Effect of Nasal Obstruction on Continuous Positive Airway Pressure Treatment: Computational Fluid Dynamics Analyses

Objective

Nasal obstruction is a common problem in continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea and limits treatment compliance. The purpose of this study is to model the effects of nasal obstruction on airflow parameters under CPAP using computational fluid dynamics (CFD), and to clarify quantitatively the relation between airflow velocity and pressure loss coefficient in subjects with and without nasal obstruction.

Methods

We conducted an observational cross-sectional study of 16 Japanese adult subjects, of whom 9 had nasal obstruction and 7 did not (control group). Three-dimensional reconstructed models of the nasal cavity and nasopharynx with a CPAP mask fitted to the nostrils were created from each subject’s CT scans. The digital models were meshed with tetrahedral cells and stereolithography formats were created. CPAP airflow simulations were conducted using CFD software. Airflow streamlines and velocity contours in the nasal cavities and nasopharynx were compared between groups. Simulation models were confirmed to agree with actual measurements of nasal flow rate and with pressure and flow rate in the CPAP machine.

Results

Under 10 cmH₂O CPAP, average maximum airflow velocity during inspiration was 17.6 ± 5.6 m/s in the nasal obstruction group but only 11.8 ± 1.4 m/s in the control group. The average pressure drop in the nasopharynx relative to inlet static pressure was 2.44 ± 1.41 cmH₂O in the nasal obstruction group but only 1.17 ± 0.29 cmH₂O in the control group. The nasal obstruction and control groups were clearly separated by a velocity threshold of 13.5 m/s, and pressure loss coefficient threshold of approximately 10.0. In contrast, there was no significant difference in expiratory pressure in the nasopharynx between the groups.

Conclusion

This is the first CFD analysis of the effect of nasal obstruction on CPAP treatment. A strong correlation between the inspiratory pressure loss coefficient and maximum airflow velocity was found.     

Abdominal Muscle Activity during Mechanical Ventilation Increases Lung Injury in Severe Acute Respiratory Distress Syndrome

ObjectiveIt has proved that muscle paralysis was more protective for injured lung in severe acute respiratory distress syndrome (ARDS), but the precise mechanism is not clear. The purpose of this study was to test the hypothesis that abdominal muscle activity during mechanically ventilation increases lung injury in severe ARDS.MethodsEighteen male Beagles were studied under mechanical ventilation with anesthesia. Severe ARDS was induced by repetitive oleic acid infusion. After lung injury, Beagles were randomly assigned into spontaneous breathing group (BIPAP_SB) and abdominal muscle paralysis group (BIPAP_AP). All groups were ventilated with BIPAP model for 8h, and the high pressure titrated to reached a tidal volume of 6ml/kg, the low pressure was set at 10 cmH₂O, with I:E ratio 1:1, and respiratory rate adjusted to a PaCO₂ of 35–60 mmHg. Six Beagles without ventilator support comprised the control group. Respiratory variables, end-expiratory volume (EELV) and gas exchange were assessed during mechanical ventilation. The levels of Interleukin (IL)-6, IL-8 in lung tissue and plasma were measured by qRT-PCR and ELISA respectively. Lung injury scores were determined at end of the experiment.ResultsFor the comparable ventilator setting, as compared with BIPAP_SB group, the BIPAP_AP group presented higher EELV (427±47 vs. 366±38 ml) and oxygenation index (293±36 vs. 226±31 mmHg), lower levels of IL-6(216.6±48.0 vs. 297.5±71.2 pg/ml) and IL-8(246.8±78.2 vs. 357.5±69.3 pg/ml) in plasma, and lower express levels of IL-6 mRNA (15.0±3.8 vs. 21.2±3.7) and IL-8 mRNA (18.9±6.8 vs. 29.5±7.9) in lung tissues. In addition, less lung histopathology injury were revealed in the BIPAP_AP group (22.5±2.0 vs. 25.2±2.1).ConclusionAbdominal muscle activity during mechanically ventilation is one of the injurious factors in severe ARDS, so abdominal muscle paralysis might be an effective strategy to minimize ventilator-induce lung injury.     

