Dysregulated endothelial cell markers in systemic lupus erythematosus: a systematic review and meta-analysis

OBJECTIVES

To perform a systematic literature review and meta-analysis on endothelial cell (EC) markers that are involved and dysregulated in systemic lupus erythematosus (SLE) in relation to disease activity, as EC dysregulation plays a major role in the development of premature atherosclerosis in SLE.

METHODS

Search terms were entered into Embase, MEDLINE, Web of Science, Google Scholar and Cochrane. Inclusion criteria were 1) studies published after 2000 reporting measurements of EC markers in serum and/or plasma of SLE patients (diagnosed according to ACR/SLICC criteria), 2) English language peer reviewed articles, and 3) disease activity measurement. For meta-analysis calculations, the Meta-Essentials tool by Erasmus Research Institute and of Management (ERIM) was used. Only those EC markers, which were 1) reported in at least two articles and 2) reported a correlation coefficient (i.e. Spearman's rank or Pearson's) between the measured levels of the EC marker and disease activity were included. For meta-analyses, a fixed effect model was used.

RESULTS

From 2133 hits, 123 eligible articles were selected. The identified SLE-related endothelial markers were involved in EC activation, EC apoptosis, disturbed angiogenesis, defective vascular tone control, immune dysregulation and coagulopathy. Meta-analyses of primarily cross-sectional studies showed significant associations between marker levels and disease activity for the following endothelial markers: Pentraxin-3, Thrombomodulin, VEGF, VCAM-1, ICAM-1, IP-10 and MCP-1. Dysregulated EC markers without associations with disease activity were: Angiopoeitin-2, vWF, P-Selectin, TWEAK and E-Selectin.

CONCLUSIONS

We provide a complete literature overview for dysregulated EC markers in SLE comprising a wide range of different EC functions. SLE-induced EC marker dysregulation was seen with, but also without, association with disease activity. This study provides some clarity in the eminent complex field of EC markers as biomarkers for SLE. Longitudinal data on EC markers in SLE are now needed to guide us more in unravelling the pathophysiology of premature atherosclerosis and cardiovascular events in SLE patients.

The effect of the location of arteriovenous fistula on the right ventricle in end stage renal disease patients indicated for hemodialysis

Background

End-stage renal disease (ESRD) has significantly increased in developing countries such as Egypt [1]. There are many sites for arteriovenous fistula (AVF) creation. The most common sites for AVF are radio-cephalic AVF (RC-AVF) followed by brachio-cephalic AVF (BC-AVF) [2]. To date, there are no significant studies discussing the possible correlation between the AVF location and abnormalities in the right ventricle (RV) in hemodialysis (HD) patients.

Objective

To determine the best location for AVF in order to ensure the least possible hazardous side effects of the AVF on the RV.

Methods

Our study, designed as an interventional study, included 50 ESRD patients referred for primary AVF construction to start HD for the first time. Patients were divided into two groups, 25 patients each. one group underwent a RC-AVF construction and the other had a BC-AVF. We assessed the RV by two dimensional transthoracic echocardiography (2D TTE) twice for each patient, firstly just before the AVF surgery and secondly three months after AVF construction.

Results

There was a statistically significant difference in between study groups regarding change in RV Tei index (p=0.001) with a decrease in the radial group (Mean ± SD = −0.19±0.2) and an increase in the brachial group (Mean ± SD = 0.02±0.12), and regarding the right ventricular outflow tract proximal diameter (p<0.001) with a decrease in the radial group (Mean ± SD = −2.32±5.49) and a larger increase in the brachial group (Mean ± SD = 2.94±3.14). Changes in the other RV dimensions and functional parameters did not show statistically significant difference.

Conclusion

After three months follow up, despite the fact that all the RV parameters remained within the normal range, the RV indices with the RC-AVF were associated with either improvement or less decline than with the BC-AVF.

Funding Acknowledgement

Type of funding sources: None.

