European Journal of Clinical Nutrition (2006) 60, 870876

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ORIGINAL ARTICLE

Energy expenditure in underweight chronic obstructive pulmonary disease patients before and during a physiotherapy programme
n1 nberg2, A Nordenson2, S Larsson2 and L Hulthe F Slinde1, K Kvarnhult2,3, AM Gro
1 2

teborg University, Go teborg, Sweden; Department of Clinical Nutrition, Institute of Internal Medicine, Sahlgrenska Academy at Go teborg University, Department of Respiratory Medicine and Allergology, Institute of Internal Medicine, Sahlgrenska Academy at Go teborg, Sweden teborg, Sweden and 3Department of Physiotherapy, Sahlgrenska University Hospital, Go Go

Objective: To investigate how total daily energy expenditure (TEE) changes when underweight patients with chronic obstructive pulmonary disease (COPD) enters a physiotherapy programme. Design: Prospective intervention study. Setting: Sahlgrenska University Hospital, Go teborg, Sweden. Subjects: Fifteen patients with severe COPD and BMIo21 kg/m2 were recruited consecutively at the outpatient COPD unit at the Department of Respiratory Medicine. Fourteen patients completed the whole study. Intervention: TEE was assessed by the doubly labelled water method in a 2-week control period and during 2 weeks of physiotherapy. Energy intake was assessed using 7-day dietary record during control and physiotherapy period. Results: Mean TEE during physiotherapy period was 500 kJ (6%) lower than during control period but the difference was not statistically significant. Ten of the 14 patients had lower and four had higher TEE. Mean energy intake during the physiotherapy period did not change from the control period (7700 vs 7600 kJ/day). Conclusions: Since underweight patients with COPD may show variable TEE during physiotherapy compared to a control period, an assessment of individual energy requirements is recommended. Sponsorship: The Swedish Heart Lung Foundation, The Swedish Heart and Lung Association, The Swedish Nutrition Foundation, The Ingabritt and Arne Lundberg Foundation.

European Journal of Clinical Nutrition (2006) 60, 870876. doi:10.1038/sj.ejcn.1602392; published online 1 February 2006
Keywords: doubly labelled water; underweight; energy intake; nutrition; rehabilitation

Introduction
Chronic obstructive pulmonary disease (COPD) is a disease of complex nature in which not only primary impairment of the lungs and the airways have been demonstrated. Physio-

Correspondence: Dr F Slinde, Department of Clinical Nutrition, Sahlgrenska Academy at Go teborg University, PO Box 459, SE-405 30 Go teborg, Sweden. E-mail: frode.slinde@nutrition.gu.se Guarantor: F Slinde. Contributors: FS was responsible for the practical managing of all parts of the project and drafted the manuscript, KK was responsible for the physiotherapy program, AN was responsible for the medical surveillance and follow-up of the patients. All authors took part in the design of the study, interpretation of the results and writing the paper. Received 26 April 2005; revised 18 November 2005; accepted 9 December 2005; published online 1 February 2006

logic abnormalities in the structure and metabolism of the skeletal muscles have also been shown (Maltais et al., 1996; Casaburi, 2000). Rehabilitation programmes, including physiotherapy (mobility training, breathing exercises and physical exercise), nutritional support, psychotherapy and education, are recommended in international treatment guidelines for COPD patients (Siafakas et al., 1995; Ries et al., 1997). Lacasse et al. (2002) concluded in a Cochrane review that rehabilitation relieves dyspnea and fatigue, increases exercise capacity and improves quality of life. Physical exercise comprises activities aiming at maintaining and improving physical and psychological functions and restoring the physiologic balance in the skeletal muscles. Both aerobic exercise and peripheral muscle training are recommended for COPD patients (Cherniack, 1987). Aerobic exercise could be walking, stair climbing and cycling while