Positive Expiratory Pressure Improves Oxygenation in Healthy Subjects Exposed to Hypoxia

Introduction

Positive end-expiratory pressure (PEEP) is commonly used in critical care medicine to improve gas exchange. Altitude sickness is associated with exaggerated reduction in arterial oxygenation. We assessed the effect of PEEP and pursed lips breathing (PLB) on arterial and tissue oxygenation under normobaric and hypobaric hypoxic conditions.

Methods

Sixteen healthy volunteers were exposed to acute normobaric hypoxia (Laboratory study, FiO₂=0.12). The protocol consisted in 3-min phases with PEEPs of 0, 5 or 10 cmH₂O, PLB or similar ventilation than with PEEP-10, interspaced with 3-min phases of free breathing. Arterial (pulse oximetry) and quadriceps (near-infrared spectroscopy) oxygenation, ventilation, cardiac function, esophageal and gastric pressures and subjects’ subjective perceptions were recorded continuously. In addition, the effect of PEEP on arterial oxygenation was tested at 4,350 m of altitude in 9 volunteers breathing for 20 min with PEEP-10 (Field study).

Results

During the laboratory study, PEEP-10 increased arterial and quadriceps oxygenation (arterial oxygen saturation +5.6±5.0% and quadriceps oxyhemoglobin +58±73 µmol.cm compared to free breathing; p<0.05). Conversely, PLB did not increase oxygenation. Oxygenation improvement with PEEP-10 was accompanied by an increase in expiratory esophageal and gastric pressures (esophageal pressure swing +5.4±3.2 cmH₂O, p<0.05) but no change in minute ventilation, breathing pattern, end-tidal CO₂ or cardiac function (all p>0.05) compared to PEEP-0. During the field study, PEEP-10 increased arterial oxygen saturation by +6.7±6.0% after the 3^rd minute with PEEP-10 without further significant increase until the 20^th minute with PEEP-10. Subjects did not report any significant discomfort with PEEP.

Conclusions

These data indicate that 10-cmH₂O PEEP significantly improves arterial and muscle oxygenation under both normobaric and hypobaric hypoxic conditions in healthy subjects. PEEP-10 could be an attractive non-pharmacological tool to limit blood oxygen desaturation and possibly symptoms at altitude.     

Introgression and confirmation of everbearing trait in strawberry (Fragaria x ananassa Duch.)

The present investigation was targeted towards a highly desirable everbearing trait in strawberry (Fragaria × ananassa Duch.) via marker assisted selection while seeing its worldwide commercial applicability through the extended harvest season. The crosses were made between everbearing and june-bearing cultivars to raise the F₁ individuals. Morphological characters (plant, floral, and fruit) were assessed that showed significant differences among the strawberry cultivars. Molecular characterization was carried out between everbearing and non-everbearing cultivars using RAPD and SSR markers. For phenotyping, a chi-square test was performed and revealed that out of all four cross combinations, the best fitted cross found to be in Mendelian segregation ratio (1:1) was ‘Confectura’ × ‘Torrey’ with χ²-value 1.58. Further, the identified polymorphic markers were assessed across the F₁ individuals of cross ‘Confectura’ × ‘Torrey’ for its genotyping. It could be revealed that the targeted everbearing trait is governed by a dominant gene(s) in the subjected strawberry genotypes. Further, the identified polymorphic markers would be successfully employed in DNA fingerprinting of strawberry under various crop improvement programme.Supplementary informationThe online version of this article (10.1007/s12298-020-00916-w) contains supplementary material, which is available to authorized users.     

