Pulmonary Alveolar Microlithiasis: An Isolated Case in a Hispanic Male

Pulmonary alveolar microlithiasis (PAM) is an uncommon hereditary lung disease characterized by widespread deposition of calcium phosphate microliths within the alveolar spaces. It is considered an autosomal recessive disease with a mutation in a gene encoding a sodium phosphate cotransporter. The imaging findings in the early phase of disease can be mistaken for miliary tuberculosis or sarcoidosis. However, the classic radiologic findings in the later phases of disease show numerous opacities causing a “snowstorm” appearance to the lungs that corresponds with widespread deposition of microliths throughout the lung parenchyma. Although the disease often progresses over a slow time course, there are no effective therapies, and bilateral lung transplantation is recommended when there are increasing oxygen requirements or evidence of pulmonary hypertension.

Lung Endothelial Transcytosis

Transcytosis of macromolecules through lung endothelial cells is the primary route of transport from the vascular compartment into the interstitial space. Endothelial transcytosis is mostly a caveolae-dependent process that combines receptor-mediated endocytosis, vesicle trafficking via actin-cytoskeletal remodeling, and SNARE protein directed vesicle fusion and exocytosis. Herein, we review the current literature on caveolae-mediated endocytosis, the role of actin cytoskeleton in caveolae stabilization at the plasma membrane, actin remodeling during vesicle trafficking, and exocytosis of caveolar vesicles. Next, we provide a concise summary of experimental methods employed to assess transcytosis. Finally, we review evidence that transcytosis contributes to the pathogenesis of acute lung injury. © 2020 American Physiological Society. Compr Physiol 10:491-508, 2020.

Platelet phenotype and function in the absence of splenic sequestration (Review)

The spleen, in addition to its role in immunity, plays key roles in erythrocyte maintenance and platelet sequestration. Loss of the spleen via splenectomy occurs in approximately 6.4 to 7.1 per 100 000 people per year globally, commonly as a life-saving emergency procedure in trauma and a therapeutic procedure in hematological and hematological malignant conditions. It is associated with increased risk of life-threatening infection and thromboembolism, presumably via loss of splenic function, but the underlying mechanisms behind post-splenectomy thromboembolism are unclear. The splenectomized individual has a two-fold risk of thromboembolism as compared to non-splenectomized individuals and the risk of thromboembolism is elevated both post-operatively and in the longer term. Although those splenectomized for hematological conditions or hematological malignant conditions are at highest risk for thromboembolism, an increase in thromboembolic outcomes is also observed amongst individuals splenectomized for trauma, suggesting underlying disease state is only a partial factor. Although the physiological role of the splenic platelet pool on platelets is unclear, platelet changes after splenectomy suggest that the spleen may play a role in maintaining platelet quality and function. In hypersplenic conditions, sequestration can increase to sequester up to 72% of the total platelet mass. Following splenectomy, a thrombocytosis is commonly seen secondary to the loss of the ability to sequester platelets. Abnormal platelet quality and function have been observed as a consequence of splenectomy. These platelet defects seen after splenectomy may likely contribute to the increase in post-splenectomy thromboembolism. Here we draw upon the literature to characterize the post-splenectomy platelet and its potential role in post-splenectomy thromboembolism.

Severe OSA Leading to Long Pauses in 24-h Holter ECG Reversed with CPAP

INTRODUCTION

Sleep-related problems like sleep apnea are increasing tremendously mostly owing to the disordered lifestyle the present generation is leading which is added like a topping on the base of obesity and metabolic syndrome. The burden on the society is huge taking into consideration the work-time loss and health-related financial issues arising out of these sleep disorders with obstructive sleep apnea (OSA) leading the way. Early diagnosis can prevent several complications of OSA. Cardiovascular diseases, including various arrhythmias, arising due to OSA, are described previously.

CASE PRESENTATION

Herein, an interesting case of OSA, whose pacemaker installation to rectify the long pause could be avoided by simple correction of his OSA using continuous positive airway pressure, is presented. This 49-year-old male patient was diagnosed with severe OSA by using polysomnography and all his significant sinus pauses (highest one with 7.8 sec) during holter ECG monitoring were found to be occurring at night and correcting his OSA with continuous positive airway pressure (CPAP) treatment reverted all those sinus pauses and the need for any further intervention with pacemaker was discarded.

DISCUSSION

OSA is caused by either partial or complete obstruction of the upper airway, and there is the simultaneously attenuated upper airway dilator muscle tone while the patient is sleeping. The gold standard test designed for the assessment of OSA is polysomnography, as approved by the American Academy of Sleep Medicine and CPAP has been found to be universally beneficial in treating OSA related complications. Physiologically, the ACC/AHA guidelines recommend pacing only in patients with prolonged asymptomatic pauses occurring during wakefulness. This case report proved the above mentioned claim of CPAP treatment.

Non-alcoholic fatty liver disease as metabolic consequence of obstructive sleep apnea

Obstructive sleep apnea (OSA) as a worldwide prevalent condition carries risk for cardiovascular and metabolic diseases, ultimately increasing overall mortality rates. Non-alcoholic fatty liver disease (NAFLD) can be considered as the primary metabolic disease, but also as a coexisting OSA comorbidity. Although prevalence of NAFLD covers quarter of world population, it increases with OSA presence. It can be speculated that chronic intermittent hypoxia (CIH) and sympathetic nervous system overactivity are involved in NAFLD pathogenesis and progression from simple steatosis through steatohepatitis to fibrosis. CIH provides the environment for liver oxidative stress, inflammation and increases the expression of genes involved in cholesterol and fatty acids synthesis. Catecholamines increase b-oxidation in liver and release free fatty acids from adipose tissue in plasma which inhibit insulin effects. Obesity and insulin resistance as key players in NAFLD development and advancement, deepen vicious circle of oxidative stress, inflammation and dyslipidemia. If not treated, OSA in NAFLD patients has been associated with inflammation, hepatocytes' necrosis, and fibrosis. Continuous positive airway pressure (CPAP) represents gold standard for OSA therapy, allowing the unimpeded air passage through upper parts of respiratory system. However, it has been demonstrated that CPAP therapy have beneficial effects on cardiometabolic outcomes and slow liver degeneration.

Clinical Characteristics and Outcomes of Acute Lung Injury Caused by Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Retrospective Cohort Study from a Single Institution in China

Background

Acute lung injury (ALI) is a rare but life-threatening pulmonary complication of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). The aim of this study was to characterize the common risk factors, clinical features, imaging findings, treatments, and outcomes of acute lung injury caused by TACE.

Methods

A retrospective study was performed on all TACE-associated ALI cases that were diagnosed at authors' hospital from January 2015 to June 2018.

Results

The study included 14 ALI cases where the mean age of patients was 60.9 ± 11.7 years (range 41-82 years), with a mean onset time of 2.4 ± 1.6 d after TACE. Of the 14 patients, 8 patients (57.1%) developed acute respiratory distress syndrome (ARDS). 7 patients (50%) had underlying chronic respiratory disease and hepatic arteriovenous fistula was detected in 6 patients (42.6%), both of which were significantly higher than control group (P < 0.05). Dyspnea (92.9%) was the most common symptoms. Pleural effusion (64.3%), diffuse pulmonary infiltration (42.9%), and accumulation of Lipiodol in lung field (42.9%) were frequent radiologic abnormalities. 11 patients (78.6%) achieved remission after treatment, and the 30-day mortality rate was approximately 21.4%. Patient's median survival time after the development of ALI was merely 4.3 months, which was obviously worse than control group (4.3 months vs. 13.5 months, P < 0.05).

Conclusion

This study illustrates that TACE-associated ALI is a rare pulmonary complication with a high mortality rate. We infer that pulmonary Lipiodol embolization might be one of the main causes of TACE-associated ALI. Thus, HCC patients who are at high risk should be closely evaluated and monitored during TACE to avoid such potentially fatal complication.

Polymyxin B hemoperfusion as a feasible therapy after source control in abdominal septic shock

BACKGROUND

Polymyxin B hemoperfusion (PMX-HP) has been used as a treatment for intra-abdominal septic shock by absorbing and removing endotoxins of gram-negative bacilli.

