Diagnostic role of rapid on-site cytologic examination (ROSE) of broncho-alveolar lavage in ALI/ARDS

BACKGROUND

While bronchoscopy should be considered in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in which the cause cannot be determined from history or clinical and laboratory data, there are no studies about the utility of rapid on-site examination (ROSE) of broncho-alveolar lavage for identification, as early as possible, of the pathological condition underlying the onset of this condition. The aim of this prospective, observational study was to evaluate the diagnostic role of ROSE of BAL in ALI/ARDS.

METHODS

71 patients with ALI/ARDS underwent bronchoalveolar lavage, and one part of the sample was examined with ROSE. The on-site report was categorized as diagnostic (specific diagnosis), presence of atypical reactive type II pneumocytes with no further comments or not diagnostic.

RESULTS

ROSE of bronco-alveolar lavage yielded 29 (41%) specific diagnoses, revealed typical features of diffuse alveolar damage without a specific diagnosis in 28 patients (39%) and did not reveal a specific diagnosis in the remaining 14 cases (20%).

CONCLUSIONS

The results of this study show that, in patients with ALI/ARDS, bronchoalveolar lavage with ROSE is diagnostic in 40% of cases: ROSE may therefore spare lung biopsies and improve the prognosis of patients with ARDS (immunocompetent or not) as therapy could be started or modified at a very early phase.

Multidetector computed tomography (MDCT) for preoperative airway assessment in children with mucopolysaccharidoses

BACKGROUND

Accumulation of glycosaminoglycans is known to cause significant problems in the anesthetic management of children with mucopolysaccharidoses (MPS). Clinical and standard radiological evaluation may convey insufficient information about the upper airway and trachea in children with MPS. Multidetector computed tomography (MDCT) images have been used to define the central airway and previous studies have recommended this tool to assess the airway of children who are considered at risk of difficult intubation. However, MDCT has not been recommended in MPS children. The aim of this clinical scenario study was to verify whether information from MDCT reconstruction of the airway is useful in airway management planning of children with MPS.

METHODS

In a two phase questionnaire-based study, 26 pediatric anesthesiologists were asked to produce airway management plans for 5 children with MPS. An initial plan for airway control was reported after assessment of standard preoperative anesthetic charts. A subsequent airway strategy was then described after reviewing tracheal MDCT images of each patient.

RESULTS

MDCT images provided additional clinically-relevant information in 87% (95% CI: 79-92%) of the evaluations. Reduction of tracheal size was the most common finding provided by the MDCT images. After reviewing the MDCT images, anesthesiologists changed their primary airway device selection in 21% of the evaluations (P=0.01).

CONCLUSION

Airway reconstruction using MDCT images from a previous CT scan may provide a useful assessment tool for preoperative airway evaluation and planning in MPS children.

Bronchoalveolar lavage. Technical notes

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Endobronchial ultrasound in Dieulafoy's disease of the bronchus: an additional application of EBUS

Dieulafoy's disease is a rare vascular malformation represented by an abnormally enlarged submucosal arterial vessel. This malformation is mostly found in gastrointestinal tract causing spontaneous bleeding although a few cases have been described in the bronchial tree. Recognizing Dieulafoy's malformation is crucial for the bronchoscopist in order to avoid biopsy that can lead to a massive hemoptysis, sometimes fatal. In this case report we show the clinical utility of endobronchial ultrasound (EBUS) in the evaluation of bronchial alteration suspicious for Dieulafoy's malformation.

Pulmonary features of Birt-Hogg-Dubé syndrome: cystic lesions and pulmonary histiocytoma

BACKGROUND

to describe clinical, radiologic and pathologic features of lung lesions in Birt-Hogg-Dubè syndrome (BHDS) (MIM 135150).

METHOD

review of 12 patients of BHDS from 3 unrelated Italian families evaluated at GB Morgagni Hospital, Forlì, from 2005 to 2010.

RESULTS

mean age (±SD) at diagnosis was 44.6 (±16) years, 8 (66%) were male. All three index cases presented with a history of recurrent pneumothorax and/or cystic lung lesions evaluated by CT scan request by referring pulmonary physicians, none were diagnosed to have BHDS at the time of initial pulmonary evaluation. One of the three cases was a middle-aged female patient with a clinical phenotype indistinguishable from lymphangioleiomyomatosis (LAM), characterized by cystic lung lesions and kidney angiomyolipoma. In one case of BHDS presenting with recurrent pneumothorax and a solitary lung nodule, surgical lung resection revealed a pulmonary histiocytoma. In one case a novel mutation of BHD gene was detected (c.771 del, exon 7).