In Vitro Surfactant and Perfluorocarbon Aerosol Deposition in a Neonatal Physical Model of the Upper Conducting Airways

Objective

Aerosol delivery holds potential to release surfactant or perfluorocarbon (PFC) to the lungs of neonates with respiratory distress syndrome with minimal airway manipulation. Nevertheless, lung deposition in neonates tends to be very low due to extremely low lung volumes, narrow airways and high respiratory rates. In the present study, the feasibility of enhancing lung deposition by intracorporeal delivery of aerosols was investigated using a physical model of neonatal conducting airways.

Methods

The main characteristics of the surfactant and PFC aerosols produced by a nebulization system, including the distal air pressure and air flow rate, liquid flow rate and mass median aerodynamic diameter (MMAD), were measured at different driving pressures (4–7 bar). Then, a three-dimensional model of the upper conducting airways of a neonate was manufactured by rapid prototyping and a deposition study was conducted.

Results

The nebulization system produced relatively large amounts of aerosol ranging between 0.3±0.0 ml/min for surfactant at a driving pressure of 4 bar, and 2.0±0.1 ml/min for distilled water (H₂Od) at 6 bar, with MMADs between 2.61±0.1 µm for PFD at 7 bar and 10.18±0.4 µm for FC-75 at 6 bar. The deposition study showed that for surfactant and H₂Od aerosols, the highest percentage of the aerosolized mass (∼65%) was collected beyond the third generation of branching in the airway model. The use of this delivery system in combination with continuous positive airway pressure set at 5 cmH₂O only increased total airway pressure by 1.59 cmH₂O at the highest driving pressure (7 bar).

Conclusion

This aerosol generating system has the potential to deliver relatively large amounts of surfactant and PFC beyond the third generation of branching in a neonatal airway model with minimal alteration of pre-set respiratory support.     

Molecular Mechanisms,Thermodynamics, and Dissociation Kinetics of Knob-Hole Interactions in Fibrin

Polymerization of fibrin, the primary structural protein of blood clots and thrombi, occurs through binding of knobs ‘A’ and ‘B’ in the central nodule of fibrin monomer to complementary holes ‘a’ and ‘b’ in the γ- and β-nodules, respectively, of another monomer. We characterized the A:a and B:b knob-hole interactions under varying solution conditions using molecular dynamics simulations of the structural models of fibrin(ogen) fragment D complexed with synthetic peptides GPRP (knob ‘A’ mimetic) and GHRP (knob ‘B’ mimetic). The strength of A:a and B:b knob-hole complexes was roughly equal, decreasing with pulling force; however, the dissociation kinetics were sensitive to variations in acidity (pH 5–7) and temperature (T = 25–37 °C). There were similar structural changes in holes ‘a’ and ‘b’ during forced dissociation of the knob-hole complexes: elongation of loop I, stretching of the interior region, and translocation of the moveable flap. The disruption of the knob-hole interactions was not an “all-or-none” transition as it occurred through distinct two-step or single step pathways with or without intermediate states. The knob-hole bonds were stronger, tighter, and more brittle at pH 7 than at pH 5. The B:b knob-hole bonds were weaker, looser, and more compliant than the A:a knob-hole bonds at pH 7 but stronger, tighter, and less compliant at pH 5. Surprisingly, the knob-hole bonds were stronger, not weaker, at elevated temperature (T = 37 °C) compared with T = 25 °C due to the helix-to-coil transition in loop I that helps stabilize the bonds. These results provide detailed qualitative and quantitative characteristics underlying the most significant non-covalent interactions involved in fibrin polymerization.     

Particle Size Concentration Distribution and Influences on Exhaled Breath Particles in Mechanically Ventilated Patients

