Lung transplantation for primary and secondary pulmonary hypertension

BACKGROUND

Single lung transplantation (SLT) and bilateral lung transplantation (BLT) are routinely performed in patients with primary pulmonary hypertension (PPH) and secondary pulmonary hypertension (SPH). It is unclear which procedure is preferable. We reviewed our experience with lung transplants for PPH and SPH to determine if any advantage exists with SLT or BLT for either PPH or SPH.

METHODS

We reviewed the outcomes of all lung transplants performed for PPH or SPH for 4.5 years (July 1995 to January 2000). Survival was reported by the Kaplan-Meier method, and log rank analysis was used to determine significance. Statistical analyses of clinical data were performed using analysis of variance and chi2 analysis.

RESULTS

A total of 57 recipients met criteria for pulmonary hypertension with a mean pulmonary artery pressure of greater than or equal to 30 mm Hg. There were 15 patients with PPH and 40 patients with SPH. There were 6 patients who had SLTs and 9 patients who had BLTs in the PPH group; and there were 9 patients who had SLTs and 21 patients who had BLTs in the SPH group. We found a survival advantage for PPH patients who underwent BLTs at all time points up to 4 years (100% vs 67%; p < or = 0.02). There was no clear advantage to SLTs or BLTs for SPH. At 4 years there was a trend toward improved survival with SLTs (91% vs 75%) in SPH patients with a mean pulmonary artery pressure less than or equal to 40 mm Hg (p < or = 0.11) with equivalent survival (80%) in patients with a mean pulmonary artery pressure greater than or equal to 40 mm Hg. There was also a trend toward improved survival in patients with a mean pulmonary artery pressure greater than or equal to 40 mm Hg (PPH and SPH) with BLTs (88% vs 62%; p = 0.19). The incidence of rejection, infection, and other complications was comparable between SLTs and BLTs in each group.

CONCLUSIONS

We believe that BLT is the procedure of choice for PPH. The procedure of choice is less clear for SPH. Patients with SPH and a mean pulmonary artery pressure greater than 40 mm Hg may benefit from a BLT and those with a mean pulmonary artery pressure less than or equal to 40 mm Hg may do better with an SLT; however, no clear advantage is seen.

[The spectroscopic study of the iodine beta-cyclodextrin complexes]

In this paper, the iodine beta-cyclodextrin complexes prepared in different techniques were investigated by Fourier transformation infrared spectrum(FTIR), FT-Raman, Ultra-violet absorption spectrum in qualitative and quantitative analysis. Results showed that the iodine existed in dissociated, bundle and polymerized forms in the complexes. Contras to the method of alcohol craft, the sample prepared in water craft method included a higher capacity of iodine, but it was not stable enough to keep a constant high iodine concentration. This analysis method was simple and convenient, it is useful for quality control of the iodine beta-cyclodextrin complexes raw material medicine.

Collapsin response mediator protein-1 and the invasion and metastasis of cancer cells

BACKGROUND

Numerous genetic changes are associated with metastasis and invasion of cancer cells. To identify differentially expressed invasion-associated genes, we screened a panel of lung cancer cell lines (CL(1-0), CL(1-1), CL(1-5), and CL(1-5)-F(4) in order of increasing invasive activity) for such genes and selected one gene, collapsin response mediator protein-1 (CRMP-1), to characterize.

METHODS

We used a microarray containing 9600 gene sequences to assess gene expression in the cell panel and selected the differentially expressed CRMP-1 gene for further study. We confirmed the differential expression of CRMP-1 with northern and western blot analyses. After transfecting and overexpressing CRMP-1 in highly invasive CL(1-5) cells, the cells were assessed morphologically and with an in vitro invasion assay. We used enhanced green fluorescent protein-tagged CRMP-1 and fluorescence microscopy to localize CRMP-1 intracellularly. CRMP-1 expression in 80 lung cancer specimens was determined by real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR). All statistical tests were two-sided.