CONCLUSIONS

BHDS is associated with cystic lung disease largely under-recognized by pulmonary physicians and can mimic LAM and may be associated with lung tumor, pulmonary histiocytoma. In one case we found a novel mutation in exon 7, c.771 del (ref.seq. NM_144997.5) never reported before.

Idiopathic nonspecific interstitial pneumonia: an interstitial lung disease associated with autoimmune disorders?

Recent evidence suggests that idiopathic nonspecific interstitial pneumonia (iNSIP) is a distinct clinical entity amongst other idiopathic interstitial pneumonias, and some data seem to suggest a possible pathogenetic role of autoimmunity. The aim of the present study was to assess if iNSIP might represent an early lung manifestation of an autoimmune disease. After initial review of cases found in the medical records database by searching for the term "NSIP" (n = 63), 37 iNSIP cases were identified, and were re-evaluated using a dynamic integrated multidisciplinary approach. 27 cases with iNSIP were selected for the study. Mean ± sd age at first respiratory symptom was 54.2 ± 8 yrs, 70% were females, and 59% were never-smokers. At follow-up (mean ± sd 59.7 ± 29 months, range 12-138 months), autoimmune diseases occurred in 14 (52%) patients, with seven (26%) cases of autoimmune thyroiditis, six (22%) of undifferentiated connective tissue disease and three (11%) of connective tissue disease. Patients developing autoimmune diseases were older and more frequently never-smoking females. In >50% of patients diagnosed with iNSIP, evidence of autoimmune diseases develops within 2 yrs, suggesting a probable link between the clinical entity of iNSIP and autoimmune disorders.

Abstract P4-06-14: Induction of Blimp-1 in Breast Cancer Cells Is Mediated by Activator Protein-1 and Promotes Transforming Growth Factor (TGF)-ß-Induced Epithelial-to-Mesenchymal Transition

The vast majority of breast cancers has been shown to display aberrant constitutive expression of NF-kB subunits, which enhances their mobility and promotes their survival and malignancy. Recently, we demonstrated that the RelB NF-kB subunit promotes migration of breast cancer cells, in part via repression of estrogen receptor (ER)α transcription. Furthemore, we showed that inhibition of the ERα promoter was mediated by the zinc finger transcriptional repressor B lymphocyte-induced maturation protein (Blimp-1), transcribed from the PRDM1 gene, which is induced by RelB-mediated activation of a Bcl-2/Ras pathway. Indeed, we showed for the first time that Blimp-1 is present in breast cancer and is more highly expressed in ERα negative breast cancer cells where it plays an essential role in their migratory and invasive abilities. Blimp-1 is a well-known zinc finger repressor, which is critical for terminal differentiation of B and T cells and for migration of primordial germ cells. Here we have examined the mechanism of activation of Blimp-1 expression in breast cancer cells. Given the role of Ras to c-Raf signaling in migration of cancer cells, we tested the role of this downstream mediator. A constitutively active c-Raf led to induction of Blimp-1 in breast cancer lines while a dominant negative variant reduced its levels. RelB/p52 NF-kB complexes induced c-Jun, c-Fos, Fra-1 and Fra-2 Activator Protein-1 (AP-1) subunits, which activated the PRDM1 gene promoter. The transforming growth factor (TGF)-β induces a more mesenchymal phenotype of breast cancer cells. Treatment of NMuMG breast epithelial cells with TGF-β led to Blimp-1 activation through AP-1 and epithelial-to-mesenchymal transition (EMT). Importantly, Blimp-1 knockdown counteracted TGF-mediated EMT and wound healing in both NMuMG and MDA-MB-231 breast cells. Thus, activation of AP-1 complexes via a Ras/Raf/Erk signaling pathway mediates induction of PRDM1 gene transcription and Blimp-1 expression in ERα negative breast cancer cells, which is essential for TGF-β-induced mesenchymal phenotype. Therefore, downstream mediators of Blimp-1 activity might emerge as new therapeutic targets for treatment of patients with ERα negative breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-06-14.

Prospective evaluation of drug-induced lung toxicity with high-resolution CT and transbronchial biopsy

PURPOSE

This study compared the results of high-resolution computed tomography (HRCT) and cytohistology after transbronchial biopsy in the evaluation of drug-related interstitial lung disease (DR-ILD).

