Conversion From Cyclosporine to Tacrolimus Stabilizes the Course of Lung Function in Lung Transplant Recipients With Bronchiolitis Obliterans Syndrome

Bronchiolitis obliterans syndrome (BOS) continues to be the main factor limiting the long-term survival of lung transplant recipients. The objective of this study was to prospectively assess the impact of conversion from cyclosporine (CsA) to tacrolimus on lung function in patients who developed BOS while receiving CsA-based immunosuppressive therapy. A total of 79 patients with BOS were included in the study. Sixty percent of patients had stage II or III BOS according to the International Society for Heart and Lung Transplantation criteria. Mean time from transplantation was 30.4 +/- 21.9 months and all patients were on CsA therapy at enrollment in the study, with mean trough levels of 232.75 +/- 98.26 ng/mL. After conversion, tacrolimus trough levels were 11.0 +/- 3.6 ng/mL at 3 months and 9.0 +/- 3.4 ng/mL at 12 months. Sixteen deaths occurred during the first year postconversion, 56% of which were due to respiratory failure. Comparison of forced expiratory volume in 1 second (FEV(1)) preconversion versus postconversion showed a change in the slope of the FEV(1)-time curve. The slope of the preconversion curve was -0.44 versus a zero slope, whereas the slope of the postconversion curve was 0.005, with a statistically significant difference between both slopes. This change in slopes, which was also seen in FEV(1%), suggests that lung function loss closed after conversion from CsA to tacrolimus supporting this therapeutic strategy in lung transplant recipients with BOS treated with CsA.

[Hemolytic uremic syndrome by Streptococcus pneumoniae]

Hemolytic uremic síndrome (HUS) is an acute disease characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure, usually,but not always, associated with the prodrome of diarrhea. A 2-year-6-month old boy with pneumonía caused by Streptococcus pneumoniae developed the third day after admission oliguric acute renal failure, anemia, and thrombocytopenia. The patient needed veno-venous hemodiafiltration/ hemofiltration during ten days. He received five packed red blood cell, and one platelet transfusions, and was treated with plasma infusions during six days. Renal function was normal at discharge. HUS caused by Streptococcus pneumoniae has more morbility and mortality that classic HUS, although they usually recovery renal function. In those cases of atypical HUS, different from others, blood transfusions that contains IgM should be avoided,because they can increase antigen-antibody reaction and cellular damage. The low incidence of HUS by Streptococcus pneumoniae and the systemic infectious component difficult the early diagnosis. Taking into account the different transfusion approach in these cases, it is necessary to be aware for diagnosing HUS by Streptococcus pneumoniae in all patients with systemic infection and sudden renal function deterioration.

A model for predicting delay in discharge of stroke patients

AIMS

To study the factors that predict delay in discharge (DD) for stroke victims when they are admitted to hospital and to build a model for predicting DD in our hospital.

METHOD

A retrospective study of 214 stroke victims admitted to the Physical Medicine and Rehabilitation Service (PMRS) of a general hospital between January 1, 1994, and December 31, 2001. Seventeen clinical and sociodemographic data were studied to determine which factors were predictors of DD: age, sex, type of stroke, side affected, sphincter control, ability to communicate, level of consciousness, deep sensitivity, antecedents of cardiovascular risk, delay before admission to the PMRS, initial functional state and solitude, whether the patient was employed prior to the cerebrovascular accident, and whether the patient's place of residence had any exterior architectural barriers.

RESULTS

A total of 26.6% of patients experienced DD. Factors influencing DD were solitude (odds ratio [OR] 6; 95% confidence interval [CI] 2.2-16.1), an initial functional independence measure (FIM) below 50 (OR 4.5; 95% CI 2.3-8.9) and age greater than 75 years (OR 2.7; 95% CI 1.2-6.1). The best model for predicting DD comprises seven variables: solitude, initial FIM below 50, older than 75 years, left hemiparesis, exterior architectonic barriers at home, cardiovascular antecedents and sex (male). This model has a specificity of 89% and a sensitivity of 40%.

CONCLUSION

Solitude, low initial FIM and age older than 75 years influence DD for patients with stroke admitted to hospital. A model for predicting DD is described.

