Focus-assessed transthoracic echocardiography in the sitting position: two life-saving cases

Focus-Assessed Transthoracic Echocardiography (FATE) is a point-of-care ultrasound protocol allowing the fast evaluation of the cardio-pulmonary status. It has been well established that patients with an exacerbation of chronic obstructive lung disease and lung oedema benefit from the sitting position. These and other medical emergency situations may prevent patients from attaining the supine position, thus precluding standard echocardiography. Portable ultrasound machines with a wide range of different probes are now available at limited costs. This allows the physician to bring point-of-care ultrasound to the patient in almost any location. We present two cases of severely ill patients where FATE was performed in the sitting position with decisive impact on subsequent therapy.

Assessment of air space size characteristics by intercept (chord) measurement: an accurate and efficient stereological approach

The mean linear intercept (chord) length (L(m)) is a useful parameter of peripheral lung structure as it describes the mean free distance in the air spaces. It is often misinterpreted as a measure of "alveolar size," and its estimation is fraught with a number of pitfalls. We present two methods for the accurate estimation of L(m): 1) the indirect method, which derives L(m) from the volume-to-surface ratio of air spaces estimated by point counting methods, and 2) the direct method, which uses a set of random intercepts and calculates L(m) from their frequency distribution, for which we introduce a new and accurate method. Both methods are efficient and, with proper precautions, unbiased. The meaning of L(m) is assessed in two different examples. In a physiological study, the effect of different inflation levels is studied, showing that L(m) critically depends on lung inflation. In an experimental study on emphysema-like changes in a genetic mouse model, the effect of heterogeneity of air space size is assessed; these results are obtained partly because of differences in lung volume due to altered recoil in the emphysematous lungs. In conclusion, although L(m) is not a robust parameter of internal lung structure because it crucially depends on lung volume, it is still a valid measure for which accurate and efficient methods are available that yield additional parameters such as size distribution or alveolar surface area.

Taste dysfunction and changes in zinc and copper metabolism during penicillamine therapy for generalized scleroderma

The taste function and the zinc and copper levels in serum and urine were followed for up tp 16 weeks in ten patients who were started on penicillamine therapy for generalized scleroderma (9 patients) and rheumatoid arthritis (one patient). During therapy the serum zinc concentration remained unchanged, whereas the serum copper concentration increased significantly during the first 4--5 weeks and then tended to decrease. Urinary copper rose significantly and remained considerably above the upper normal limit throughout the study. Six of the patients complained after about 4--5 weeks of a decreased taste function, which was gradually restored whether the medication was stopped or continued. The alterations in the taste acuity for sweet, salt, sour, and bitter significantly paralleled the variations in urinary copper before as well as during therapy. Thus, the patients who showed the most pronounced loss of taste, had a lower urinary copper output than those whose taste acuity was less disturbed.

Truncated recombinant human SP-D attenuates emphysema and type II cell changes in SP-D deficient mice

BACKGROUND

Surfactant protein D (SP-D) deficient mice develop emphysema-like pathology associated with focal accumulations of foamy alveolar macrophages, an excess of surfactant phospholipids in the alveolar space and both hypertrophy and hyperplasia of alveolar type II cells. These findings are associated with a chronic inflammatory state. Treatment of SP-D deficient mice with a truncated recombinant fragment of human SP-D (rfhSP-D) has been shown to decrease the lipidosis and alveolar macrophage accumulation as well as production of proinflammatory chemokines. The aim of this study was to investigate if rfhSP-D treatment reduces the structural abnormalities in parenchymal architecture and type II cells characteristic of SP-D deficiency.

METHODS

SP-D knock-out mice, aged 3 weeks, 6 weeks and 9 weeks were treated with rfhSP-D for 9, 6 and 3 weeks, respectively. All mice were sacrificed at age 12 weeks and compared to both PBS treated SP-D deficient and wild-type groups. Lung structure was quantified by design-based stereology at the light and electron microscopic level. Emphasis was put on quantification of emphysema, type II cell changes and intracellular surfactant. Data were analysed with two sided non-parametric Mann-Whitney U-test.