Humans produce exhaled breath particles (EBPs) during various breath activities, such as normal breathing, coughing, talking, and sneezing. Airborne transmission risk exists when EBPs have attached pathogens. Until recently, few investigations had evaluated the size and concentration distributions of EBPs from mechanically ventilated patients with different ventilation mode settings. This study thus broke new ground by not only evaluating the size concentration distributions of EBPs in mechanically ventilated patients, but also investigating the relationship between EBP level and positive expiratory end airway pressure (PEEP), tidal volume, and pneumonia. This investigation recruited mechanically ventilated patients, with and without pneumonia, aged 20 years old and above, from the respiratory intensive care unit of a medical center. Concentration distributions of EBPs from mechanically ventilated patients were analyzed with an optical particle analyzer. This study finds that EBP concentrations from mechanically ventilated patients during normal breathing were in the range 0.47–2,554.04 particles/breath (0.001–4.644 particles/mL). EBP concentrations did not differ significantly between the volume control and pressure control modes of the ventilation settings in the mechanically ventilated patients. The patient EBPs were sized below 5 µm, and 80% of them ranged from 0.3 to 1.0 µm. The EBPs concentrations in patients with high PEEP (> 5 cmH₂O) clearly exceeded those in patients with low PEEP (≤ 5 cmH₂O). Additionally, a significant negative association existed between pneumonia duration and EBPs concentration. However, tidal volume was not related to EBPs concentration.     

Perceived Stress and Coping Strategies in Relation to Body Mass Index: Cross-Sectional Study of 12,045 Japanese Men and Women

BackgroundAccumulated evidence suggests a weak positive relationship between psychosocial stress and body mass index (BMI), but little is known about stress coping strategies and BMI.ObjectiveWe aimed to examine if perceived stress and coping strategies are related to BMI, with any of their mutual interactions on BMI.MethodsThis cross-sectional study included 5,063 men and 6,982 women aged 40-69 years. A self-administered questionnaire ascertained perceived stress and 5 items of coping strategies (emotion expression, emotional support seeking, positive reappraisal, problem solving, and disengagement). Analyses were performed by gender with adjustment for age, socioeconomic status, and lifestyle factors.ResultsNo significant associations were detected between perceived stress and BMI in either men (P_trend = 0.09) or women (P_trend = 0.58). In men, however, ‘disengagement’ showed an inverse association with BMI (P_trend < 0.001), and ‘positive reappraisal’ and ‘problem solving’ revealed a positive association with BMI (P_trend = 0.04 and 0.007, respectively) even after controlling for perceived stress. A possible interaction between perceived stress and ‘disengagement’ on BMI was found in men (P_interaction = 0.027); the inverse association between ‘disengagement’ and BMI was more evident in higher levels of stress (β = −0.13, P_trend = 0.21 in low; β = −0.22, P_trend = 0.01 in medium; and β = −0.24, P_trend = 0.06 in high). In men, ‘disengagement’ was inversely associated with overweight/obesity (odds ratio 0.79, 95% confidential interval 0.67-0.95), and “positive reappraisal” was positively associated with it (1.25, 1.02-1.54).ConclusionsCoping strategies may have an important role in developing overweight/obesity, particularly in men.     

Nasal Continuous Positive Airway Pressure Inhibits Gastroesophageal Reflux in Newborn Lambs

BackgroundUsing esophageal pHmetry, nasal CPAP (nCPAP) has been shown to decrease acid gastroesophageal reflux (GER) in adult humans. Although both GER (mainly non-acid) and nCPAP use are very frequent in newborns, the effect of nCPAP on GER in early life is unknown. Having recently shown that the newborn lamb is a unique model for studying neonatal GER, our main objective was to assess the effect of nCPAP on GER in newborn lambs.MethodsEight newborn lambs, aged 2–3 days, were studied. Continuous esophageal pH-Impedance monitoring and polysomnography were performed for six hours during both spontaneous breathing and nCPAP application at 6 cmH₂O (nCPAP6), in a randomized order. Results were compared in the two experimental conditions, as well as without CPAP during the following 6 hours.Resultsi) nCPAP₆ virtually abolished GER [mean ±SD reflux number for 6 h = 9.1±8.6 without nCPAP₆ vs. 0.6±1 with nCPAP₆, P<0.05]; ii) GER number was also reduced during the 6 h-period following nCPAP6 application (18±16 without nCPAP₆ vs. 7±8.1 with nCPAP₆, P<0.05); iii) nCPAP₆ decreased the depth and duration of lower esophageal sphincter relaxation.ConclusionsnCPAP inhibits GER in the newborn lamb. Further clinical studies using different levels of nasal CPAP are needed to confirm this result in human infants.     