AIM

To investigate the clinical efficacy of PMX-HP in patients with gram-negative septic shock who underwent abdominal surgery.

METHODS

From January 2012 to December 2018, patients who had septic shock secondary to peritonitis were enrolled. They were classified into PMX-HP treated and control groups based on postopreative intervention using PMX-HP. The clinical outcomes were compared using 1:1 propensity score matching methods to balance the overall distribution between the two groups.

RESULTS

After propensity score matching, 40 patients were analyzed (20 patients in the PMX group and 20 patients in the control group). The scores of total Sequential Organ Failure Assessment (SOFA) score, renal SOFA and coagulation SOFA were significantly improved in the PMX group but not in the control group. (from 11.2 ± 5.8 to 4.7 ± 3.5 in PMX group vs 10.0 ± 4.0 to 8.7 ± 7.3 in control group, P = 0.047 from 2.6 ± 1.0 to 0.7 ± 1.0 in PMX group vs 2.6 ± 1.5 to 2.8 ± 1.6 in control group, P = 0.000, from 1.6 ± 1.5 to 1.3 ± 1.3 in PMX group vs 1.2 ± 1.2 to 2.8 ± 1.8 in control group, P = 0.014, respectively). Further, the length of intensive care unit (ICU) stay was significantly shorter in PMX group. However, no statistically significant difference was found in ICU mortality (50% in PMX group vs 50% in control group).

CONCLUSION

PMX-HP is a feasible adjunct treatment for peritonitis in ICU patients with peritonitis for improved organ impairment and to stabilize hemodynamics. It would be helpful to enhance clinical outcomes especially in patients with complete elimination of the source of gram-negative bacilli infection by surgical procedure accompanied with conventional treatment of sepsis.

Decrements of body mass index are associated with poor outcomes of idiopathic pulmonary fibrosis patients

BACKGROUND

The processes that result in progression of idiopathic pulmonary fibrosis (IPF) remain enigmatic. Moreover, the course of this disease can be highly variable and difficult to accurately predict. We hypothesized analyses of body mass index (BMI), a simple, routine clinical measure, may also have prognostic value in these patients, and might provide mechanistic insights. We investigated the associations of BMI changes with outcome, plasma adipokines, and adaptive immune activation among IPF patients.

METHODS

Data were analyzed in an IPF discovery cohort (n = 131) from the University of Pittsburgh, and findings confirmed in patients from the University of Alabama at Birmingham (n = 148). Plasma adipokines were measured by ELISA and T-cell phenotypes determined by flow cytometry.

RESULTS

Transplant-free one-year survivals in subjects with the greatest rates of BMI decrements, as percentages of initial BMI (>0.68%/month), were worse than among those with more stable BMI in both discovery (HR = 1.8, 95%CI = 1.1-3.2, p = 0.038) and replication cohorts (HR = 2.5, 95%CI = 1.2-5.2, p = 0.02), when adjusted for age, baseline BMI, and pulmonary function. BMI decrements >0.68%/month were also associated with greater mortality after later lung transplantations (HR = 4.6, 95%CI = 1.7-12.5, p = 0.003). Circulating leptin and adiponectin levels correlated with BMI, but neither adipokine was prognostic per se. BMI decrements were significantly associated with increased proportions of circulating end-differentiated (CD28null) CD4 T-cells (CD28%), a validated marker of repetitive T-cell activation and IPF prognoses.

CONCLUSIONS

IPF patients with greatest BMI decrements had worse outcomes, and this effect persisted after lung transplantation. Weight loss in these patients is a harbinger of poor prognoses, and may reflect an underlying systemic process, such as adaptive immune activation.

Splenectomy is not associated with a higher tricuspid regurgitant jet velocity in people with sickle cell anemia

BACKGROUND

Vascular complications such as pulmonary hypertension (PH) occur at an increased rate following splenectomy in patients with various hemolytic blood disorders including thalassemia. The goal of this retrospective cross-sectional analysis was to assess the independent association of splenectomy with an elevated tricuspid regurgitation velocity (TRV) in people with homozygous sickle cell disease (HbSS). TRV is a noninvasive screening test for PH and a surrogate marker of prognosis in sickle cell disease (SCD).

PROCEDURE

Data were obtained from the multicenter Walk-PHaSST (treatment of pulmonary hypertension and sickle cell disease with sildenafil therapy) study of PH (NCT00492531). We compared TRV in the cohort of patients with HbSS who were surgically splenectomized with patients who were not surgically splenectomized.

RESULTS

We found no significant differences in TRV between the two groups.

CONCLUSIONS

The lack of difference in TRV between the two groups is most likely because members of the comparator nonsurgical group in many cases experienced autoinfarction of the spleen in childhood. Splenectomy does not seem to confer additional risk for the development of a higher TRV in HbSS, unlike in patients with thalassemia or other hemolytic anemias. This could be an important consideration when weighing the risks and benefits of splenectomy in patients with HbSS.

Vascular endothelial growth factor and pulmonary hypertension in children with beta thalassemia major

OBJECTIVE

The purpose of this study was to illustrate the association between vascular endothelial growth factor level and pulmonary artery hypertension in children with β-thalassemia major.

METHOD

This case-control study was conducted on 116 children with β-thalassemia major; 58 of them had pulmonary artery hypertension. They were compared to 58 healthy children who were age and sex-matched (control group). Serum levels of vascular endothelial growth factor and echocardiographic assessment were done for all children.

RESULTS

Vascular endothelial growth factor serum level was significantly higher in children with β-thalassemia major with pulmonary artery hypertension than in those without pulmonary artery hypertension, as well as in control groups (p<0.001). Vascular endothelial growth factor serum level had a significant positive correlation with pulmonary artery pressure and serum ferritin, as well as a significant negative correlation with the duration of chelation therapy. Logistic regression analysis revealed that elevated vascular endothelial growth factor (Odd Ratio=1.5; 95% Confidence Interval, 1.137-2.065; p=0.005) was an independent risk factor of pulmonary artery hypertension in such children. Vascular endothelial growth factor serum level at a cutoff point of >169pg/mL had 93.1% sensitivity and 93.1% specificity for the presence of pulmonary artery hypertension in children with β-thalassemia major.

CONCLUSION

Elevated vascular endothelial growth factor serum level is associated with pulmonary artery hypertension in children with β-thalassemia.

Autotaxin and chronic inflammatory diseases

Autotaxin (ATX) is a secreted glycoprotein, widely present in biological fluids including blood. ATX catalyzes the hydrolysis of lysophosphatidylcholine (LPC) to lysophosphatidic acid (LPA), a growth factor-like, signaling phospholipid. LPA exerts pleiotropic effects mediated by its G-protein-coupled receptors that are widely expressed and exhibit overlapping specificities. Although ATX also possesses matricellular properties, the majority of ATX reported functions in adulthood are thought to be mediated through the extracellular production of LPA. ATX-mediated LPA synthesis is likely localized at the cell surface through the possible interaction of ATX with integrins or other molecules, while LPA levels are further controlled by a group of membrane-associated lipid-phosphate phosphatases. ATX expression was shown to be necessary for embryonic development, and ATX deficient embryos exhibit defective vascular homeostasis and aberrant neuronal system development. In adult life, ATX is highly expressed in the adipose tissue and has been implicated in diet-induced obesity and glucose homeostasis with multiple implications in metabolic disorders. Additionally, LPA has been shown to affect multiple cell types, including stromal and immune cells in various ways. Therefore, LPA participates in many processes that are intricately involved in the pathogenesis of different chronic inflammatory diseases such as vascular homeostasis, skeletal and stromal remodeling, lymphocyte trafficking and immune regulation. Accordingly, increased ATX and LPA levels have been detected, locally and/or systemically, in patients with chronic inflammatory diseases, most notably idiopathic pulmonary fibrosis (IPF), chronic liver diseases, and rheumatoid arthritis. Genetic and pharmacological studies in mice have confirmed a pathogenetic role for ATX expression and LPA signaling in chronic inflammatory diseases, and provided the proof of principle for therapeutic interventions, as exemplified by the ongoing clinical trials for IPF.

