A 53-year-old man with dyspnoea, respiratory failure, consistent with infliximab-induced acute interstitial pneumonitis after an accelerated induction dosing schedule

A 53-year-old man with ulcerative colitis (UC) suffered fatal acute interstitial pneumonitis (AIP) post completing an accelerated infliximab induction course. This is the first case reported in this setting. A literature review found four similar cases of infliximab-induced interstitial lung disease in the setting of treating patients with UC using standard infliximab regimens had successful treatment of the subjects post infliximab discontinuation. Unfortunately, the patient we are presenting, who had an accelerated infliximab induction course, did not survive. Although a prior small trial along more recent new small studies continue to show a benefit in reducing the need for early colectomy with the accelerated infliximab induction regimen as salvage therapy, it should be used cautiously until more safety data are available. Further larger trials are required to investigate rare side effects that may be associated with this regimen such as rapidly progressive lung toxicity as seen in this patient.

A simple dyspnoea scale as part of the assessment to predict outcome across chronic interstitial lung disease

BACKGROUND AND OBJECTIVE

The Medical Research Council dyspnoea score (MRCDS) is a simple, objective scale to assess dyspnoea, the main complaint in patients with chronic interstitial lung disease (ILD). We sought to investigate whether MRCDS is a predictor of outcome in patients with chronic ILD.

METHODS

One hundred and fifteen patients (50 idiopathic pulmonary fibrosis (IPF) and 65 non-IPF ILD) were retrospectively studied. Baseline (time of diagnosis) MRCDS and 3-6-month changes were considered. Endpoints were (i) 18-month clinical progression, defined as either: ≥10% absolute reduction in forced vital capacity (FVC) percent predicted; ≥50-m decline in 6-min walk distance; hospitalization for respiratory causes; lung transplantation (LTx) assessment or death and (ii) 18-month survival.

RESULTS

At the end of the observation period, 54 subjects (47%) experienced clinical progression (including 22 deaths and 3 LTx). In patients with IPF, a longitudinal increase in MRCDS predicted clinical progression significantly (area under the curve (AUC) = 0.76, sensitivity = 62%, specificity = 91%); baseline MRCDS was a strong predictor of mortality (AUC = 0.80, sensitivity = 87%, specificity = 57%). In patients with non-IPF ILD, longitudinal increases in MRCDS, but not baseline values, were predictive of both clinical progression (AUC = 0.81, sensitivity = 85%, specificity = 77%) and mortality (AUC = 0.76, sensitivity = 91%, specificity = 61%). Considering the whole population, MRCDS increase and FVC decline were independent predictors of mortality.

CONCLUSION

Longitudinal increases of MRCDS predict poor outcome in chronic ILD, with good accuracy. Baseline MRCDS remains a strong predictor of mortality in IPF. MRCDS should be included in the global assessment of the clinical course of chronic ILD.

Successful Treatment of Fibrosing Organising Pneumonia Causing Respiratory Failure with Mycophenolic Acid

Organising pneumonia (OP) is usually promptly responsive to corticosteroid treatment. We describe a series of 3 cases of severe, progressive, biopsy-proven fibrosing OP causing respiratory failure. All cases presented with peribronchial and subpleural consolidations, had a fibro-inflammatory infiltrative component in the alveolar septa, and only had a partial and unsatisfactory response to corticosteroids. However, they responded to mycophenolic acid (MPA) treatment with resolution of respiratory failure as well as clinical and functional improvement. MPA as an additional treatment option for aggressive forms of fibrosing OP and interstitial lung disease needs to be further explored.

T-shaped macular buckling combined with 25G pars plana vitrectomy for macular hole, macular schisis, and macular detachment in highly myopic eyes

OBJECTIVE

To report our experience using the T-shaped macular buckle (MB) with or without pars plana vitrectomy (PPV) as primary surgery or with a previous failed surgical approach in patients affected by high myopia and macular hole (MH) with or without macular detachment and with or without macular schisis. The primary goal was to evaluate complete closure of the MH and reattachment of the retina.

DESIGN

Retrospective case series of 21 consecutive patients who underwent T-shaped MB implant alone or combined with PPV at the Academic Medical Center in Amsterdam, The Netherlands, between January 2013 and November 2014. The mean axial length was 31.22 mm. The mean follow-up period was 7 months.

RESULTS

Retinal reattachment was achieved in 100% of cases while MH closure was achieved in 90.5%. No major perioperative complications were observed. Best corrected visual acuity improved in 71.4% of patients.

CONCLUSIONS

MB combined with PPV should be considered as the preferred surgical approach both in primary and recurrent retinal detachment secondary to MH in high myopic eyes.