RESULTS

Expression of CRMP-1 was inversely associated with invasive activity in the cell panel, an observation confirmed by northern and western blot analyses. CRMP-1-transfected CL(1-5) cells became rounded and had fewer filopodia and statistically significantly lower in vitro invasive activity than untransfected cells (all P< .001). During interphase, CRMP-1 protein was present uniformly throughout the cytoplasm and sometimes in the nucleus; during mitosis, CRMP-1 was associated with mitotic spindles, centrosomes, and the midbody (in late telophase). Real-time RT-PCR of lung cancer specimens showed that reduced expression of CRMP-1 was statistically significantly associated with advanced disease (stage III or IV; P = .010), lymph node metastasis (N1, N2, and N3; P =.043), early postoperative relapse (P = .030), and shorter survival (P = .016).

CONCLUSIONS

CRMP-1 appears to be involved in cancer invasion and metastasis and may be an invasion-suppressor gene.

Cigarette smoking is strongly associated with mutation of the K-ras gene in patients with primary adenocarcinoma of the lung

BACKGROUND

The majority of lung carcinoma cases occur in current or former smokers. K-ras gene mutations are common in lung adenocarcinoma and have been associated with cigarette smoking, asbestos exposure, and female gender.

METHODS

In the current study, the authors examined the contribution of cigarette smoking to K-ras gene mutations in patients with primary lung adenocarcinoma. Smoking histories were obtained from 106 prospectively enrolled patients with primary adenocarcinoma of the lung.

RESULTS

K-ras mutations were detected in the primary tumor using an allele-specific ligation assay. Ninety-two of the 106 patients (87%) with lung adenocarcinoma were smokers. Nonsmokers with this tumor were more likely to be women (11 of 14; 79%), whereas the majority of smokers (57%) were men. K-ras mutations were detected in 40 of 106 tumors (38%) and were significantly more common in smokers compared with nonsmokers (43% vs. 0%; P = 0.001).

CONCLUSIONS

The results of the current study confirm and extend previous observations that smokers with adenocarcinoma of the lung are more likely to have K-ras mutant tumors compared with nonsmokers. The strong link between cigarette smoking and K-ras mutations in adenocarcinoma of the lung supports the role of specific tobacco carcinogens in the etiology of this malignancy.

Global analysis of gene expression in invasion by a lung cancer model

Metastasis is a complicated multistep process that involves interactions between cancer cells and their surrounding microenvironments. Previously, we have established a series of lung adenocarcinoma cell lines with varying degrees of invasiveness. Tracheal graft assay confirmed that cell lines with higher in vitro invasiveness had greater in vivo invasive potential. In this study, we used these model cell lines to identify invasion-associated genes using cDNA microarray with colorimetric detection. A more invasive subline, CL 1-5-F 4, derived from metastatic lung tumor of severe combined immunodeficient mice inoculated with CL 1-5 cells, was combined with CL 1-0, CL 1-1, and CL 1-5 in cDNA microarray screening. cDNA microarray membranes, each containing 9600 nonredundant expressed sequence tag clones, were used to identify differentially expressed genes in these cell lines. For statistical analysis, self-organizing map algorithm was performed to identify the expression patterns. Positive correlation between gene expression levels and cell line invasiveness was found in 2.9% of the 9600 putative genes. On the other hand, negative correlation was found in 3.3% of the genes. The trends of expression of some of the genes were also confirmed by Northern hybridization and flow cytometry. Our data demonstrated that genes related to cell adhesion, motility, angiogenesis, signal transduction, and some other expressed sequence tag genes may play significant roles in the metastasis process. These results substantiate the model system with which one can identify invasion-associated genes by using cDNA microarray and cancer cell lines of different invasiveness. This technique may allow us to explore complex interactions between multiple genes that orchestrate the process of cancer metastasis.

Eosinophilic infiltrates in a pulmonary allograft: a case and review of the literature

An unusual case of peribronchial eosinophilic infiltrates associated with peripheral blood eosinophilia in a lung transplant patient is described. The role that eosinophils play in lung allograft rejection is reviewed. Tissue eosinophils have been associated with acute pulmonary allograft rejection. Although, eosinophils in bronchoalveolar lavage fluid (BAL) have been observed in allograft rejection, this relationship is less well defined. The role of eosinophils in the pathophysiology of allograft rejection is unclear.