Taste Receptor Activation in Tracheal Brush Cells by Denatonium Modulates ENaC Channels via Ca2+, cAMP and ACh

Mucociliary clearance is a primary defence mechanism of the airways consisting of two components, ciliary beating and transepithelial ion transport (I_SC). Specialised chemosensory cholinergic epithelial cells, named brush cells (BC), are involved in regulating various physiological and immunological processes. However, it remains unclear if BC influence I_SC. In murine tracheae, denatonium, a taste receptor agonist, reduced basal I_SC in a concentration-dependent manner (EC₅₀ 397 µM). The inhibition of bitter taste signalling components with gallein (G_βγ subunits), U73122 (phospholipase C), 2-APB (IP3-receptors) or with TPPO (Trpm5, transient receptor potential-melastatin 5 channel) reduced the denatonium effect. Supportively, the I_SC was also diminished in Trpm5^−/− mice. Mecamylamine (nicotinic acetylcholine receptor, nAChR, inhibitor) and amiloride (epithelial sodium channel, ENaC, antagonist) decreased the denatonium effect. Additionally, the inhibition of G_α subunits (pertussis toxin) reduced the denatonium effect, while an inhibition of phosphodiesterase (IBMX) increased and of adenylate cyclase (forskolin) reversed the denatonium effect. The cystic fibrosis transmembrane conductance regulator (CFTR) inhibitor CFTR_inh172 and the KCNQ1 potassium channel antagonist chromanol 293B both reduced the denatonium effect. Thus, denatonium reduces I_SC via the canonical bitter taste signalling cascade leading to the Trpm5-dependent nAChR-mediated inhibition of ENaC as well as G_α signalling leading to a reduction in cAMP-dependent I_SC. Therefore, BC activation contributes to the regulation of fluid homeostasis.

Bitter taste signaling in tracheal epithelial brush cells elicits innate immune responses to bacterial infection

Constant exposure of the airways to inhaled pathogens requires efficient early immune responses protecting against infections. How bacteria on the epithelial surface are detected and first-line protective mechanisms are initiated are not well understood. We have recently shown that tracheal brush cells (BCs) express functional taste receptors. Here we report that bitter taste signaling in murine BCs induces neurogenic inflammation. We demonstrate that BC signaling stimulates adjacent sensory nerve endings in the trachea to release the neuropeptides CGRP and substance P that mediate plasma extravasation, neutrophil recruitment, and diapedesis. Moreover, we show that bitter tasting quorum-sensing molecules from Pseudomonas aeruginosa activate tracheal BCs. BC signaling depends on the key taste transduction gene Trpm5, triggers secretion of immune mediators, among them the most abundant member of the complement system, and is needed to combat P. aeruginosa infections. Our data provide functional insight into first-line defense mechanisms against bacterial infections of the lung.

Biogeography and Environmental Drivers of Legionella pneumophila Abundance and Genotype Composition Across the West Bank: Relevance of a Genotype-Based Ecology for Understanding Legionella Occurrence

The West Bank can be considered as a high-risk area for Legionella prevalence in drinking water due to high ambient temperature, intermittent water supply, frequent pressure loss, and storage of drinking water in roof containers. To assess occurrence of Legionella species, especially L. pneumophila, in the drinking water of the West Bank, the drinking water distribution systems of eight hospitals were sampled over a period of 2.3 years covering the seasonal cycle and the major geographic regions. To gain insight into potential environmental drivers, a set of physico-chemical and microbiological parameters was recorded. Sampling included drinking water and biofilm analyzed by culture and PCR-based methods. Cultivation led to the isolation of 180 strains of L. pneumophila that were genotyped by Multi-Locus Variable Number of Tandem Repeat Analysis (MLVA). Surprisingly, the abundance of culturable L. pneumophila was low in drinking water of the sampling sites, with only three out of eight sites where Legionella was observed at all (range: 30–500 CFU/Liter). By contrast, biofilm and PCR-based analyses showed a higher prevalence. Statistical analyses with physico-chemical parameters revealed a decrease of L. pneumophila abundance for water and biofilm with increasing magnesium concentrations (>30 mg/L). MLVA-genotype analysis of the L. pneumophila isolates and their spatial distribution indicated three niches characterized by distinct physico-chemical parameters and inhabited by specific consortia of genotypes. This study provides novel insights into mechanisms shaping L. pneumophila populations and triggering their abundance leading to an understanding of their genotype-specific niches and ecology in support of improved prevention measures.

Monitoring Of IGF-1 Levels In Type 2 Diabetic Patients With Macro And Microvascular Complications

Introduction/Objective

Introduction: Type-2 diabetes have a risk factor of multiple complications such as coronary artery diseases (CAD), premature atheroscalerosis and diabetic retinopathy. IGF-1 is regulated by a balance of hormones such as growth hormone and insulin. It is important that circulating IGF1 in serum has normal levels to maintain glucose metabolism.