Usefulness of percutaneous microwave ablation for large non-small cell lung cancer: A preliminary report

The role of microwave ablation (MWA) in patients with non-small cell lung cancer (NSCLC) remains ill-defined. This retrospective study evaluated the oncological outcomes of CT-guided MWA in patients with large NSCLC. Kaplan-Meier analysis was used to evaluate overall survival (OS) and cancer-specific survival (CSS). The log-rank test was used to compare survival between patients with an NSCLC size greater or smaller than 4 cm. The likelihood of local tumor progression (LTP) was analyzed using a multivariable regression model. A total of 53 patients with 65 tumors were analyzed. The mean tumor size was 5.0±1.8 cm. At the 1-month CT scan, complete tumor ablation was observed in 44.6% of cases. In 18.5% of cases a redo-MWA session was carried out, while in 4.6%, a third MWA was necessary to obtain complete tumor necrosis. The mean follow-up was 28.1±20.6 months with a median duration of 21.5 months. The 1-year, 2-year, 3-year and 5-year OS rates were 78.2, 48.3, 34.8 and 18.3%, respectively. The median CSS was 25 months (95% CI 15.5-34.5). The 1-year, 2-year, 3-year and 5-year CSS rates were 84.3, 53.7, 42.1 and 30.0%, respectively. OS in patients with tumor size ≥4 cm was significantly lower when compared with those having smaller tumors (P=0.03). LTP was observed in 19 patients (35.8%). Incomplete tumor ablation [odds ratio (OR) 6.57; P<0.05] and tumor size ≥4 cm (OR 0.18; P<0.05) were significant independent predictors of LTP. In conclusion, CT-guided MWA may represent a useful tool in the multimodality treatment of patients with large advanced NSCLC.

Sulforaphane treatment reverses corticosteroid resistance in a mixed granulocytic mouse model of asthma by upregulation of antioxidants and attenuation of Th17 immune responses in the airways

Sulforaphane has received considerable attention in recent years due to its antioxidant and anti-inflammatory properties. Its preventive effect in the inhibition of airway inflammation is known; however, whether it affects mixed granulocyte asthma (corticosteroid resistance phenotype) is largely undiscovered. Therefore, we assessed the effect of pharmacological activation of Nrf2, a redox-sensitive transcription factor, using sulforaphane in a mouse model of mixed granulocyte airway inflammation. Mice were sensitized and challenged with cockroach allergen extract (CE), and airway inflammatory parameters and markers of steroid resistance [Nrf2 activity, oxidant-antioxidant balance in airway epithelial cells (AECs)/lung, and IL-17A-related pathway in Th17 cells and dendritic cells (DCs)] were investigated. Our results show that sulforaphane administration reduced neutrophilic airway inflammation, myeloperoxidase (MPO) activity, and Th17 immune responses in a mixed granulocyte mouse model of asthma through Nrf2 activation. On the other hand, corticosteroid treatment decreased Th2/eosinophilic immune responses but had little on Th17/neutrophilic immune responses. However, combined treatment with both almost completely blocked both neutrophilic/eosinophilic and Th17/Th2 immune responses in the lung. Sulforaphane treatment led to induction of antioxidant enzymes (SOD, GPx) in AECs and pulmonary non-enzymatic antioxidants. Further, it led to reduction in inflammatory cytokines (IL-6/IL-23/IL-17A) in Th17 cells/CD11c + DCs during mixed granulocytic inflammation. Collectively, our study presents the evidence that activation of Nrf2 by sulforaphane reduces neutrophilic airway inflammation by upregulation of antioxidants and downregulation of inflammatory cytokines in airways. This is possibly the basis for reversal of corticosteroid resistance in this model. This shows the therapeutic potential of sulforaphane in mixed granulocyte asthma.

Acute Exacerbation of Idiopathic Interstitial Pneumonia in a Patient with Hepatocellular Carcinoma after Transcatheter Arterial Therapy Using Miriplatin

A 76-year-old Japanese woman with recurrent hepatocellular carcinoma presented with acute exacerbation of idiopathic interstitial pneumonia (AE-IIP) after transcatheter arterial therapy using miriplatin. She had a history of preexisting IIP five years before presenting at our hospital. On day 4 after transcatheter arterial therapy, she complained of shortness of breath. Subsequently, she developed acute respiratory failure on day 11 after transcatheter arterial therapy. Chest computed tomography revealed extensive ground-glass opacity and traction bronchiectasis in bilateral lung fields; subsequently, she was diagnosed with AE-IIP triggered by transcatheter arterial therapy using miriplatin. Despite systemic administration of high-dose corticosteroid and cyclophosphamide, she died of respiratory failure on day 36.

Screening for Lung Cancer Using Low-dose Chest Computed Tomography in Korean Long-term Colorectal Cancer Survivors

Background

The National Lung Screening Trial (NLST) and NELSON trial showed that low-dose chest computed tomography (LDCT) screening significantly reduced the mortality form lung cancer. Although cancer survivors are known to have high risk for second malignant neoplasm (SMN), the usefulness of LDCT screening for lung cancer in cancer survivors is not clear.

Methods

Between August 2016 and August 2017, 633 long-term colorectal cancer (CRC) survivors visited the survivorship clinic in Cancer Prevention Center, Yonsei Cancer Center, Seoul, Republic of Korea. We surveyed the smoking status and recommended LDCT screening to ever-smoking CRC survivors aged 55–80 years. The participants were classified into three risk groups: risk group 1 (RG1) who met the NLST criteria (Age 55–74 years, ≥ 30 pack-years of smoking, smoking cessation < 15 years); risk group 2 (RG2) who would not meet the NLST criteria but were at increased 6-year risk of lung cancer (PLCO_M2012 ≥ 0.0151); risk group 3 (RG3) who did not meet any of the criteria above.

Results

Among 176 ever-smoking CRC survivors, 173 (98.3%) were male, 32 (18.2%) were current-smoker, and median age was 66 years (range, 55–79 years). We found 38 positive findings (non-calcified nodule ≥ 4 mm), 8 clinically significant findings, 66 minor abnormalities, and 64 negative findings on LDCT. Positive findings were identified in 15 of 79 (19.0%) of RG1, in 9 of 36 (25%) of RG2, and in 14 of 61 (23.0%) of RG3. Second primary lung cancers were found in 2 patients of RG2, and in 1 patient of RG3. SMN was most frequently found in RG2 (11 of 36 patients, 30.6%), compared with RG1 (12.7%) or RG3 (9.8%) (P = 0.016).

Conclusions

LDCT screening for lung cancer in Korean CRC survivors is feasible. Well-designed clinical trial for defining high risk patients for lung cancer among CRC survivors is needed.

Dietary Pattern and Their Association With Level of Asthma Control Among Patients With Asthma at Al-Shifa Medical Complex in Gaza Strip, Palestine

Background:

This study was conducted to identify major dietary patterns and their association with level of asthma control among patients with asthma in Gaza Strip, Palestine.

Methods:

This cross-sectional study was conducted among a representative sample of Palestinian patients with asthma (both sex, aged 19-64 years) receiving care in chest department at Al-Shifa Medical Complex. Asthma control level was obtained using asthma control test. Data regarding other variables were obtained using an interview-based questionnaire and a semi-quantitative food frequency questionnaire. Statistical analysis was performed using SPSS version 20.

Results:

Two major dietary patterns were identified including (1) Prudent pattern characterized by a high intake of whole grains, beans and legumes, fish and shellfish products, vegetables, tomatoes, fruits, and vegetable oils, and (2) Western pattern characterized by a high intake of refined grains, red meat, poultry, fast foods, eggs, low-fat dairy product, high-fat dairy products, hydrogenated fats, olive, sugar, sweets, desserts, and snacks. After adjustment for confounding variables, patients in the lowest tertile (T1) of Prudent pattern had a lower odds for poorly controlled asthma (odds ratio [OR] = 0.044, 95% confidence interval [CI] = [0.002-1.316], P value < 0.05), whereas patients in the lowest tertile (T1) of Western pattern had a higher odds for poorly controlled asthma (OR = 2.499, 95% CI = [1.288-4.850], P value < 0.05), compared with those in the highest tertile (T3).