Catch-up growth follows an abnormal pattern in experimental renal insufficiency and growth hormone treatment normalizes it

The primary goal of this study was to determine if the ability to undergo catch-up growth following a transient injury is preserved in an experimental model of moderate chronic renal failure (CRF) and the effect of growth hormone (GH) administration on such phenomenon. Young rats were subtotally nephrectomized (days 0 and 4) (Nx). From days 11 to 13, food intake was restricted in subgroups of Nx and control (C) rats (NxR and CR). After refeeding, subgroups of NxR and CR rats received GH from days 14 to 20 (NxRGH and CRGH). Rats were killed on days 14 (C, CR, Nx, NxR), 17 and 21 (C, CR, CRGH, Nx, NxR, NxRGH), and 36 (C, CR, Nx, NxR). Longitudinal growth rate was measured by osseous front advance in the proximal tibiae. With refeeding, growth rate of CR, NxR, and NXrGH rats became significantly greater than that of C, indicating catch-up growth. This occurred later and with lower growth rate in NxR than in CR rats, whereas the characteristics of catch-up growth in CR and NxRGH animals were similar. Changes in growth rate were associated with modifications in the morphology and proliferative activity of growth cartilage. We conclude that catch-up growth occurs in renal insufficiency but follows a different pattern from that observed with normal renal function. GH treatment normalizes the pattern of catch-up growth in CRF. Changes in growth velocity are associated to modifications in the structure and dynamics of growth cartilage.

Atmospheric mercury emissions from polluted gold mining areas (Venezuela)

Soil, waste rock and mud from mercury-gold amalgamation mining areas of El Callao (Venezuela) are highly enriched in Hg (0.5-500 microg g(-1)) relative to natural background concentrations (<0.1 microg g(-1)). Mercury fluxes to the atmosphere from twelve polluted sites of this area were measured in situ (6 a.m. to 8 p.m.) using a Plexiglas flux chamber connected to a portable mercury analyzer (model RA-915+; Lumex, St. Petersburg, Russia). Mercury fluxes ranged between 0.65 and 420.1 microg m(-2) h(-1), and the average flux range during the diurnal hours was 9.1-239.2 microg m(-2) h(-1). These flux values are five orders of magnitude higher than both reported world background Hg fluxes (1-69 ng m(-2) h(-1)) and the regional values, which are in the range 2-10 ng m(-2) h(-1). The flux results obtained in this study are, however, similar to those measured at Hg polluted sites such as chloro-alkali plants or polymetallic ore mining districts (>100,000 ng m(-2) h(-1)). The results from this study also show that Hg emissions from the soil are influenced by solar radiation, soil temperature and soil Hg concentration. Our data suggest that solar radiation may be the dominant factor affecting Hg degrees emission since the major species of mercury in polluted soil is Hg degrees (85-97% of total Hg). The simple release of Hg degrees vapor is probably the dominant process occurring with incident light in the field. The apparent activation energy for mercury emission indicates that the volatilization of mercury mainly occurred as a result of the vaporization of elemental mercury in soil. The degree of Hg emission differed significantly among the soil sites studied, which may be due to variations in soil texture, organic matter content and soil compaction.

Evaluation of Patients Referred for Lung Transplantation: Fourteen Years Experience

We present a descriptive study of patients referred as candidates for lung transplantation in the last 14 years. The 837 requests were evaluated stepwise in three phases: phase I, derivation report; phase II, outpatient evaluation; and phase III, inpatient evaluation. Chronic obstructive pulmonary disease was the most common reason for referral (31%). Cystic fibrosis was the referral disease with the best transplanted/referred relation (57%) and pulmonary fibrosis was the disease that had the highest mortality (39.7% of all deaths). Forty-three percent of all patients reached phase III and 29% were transplanted. Mortality on the waiting list was 3.7%. The most important causes of exclusion were inadequate indications and the presence of severe associated diseases. The mean study was 44 days. Knowledge of the natural history, local factors that influence organ availability, expected time on the waiting list, and disease progression allow optimization of this therapeutic option.

Tracheo-esophageal fistula: combined surgical and endoscopic approach

We present a case of benign acquired tracheo-esophageal fistula caused by cuffed tracheal tube. The patient was septic and weaning from the mechanical ventilation was unlikely, so immediate repair of the tracheal and esophageal lesions was imperative. A silicone endoprosthesis was inserted in the tracheal lumen and the esophageal lesion was repaired with direct suture. After weaning from mechanical ventilation and recovery, the patient was discharged with a silicone tracheal stent. Three months later the stent was removed without complications or need for further treatment. This combined approach as never been published before, and can be a very useful alternative for the treatment of this rare but taxing complication.

