and killing rate for Borrelia burgdorferi, the etiological agent of Lyme disease, were assessed for cefodizime in comparison with ceftriaxone, minocycline, azithromycin, roxithromycin, and ciprofloxacin. The range of cefodizime MICs was greater than those of azithromycin and roxithromycin but comparable to those of ceftriaxone and minocycline. The MSCs were 1 to 2 dilutions higher than the MICs of all of the tested compounds. The killing curves of cefodizime and ceftriaxone showed parallel courses. In conclusion, cefodizime exerted an activity comparable to that of ceftriaxone against B. burgdorferi.

Integrin CR3 mediates the binding of nonspecifically opsonized Borrelia burgdorferi to human phagocytes and mammalian cells.

Like other pathogens, the spirochete Borrelia burgdorferi, the agent of Lyme disease, possesses multiple pathways for cell binding; adhesion to phagocytic cells is of particular interest since it reportedly occurs even in the absence of specific antibodies. This study sets out to investigate how B. burgdorferi binds to human polymorphonuclear leukocytes (PMNs) when an exogenous complement is added and how the CR3 complement receptor, known as Mac-1 or alpha(m)beta2 integrin, is involved in the binding process. Experiments performed on PMNs and CHO Mac-1-expressing cells demonstrate that binding is inhibited by monoclonal anti-iC3b site antibodies, fibrinogen, and N-acetyl-D-glucosamine. These findings, which are not present with non-Mac-transfected CHO cells, indicate that the integrin alpha(m)beta2 acts as a receptor for spirochetes in nonimmune phagocytosis; furthermore, binding occurs on different domains of the CD11b subunit, involving the iC3b site and the lectin domain. The interaction of B. burgdorferi with alpha(m)beta2 integrin adds a novel pathway to Borrelia-phagocyte binding; not only does this binding affect the early stages of phagocytosis, but also it can influence the effector intracellular mechanisms which are activated by the beta2 integrin, as are the cytotoxic mechanisms.

Elastase is the only human neutrophil granule protein that alone is responsible for in vitro killing of Borrelia burgdorferi.

Phagocytosis of Borrelia burgdorferi by human polymorphonuclear leukocytes triggers oxygen-dependent and -independent mechanisms of potentially cidal outcome. Nevertheless, no factor or process has yet been singled out as being borreliacidal. We have studied the B. burgdorferi-killing ability of the myeloperoxidase-H2O2-chloride system and that of primary and secondary granule components in an in vitro assay. We found that neither secondary granule acid extracts nor the chlorinating system could kill these microorganisms, while primary granule extracts were effective. The Borrelia-killing factor was purified to homogeneity and demonstrated to be elastase. Its cidal activity was found to be independent of its proteolytic activity.

Evidence of involvement of the mannose receptor in adhesion of Borrelia burgdorferi to monocyte/macrophages.

The mannose receptor (MR) plays an important role in the recognition of some pathogens in nonopsonic phagocytosis and in antigen presentation to T cells. We found that Borrelia burgdorferi, the agent of Lyme borreliosis, adheres to monocyte-derived macrophages and to rat MR-transfected cells but not to untransfected cells. Antibodies to MR and sugars such as mannose, mannan, fucose, and some lectins significantly lowered the adhesion, confirming participation of the MR in the binding.

Acarological risk of exposure to agents of tick-borne zoonoses in the first recognized Italian focus of Lyme borreliosis.

Acarological risk was calculated as the probability of encountering at least one host-seeking Ixodes ricinus tick infected by the pathogen Borrelia burgdorferi sensu lato, in 100 m transects in the province of Genoa, Italy. The seasonal pattern of I. ricinus was studied using generalized estimating equations (GEE) with negative binomial error, to consider overdispersion of tick counts and repeated sampling of the same dragging sites from April 1998 to March 1999. Prevalence of infection by B. burgdorferi s.l. was evaluated by PCR and hybridization with genospecies-specific probes. Acarological risk (R) peaked in April (R = 0.2, 95% CI 0.13-0.26) and November (R = 0.29, 95% CI 0.10-0.46). Borrelia garinii and B. valaisiana were the most common genospecies at our study site suggesting a major role of birds as reservoirs. DNA from Anaplasma phagocytophilum, the agent of granulocytic ehrlichiosis in humans and animals, was amplified from an adult I. ricinus.

Isolation and characterization of Borrelia burgdorferi sensu lato strains in an area of Italy where Lyme borreliosis is endemic.

Between 1993 and 1998, we isolated Borrelia burgdorferi sensu lato from 55 of the 119 patients with clinically diagnosed Lyme borreliosis who were admitted to "San Martino" Hospital in Belluno, Veneto, an Adriatic region in northeastern Italy where Lyme borreliosis is endemic. Upon hospitalization, all patients presented erythema migrans. Isolates were typed using ribosomal DNA PCR-restriction fragment length polymorphism (RFLP) analysis of the rrfA-rrlB intergenic spacer. Of the 41 isolates typed, 37 belonged to Borrelia afzelii, 2 to Borrelia garinii, and 2 to B. burgdorferi sensu stricto. Pulsed-field gel electrophoresis, performed on 21 strains (13 new isolates and 8 controls), revealed different RFLP patterns within the B. garinii and B. afzelii strains; among the five B. garinii strains and the 12 B. afzelii strains, three or two different RFLP patterns were identified, according to the restriction enzyme used. The protein patterns of the new isolates confirmed their genotypic classification and revealed the level of expression of some immunodominant proteins like OspA and other characteristic Osps. These findings constitute the first report of such a high recovery rate of B. burgdorferi from patients in a very restricted area in Italy; they also indicate the predominance of the genospecies B. afzelii in the study area and the heterogeneity of the circulating strains.