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peripheral muscle training could contain exercising with weights, pulleys and elastic rubber bands (Hodgkin, 1987). COPD rehabilitation programmes often include some kind of nutritional support or dietary intervention. A recent Cochrane review, including 11 studies, concluded that nutritional support had no significant effects in anthropometric measures, lung function or exercise capacity in patients with stable COPD (Ferreira et al., 2005). One of the explanations for this lack of effect was described to be that the judgement of energy expenditure might have been incorrect. We have shown slight, but uniform, indications of positive effects on body weight and physical performance of dietary intervention during multidisciplinary rehabilitation in a group of patients with severe COPD (Slinde et al., 2002). However, in the underweight patients, where one of the goals is to increase body weight, we found that the extra intake of energy was not sufficient to provide both an increase in physical performance and a gain in body weight. This fact raised the question concerning how much extra energy that is expended during a rehabilitation programme. To our knowledge, only one study has examined this thoroughly. Tang et al. (2002) compared 1 single day without rehabilitation exercise to 1 day including exercise using the bicarbonate urea method. In the 10 patients studied, the total daily energy expenditure (TEE) increased from a mean of 1508 to 1568 kcal/day (ns). A limitation of that study, as the authors state, was the short measurement time period, mainly dependent on the principles of the bicarbonateurea method. The doubly labelled water (DLW) method has made it possible to determine the TEE in free-living subjects. The technique is well established and validated both in animals and humans (Schoeller and van Santen, 1982; Schoeller, 1988), and is today considered to be the reference standard for assessment of TEE which is assessed with high precision without limiting the subjects way of life. The result represents energy expenditure for a relatively long period of time, in contrast to short-term measurements with major limitations in way of life using direct calorimetry. Baarends et al. (1997) studied 10 male COPD patients admitted to a pulmonary rehabilitation centre, using the DLW method, and found that the ratio between TEE and resting energy expenditure (REE) ranged from 1.5 to 2.0 compared with a range from 1.3 to 1.6 in healthy free-living controls. None has however studied the effect on energy expenditure before and during rehabilitation in COPD patients using the DLW technique. The aim of this study was therefore to investigate how TEE changes when underweight patients with COPD enters a physiotherapy programme using the DLW technique. which lasted for 4 weeks. Measurement of energy expenditure and assessment of energy intake was performed in both periods. Control period. At day 1, patients underwent measurements of body composition, resting energy expenditure and received a first dose of DLW for assessment of TEE. They were also instructed to record dietary intake during 7 consecutive days. Physical activity was assessed by an activity monitor (ActiReg) during the same 7 days as the dietary record. A visit at home was performed by the dietitian (FS) at day 8, to discuss and collect the food record, to check the use of medications and nicotine and to collect the activity monitor. On day 15, the patient delivered the urine samples for DLW analysis to the hospital and body weight was measured. Physiotherapy period. Measurements in the physiotherapy period were performed during the last 2 weeks of the 4-week long intervention. After 2 weeks of physiotherapy, the patient received the second dose of doubly labelled water at day 1 in the measurement period. They were instructed to record dietary intake during 7 days and the ActiReg recording was started. A visit at home was performed by the dietitian at day 8, to discuss and collect the food record and to collect the ActiReg. On the last day of the physiotherapy period (day 15 in the measurement period), the patient underwent measurement of body weight and delivered the urine samples.

Subjects Fifteen patients (five men and 10 women) with severe and stable COPD were included in this study. Severe COPD was diagnosed as forced expiratory volume in one second (FEV1)o50% predicted, as determined by criteria from The European Respiratory Society (Siafakas et al., 1995). All patients were recruited consecutively from the outpatient COPD unit at the Department of Respiratory Medicine, teborg, Sweden. IncluSahlgrenska University Hospital, Go sion criteria was body mass index (BMI)o21 kg/m2, as suggested as definition of underweight in COPD (Celli et al., 2004) and exclusion criteria were earlier performed rehabilitation, oxygen treatment, cancer, diabetes mellitus, hypothyreoidism, heart failure and angina pectoris during exercise test or other major diseases. The patients were informed of the nature and purpose of the study and gave written informed consent. The study was approved by the teborg. Ethics Research Committee of the University of Go

Subjects and methods

Study design Prior to the study pulmonary function tests were performed. A 2-week control period preceded a physiotherapy period

Pulmonary function tests Spirometry was performed with a Vitalograph spirometer (Selefa, Buckingham, Ireland) before and 15 min after inhalation of 1 mg terbutaline to reach optimal standardization. The European Coal and Steel Community (ECSC) European Journal of Clinical Nutrition

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reference values were used for prediction (Quanjer et al., 1993). Arterial blood gases (partial pressure of oxygen (PO2) and partial pressure of carbon dioxide (PCO2)) were measured in all patients. (ThermoFinnigan, Uppsala, Sweden). TEE was calculated by the multi-point method by linear regression from the difference between elimination constants of deuterium and oxygen-18, with the assumptions for fractionating as suggested by IAEA (International Dietary Energy Consultancy Group, 1990). The energy equivalence of the CO2 excreted was calculated from the macronutrient intake using estimated food quotient from the 7-day dietary record (Black et al., 1986). The relationship between pool size deuterium (ND) and pool size oxygen-18 (NO) was used as a quality measurement of the DLW analysis as proposed by IAEA (International Dietary Energy Consultancy Group, 1990).