Conclusion:

A Prudent pattern may be associated with a lower prevalence of poorly controlled asthma, whereas a Western pattern may be associated with a higher prevalence of poorly controlled asthma.

Pulmonary hypertension with massive megalosplenia: A case report

RATIONALE

Pulmonary hypertension (PH) is a complicated disease which has complex causes and poor outcome. Many factors are involved in the increase of pulmonary artery pressure. It is often difficult to identify the specific cause of a particular patient. However, identifying the etiology is of great importance for specifying treatment strategies and improving the prognosis of patients.

PATIENT CONCERNS

A 58-year-old male was admitted because of fatigue, breath shortness for 6 months, which got worse in the last 3 months. The ultrasound cardiogram (UCG) indicated a remarkably elevated pulmonary artery systolic pressure (PASP = 82 mm Hg). He had hypertension for 15 years. Besides, his spleen was found to be enlarged since 15 years ago. Bone marrow biopsy of the patient revealed myeloproliferative neoplasm (MPN) with severe myelofibrosis (MF).

DIAGNOSIS

Myeloproliferative neoplasm (MPN) with severe myelofibrosis (MF) which in turn caused PH and portal vein hypertension (PVH).

INTERVENTIONS

We treated the patient with diuretics and fosinopril, and also steroids and thalidomide for his MPN/MF.

OUTCOMES

Two weeks later, the pulmonary artery pressure (PAP) was remarkably decreased (PASP = 53.1 mm Hg by UCG, mean PAP = 21 mm Hg by right cardiac catheterization). Within 2 years' follow-up, his circulatory state and hematological state remained stable.

LESSONS

It is often difficult to define the cause of PH, but it is important for making the appropriate treatment at the same time.

Non-alcoholic fatty liver disease is an independent risk factor for inflammation in obstructive sleep apnea syndrome in obese Asian Indians

INTRODUCTION

Obstructive sleep apnea (OSA) has been estimated to affect 4-11% of the population and causes systemic inflammation which leads to metabolic syndrome (MS). Non-alcoholic fatty liver disease (NAFLD) is also associated with MS whether NAFLD is an additional risk factor for the systemic inflammation that occurs in OSA is unclear.

OBJECTIVE

In this study, we aimed to analyze the association of OSA and NAFLD with MS and systemic inflammation in Asian Indians.

METHODS

Total 240 (132 males and 108 females) overweight/obese subjects [body mass index (BMI > 23 kg/m2)] were recruited; of these, 124 subjects had OSA with NAFLD, 47 had OSA without NAFLD, 44 did not have OSA but had NAFLD and 25 had neither OSA nor without NAFLD. Severity of NAFLD was based on abdomen ultrasound and of OSA on overnight polysomnography. Clinical examinations, anthropometry, body composition, metabolic parameters, and inflammatory biomarkers were recorded.

RESULTS

Serum levels of leptin, macrophage migration inhibitory factor (MIF), interleukin-6 (IL-6), high sensitive C-reactive protein (Hs-CRP), and tumor necrosis factor alpha (TNF-α) were significantly higher, and adiponectin levels were significantly lower in OSA with NAFLD subjects. Prevalence of MS was significantly increased in OSA and NAFLD subjects (p = 0.001). There was a strong association and correlation between leptin, IL-6, Hs-CRP, MIF, and TNF-α in OSA and NAFLD subjects. Multivariate logistic regression showed that OSA was positively associated with the NAFLD [odds ratio (OR), (95% confidence interval (CL) 3.12 (2.58-7.72), (P = 0.002)].

CONCLUSION

NAFLD is an additional risk factor in OSA subject which contributes to systemic inflammation in Asian Indians.

Inflammatory and oxidative stress biomarkers at protein and molecular levels in workers occupationally exposed to crystalline silica

Workers chronically exposed to respirable crystalline silica (CS) are susceptible to adverse health effects like silicosis and lung cancer. This study aimed to investigate potential early peripheral biomarkers of inflammation and oxidative stress in miners. The subjects enrolled in this study were occupationally unexposed workers (OUW, n = 29) and workers exposed to crystalline silica (WECS), composed by miners, which were divided into two subgroups: workers without silicosis (WECS I, n = 39) and workers diagnosed with silicosis, retired from work (WECS II, n = 42). The following biomarkers were evaluated: gene expression of L-selectin, CXCL2, CXCL8 (IL-8), HO-1, and p53; malondialdehyde (MDA) plasma levels and non-protein thiol levels in erythrocytes. Additionally, protein expression of L-selectin was evaluated to confirm our previous findings. The results demonstrated that gene expression of L-selectin was decreased in the WECS I group when compared to the OUW group (p < 0.05). Regarding gene expression of CXCL2, CXCL8 (IL-8), HO-1, and p53, significant fold change decreases were observed in workers exposed to CS in relation to unexposed workers (p < 0.05). The results of L-selectin protein expression in lymphocyte surface corroborated with our previous findings; thus, significant downregulation in the WECS groups was observed compared to OUW group (p < 0.05). The MDA was negatively associated with the gene expression of CXCL-2, CXCL8 (IL-8), and p53 (p < 0.05). The participants with silicosis (WECS II) presented significant increased non-protein thiol levels in relation to other groups (p < 0.05). Taken together, our findings may contribute to help the knowledge about the complex mechanisms involved in the silicosis pathogenesis and in the risk of lung cancer development in workers chronically exposed to respirable CS.

Vitex agnus-castus safeguards the lung against lipopolysaccharide-induced toxicity in mice

Vitex agnus-castus (VAC, Verbenaceae) is widely used in Chinese traditional medicine as an antiinflammatory agent. This study aimed to explore the efficacy of the VAC extract to protect against lipopolysaccharide (LPS)-induced acute lung injury. The results have shown that VAC had a potent protective activity against LPS-induced acute lung damage. It significantly decreased pulmonary edema as there was a significant decrease in lung wet/dry ratio and in protein content. VAC also decreased the lactate dehydrogenase's activity in the bronchoalveolar fluid. VAC ameliorated LPS-induced inflammatory cells infiltration into the lung tissue and reversed the histopathological lesions of the lung. Furthermore, VAC counteracted LPS-induced oxidative stress as it attenuated the lipid peroxidation marker, malondialdehyde, in the lung. VAC increased the antioxidant activity as evident by elevated superoxide dismutase activity and increased reduced glutathione content in the lung tissue. Collectively, VAC has a protective activity against LPS-induced acute lung damage through its antioxidant potential. PRACTICAL APPLICATIONS: Vitex agnus-castus has been used in various traditional medicines for treating various ailments as digestive complains, acne, rheumatic pains, menstrual irregularities, premenstrual syndrome, infertility, and hyperprolactinemia. Its leaves are used as a spice and the fruits are used as a substitute for pepper. VAC food supplements are used by women against psychic and somatic premenstrual symptoms. The findings of this study can demonstrate the potent protective activity of the VAC extract against LPS-induced acute lung damage due to its antioxidative effects. Therefore, VAC could be developed as a health functional food to improve acute lung damage and many diseases caused by oxidative damage.

Impact of nitrate therapy on the expression of caveolin-1 and its phosphorylated isoform in lungs in the model of monocrotaline induced pulmonary hypertension

Aim: Nitric oxide signalling pathway showed to be one of the crucial factors in the treatment and pathogenesis of pulmonary arterial hypertension. The aim of this study was to determine the effect of administration of inorganic nitrate, NaNO3, on the expression of caveolin-1 and its phosphorylated isoform (pTyr14Cav-1) in lungs in the experimental model of monocrotaline induced pulmonary hypertension.

Methods: 10 weeks old male Wistar rats were subcutaneously injected with 60 mg/kg dose of monocrotaline (MCT) or vehicle (CON). Twelve days after the injection, part of the MCT group was receiving 0.3 mM NaNO3 (MCT+N0.3) daily in the drinking water and rest was receiving 0.08% NaCl solution. Four weeks after MCT administration, the rats were sacrificed in CO2. Protein expression in lungs was determined by western blot.

Results: We observed a significant decrease in the caveolin-1 expression and a significant shift towards the expression of pTyr14Cav-1 in the group treated with nitrate (p < 0.05).