Objectives: Monitoring of IGF-1levels in T2DM with macrovascular complications (CVD) and microvascular complications (retinopathy).

Methods

Subjects and methods: The collection of samples started in June 2018 and ended in December 2018. A total of 114 subjects were enrolled in this study; 98 clinically diagnosed T2D patients who were recruited from the outpatient clinic of the National Institute for Diabetes and Endocrinology “NIDE”, in addition to 16 healthy comparable control subjects (without diabetes). The subjects divided into 3 groups. Group 1; a population of 44 T2D patients with macrovascular complications (28 females and 16 males), the mean age was 57.4 years. Group 2; a population of 54 T2D patients with microvascular complicatios (34 females and 20 males), the mean age was 59.1 years. Group 3; a population of 16 healthy subjects (12 female and 4 males), the mean age was 59.2 years. Levels of FBS, C-peptide, HbA1c, Lipid profile, lipoprotein(a), hs-CRP and microalbuminurea were measured in all subjects. Seum concentration of IGF-1 was measured by commercially immunoenzymatic ELIZA method.

Results

It was found that serum concentration of IGF-1 decreased in diabetic patients groups compared to the control one. The mean±SD of group 1, group 2 and group 3 were (332.2±152.2), (316.9 ±142.2) and (625.4 ± 257.7) respectively.

Conclusion

It was observed that there was a negative correlation between serum IGF-1 levels in T2D patients compared to the control group. Also, it was found that T2D patients with microvascular complications had lower IGF-1 levels than patients with macrovascular ones. It seems that IGF-1 strongly involved in the incidence and pathogenesis of T2DM complications.

Characterization of Legionella pneumophila Populations by Multilocus Variable Number of Tandem Repeats (MLVA) Genotyping from Drinking Water and Biofilm in Hospitals from Different Regions of the West Bank

The West Bank can be considered a high-risk area for Legionnaires' disease (LD) due to its hot climate, intermittent water supply and roof storage of drinking water. Legionella, mostly L. pneumophila, are responsible for LD, a severe, community-acquired and nosocomial pneumonia. To date, no extensive assessment of Legionella spp and L. pneumophila using cultivation in combination with molecular approaches in the West Bank has been published. Two years of environmental surveillance of Legionella in water and biofilms in the drinking water distribution systems (DWDS) of eight hospitals was carried out; 180 L. pneumophila strains were isolated, mostly from biofilms in DWDS. Most of the isolates were identified as serogroup (Sg) 1 (60%) and 6 (30%), while a minor fraction comprised Sg 8 and 10. Multilocus Variable number of tandem repeats Analysis using 13 loci (MLVA-8(12)) was applied as a high-resolution genotyping method and compared to the standard Sequence Based Typing (SBT). The isolates were genotyped in 27 MLVA-8(12) genotypes (Gt), comprising four MLVA clonal complexes (VACC 1; 2; 5; 11). The major fraction of isolates constituted Sequence Type (ST)1 and ST461. Most of the MLVA-genotypes were highly diverse and often unique. The MLVA-genotype composition showed substantial regional variability. In general, the applied MLVA-method made it possible to reproducibly genotype the isolates, and was consistent with SBT but showed a higher resolution. The advantage of the higher resolution was most evident for the subdivision of the large strain sets of ST1 and ST461; these STs were shown to be highly pneumonia-relevant in a former study. This shows that the resolution by MLVA is advantageous for back-tracking risk sites and for the avoidance of outbreaks of L. pneumophila. Overall, our results provide important insights into the detailed population structure of L. pneumophila, allowing for better risk assessment for DWDS.

Association of ficolin-2 gene polymorphisms and susceptibility to systemic lupus erythematosus in Egyptian children and adolescents: a multicenter study

BACKGROUND

Pediatric-onset SLE (pSLE) is a multisystem autoimmune disease. Recently, the ficolin-2 (FCN2) gene has emerged as a potential candidate gene for susceptibility to SLE.

OBJECTIVES

The objective of this study was to evaluate the association of the FCN2 gene polymorphisms at positions -986 (G/A), -602 (G/A), -4 (A/G) and SNP C/T (rs3124954) located in intron 1, with susceptibility to pSLE in Egyptian children and adolescents.

