Lung transplantation as rescue therapy in patients too sick to be discharged from acute care

BACKGROUND

There is an increasing demand for lung transplantation in patients in advanced respiratory failure. Although many of these patients do not require mechanical ventilation or extracorporeal membrane oxygenation, an increasing number are critically ill. In this single-center study, we have analyzed our experience with lung transplantation in subjects who were inpatients at the time of their transplant and not expected to survive to discharge.

METHODS

Between July 2006 and March 2012, we performed 274 bilateral sequential lung transplants and 34 single-lung transplants. Twenty-six patients who were inpatients at the time of their transplant, and were not expected to survive to hospital discharge, formed the inpatient group in this retrospective review. The remaining 281 outpatient lung transplant patients formed the comparison group.

RESULTS

The inpatient group spent significantly fewer days on the waiting list compared to the outpatient group. Postoperative survival was significantly poorer in the inpatient group compared to the outpatient group (P = .001), and this was most noticeable in the first 90 days. There was no significant difference in survival between the inpatient transplant cohort and a historically comparable wait list cohort (P = .614).

CONCLUSION

Lung transplantation in critically ill inpatients, although associated with a survival advantage compared to not transplanting them, does give poorer survival results compared to postoperative survival in outpatient patients.

A comparison of non-integrating reprogramming methods

Human induced pluripotent stem cells (hiPSCs) are useful in disease modeling and drug discovery, and they promise to provide a new generation of cell-based therapeutics. To date there has been no systematic evaluation of the most widely used techniques for generating integration-free hiPSCs. Here we compare Sendai-viral (SeV), episomal (Epi) and mRNA transfection mRNA methods using a number of criteria. All methods generated high-quality hiPSCs, but significant differences existed in aneuploidy rates, reprogramming efficiency, reliability and workload. We discuss the advantages and shortcomings of each approach, and present and review the results of a survey of a large number of human reprogramming laboratories on their independent experiences and preferences. Our analysis provides a valuable resource to inform the use of specific reprogramming methods for different laboratories and different applications, including clinical translation.

Early skin toxicity predicts better outcomes, and early tumor shrinkage predicts better response after cetuximab treatment in advanced colorectal cancer

Cetuximab-containing treatments for metastatic colorectal cancer have been shown to have higher overall response rates and longer progression-free and overall survival than other systemic therapies. Cetuximab-related manifestations, including severe skin toxicity and early tumor shrinkage, have been shown to be predictors of response to cetuximab. We hypothesized that early skin toxicity is a predictor of response and better outcomes in patients with advanced colorectal carcinoma. We retrospectively evaluated 62 patients with colorectal adenocarcinoma who had unresectable tumors and were treated with cetuximab in our institution. Skin toxicity grade was evaluated on each treatment day. Tumor size was evaluated using computed tomography prior to treatment and 4-8 weeks after the start of treatment with cetuximab.Patients with early tumor shrinkage after starting treatment with cetuximab had a significantly higher overall response rate (P = 0.0001). Patients with early skin toxicity showed significantly longer overall survival (P = 0.0305), and patients with higher skin toxicity grades had longer progression-free survival (P = 0.0168).We have shown that early tumor shrinkage, early onset of skin toxicity, and high skin toxicity grade are predictors of treatment efficacy and/or outcome in patients with advanced colorectal carcinoma treated with cetuximab.

Terahertz phase contrast imaging of sorption kinetics in porous coordination polymer nanocrystals using differential optical resonator

The enhancement of light-matter coupling when light is confined to wavelength scale volumes is useful both for studying small sample volumes and increasing the overall sensing ability. At these length scales, nonradiative interactions are of key interest to which near-field optical techniques may reveal new phenomena facilitating next-generation material functionalities and applications. Efforts to develop novel chemical or biological sensors using metamaterials have yielded innovative ideas in the optical and terahertz frequency range whereby the spatially integrated response over a resonator structure is monitored via the re-radiated or leaked light. But although terahertz waves generally exhibit distinctive response in chemical molecules or biological tissue, there is little absorption for subwavelength size sample and therefore poor image contrast. Here, we introduce a method that spatially resolves the differential near-field phase response of the entire resonator as a spectral fingerprint. By simultaneously probing two metallic ring resonators, where one loaded with the sample of interest, the differential phase response is able to resolve the presence of guest molecules (e.g. methanol) as they are adsorbed or released within the pores of a prototypical porous coordination polymer.

The cellular building blocks of breathing

Respiratory brainstem neurons fulfill critical roles in controlling breathing: they generate the activity patterns for breathing and contribute to various sensory responses including changes in O2 and CO2. These complex sensorimotor tasks depend on the dynamic interplay between numerous cellular building blocks that consist of voltage-, calcium-, and ATP-dependent ionic conductances, various ionotropic and metabotropic synaptic mechanisms, as well as neuromodulators acting on G-protein coupled receptors and second messenger systems. As described in this review, the sensorimotor responses of the respiratory network emerge through the state-dependent integration of all these building blocks. There is no known respiratory function that involves only a small number of intrinsic, synaptic, or modulatory properties. Because of the complex integration of numerous intrinsic, synaptic, and modulatory mechanisms, the respiratory network is capable of continuously adapting to changes in the external and internal environment, which makes breathing one of the most integrated behaviors. Not surprisingly, inspiration is critical not only in the control of ventilation, but also in the context of "inspiring behaviors" such as arousal of the mind and even creativity. Far-reaching implications apply also to the underlying network mechanisms, as lessons learned from the respiratory network apply to network functions in general.