[Correlations of father's attitudes regarding breast feeding, father-infant attachment and marital adjustment]

The purposes of this study were to examine the relationships of fathers' attitudes regarding breast feeding, father-infant attachment, marital adjustment, and partner's feeding method, and explore the predictors of fathers' attitudes regarding breast-feeding and partner's feeding method. A descriptive correlational method of investigation was implemented. A total of 210 fathers were recruited to participate in this study from the Kaohsiung City area. The results of this study were: (1) Fathers' attitudes regarding breast feeding were positive. (2) Fathers of breast-fed infants showed significantly more positive attitudes to breast feeding and significantly better marital adjustment. (3) Father's attitudes regarding breast-feeding, father-infant attachment, were positively or related with marital adjustment. (4) The best subsets to predict fathers' attitudes regarding breast-feeding included partner's feeding method, socioeconomic status, marital adjustment, and whether they had participated in deciding the feeding method; together, these subsets accounted for 20% of the total variance. (5) The best subsets to predict partner's feeding method were parity and father's attitudes regarding breast-feeding. This study reveals the importance of evaluating fathers' attitudes regarding breast-feeding and marital adjustment in terms of enhancing family-centered nursing and breast-feeding compliance.

Trial of a novel synthetic sealant in preventing air leaks after lung resection

BACKGROUND

Postoperative air leaks are a major cause of morbidity after lung resections. This study was designed to evaluate the efficacy and safety of a new synthetic, bioresorbable surgical sealant in preventing air leaks after pulmonary resection.

METHODS

In a multicenter trial, 172 patients undergoing thoracotomy were randomized intraoperatively in a 2:1 ratio to receive surgical sealant applied to sites at risk for air leak after standard methods of lung closure (treatment group) or to have standard lung closure only (control group). The primary outcome variable was the percentage of patients free of air leakage throughout hospitalization. Secondary outcome variables were the control of air leaks intraoperatively and the time to postoperative air leak cessation. Time to chest tube removal, time to hospital discharge, and safety outcomes were also evaluated.

RESULTS

Air leaks were identified before randomization in 89 of 117 patients in the treatment group and in 39 of 55 patients in the control group. Application of the sealant resulted in control of air leaks in 92% of treated patients (p < or = 0.001). A significantly higher percentage of treated patients than control patients remained free of air leaks during hospitalization (39% versus 11%, p < or =0.001). The mean times to last observable air leak were 30.9 hours in the treatment group and 52.3 hours in the control group (p = 0.006). In the treatment group, trends were observed for reduced time to chest tube removal and earlier discharge. No significant difference was identified in postoperative morbidity and mortality between the two groups.

CONCLUSIONS

Air leaks after lung resection occur in most patients. The application of this novel surgical sealant appears to be effective and safe in preventing postoperative air leaks.

TT virus infection in screened Taiwanese blood donors

OBJECTIVE

TT virus (TTV) is a newly discovered human DNA virus of uncertain clinical significance. The aim of this study was to determine the prevalence of TTV infection among blood donors in Taiwan.

METHODS

Viral DNA was studied in 224 healthy blood donors and 118 deferred donors. DNA was extracted from plasma and amplified by seminested polymerase chain reaction with reported primer sets from a conserved region of the TTV genome.

RESULTS

The prevalence of TTV DNA in the deferred donors was 24.6%, significantly higher than in the healthy donors (11.9%). TTV was also more prevalent in those with hepatitis B surface antigen than in those without it (p = 0.002).

CONCLUSION

In comparing normal with deferred Taiwanese blood donors, hepatitis B virus infection is linked to a higher prevalence of TTV infection.