Cryopreservation and conservation of microalgae: the development of a Pan-European scientific and biotechnological resource (the COBRA project)

Microalgae are one of the most biologically important elements of worldwide ecology and could be the source of diverse new products and medicines. COBRA (The COnservation of a vital european scientific and Biotechnological Resource: microAlgae and cyanobacteria) is the acronym for a European Union, RTD Infrastructures project (Contract No. QLRI-CT-2001-01645). This project is in the process of developing a European Biological Resource Centre based on existing algal culture collections. The COBRA project's central aim is to apply cryopreservation methodologies to microalgae and cyanobacteria, organisms that, to date, have proved difficult to conserve using cryogenic methods. In addition, molecular and biochemical stability tests have been developed to ensure that the equivalent strains of microorganisms supplied by the culture collections give high quality and consistent performance. Fundamental and applied knowledge of stress physiology form an essential component of the project and this is being employed to assist the optimisation of methods for preserving a wide range of algal diversity. COBRA's "Resource Centre" utilises Information Technologies (IT) and Knowledge Management practices to assist project coordination, management and information dissemination and facilitate the generation of new knowledge pertaining to algal conservation. This review of the COBRA project will give a summary of current methodologies for cryopreservation of microalgae and procedures adopted within the COBRA project to enhance preservation techniques for this diverse group of organisms.

Analysis of Lung Transplant Recipients Surviving Beyond 5 Years

INTRODUCTION

We started lung transplantation (LT) in October 1993 and review the status of recipients who have survived beyond 5 years.

METHODS

A retrospective review of patients undergoing LT from October 1993 to October 1998 included pulmonary function data, incidence of bronchiolitis obliterans syndrome (BOS), functional status, and survival.

RESULTS

Of 73 transplantations 41 (56%) patients have survived beyond 5 years (study group), including 23 men and 18 women of age 33.2 +/- 15.6 years. Indications for LT were as follows: cystic fibrosis (n = 16), emphysema (n = 13), pulmonary fibrosis (n = 8), and other (n = 4). Actuarial survival at 5, 7, and 9 years was 56%, 53%, and 43%, respectively. Freedom from BOS was 63%, 56%, and 50% at 5, 7, and 9 years, respectively. The median percent predicted FEV1 was 67%, 56%, and 56%, respectively. Also, 79% of recipients had no limitations in their daily activities; 65% were active and working. Only 5% of patients showed some degree of limitation at 5 years posttransplantation. When survivors beyond 5 years were compared with nonsurvivors beyond 5 years, differences were observed: nonsurvivors more frequently required bypass (P = .01), experienced longer postoperative intubation times (P = .01), and exhibited lower PaO2 at 12 months posttransplantation (P < .01).

CONCLUSION

Our data show good survival rates among patients surviving beyond 5 years after LT, with a moderate incidence of BOS at 9 years posttransplantation. Despite the incidence of BOS, these patients have good pulmonary function and activity status.

Respiratory Disorders and Quality of Sleep in Patients on the Waiting List for Lung Transplantation

BACKGROUND

The purpose of this study was to assess the quality of sleep and extent of respiratory disorders in patients awaiting lung transplantation as compared with a control group.

METHODS

From September 2003 to November 2003, 17 clinically stable patients on the waiting list for lung transplantation and 14 healthy controls (with similar age, gender, and body mass index) were studied. Diagnostic polysomnography (PSG) was carried out for all subjects.

RESULTS

Seventeen patients were included, 15 men and 2 women, aged 51 +/- 14 years. The indication for lung transplantation was emphysema in 7 cases, pulmonary fibrosis in 6, and "other" in 4. Patients awaiting lung transplantation had the following respiratory values: mean FEV1, 1105 mL (34% of predicted); PaO2, 54 mm Hg; and PaCO2, 44 mm Hg. Significant differences were found among the waiting-list patients in terms of predominance of light sleep, wakeful periods, and phase changes per sleep-hour, as compared with the control group. The recording of the respiratory events showed an apnea-hypopnea index of 6.13, sleeping time with SaO2 <90% of 1.80%, and a mean number of significant desaturations (<4%) of 6.38. There were no statistically significant differences with respect to the control group.

CONCLUSIONS

Poor quality of sleep was observed in patients awaiting lung transplantation as compared with a healthy control group. There was no evidence of more respiratory events or significant desaturations in these patients, probably due to the provision of supplementary oxygen therapy during the PSG.

