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Martinez C, Wallenhorst C, Teal S, Cohen AT, Peacock AJ. Incidence and risk factors of chronic thromboembolic pulmonary hypertension following venous thromboembolism, a population-based cohort study in England. Pulm Circ 2018; 8:2045894018791358. [PMID: 29985100 PMCID: PMC6066824 DOI: 10.1177/2045894018791358] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of
unresolved organised pulmonary emboli/thrombi obstructing the major pulmonary
arteries. The aim of this study was to estimate the incidence and risk factors
of CTEPH in a cohort with first venous thromboembolism (VTE). This was a
population-based cohort study of patients with first VTE and no active cancer in
England between 2001 and 2012. CTEPH was assessed using a rigorous
case-ascertainment algorithm. Risk factors for CTEPH were studied using a nested
case-control approach by matching CTEPH cases to VTE patients without CTEPH.
Adjusted odds ratios (OR) of comorbidities were estimated from conditional
logistic regression. During 81,413 person-years of follow-up among 23,329
patients with first VTE (mean follow-up 3.5 years; maximum 11.0 years) 283
patients were diagnosed with CTEPH (incidence rate 3.5 per 1000 person-years);
cumulative incidence was 1.3% and 3.3% at 2 and 10 years after pulmonary
embolism, and 0.3% and 1.3% following deep vein thrombosis (DVT), respectively.
Risk factors for CTEPH included age over 70, OR 2.04 (95% CI 1.23 to 3.38),
female gender, 1.44 (1.06 to 1.94), pulmonary embolism at first VTE, 3.11 (2.23
to 4.35), subsequent pulmonary embolism and DVT, 3.17 (2.02 to 4.96) and 2.46
(1.34 to 4.51) respectively, chronic obstructive pulmonary disease 3.17 (2.13 to
4.73), heart failure 2.52 (1.76 to 3.63) and atrial fibrillation, 2.42 (1.71 to
3.42). CTEPH develops most commonly after pulmonary embolism and less frequently
after DVT. Awareness of risk factors may increase referrals to specialised
centres for confirmation of CTEPH and initiation of specific treatment.
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Affiliation(s)
- C Martinez
- 1 Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt, Germany
| | - C Wallenhorst
- 1 Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt, Germany
| | - S Teal
- 2 Real-World Evidence Strategy & Outcomes Data Generation, Bayer AG, Berlin, Germany
| | - A T Cohen
- 3 Department of Haematology, Guy's and St Thomas' Hospitals, King's College, London, UK
| | - A J Peacock
- 4 Scottish Pulmonary Vascular Unit, Regional Heart and Lung centre, Glasgow, UK
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Crowe TM, Sonecki P, Mackenzie A, Jayasekera G, Church AC, Johnson MK, Peacock AJ. S110 2-d segmental longitudinal strain rates correlate with prognostic indicators in idiopathic pulmonary arterial hypertension. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Reid GS, Wilson KS, Suveizdyte K, Brash L, Peacock AJ, Welsh DJ. P267 The effects of Apelin on serum NT-proBNP levels in Pulmonary Hypertension Patients versus Controls. Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Reid GS, Wilson KS, Suveizdyte K, Brash L, Peacock AJ, Welsh DJ. 22 The effects of apelin on serum NT-proBNP levels in pulmonary hypertension patients. Heart 2015. [DOI: 10.1136/heartjnl-2015-308734.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Wilson KS, Suveizdyte K, Liles J, Budas GR, Peacock AJ, Welsh DJ. 44 ASK-1 inhibition prevents hypoxia-induced pulmonary artery fibroblast proliferation and migration in an in vitrocellular model of pulmonary hypertension. Heart 2015. [DOI: 10.1136/heartjnl-2015-308734.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
Cardiac magnetic resonance imaging (CMRI) provides accurate information about right ventricular (RV) mass, RV volumes and other markers of RV function. CMRI is proving to be a particularly useful tool in pulmonary arterial hypertension (PAH), as measures of RV function have been shown to be prognostic of long-term outcomes in this disease. Changes in RV function can also provide important information about a patient's disease course and response to treatment. As CMRI is noninvasive it can be used to regularly monitor patients with PAH, which is an important advantage over invasive right heart catheterisation. This review will explore the use of CMRI in the context of existing monitoring tools for PAH and will explore the forthcoming developments that are likely to be important in the future monitoring of patients with PAH.