Effects of Gosha-jinki-gan (Chinese herbal medicine: Niu-Che-Sen-Qi-Wan) on hyperinsulinemia induced in rats fed a sucrose-rich diet

We investigated the effects of a Chinese herbal medicine, Gosha-jinki-gan (GJG), on the regulation of insulin levels in rats fed a sucrose-rich diet (SRD). Normal Wistar rats in the SRD group were fed an SRD for 4 weeks. Increased dietary sucrose did not alter plasma glucose levels but it increased plasma insulin levels at 2 and 4 weeks in the SRD-fed rats relative to control rats that were fed standard chow. GJG treatment significantly suppressed the SRD-induced elevation in plasma insulin levels. These results suggest that GJG improves hyperinsulinemia caused by an SRD.

[Anesthetic management of a patient with thrombocytopenia induced by methotrexate undergoing emergent clipping surgery]

A 70-year-old woman underwent emergent clipping surgery for subarachnoid hemorrhage under general anesthesia. Her laboratory data showed thrombocytopenia (4.0 x 10(4) microl(-1)). She had taken prednisolone (3 mg x day(-1)) and methotrexate (MTX) (10 mg x week(-1)) for rheumatoid arthritis for the last 10 years. Anesthesia was induced with remifentanil as well as propofol, maintained with remifentanil and sevoflurane in oxygen. The operation was performed uneventfully without platelet transfusion. Since the cause of thrombocytopenia was suspected to be MTX, we started rescue therapy by calcium folinate postoperatively. Platelet count was normalized two days later (11.6 x 10(4) microl(-1)). One month after the operation, she was discharged uneventfully.

Terahertz spectroscopy of the reactive and radiative near-field zones of split ring resonator

A terahertz microscope has been used to excite and observe the resonant modes of a single split ring resonator in the reactive and radiative near-field zones. The two lowest resonant modes of an isolated split ring resonator with their corresponding radiation patterns are reported; they showed good agreement to simulations. The passage from the reactive to radiative near-field zone is also discussed. Further, our result introduced a novel technique to perform terahertz time-domain spectroscopy of samples a few tens of micrometers in size by measuring the in-plane radiative near-field zone.

[Unexpectedly complicated laryngoscopy caused by a massive mandibular tori]

Here, we report a case of an unexpectedly complicated laryngoscopy caused by massive mandibular tori. A 64-year-old man with mitral regurgitation and aortic regurgitation was scheduled for a double valve replacement. Thyromental distance and the Mallampati score were used as predictive factors of difficult intubation, and both factors were within the normal range. Anesthesia with controlled ventilation was started with fentanyl, propofol and vecuronium. After the attainment of full muscle relaxation, an experienced anesthesiologist performed direct laryngoscopy. It was not possible to intubate the patient under direct laryngoscopy because of massive mandibular tori which had not been detected prior to induction. Following the failure of direct laryngoscopy, a McCoy laryngoscope and a gum elastic bougie were deployed to improve vision. Intubation with a 7.5 mm tube was successful at the third attempt. We hope our experience will serve as a reminder to clinicians that mandibular tori, although benign and without subjective symptoms, could have significant effects upon direct laryngoscopy by compromising the line of vision. Preoperative oral evaluation is critical and aggressive treatment should be considered.

Genome-scale epigenetic reprogramming during epithelial-to-mesenchymal transition

Epithelial-to-mesenchymal transition (EMT) is an extreme example of cell plasticity that is important for normal development, injury repair and malignant progression. Widespread epigenetic reprogramming occurs during stem cell differentiation and malignant transformation, but EMT-related epigenetic reprogramming is poorly understood. Here we investigated epigenetic modifications during EMT mediated by transforming growth factor beta. Although DNA methylation was unchanged during EMT, we found a global reduction in the heterochromatin mark H3 Lys9 dimethylation (H3K9Me2), an increase in the euchromatin mark H3 Lys4 trimethylation (H3K4Me3) and an increase in the transcriptional mark H3 Lys36 trimethylation (H3K36Me3). These changes depended largely on lysine-specific demethylase-1 (Lsd1), and loss of Lsd1 function had marked effects on EMT-driven cell migration and chemoresistance. Genome-scale mapping showed that chromatin changes were mainly specific to large organized heterochromatin K9 modifications (LOCKs), which suggests that EMT is characterized by reprogramming of specific chromatin domains across the genome.

Real-time terahertz near-field microscope

We report a terahertz near-field microscope with a high dynamic range that can capture images of a 370 x 740 μm2 area at 35 frames per second. We achieve high spatial resolution (14 μm corresponding to λ/30 for a center frequency at 0.7 THz) on a large area by combining two novel techniques: terahertz generation by tilted-pulse-front excitation and electro-optic balanced imaging detection using a thin crystal. To demonstrate the microscope capability, we reveal the field enhancement at the gap position of a dipole antenna after the irradiation of a terahertz pulse.