Pediatric Lung Transplantation

INTRODUCTION

Pediatric lung transplantation (LT) was started in Spain in 1996 at our institution. We compare the results of pediatric LT with those in adult patients.

METHODS

A retrospective review of LT patients from 1993 to 2003 included demographic donor and recipient data, pulmonary function, gas exchange parameters, complications, episodes of rejection and pneumonia, as well as survival. Patients were divided into 2 groups: pediatric (<16 years) and adult (>16 years) LT patients.

RESULTS

Of 165 LTs performed, 23 recipients were pediatric patients (10 boys, 13 girls; mean age, 11.9 +/- 2.9 years [range, 5-16 years]). The indications were cystic fibrosis (n = 21), pulmonary fibrosis (n = 1), and Kartagener syndrome (n = 1). The actuarial survival rate was 73%, 67%, and 62% at 1, 3, and 8 years post-LT in children, versus 67%, 56%, and 41% at 1, 3, and 8 years post-LT in adult patients (P = NS). Of the pediatric patients, 35% required mechanical ventilation preoperatively (P < .001). Pediatric patients showed a higher incidence of pneumonia (P < .01) and acute rejection episodes (P = .02) during the first month post-LT, and longer stays in the intensive care unit (P = .02). Pediatric patients displayed more immunosuppression-related adverse effects: diabetes (P = .04), neuropathy (P < .01), and hirsutism (P < .001). In children, arterial oxygen tension improved, from 51 mm Hg pre-LT to 93 mm Hg at 5 years post-LT. Forced expiratory volume in 1 second improved from 28% pre-LT to 84% at 5 years post-LT.

CONCLUSION

In children, LT is a high-risk procedure because of the critical status of these patients. However, the results of pediatric LT are similar to those in adults, but with better long-term survival.

Pulmonary Tailoring and Lobar Transplantation to Overcome Size Disparities in Lung Transplantation

Size matching between donors and recipients represents one of the organ distribution criteria widely accepted by lung transplant teams. However, in some cases it is not possible to allocate a donor to the corresponding size-compatible recipient. To avoid possible complications derived from the implantation of oversized lungs into smaller recipients, surgical procedures such as pulmonary tailoring and lobar transplantation have been advocated. We review our experience in 13 patients undergoing volume reduction of the lung graft at the time of transplantation, either by nonanatomical lung volume reduction or by lobar transplantation. There were no significant differences between lung-downsized patients and standard lung transplantation patients in terms of donor characteristics, surgical and postoperative complications, functional outcome, and survival. We conclude that downsizing the lung graft either by nonanatomical resection or lobar transplantation is safe and reliable to overcome size disparities between donor and recipients, with no additional morbidity and with similar early and midterm outcomes to those in standard lung transplants.

Long-Term Results of Lung Transplantation for Emphysema

INTRODUCTION

We sought to assess the differences between lung transplantation (LT) to treat emphysema, versus other pulmonary diseases.

METHODS

This retrospective review of lung transplantations (LTs) performed from October 1993 to September 2003, included donor and recipient demographic data, pulmonary function, oxygenation, postoperative complications, incidence of rejection and pneumonia, and survival.

RESULTS

Of 159 LTs performed the 39 transplanted to treat emphysema (24.4%), were in 33 men and 6 women of age 50.9 +/- 8.7 years (men, 25 to 65 years). There were differences between the emphysema vs other groups in terms of age (P < .001), gender (P = .001), need for bypass (P = .004), and immediate posttransplantation oxygenation index (P = .001). Perioperative mortality tended to be lower among patients with emphysema (2.7% vs 10.8%; P = .131). The incidences of complications and acute rejections was similar. Forced vital capacity, forced expiratory volume in 1 second, arterial oxygen tension, and arterial carbon dioxide tension improved significantly post-Tx. Actuarial survivals were 82%, 68%, and 63%, respectively, at 1, 3, and 7 years posttransplantation for emphysema patients vs 60%, 53%, and 42%, respectively, at 1, 3, and 7 years posttransplantation for non-emphysema patients (P = .049).

CONCLUSION

Lung transplantation in patients with emphysema offers good long-term survival, with significant improvement in functional status and low morbidity. The older age of emphysema patients was not associated with a higher incidence of postoperative complications.