Conclusion: NaNO3 administration affected the expression of caveolin-1 and the ratio of its active (phosphorylated) isoform increased.

Hepatopulmonary shunting on Tc99m-MAA liver mapping: correlation with dynamic cross-sectional imaging and description of different shunting patterns

PURPOSE

The purpose of the study was to correlate lung shunt fraction (LSF) calculated by intra-arterial injection of Technetium-99m (Tc-99m)-labeled macroaggregated albumin (MAA) in a hepatic artery branch with the presence of certain patterns of vascular shunts on dynamic CT or MRI of the liver.

METHODS

This retrospective study was approved by the institutional review board and informed consent was waived. We reviewed 523 MAA scans in 453 patients (301 men, 152 women) performed from July 2007 to June 2015 and their correlative cross-sectional imaging. Patterns of vascular shunts on dynamic CT or MRI performed within 3 months of the MAA study and that potentially divert hepatic arterial inflow to the systemic venous return were defined as "target shunts." Dynamic CT or MRI was classified into three groups with target shunt present, absent, or indeterminate. The mean LSF was compared across the first and second groups using paired t test.

RESULTS

342 CT and MRI studies met inclusion criteria: target shunts were present in 63 studies, absent in 271 studies, and 8 studies were indeterminate. When target shunts were visualized, the mean LSF on corresponding MAA scans was 12.9 ± 10.36% (95% CI 10.29-15.15%) compared to 4.3 ± 3.17% (95% CI 3.93-4.68%) when no target shunt was visualized. The difference was statistically significant (p value < 0.001). Identified target shunts were either direct (arteriohepatic venous shunt) or indirect (arterioportal shunt combined with a portosystemic shunt).

CONCLUSIONS

Visualizing certain patterns of vascular shunting on a dynamic CT or MRI scan is associated with high LSF.

Does a carrot a day keep the allergy away?

Vitamin A is an important micronutrient, from plants diet taken up as carotenoids, from animal food sources as retinol. Its active metabolite retinoic acid (RA) binds to nuclear hormone receptors, thereby regulating gene transcription programs in various cells. Adequate nutritional intake of vitamin A is essential for pre- and postnatal development, eyesight and reproduction, and it contributes to the maintenance and regulation of the immune system. Recent molecular studies indicate that lipocalins play an important role in the bioavailability of RA and its immune modulation against Th2 responses. There is emerging evidence that supply with vitamin A determines the susceptibility to allergic diseases: significantly reduced serum vitamin A levels are commonly observed in allergic patients compared to healthy controls. In line, findings from nutritional and clinical trials suggest that sufficient vitamin A supplementation in pregnancy prevents the development of allergic diseases in the offspring, and helps in controlling symptoms in adult asthmatics. Overall, retinoids have a key role in regulating immune homeostasis on mucosal surfaces because they are able to interfere with inflammatory signalling pathways. In this mini-review we will concentrate on the current knowledge about the influence of dietary and supplementary vitamin A on allergic diseases in humans from infancy to adulthood.

Ventilatory disorders associated with occupational inhalation exposure to nitrogen trihydride (ammonia)

Respiratory effects of long term exposure to low levels of ammonia have not been thoroughly investigated. In this cross sectional study, 124 male subjects (67 high exposed and 57 low exposed), occupationally exposed to low levels of ammonia and 120 male referent individuals were investigated. Airborne concentrations of ammonia were measured and subjects underwent spirometry tests prior to and at end of their daily work shift. Average concentrations of ammonia in the breathing zones of the high and low exposed employees were found to be 1.35 ± 4.59 and 0.29 ± 0.31 ppm, respectively. Additionally, mean baseline values of some parameters of pulmonary function such as Vital Capacity (VC) and Forced Expiratory Volume in the first second (FEV1) in the high exposed group were significantly lower than those of referent individuals. Similarly, significant reversible cross shift decrements were noted in FEV1, VC and Forced Vital Capacity (FVC) of exposed employees. These findings indicate that exposure to low levels of ammonia is associated with significant chronic irreversible and acute reversible decrements in the lungs' functional capacity.

The host microbiome and impact of tuberculosis chemotherapy

The treatment of Mycobacterium tuberculosis infection is often viewed in isolation from other human microbial symbionts. Understandably, the clinical priority is eliminating active or latent tuberculosis (TB) in patients. With the increasing resolution of molecular biology technologies, it is becoming apparent that antibiotic treatment can perturb the homeostasis of the host microbiome. For example, dysbiosis of the gut microbiota has been associated with an increased risk of the development of asthma, obesity and diabetes. Therefore, fundamental questions include: Does TB chemotherapy cause disruption of the human microbiome and adverse effects in patients; and are there signature taxa of dysbiosis following TB treatment. In this review, we examine recent research on the detection of changes in the microbiome during antibiotic administration and discuss specific findings that relate to the impact of anti-tubercular chemotherapy.

The role of splenectomy in lipid metabolism and atherosclerosis (AS)

The extensive performance of splenectomy worldwide for patients suffered from splenic trauma has given rise to high risks of postoperative complications, which has been attracting increasing attention in recent years. Nowadays the spleen is regarded as a versatile organ of the human body, invested with various excellent properties. The spleen has been recognized to take a great part in lipid metabolism. While removal of the spleen intends to alter lipid values, especially with an elevated LDL, splenic autotransplantation is able to normalize these lipid alterations. What is more, conservative surgical procedures like subtotal or partial splenectomy, could as well, afford a correction of dyslipidemia. At the same time, clinically, splenectomy demonstrates a high rate of atherosclerosis (AS), whereas non-surgical treatment after splenic trauma shows unchanged propagation of AS. Based on the intimate relationship between serum lipids and AS, the lipid changes modulated by splenectomy are believed to be responsible for the development of AS. Therefore, a "splenic factor" is most likely present in the regulation of lipidation and AS. Several theories have been postulated to elucidate the possible mechanism involved, among which most are primarily based on its forceful natural immune function, that is to say, the mononuclear phagocytic system.However, the accurate mechanisms behind this mysterious phenomenon still remain unclear so far. Of importance, lipid fractions should be monitored consecutively in case of inevitable splenectomy.

Complications of transarterial chemoembolization (TACE) in the treatment of liver tumors

INTRODUCTION

Transarterial chemoembolization (TACE) is considered a therapeutic option. It is mostly used in hepatocellular carcinoma or liver colorectal, neuroendocrine or melanoma metastases. Although it is considered a safe procedure, TACE presents complications, such as acute cholecystitis, which is the most common. Other procedure-related complications include pulmonary embolism, hepatic abscess, bile duct injury, gastric mucosa injury and, less frequently, acute pancreatitis. The aim of this study is to review the complications following TACE for liver tumors.

METHODS

We performed a retrospective study including all the TACE procedures performed in a single center during the period between January 2013 and December 2016.

RESULTS

Out of the 196 patients with liver tumors who had undergone 322 TACE, 258 (80%) were male and 64 (20%) were female. Mean patient age was 66.5years. Major complications after chemoembolization included: decompensation with edema/ascites (6patients), acute cholecystitis (4), acute pancreatitis (3), liver rupture (1), liver abscess (1) and renal failure (1). Postembolization syndrome appeared in 71 (20%) patients. On multivariate analysis, it was observed that concomitant cardiovascular disease (OR: 4.5; 95%CI: 1.2-17; P=.025) is a risk factor for the development of complications.

CONCLUSIONS

TACE is a safe and effective procedure for liver tumor treatment. The majority of the complications are rare and present a low incidence of mortality.

Oximetry use in obstructive sleep apnea

INTRODUCTION

Overnight oximetry has been proposed as an accessible, simple, and reliable technique for obstructive sleep apnea syndrome (OSAS) diagnosis. From visual inspection to advanced signal processing, several studies have demonstrated the usefulness of oximetry as a screening tool. However, there is still controversy regarding the general application of oximetry as a single screening methodology for OSAS. Areas covered: Currently, high-resolution portable devices combined with pattern recognition-based applications are able to achieve high performance in the detection of this disease. In this review, recent studies involving automated analysis of oximetry by means of advanced signal processing and machine learning algorithms are analyzed. Advantages and limitations are highlighted and novel research lines aimed at improving the screening ability of oximetry are proposed. Expert commentary: Oximetry is a cost-effective tool for OSAS screening in patients showing high pretest probability for the disease. Nevertheless, exhaustive analyses are still needed to further assess unattended oximetry monitoring as a single diagnostic test for sleep apnea, particularly in the pediatric population and in populations with significant comorbidities. In the following years, communication technologies and big data analyses will overcome current limitations of simplified sleep testing approaches, changing the detection and management of OSAS.

