A Rapid Antigen Detection Test to Diagnose SARS-CoV-2 Infection Using Exhaled Breath Condensate by A Modified Inflammacheck® Device.

BACKGROUND: The standard test that identifies the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is based on reverse transcriptase-polymerase chain reaction (RT-PCR) from nasopharyngeal (NP) swab specimens. We compared the accuracy of a rapid antigen detection test using exhaled breath condensate by a modified Inflammacheck® device with the standard RT-PCR to diagnose SARS-CoV-2 infection. METHODS: We performed a manufacturer-independent, cross-sectional, diagnostic accuracy study involving two Italian hospitals. Sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), positive (PPV) and negative predictive value (NPV) and diagnostic accuracy with 95% confidence intervals (95% CI) of Inflammacheck® were calculated using the RT-PCR results as the standard. Further RT-PCR tests were conducted on NP specimens from test positive subjects to obtain the Ct (cycle threshold) values as indicative evidence of the viral load. RESULTS: A total of 105 individuals (41 females, 39.0%; 64 males, 61.0%; mean age: 58.4 years) were included in the final analysis, with the RT-PCR being positive in 13 (12.4%) and negative in 92 (87.6%). The agreement between the two methods was 98.1%, with a Cohen's κ score of 0.91 (95% CI: 0.79-1.00). The overall sensitivity and specificity of the Inflammacheck® were 92.3% (95% CI: 64.0%-99.8%) and 98.9% (95% CI: 94.1%-100%), respectively, with a PLR of 84.9 (95% CI: 12.0-600.3) and a NLR of 0.08 (95% CI: 0.01-0.51). Considering a 12.4% disease prevalence in the study cohort, the PPV was 92.3% (95% CI: 62.9%-98.8%) and the NPV was 98.9% (95% CI: 93.3%-99.8%), with an overall accuracy of 98.1% (95% CI: 93.3%-99.8%). The Fagan's nomogram substantially confirmed the clinical applicability of the test in a realistic scenario with a pre-test probability set at 4%. Ct values obtained for the positive test subjects by means of the RT-PCR were normally distributed between 26 and 38 cycles, corresponding to viral loads from light (38 cycles) to high (26 cycles). The single false negative record had a Ct value of 33, which was close to the mean of the cohort (32.5 cycles). CONCLUSIONS: The modified Inflammacheck® device may be a rapid, non-demanding and cost-effective method for SARS-CoV-2 detection. This device may be used for routine practice in different healthcare settings (community, hospital, rehabilitation).

Effects of a high-intensity pulmonary rehabilitation program on the minute ventilation/carbon dioxide output slope during exercise in a cohort of patients with COPD undergoing lung resection for non-small cell lung cancer.

OBJECTIVE: Preoperative functional evaluation is central to optimizing the identification of patients with non-small cell lung cancer (NSCLC) who are candidates for surgery. The minute ventilation/carbon dioxide output (VE/VCO2) slope has proven to be a predictor of surgical complications and mortality. Pulmonary rehabilitation programs (PRPs) could influence short-term outcomes in patients with COPD undergoing lung resection. Our objective was to evaluate the effects of a PRP on the VE/VCO2 slope in a cohort of patients with COPD undergoing lung resection for NSCLC. METHODS: We retrospectively evaluated 25 consecutive patients with COPD participating in a three-week high-intensity PRP prior to undergoing lung surgery for NSCLC, between December of 2015 and January of 2017. Patients underwent complete functional assessment, including spirometry, DLCO measurement, and cardiopulmonary exercise testing. RESULTS: There were no significant differences between the mean pre- and post-PRP values (% of predicted) for FEV1 (61.5 ± 22.0% vs. 62.0 ± 21.1%) and DLCO (67.2 ± 18.1% vs. 67.5 ± 13.2%). Conversely, there were significant improvements in the mean peak oxygen uptake (from 14.7 ± 2.5 to 18.2 ± 2.7 mL/kg per min; p < 0.001) and VE/VCO2 slope (from 32.0 ± 2.8 to 30.1 ± 4.0; p < 0.01). CONCLUSIONS: Our results indicate that a high-intensity PRP can improve ventilatory efficiency in patients with COPD undergoing lung resection for NSCLC. Further comprehensive prospective studies are required to corroborate these preliminary results.