Field and storage testing Bt potatoes for resistance to potato tuberworm (Lepidoptera: Gelichiidae)

Potato tuberworm, Phthorimaea operculella (Zeller), is the most serious insect pest of potatoes worldwide. The introduction of the Bacillus thuringiensis (Bt) toxin gene through genetic engineering offers host plant resistance for the management of potato tuberworm. We report on the field and storage studies to evaluate Bt-cry5 potato lines for resistance to potato tuberworm in Egypt under natural infestations and their agronomic performance in both Egypt and Michigan. From 1997 to 2001, field experiments were conducted at the International Potato Center (CIP) Research Station, Kafr El-Zyat, Egypt, and/or Agricultural Genetic Engineering Institute (AGERI), Giza, Egypt, to evaluate resistance to tuberworm. A total of 27 Bt-transgenic potato lines from six different Bt constructs were evaluated over a 5-yr period. After harvest and evaluation of the agronomic trials, storage evaluation of potato tuberworm damage was done at the CIP Research Station. The 1997 field trial was the first field test of genetically engineered crops in Egypt. Field tests to assess potato tuberworm resistance in Egypt were able to differentiate between the Bt-transgenic lines and the nontransgenic lines/cultivars in 1999, 2000, and 2001. The Bt-cry5-Spunta lines (Spunta-G2, Spunta-G3, and Spunta-6a3) were the most resistant lines in field with 99-100% of tubers free of damage. In the 2001 storage study, these lines were also over 90% free of tuberworm damage after 3 mo. NYL235-4.13, which combines glandular trichomes with the Bt-cry5/gus fusion construct, also had a high percentage of clean tubers in the field studies. In agronomic field trials in Michigan from 1997 to 2001, the Bt-transgenic lines in most instances performed similar to the nontransgenic line in the agronomic trials; however, in Egypt (1998-1999), the yields were less than one-half of those in Michigan. Expression of the Bt-cry5 gene in the potato tuber and foliage will provide the seed producer and grower a tool in which to reduce potato tuberworm damage to the tuber crop in the field and storage.

Portal Drained Visceral Flux, Hepatic Metabolism, and Mammary Uptake of Free and Peptide-Bound Amino Acids and Milk Amino Acid Output in Dairy Cows Fed Diets Containing Corn Grain Steam Flaked at 360 or Steam Rolled at 490 g/L

Objectives were to measure net fluxes of free (FAA) and peptide bound amino acids (AA) (PBAA) across portal-drained viscera (PDV), liver, splanchnic, and mammary tissues, and of milk AA output of lactating Holstein cows (n = 6, 109 +/- 9 d in milk) as influenced by flaking density of corn grain. Cows were fed alfalfa-based total mixed ration (TMR) containing 40% steam-flaked (SFC) or steam-rolled corn (SRC) grain. The TMR were offered at 12-h intervals in a crossover design. Six sets of blood samples were obtained from indwelling catheters in portal, hepatic, and mammary veins and mesenteric or costoabdominal arteries every 2 h from each cow and diet. Intake of dry matter (18.4 +/- 0.4 kg/d), N, and net energy for lactation were not altered by corn processing. Milk and milk crude protein yields (kg/12-h sampling) were 14.2 vs. 13.5 and 0.43 vs. 0.39 for cows fed SFC or SRC, respectively. The PDV flux of total essential FAA was greater (571.2 vs. 366.4 g/12 h, SEM 51.4) in cows fed SFC. The PDV flux of total essential PBAA was 69.3 +/- 10.8 and 51.5 +/- 13.2 g/12 h for cows fed SFC and SRC, respectively, and differed from zero, but fluxes of individual PBAA rarely differed between treatments. Liver flux of essential FAA was greater in cows fed SRC, but only the PBAA flux in cows fed SRC differed from zero. Splanchnic flux of FAA and PBAA followed the pattern of PDV flux, but variation was greater. Mammary uptake (g/12 h) of total essential FAA was greater in cows fed SFC than SRC (224.6 vs. 198.3, SEM 7.03). Mammary uptake of essential PBAA was 25.0 vs. 15.1, SEM 5.2, g/12 h for cows fed SFC or SRC, respectively, and differed from zero in half of the PBAA. Milk output of EAA was 187.8 vs 175.4, SEM 4.4 g/12 h in cows fed SFC and SRC, respectively, and output of most essential AA consistently tended to be greater in cows fed SFC. It is apparent that PBAA comprise a portion of total AA flux across PDV and are affected by grain processing. Further, this pool supplies an important component of AA taken up by the mammary gland. Quantifying the contribution of PBAA may improve diet formulation with respect to intestinal absorption and mammary uptake of AA.