MAIN RESULTS

After 3 weeks of treatment, alveolar number was higher and mean alveolar size was smaller compared to saline-treated SP-D knock-out controls. There was no significant difference concerning these indices of pulmonary emphysema within rfhSP-D treated groups. Type II cell number and size were smaller as a consequence of treatment. The total volume of lamellar bodies per type II cell and per lung was smaller after 6 weeks of treatment.

CONCLUSION

Treatment of SP-D deficient mice with rfhSP-D leads to a reduction in the degree of emphysema and a correction of type II cell hyperplasia and hypertrophy. This supports the concept that rfhSP-D might become a therapeutic option in diseases that are characterized by decreased SP-D levels in the lung.

Mortality in Patients with Branch Retinal Vein Occlusion

PURPOSE

To assess the impact of branch retinal vein occlusion (BRVO), a condition related to arteriolar wall thickening, as a prognostic marker of mortality.

DESIGN

Long-term follow-up study comparing cases with background population.

PARTICIPANTS

Patients diagnosed with BRVO.

METHODS

Diagnosis of BRVO confirmed by fundus photographic records including color diapositives and fluorescein angiograms.

MAIN OUTCOME MEASURES

Observed and expected numbers of deaths determined from comprehensive civic records in cases compared with the background population (5.4 million).

RESULTS

Branch retinal vein occlusion was found in 329 patients (173 women, 156 men) born between 1902 and 1956, who were 39 to 91 years old when diagnosed between 1973 and 1998. Follow-up was concluded on July 8, 2004, when 144 deaths were recorded in patients (74 women, 70 men), compared with an expected number of 145.5 deaths in the background population (standardized mortality rate, 0.99; 95% confidence interval, 0.84-1.16). Stratified analyses revealed no significant effect of age, gender, or time of diagnosis.

CONCLUSIONS

In this study of 329 patients with BRVO, we found no significant difference in mortality between patients and the background population. An association between BRVO and cardiovascular/cerebrovascular risk factors has previously been documented in cross-sectional studies. The contrasting outcome in this longitudinal study may have been influenced by interventions instituted after the diagnosis of BRVO was made and by preferential survival before the diagnosis of BRVO of the more fit patients with the necessary precursor condition of having arteriovenous nicking, which is more prevalent in subjects with diabetes and hypertension.

Toll-like receptors mediate proliferation and survival of multiple myeloma cells

Multiple myeloma (MM) is an incurable B-cell malignancy characterized by accumulation of malignant plasma cells in bone marrow (BM) and recurrent or persistent infections. Toll-like receptors (TLRs) are essential in the host defense against infections and today 10 human TLRs (TLR1-TLR10) and one TLR-homolog (RP105) have been characterized. B cells express several TLRs (mainly TLR1, 6, 7, 9, 10 and RP105) and TLR-initiated responses in B cells include proliferation, anti-apoptosis effect and plasma cell (PC) differentiation. The present study was designed to analyze the role of TLRs in MM. We show that frequent expressions of TLRs were detected in cell lines from MM patients (minimum six TLRs in each). In comparison, only few TLRs (mainly TLR1 and or RP105) were found expressed in PCs from BM of healthy donors. In addition, TLR-specific ligands induce increased proliferation and survival of the MM cell lines, partially due to an autocrine interleukin-6 production. Importantly, we demonstrate that also PC from MM patients proliferates in response to TLR-specific ligands. In conclusion, TLR-ligands may contribute to increased growth and survival of MM cells in MM patients.

Improvement of glucose tolerance in type 2 diabetic patients: traditional vs. modern insulin regimens (results from the Austrian Biaspart Study)

OBJECTIVE

Major advantages of modern insulin regimens containing premixed insulin analogues in comparison to traditional insulin regimens have not been evaluated yet. The aim of the present study was to investigate whether meal-related (breakfast, lunch, dinner) application of biphasic insulin aspart 30 (BIAsp 30) provides better glycaemic control than administration of biphasic human insulin 30 (BHI 30) twice per day.