METHODS

This was a multicenter study of 280 patients diagnosed with pSLE, and 280 well-matched healthy controls. The FCN2 promoter polymorphisms at -986 G/A (rs3124952), -602 G/A (rs3124953), -4 A/G (rs17514136) and SNP C/T (rs3124954) located in intron 1 were genotyped by polymerase chain reaction, while serum ficolin-2 levels were assessed using enzyme-linked immunosorbent assay.

RESULTS

The frequencies of the FCN2 GG genotype and G allele at -986 and -602 positions were significantly more represented in patients with pSLE than in controls (p < 0.001). Conversely, the FCN2 AA genotype and A allele at position -4 were more common in patients than in controls (p < 0.001). Moreover, patients carrying the FCN2 GG genotype in -986 position were more likely to develop lupus nephritis (odds ratio: 2.6 (95% confidence interval: 1.4-4.78); p = 0.006). The FCN2 AA genotype at position -4 was also identified as a possible risk factor for lupus nephritis (odds ratio: 3.12 (95% confidence interval: 1.25-7.84); p = 0.024).

CONCLUSION

The FCN2 promoter polymorphisms may contribute to susceptibility to pSLE in Egyptian children and adolescents. Moreover, the FCN2 GG genotype at position -986 and AA genotype at position -4 were associated with low serum ficolin-2 levels and may constitute risk factors for lupus nephritis in pSLE.

Predictors of Mortality in Living Donor Liver Transplantation

BACKGROUND

Egypt has the highest prevalence of the world hepatitis C virus (HCV) load. Hence, the problem of end-stage liver disease (ESLD) is considered a huge burden on the community. Living donor liver transplantation (LDLT) is the only source of donation in Egypt till now. Survival rates had shown significant improvement in the past decades. This study provides analysis of the mortality rates and possible predictors of mortality following LDLT. It also aids in developing a practical and easy-to-apply risk index for prediction of early mortality.

PATIENTS AND METHODS

This study is a retrospective study that was designed to analyze data from 128 adult patients with ESLD who underwent LDLT in the Liver Transplantation Unit at Faculty of Medicine, Cairo University. Early and late mortality were identified. All potential risk factors were tested using univariate regression for association with early and late mortality. Significant variables were then entered into a multivariable logistic regression model for identifying the predictors for mortality.

RESULTS

Sepsis was the most common cause of early mortality. Early mortality and 1-year mortality were 29 (23%) and 23 (18%), respectively. Model for End-Stage Liver Disease (MELD) score, intraoperative packed red blood corpuscles (RBCs), and duration of intensive care unit (ICU) stay were found to be independently associated with early mortality.

CONCLUSION

A MELD score >20, intraoperative transfusion >8 units of packed RBCs, and ICU stay >9 days are three independent predictors of early mortality. Their incorporation into a combined Risk Index can be used to improve outcomes of LDLT.

Different Score Systems to Predict Mortality in Living Donor Liver Transplantation: Which Is the Winner? The Experience of an Egyptian Center for Living Donor Liver Transplantation

INTRODUCTION

Many scoring systems have been proposed to predict the outcome of deceased donor liver transplantation. However, their impact on the outcome in living donor liver transplantation (LDLT) has not yet been elucidated. This study sought to assess performance of preoperative Model for End-Stage Liver Disease (MELD) score in predicting postoperative mortality in LDLT and to compare it with other scores: MELDNa, United Kingdom End-Stage Liver Disease (UKELD), MELD to serum sodium ratio (MESO), updated MELD, donor age-MELD (D-MELD) and integrated MELD (iMELD).

METHODS

We retrospectively analyzed data from 86 adult Egyptian patients who underwent LDLT in a single center. Preoperative MELD, MELDNa, MESO, UKELD, updated MELD, D-MELD, and iMELD were calculated. Receiver-operator characteristic (ROC) curves and area under the curve (AUC) were used to assess the performance of MELD and other scores in predicting postoperative mortality at 3 months (early) and 12 months.

RESULTS

Among the 86 patients, mean age 48 ± 7 years, 76 (88%) were of male sex and 27 (31.4%) had died. Preoperative MELD failed to predict early mortality (AUC = 0.63; P = .066). Comparing preoperative MELD with other scores, all other scores had better predictive ability (P < .05), with D-MELD on the top of the list (AUC = 0.68, P = .016), followed closely by UKELD (AUC = 0.67, P = .025). After that were iMELD, MESO, and MELDNa with the same predictive performance (AUC = 0.65; P < .05); updated MELD had the lowest prediction (AUC = 0.640; P = .04). Moreover, all scores failed to predict mortality at 12 months (P > .05).