MATERIALS AND METHODS

Patients with a clinical and imaging diagnosis of DR-ILD were prospectively included in a study protocol lasting 5 years. All patients were evaluated by bronchoscopy with transbronchial biopsy or bronchoalveolar lavage (BAL) following an HRCT examination that raised a suspicion of DR-ILD. Two radiologists (one senior and one junior), unaware of the diagnosis, reported the single HRCT findings, their distribution and predominant pattern. In the event of disagreement, the diagnosis was subsequently reached by consensus. Cytohistological examination was considered the gold standard in the diagnosis of DR-ILD. Patients who were unable to undergo the endoscopic procedure were excluded from the study.

RESULTS

The study included 42 patients (25 men, 17 women; age range 20-84 years). Transbronchial biopsy was performed in all but four patients (one case of alveolar haemorrhage and three cases of lipoid pneumonia) in whom the diagnosis was established with BAL. Assessment of the HRCT images revealed the following patterns: noncardiogenic pulmonary oedema (n=13); organising pneumonia (OP) (n=9); hypersensitivity pneumonitis (HP) (n=2); alveolar haemorrhage (AH) (n=2); nonspecific interstitial pneumonia (NSIP) (n=5); lipoid pneumonia (LP) (n=1); sarcoid-like pattern (n=1). Cytohistological diagnosis revealed diffuse alveolar damage (DAD) in 11 patients, OP in seven, HP in three, AH in three, chronic interstitial pneumonia (CIP) in eight, LP in three and pseudosarcoidosis in one. Subdivision of the drugs into antineoplastic and nonantineoplastic agents showed that the most common patterns were CIP (n=6), DAD (n=2) and OP (n=2) in the antineoplastic group and DAD (n=9) and OP (n=5) in the nonantineoplastic group. Sensitivity and specificity of the radiological analysis was excellent, especially for patterns such as OP and DAD (sensitivity 0.86 and specificity 0.88 for OP; sensitivity 1 and specificity 0.93 for DAD).

CONCLUSIONS

HRCT demonstrated excellent sensitivity and specificity. In cases in which its specificity was low, HRCT was nonetheless useful for biopsy planning and clinical-radiological monitoring after discontinuation of the drug treatment.

The role of transbronchial lung biopsy for the diagnosis of diffuse drug-induced lung disease: a case series of 44 patients

At present, no studies have evaluated the role of bronchoscopic transbronchial lung biopsy (TBLB) in the diagnosis of diffuse drug-induced lung disease (DILD), and there is no consensus for a definite diagnostic workup approach for this rare clinical entity. The aim of the present study was to evaluate the clinical usefulness of TBLB in diffuse DILD. This study was a retrospective analysis of patients with diffuse DILD, who underwent bronchoscopy. The role of TBLB was assessed to determine whether the histological results are useful for the final diagnosis. Over a 5-yr period, 44 patients underwent bronchoscopy, and all had a bronchoalveolar lavage (BAL). Thirty-three of the 44 patients underwent TBLB (75%), and the results of TBLB were diagnostically helpful in 25 (75.7%) of the procedures. No histopathologic abnormality was identified in 6 (18%) of the 33 patients. In 2 patients (6%) the obtained samples were not adequate, since no lung parenchyma was obtained. No severe complications related to bronchoscopic procedures occurred. In conclusion, TBLB is a safe procedure, and is diagnostically helpful in the majority of cases of patients with diffuse DILD. Histological data obtained by TBLB further corroborate clinical, laboratory, radiologic and BAL results for a definitive diagnosis of diffuse DILD.

Haemorheological profile in patients with systemic sclerosis

The relationship between rheological alterations and systemic sclerosis (SSc) is not well established. We have determined in 27 patients with SSc (4 male, 21 female ) aged 59 +/- 14 years and in a well matched control group the whole rheological profile, i.e. blood viscosity (BV), plasma viscosity (PV), erythrocyte aggregation (EA), erythrocyte deformability (ED) along with fibrinogen (Fbg), C-reactive protein (CRP), lipids, and erythrocyte indices. Patients show higher Fbg, PV and EA (P<0.01) and lower ED (P<0.01). A negative significant correlation was found between ED and inflammation markers, both CRP (P<0.05) and Fbg (P<0.01), indicating that decreased ED seems to be related to inflammatory changes at microcirculatory levels. In addition, patients with anticentromere antibodies show significantly lower ED than those without (P<0.05). The clinical significance of this observation needs to be clarified, deserving further research.