Use of a new intra-ocular spectral domain optical coherence tomography in vitreoretinal surgery

PURPOSE

To describe the use of a novel intra-ocular side-scanning probe enabling the acquisition of spectral-domain optical coherence tomography (SD-OCT) images during surgery in a series of patients with complex forms of retinal detachment.

METHODS

A 23-gauge, side-scanning SD-OCT probe (C7 System; LightLab Imaging, Inc/St Jude Medical, St. Paul, MN, USA) in a 20-gauge catheter, was used to acquire the intra-operative OCT images in seven patients with vitreoretinal diseases. Twenty-five gauge pars plana vitrectomy (PPV) was performed in every patient in a standard fashion. After enlarging the temporal sclerotomy to a 20-gauge port, all the patients were scanned with intra-ocular side-scanning SD-OCT, during different steps of the surgery based on surgeon needs. Scans were recorded real time and directly evaluated on a screen during surgery. Optical coherence tomography (OCT) scans were judged beneficial when they would recognize structures otherwise not seen on biomicroscopy.

RESULTS

The intra-ocular SD-OCT has been helpful in acquiring extra information during vitreoretinal surgery such as the detection of the presence of otherwise invisible membranes (epiretinal membrane, subretinal membrane), the location of small tears and the identification of the retinal plane under suboptimal conditions for visualization.

CONCLUSION

The use of an intra-ocular SD-OCT can expand upon visual cues during surgery, helping in the decision-making process and allowing additional deliberate surgical manoeuvres aimed at improving surgical outcomes.

LARP1 post-transcriptionally regulates mTOR and contributes to cancer progression

RNA-binding proteins (RBPs) bind to and post-transcriptionally regulate the stability of mRNAs. La-related protein 1 (LARP1) is a conserved RBP that interacts with poly-A-binding protein and is known to regulate 5'-terminal oligopyrimidine tract (TOP) mRNA translation. Here, we show that LARP1 is complexed to 3000 mRNAs enriched for cancer pathways. A prominent member of the LARP1 interactome is mTOR whose mRNA transcript is stabilized by LARP1. At a functional level, we show that LARP1 promotes cell migration, invasion, anchorage-independent growth and in vivo tumorigenesis. Furthermore, we show that LARP1 expression is elevated in epithelial cancers such as cervical and non-small cell lung cancers, where its expression correlates with disease progression and adverse prognosis, respectively. We therefore conclude that, through the post-transcriptional regulation of genes such as mTOR within cancer pathways, LARP1 contributes to cancer progression.

Electromagnetic Control System for Capsule Navigation: Novel Concept for Magnetic Capsule Maneuvering and Preliminary Study

The gastrointestinal tract is home of some of the most deadly human diseases. The main problems are related to the difficulty of accessing it for diagnosis or intervention and concomitant patient discomfort. The flexible endoscopy technique has established itself in medical practice due to its high diagnostic accuracy and reliability; however, several technical limitations still remain and the procedure is poorly tolerated by patients. The use of magnetic fields to control and steer endoscopic capsules is increasing in minimally invasive procedures. In fact, magnetic coupling is one of the few physical phenomena capable of transmitting motion beyond a physical barrier, allowing for the compact design of the device itself. In this framework, the authors present the preliminary design and assessment of a magnetic coupling for magnetic endoscopic capsules considering an electromagnetic approach. In particular, a novel toroidal electromagnet is proposed as the control and driving system. The system concept, design, and preliminary results are reported.

A computer-assisted robotic platform for Focused Ultrasound Surgery: Assessment of high intensity focused ultrasound delivery

In the last century, medicine showed considerable advancements in terms of new technologies, devices and diagnostic/therapeutic strategies. Those advantages led to a significant reduction of invasiveness and an improvement of surgical outcomes. In this framework, a computer-assisted surgical robotic platform able to perform non-invasive Focused Ultrasound Surgery (FUS) - the FUTURA platform - has the ambitious goal to improve accuracy, safety and flexibility of the treatment, with respect to current FUS procedures. Aim of this work is to present the current implementation of the robotic platform and the preliminary results about high intensity focused ultrasound (HIFU) delivery in in-vitro conditions, under 3D ultrasound identification and monitoring. Tests demonstrated that the average accuracy of the HIFU delivery is lower than 0.7 mm in both X and Y radial directions and 3.7 mm in the axial direction (Z) with respect to the HIFU transducer active surface.

Early decline in six-minute walk distance from the time of diagnosis predicts clinical worsening in pulmonary arterial hypertension

BACKGROUND

The six-minute walk distance (6MWD) is commonly used to assess pulmonary arterial hypertension (PAH). However, the role of 6MWD in predicting outcomes in PAH is controversial. Clinical worsening is being increasingly considered as a clinically meaningful end point in PAH.

OBJECTIVES

We aimed to investigate whether early longitudinal changes in 6MWD (Δ6MWD) in meters and percent predicted (%pred) from the time of diagnosis predict clinical worsening of PAH.