X-ray micro-tomography of Carboniferous stem-Dictyoptera: new insights into early insects

Computer reconstructions of Archimylacris eggintoni, a Carboniferous stem-group dictyopteran (‘roachoid’), are presented. A siderite-hosted specimen was scanned using high-resolution X-ray microtomography (µCT), and a ‘virtual fossil’ was created with a resolution of 17.7 µm. This has revealed the morphology in great detail, including adhesive limb structures indicative of climbing and specializations for rapid movement. The antennae are filiform, and the mandibles are comparable to those of certain extant cockroaches, suggesting a similar generalist, saprophagous diet. The reconstruction reveals a high degree of specialization, and provides insights into the mode of life of these common Palaeozoic insects. Further µCT study of insect fossils has the potential to supplement wing venation with new characters, and hence improve fossil insect phylogenies.     

Recognition of 5-aminouracil (U(#)) in the central strand of a DNA triplex: orientation selective binding of different third strand bases

A necessary feature of the natural base triads for triplex formation is the requirement of a purine (A or G) in the central position, since only these provide sets of two hydrogen bond donors/acceptors in the major groove of the double helix. Pyrimidine bases devoid of this feature have incompatible complementarity and lead to triplexes with lower stability. This paper demonstrates that 5-aminouracil (U^#) (I), a pyrimidine nucleobase analogue of T in which 5-methyl is replaced by 5-amino group, with hydrogen bonding sites on both sides, is compatible in the central position of triplex triad X*U^#·A, where X = A/G/C/T/2-aminopurine (AP), and * and · represent Hoogsteen and Watson–Crick hydrogen bonding patterns respectively. A novel recognition selectivity based on the orientation (parallel/antiparallel) of the third strand purines A, G or AP with A in the parallel motif (A_p*U^#·A), and G/AP in the antiparallel motif (G_ap/AP_ap*U^#·A) is observed. Similarly for pyrimidines in the third strand, C is accepted only in a parallel mode (C_p*U^#·A). Significantly, T is recognised in both parallel and antiparallel modes (T_p/T_ap*U^#·A), with the antiparallel mode being stable compared to the parallel one. The ‘U^#’ triplexes are also more stable than the corresponding control ‘T’ triplexes. The results expand the lexicon of triplex triads with a recognition motif consisting of pyrimidine in the central strand.     

A Four-Way Comparison of Cardiac Function with Normobaric Normoxia,Normobaric Hypoxia,Hypobaric Hypoxia and Genuine High Altitude

BackgroundThere has been considerable debate as to whether different modalities of simulated hypoxia induce similar cardiac responses.ResultsAll 14 subjects completed the experiment at GHA, 11 at NN, 12 under NH, and 6 under HH. The four groups were similar in age, sex and baseline demographics. At baseline rest right ventricular (RV) systolic pressure (RVSP, p = 0.0002), pulmonary vascular resistance (p = 0.0002) and acute mountain sickness (AMS) scores were higher and the SpO₂ lower (p<0.0001) among all three hypoxic groups (GHA, NH and HH) compared with NN. At both 15 minutes and 120 minutes post exercise, AMS scores, Cardiac output, septal S’, lateral S’, tricuspid S’ and A’ velocities and RVSP were higher and SpO₂ lower with all forms of hypoxia compared with NN. On post-test analysis, among the three hypoxia groups, SpO₂ was lower at baseline and 15 minutes post exercise with GHA (89.3±3.4% and 89.3±2.2%) and HH (89.0±3.1 and (89.8±5.0) compared with NH (92.9±1.7 and 93.6±2.5%). The RV Myocardial Performance (Tei) Index and RVSP were significantly higher with HH than NH at 15 and 120 minutes post exercise respectively and tricuspid A’ was higher with GHA compared with NH at 15 minutes post exercise.ConclusionsGHA, NH and HH produce similar cardiac adaptations over short duration rest despite lower SpO₂ levels with GHA and HH compared with NH. Notable differences emerge following exercise in SpO_2, RVSP and RV cardiac function.     

