Cornelius Barlascini

Increased Transcapillary Escape Rate of Albumin in Nondiabetic Men in Response to Hyperinsulinemia

Diabetic patients manifest increased vascular permeability. To determine whether insulin per se might increase vascular permeability, five nondiabetic men were studied by the hyperinsulinemic-euglycemic clamp technique. Each subject received a 0.72-nmol/kg body wt i.v. insulin bolus, followed by a 72-pmol · kg−1 ·min−1 insulin infusion for 4 h. Euglycemia was maintained by the Biostator glucose controller. At 7 h of study, 10 μCi i.v. 125I-labeled albumin was injected as bolus dose. Frequent blood samples were drawn during the next 70 min for determination of the transcapillary escape rate (TER) of albumin. Subjects returned 1–2 wk later for a control study, during which 0.45% saline was infused at a rate identical to the dextrose and insulin infusion rates during the hyperinsulinemic clamp. The mean ± SE serum insulin levels during the hyperinsulinemic clamp and saline infusion were 9786 ± 126 and 46 ± 4 pM, respectively, whereas serum glucose during the two sessions was similar (5.0 ± 0.2 vs. 4.8 ± 0.1 mM, NS). Identical fluid volumes were infused during the two sessions (1767 ± 197 ml/7 h), and urine outputs did not differ significantly (1615 ± 309 vs. 1035 ± 248 ml/7 h). The TER of albumin was greater in all five men after hyperinsulinemia than after saline infusion (18.3 ± 2.7 vs. –2.8 ± 2.3%/h, P = 0.01). The serum albumin level at the end of the hyperinsulinemic-euglycemic clamp study was 14% lower than the value at the start of the study (37 ± 1 vs. 42 ± 1 g/L, P < 0.05), whereas no significant change in serum albumin levels occurred during the saline infusion. These observations suggest that acute hyperinsulinemia can increase the TER of radiolabeled albumin, probably by increasing vascular permeability.

Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis

AbstractBackgroundHigh-frequency airway clearance (HFCWC) assist devices generate either positive or negative trans-respiratory pressure excursions to produce high-frequency, small-volume oscillations in the airways.HFCWC can lead to changes in volume of 15–57 ml and in flow up to 1.6 L/s, which generate minimal coughing to mobilize secretions. The typical treatment lasts 20–30 minutes, and consists of short periods of compression at different frequencies, separated by coughing.The aim of this study was to find the more efficacious treatment in patients with bronchiectasis: traditional techniques of chest physiotherapy (CPT) versus high frequency oscillation of the chest wall in patients with bronchiectasis.Methods37 patients were enrolled. Seven of them were excluded. Computer randomization divided the patients into three groups:10 patients treated with HFCWO by using the Vest® Airway Clearance System;10 patients treated with traditional techniques of air way clearance (PEP bottle, PEP mask, ELTGOL, vibratory positive expiratory pressure);10 patients received medical therapy only (control group). To be eligible for enrollment, participants had to be between 18 and 85 years old and have a diagnosis of bronchiectasis, confirmed on high resolution computed tomography. Exclusion criteria: lack of informed consent, signs of exacerbation, cystic fibrosis. Before the treatment, each patient had blood tests, sputum volume and cell count, pulmonary function tests and on the quality of life inventories (MMRC, CAT, BCSS). The results were processed through the covariance analysis, performed with the R-Project statistical program. It has been considered a positive result p <005.ResultsBoth treatments (traditional CPT and HFCWO) showed a significant improvement in some biochemical and functional respiratory tests as well as in the quality of life compared to the control group. The use of HFCWO compared to CPT also produced a significant improvement in blood inflammation parameter C-RP (p ≤0.019), parameters of lung functionality associated with bronchial obstruction (FVC, FEV1) (p ≤0.006 and p ≤0.001), and in the dyspnea. Improvement in quality of life scales was noted. (BCSS, CAT) (both p ≤0.001). No significant changes of total cell counts in sputum samples were observed in the two groups. In the HFCWO group a significant reduction of neutrophils percentage (p≤0.002) and a significant increase of macrophages percentage (p ≤0.012).ConclusionsThe HFCWO technique provides an improvement both in pulmonary function and quality of life related parameters in patients with chronic hypersecretive disease. Since those patients need daily airway clearance, this treatment should be included among the principal options in chest physiotherapy. The study was registered as ChiCTR-TRC-12002134 at http://www.chictr.org.