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Church AC, Wadsworth R, Bryson G, Welsh DJ, Peacock AJ. S36 P38 MAPK: An Important Pathway in the Pathobiology of Pulmonary Hypertension and Pulmonary Vascular Remodelling. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Burns RM, Peacock AJ, Johnson MK, Church AC. Hypoxaemia in patients with pulmonary arterial hypertension during simulated air travel. Respir Med 2012; 107:298-304. [PMID: 23127571 DOI: 10.1016/j.rmed.2012.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 10/02/2012] [Accepted: 10/15/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent air travel recommendations suggest patients with precapillary pulmonary hypertension (PCPH) in New York Heart Association (NYHA) functional class 3 and 4 should have in-flight oxygen without the need for pre-flight testing. However it remains unclear as to how best to determine patients fitness to fly. METHODS This study (i) investigates the effect of hypoxic challenge testing (HCT) on the arterial oxygen levels in a cohort of 36 patients with PCPH and (ii) compares the relative frequency with which FC and HCT predict the requirement for in-flight oxygen. RESULTS The degree of arterial hypoxaemia induced by HCT (fall in partial pressure of oxygen in arterial blood (PaO(2)) 2.36 kPa, 95% CI 2.06-2.66 kPa) was similar to the drop observed in other published studies of chronic respiratory diseases. Following current air travel recommendations based on FC, 25 patients of the cohort would require in-flight oxygen whilst 10 subjects failed the HCT. Fourteen subjects had flown post-diagnosis. Of these, nine subjects should have had in-flight oxygen based on FC but were asymptomatic without. Also one who passed the HCT had developed symptoms during the flight whilst three who failed the HCT were asymptomatic flying without in-flight oxygen. CONCLUSIONS Hypoxaemia induced by simulated air travel in patients with PCPH is similar to that seen in published studies of patients with other chronic respiratory diseases. HCT failed to predict correctly who had developed symptoms during an aircraft flight in a significant minority of the study subjects. Similarly guidelines based on functional class result in a major increase in the proportion of patients being advised to use oxygen, many of whom had been asymptomatic on previous flights without it. More work is required to improve prediction of need for in-flight oxygen in patients with PCPH.
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Affiliation(s)
- R M Burns
- Scottish Pulmonary Vascular Unit, Golden Jubilee Hospital, Agamemnon Street, Clydebank, Glasgow G81 4DY, UK
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Ling Y, Johnson MK, Kiely D, Condliffe R, Elliot C, Gibbs S, Howard L, Pepke-Zaba J, Sheares K, Corris P, Fisher A, Lordan J, Gaine S, Coghlan G, Wort J, Gatzoulis M, Peacock AJ. S71 Influence of age on clinical phenotypes of incident idiopathic pulmonary arterial hypertension. Results from the pulmonary hypertension registry of the UK and Ireland. Thorax 2011. [DOI: 10.1136/thoraxjnl-2011-201054b.71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ling Y, Johnson MK, Kiely D, Condliffe R, Elliot C, Gibbs S, Howard L, Pepke-Zaba J, Sheares K, Corris P, Fisher A, Lordan J, Gaine S, Coghlan G, Wort J, Gatzoulis M, Peacock AJ. S72 Prediction of survival in pulmonary arterial hypertension using survival equations. Results from the pulmonary hypertension registry of the UK and Ireland. Thorax 2011. [DOI: 10.1136/thoraxjnl-2011-201054b.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Church AC, Wadsworth R, Bryson G, Welsh DJ, Peacock AJ. S68 Inhibition of p38 mitogen activated protein kinase (MAPK) prevents the development of experimental pulmonary hypertension. Thorax 2011. [DOI: 10.1136/thoraxjnl-2011-201054b.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Burns RM, Peacock AJ, Johnson MK, Church AC. P2 In-flight hypoxaemia in patients with pulmonary arterial hypertension (PAH). Thorax 2011. [DOI: 10.1136/thoraxjnl-2011-201054c.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lee WTN, Kirkham N, Johnson MK, Lordan JL, Fisher AJ, Peacock AJ. Sitaxentan-related acute liver failure in a patient with pulmonary arterial hypertension. Eur Respir J 2011; 37:472-4. [PMID: 21282815 DOI: 10.1183/09031936.00091610] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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McLure LER, Peacock AJ. Cardiac magnetic resonance imaging for the assessment of the heart and pulmonary circulation in pulmonary hypertension. Eur Respir J 2009; 33:1454-66. [PMID: 19483048 DOI: 10.1183/09031936.00139907] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pulmonary hypertension is a disease of the pulmonary arteries resulting in a progressive increase in pulmonary vascular resistance, ultimately leading to right ventricular failure and death. The functional capacity of the right ventricle is a major prognostic determinant. Our understanding of right ventricle performance in pulmonary hypertension has been hindered by the lack of techniques that give a reliable picture of right ventricle morphology and function. Cardiac magnetic resonance (CMR) imaging enables a unique combination of morphological and functional assessment of the right ventricle and pulmonary circulation. In this review article, we introduce the technique of CMR imaging, review its use in imaging of the heart and pulmonary circulation and discuss its current and future application to the management of patients with pulmonary hypertension. There have been recent major advances in our understanding of the mechanism of disease development, in the diagnostic process, and in the treatment of pulmonary hypertension. Therapeutic advances in the management have reinforced the requirement for noninvasive, accurate and reproducible methods of assessment to act as "end-points" to measure the effects of treatment. We anticipate CMR imaging will increasingly be utilised as the primary modality for combined anatomic and functional assessments that enable more complete and efficient evaluation of pulmonary hypertension patients.