CONCLUSIONS

Preoperative MELD failed to predict either early or 1-year mortality after LDLT. D-MELD, UKELD, MELDNa, iMELD, and MESO could be used as better predictors of early mortality than MELD; however, we need to develop an effective score system to predict mortality after LDLT.

Fertility and pregnancy in patients under age 38 following chemotherapy for breast cancer

e11541

Background: Chemotherapy improves breast cancer outcome, but may impact fertility. Post chemotherapy fertility rates range between 10–90% among studies. Fertility post chemotherapy is most often assessed by rate of menstruation resumption- an indirect method of evaluating childbearing potential. It is noteworthy that future pregnancy is a woman's first concern not menses preservation. Variability in fertility rates along with limited data on post chemotherapy pregnancies led us to undertake this single institute retrospective study evaluating fertility and pregnancy post chemotherapy in ≤ 38 y old breast cancer patients. Methods: We reviewed medical records of 222 consecutive stage II-IIIB breast cancer patients diagnosed, treated and followed at Sharette Institute of Hadassah-Hebrew University Medical Center from 1990–2004. Inclusion criteria included age ≤ 38 years, ≥3 cycles of standard metothrexate or adriamycine based chemotherapy, metastasis-free 12 months post chemotherapy initiation or one year following GnRH analog withdrawal. Patients diagnosed with infertility prior to breast cancer diagnosis (data present for part of patients), bilateral oophorectomy or patients surviving ≤3 years from diagnosis were excluded. Patient pregnancy preference was not recorded. Fertility was defined as resumption of recurrent menses or pregnancy anytime during follow up. In case of recurrence, date of recurrence diagnosis was assigned as date of last follow up. Results: Cohort included 65 patients. Mean age 32.5±4 ys (20.3–38.5) Almost all patients (95.4%), 38 ys or younger, preserve menses following chemotherapy, and 33.9% become pregnant. Most of patients who did not conceive post chemotherapy (66.1%), were under a familial status not promoting pregnancy; 44% of all women who did not give birth post chemotherapy had at least 3 offspring at the time of diagnosis and 83% out of all women who did not have any offspring by the end of follow up were single. Conclusions: This data suggest that pregnancy potential may be even higher than our actual finding, since pregnancy is most probably not attempted by multiparous or most single patients, whom cultural constrains affect their decisions. It seems prudent to offer the subgroup of unmarried women fertility preservation.

No significant financial relationships to disclose.

Sensitivity and specificity of bispectral index for classification of overt hepatic encephalopathy: a multicentre, observer blinded, validation study

BACKGROUND

The severity of hepatic encephalopathy is currently graded clinically using West Haven criteria and psychometric tests.

OBJECTIVE

To assess the discriminative power of the bispectral index (BIS) monitor to classify the degree and progression of hepatic encephalopathy.

DESIGN

A consecutive, multicentre, observer blinded validation study.

SETTING

Medical University of Graz (Graz, Austria), Zhejiang University First Affiliated Hospital (Hang Zhou, China), and Cairo University (Cairo, Egypt).

PATIENTS

28 consecutive patients with hepatic encephalopathy were first enrolled at Medical University of Graz as a test set. The estimated BIS cut off values were subsequently tested in a validation set of 31 patients at Zhejiang University First Affiliated Hospital and 26 patients at Cairo University; 18 patients were reassessed later in a longitudinal study. Fifteen of 85 patients (18%) were excluded from the final analysis (11 became too agitated with high electromyographic activity; four fell asleep during the recording).

RESULTS

Applying the Austrian BIS cut off values of 85, 70, and 55 for discriminating West Haven grades 1 to 4 yielded agreement between BIS classification and West Haven grades in 40 of the 46 validation patients (87%), and in 16 of the 18 follow up patients (89%). Mean (SD) BIS values differed significantly between patients with West Haven grade 1 (90.2 (2.5)), grade 2 (78.4 (6.6)), grade 3 (63.2 (4.8)), and grade 4 (45.4 (5.0)).

CONCLUSIONS

BIS is a useful measure for grading and monitoring the degree of involvement of the central nervous system in patients with chronic liver disease.