Nationwide survey on the organ-specific prevalence and its interaction with sarcoidosis in Japan

Previous studies attempted to characterize the subjects with sarcoidosis according to differences in sex, age, and the presence of specific organ involvement. However, significant interactions among these factors precluded a clear conclusion based on simple comparison. This study aimed to clarify the age- and sex-stratified prevalence of specific organ involvement and the heterogenous nature of sarcoidosis. Using the data of 9,965 patients who were newly registered into a database at the Ministry of Health, Labour and Welfare, Japan between 2002 and 2011, we evaluated the age- and sex-specific prevalence of the eye, lung, and skin involvement of sarcoidosis. We also attempted corresponding analysis considering multiple factors. As compared with several decades ago, the monophasic age distribution in men became biphasic, and the biphasic distribution in women, monophasic. The prevalence of pulmonary and cutaneous lesions was significantly associated with age, whereas the prevalence of ocular involvement showed a biphasic pattern. The prevalence of bilateral hilar lymphadenopathy was significantly higher, whereas the prevalence of diffuse lung shadow was significantly lower, in subjects with ocular involvement than those without ocular involvement. Corresponding analysis visually clarified the complex interactions among factors. Our results contribute to a better understanding of the heterogeneous features of sarcoidosis.

Autotaxin in Pathophysiology and Pulmonary Fibrosis

Lysophospholipid signaling is emerging as a druggable regulator of pathophysiological responses, and especially fibrosis, exemplified by the relative ongoing clinical trials in idiopathic pulmonary fibrosis (IPF) patients. In this review, we focus on ectonucleotide pyrophosphatase-phosphodiesterase 2 (ENPP2), or as more widely known Autotaxin (ATX), a secreted lysophospholipase D (lysoPLD) largely responsible for extracellular lysophosphatidic acid (LPA) production. In turn, LPA is a bioactive phospholipid autacoid, forming locally upon increased ATX levels and acting also locally through its receptors, likely guided by ATX's structural conformation and cell surface associations. Increased ATX activity levels have been detected in many inflammatory and fibroproliferative conditions, while genetic and pharmacologic studies have confirmed a pleiotropic participation of ATX/LPA in different processes and disorders. In pulmonary fibrosis, ATX levels rise in the broncheoalveolar fluid (BALF) and stimulate LPA production. LPA engagement of its receptors activate multiple G-protein mediated signal transduction pathways leading to different responses from pulmonary cells including the production of pro-inflammatory signals from stressed epithelial cells, the modulation of endothelial physiology, the activation of TGF signaling and the stimulation of fibroblast accumulation. Genetic or pharmacologic targeting of the ATX/LPA axis attenuated disease development in animal models, thus providing the proof of principle for therapeutic interventions.

Inflammatory and oxidative stress parameters as potential early biomarkers for silicosis

Workers involved in mining activities are exposed to crystalline silica, which leads to constant pulmonary inflammatory reactions and severe oxidative damage, resulting in silicosis. In this work, we aimed to evaluate inflammatory and oxidative stress parameters as potential early biomarkers of effect to assess crystalline silica toxicity in workers who had occupational exposure during mining. We enrolled 38 workers exposed to crystalline silica (WECS), 24 individuals with silicosis (IWS), and 30 occupationally unexposed workers (OUW), a total of 92 participants. The WECS were divided into 2 groups, according to the time of exposure: 19 workers with 1-15 years of occupational exposure (WECS I) and 19 workers with >16 years of occupational exposure (WECS II). The inflammatory parameters assessed were L-selectin, β-2 integrin, and intercellular adhesion molecule-1 (ICAM-1) surface protein expression in lymphocytes and monocytes, complement C3 and C4, high sensitivity C-reactive protein (hsCRP), and adenosine deaminase (ADA) in serum. Plasma levels of malondialdehyde (MDA) and serum levels of vitamin C were determined as biomarkers of oxidative stress. Biochemical and hematological parameters were also investigated. L-selectin surface protein expression was significantly decreased in the WECS II group (p < 0.05), indicating the importance of this immune system component as a potential marker of crystalline-silica-induced toxicity. The MDA levels were significantly increased in the WECS I, WECS II, and IWS groups compared to the OUW group (p < 0.05). Vitamin C levels were decreased, while C3, hsCRP, ADA, and aspartate aminotransferase (AST) levels were increased in the IWS group compared to the OUW group (p < 0.05). Glucose and urea levels were significantly higher in the WECS I, II, and IWS groups compared to the OUW group (p < 0.05). Negative partial association was found between L-selectin and time of exposure (p < 0.001), supporting the relevance of this biomarker evaluation in long-term exposure to crystalline silica. Significant associations were also observed among inflammatory and oxidative stress biomarkers. Therefore, our results demonstrated the relevance of L-selectin as a potential peripheral biomarker for monitoring crystalline silica-induced toxicity in miners after chronic exposure, before silicosis has developed. However, more studies are necessary for better understanding of the use L-selectin as an early biomarker in exposed workers.

Is the adenosine A2B 'biased' receptor a valuable target for the treatment of pulmonary arterial hypertension?

Pulmonary arterial hypertension (PAH) is a maladaptive disorder characterized by increased pulmonary vascular resistance leading to right ventricular failure and death. Adenosine released by injured tissues, such as the lung and heart, influences tissue remodeling through the activation of adenosine receptors. Evidence regarding activation of the low-affinity A_2BAR by adenosine points towards pivotal roles of this receptor in processes associated with both acute and chronic lung diseases. Conflicting results exist concerning the beneficial or detrimental roles of the A_2B 'biased' receptor in right ventricular failure secondary to PAH. In this review, we discuss the pros and cons of manipulating A_2BARs as a putative therapeutic target in PAH.

The Autotaxin-Lysophosphatidic Acid Axis Promotes Lung Carcinogenesis

Pathogenesis and progression of lung cancer are governed by complex interactions between the environment and host genetic susceptibility, which is further modulated by genetic and epigenetic changes. Autotaxin (ATX, ENPP2) is a secreted glycoprotein that catalyzes the extracellular production of lysophosphatidic acid (LPA), a growth-factor-like phospholipid that is further regulated by phospholipid phosphatases (PLPP). LPA's pleiotropic effects in almost all cell types are mediated through at least six G-protein coupled LPA receptors (LPAR) that exhibit overlapping specificities, widespread distribution, and differential expression profiles. Here we use both preclinical models of lung cancer and clinical samples (from patients and healthy controls) to investigate the expression levels, activity, and biological role of the above components of the ATX/LPA axis in lung cancer. ENPP2 was genetically altered in 8% of patients with lung cancer, whereas increased ATX staining and activity were detected in patient biopsies and sera, respectively. Moreover, PLPP3 expression was consistently downregulated in patients with lung cancer. Comparable observations were made in the two most widely used animal models of lung cancer, the carcinogen urethane-induced and the genetically engineered K-ras^G12D -driven models, where genetic deletion of Enpp2 or Lpar1 resulted in disease attenuation, thus confirming a procarcinogenic role of LPA signaling in the lung. Expression profiling data analysis suggested that metabolic rewiring may be implicated in the procarcinogenic effects of the ATX/LPA axis in K-ras- ^G12D -driven lung cancer pathogenesis.Significance: These findings establish the role of ATX/LPA in lung carcinogenesis, thus expanding the mechanistic links between pulmonary fibrosis and cancer. Cancer Res; 78(13); 3634-44. ©2018 AACR.