RESEARCH DESIGN AND METHODS

In a multi-centre, randomized, open-label parallel trial, a total of 177 patients with type 2 diabetes mellitus were exposed to the two different insulin regimens described above over a study period of 24 weeks. HbA1c and glycemic exposure parameters were measured at predefined intervals.

RESULTS

The mean difference between treatment groups in HbA1c after 24 weeks of treatment was 0.08% (p = 0.6419). Analysing the 7-point blood-glucose (BG) profiles, significant differences in BG levels were observed after lunch (156 vs. 176 mg/dl, p = 0.0289), before dinner (142 vs. 166 mg/dl p = 0.006) and after dinner (154 vs. 182 mg/dl p = 0.002) in favour of BIAsp 30 insulin. Prandial BG increment was lower in the BIAsp 30 group at breakfast (p = 0.057) and lunch (p < 0.0005). No difference was found regarding safety parameters in the two treatment groups.

CONCLUSIONS

This study demonstrates that meal-related BIAsp 30-insulin maintains postprandial BG control more effectively than traditional BHI 30 insulin twice per day in type 2 diabetic patients.

Inhalative Pre-Treatment of Donor Lungs Using the Aerosolized Prostacyclin Analog Iloprost Ameliorates Reperfusion Injury

BACKGROUND

Lung transplantation is effective for end-stage pulmonary disease, but its successful application is still limited by organ shortage and sub-optimal preservation techniques. Therefore, optimal allograft protection is essential to reduce organ dysfunction, especially in the early post-operative period. Intravenous prostanoids are routinely used to ameliorate reperfusion injury. However, the latest evidence suggests similar efficacy using inhaled prostacyclin. Thus, we evaluated the impact of donor pre-treatment using the prostacyclin analog, iloprost, on post-ischemic function of Perfadex-protected allografts.

METHODS

In Group 1, 5 pig lungs were preserved with Perfadex (PER group) solution and stored for 27 hours. In Group 2, 100 microg of iloprost was aerosolized over 30 minutes using a novel mobile ultrasonic nebulizer (Optineb) before identical organ harvest (PER-ILO group). After left lung transplantation and contralateral lung exclusion, hemodynamic variables, Po2/Fio2 and dynamic compliance were monitored for 6 hours and compared with sham-operated controls. Pulmonary edema was determined stereologically and by wet-to-dry (W/D) weight ratio. Statistical assessment included analysis of variance (ANOVA) with repeated measures.

RESULTS

Dynamic compliance and pulmonary vascular resistance (PVR) were superior in iloprost-treated compared with untreated organs (p < 0.05), whereas oxygenation was comparable between groups. W/D ratio revealed a significantly smaller amount of lung water in PER-ILO organs (p = 0.048), whereas stereologic data showed a trend toward less intra-alveolar edema.

CONCLUSIONS

Endobronchial application of iloprost in donor lungs before Perfadex preservation decreases post-ischemic edema and significantly improves lung compliance and vascular resistance. This innovative approach is easily applicable in the clinical setting and offers a new strategy for improvement of pulmonary allograft preservation.

Experimental Lung Transplantation: Impact of Preservation Solution and Route of Delivery

BACKGROUND

Optimal preservation of allograft integrity is essential to reduce post-ischemic organ dysfunction after lung transplantation. Retrograde organ preservation leads to homogeneous intrapulmonary distribution and eliminates intravascular thrombi. So far, no comparative studies exist with regard to preservation quality following retrograde preservation with Perfadex and Celsior after extended cold-ischemia intervals.

METHODS

In an in vivo pig model, 5 lungs each were preserved for 27 hours using antegrade or retrograde perfusion techniques with Celsior (Ce(ant)/CE(ret)) and Perfadex (PER(ant)/PER(ret)). After left lung transplantation and contralateral lung exclusion, hemodynamics, oxygenation and dynamic compliance were monitored for 6 hours and compared with sham-operated controls. Pulmonary edema was determined stereologically. Statistics consisted of analysis of variance (ANOVA) with repeated measures.