Glucocorticoid treatment in patients with septic shock: effects on vasopressor use and mortality

Corticosteroids were proposed for the treatment of sepsis as early as 1940. Several RCTs cast serious doubts on the usefulness of high dose corticosteroids and doubt still persists regarding the efficacy of replacement therapy. Adrenal insufficiency (non-responders to the 250 microg corticotropin test: increase in cortisol < 9 microg/dl) is present in about half of patients with septic shock and is associated with higher rates of refractory hypotension and mortality. Peripheral glucocorticoid resistance, which may even occur more frequently, can be easily assessed at bedside using skin tests. Cortisol antagonizes the migration of inflammatory cells, the synthesis or action of virtually all proinflammatory mediators, promotes virtually all anti-inflammatory components and enhances humoral immunity by means of transcriptional interference between its receptor and both AP-1 and NF-kappaB. Cortisol mediates cardiovascular tolerance to endotoxin and the maintenance of vascular sensitivity to catecholamines. Low doses (about 300 mg daily for 5 days or more) of hydrocortisone increase vasoconstrictor response to catecholamines in animals, in healthy volunteers challenged with LPS and in several RCTs. Hydrocortisone also increases arterial pressure and decreases the duration of shock. A meta-analysis of all available clinical controlled studies showed a reduction in 28 days, all-cause mortality with glucocorticoids (RR = 0.88, 95% CI: 0.78 - 1.00; p = 0.04). However, there was a significant heterogeneity across the trials (p = 0.006). On the other hand, analysis of studies where low doses of glucocorticoids were given for prolonged periods showed a 24% reduction in the risk of all-cause mortality at 28 days in treated patients (RR = 0.76, 95% CI: 0.64 - 0.90; p = 0.002) without heterogeneity across the trials (p = 0.28). In conclusion, in severe sepsis, high doses of corticosteroids should not be given. Septic shock should be treated with a replacement dose of hydrocortisone.

A prospective study of posttraumatic stress symptoms and nonadherence in survivors of a myocardial infarction (MI)

We examined a novel hypothesis that links symptoms of MI-related posttraumatic stress disorder (PTSD) to nonadherence. According to this hypothesis, patients who are traumatized by their medical illness do not take their medications as prescribed. As a part of the avoidance dimension of PTSD, patients who are traumatized may avoid being reminded of the MI by not taking the medication. MI survivors were prospectively followed for 6 months to 1 year. Adherence was assessed by pill count of Captopril. Demographic variables, medical risk factors, PTSD, and other psychiatric symptom dimensions were evaluated during follow-up. One hundred two of 140 recruited patients completed follow-up. Nonadherence to Captopril was associated with poor medical outcome (r=.93, P=.006). Above-Threshold PTSD symptoms were associated with nonadherence to medications (P=.05). No other psychiatric symptom dimensions were independently associated with nonadherence. Nonadherence to medications predicts adverse outcome during the first year after an acute MI. Nonadherence is associated with PTSD symptoms, which may either be a marker for or a cause of nonadherence. Treatment of PTSD may prove to be a useful approach for improving adherence.

BAL neopterin : a novel marker for cell-mediated immunity in patients with pulmonary tuberculosis and lung cancer

BACKGROUND

Neopterin is derived from guanosine triphosphate and is produced by stimulated macrophages under the influence of gamma-interferon of lymphocyte origin. It has been suggested that it is an excellent marker for the activation of the monocyte/macrophage axis in some clinical situations. However, to our knowledge, the relationship of BAL neopterin levels to disease states has not been studied.

AIM

To assess the usefulness of BAL neopterin levels as an index of disease activity in patients with pulmonary tuberculosis and lung cancer.

METHODS

BAL and serum neopterin levels were evaluated in 20 patients with pulmonary tuberculosis, 20 patients with bronchogenic carcinoma, and 10 healthy individuals. The concentration of neopterin was evaluated by radioimmunoassay technique. The BAL level of neopterin was standardized using the BAL urea level.