Effects of a high-intensity pulmonary rehabilitation program on the minute ventilation/carbon dioxide output slope during exercise in a cohort of patients with COPD undergoing lung resection for non-small cell lung cancer / Efeitos de um programa de reabilitação de alta intensidade no comando VE/VCO2 durante exercício em um grupo de pacientes submetidos à ressecção para câncer de pulmão de células não pequenas

ABSTRACT Objective: Preoperative functional evaluation is central to optimizing the identification of patients with non-small cell lung cancer (NSCLC) who are candidates for surgery. The minute ventilation/carbon dioxide output (VE/VCO2) slope has proven to be a predictor of surgical complications and mortality. Pulmonary rehabilitation programs (PRPs) could influence short-term outcomes in patients with COPD undergoing lung resection. Our objective was to evaluate the effects of a PRP on the VE/VCO2 slope in a cohort of patients with COPD undergoing lung resection for NSCLC. Methods: We retrospectively evaluated 25 consecutive patients with COPD participating in a three-week high-intensity PRP prior to undergoing lung surgery for NSCLC, between December of 2015 and January of 2017. Patients underwent complete functional assessment, including spirometry, DLCO measurement, and cardiopulmonary exercise testing. Results: There were no significant differences between the mean pre- and post-PRP values (% of predicted) for FEV1 (61.5 ± 22.0% vs. 62.0 ± 21.1%) and DLCO (67.2 ± 18.1% vs. 67.5 ± 13.2%). Conversely, there were significant improvements in the mean peak oxygen uptake (from 14.7 ± 2.5 to 18.2 ± 2.7 mL/kg per min; p < 0.001) and VE/VCO2 slope (from 32.0 ± 2.8 to 30.1 ± 4.0; p < 0.01). Conclusions: Our results indicate that a high-intensity PRP can improve ventilatory efficiency in patients with COPD undergoing lung resection for NSCLC. Further comprehensive prospective studies are required to corroborate these preliminary results.

RESUMO Objetivos: A avaliação funcional pré-operatória é fundamental para otimizar a seleção dos pacientes para cirurgia torácica para tratamento do CPCNP. Uma alta inclinação VE/VCO2 se mostrou um preditor de complicações cirúrgicas e de aumento da mortalidade. Programas de reabilitação pulmonar (PRP) demonstraram aumentar os parâmetros funcionais e os desfechos de curto prazo em pacientes com DPOC submetidos à ressecção pulmonar. O impacto dos PRP na inclinação VE/VCO2 não foi totalmente investigado. Métodos: Avaliamos retrospectivamente 25 pacientes com DPOC consecutivos submetidos aos efeitos de um programa de reabilitação pulmonar de alta intensidade (PRP) na inclinação VE/VCO2. Resultados: Não foram observadas variações significativas nos principais parâmetros espirométricos após o programa de reabilitação de três semanas (pré-reabilitação VEF1 versus pós-reabilitação VEF1 %prev: 61,5 ± 22,0% para 62,0 ± 21,1%, ns; pré-reabilitação DLCO para pós-reabilitação DLCO %prev: 67,2 ± 18,1% para 67,5 ± 13,2%, ns). Por outro lado, o pico de VO2 e a inclinação VE/VCO2 melhoraram significativamente após PRP (pico de VO2 pré-reabilitação para pico de VO2 pós-reabilitação: 14,7 ± 2,5 para 18,2 ± 2,7 mL/kg/min, p < 0,0000001; inclinação pré-reabilitação VE/VCO2 para pós-reabilitação inclinação VE/VCO2: 32,0 ± 2,8 para 30,1 ± 4,0, p<0,01). Conclusão: Documentamos o benefício no desempenho físico de um treinamento de três semanas em um grupo de pacientes com DPOC com um comprometimento funcional notável em parâmetros de esforço. Dados adicionais e mais abrangentes são necessários para esclarecer os mecanismos fisiológicos.