RESULTS

Mortality of all Celsior-protected lungs was 100% due to severe reperfusion injury with profound lung edema. In contrast, organ preservation with PER(ant) led to sufficient graft function without mortality. Preservation quality after retrograde administration of Perfadex resulted in optimized oxygenation capacity compared with PER(ant) (p = 0.046). Furthermore, intra-alveolar edema was reduced and generally comparable with sham controls. In general, retrograde preservation led to continuous washout of small blood and fibrin clots from the pulmonary capillary system.

CONCLUSIONS

Perfadex solution provided sufficient lung preservation for 27 hours of cold ischemia, and its retrograde application led to significant functional and histologic improvement compared with antegrade perfusion. In contrast, preservation with Celsior solution resulted in lethal post-ischemic outcome, regardless of the route of administration, and therefore must be considered unsuitable for extended lung procurement.

Donor pretreatment using the aerosolized prostacyclin analogue iloprost optimizes post-ischemic function of non-heart beating donor lungs

BACKGROUND

Ischemia-reperfusion injury accounts for one-third of early deaths after lung transplantation. To expand the limited donor pool, lung retrieval from non-heart beating donors (NHBD) has been introduced recently. However, because of potentially deleterious effects of warm ischemia on microvascular integrity, use of NHBD lungs is limited by short tolerable time periods before preservation. After intravenous prostanoids are routinely used to ameliorate reperfusion injury, the latest evidence suggests similar efficacy of inhaled prostacyclin. Therefore, the impact of donor pretreatment with the prostacyclin analogue iloprost on postischemic NHBD lung function and preservation quality was evaluated.

METHODS

Asystolic pigs (5 per group) were ventilated for 180 minutes of warm ischemia (Group 2). In Group 3, 100 microg iloprost was aerosolized during the final 30 minutes of ventilation with a novel mobile ultrasonic nebulizer. Lungs were then retrogradely preserved with Perfadex and stored for 3 hours. After left lung transplantation and contralateral lung exclusion, hemodynamics, rO2/FiO2, and dynamic compliance were monitored for 6 hours and compared with sham-operated controls (Group 1). Pulmonary edema was determined both stereologically and by wet-to-dry weight ratio (W/D). Statistics comprised analysis of variance with repeated measures and Mann-Whitney test.

RESULTS

Flush preservation pressures, dynamic compliance, inspiratory pressures, and W/D were significantly superior in iloprost-treated lungs, and oxygenation and pulmonary hemodynamics were comparable between groups. Stereology revealed a trend toward lower intraalveolar edema formation in iloprost-treated lungs compared with untreated grafts.

CONCLUSIONS

Alveolar deposition of Iloprost and NHBD lungs before preservation ameliorates postischemic edema and significantly improves lung compliance. This easily applicable innovation approach, which uses a mobile ultrasonic nebulizer, offers an important strategy for improvement of pulmonary preservation quality and might expand the pool of donor lungs.

GM-CSF mediates alveolar epithelial type II cell changes, but not emphysema-like pathology, in SP-D-deficient mice