Absorption Characteristic of Breakfast Determines Insulin Sensitivity and Carbohydrate Tolerance for Lunch

To test the hypothesis that prolonging absorption of breakfast might improve the glucose tolerance of the subsequent meal served at lunch, normal male volunteers were administered the same carbohydrate in either a rapidly absorbed (sucrose, S) or slowly absorbed (sucrose with guar, S + G) form for breakfast (0800) and lunch (1145). Area under the curve (AUC) for glucose did not differ for S at breakfast vs. S + G at breakfast, although AUCinsulin for S at breakfast was greater than that for S + G at breakfast (3389 ± 608 vs. 1523 ± 246 μU · min · ml−1, P < .002). Plasma glucose and insulin profiles for the two breakfast meals differed markedly. Once S was ingested, plasma glucose and insulin returned to baseline after 120 and 160 min, respectively. However, once S + G was ingested, plasma glucose and insulin were still significantly above baseline values after 180 min. When S was eaten for breakfast, AUCgiucose for lunch was similar to that for breakfast, regardless of whether lunch consisted of S or S + G. However, if S + G was eaten for breakfast, AUCglucose for S + G or S at lunch was 44% (P < .005) and 75% of that for breakfast, respectively. Only one of five subjects who ingested S + G for breakfast failed to exhibit a fall in AUCglucose when S was eaten for lunch. The beneficial effect of prolonged absorption of breakfast on the glucose tolerance of lunch was not observed if the timing of lunch was delayed by 2 h (i.e., served at 1345). These observations suggest that in normal humans, prolonged absorption of breakfast results in prolonged elevation of plasma insulin levels and enhanced insulin sensitivity at lunch, thereby improving carbohydrate tolerance for lunch.

The effect of phenylpropanolamine on ambulatory blood pressure

Phenylpropanolamine (PPA) is a sympathomimetic amine and component of many over‐the‐counter decongestants and anorectic agents. It has been reported to cause elevated blood pressure and even hypertensive crises. The pressor effects with therapeutic doses are not well established. We monitored the effects of acute and chronic PPA dosing using 24‐hour ambulatory blood pressure recording as a sensitive method of monitoring blood pressure variability. Eighteen normotensive male subjects were randomly assigned to receive 75 mg PPA (sustained‐release preparation) or placebo in a double‐blind crossover design with blood pressure monitored on days 1 (Dl) and 6 (D6) of each period. There was no significant difference in blood pressure when compared as either 2‐hour intervals or 24‐hour global means: (placebo) 116/68 (Dl), 117/68 (D6); (PPA) 118/69 (Dl), 119/69 (D6). Our results document the absence of pressor effect with PPA in therapeutic doses even with repeated measurements and further confirm the reproducibility of 24‐hour blood pressure monitoring.

Early non‐invasive ventilation treatment for respiratory failure due to severe community‐acquired pneumonia

Severe community‐acquired pneumonia (sCAP) have been as defined pneumonia requiring admission to the intensive care unit or carrying a high risk of death. Currently, the treatment of sCAP consists of antibiotic therapy and ventilator support. The use of invasive ventilation causes several complications as does admission to ICU. For this reason, non‐invasive ventilation (NIV) has been used for acute respiratory failure to avoid endotracheal intubation. However, few studies have currently assessed the usefulness of NIV in sCAP.