Osmometry with single Sephadex beads

1. The measurement of osmotic pressure by means of a single bead of Sephadex (Edmond, Farquhar, Dunstone & Ogston, 1968) has been made more precise by immobilizing the bead on a fine needle. The design, calibration and use of the osmometer are described. 2. The method is particularly suitable for measuring high osmotic pressures in solutions of high-molecular-weight solutes, which must not penetrate the Sephadex to a significant extent. 3. With Sephadex G-50 the limit of precision is about 1.5cmH₂O and the lower limit of molecular weight for a solute of compact molecular form is about 10⁵. 4. The time required for each equilibration is less than 10min. 5. An impaled bead can be stored in the dry state without affecting its calibration. 6. Measurements on a sample of polyvinyl alcohol, degree of polymerization stated as 1750±50, gave ¯m_n 43000±3000 and A₂ (6.0±0.24)×10⁻⁴.     

Synthesis and crystal structure of an octamer RNA r(guguuuac)/r(guaggcac) with G.G/U.U tandem wobble base pairs: comparison with other tandem G.U pairs

We have determined the crystal structure of the RNA octamer duplex r(guguuuac)/r(guaggcac) with a tandem wobble pair, G·G/U·U (motif III), to compare it with U·G/G·U (motif I) and G·U/U·G (motif II) and to better understand their relative stabilities. The crystal belongs to the rhombohedral space group R3. The hexagonal unit cell dimensions are a = b = 41.92 Å, c = 56.41 Å, and γ = 120°, with one duplex in the asymmetric unit. The structure was solved by the molecular replacement method at 1.9 Å resolution and refined to a final R factor of 19.9% and R_free of 23.3% for 2862 reflections in the resolution range 10.0–1.9 Å with F ≥ 2σ(F). The final model contains 335 atoms for the RNA duplex and 30 water molecules. The A-RNA stacks in the familiar head-to-tail fashion forming a pseudo-continuous helix. The uridine bases of the tandem U·G pairs have slipped towards the minor groove relative to the guanine bases and the uridine O2 atoms form bifurcated hydrogen bonds with the N1 and N2 of guanines. The N2 of guanine and O2 of uridine do not bridge the ‘locked’ water molecule in the minor groove, as in motifs I and II, but are bridged by water molecules in the major groove. A comparison of base stacking stabilities of motif III with motifs I and II confirms the result of thermodynamic studies, motif I > motif III > motif II.     

Predicting Recovery of Voluntary Upper Extremity Movement in Subacute Stroke Patients with Severe Upper Extremity Paresis

DesignProspective cohort study.Methods140 (out of 590) stroke patients with severe UE paresis completed all assessments. Voluntary UE movement was assessed using the UE subscale of the Stroke Rehabilitation Assessment of Movement (STREAM-UE). Two outcome measures, STREAM-UE scores at discharge (DC_STREAM-UE) and changes between admission and discharge (Δ_STREAM-UE), were investigated to represent the final states and improvement of the recovery of voluntary UE movement. Stepwise regression analyses were used to investigate 19 clinical variables and to find the best predictive models of the two outcome measures.ResultsThe participants showed wide variation in both DC_STREAM-UE and Δ_STREAM-UE. 3.6% of the participants almost fully recovered at discharge (DC_STREAM-UE > 15). A large improvement (Δ_STREAM-UE >= 10) occurred in 16.4% of the participants, while 32.9% of the participants did not have any improvement. The four predictors for the DC_STREAM-UE (R² = 35.0%) were ‘baseline STREAM-UE score’, ‘hemorrhagic stroke’, ‘baseline National Institutes of Health Stroke Scale (NIHSS) score’, and ‘cortical lesion excluding primary motor cortex’. The three predictors for the Δ_STREAM-UE (R² = 22.0%) were ‘hemorrhagic stroke’, ‘baseline NIHSS score’, and ‘cortical lesion excluding primary motor cortex’.ConclusionsRecovery of voluntary UE movement varied widely in patients with severe UE paresis after stroke. The predictive power of clinical variables was poor. Both results indicate the complex nature of voluntary UE movement recovery in patients with severe UE paresis after stroke.     

