A. Rembert Koczulla

Acute and chronic effects of smoking on inflammation markers in exhaled breath condensate in current smokers.

Background: Long-term cigarette smoking is associated with pulmonary inflammation, but the acute effects of smoking have been less well studied. Analysis of the exhaled breath condensate (EBC) can provide noninvasive markers that might be indicative of inflammation. Objectives: The aim of the study was to determine whether the pH , electrical conductivity and the levels of ammonium and interleukin 8 (IL-8) of EBC were altered in smokers and whether they changed after smoking a single cigarette. Methods: We included 19 healthy nonsmokers (controls), 29 asymptomatic smokers, 10 patients with stable chronic obstructive pulmonary disease (COPD) [Global Initiativefor Chronic Obstructive Lung Disease stages (GOLD) stages II–III], and 10 patients with exacerbated COPD. In 13 smokers, EBC was also analyzed before and after smoking. EBC was obtained during 10 min tidal breathing with a cooled RTube™. pH was determined after deaeration with argon. Results: Acute smoking did not alter the pH or ammonium and IL-8 levels, but raised conductivity. As in COPD patients, the pH was significantly decreased in chronic smokers with a history of at least 10 pack-years compared to controls. Conclusions: EBC can be used to detect the acute and chronic effects of smoking. The increased conductivity of EBC after smoking suggests acute inflammatory effects. The reduced pH in chronic smokers shows cigarette-induced inflammation.

Detection of microorganisms in exhaled breath condensate during acute exacerbations of COPD

Background and objective:  One hallmark of COPD is colonization and infection of the lung. Acute exacerbations of COPD (AECOPD) are acute deteriorations of the chronic disease and are associated with a change of the pulmonary microbial balance. The collection of exhaled breath condensate (EBC) can be used to non‐invasively determine markers of lung disease. The aim of the present study was to compare the results of assays based on the detection of microbial nucleic acids from EBC and from spontaneous sputum in patients with AECOPD.

Wall stress determines systolic and diastolic function — Characteristics of heart failure

INTRODUCTION Heart failure can be caused by systolic or diastolic dysfunction. Diagnosing diastolic dysfunction remains challenging, although several criteria have been identified. Ventricular wall stress is crucially involved. It is hypothesized whether increased end-diastolic and end-systolic ventricular wall stress as assessed by the wall stress index is associated with cardiac dysfunction and thus provide novel diagnostic criteria. METHODS 1050 consecutive patients with suspected non-ischemic heart failure covering a broad spectrum from normal to severely impaired cardiac function were observed. Cardiac magnetic resonance imaging was performed to assess left ventricular (LV) volumes, myocardial mass, peak ejection (PER) and filling rate (PFR). RESULTS A reduced PFR was found in 348 patients (33.1%), which resulted from 275 of 422 patients (65.2%) with reduced and from 73 of 628 patients (11.6%) with preserved LVEF (p<0.0001). Increased LV volume and mass was correlated with reduced PER and PFR (p<0.0001). Increased end-diastolic wall stress was the strongest predictor of a reduced PER (OR 4.5 [2.6 to 7.8], p<0.0001) and increased end-systolic wall stress predicted a reduced PFR (OR 1.2 [1.1 to 1.3], p<0.0001). Increased end-systolic wall stress was correlated with increased pulmonary pressure (p<0.0001). Normal end-systolic wall stress<18 kPa had a favorable predictive value for the absence of an impaired filling and increased pulmonary capillary pressure. CONCLUSION Increased end-diastolic wall stress precedes a reduced ventricular ejection rate and increased end-systolic wall stress determines an impaired diastolic filling. It is thus suggested to add assessment of ventricular wall stress as diagnostic criterion of heart failure.

Benefits of High-Intensity Exercise Training to Patients with Chronic Obstructive Pulmonary Disease: A Controlled Study

Background: Various exercise training programs are used for patients with chronic obstructive pulmonary disease (COPD) of different severity. Objectives: To investigate the impact of individualized high-intensity training on exercise capacity with COPD. Methods: A total of 49 patients agreed to participate. Of these, 31 were assigned to the training group and 18 served as controls. The training group exercised twice a week for 90 min with consecutively increasing loads. At the time of enrollment (T0), as well as after 3 (T1) and 6 (T2) months, a 6-min walk test (6-MWT) was performed and data on health-related quality of life, femoral muscle thickness, and various serum markers were obtained. Results: The training group improved in their 6-MWT results (T0 = 407 ± 152 m vs. T1 = 459 ± 127 m, p = 0.002, vs. T2 = 483.2 ± 130.1 m, p = 0.004), in their cross-sectional area of the musculus rectus femoris (T0 = 6.2 ± 1.2 cm2 vs. T1 = 6.9 ± 1.2 cm2, p = 0.003, vs. 7.5 ± 1.6 cm2, p = 0.002), and in their St. Georges Respiratory Questionnaire (SGRQ) score (T0 = 43.3 ± 18.0 vs. T1 = 36.0 ± 18.4, p = 0.001, vs. T2 = 34.7 ± 18. 0, p = 0.004). Serum levels of myostatin, irisin, resistin, and α-Klotho did not change significantly within the training period. Of note, the exercise group showed an inverse relationship between serum levels of resistin and those of α-Klotho after 6 months (r = -0.608, p = 0.021). Conclusions: COPD patients undergoing an individualized, structured, high-intensity training program improved their exercise capacity, gained muscle mass, and improved their quality of life.