[Anesthetic management of a hemodialysis-dependent patient implanted with a CRT-D device undergoing an operation for perforated peritonitis]

A 53-year-old man was admitted to our hospital for hematochezia, and an emergency operation was scheduled for his perforated sigmoid colon. He had received a CRT-D (cardiac resynchronization therapy with defibrillator) device for dilated cardiomyopathy two years before and had been receiving hemodialysis for the past year. Anesthesia was induced with midazolam and remifentanil and maintained with remifentanil and sevoflurane in oxygen. Before surgery, we disabled the defibrillation function of the CRT-D device and changed its pacing mode from VVI to VOO, and electrodes of an external defibrillator were attached to the chest wall. Dopamine and norepinephrine were administered via a central venous catheter, and systolic blood pressure was maintained between 70 and 80 mmHg and CVP between 8 and 13 mmHg. Sigmoidectomy was performed and he was transferred to the ICU intubated. Although intensive care procedures, such as mechanical ventilation, continuous hemodiafiltration, and direct hemoperfusion with polymyxin B-immobilized fibers were performed, he died of multiple organ failure on postoperative day 48. CRT-D has become mainstream cardiac resynchronization therapy and will require attention for anesthetic management of patients implanted with the CRT-D device.

Epigenetic memory in induced pluripotent stem cells

Somatic cell nuclear transfer and transcription-factor-based reprogramming revert adult cells to an embryonic state, and yield pluripotent stem cells that can generate all tissues. Through different mechanisms and kinetics, these two reprogramming methods reset genomic methylation, an epigenetic modification of DNA that influences gene expression, leading us to hypothesize that the resulting pluripotent stem cells might have different properties. Here we observe that low-passage induced pluripotent stem cells (iPSCs) derived by factor-based reprogramming of adult murine tissues harbour residual DNA methylation signatures characteristic of their somatic tissue of origin, which favours their differentiation along lineages related to the donor cell, while restricting alternative cell fates. Such an 'epigenetic memory' of the donor tissue could be reset by differentiation and serial reprogramming, or by treatment of iPSCs with chromatin-modifying drugs. In contrast, the differentiation and methylation of nuclear-transfer-derived pluripotent stem cells were more similar to classical embryonic stem cells than were iPSCs. Our data indicate that nuclear transfer is more effective at establishing the ground state of pluripotency than factor-based reprogramming, which can leave an epigenetic memory of the tissue of origin that may influence efforts at directed differentiation for applications in disease modelling or treatment.

Near-field THz imaging of free induction decay from a tyrosine crystal

We demonstrate images of free induction decay (FID) signals from a grain of tyrosine in the near-field of the THz frequency region. By combining electro-optic sampling with a charge-coupled-device (CCD) camera, our near-field THz microscope allows us to visualize the electric field blinking with the FID signal with spatial resolution of better than 70 microm. The oscillating frequency of the FID signal centered at approximately 1 THz corresponds to the vibrational mode of the tyrosine crystal. These results confirm that the THz near-field microscope can take spectroscopic images with subwavelength spatial resolution (approximately lambda/4).

Comprehensive methylome map of lineage commitment from haematopoietic progenitors

Epigenetic modifications must underlie lineage-specific differentiation as terminally differentiated cells express tissue-specific genes, but their DNA sequence is unchanged. Hematopoiesis provides a well-defined model to study epigenetic modifications during cell-fate decisions, as multipotent progenitors (MPPs) differentiate into progressively restricted myeloid or lymphoid progenitors. While DNA methylation is critical for myeloid versus lymphoid differentiation, as demonstrated by the myeloerythroid bias in Dnmt1 hypomorphs1, a comprehensive DNA methylation map of hematopoietic progenitors, or of any multipotent/oligopotent lineage, does not exist. Here we examined 4.6 million CpG sites throughout the genome for MPPs, common lymphoid progenitors (CLPs), common myeloid progenitors (CMPs), granulocyte/macrophage progenitors (GMPs), and thymocyte progenitors (DN1, DN2, DN3). Dramatic epigenetic plasticity accompanied both lymphoid and myeloid restriction. Myeloid commitment involved less global DNA methylation than lymphoid commitment, supported functionally by myeloid skewing of progenitors following treatment with a DNA methyltransferase inhibitor. Differential DNA methylation correlated with gene expression more strongly at CpG island shores than CpG islands. Many examples of genes and pathways not previously known to be involved in choice between lymphoid/myeloid differentiation have been identified, such as Arl4c and Jdp2. Several transcription factors, including Meis1, were methylated and silenced during differentiation, suggesting a role in maintaining an undifferentiated state. Additionally, epigenetic modification of modifiers of the epigenome appears to be important in hematopoietic differentiation. Our results directly demonstrate that modulation of DNA methylation occurs during lineage-specific differentiation and defines a comprehensive map of the methylation and transcriptional changes that accompany myeloid versus lymphoid fate decisions.