RESULTS

The neopterin levels (mean +/- SD) in the BAL and serum of tuberculous patients (88.6 +/- 27.4 nmol/L epithelial lining fluid [ELF], 61.3 +/- 29.4 nmol/L, respectively) were significantly higher when compared with those in lung cancer patients (40.7 +/- 16.6 nmol/L ELF, 26.8 +/- 6.58 nmol/L, respectively, p < 0.001) and when compared with those in control subjects (26.3 +/- 11.3 nmol/L ELF, 6.8 +/- 2.7 nmol/L, respectively, p < 0.001). In the tuberculous group, BAL and serum neopterin levels in patients with far-advanced disease were significantly higher when compared with those in patients with moderately and minimally advanced diseases (p < 0.001). BAL and serum neopterin levels were significantly higher in patients with small cell carcinoma than in those with adenocarcinoma (p < 0.05). BAL neopterin levels were significantly (p < 0.001) higher than serum levels in all patients and control groups. In addition, there were significant positive correlations between BAL and serum neopterin levels in tuberculous (r = 0.92, p < 0.001), lung cancer (r = 0.62, p < 0.001), and control groups (r = 0.93, p < 0.001).

CONCLUSIONS

The levels of neopterin in BAL fluid may reflect the degree of disease activity in pulmonary tuberculous patients. In addition, BAL neopterin levels are elevated in patients with lung cancer, especially the small-cell carcinoma type.

Plasma angiotensin II, renin activity and serum angiotensin-converting enzyme activity in non-insulin dependent diabetes mellitus patients with diabetic nephropathy

The renin-angiotensin system (RAS) has been unequivocally implicated as a mediator of diabetic complications. The present study was designed to evaluate the RAS in non-insulin dependent diabetic patients with diabetic nephropathy. Plasma renin activity, plasma angiotensin II and serum angiotensin-converting enzyme (ACE) activity were measured in 45 non-insulin dependent diabetes mellitus (NIDDM) patients and 15 healthy non-diabetic controls. Diabetics were subdivided into 15 normoalbuminuric NIDDM subjects, 15 NIDDM patients with microalbuminuria and 15 diabetics with macroalbuminuria. Mean plasma renin activity for macroalbuminuric diabetics (0.65+/-0.10 ng/ml/hr) was significantly reduced than the controls (1.28+/-0.37 ng/ml/hr) (P<0.001), the diabetic group with microalbuminuria (1.08+/-0.48 ng/ml/hr) (P<0.05) and normoalbuminuric patients (1.56+/-0.82 ng/ml/hr) (P<0.001). A significant negative correlation was obtained between serum creatinine and plasma renin activity (r=-0.842, p<0.001) in macroalbuminuric NIDDM patients. Plasma angiotensin II was significantly decreased in non-complicated diabetics compared to healthy controls (4.36+/-1.49 pg/ml vs 14.87+/-3.48 pg/ml respectively, p<0.001). Non-insulin dependent diabetic patients with nephropathy had significantly higher plasma angiotensin II levels (28.99+/-5.88 pg/ml) than non-complicated diabetics (p<0.001). Serum ACE activity was increased in 53.3% of NIDDM patients. All diabetic groups showed increased serum ACE activity (normoalbuminuric NIDDM 114.9+/-28.3 nmol/min/ml, microalbuminuric NIDDM 127.9+/-31.2 nmol/min/ml and macroalbuminuric NIDDM 127.0+/-29.3 nmol/min/ml) when compared to the normal control group (76.3+/-16.5 nmol/min/ml) (p<0.001). No significant difference in serum ACE activity was obtained between normoalbuminuric and nephropathic diabetics or between diabetics with and without retinopathy. No significant correlation was obtained between serum ACE activity and blood pressure, blood glucose level and duration of diabetes. Thus plasma renin activity is decreased in diabetic nephropathy and negatively correlates with serum creatinine. Plasma angiotensin II is decreased in normoalbuminuric diabetics and elevated in diabetic nephropathy. Serum ACE activity is raised in NIDDM patients with no relation to albumin excretion rate. The role of increased ACE activity in NIDDM remains to be established.

Pleural Lavage: A Novel Diagnostic Approach For Diagnosing Exudative Pleural Effusion