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Affiliation(s)
- L E R McLure
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Clydebank, West Dumbartonshire, Scotland, UK
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Peacock AJ, Naeije R, Galie N, Rubin L. End-points and clinical trial design in pulmonary arterial hypertension: have we made progress? Eur Respir J 2009; 34:231-42. [DOI: 10.1183/09031936.00107108] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Johnson MK, Lee WN, Sproule MW, Peacock AJ. Regional variations in pulmonary endarterectomy rates within the UK. Eur Respir J 2009; 33:453-4; author reply 454-5. [PMID: 19181927 DOI: 10.1183/09031936.00147608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Condliffe R, Kiely DG, Gibbs JSR, Corris PA, Peacock AJ, Jenkins DP, Goldsmith K, Coghlan JG, Pepke-Zaba J. Prognostic and aetiological factors in chronic thromboembolic pulmonary hypertension. Eur Respir J 2008; 33:332-8. [DOI: 10.1183/09031936.00092008] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Pulmonary hypertension (PH) is a disease of the pulmonary arteries resulting in a progressive increase in pulmonary vascular resistance, ultimately leading to right ventricular failure and death. It is a rare disease with a poor prognosis. The functional capacity of the right ventricle (RV) is a major prognostic determinant in PH. Our understanding of RV performance in PH has been hindered by the lack of techniques that give a reliable picture of right ventricular morphology and function. There have been recent major advances in our understanding of the mechanism of disease development, in the diagnostic process and in the treatment of PH. There are now three classes of medications that are effective in the treatment of PH: prostanoids, endothelin receptor antagonists and phosphodiesterase-5 inhibitors. Therapeutic advances in the management of PH have reinforced the requirement for non-invasive, accurate and reproducible methods of assessment to act as 'end-points' to measure the effects of treatment. It is our opinion that the most useful 'end-point' would be one that evaluates right heart morphology and function. We introduce and discuss the techniques currently used to image the heart in patients with PH. Imaging modalities discussed include echocardiography, radionuclide ventriculography, cardiac computed tomography and cardiac magnetic resonance (CMR) imaging focusing on the rapidly evolving technique of CMR imaging.
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Affiliation(s)
- L E R McLure
- Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow, UK
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Abstract
All hospitalisations for pulmonary arterial hypertension (PAH) in the Scottish population were examined to determine the epidemiological features of PAH. These data were compared with expert data from the Scottish Pulmonary Vascular Unit (SPVU). Using the linked Scottish Morbidity Record scheme, data from all adults aged 16-65 yrs admitted with PAH (idiopathic PAH, pulmonary hypertension associated with congenital heart abnormalities and pulmonary hypertension associated with connective tissue disorders) during the period 1986-2001 were identified. These data were compared with the most recent data in the SPVU database (2005). Overall, 374 Scottish males and females aged 16-65 yrs were hospitalised with incident PAH during 1986-2001. The annual incidence of PAH was 7.1 cases per million population. On December 31, 2002, there were 165 surviving cases, giving a prevalence of PAH of 52 cases per million population. Data from the SPVU were available for 1997-2006. In 2005, the last year with a complete data set, the incidence of PAH was 7.6 cases per million population and the corresponding prevalence was 26 cases per million population. Hospitalisation data from the Scottish Morbidity Record scheme gave higher prevalences of pulmonary arterial hypertension than data from the expert centres (Scotland and France). The hospitalisation data may overestimate the true frequency of pulmonary arterial hypertension in the population, but it is also possible that the expert centres underestimate the true frequency.
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Affiliation(s)
- A J Peacock
- Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow, G61 2SW, UK.
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Blyth KG, Groenning BA, Mark PB, Martin TN, Foster JE, Steedman T, Morton JJ, Dargie HJ, Peacock AJ. NT-proBNP can be used to detect right ventricular systolic dysfunction in pulmonary hypertension. Eur Respir J 2007; 29:737-44. [PMID: 17135228 DOI: 10.1183/09031936.00095606] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Right ventricular systolic dysfunction (RVSD) at baseline (pre-treatment) predicts early death in patients with pulmonary hypertension (PH). However, RVSD can only be detected reliably by prohibitively invasive or expensive techniques. N-terminal B-type natriuretic peptide concentration ([NT-proBNP]) correlates with RV function in PH; however, an [NT-proBNP] threshold that indicates RVSD in individual patients has not previously been determined. Twenty-five patients with PH (pulmonary arterial hypertension (n = 19) or chronic thromboembolic PH (n = 6)) underwent cardiovascular magnetic resonance (CMR) imaging and NT-proBNP measurement at baseline. [NT-proBNP] was correlated against RV dimensions and ejection fraction (RVEF) measured directly by CMR imaging. The ability of NT-proBNP to detect RVSD (defined as a CMR-derived RVEF >2 SDS below control values) was tested and predictors of [NT-proBNP] identified. [NT-proBNP] correlated negatively with RVEF. RVSD was present in nine out of 25 patients. An [NT-proBNP] threshold of 1,685 pg.mL(-1) was sensitive (100%) and specific (94%) in detecting RVSD. RVEF and RV mass index independently predicted [NT-proBNP]. In pulmonary hypertension, a baseline N-terminal B-type natriuretic peptide concentration of >1,685 ng.L(-1) suggests right ventricular systolic dysfunction, and thus an increased risk of early death. N-terminal B-type natriuretic peptide could prove useful as an objective, noninvasive means of identifying patients with pulmonary hypertension who have right ventricular systolic dysfunction at presentation.