Ventilatory defect in coal workers with simple pneumoconiosis: early detection of functional abnormalities

Airway obstruction is a prominent feature in coal workers' pneumoconiosis (CWP). However, many patients with CWP have even demonstrated a normal forced vital capacity (FVC) and forced expiratory volume in 1s (FEV1). The purpose of this study was to evaluate the ventilatory defect by spirometry and search for parameters, other than FVC and FEV1, suitable for early detection of pulmonary impairment in CWP. A sample of 227 coal miners was selected from the medical clinics of two teaching hospitals. Maximal expiratory flow volume measurement and determination of functional residual capacity (FRC) and residual volume (RV) were carried out with an automated plethysmograph. The prevalence of airway obstruction (FEV1/FVC < 70%) in this sample of miners was 52.9% (120/227). There was a progression of functional impairment with the transition from category 0 to categories 2 and 3, no matter what the miners smoking habits. All of the 107 non-obstructed miners had a normal FVC and FEV1. However, the mean values for FEF25-75% (mean forced expiratory flow during the middle half of FVC) and Vmax50 (maximal expiratory flow rate at 50% FVC) were abnormally low, and RV was already elevated, in those non-obstructed subjects with category 1 simple pneumoconiosis. A borderline abnormally elevated FRC in the miners with radiological category 3 of CWP was also noted. We conclude that the Vmax50, FEF25-75%, and RV appeared to be the discriminative indices for detecting early ventilatory defect in non-obstructed patients with simple CWP. Further studies is still needed to clarify the cause of small airway dysfunction.

Fournier's gangrene--Taiwan experience

BACKGROUND

Synergistic necrotizing fascitis of the scrotum, penis and perianal region was first described by Fournier in 1883. If not recognized early, this infectious process will extend along the fascia plane to the lower abdominal and back regions, causing severe morbidity and even mortality.

METHODS

The records of 8 patients diagnosed of Fournier's gangrene were reviewed between 1988 and 2000. The sex, age, etiology, associated diseases, bacteriological studies and treatments were analyzed.

RESULTS

The 8 patients were all males, age ranging from 42 to 78 years old, with average 55.1 years. Six patients were due to perianal abscess, one patient was a complication of hemorroidectomy, and one patient had traumatic injury of scrotum. Six patients had poor controlled diabetes mellitus, and there were two patients with cirrhosis of the liver and hepatoma, respectively. Even with aggressive treatments, two patients died; the other 6 recovered completely. The mortality rate was 25%.

CONCLUSIONS

Fournier's gangrene is a not common but life-threatening disease which needs radical debridement and effective antibiotics to control the infection and early reconstruction with skin graft and myocutaneous flaps. Mortality is usually due to delayed diagnosis.

An unusual case of fatal pulmonary allograft rejection

This case report describes an atypical form of acute pulmonary allograft rejection that was refractory to conventional therapy. The rejection manifested primarily as interstitial lymphocytic infiltrates with little perivascular involvement. Despite aggressive therapy the patient died within 7 months of transplant. The timely recognition and treatment of unusual forms of allograft rejection is vital in the management of pulmonary transplant patients.

Retroperitoneoscopy assisted live donor nephrectomy: the Yonsei experience

PURPOSE

Retroperitoneoscopy assisted live donor nephrectomy has become standard based on our experience with 103 consecutive cases operated on between January 1993 and May 2000. We describe the advantages of retroperitoneoscopy assisted compared to laparoscopic live donor nephrectomy.

MATERIALS AND METHODS

After performing more than 1,200 cases of open live donor nephrectomy (S. C. Y.), we combined our experience with open and laparoscopic surgery to develop a specific technique of minilaparotomy live donor nephrectomy. Operations were performed by 1 senior surgeon and 1 assistant, with the help of specially designed piercing abdominal and peritoneal retractors. A 5 to 7 cm. transverse pararectal skin incision is made at the level of 10th rib and the abdominal muscles are split without division. A 10 mm. port is placed at the lower abdomen to allow for the telescope. The procedure is performed extraperitoneally, combining open and laparoscopic instruments under direct vision. Renal pedicles and ureters are ligated using laparoscopic clips and sutures. The kidney is removed via laparotomy and the wound is closed.