SEIPIN Proteins Mediate Lipid Droplet Biogenesis to Promote Pollen Transmission and Reduce Seed Dormancy.

Lipid droplets (LDs) are ubiquitous organelles in plant cells, but their physiological roles are largely unknown. To gain insight into the function of LDs in plants, we have characterized the Arabidopsis homologs of SEIPIN proteins, which are crucial factors for LD biogenesis in yeast and animals. SEIPIN1 is expressed almost exclusively in embryos, while SEIPIN2 and SEIPIN3 have broader expression profiles with maximal levels in embryos and pollen, where LDs accumulate most abundantly. Genetic analysis demonstrates that all three SEIPINs contribute to proper LD biogenesis in embryos, whereas in pollen, only SEIPIN2 and SEIPIN3 play a significant role. The double seipin2 seipin3 and triple seipin mutants accumulate extremely enlarged LDs in seeds and pollen, which hinders their subsequent mobilization during germination. Interestingly, electron microscopy analysis reveals the presence of nuclear LDs attached to type I nucleoplasmic reticulum in triple seipin mutant embryos, supporting that SEIPINs are essential for maintaining the correct polarity of LD budding at the nuclear envelope, restricting it to the outer membrane. In pollen, the perturbations in LD biogenesis and turnover are coupled to reduced germination in vitro and with lower fertilization efficiency in vivo. In seeds, germination per se is not affected in seipin2 seipin3 and triple seipin mutants, but there is a striking increase in seed dormancy levels. Our findings reveal the relevance of SEIPIN-dependent LD biogenesis in pollen transmission and in adjusting the timing of seed germination, two key adaptive traits of great importance in agriculture.

Exercise related ventilation dynamics and clinical correlates in patients with fibrotic idiopathic interstitial pneumonias.

Assessment of exercise performance is a key component in the management of interstitial lung diseases, as its limitation may occur very early. Aim of the present study was to assess ventilation dynamics in combination with pulse-oximetry changes in 54 clinically stable patients affected by idiopathic pulmonary fibrosis or idiopathic fibrotic nonspecific interstitial pneumonia. Testing was successfully performed with the Spiropalm 6-MWT Hand-held spirometer by the majority of cases (94%). End test oxygen saturation (SpO2) values <88% were common in most of patients (76%), with a mean distance walked of 403 meters. Ventilation significantly increased due to the contribution of the tidal volume and the respiratory frequency (RF). This finding was associated with a decrease of the end of test respiratory reserve (RR), that was <20% in 9 cases (17.6%). Lung function was inversely related to the end of test RF, while a positive correlation occurred with the end of test RR and the estimated maximal voluntary ventilation (MVV). RR was also a predictive factor of declining forced vital capacity and lung diffusion capacity for carbon monoxide (DLCO) over a 6-month period. Further factors of DLCO impairment were low SpO2 and MVV. Comparison with the cardio-pulmonary exercise test (CPET) showed that the 6-MWT end of test RR was inversely related to the CPET-derived peak RF and VE/VCO2 suggesting RR as pivotal in exercise limitation assessment. Our results open challenging perspectives in an unexplored field. Future research will include management of latent respiratory failure and monitoring of disease progression and therapy response.

Impact of long-term treatment with inhaled corticosteroids and bronchodilators on lung function in a patient with post-infectious bronchiolitis obliterans.