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Affiliation(s)
- K G Blyth
- Scottish Pulmonary Vascular Unit, University of Glasgow, Glasgow G11 6NT, UK
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Fisher NI, Cribb JHJ, Peacock AJ. Reading the public mind: a novel approach to improving the adoption of new science and technology. ACTA ACUST UNITED AC 2007. [DOI: 10.1071/ea07004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This paper describes a new approach to measuring and monitoring the quality of dialogue between research groups and the wider community about specific scientific matters. It is an adaptation of a proven marketing process for monitoring customer satisfaction: key drivers of community perception are elicited and measured, so that managers can respond to the issues that are most important to the community, rather than relying on their own perceptions. One important benefit of the approach is that the method provides a means of linking an overall score for the community’s perceived value of a research project to an important business driver such as ‘percentage of people very willing to support deployment of the research results’. The method is illustrated by a case study exploring the views of the Australian public about research into genetic manipulation for pest mouse control. For the population surveyed (the community in New South Wales, Australia), some 40% were very willing to support the use of genetic manipulation to manage pest mice. If an increase of 1.5 in the score for the perceived value of a research project (measured on a scale from 1 to 10) were achieved, the prediction is that overall community support for eventual deployment would rise to about 80%. The approach would appear to have a useful role to play in assisting eventual technology adoption.
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Vonk-Noordegraaf A, van Wolferen SA, Marcus JT, Boonstra A, Postmus PE, Peeters JWL, Peacock AJ. Noninvasive assessment and monitoring of the pulmonary circulation. Eur Respir J 2005; 25:758-66. [PMID: 15802353 DOI: 10.1183/09031936.05.00122104] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In pulmonary vascular disease, changes in the pulmonary vascular bed will lead to altered pulmonary haemodynamics. This review describes the application of several physiological principles to measure these changes noninvasively by means of novel techniques. Flow characteristics of blood through the pulmonary vascular bed alter in pulmonary vascular disease. Recent developments in magnetic resonance imaging and computed tomography make it possible to visualise and quantify these abnormal flow patterns. Information regarding pulmonary perfusion can also be obtained by measuring the electrical impedance changes in the lung by electrical impedance tomography. A more indirect approach to measure the pulmonary blood flow is the measurement of the absorption of acetylene, a perfusion limited gas. Information on the pulmonary vascular bed can also be obtained by the measurement of exhaled products of the pulmonary vascular endothelium, such as nitric oxide. Although all the techniques described offer new ways to diagnose or monitor pulmonary vascular disease, clinical data on these techniques are limited. Further improvement and evaluation of the clinical value of these techniques are therefore obligatory before they can be used in clinical practice.
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Affiliation(s)
- A Vonk-Noordegraaf
- Dept of Pulmonology, VU University Medical Center, Amsterdam, The Netherlands.
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Patel S, Woods DR, Macleod NJ, Brown A, Patel KR, Montgomery HE, Peacock AJ. Angiotensin-converting enzyme genotype and the ventilatory responseto exertional hypoxia. Eur Respir J 2003; 22:755-60. [PMID: 14621081 DOI: 10.1183/09031936.03.00086402] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The "insertion" (I) rather than "deletion" (D) variant of the human angiotensin-converting enzyme (ACE) gene is associated with both lower tissue ACE activity and elite performance at high altitude. Three genotypes, II, ID and DD, are thus represented in the population. The authors examined whether an improved ventilatory response to hypoxic exercise may contribute to this effect. Subjects (n=60; 37 male, mean+/-SEM age 23.6+/-0.6 yrs, 14 II, 30 ID, 16 DD) underwent incremental cardiopulmonary exercise testing to establish maximal oxygen uptake and ventilatory threshold (VT). Four hours later, subjects exercised for 6 mins at 50% of the workload at VT. The protocol was repeated 15 mins later while breathing 12.5+/-0.5% oxygen in nitrogen. All subject characteristics were independent of genotype, as were data during normoxic exercise. However, the hypoxia-induced rise in minute ventilation was significantly greater among those of II genotype (39.6+/-4.1% versus 27.9+/-2.0% versus 28.4+/-2.2% for II versus ID versus DD, respectively). These data are supported by a significantly greater decrease in end tidal carbon dioxide (consistent with an increase in alveolar ventilation) among those homozygous for the I allele (II -18.7+/-1.3%, ID -15.7+/-0.4%, DD -15.1%+/-1.1). The ventilatory response to hypoxic exercise is influenced by angiotensin-converting enzyme genotype. Potential implications concern high altitude performance and the pathogenesis and management of hypoxic lung disease.