RESULTS

Average operating time for the 103 live donor nephrectomies was 130 minutes (range 85 to 210), and there was no case of kidney loss, open surgical conversion or blood transfusion. Mean warm ischemia time was 2.3 +/- 1.2 minutes and average incision length was 6.5 cm. (range 5.1 to 7.0). Postoperative pain was minimal and analgesics were generally not required by postoperative day 2. Patients were fully ambulatory a mean 1.5 days (range 1 to 3.5) postoperatively.

CONCLUSIONS

Retroperitoneoscopy assisted live donor nephrectomy is not only feasible, but reproducible. Any surgeon with previous experience with conventional open live donor nephrectomy can perform this hybrid, minimally invasive procedure.

Wegener's granulomatosis presenting as mediastinal soft tissue mass invading the tracheal wall

Wegener's granulomatosis (WG) is a clinicopathologic entity of unknown cause characterised by a necrotising granulomatous vasculitis affecting multiple organs, especially the upper and lower respiratory tracts, lung and kidney. The lung is the most frequently, and sometimes the only involved organ. Single or multiple nodules, with or without cavitation, are the most common pulmonary manifestations in WG, but mediastinal involvement is atypical. The sole tracheal involvement is rare and hilar and mediastinal involvement has been thought not to be part of the clinical feature. We experienced a rare case of WG presenting as paratracheal mediastinal lesions with tracheal wall invasion, which responded dramatically to corticosteroid treatment. We present this case with a review of the literature.

Lung transplantation and systemic sclerosis

We performed lung transplantation in nine patients with Scleroderma related lung disease. Patient characteristics included: 7 (78%) females, 6 (67%) with limited and 3 (33%) with diffuse Scleroderma. Pulmonary fibrosis was present in 7 (78%) and pulmonary hypertension in 4 (44%). All patients were carefully screened by the Johns Hopkins and University of Maryland Scleroderma Center and only referred for transplantation when concomitant renal insufficiency (creatinine clearance < or = 50 ml/min), aspiration, and skin brakdown were excluded. When compared to a similar group of transplant patients with nonscleroderma lung disease (primary pulmonary fibrosis), there was no significant difference in post-transplant survival at four years (76.2 +/- 0.15% vs. 69.2% +/- 0.12%), mean annual incidence rate for acute rejection (0.14 +/- 0.14 vs. 0.47 +/- 0.13) and infection (viral 0.17 +/- 0.17 vs. 0.29 +/- 0.11) (bacterial 0.17 +/- 0.17 vs. 1.4 +/- 0.4) (fungal 0.99 +/- 0.69 vs. 0.36 +/- 0.16) or serum creatinine (1.55 +/- 0.34 mg/dl vs. 1.15 +/- 0.09 mg/dl). We conclude that lung transplantation is viable option for carefully selected patients with scleroderma related lung disease.

Detection of malignant cells in pleural fluid or ascites by CD44v8-10/CD44v10 competitive RT-PCR

BACKGROUND

CD44 is a cell surface adhesion molecule which has been implicated in various biologic functions as lymphocyte homing and activation, cellular migration and extracellular matrix adhesion. Over-expression of CD44v8-10 has been found in several cancers and is considered to be associated with tumor progression and metastasis. Recently, a novel molecular method, CD44v8-10/CD44v10 competitive reverse transcription-polymerase chain reaction(RT-PCR) has been developed for detecting cancer cells over-expressing CD44v8-10.

METHODS

We analyzed from benign and malignant pleural effusion and ascites by CD44 competitive RT-PCR and compared to the conventional cytology.

RESULTS

The CD44 competitive RT-PCR analysis showed that all the 24 samples associated with benign disease presented a predominant expression of the CD44v10 transcript (v8-10/v10 ratio: 0.126-0.948), whereas 6 of 7 malignant pleural samples associated with cytology positive cancer expressed the CD44v8-10 transcript (v8-10/v10 ratio > 1.00).

CONCLUSION

These results indicate that CD44 competitive RT-PCR assay is a useful and adjunct to cytological examination in cancer diagnosis, especially in detecting exfoliated cancer cells in pleural effusion.