Effect of PEEP and Tidal Volume on Ventilation Distribution and End-Expiratory Lung Volume: A Prospective Experimental Animal and Pilot Clinical Study

Introduction

Lung-protective ventilation aims at using low tidal volumes (V_T) at optimum positive end-expiratory pressures (PEEP). Optimum PEEP should recruit atelectatic lung regions and avoid tidal recruitment and end-inspiratory overinflation. We examined the effect of V_T and PEEP on ventilation distribution, regional respiratory system compliance (C_RS), and end-expiratory lung volume (EELV) in an animal model of acute lung injury (ALI) and patients with ARDS by using electrical impedance tomography (EIT) with the aim to assess tidal recruitment and overinflation.

Methods

EIT examinations were performed in 10 anaesthetized pigs with normal lungs ventilated at 5 and 10 ml/kg body weight V_T and 5 cmH₂O PEEP. After ALI induction, 10 ml/kg V_T and 10 cmH₂O PEEP were applied. Afterwards, PEEP was set according to the pressure-volume curve. Animals were randomized to either low or high V_T ventilation changed after 30 minutes in a crossover design. Ventilation distribution, regional C_RS and changes in EELV were analyzed. The same measures were determined in five ARDS patients examined during low and high V_T ventilation (6 and 10 (8) ml/kg) at three PEEP levels.

Results

In healthy animals, high compared to low V_T increased C_RS and ventilation in dependent lung regions implying tidal recruitment. ALI reduced C_RS and EELV in all regions without changing ventilation distribution. Pressure-volume curve-derived PEEP of 21±4 cmH₂O (mean±SD) resulted in comparable increase in C_RS in dependent and decrease in non-dependent regions at both V_T. This implied that tidal recruitment was avoided but end-inspiratory overinflation was present irrespective of V_T. In patients, regional C_RS differences between low and high V_T revealed high degree of tidal recruitment and low overinflation at 3±1 cmH₂O PEEP. Tidal recruitment decreased at 10±1 cmH₂O and was further reduced at 15±2 cmH₂O PEEP.

Conclusions

Tidal recruitment and end-inspiratory overinflation can be assessed by EIT-based analysis of regional C_RS.     

Trading Off Global Fuel Supply,CO2 Emissions and Sustainable Development

The United Nations Conference on Climate Change (Paris 2015) reached an international agreement to keep the rise in global average temperature ‘well below 2°C’ and to ‘aim to limit the increase to 1.5°C’. These reductions will have to be made in the face of rising global energy demand. Here a thoroughly validated dynamic econometric model (Eq 1) is used to forecast global energy demand growth (International Energy Agency and BP), which is driven by an increase of the global population (UN), energy use per person and real GDP (World Bank and Maddison). Even relatively conservative assumptions put a severe upward pressure on forecast global energy demand and highlight three areas of concern. First, is the potential for an exponential increase of fossil fuel consumption, if renewable energy systems are not rapidly scaled up. Second, implementation of internationally mandated CO₂ emission controls are forecast to place serious constraints on fossil fuel use from ~2030 onward, raising energy security implications. Third is the challenge of maintaining the international ‘pro-growth’ strategy being used to meet poverty alleviation targets, while reducing CO₂ emissions. Our findings place global economists and environmentalists on the same side as they indicate that the scale up of CO₂ neutral renewable energy systems is not only important to protect against climate change, but to enhance global energy security by reducing our dependence of fossil fuels and to provide a sustainable basis for economic development and poverty alleviation. Very hard choices will have to be made to achieve ‘sustainable development’ goals.     