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Affiliation(s)
- S Patel
- Scottish Pulmonary Vascular Unit, Western Infirmary, Dumbarton Road, Glasgow, UK
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Saba TS, Foster J, Cockburn M, Cowan M, Peacock AJ. Ventricular mass index using magnetic resonance imaging accurately estimates pulmonary artery pressure. Eur Respir J 2002; 20:1519-24. [PMID: 12503713 DOI: 10.1183/09031936.02.00014602] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Magnetic resonance imaging (MRI) can provide accurate anatomical measurements of the cardiac ventricles. This study investigated whether a calculated ventricular mass index (VMI) would provide an accurate means of estimating pulmonary artery pressure noninvasively, and compared the results with conventional Doppler echocardiography and invasive measurement. A total of 26 subjects referred for investigation of pulmonary hypertension were studied by MRI and echocardiography within 2 weeks of cardiac catheterisation. The correlations for mean pulmonary artery pressure were as follows: VMI (ratio of right ventricular mass over left ventricular mass) r=0.81; pulmonary artery systolic pressure (echocardiography) r=0.77. The confidence intervals for the VMI were narrower than for echocardiography. Sensitivity and specificity for pulmonary hypertension were 84 and 71% respectively for the VMI compared with 89 and 57% for echocardiography. The calculated ventricular mass index provides an accurate and practical means of estimating pulmonary artery pressure noninvasively in pulmonary hypertension and may provide a more accurate estimate than Doppler echocardiography. This may be because it reflects the right ventricular response to sustained pulmonary hypertension over a long period and is not influenced by short-term physiological variables affecting echocardiography, such as heart rate, posture, hydration status and oxygen supplementation.
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Affiliation(s)
- T S Saba
- Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow, Scotland, UK
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Raeside DA, Brown A, Patel KR, Welsh D, Peacock AJ. Ambulatory pulmonary artery pressure monitoring during sleep and exercise in normal individuals and patients with COPD. Thorax 2002; 57:1050-3. [PMID: 12454300 PMCID: PMC1758791 DOI: 10.1136/thorax.57.12.1050] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Pulmonary hypertension is a common complication of chronic obstructive airways disease (COPD) and its presence implies a poor prognosis. However, it is difficult to measure and its specific contribution to symptoms is difficult to quantify. A micromanometer tipped pulmonary artery catheter was used to measure pulmonary artery pressure (PAP) during sleep and on exercise. METHODS Ten patients (five with COPD receiving long term oxygen therapy and five normal individuals) were studied. Pulmonary artery pressure was recorded continuously during two periods of sleep (breathing oxygen followed by air for the COPD group) and during exercise. RESULTS In the COPD group PAP during sleep on oxygen was significantly lower than PAP during sleep breathing air (mean (SD) difference 9.6 (5.3) mm Hg, 95% CI 4.9 to 14.3, p= 0.016). PAP during exercise was not significantly different from PAP during sleep breathing air (mean (SD) difference 0.8 (8.9) mm Hg, 95% CI -7.0 to 8.6, p= 0.851). In normal individuals the group mean (SD) PAP was 15 (5.9) mm Hg for the first nocturnal period and 15 (5.7) mm Hg for the second nocturnal period. PAP during exercise was not significantly different from PAP during sleep breathing air (mean (SD) difference 3.3 (2.2) mm Hg, 95% CI 1.1 to 5.5, p= 0.061). CONCLUSION In patients with COPD, PAP rose significantly during sleep to levels similar to those measured during exercise, but this could be reversed with oxygen.
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Affiliation(s)
- D A Raeside
- Monklands District General Hospital, Airdrie ML6 0JS, UK
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Hagemann H, Snyder RG, Peacock AJ, Mandelkern L. Quantitative infrared methods for the measurement of crystallinity and its temperature dependence: polyethylene. Macromolecules 2002. [DOI: 10.1021/ma00199a017] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kennedy MA, Peacock AJ, Failla MD, Lucas JC, Mandelkern L. Tensile Properties of Crystalline Polymers: Random Copolymers of Ethylene. Macromolecules 2002. [DOI: 10.1021/ma00109a012] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Infection control is everyone's business and it is important that all members of staff observe good infection control practice. An effective infection control link nurse system has been shown to support and develop this approach. The strength of ward-based infection control link nurses depends upon their effectiveness as role models and their ability to influence practice on their wards and beyond. In addition, the degree of respect they command from their peers and colleagues and the amount and quality of knowledge they possess is crucial. This paper describes an innovative approach taken in Mid-Essex, which allowed infection control link nurses to assess their capabilities and limitations in communicating with and influencing colleagues. In addition, we show how quantitative measures may be made available by this approach. Such measures may be used to explain to management how particular areas of infection control practice (e.g. the need for infection control link nurses to have more authority and more 'muscle') may be important.
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Affiliation(s)
- E L Teare
- Public Health Laboratory Service, New Writtle Street, Chelmsford, Essex, CM2 0YX, UK
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Welsh DJ, Peacock AJ, MacLean M, Harnett M. Chronic hypoxia induces constitutive p38 mitogen-activated protein kinase activity that correlates with enhanced cellular proliferation in fibroblasts from rat pulmonary but not systemic arteries. Am J Respir Crit Care Med 2001; 164:282-9. [PMID: 11463602 DOI: 10.1164/ajrccm.164.2.2008054] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension occurs commonly in patients with chronic hypoxic lung disease and is characterized by the remodeling of the pulmonary artery walls. The molecular mechanisms underlying such remodeling are unknown but we have recently shown that the stress-activated (Jnk and p38) mitogen-activated protein (MAP) kinases are activated in pulmonary artery fibroblasts following acute hypoxia. We now show that Erk and p38 MAP kinases are constitutively activated in fibroblasts derived from the remodeled pulmonary, but not the systemic circulation from rats exposed to chronically hypoxic conditions. Moreover, we find that such fibroblasts show sustained enhanced proliferative capacities relative to pulmonary artery fibroblasts derived from normoxic rats or to aortic fibroblasts from either normoxic or hypoxic rats. Finally, abrogation of p38, but not Erk MAP kinase activity by use of specific inhibitors, prevents the enhanced proliferative capacity exhibited by pulmonary artery fibroblasts. Taken together, these data suggest that enhanced p38 MAP kinase activity provides a molecular mechanism to explain the proliferation of pulmonary artery fibroblasts required for remodeling of the pulmonary vasculature.