Post-infectious bronchiolitis obliterans (PIBO) is a small airways disease characterized by fixed airflow limitation. Therefore, inhaled bronchodilators and corticosteroids are not recommended as maintenance therapy options. The management of PIBO currently consists only of close monitoring of affected patients, aimed at the prevention and early treatment of pulmonary infections. In recent years, there has been an increase in the incidence of PIBO in the pediatric population. Patients with PIBO are characterized by a progressive decline in lung function, accompanied by a decrease in overall functional capacity. Here, we report the case of a relatively young man diagnosed with PIBO and followed for three years. After short- and long-term therapy with an inhaled corticosteroid/long-acting 2 agonist combination, together with an inhaled long-acting antimuscarinic, the patient showed relevant improvement of airway obstruction that had been irreversible at the time of the bronchodilator test. The lung function of the patient worsened when he interrupted the triple inhaled therapy. In addition, a 3-week pulmonary rehabilitation program markedly improved his physical performance. RESUMO A bronquiolite obliterante pós-infecciosa (BOPI) é uma doença das pequenas vias aéreas caracterizada por limitação fixa do fluxo aéreo. Portanto, os broncodilatadores e os corticosteroides inalatórios não são recomendados como opções de terapia de manutenção. Atualmente, o manejo da BOPI consiste apenas de um acompanhamento rigoroso dos pacientes afetados, visando à prevenção e ao tratamento precoce de infecções pulmonares. A incidência de BOPI tem aumentado na população pediátrica nos últimos anos. Os pacientes com BOPI caracterizam-se por um declínio progressivo da função pulmonar, associado a uma diminuição da capacidade funcional global. Relatamos aqui o caso de um homem relativamente jovem diagnosticado com BOPI, acompanhado por três anos. Após terapia de curto e de longo prazo com uma combinação de corticosteroide/2-agonista de longa duração inalatórios, associada a um agente antimuscarínico de longa duração inalatório, o paciente apresentou uma melhora relevante da obstrução das vias aéreas, a qual fora irreversível durante o teste de broncodilatação. A função pulmonar do paciente piorou quando ele interrompeu a terapia inalatória tripla. Além disso, um programa de reabilitação pulmonar de três semanas significativamente melhorou seu desempenho físico.

Spirometry in elderly laryngectomized patients: A feasibility study.

BACKGROUND: Laryngeal cancer is the second most common respiratory neoplasm after lung cancer. Laryngectomy is a well established treatment for larynx cancers which involve relevant anatomic alterations. Spirometry is an essential investigation tool for diagnosis and severity of respiratory diseases, difficult to perform in laryngectomees. METHODS: 43 consecutive laryngectomized patients were enrolled from July 2014 to March 2015. Patients fulfilling inclusion criteria underwent spirometry at baseline assessment and after two days. During the examination, the spirometer was placed directly on the stoma of the patient, through mouthpiece "Spirometry Filter 74". RESULTS: At baseline, 26 eligible laryngectomees correctly performed the spirometry test with mouthpiece adhering to the stoma; 4 patients refused to perform the second spirometry after 2 days. The feasibility of spirometry examination in these patients was 100% despite difficulties in the execution of the test. The Pearson coefficient of reproducibility for FEV1, FVC and Tiffeneau Index was, respectively, 0.98, 0.94 and 0.77. DISCUSSION: Spirometry in laryngectomee patients is a feasible procedure for assessment of respiratory function; despite technical difficulties in the execution of the test, our results underline the reproducibility and repeatability of the spirometry. In conclusion, when performed within dedicated respiratory pathophysiology unit, spirometry is a reliable tool in the assessment and follow up of laryngectomees.