Very Preterm Infants Failing CPAP Show Signs of Fatigue Immediately after Birth

Objective

To investigate the differences in breathing pattern and effort in infants at birth who failed or succeeded on continuous positive airway pressure (CPAP) during the first 48 hours after birth.

Methods

Respiratory function recordings of 32 preterm infants were reviewed of which 15 infants with a gestational age of 28.6 (0.7) weeks failed CPAP and 17 infants with a GA of 30.1 (0.4) weeks did not fail CPAP. Frequency, duration and tidal volumes (VT) of expiratory holds (EHs), peak inspiratory flows, CPAP-level and FiO₂-levels were analysed.

Results

EH incidence increased <6 minutes after birth and remained stable thereafter. EH peak inspiratory flows and VT were similar between CPAP-fail and CPAP-success infants. At 9-12 minutes, CPAP-fail infants more frequently used smaller VTs, 0-9 ml/kg and required higher peak inspiratory flows. However, CPAP-success infants often used large VTs (>9 ml/kg) with higher peak inspiratory flows than CPAP-fail infants (71.8 ± 15.8 vs. 15.5 ± 5.2 ml/kg.s, p <0.05). CPAP-fail infants required higher FiO₂ (0.31 ± 0.03 vs. 0.21 ± 0.01), higher CPAP pressures (6.62 ± 0.3 vs. 5.67 ± 0.26 cmH₂O) and more positive pressure-delivered breaths (45 ± 12 vs. 19 ± 9%) (p <0.05)

Conclusion

At 9-12 minutes after birth, CPAP-fail infants more commonly used lower VTs and required higher peak inspiratory flow rates while receiving greater respiratory support. VT was less variable and larger VT was infrequently used reflecting early signs of fatigue.     

Crystal structure of 9-amino-N-[2-(4-morpholinyl)ethyl]-4-acridinecarboxamide bound to d(CGTACG)2: implications for structure–activity relationships of acridinecarboxamide topoisomerase poisons

The structure of the complex formed between d(CGTACG)₂ and 9-amino-N-[2-(4-morpholinyl)ethyl]-4-acridinecarboxamide, an inactive derivative of the antitumour agents N-[2-(dimethylamino)ethyl]acridine-4-carboxamide (DACA) and 9-amino-DACA, has been solved to a resolution of 1.8 Å using X-ray crystallography. The complex crystallises in the space group P6₄ and the final structure has an overall R factor of 21.9%. A drug molecule intercalates between each of the CpG dinucleotide steps with its side chain lying in the major groove, and its protonated morpholino nitrogen partially occupying positions close to the N7 and O6 atoms of guanine G2. The morpholino group is disordered, the major conformer adopting a twisted boat conformation that makes van der Waals contact with the O4 oxygen of thymine T3. A water molecule forms bridging hydrogen bonds between the 4-carboxamide NH and the phosphate group of guanine G2. Sugar rings are found in alternating C3′-exo/C2′-endo conformations except for cytosine C1 which is C3′-endo. Intercalation perturbs helix winding throughout the hexanucleotide compared with B-DNA, steps 1 and 2 being unwound by 10 and 8°, respectively, while the central TpA step is overwound by 11°. An additional drug molecule lies at the end of each DNA helix linking it to the next duplex to form a continuously stacked structure. The protonated morpholino nitrogen of this ‘end-stacked’ drug hydrogen bonds to the N7 atom of guanine G6, and its conformationally disordered morpholino ring forms a C–H···O hydrogen bond with the guanine O6 oxygen. In both drug molecules the 4-carboxamide group is internally hydrogen bonded to the protonated N10 atom of the acridine ring. We discuss our findings with respect to the potential role played by the interaction of the drug side chain and the topoisomerase II protein in the poisoning of topoisomerase activity by the acridinecarboxamides.