The oxidation of cholesterol in the yolk of selective traditional Chinese egg products

The yolks of traditional chicken egg products (Tiedan, Ludan, and Chayedan) and duck egg products (raw and cooked Xiandan, immersed and coated Pidan) were subjected to moisture, lipid, and thiobarbituric acid (TBA) determinations as well as cholesterol and cholesterol oxidation products (COP) analysis. The main COP detected for these egg products included 20-hydroxycholesterol and 7beta-hydroxycholesterol, other types of COP were not detected. The contents of COP formed in traditional egg products varied, depending upon the types of egg products. The cholesterol oxidation ratio for traditional Chinese chicken egg products ranged from 1.14 to 1.75%, whereas that for traditional Chinese duck egg products ranged from 1.18 to 1.90%. Those traditional egg products that required pickling in salt or alkaline, cooking, hot air drying, and exposure to oxygen and heat all produced COP.

Chromosomal alterations in lung adenocarcinoma from smokers and nonsmokers

The etiology of lung tumors arising in nonsmokers remains unclear. Although mutations in the K-ras and p53 genes have been reported to be significantly higher in smoking-related lung carcinomas, in the present study we performed a more comprehensive analysis in search of additional genetic changes between lung adenocarcinoma from tobacco- and non-tobacco-exposed patients. We selected a matched cohort of 18 lifetime nonsmoking and 27 smoking patients diagnosed with primary adenocarcinoma of the lung and searched for chromosomal alterations in each tumor by testing normal and tumor tissue with 54 highly polymorphic microsatellite markers located on 28 different chromosomal arms. Allelic losses or gains at chromosomal arms 3p (37 versus 6%), 6q (46 versus 12%), 9p (65 versus 22%), 16p (28 versus 0%), 17p (45 versus 11%), and 19p (58 versus 16%) were present significantly more often in adenocarcinomas from smokers than from nonsmokers. Chromosomal arms showing allelic imbalance in lung tumors from nonsmokers were rare but occurred more often at 19q (22%), 12p (22%), and 9p (22%). The FAL (fractional allelic loss or gain) is defined as the percentage of chromosomal arm losses/gains among the total informative chromosomal arms. Tumors from smokers harbored higher levels of FAL (13 (48%) of 27 showed FAL > or = 0.3) compared with the lung tumors from the nonsmoker patients (2 (11%) of 18 showed FAL > or = 0.3; P = 0.02; odds ratio, 0.13; 95% confidence interval, 0.01-0.79). Our data demonstrate that widespread chromosomal abnormalities are frequent in lung adenocarcinoma from smokers, whereas these abnormalities are infrequent in such tumors arising in nonsmokers. These observations support the notion that lung cancers in nonsmokers arise through genetic alterations distinct from the common events observed in tumors from smokers.

Functional implication of human serine/threonine kinase, hAIK, in cell cycle progression

Protein phosphorylation is involved in many biological activities and plays important roles in cell cycle progression. In the present study, we identified a serine/threonine kinase, hAIK, from human hepatic cells using degenerated polymerase chain reactions with a pair of primers derived from the highly conserved sequence in the catalytic domain of kinases. The full-length hAIK cDNA was then obtained, which contained 403 amino acids and was homologous to Drosophila Aurora2 and yeast Ipl1 proteins. Northern blotting analysis revealed that hAIK was highly expressed in the testis but not in other tissues. Expressions of hAIK drastically increased in cancer tissues/cell lines but not in fibroblasts or nontumorigenic cell lines. The recombinant hAIK protein phosphorylated itself and histone H1; this phosphorylation activity was totally abolished after a point mutation at the catalytic domain (hAIKm). During the interphase cell, hAIK was found mainly in the cytoplasm; during mitosis hAIK accumulated at the centrosomes. In addition, overexpression of hAIK in cancer cell lines (HEK293T and HeLa) appeared to inhibit cell cycle progression. None of these phenomena were observed in hAIKm whose kinase activity was rendered inactive. Our results suggest that hAIK protein/activity might modulate cell cycle progression by interacting with the centrosomes and/or proteins associated with these structures.