Impact of long-term treatment with inhaled corticosteroids and bronchodilators on lung function in a patient with post-infectious bronchiolitis obliterans / Impacto do tratamento de longo prazo com corticosteroides e broncodilatadores inalatórios na função pulmonar em um paciente com bronquiolite obliterante pós-infecciosa

ABSTRACT Post-infectious bronchiolitis obliterans (PIBO) is a small airways disease characterized by fixed airflow limitation. Therefore, inhaled bronchodilators and corticosteroids are not recommended as maintenance therapy options. The management of PIBO currently consists only of close monitoring of affected patients, aimed at the prevention and early treatment of pulmonary infections. In recent years, there has been an increase in the incidence of PIBO in the pediatric population. Patients with PIBO are characterized by a progressive decline in lung function, accompanied by a decrease in overall functional capacity. Here, we report the case of a relatively young man diagnosed with PIBO and followed for three years. After short- and long-term therapy with an inhaled corticosteroid/long-acting 2 agonist combination, together with an inhaled long-acting antimuscarinic, the patient showed relevant improvement of airway obstruction that had been irreversible at the time of the bronchodilator test. The lung function of the patient worsened when he interrupted the triple inhaled therapy. In addition, a 3-week pulmonary rehabilitation program markedly improved his physical performance.

RESUMO A bronquiolite obliterante pós-infecciosa (BOPI) é uma doença das pequenas vias aéreas caracterizada por limitação fixa do fluxo aéreo. Portanto, os broncodilatadores e os corticosteroides inalatórios não são recomendados como opções de terapia de manutenção. Atualmente, o manejo da BOPI consiste apenas de um acompanhamento rigoroso dos pacientes afetados, visando à prevenção e ao tratamento precoce de infecções pulmonares. A incidência de BOPI tem aumentado na população pediátrica nos últimos anos. Os pacientes com BOPI caracterizam-se por um declínio progressivo da função pulmonar, associado a uma diminuição da capacidade funcional global. Relatamos aqui o caso de um homem relativamente jovem diagnosticado com BOPI, acompanhado por três anos. Após terapia de curto e de longo prazo com uma combinação de corticosteroide/2-agonista de longa duração inalatórios, associada a um agente antimuscarínico de longa duração inalatório, o paciente apresentou uma melhora relevante da obstrução das vias aéreas, a qual fora irreversível durante o teste de broncodilatação. A função pulmonar do paciente piorou quando ele interrompeu a terapia inalatória tripla. Além disso, um programa de reabilitação pulmonar de três semanas significativamente melhorou seu desempenho físico.

Preoperative high-intensity training in frail old patients undergoing pulmonary resection for NSCLC.

Thoracic surgery remains the better therapeutic option for non-small cell lung cancer patients that are diagnosed in early stage disease. Preoperative lung function assessment includes respiratory function tests (RFT) and cardio-pulmonary exercise testing (CPET). Vo2 peak, FEV1 and DLCO as well as recognition of performance status, presence of co-morbidities, frailty indexes, and age predict the potential impact of surgical resection on patient health status and survival risk. In this study we have retrospectively assessed the benefit of a high-intensity preoperative pulmonary rehabilitation program (PRP) in 14 patients with underlying lung function impairment prior to surgery. Amongst these, three patients candidate to surgical resection exhibited severe functional impairment associated with high score of frailty according CHS and SOF index, resulting in a substantial mortality risk. Our observations indicate that PRP appear to reduce the mortality and morbidity risk in frail patients with concurrent lung function impairment undergoing thoracic surgery. PRP produced improvement of VO2 peak degree and pulmonary function resulting in reduced postoperative complications in high-risk patients from our cases. Our results indicate that a preoperative training program may improve postoperative clinical outcomes in fraillung cancer patients with impaired lung function prior to surgical resection.

High-intensity training and cardiopulmonary exercise testing in patients with chronic obstructive pulmonary disease and non-small-cell lung cancer undergoing lobectomy.