Resting energy expenditure REE was measured by indirect calorimetry using a ventilatedhood system. The equipment used was a Deltatract II Metabolic Monitor (Datex, Helsinki, Finland). The equipment was calibrated with Quick Calt calibration gas (DatexOhmeda, Helsinki, Finland) constituting of 95% O2 and 5% CO2 according to the manufacturers instructions before each measurement. The subjects were instructed to limit their physical activity the evening before the measurement. All subjects were measured after an overnight fast and they arrived from their home by car or public transport. After a 30 min rest in the supine position, REE was measured during 30 min when the subjects were awake in the supine position. The measurements were performed in an environmental temperature between 22 and 231C. The presented mean REE for each patient is based on the last 25 min of the measurement.

Body composition Body weight was measured, with subjects wearing light clothing without shoes to the nearest 0.1 kg on a System 31 electronic scale (The Advanced Weighing Co. Ltd, New Haven, East Sussex, UK). Height was measured and determined to the nearest centimeter using a horizontal headboard with an attached wall-mounted metric rule (Hultafors, Sweden). BMI was calculated as weight (kg) divided by height2 (m). Body composition was measured with dual energy X-ray absorptiometry (Lunar Prodigy, GE Lunar Corp., Madison, USA) and fat-free mass index was calculated as fat free mass (kg) divided by height2 (m).

Dietary intake During the first 7 days of each measurement period, the patients recorded their total food and beverage intake with the help of household measures. On the home visit at day 8, the dietitian checked the food record and weighed the patients usual glasses, cups, pieces of bread etc. in order to calculate energy intake as accurate as possible. At the same time a list of drugs they used was collected for each patient. For nutrient calculation we used the nutrient program ringsdata AB, Bromma, Sweden) using Dietist (Kost och Na the Swedish Food Data Base from the National Food Administration (updated 31 March 2005). Data on the nutrient content of dietary supplements were added to the database.

Doubly labelled water TEE was determined by the DLW technique. TEE from the DLW method was measured over two 14-day periods (control and physiotherapy period). Sample analysis and calculation procedures have been described elsewhere (Slinde et al., 2003). Prior to dosing, a voiding was collected for determination of background isotope enrichment. The patients ingested a weighed mixture of deuteriated and oxygen-18enriched water, corresponding to 0.05 g of deuterium oxide (2H2O) and 0.10 g of oxygen-18-water (H18 2 O) per kilogram body weight. The dose was flushed down the throat with a glass of tap water. The exact time of dosing was recorded, an the subjects were equipped with 21 screw-capped glass vials to be filled with the second voiding from days 2, 3, 4, 8, 13, 14 and 15. Exact voiding times were recorded, and the urine samples were stored in the patients freezer before delivery to the laboratory. Samples were analysed in triplicates on a Finnigan MAT Delta Plus Isotope-Ratio Mass Spectrometer European Journal of Clinical Nutrition

Physical activity During the first 7 days of each measurement period, an ActiReg was used to monitor physical activity in the patients. The ActiReg is using combined recordings of body position and motion to measure physical activity (Hustvedt et al., 2004) and consists of two pairs of position and motion sensors connected by cables to a storage unit fixed to a waist belt. ActiReg has been shown to have good validity in patients with severe COPD (Arvidsson et al., 2005). Sensors were attached by medical tape to the chest and the right thigh and the patients were requested to use ActiReg continuously during 7 days, except during night and during bathing or taking a shower. The results were analysed in the computer program ActiCalc that enables calculation of the physical activity level (PAL) (Hustvedt et al., 2004).