Alignments and clinical results in conventional and navigated total knee arthroplasty

In this prospective, randomized, controlled study, we compared the performance of conventional and navigated total knee arthroplasties. Component alignment was measured in 60 patients operated on using navigation and in 60 patients operated on using the conventional technique. The groups then were divided into a subpopulation to measure alignments of the distal femoral cuts in the three anatomic planes, the proximal tibial cut in the frontal and sagittal planes, and the resulting lower limb mechanical axis in the frontal plane. Postoperative weightbearing long-view radiographs were evaluated as were clinical results using three standard questionnaires at 28 months followup. The intraoperative measurements (mean +/- standard deviation) at the resection planes showed navigated surgeries result in more accurate alignments than conventional surgeries for the femur: in the frontal plane, 0.1 degrees +/- 0.9 degrees and 0.7 degrees +/- 1.6 degrees valgus, respectively; in the sagittal plane, 1.1 degrees +/- 1.8 degrees and 2.8 degrees +/- 2.0 degrees flexion; and in the transversal plane, 0.1 degrees +/- 1.2 degrees and 0.9 degrees +/- 1.7 degrees internal rotation. The navigated technique also reduced the number of cases with final mechanical axes greater than 3 degrees from 20.0% to 1.7%. Postoperative radiographs showed better component alignment using navigation, particularly at the femur. However, clinical scoring systems showed this radiographic improvement did not necessarily result in a better clinical outcome at short-term followup.

Near-fatal asthma phenotype in the ENFUMOSA Cohort

BACKGROUND

Near-fatal asthma (NFA) is characterized by severe asthma attacks usually requiring intensive care unit admission. This phenotype of asthma has been studied mainly in acute conditions.

METHODS

The aim of our study was to compare the clinical, functional and inflammatory characteristics of NFA patients with mild to severe asthmatics in stable conditions. We recruited 155 asthmatic patients from five centres of the European Network for Understanding Mechanisms of Severe Asthma: 67 patients with mild-to-moderate asthma controlled by low/medium doses of inhaled corticosteroids; 64 with severe asthma that, despite treatment with high doses of inhaled corticosteroids, long-acting beta2-agonists and for 1/3 also with regular oral corticosteroids, had at least one asthma exacerbation in the previous year; 24 with an NFA episode in the previous 5 years in the absence of inclusion criteria for the previous groups. All the patients were examined in stable conditions.

RESULTS

NFA patients were taking less corticosteroids and were less compliant to prescribed asthma medications than the other two groups of patients. Lung function, blood gases, atopic status, sputum and blood inflammatory cell count of NFA patients were similar to mild-to-moderate, but not severe, asthmatic patients.

CONCLUSIONS

In stable conditions patients with an NFA attack in the previous 5 years cannot be distinguished from patients with mild-to-moderate asthma, while they are different from severe asthmatics both in terms of lung function and of airway inflammation. The risk factor that characterizes this group of patients is reduced usage of prophylactic corticosteroids.

Significant impact of survivin on myeloma cell growth

Survivin is a fascinating member of the inhibitor of apoptosis protein (IAP) family with its dual roles in mitosis and apoptosis, and emerges as an attractive target for cancer therapy. Multiple myeloma (MM) is a plasma cell malignancy, characterized by deregulated proliferation, cell-death processes and fatal outcome. We thus investigated survivin expression in myeloma cells and its role in MM biology to evaluate its potential interest as a target in MM treatment. Our results describe the cancer-specific overexpression of survivin in myeloma cells and show a significant correlation between survivin expression at protein level and clinical course of MM. Moreover, survivin knockdown by RNA interference led to growth rate inhibition of myeloma cells related to apoptosis induction and deep cell-cycle disruption. Finally, survivin knockdown sensitized myeloma cells to conventional anti-myeloma agents. Altogether, these data argue for the interest to evaluate survivin antagonists in MM treatment.