OBJECTIVES: Peak VO2, as measure of physical performance is central to a correct preoperative evaluation in patients with both non-small-cell lung cancer (NSCLC) and chronic obstructive pulmonary disease (COPD) because it is closely related both to operability criteria and the rate of postoperative complications. Strategies to improve peak VO2, as a preoperative pulmonary rehabilitation programme (PRP), should be considered favourably in these patients. In order to clarify the role of pulmonary rehabilitation, we have evaluated the effects of 3-week preoperative high-intensity training on physical performance and respiratory function in a group of patients with both NSCLC and COPD who underwent lobectomy. METHODS: We studied 40 patients with both NSCLC and COPD, age < 75 years, TNM stages I-II, who underwent lobectomy. Patients were randomly divided into two groups (R and S): Group R underwent an intensive preoperative PRP, while Group S underwent only lobectomy. We evaluated peak VO2 in all patients at Time 0 (T0), after PRP/before surgery in Group R/S (T1) and 60 days after surgery, respectively, in both groups (T2). RESULTS: There was no difference between groups in peak VO2 at T0, while a significant difference was observed both at T1 and T2. In Group R, peak VO2 improves significantly from T0 to T1: 14.9 ± 2.3-17.8 ± 2.1 ml/kg/min ± standard deviation (SD), P < 0.001 (64.5 ± 16.5-76.1 ± 14.9% predicted ± SD, P < 0.05) and deteriorates from T1 to T2: 17.8 ± 2.1-15.1 ± 2.4, P < 0.001 (76.1 ± 14.9-64.6 ± 15.5, P < 0.05), reverting to a similar value to that at T0, while in Group S peak VO2 did not change from T0 to T1 and significantly deteriorates from T1 to T2: 14.5 ± 1.2-11.4 ± 1.2 ml/kg/min ± SD, P < 0.00001 (60.6 ± 8.4-47.4 ± 6.9% predicted ± SD, P < 0.00001). CONCLUSIONS: PRP was a valid preoperative strategy to improve physical performance in patients with both NSCLC and COPD and this advantage was also maintained after surgery.

The impact of decreasing cutoff values for maximal oxygen consumption (VO(2)max) in the decision-making process for candidates to lung cancer surgery.

BACKGROUND: Maximal oxygen consumption (VO(2)max) is considered a decisive test for risk prediction in patients with borderline cardiopulmonary reserve. Guidelines have adopted decreasing VO(2)max cut-off values to define operability within acceptable mortality and morbidity limits. We wanted to investigate how the adoption of decreasing VO(2)max cut-off-values assessment contributed to better select lung surgery candidates. METHODS: One hundred and nineteen consecutive surgical candidates have been prospectively analyzed as a sample population. Preoperative work-up included spirometry and transfer factor (DLco); irrespective of the spirometric values, these patients were subjected to VO(2)max assessment. Surgical eligibility was decided by the same surgeon throughout the series. In the postoperative period, overall mortality and the occurrence of any, major or minor complications was recorded and graded according to the Common Terminology Criteria for Adverse Events v.4.3. RESULTS: Three arbitrary cut-offs were introduced at 15, 14 and 12 mL(.)kg(-1) (.)min(-1). Notably, 15 and 12 mL(.)kg(-1) (.)min(-1) correlated with percentage VO(2)max values of 50% and 35% of predicted (P<0.0001 and 0.0079), respectively. Accordingly, the patients were subdivided into groups in which the prevalence of postoperative morbidity was recorded. The groups were homogeneous as to age, BMI, preoperative absolute and percentage FEV1 and DLco. In the Cox proportionate-hazards multivariate analysis, VO(2)max less than 35% (P=0.0017) and CTCAE >2 (P=0.0457) emerged as significant predictors of survival after surgery. Conversely on logistic regression analysis, age over 70 years (P=0.03) and pneumonectomy (P=0.001), but not VO(2)max cut-off values, were significant predictors of major (CTCAE >2) morbidity. CONCLUSIONS: Since VO(2)max is increasingly used to contribute to risk prediction for the individual patient, surgeons need to be advised that the concept of a definitive, generalized cut-off value for VO(2)max is probably a contradiction in terms. Patient-specific VO(2)max values are more likely to contribute to risk assessment since they may reflect the primarily affected component among the determinants of maximal oxygen consumption. Whether patient-specific VO(2)max should be routinely used by surgeons to define operability for borderline patients needs further evaluation.