The physiotherapy programme The physiotherapy programme took place at the Department of Physiotherapy, Sahlgrenska University Hospital. It comprised eight individual 90-min sessions (twice a week) of education and physical exercise plus a home-exercise programme. Education included some elements of basic anatomy, respiratory physiology and pathophysiology of COPD. Moreover, instructions on disease management and practical-coping skills were given. Physical exercises composed of mobility training, aerobic exercise on a treadmill

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and peripheral muscle training. All patients but two were managed by the same physiotherapist (KK). Practical-coping skills focused on managing breathlessness by breathing exercises and sputum removal techniques. Breathing exercises included the pursed-lip-breathing technique, breathing exercises with positive expiratory pressure using a BA tube and postural drainage. Instructions on coughing techniques were also given. Mobility training consisted of mobility exercises for the thoracic, shoulder girdle and neck muscles. Aerobic exercise was conducted on a treadmill (Power Jog, Sport Engineering Ltd, UK). Intensity and duration of exercise were based upon symptom scores, arterial oxygen saturation (SaO2) and the current level of physical activity. Degree of perceived breathlessness was assessed by the modified Borg-scale, scores 010 and the degree of perceived fatigue was assessed by the Borg-scale, scores 620. SaO2 was to be equal to or above 90%. If the SaO2 fell below 90%, supplemental oxygen was given. The speed and duration of the aerobic exercise was each session based upon symptom scores and SaO2. In peripheral muscle training muscle endurance was emphasized. Exercises were focused on the lower extremities and were related to functional activities. The intensity was set to 4080% of the repetition maximum. The 6-min walking distance test with assessment of perceived breathlessness and SaO2 every minute was performed at the first and last appointment with the physiotherapist and all patients had one training test before the study started. The home exercise programme was individualized and based on each patients needs, as judged by the physiotherapist. All patients were instructed to do breathing exercises, mobility training and peripheral muscle training. (Po0.05) difference between periods of 650 kJ (s.d. 850 kJ) (judged as clinically significant) with 80% power. Results are described as mean and s.d. Skewed variables (number of days between periods) are presented as median and range. Relation between number of days between period and change in TEE between periods was investigated using the s rank correlation coefficient rho (r). Paired twoSpearman sample t-test was used to compare body weight, energy intake and total energy expenditure between control and rehabilitation period and results were judged statistically significant if Po0.05.

Results
Patient characteristics Fourteen patients (five men and nine women) completed the whole study. One patient (patient no. 10) decided to drop out after 1 week of physiotherapy. She had 1 h travel by bus to the hospital and found it too strenuous to travel this distance twice a week. All presented results are based on the 14 patients completing the whole study. One patient had a BMI at 21.2 kg/m2. In the recruitment process the patient had a BMIo21 kg/m2, but her body weight had increased at inclusion to the study. We still considered her to be representative of the patients with underweight and severe COPD. Table 1 shows characteristics of the patients at inclusion and during the study. A significant increase in body weight, and hence BMI were observed during the control period, however, at the end of the rehabilitation period the body weight, and BMI were not statistically different from inclusion values. Median time between day 15 in the control period and day 1 in the physiotherapy period was 28 days. Owing to an exacerbation, one patient had a period of 7 months between control and physiotherapy period, for the other patients the time between control and physiotherapy ranged between six and 85 days.

Statistics Calculation of statistical power showed that inclusion of 15 patients would allow detection of a statistically significant

Table 1

Patient characteristics, lung function and body composition in 14 underweight COPD patients during control (C) and physiotherapy (PT) period Mean (s.d.) day 1 in C period Mean (s.d.) day 15 in C period 64 53.1 1.67 19.2 (8) (5.6)* (0.08) (1.9)*
b b b b b

Mean (s.d.) day 1 in PT period 64 53.3 1.66 19.3 (8) (6.0)* (0.8) (2.1)*
b b b b b

Mean (s.d.) day 15 in PT period 64 53.0 1.67 19.2 (8) (6.0) (0.8) (2.0)
b b b b b

Age (year) Weight (kg) Height (m) BMI (kg/m2) FEV1a (% pred) PO2c (kPa) PCO2d (kPa) FMe (kg) FFMIf (kg/m2)
a b

64 52.6 1.67 19.0 34 9.7 5.2 11.6 14.7

(8) (5.5) (0.08) (1.9) (9) (1.3) (0.6) (5.6) (1.8)

Forced expiratory volume in 1 s, as percentage of predicted. Not examined. c Arterial partial pressure of oxygen. d Arterial partial pressure of carbon dioxide. e Fat mass (kg). f Fat-free mass index. *Po0.05.