Pattern VEP alterations in psoriatic patients may indicate a sub clinic optic neuritis

We examined 44 subject (Group A) of both sexes (27 males and 17 females) aging between 16 and 80 (average: 45+/-16.6), divided into age bands, affected by mild-medium psoriasis with PASI (psoriasis area and severity index) between 1.2 and 48.6 (average: 11.2+/-9.7) without any other disease and we performed pattern transient VEP (Visual Evoked Potential) at the frequencies usually used in clinical experience (73', 36', 18' check size). For a good statistic comparison we choose 55 healthy subjects (group B) divided into age bands on which we performed the same test. Comparison of VEP parameters between psoriatic and healthy subjects, showed in group A 10 normal (22.7%) and 34 pathological (77.3%). In the latter group there are 16 subjects who show only a P100 reduced amplitude (36.3%), 3 with only increased latency (6.8%), 15 with alterations of both values (34%). The achieved data show that more than 3/4 of group A subjects have VEP alterations as index of the presence of a sub clinic optic neuritis with a probably toxic autoimmune origin due to the action of TNFalpha, of IgG, of ECP or of other cytokines (IL6, IL7, etc) that are increased in the blood of this patients. The electro physiologic monitoring of optic nerve seems to represent a good routine test to evaluate the global conditions of psoriatic patients.

Determination of moisture fraction in wood by mobile NMR device

A mobile NMR probe has been used as a non-destructive and non-invasive tool for water content analysis on wood samples. The porosity index, express as the fraction of the sensitivity volume of the probe occupied by water, is here proposed as an alternative to the moisture content index, namely the amount of water mass with respect to the mass of dried sample. In principle the method can be applied to any kind of porous media that has not detectable proton signal from the rigid matrix as, for instance, in building materials. In wood, where proton signal can be detected also from cellulose and others macromolecular components, some considerations and artifices are here proposed for eliminating this contribution. The method has allowed performing moisture volume fraction analysis on wood samples characterized by different wood species, cutting and moisture contents. The NMR data of moisture detection as volume fraction have successfully been compared with those obtained by the gravimetric method.

Rehabilitation of COPD patients: which training modality

Non pharmacological therapy has been gaining more interest and has been evolving rapidly over the last decade as an essential part of therapy for COPD patients. Pulmonary Rehabilitation (PR), the most important non pharmacological treatment in patients with COPD, has a primary goal: to achieve the highest possible level of individual exercise tolerance, thus reducing the primary and/or secondary health care utilisation. The aim of the present review is to focus the role of exercise training in these patients as well as to address the question on which training methods are the most beneficial. We have therefore undertaken a MEDLINE-based search including the terms: pulmonary rehabilitation, exercise, lung disease/obstructive. Several strategies based on endurance or strength training are nowadays implemented during PR programmes in order to maximise the benefits for each patient. The impaired function of ambulation muscles causing breathlessness as one of the more frequent symptoms in many COPD, suggests that training the lower extremities is the most important goal to achieve during pulmonary rehabilitation of these patients. On the other hand, as muscle strength appears to be an independent contributor to survival and utilisation of health care resources, it seems largely justified also to include this further modality in the PR program of these patients. In conclusion, both modalities are effective and useful for COPD patients. However, whether resistance training should be administered to all COPD and which is the optimal length of strength training still needs to be elucidated.

Psychic and occlusal factors in bruxers

BACKGROUND

The aim of this study was to investigate the existence of associations between bruxism and psychic and occlusal factors.

METHODS

Participants in this study (n=85) were recruited from the Section of Odontostomatology, Deparent of Neuroscience, University of Pisa, Italy. They were split into two groups, bruxers (n=34) and non-bruxers (n=51), on the basis of the presence of both clinical and anamnestical indicators of bruxim. All participants were administered two self-reported validated questionnaires to evaluate (MOODS-SR) and panic-agoraphobic (PAS-SR) spetra. A number of occlusal variables (deep-bite: cross-bite, open-bite, mediotrusive and laterotrusive interferences, slide RCP-ICP, laterotrutsive guides, canine and molar classes) were also recorded.

RESULTS

With regards to occlusal factors, the only association was revealed between bruxism mediotrusive interferences (p < 0.05). As for psychiatric investigation, significant differences between bruxers and controls emerged for the presence of both depressive (p < 0.01) and manic symptoms (p < 0.01) in MOODS-SR, and for stress sensitivity (p < 0.01), anxious expectation (p < 0.05), and reassurance sensitivity symptoms (p < 0.05) in PAS-SR. In particular, both mood (p < 0.01) and panic-agoraphobic (p < 0.05) spectra symptoms seem to differentiate bruxers from controls in males, while in females strong differences emerged for stress sensitivity symptoms (p < 0.05).

CONCLUSIONS

It can be confirmed that certain psychic traits are present in bruxers, while occlusal factors are not useful parameters to discern bruxers from non-bruxers.