Morning Insulin Requirements: Critique of Dawn and Meal Phenomena

Morning insulin resistance has frequently been invoked to explain early-morning increases in both basal and breakfast-associated insulin requirements in diabetic patients. This increase in insulin requirements and plasma glucose from 0600 to 0900, when compared with midnight to 0600, has been termed the dawn phenomenon. We believe that the increased need for insulin in the morning has been misinterpreted. Data are reviewed that suggest the major perturbation overnight is a sleep-associated fall in hepatic glucose output, with a return to basal production rates on arousal in the morning. Moreover, the apparent increased insulin requirement for breakfast compared with lunch or supper (meal phenomenon) appears to be related more to lack of residual insulin effect from a preceding meal than to any putative morning insulin resistance. Thus, we found little evidence to support morning insulin resistance as a cause of either the dawn phenomenon (more appropriately designated the sleep phenomenon) or the meal phenomenon. A proper understanding of these phenomena is essential to the management of diabetic patients receiving insulin.

Use of positive expiratory pressure during six minute walk test: results in patients with moderate to severe chronic obstructive pulmonary disease

BackgroundThe six-minute walk test (6MWT) is widely used because it is both simple and reliable as a measure of exercise capacity. Individuals with chronic obstructive pulmonary disease (COPD) usually show a limited capacity to perform exercise.MethodsOur study is a prospective, randomized controlled trial which uses the 6MWT in one hundred consecutive in and out- patients with moderate to severe COPD to assess the benefit of a simple positive expiratory pressure (PEP) device. PEP device consisted of a PEP valve 5 cmH2O connected to 1-meter tube and a mouthpiece. All the enrolled patients performed a 6MWT before randomization. The following day PEP group patients performed the 6MWT using PEP device. Control group patients performed the 6MWT without this device. The primary outcome was the difference in distance (meters) walked.ResultsFunctional capacity assessed by the distance covered during 6MWT improved in the PEP group more than in the control group. The difference was statistically significant (p < 0.001).Oxygen saturation improved to a statistically significant level during 6MWT (p < 0.01). Heart rate was also reduced (p < 0.03).ConclusionsThere are few studies demonstrating that PEP devices enhance exercise capacity in COPD patients. Our results has been obtained using only a low positive expiratory pressure (5 cmH2O). In our opinion the strength of this study is the simplicity and the lower cost when compared to other devices and approaches. The study was registered as Chi CTR-ORC-12002173 at http://www.chictr.org.

The use of non-invasive ventilation in very old patients with hypercapnic acute respiratory failure because of COPD exacerbation

We prospectively enrolled 207 patients (121 were 75 or older and 86 younger than 75) who were admitted to three Respiratory Monitoring Units. The primary outcomes were intubation and mortality rates; the secondary outcomes were changes in arterial blood gases analysis, non‐invasive ventilation (NIV) duration and length of hospital stay.

Non-invasive mechanical ventilation in elderly patients: A narrative review

The treatment of acute respiratory failure with non‐invasive ventilation (NIV) as a first‐line therapy is increasingly common in intensive care units. The reduced invasiveness of NIV leads to better outcomes than endotracheal intubation in carefully selected groups of patients. Furthermore, the use of NIV as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NIV also has an impact on the use of “do not intubate” orders. In the present narrative review, we explore the use and outcome of NIV in elderly patients. To accomplish this, we reviewed the most recent available medical literature. Geriatr Gerontol Int 2017; 17: 689–696.

Non-invasive ventilation in the treatment of sleep-related breathing disorders: A review and update.

Non-invasive mechanical ventilation (NIV) was originally used in patients with acute respiratory compromises or exacerbations of chronic respiratory diseases as an alternative to intubation. Over the last thirty years NIV has been used during the night in patients with stable chronic lung diseases such as obstructive sleep apnea, the overlap syndrome (COPD and obstructive sleep apnea), neuromuscular disorders, obesity-hypoventilation syndrome and in other conditions such as sleep disorders associated with congestive heart failure. In this review we discuss the different types of NIV, the specific conditions in which they can be used as well as the indications, recommendations, and evidence supporting the efficacy of NIV.