Nonthrombotic Pulmonary Embolism From Inorganic Particulate Matter and Foreign Bodies

Nonthrombotic pulmonary embolism (NTPE) is a complete or partial occlusion of the pulmonary vasculature by various organic and inorganic materials. These materials include organic particulate matter (PM) such as adipocytes, tumor cells, bacteria, fungi, or gas and inorganic PM. Although NTPE due to organic PM has been extensively reported in the medical literature, there are no comprehensive reviews of inorganic material embolizing to the lungs. The purpose of this article is to examine the current literature describing NTPE resulting from inorganic PM and foreign bodies. Cases of NTPE are uncommon and often difficult to diagnose. The diagnosis is challenging due to its varied presentation, clinical features, and unusual radiologic features. In contrast to the "classic" pulmonary thromboembolism, the pathophysiologic effects of embolism by PM are not only mechanical but also a consequence of the nature of the offending material. NTPE caused by these substances can be relatively innocuous, life-threatening, or lead to chronic pulmonary disease, if left undetected. We hope that the heightened sense of awareness of this entity may allow earlier diagnosis and recognition of its complications.

Inflammatory Macrophage Expansion in Pulmonary Hypertension Depends upon Mobilization of Blood-Borne Monocytes

Pulmonary inflammation, which is characterized by the presence of perivascular macrophages, has been proposed as a key pathogenic driver of pulmonary hypertension (PH), a vascular disease with increasing global significance. However, the mechanisms of expansion of lung macrophages and the role of blood-borne monocytes in PH are poorly understood. Using multicolor flow cytometric analysis of blood in mouse and rat models of PH and patients with PH, an increase in blood monocytes was observed. In parallel, lung tissue displayed increased chemokine transcript expression, including those responsible for monocyte recruitment, such as Ccl2 and Cx₃cl1, accompanied by an expansion of interstitial lung macrophages. These data indicate that blood monocytes are recruited to lung perivascular spaces and differentiate into inflammatory macrophages. Correspondingly, parabiosis between congenically different hypoxic mice demonstrated that most interstitial macrophages originated from blood monocytes. To define the actions of these cells in PH in vivo, we reduced blood monocyte numbers via genetic deficiency of cx₃cr1 or ccr2 in chronically hypoxic male mice and by pharmacologic inhibition of Cx₃cl1 in monocrotaline-exposed rats. Both models exhibited decreased inflammatory blood monocytes, as well as interstitial macrophages, leading to a substantial decrease in arteriolar remodeling but with a less robust hemodynamic effect. This study defines a direct mechanism by which interstitial macrophages expand in PH. It also demonstrates a pathway for pulmonary vascular remodeling in PH that depends upon interstitial macrophage-dependent inflammation yet is dissociated, at least in part, from hemodynamic consequences, thus offering guidance on future anti-inflammatory therapeutic strategies in this disease.

Protective effect of pristimerin against LPS-induced acute lung injury in mice

Pristimerin (Pris) is a triterpenoid derivative obtained from Celastraceae and Hippocrateaceae families. This compound has been extensively tested for its potent anti-cancer activity against different types of tumors. However, its effects against acute lung injury (ALI) remain to be investigated. This study explored the efficacy of Pris to protect against lipopolysaccharide (LPS)-induced ALI and its possible pathways. Results have shown that Pris possesses potent protective activity against LPS-induced acute lung damage. It significantly decreased pulmonary edema as presented by significant decrease in lung W/D ratio and in protein content. Pris attenuated LPS-induced inflammatory cell infiltration into the lung tissue and suppressed the activity of myeloperoxidase in lung. LPS-induced histopathological lesions were significantly improved via Pris pretreatment. Pris exhibited not only inhibition of LPS-induced oxidative stress, but also enhancement of the suppressed antioxidant capacity of the lung tissue. The anti-inflammatory activity of Pris against LPS-induced ALI was clearly evident via attenuation of the levels of pro-inflammatory cytokines namely, tumor necrosis factor-α and interleukin-6. Similarly, Pris inhibited LPS-induced elevation of pro-apoptotic protein, Bax, and caspase-3. Pris also increased the diminished level of Bcl2 induced by LPS. Collectively, Pris exerted protective activity against LPS-induced ALI via anti-oxidant, anti-inflammatory and anti-apoptotic pathways.

Relationship between portopulmonary hypertension and splenectomy: Mayo Clinic experience and review of published works

AIM

Portopulmonary hypertension is a serious complication of portal hypertension that can lead to right heart failure and death. To our knowledge, an association between portopulmonary hypertension and prior splenectomy has not been described previously. The goals of this study were to describe the frequency of splenectomy in portopulmonary hypertension and compare selected parameters between portopulmonary hypertension subgroups.

METHODS

This is a retrospective analysis of patients diagnosed with portopulmonary hypertension between 1 January 1988 and 30 June 2015 at Mayo Clinic (Rochester, MN, USA). We compared age, sex, right ventricle systolic pressure by echocardiography, and right heart catheterization measurements/calculations among subgroups of portopulmonary hypertension patients with splenectomy and/or autoimmune liver disease (autoimmune hepatitis/primary biliary cirrhosis/primary sclerosing cholangitis).

RESULTS

The cohort consisted of 141 patients, of whom 8 (6%) had a history of splenectomy prior to the development of portopulmonary hypertension. Twenty-seven (19%) portopulmonary hypertension patients had autoimmune liver disease, and 5 of 8 (62.5%) splenectomized portopulmonary hypertension patients had autoimmune liver disease. No significant difference was noted in right heart catheterization measurements/calculations between splenectomized and non-splenectomized portopulmonary hypertension patients. Right ventricle systolic pressure by echocardiography was significantly higher in those splenectomized.

CONCLUSIONS

Prior history of splenectomy in portopulmonary hypertension was 6% in this cohort. The combination of autoimmune liver disease and splenectomy in portopulmonary hypertension was not uncommon. History of splenectomy in patients with portal hypertension and/or autoimmune liver disease may have clinical implications.

Successful pulmonary thromboendarterectomy in a patient with sickle cell disease and associated resolution of a leg ulcer

Pulmonary hypertension (PH) is a relatively frequent and severe complication of sickle cell disease (SCD). PH associated with SCD is classified as Group 5 PH. The exact pathogenesis of PH in SCD in not known. There are also very limited treatment options available at this time for such patients with Group 5 PH. Patients with SCD are predisposed to a hypercoagulable state and thus can also suffer from chronic thromboembolism. These patients can have associated chronic thromboembolic pulmonary hypertension (CTEPH), thus being classified as Group 4 PH. We present such a case of a patient with SCD diagnosed with severe PH who was found to have CTEPH and successfully underwent a thromboendarterectomy with resolution of his symptoms such as reduction of his oxygen requirements and healing of chronic leg ulcer. This case illustrates the importance of screening patients with SCD and elevated pulmonary artery pressures for CTEPH as this would offer possible treatment options such as pulmonary thromboendarterectomy and/or riociguat in this subset of patients.

Assessment of automated analysis of portable oximetry as a screening test for moderate-to-severe sleep apnea in patients with chronic obstructive pulmonary disease

BACKGROUND

The coexistence of obstructive sleep apnea syndrome (OSAS) and chronic obstructive pulmonary disease (COPD) leads to increased morbidity and mortality. The development of home-based screening tests is essential to expedite diagnosis. Nevertheless, there is still very limited evidence on the effectiveness of portable monitoring to diagnose OSAS in patients with pulmonary comorbidities.

OBJECTIVE

To assess the influence of suffering from COPD in the performance of an oximetry-based screening test for moderate-to-severe OSAS, both in the hospital and at home.

METHODS

A total of 407 patients showing moderate-to-high clinical suspicion of OSAS were involved in the study. All subjects underwent (i) supervised portable oximetry simultaneously to in-hospital polysomnography (PSG) and (ii) unsupervised portable oximetry at home. A regression-based multilayer perceptron (MLP) artificial neural network (ANN) was trained to estimate the apnea-hypopnea index (AHI) from portable oximetry recordings. Two independent validation datasets were analyzed: COPD versus non-COPD.