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Affiliation(s)
- D J Welsh
- Scottish Pulmonary Vascular Unit and Department of Immunology, Western Infirmary, Glasgow G11 6NT, Scotland, United Kingdom
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Raeside DA, Smith A, Brown A, Patel KR, Madhok R, Cleland J, Peacock AJ. Pulmonary artery pressure measurement during exercise testing in patients with suspected pulmonary hypertension. Eur Respir J 2000; 16:282-7. [PMID: 10968504 DOI: 10.1034/j.1399-3003.2000.16b16.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
It is recognized that exercise produces abnormally large increases in pulmonary artery pressure in patients with pulmonary vascular disease as a consequence of a variety of disorders, but the relationship between pressure and cardiopulmonary exercise performance is poorly understood. This lack of understanding is due (in part) to difficulty making measurements of pulmonary haemodynamics using conventional fluid filled catheters. This article seeks to improve understanding by comparing variables measured during formal exercise testing with simultaneous measurements of pulmonary artery pressure using a micro-manometer tipped catheter. Ten patients with suspected pulmonary hypertension were studied using a micromanometer tipped pulmonary artery catheter, during cardiopulmonary exercise testing. Ventilatory equivalents for oxygen and carbon dioxide correlated with the pulmonary artery pressure measured on exercise, but oxygen pulse and oxygen uptake did not. Ventilatory equivalents, noninvasively measured during exercise, may merit further study as potential surrogates of pulmonary artery pressure and hence be useful in identifying individuals at risk of developing pulmonary hypertension.
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Affiliation(s)
- D A Raeside
- Dept of Respiratory Medicine, West Glasgow Hospitals University NHS Trust, Western Infirmary
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37
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Abstract
Calcium antagonists are known to reduce the incidence of high-altitude pulmonary oedema, but the mechanism is unclear. The aim of this study was to examine the effects of the calcium antagonist, amlodipine, on cardiac and respiratory responses in normoxia and hypoxia. Fourteen normal subjects aged 31+/-4 yrs who had climbed to altitudes of 5,000-7,500 m without problems were randomly assigned to a double-blind crossover trial of amlodipine versus placebo, using sea-level inspiratory hypoxia to simulate altitude. Doppler echocardiographic estimates of resting pulmonary haemodynamics and cycle ergometer test results of cardiorespiratory responses to exercise were recorded in normoxia and hypoxia. It was found that, although hypoxic pulmonary vasoconstriction (HPV) was not significantly reduced by amlodipine, the effect of the drug on HPV was inversely related to the serum level of amlodipine. Amlodipine did not alter left ventricular function measured echocardiographically. During exercise, amlodipine increased breathlessness, measured using standard scales, in both normoxia and hypoxia but had no effect on ventilatory variables. It was concluded that amlodipine has the potential to block hypoxic pulmonary vasoconstriction as evidenced by a drug concentration-related decrease in resting tricuspid regurgitation jet velocity without any change in resting myocardial contractility. However, with amlodipine, the subjects felt more breathless during exercise. The reasons for this increase in breathlessness are not clear.
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Affiliation(s)
- M Watt
- Accident and Emergency Department, Monklands Hospital, Airdrie, UK
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38
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Abstract
The hypothesis that chronic thromboembolic pulmonary hypertension results from unresolved pulmonary embolism has strongly influenced the diagnosis and management of this disease since the 1960s. However, it is nearly impossible to induce chronic pulmonary hypertension in any animal species by means of repeated embolization of thrombotic material. The haemodynamic effects of thrombotic pulmonary embolism of different degrees of magnitude have also been studied in humans and there is little to suggest that chronic pulmonary hypertension is a likely long term outcome. Furthermore many conditions which predispose to venous thromboembolism do not appear to cause thromboembolic pulmonary hypertension. Other arteriopathic and atherosclerotic risk factors, are found in patients with chronic thromboembolic pulmonary hypertension, but not in those with venous thrombosis, suggesting that these may be unrelated conditions. Thrombosis in situ of the pulmonary arteries is common in severe pulmonary hypertension of any cause. Such thrombosis cannot usually be distinguished from pulmonary embolism. It is hypothesized that in situ thrombosis and pulmonary arteriopathy are common causes of vascular occlusion which is usually diagnosed as "chronic thromboembolic pulmonary hypertension" and that venous thromboembolism is unlikely to be a common cause of chronic pulmonary hypertension. It is further hypothesized that pulmonary embolism is seldom the sole cause of "chronic thromboembolic pulmonary hypertension".