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Physiotherapy Ten of the 14 patients completing the physiotherapy programme attended seven or more of the eight appointments with the physiotherapist. One patient attended in four and three patients in six of the eight appointments. All patients, except one, performed an individualized homeexercise programme at least twice a week, but most of them several times a week. All patients, except two, performed both 6-min walking distance tests with a mean result of 366 m. No clinical relevant change (a reduction of 6 m) in mean distance was detected between the first and second test, however, there was a nonsignificant improvement in mean perceived breathlessness, assessed by the modified Borg-scale, from 3.3 to 2.7 (n.s.). SaO2 also improved nonsignificantly from a mean of 87% in the first test to 89% in the second test (n.s.). (n.s). There was no relation between change in PAL from ActiReg and change in TEE from DLW (Figure 2), and only eight of the patients had a change in the two variables indicating the same direction (either positive or negative change).

Discussion
In this study, we have found unexpected results concerning change in TEE when COPD patients were engaged in a physiotherapy programme. Some patients expended more energy, but most of them, contrary to our hypothesis, had a lower TEE during the physiotherapy, compared to a control

Change in body weight, TEE and energy intake As shown in Table 2, no statistically significant differences between control and physiotherapy period were found in any of the measurements. However, as presented in Figure 1, there were large individual variations in change in TEE. Ten of the patients had lower and four had higher TEE during 2 weeks of physiotherapy compared to the control period. Mean difference in TEE between the periods was 6% or 500 kJ per day, the difference did not reach statistical significance. This was not related to changes in body weight, the mean change in TEE/kg BW was an 8% reduction (11 kJ/ kg) (Po0.05). Change in TEE was positively correlated with number of days between period (r 0.73 (Po0.01)). Mean energy intake during the physiotherapy period did not change from the control period.

-40

-20

0 Change in percent

20

40

Figure 1 Changes (%) in total daily energy expenditure (TEE) from control to physiotherapy period for each of the 14 underweight COPD patients, each staple represent one patient.

% change in PAL (ActiReg) from control to physiotherapy period

Change in physical activity Owing to technical problems, two of the patients had no results from the ActiReg in the control period. The mean (s.d.) PAL in the remaining 12 patients was 1.52 (0.16) in the control period and 1.52 (0.25) in the physiotherapy period

20

10

Table 2 Resting energy expenditure, total daily energy expenditure and energy intake in 14 underweight COPD patients during control (C) period and physiotherapy (PT) period Mean (s.d.) C period REEa (kJ) TEEc (kJ) EId (kJ) TEEActiReg (kJ) TEE/REE EI/REE TEEActiReg/REE
a

-20

-10 -10

10

20

Mean (s.d.) PT period

b

5000 7700 7600 7500 1.53 1.50 1.52

(700) (1200) (2200) (1300) (0.18) (0.32) (0.16)

7200 7700 7500 1.44 1.53 1.52

(1400) (2200) (1400) (0.24) (0.33) (0.25)

-20 % change in TEE (DLW) from control to physiotherapy period

Resting energy expenditure. b Not examined. c Total daily energy expenditure. d Energy intake.

Figure 2 Change (%) in total energy expenditure (TEE) measured by doubly labelled water related to change (%) in physical activity level (PAL) measured by ActiReg between a control period and a physiotherapy period in 12 COPD patients.