RESULTS

The portable oximetry-based MLP ANN reached similar intra-class correlation coefficient (ICC) values between the estimated AHI and the actual AHI for the non-COPD and the COPD groups either in the hospital (non-COPD: 0.937, 0.909-0.956 CI95%; COPD: 0.936, 0.899-0.960 CI95%) and at home (non-COPD: 0.731, 0.631-0.808 CI95%; COPD: 0.788, 0.678-0.864 CI95%). Regarding the area under the receiver operating characteristics curve (AUC), no statistically significant differences (p >0.01) between COPD and non-COPD groups were found in both settings, particularly for severe OSAS (AHI ≥30 events/h): 0.97 (0.92-0.99 CI95%) non-COPD vs. 0.98 (0.92-1.0 CI95%) COPD in the hospital, and 0.87 (0.79-0.92 CI95%) non-COPD vs. 0.86 (0.75-0.93 CI95%) COPD at home.

CONCLUSION

The agreement and the diagnostic performance of the estimated AHI from automated analysis of portable oximetry were similar regardless of the presence of COPD both in-lab and at-home. Particularly, portable oximetry could be used as an abbreviated screening test for moderate-to-severe OSAS in patients with COPD.

Pulmonary hypertension associated with antiphospholipid antibody: Call for a screening tool?

Antiphospholipid (aPL) antibodies are antibodies specific for anionic phospholipids. They are immunoglobulins that attack phospholipids, phospholipid-binding proteins, or phospholipid-protein complexes and are detected in anticardiolipin and lupus anticoagulant assays. aPL antibodies are often associated with antiphospholipid syndrome (APS) which can be idiopathic or from secondary causes such as systemic lupus erythematosus (SLE), infection or drugs. They have also been shown to be associated with Pulmonary Hypertension. We conducted a review of the literature that included all articles on PubMed with keywords 'antiphospholipid antibody' and 'pulmonary hypertension' between January 1980 and July 2017 and identified 217 articles. A total of 47 articles were found to be relevant to the topic and included as references. We ascertained that aPL antibodies have been implicated in the development of both idiopathic pulmonary arterial hypertension (PAH) and PAH associated with connective tissue disease (CTD). aPL antibodies were also noted to be associated with left-sided valvular heart disease that can lead to pulmonary venous hypertension (PVH). Patients with anitiphospholipid antibody syndrome (Diagnostic criteria incudes +aPL antibodies) were noted to have a high risk of developing chronic thromboembolic pulmonary hypertension (CTEPH). A recent study also found a positive association of aPL antibodies with ILD and PH in patients with systemic sclerosis. While association between autoimmune thyroid disease and PH (Group V PH), and autoimmune thyroid disease and aPL antibodies is established, no studies linked these three phenomena together. Thus, aPL antibodies had an association with all WHO groups of Pulmonary hypertension (PH). In this review article, we study the association and discuss the need for screening for PH in patients with positive aPL antibodies.

Partial Splenectomy is Superior to Total Splenectomy for Selected Patients with Hemangiomas or Cysts

BACKGROUND

The superiority of partial splenectomy (PS) as a treatment for benign tumors has not well been confirmed. This study aimed to identify the short- and long-term outcomes of PS, to compare laparoscopic and laparotomic PS, and to demonstrate whether the effects of PS are superior to that of total splenectomy (TS).

METHODS

Patients with either a hemangioma or cyst who underwent PS or TS from 2009 to 2015 at Qilu Hospital of Shandong University were included. Clinical parameters were collected and analyzed.

RESULTS

A total of 17 patients underwent PS were collected, including 2 men and 15 women with a mean age of 43.9 ± 11.3 years old. Patients who underwent laparoscopic PS (9 cases) had a longer operative time and shorter postoperative hospital stay than those who underwent laparotomy (8 cases). Compared with TS (22 cases), PS significantly decreased the incidence of thrombocytosis, shortened time until drainage removal, and shortened postoperative hospital stay. After an average follow-up of 34.8 months, patients who underwent TS showed a higher incidence of thrombocytosis and splenic vein thrombosis compared with patients underwent PS.

CONCLUSIONS

PS is technically feasible and provides favorable short- and long-term outcomes for selected patients with either a hemangioma or cyst compared with TS. Laparoscopic PS shows lower morbidity and equal therapeutic efficacy compared with laparotomic PS and can be widely performed.

Improved control of hypertension following laparoscopic fundoplication for gastroesophageal reflux disease

This study aims to determine whether successful laparoscopic fundoplication for gastroesophageal reflux disease (GERD) can improve the control of hypertension. We conducted an observational study of GERD patients with hypertension. The esophageal and gastroesophageal symptoms of these patients were successfully treated with laparoscopic fundoplication, as measured by the reduced GERD symptoms and proton pump inhibitor consumption. A hypertension control scale was used to classify the use of antihypertensive medications and the quality of blood pressure control before and after anti-reflux surgery.Wilcoxon signed-ranks test was used for the statistical analyses. Seventy GERD patients were included in the analysis and followed up for a mean period of 3.5 ± 1.4 years. Prior to surgery, all participating patients were taking at least one class of antihypertensive medication, and 56 patients (80%) had intermittently high blood pressure. After surgery, the mean number of antihypertensive medication classes per patient was significantly reduced from 1.61 ± 0.77 pre-procedure to 1.27 ± 0.88 post-procedure (P < 0.001). The blood pressure of 48 of the 56 cases (86%) with preoperative intermittent high blood pressure returned to normal post procedure. A total of 50 patients (71%) recorded improvements on the hypertension control scale, with the overall mean score decreasing from 3.1 ± 1.0 preprocedure to 1.4 ± 1.0 post-procedure (P < 0.001). Therefore, successful laparoscopic fundoplication may result in better blood pressure control in some hypertensive GERD patients. This result suggests a possible connection between gastroesophageal reflux and hypertension.

The Mechanisms of the Regulation of Immune Response in Patients with Comorbidity of Chronic Obstructive Pulmonary Disease and Asthma

Background. Comorbidity of chronic obstructive pulmonary disease (COPD) and asthma (asthma COPD overlap syndrome, ACOS) is a significant problem in pulmonary practice, whose pathogenetic issues are not clarified yet. Objective. To study the features of the regulation of immune response in patients with comorbid COPD and asthma. Methods. We assessed the levels of CD3+, CD4+, CD8+, CD4+/CD8+, CD19+, CD25+, HLA-DR, total IgE, TNF-α, IL-4, IFN-γ, TXB2, and LTB4 in patients with comorbid COPD and asthma. Results. The study involved 44 people with COPD, 39 people with asthma, and 12 people with comorbid COPD and asthma. The specific features in comorbid COPD and asthma were lymphocytosis, increased absolute count of T-helper cells, increased cytotoxic T-lymphocytes in relative and absolute count, increased relative and absolute numbers of B-lymphocytes, and high levels of total IgE. The elevated levels of TNF-α and IL-4 and inhibition of IFN-γ production were detected. The content of LTB4 was maximal; TXB2 levels were higher than in control group but lower than in COPD and asthma. Conclusion. In comorbid COPD and asthma inflammation increased even during stable period. High levels of eicosanoids, low production of Th1-type cytokines, and active synthesis of opposition IL-4, along with increased IgE, indicate the activation of Th2-type immune response.

Novel Inhibitory Effect of a Lysophosphatidic Acid 2 Agonist on Allergen-Driven Airway Inflammation

Lysophosphatidic acid (LPA) is a pleiotropic lipid signaling molecule associated with asthma pathobiology. LPA elicits its effects by binding to at least six known cell surface G protein-coupled receptors (LPA1-6) that are expressed in the lung in a cell type-specific manner. LPA2 in particular has emerged as an attractive therapeutic target in asthma because it appears to transduce inhibitory or cell-protective signals. We studied a novel and specific small molecule LPA2 agonist (2-[4-(1,3-dioxo-1H,3H-benzoisoquinolin-2-yl)butylsulfamoyl] benzoic acid [DBIBB]) in a mouse model of house dust mite-induced allergic airway inflammation. Mice injected with DBIBB developed significantly less airway and lung inflammation compared with vehicle-treated controls. Levels of lung Th2 cytokines were also significantly attenuated by DBIBB. We conclude that pharmacologic activation of LPA2 attenuates Th2-driven allergic airway inflammation in a mouse model of asthma. Targeting LPA receptor signaling holds therapeutic promise in allergic asthma.