METHODS

One hundred patients with group I PAH were retrospectively assessed. 6MWD was calculated using American (%pred US) or Canadian (%pred CAN) reference equations. Δ6MWD at 6 months were recorded. Clinical worsening was defined as either: development of right heart failure, hospital admission for PAH, referral for lung transplantation or initiation of prostanoids after oral therapy failed. Optimal 6-month differences in 6MWD to detect worsening were defined with receiver operating characteristics (ROC) analysis.

RESULTS

Progressors, i.e. patients with clinical worsening, and nonprogressors showed significant differences in Δ6MWD. The most clinically significant declines in 6MWD at 6 months were ≥35 m, ≥8%pred US and ≥6%pred CAN. ROC and Cox proportional hazard analyses showed equivalent results for 6MWD %pred and meters. Six-month declines in 6MWD predicted worsening with a high specificity (94%) but a low sensitivity (33%).

CONCLUSIONS

Early declines in 6MWD (within the first 6 months) predict future clinical worsening of PAH with high specificity. Δ6MWD may still be part of a comprehensive assessment of a patient's clinical status. However, given the poor sensitivity, a decline in 6MWD should be used with other clinical tools to make an appropriate assessment of the progression of PAH.

A New Concept for Magnetic Capsule Colonoscopy Based on an Electromagnetic System

Traditional endoscopy based on flexible endoscopes is reliable and effective, but poorly tolerated by patients; it also requires extended training by physicians. In order to reduce the invasiveness of these procedures, wireless passive capsule endoscopy has been proposed and clinically used during the past decade. A capsule endoscope with an active locomotion mechanism is desirable for carrying out controllable interactive procedures that are normally not possible using passive devices. Due to many difficulties in embedding actuators in swallowable devices, many researchers and companies have adopted an external magnetic field actuation solution. Magnetic resonance modified systems or permanent magnets are used to manoeuvre capsules remotely; however, both these cases present some limitations: magnetic resonance systems are bulky and expensive and permanent magnets are intrinsically unstable to control, and it is impossible to switch them off. Within this framework, the authors present the design and assessment of a magnetic system for endoscopic capsules based on an electromagnetic approach. In particular, the use of a single electromagnet was proposed and investigated: magnetic attraction, locomotion forces and magnetic torques were modelled for guaranteeing the reliable navigation of the capsule and based on these specifications, an electromagnet was designed, developed and experimentally evaluated. The results demonstrated the feasibility of the proposed approach for active locomotion capsule endoscopy.

Depletion of bone marrow CCSP-expressing cells delays airway regeneration

The contribution of bone marrow cells (BMC) in lung repair is controversial. We previously reported a subpopulation of BMC that express Clara cell secretory protein (CCSP). To determine the contribution of endogenous CCSP(+) BMC to airway regeneration, we performed bone marrow transplantation studies using the CCtk mouse, which expresses a thymidine kinase suicide gene under regulation of the CCSP promoter. Mice were transplanted with wild-type or CCtk BMC and treated with ganciclovir to eliminate CCSP(+) cells. After airway injury using naphthalene, mice depleted of CCSP(+) BMC had more inflammatory cells in lung and decreased levels of oxygen in arterial blood. They also had reduced expression of airway epithelial genes and less Clara cells compared to control mice that had intact CCSP(+) BMC and bone marrow derived CCSP(+) cells in the airways. After naphthalene injury, administration of CCSP reproduced the beneficial effect of CCSP(+) BMC by improving recovery of airway epithelium, reducing lung inflammation and increasing oxygen in arterial blood from mice depleted of CCSP(+) BMC. Our data demonstrate that ablation of CCSP(+) BMC delays airway recovery and suggests the beneficial effect of CCSP(+) BMC in lung recovery is in part due to production of CCSP itself.

25-Gauge vitrectomy

The development of a 25-gauge vitrectomy system represents a major step forward in vitreoretinal surgery. The main advantages of small-gauge incisions are reduction of surgical time, decreased postoperative inflammation, and fast postoperative recovery time. The use of this technique requires research, training, knowledge, and experience on the part of the vitreoretinal surgeon and the personnel in the operation room. At the same time the indications for 25-gauge vitrectomy have changed a lot in the last years due to improvement in materials and technology and the advent of new instruments. Nowadays, with the development of new surgical instrumentation and the improvement of surgical skills, we can approach the whole spectrum of vitreoretinal pathology. This chapter describes the instruments used in 25-gauge vitrectomy, explains how to set the vitrectomy machine for safe surgery and what the indications for 25-gauge vitrectomy are (with particular reference to vitreoretinal interface diseases, retinal detachment, and proliferative diabetic retinopathy) as well as the complications that can occur, and provides some pearls for challenging cases.