From Heart Failure to Highly Unsaturated Fatty Acid Deficiency and Vice Versa: Bidirectional Heart and Liver Interactions

BACKGROUND In several trials, beneficial prognostic effects of highly unsaturated fatty acids (HUFAs) in heart failure were shown. Because other studies showed no incremental benefit in nearly preserved cardiac function, the question arises, whether the degree of cardiac dysfunction is involved. It is hypothesized that increased left ventricular (LV) wall stress affects the endogenous hepatic HUFA metabolism, which in turn exhibits adverse cardiac consequences. METHODS Cardiac magnetic resonance imaging was performed in 30 patients with suspected cardiomyopathy. The serum fatty acid profile was assessed using gas chromatography/mass spectrometry. RESULTS Docosahexaenoic acid (DHA; P = 0.002) and eicosapentaenoic acid (EPA; by trend) levels were decreased in patients with reduced LV ejection fraction (≤ 50%) or LV dilatation (≥ 90 mL/m(2)). Decreased DHA (P = 0.003) and EPA (P = 0.022) levels were associated with a reduced LV ejection fraction. Decreased DHA level was correlated with increased end-diastolic (P = 0.047) and end-systolic LV wall stress (P = 0.001). Pseudocholinesterase activity was inversely correlated with end-diastolic (P = 0.020) and end-systolic LV wall stress (P = 0.025). CONCLUSIONS DHA level was significantly reduced in heart failure. Similar, but less pronounced effects were found for EPA and arachidonic acid by trend. Increased LV wall stress was correlated with a reduced DHA level. Increased LV wall stress exhibits various adverse consequences (eg, increased oxygen consumption, favouring of arrhythmias, and an unfavourable remodelling). The increase of wall stress was paralleled by reduced HUFA level. Increased LV wall stress was correlated with reduced pseudocholinesterase, which is suggestive of hepatic congestion (ie, a cardiohepatic syndrome, involved in the altered fatty acid profile in heart failure) and has major consequences regarding the dose-efficacy of HUFA treatment.

Late Gadolinium Enhancement in Sarcoidosis: Ventricular Wall Stress Should Not Be Overlooked

With great interest, we read in CHEST (October 2014) the study by Nagai et al, 1 who examined the occurrence of late gadolinium enhancement (LGE) by cardiovascular MRI (CMR) in patients with sarcoidosis. In sum, 13% of 61 patients exhibited perimyocardial, transmyocardial, or intramyocardial LGE. Noteworthy was that thinning of the interventricular septum, as measured by echocardiography, was revealed as an independent predictor of LGE. Th us, the question of the pathophysiologic rationale behind linking LGE to a thinned septum is addressed to the authors. Since no prognostic infl uences of LGE were found, the question on the morphologic or functional substrate also arises.

Myocardial homing of mesenchymal stem cells following intrapericardial application and amplification by inflammation — an experimental pilot study

Recent studies demonstrated potential effects of stem cells on cardiac function in heart failure. However, influences of the technique of application remained undetermined. In the present study, the pericardial sac was used as depot for fluorescent-labeled mesenchymal stem cells in rats. To evaluate influences of inflammation on cell homing, a sterile pericarditis was induced by talc. It is shown that intrapericardial stem cell application is sufficient to provide myocardial penetration. The extent of homing was amplified by inflammation in a talc-induced pericarditis.

High-pressure non-invasive ventilation during exercise in COPD patients with chronic hypercapnic respiratory failure: A randomized, controlled, cross-over trial: NIV during exercise in COPD

Patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnic respiratory failure (CHRF) characteristically have exercise intolerance and limitations in performing conventional training. Therefore, the aim of this study was to investigate the acute effects of non‐invasive ventilation (NIV) as a supportive tool during exercise in CHRF.

Feasibility and safety of whole-body vibration therapy in intensive care patients

We read with great interest the article by Wollersheim and colleagues who examined whole-body vibration (WBV) in intensive care unit patients [1]. Hemodynamic characteristics were monitored during WBV application. The study underscores previous findings showing that no significant changes in heart rate, blood pressure, or oxygen saturation occurred during WBV in critically ill patients, nor when compared with healthy controls [2]. In the present study, unconscious sedated patients received WBV in a flat supine position without any changes in body position, except flexion of the hips and knees. The method raises the question whether enough load was applied to the vibrating plate to lead to a sufficient neuromuscular response. To increase this load and involve neuromuscular recruiting, it might be helpful to modify the patient’s position by inclination of the bed to approximately 20° to 25° degrees of tilt [2]. It is suggested that this would involve a greater muscular proportion of the whole body. In conscious patients, additional training effects may be achieved by the use of a (yet customized) vibrating dumbbell for the upper extremities. Since the recent method is preliminary in the current setting, potential effects on muscle function and morphology should be assessed in further studies [3]. A short-term response could be detected, e.g., by electromyography [2]. Longer-term effects involve muscular morphology, e.g., hypertrophy, which can be assessed by sonography-based morphometry [4]. It remains debatable whether catecholamines influenced the findings in the present study, since no controls were examined [5]. In summary, WBV, if applicable in conjunction with a vibrating dumbbell, appears safe and feasible in early rehabilitation. Potential beneficial long-term effects remain to be shown. Abbreviations WBV: Whole-body vibration

CorrespondenceLate Gadolinium Enhancement in Sarcoidosis: Ventricular Wall Stress Should Not Be Overlooked

With great interest, we read in CHEST (October 2014) the study by Nagai et al, 1 who examined the occurrence of late gadolinium enhancement (LGE) by cardiovascular MRI (CMR) in patients with sarcoidosis. In sum, 13% of 61 patients exhibited perimyocardial, transmyocardial, or intramyocardial LGE. Noteworthy was that thinning of the interventricular septum, as measured by echocardiography, was revealed as an independent predictor of LGE. Th us, the question of the pathophysiologic rationale behind linking LGE to a thinned septum is addressed to the authors. Since no prognostic infl uences of LGE were found, the question on the morphologic or functional substrate also arises.