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Affiliation(s)
- P Egermayer
- The Canterbury Respiratory Research Group, Christchurch School of Medicine, New Zealand
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Affiliation(s)
- A J Peacock
- Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow G11 6NT, UK
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Affiliation(s)
- S Brij
- Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow, UK
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41
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Affiliation(s)
- P Egermayer
- Canterbury Respiratory Research Group, Christchurch School of Medicine, New Zealand
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Affiliation(s)
- S O Brij
- Department of Respiratory Medicine, Western Infirmary, Glasgow, UK
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Welsh DJ, Scott P, Plevin R, Wadsworth R, Peacock AJ. Hypoxia enhances cellular proliferation and inositol 1,4, 5-triphosphate generation in fibroblasts from bovine pulmonary artery but not from mesenteric artery. Am J Respir Crit Care Med 1998; 158:1757-62. [PMID: 9847264 DOI: 10.1164/ajrccm.158.6.9706054] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
When pulmonary hypertension occurs in the face of hypoxia there is remodeling of all three layers of the pulmonary vessels, but in particular, there is an increase in number of adventitial fibroblasts. Hypoxia causes vasoconstriction in the pulmonary circulation and vasodilation in the systemic circulation. We hypothesized that there are fundamental differences in oxygen sensing and cell signaling between systemic and pulmonary artery cells in response to hypoxia. Here, we determined the effect of hypoxia either alone or in combination with known growth factors such as serum, endothelin-1 (ET-1), and platelet-derived growth factor (PDGF) on the proliferative responses of bovine pulmonary artery and mesenteric artery fibroblasts. Fibroblasts were obtained from primary cultures. Growth was assessed by [3H]thymidine incorporation. Inositol 1,4,5-triphosphate (IP3) generation was measured using a competitive binding assay. Hypoxia alone increased proliferation of pulmonary artery fibroblasts (611 +/- 24%), but not in those from the mesentery. Furthermore, hypoxia had the effect of increasing the replicative response of pulmonary fibroblasts to serum and PDGF, but no change was observed in the mesenteric cells. ET-1 had no effect on growth of either cell type. PDGF gave rise to a significant elevation in IP3 production under hypoxic conditions in the pulmonary artery cells (234%), but not in the mesenteric cells. ET-1 caused no change in IP3 production in any cell type. These data suggest that hypoxia sensitizes pulmonary artery fibroblasts to the proliferative effect of mitogens through a pathway that is not present, or is present but repressed, in the mesenteric cells.
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Affiliation(s)
- D J Welsh
- Pulmonary Vascular Unit, Department of Respiratory Medicine, Western Infirmary, and Department of Physiology and Pharmacology, University of Strathclyde, Glasgow, United Kingdom
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Raeside DA, Chalmers G, Clelland J, Madhok R, Peacock AJ. Pulmonary artery pressure variation in patients with connective tissue disease: 24 hour ambulatory pulmonary artery pressure monitoring. Thorax 1998; 53:857-62. [PMID: 10193372 PMCID: PMC1745077 DOI: 10.1136/thx.53.10.857] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The specific contribution of secondary pulmonary hypertension to the morbidity and mortality of patients with underlying lung disease can be difficult to assess from single measurements of pulmonary artery pressure. We have studied patients with secondary pulmonary hypertension using an ambulatory system for measuring continuous pulmonary artery pressure (PAP). We chose to study patients with connective tissue disease because they represent a group at high risk of pulmonary vascular disease, but with little disturbance of lung function. METHODS Six patients (five with progressive systemic sclerosis and one with systemic lupus erythematosis) were studied. They underwent preliminary cardiopulmonary investigations followed by Doppler echocardiography, right heart catheterisation, and ambulatory pulmonary artery pressure monitoring to measure changes in pressure over a 24 hour period including during a formal exercise test. RESULTS All patients had pulmonary hypertension as measured by Doppler echocardiography with estimated pulmonary artery systolic pressures of 40-100 mm Hg. Pulmonary function testing revealed virtually normal spirometric values (mean FEV1 86.9% predicted) but marked reduction in CO gas transfer factor (KCO 57.8% predicted). Exercise responses were impaired with mean VO2max 50.6% predicted. Ambulatory PAP monitoring indicated significant changes in pressures with variation in posture and activity throughout 24 hours. Resting PAP did not predict the change in PAP seen on exercise. CONCLUSION Conventional methods of assessment of the pulmonary circulation based on single measurements in the supine position may underestimate the stresses faced by the right side of the circulation. This ambulatory system allows monitoring of pulmonary haemodynamics continuously over 24 hours during normal activities of daily living. These measurements may increase our understanding of the contribution made by secondary pulmonary hypertension to the morbidity and mortality of the underlying lung disease.