Surfactant protein D (SP-D) is a member of the collectin subfamily of C-type lectins, pattern recognition proteins participating in the innate immune response. Gene-targeted mice deficient in SP-D develop abnormalities in surfactant homeostasis, hyperplasia of alveolar epithelial type II cells, and emphysema-like pathology. Granulocyte/macrophage colony-stimulating factor (GM-CSF) is required for terminal differentiation and subsequent activation of alveolar macrophages, including the expression of matrix metalloproteinases and reactive oxygen species, factors thought to contribute to lung remodeling. Type II cells also express the GM-CSF receptor. Thus we hypothesized GM-CSF might mediate some or all of the cellular and structural abnormalities in the lungs of SP-D-deficient mice. To test this, SP-D (D−G+) and GM-CSF (D+G−) single knockout mice as well as double knockout mice deficient for both SP-D and GM-CSF (D−G−) were analyzed by design-based stereology. Compared with wild type, D−G+ as well as D+G− mice showed decreased alveolar numbers, increased alveolar sizes, and decreased alveolar epithelial surface areas. These emphysema-like changes were present to a greater extent in D−G− mice. D−G+ mice developed type II cell hyperplasia and hypertrophy with increased intracellular surfactant pools, whereas D+G− mice had smaller type II cells with decreased intracellular surfactant pools. In contrast to the emphysematous changes, the type II cell alterations were mostly corrected in D−G− mice. These results indicate that GM-CSF-dependent macrophage activity is not necessary for emphysema development in SP-D-deficient mice, but that type II cell metabolism and proliferation are, either directly or indirectly, regulated by GM-CSF in this model.

Treatment of a transdiaphragmatic fistula with an endobronchial-blocking catheter

We report a case of a bronchosubphrenic fistula in a 59-year-old female following hemicolectomy complicated by fecal peritonitis. The patient needed intubation and positive-pressure ventilation, which caused a massive air leak. The fistula was treated using an endobronchial blocking catheter in combination with antibiotic treatment and drainage.

The number of alveoli in the human lung

The number of alveoli is a key structural determinant of lung architecture. A design-based stereologic approach was used for the direct and unbiased estimation of alveolar number in the human lung. The principle is based on two-dimensional topology in three-dimensional space and is free of assumptions on the shape, size, or spatial orientation of alveoli. Alveolar number is estimated by counting their openings at the level of the free septal edges, where they form a two-dimensional network. Mathematically, the Euler number of this network is estimated using physical disectors at a light microscopic level. In six adult human lungs, the mean alveolar number was 480 million (range: 274-790 million; coefficient of variation: 37%). Alveolar number was closely related to total lung volume, with larger lungs having considerably more alveoli. The mean size of a single alveolus was rather constant with 4.2 x 10(6) microm3 (range: 3.3-4.8 x 10(6) microm3; coefficient of variation: 10%), irrespective of the lung size. One cubic millimeter lung parenchyma would then contain around 170 alveoli. The method proved to be very efficient and easy to apply in practice. Future applications will show this approach to be an important addition to design-based stereologic methods for the quantitative analysis of lung structure.

Retrospective exposure assessment and quality control in an international multi-centre case-control study

The paper presents the exposure assessment method and quality control procedure used in an international, multi-centre case-control study within a joint Nordic and Italian cohort. This study was conducted to evaluate whether occupational exposure to carcinogens influenced the predictivity of high frequency of chromosomal aberrations (CA) in peripheral lymphocytes for increased cancer risk. Occupational hygienists assessed exposures in each participating country: Denmark, Finland, Italy, Norway and Sweden. The exposure status to a carcinogen or a clastogen was coded in the cohort according to the original CA studies at the time of CA testing, but not for the whole work life. An independent occupational hygienist coordinated harmonization of the assessment criteria and the quality control procedure. The reliability of the exposure assessments was calculated as deviation from the majority of the assessors, as Cohen's kappa and as overall proportion of the agreements. The reassessment of the exposures changed the exposure statuses significantly, when compared with the original cohort. Harmonization of the exposure criteria increased the conformity of the assessments. The prevalence of exposure was higher among the original assessors (the assessor from the same country as the subject) than the average prevalence assessed by the other four in the quality control round. The original assessors classified more job situations as exposed than the others. Several reasons for this are plausible: real country-specific differences, differences in information available to the home assessor and the others and misunderstandings or difficulties in translation of information. To ensure the consistency of exposure assessments in international retrospective case-control studies it is important to have a well-planned study protocol. Due to country-specific environments a hygienist from each participating country is necessary. A quality control study is recommended, to be performed as described, combined with round-table meetings to minimize information bias between the assessors.