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period. There were no statistically significant differences in TEE between the control and physiotherapy period. In a study in 11 healthy elderly (mean age 66 years), Goran and Poehlman (1992) found similar findings as in the current study. Mean TEE was not higher during a period of cycling exercises three times per week compared to a control period. They calculated that this was due to a compensatory decline in physical activity during the remainder of the day. Our finding is also consistent with the findings of Tang et al. (2002), even if they studied only one day. Tang et al. also suggested that lack of increase in TEE during rehabilitation in COPD patients may be caused by a decrease in the patients normal activity pattern. That means that the training sessions make the patients so feeble that they do not perform their usual activities. This does not seem to be the main explanation in the current study since the results from the activity monitor shows that this is not the case in most of the patients. The decrease in PAL from DLW (1.53 in control period to 1.44 in physiotherapy period) could not be seen in PAL from ActiReg (1.52 in both periods). Five of the patients have both a lower TEE and a lower PAL, indicating a lower physical activity as the reason for the lower TEE, while three patients have a higher TEE and a higher PAL, indicating increasing physical activity as the reason for the higher TEE. Three patients had a decrease in TEE and an increase in PAL while one patient had an increase in TEE and a decrease in PAL, indicating that other factors than physical activity might be the reason for the observed change in TEE. Other explanations must therefore be sought. One part of the physiotherapy is breathing exercises. The patients do exercise aiming at reducing breathlessness and learn techniques to cope with the experienced dyspnea. Oxygen cost of breathing has been shown to be elevated in COPD patients, especially underweight patients (Donahoe et al., 1989; Palange et al., 1995). When underweight COPD patients do breathing exercises, this could reduce the elevated oxygen cost of breathing and thereby could limit the increase in energy expenditure, one would expect to occur during a period of increased load of physical exercise. To our knowledge, this remains to be studied. Another possible explanation could be the effect of exercise on muscle metabolism. Studies have demonstrated that exercise training in COPD patients increase concentrations of enzymes facilitating oxidative metabolism, a smaller increase in blood lactic acid level after exercise, and a faster kinetics of oxygen uptake indicating a better aerobic function of the muscles (Casaburi, 2000). One could also argue that some of the patients did not fulfil all of the appointments with the physiotherapist, reducing the possibility to detect an increase in TEE. There was however no relation between compliance of physiotherapy and change in TEE between the periods. There was a significant correlation between change in TEE and number of days between control and physiotherapy period. The patients with a short period between control period and physiotherapy had the largest decrease in TEE. No apparent explanation for this could be found. This study was performed over relatively long time on patients having a severe chronic disease, so time between periods had to be made with consideration to each patients daily life, holidays, etc. TEE measured by doubly labelled water does not give information about day-to-day variation in TEE or time and intensity of physical activities performed, which is a limitation with the method. However, compared to measures like the bicarbonateurea method, which only give results from one day, DLW gives a long-term result. Owing to the design of this study, we cannot exclude the possibility that the patients have changed their activity pattern from the control period to the physiotherapy period, but the results from the ActiReg indicate that this is not the case. Furthermore, we have to bear in mind, that the patients had a severe COPD, hence they were sedentary in both periods. Sixty percent of the patients had a ratio between TEE and REE lower than 1.5, indicating a lower level of physical activity than the mean in a sample of healthy elderly (475 years old) men (Fuller et al., 1996). It might be surprising that we in the current study with a rather homogenous patient group from many aspects found a large variation in the relation between TEE and REE ranging from 1.24 to 1.90 in the control period preceding the period including physiotherapy. This is however in consistency with earlier findings of similar patient groups (Goris et al., 2003; Slinde et al., 2003). The main advantage in this study is the long study period and the use of reference standard techniques such as doubly labelled water and DXA. Since one of the main findings was the large variation between subjects in effect on TEE of physiotherapy, individual assessment of each patients energy requirement should be wished for in the future. Even if doubly labelled water is considered to be the reference standard method for assessment of TEE, the cost of the method limits its use in the clinical setting. Other methods have therefore to be considered. Alternatives currently available are subjective (e.g. activity recalls) or motion detectors (e.g. accelerometers). Steele et al. (2000) found no correlation between the outcome of a physical activity recall and a triaxial accelerometer in their study in COPD patients. They suggested that this could be due to the fact that motion detectors like accelerometers are able to cover all periods of physical activity, including low-intensity activities, which are difficult to recall, and these activities are dominating in patients with chronic diseases. The large variation in physical activity and energy expenditure shown in the present study and in other studies (Goris et al., 2003; Slinde et al., 2003) emphasize the importance of using methods which are precise in low-intensity activities as well as in moderate-to-high intensity activities. To conclude, inclusion in a physiotherapy programme is not necessarily followed by an increase in TEE. Contrary to what we expected, 10 out of 14 patients had a lower TEE during a period of physiotherapy compared to a control period. Hence, underweight patients with COPD may show European Journal of Clinical Nutrition

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a stable, increased or decreased TEE during a period with physiotherapy compared to a control period. This calls for individual assessment of each patients energy requirements.
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Acknowledgements
We acknowledge the assistance of Mrs Elisabeth Gramatkovski for performing the DLW analysis in the mass spectrometer and Mr Daniel Arvidsson for valuable advice concerning the ActiReg.

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