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Affiliation(s)
- D A Raeside
- Department of Respiratory Medicine, West Glasgow Hospitals University NHS Trust, Western Infirmary, UK
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Scott PH, Paul A, Belham CM, Peacock AJ, Wadsworth RM, Gould GW, Welsh D, Plevin R. Hypoxic stimulation of the stress-activated protein kinases in pulmonary artery fibroblasts. Am J Respir Crit Care Med 1998; 158:958-62. [PMID: 9731031 DOI: 10.1164/ajrccm.158.3.9712130] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension in response to chronic hypoxia is invariably accompanied by remodeling of the pulmonary vessels but the mechanism by which hypoxia increases the replication of vascular cells is unknown. To investigate the hypothesis that hypoxia stimulates intracellular kinase cascades we measured the activity of "classic" mitogen-activated protein (MAP) kinase pathways and "stress- activated" MAP kinase pathways in bovine pulmonary artery fibroblasts subjected to hypoxia for up to 30 h. Hypoxia (1% O2) stimulated strongly the stress-activated protein kinases, c-Jun NH2-terminal kinase (JNK) and p38 MAP kinase. Two peaks of p38 MAP kinase activity at 6 and 24 h were associated with an increase in the activity of mitogen-activated protein kinase-activated protein (MAPKAP) kinase-2, the immediate downstream target of p38 MAP kinase. Furthermore, the second phase of p38 MAP kinase activity could be reversed if cells were reoxygenated after 12 h. These data suggest that hypoxic stimulation of pulmonary artery cells is mediated by activation of the stress-activated protein kinases.
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Affiliation(s)
- P H Scott
- Department of Physiology and Pharmacology, University of Strathclyde, Royal College; Pulmonary Vascular Unit, Department of Respiratory Medicine, Western Infirmary, Glasgow G11, 6NT, UK
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McLean AN, Bicknell SR, McAlpine LG, Peacock AJ. Investigation of pleural effusion: an evaluation of the new Olympus LTF semiflexible thoracofiberscope and comparison with Abram's needle biopsy. Chest 1998; 114:150-3. [PMID: 9674462 DOI: 10.1378/chest.114.1.150] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Recently, pulmonologists have performed thoracoscopy under local anesthesia using rigid thoracoscopes or flexible bronchoscopes. The latter allow greater access within the pleural cavity but are difficult to manipulate. The Olympus LTF semiflexible fiberoptic thoracoscope combines features of both instruments, having a solid body and a flexible terminal section. In the first study with this instrument, we evaluated ease of use and compared diagnostic yield with closed needle biopsy. PATIENTS Twenty-four patients with pleural effusion were investigated. SETTING Scottish University Hospital. DESIGN Thoracoscopy was performed in the bronchoscopy suite after premedication with atropine and papaveretum. Following a standard Abram's needle biopsy, the LTF thoracoscope was inserted through a flexible introducer (Olympus Optical Co Ltd; Tokyo, Japan). The pleura was inspected and biopsy specimens were taken of suspicious areas. RESULTS The final diagnosis was malignant pleural effusion in 16 of 24 patients. Ten of 16 were positive by Abram's biopsy, giving a sensitivity of 62%. Thirteen of 16 were positive by fiberoptic thoracoscopy, giving an improved sensitivity of 81%. The LTF thoracoscope was easy to use for pulmonologists experienced in rigid thoracoscopy and flexible bronchoscopy. Excellent views of the pleura were obtained from a single entry point. The procedure was well tolerated and no complications were encountered. CONCLUSION The LTF thoracoscope allows excellent pleural access but a larger biopsy channel (currently 2 mm) might increase the accuracy of diagnosis.
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Affiliation(s)
- A N McLean
- Department of Respiratory Medicine, West Glasgow Hospitals University NGS Trust, Glasgow, UK
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Peacock AJ, Scott P, Plevin R, Wadsworth R, Welsh D. Hypoxia enhances proliferation and generation of IP3 in pulmonary artery fibroblasts but not in those from the mesenteric circulation. Chest 1998; 114:24S. [PMID: 9676608 DOI: 10.1378/chest.114.1_supplement.24s] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- A J Peacock
- Department of Respiratory Medicine, Western Infirmary, University of Strathclyde, Glasgow, Scotland
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Menon N, McAlpine L, Peacock AJ, Madhok R. The acute effects of prostacyclin on pulmonary hemodynamics in patients with pulmonary hypertension secondary to systemic sclerosis. Arthritis Rheum 1998; 41:466-9. [PMID: 9506575 DOI: 10.1002/1529-0131(199803)41:3<466::aid-art13>3.0.co;2-o] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine whether patients with isolated pulmonary hypertension secondary to systemic sclerosis (SSc) have a pulmonary vasculature that is responsive to treatment with vasodilators. METHODS Seven SSc patients with pulmonary hypertension underwent right heart catheterization. Pulmonary pressures and cardiac output were measured before and during a systemic intravenous infusion of prostacyclin. RESULTS Both pulmonary arterial mean pressure and pulmonary vascular resistance decreased significantly with prostacyclin infusion (median decrease 11% and 32%, respectively), with a concomitant increase in cardiac output (median increase 26%). No adverse hemodynamic effects were noted during the infusion. CONCLUSION Vasospasm contributes to the pulmonary hypertension complicating SSc. This feature may be amenable to treatment with vasodilators.
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Affiliation(s)
- N Menon
- Glasgow Royal Infirmary University National Health Service Trust, Scotland, UK
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50
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Affiliation(s)
- A J Peacock
- Department of Respiratory Medicine, Western Infirmary, Glasgow, UK
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