Patients with pleural effusions frequently present a diagnostic and therapeutic challenge. The diagnosis is based on the interpretation of the results of thoracentesis or pleural biopsy. When a malignant tumor metastasizes to the pleura, tumor cells can be seeded over the mesothelial surface or in the subserous layer. In the former situation, tumor cells are abundant in pleural fluid, but in the latter, few malignant cells are exfoliated into the pleural cavity, and microscopic deposits may not be visualized at thoracoscopy. Pleural lavage cytologic study at the time of thoracoscopy has not been studied. The purpose of this study was to assess the value of thoracoscopic pleural lavage as an adjuvant in the diagnostic workup of patients with exudative pleural effusions. Fifty patients with exudative pleural effusions were investigated by pleural fluid cytologic findings, Abram's pleural biopsy, thoracoscopy, and pleural lavage cytologic findings. After aspiration of all pleural fluid, 300 mL saline was instilled into the pleural cavity and then recovered for cytologic analysis. The final diagnoses were 32 malignant (64%), 15 tuberculous (30%), and 3 idiopathic (6%) effusions. In the malignant group, thoracoscopic biopsy had the highest yield (94%) followed by lavage cytologic analysis (84%), fluid cytologic analysis (62%), and biopsy with Abram's needle (50%). The sensitivity of combined thoracoscopy and lavage cytologic analysis was 96%. In the patients with tuberculous pleuritis, the yield from the pathologic examination of the biopsy specimen was 93% with thoracoscopy and 60% with the Abrams needle. The diagnostic yield with cytologic analysis on pleural lavage fluid is significantly higher than that on pleural fluid. This is probably because the cells in the lavage fluid are fresher and better preserved than those in the regular pleural fluid, which may have undergone degenerative changes, yielding false-negative results. Pleural lavage cytologic analysis should be performed in patients with suspected malignant pleural effusion who are subjected to diagnostic thoracoscopy, because it may provide additional information to thoracoscopic biopsy.

L-NMMA (a nitric oxide synthase inhibitor) is effective in the treatment of cardiogenic shock

BACKGROUND

The objective was to assess the safety and efficacy of L-NMMA in the treatment of cardiogenic shock.

METHODS

We enrolled 11 consecutive patients with cardiogenic shock that persisted after >24 hours from admission, despite coronary catheterization and primary percutaneous transluminal coronary revascularization, when feasible, and treatment with mechanical ventilation, intraaortic balloon pump (IABP), and high doses of catecholamines. L-NMMA was administered as an IV bolus of 1 mg/kg and continuous drip of 1 mg. kg(-1). h(-1) for 5 hours. Treatment with catecholamines, mechanical ventilation, and IABP was kept constant throughout the study.

RESULTS

Within 10 minutes of L-NMMA administration, mean arterial blood pressure (MAP) increased from 76+/-9 to 109+/-22 mm Hg (+43%). Urine output increased within 5 hours from 63+/-25 to 156+/-63 cc/h (+148%). Cardiac index decreased during the steep increase in MAP from 2. 0+/-0.5 to 1.7+/-0.4 L/(min. m(2)) (-15%); however, it gradually increased to 1.85+/-0.4 L/(min. m(2)) after 5 hours. The heart rate and the wedge pressure remained stable. Twenty-four hours after L-NMMA discontinuation, MAP (+36%) and urine output (+189%) remained increased; however, cardiac index returned to pretreatment level. No adverse events were detected. Ten out of eleven patients could be weaned off mechanical ventilation and IABP. Eight patients were discharged from the coronary intensive care unit, and seven (64%) were alive at 1-month follow-up.

CONCLUSIONS

L-NMMA administration in patients with cardiogenic shock is safe and has favorable clinical and hemodynamic effects.

Lactobacillus species as emerging pathogens in neutropenic patients

The intensive use of broad-spectrum antibiotics in the context of prolonged and severe neutropenia has contributed to the emergence of unusual pathogens. Four new cases of severe Lactobacillus infections-three of septicemia and one of pneumonia-are reported. They occurred in patients with acute leukemia who had chemotherapy-induced neutropenia. All patients were treated in the same intensive care unit and received the same antimicrobial prophylaxis which included a total bowel decontamination containing vancomycin. The four patients were treated with a combination of intravenous ceftazidime and vancomycin prior to the development of Lactobacillus infection. Improvement in the condition of all patients was obtained with a treatment including penicillin and concurrent recovery of granulopoiesis.

Photorefractive Keratectomy and Laser In Situ Keratomileusis for Myopia Between 6.00 and 10.00 Diopters

BACKGROUND

Excimer laser photorefractive keratectomy (PRK) can be effective in correcting myopia up to -6.00 diopters (D). Between -6.00 D and -10.00 D, the procedure is considered less effective and safe because it has been associated with dense scar formation and a high rate of regression. We compared photorefractive keratectomy (PRK) in this group of myopes with excimer laser keratomileusis in situ (LASIK).

METHODS

Forty consecutive eyes with a manifest refraction between -6.00 and -10.00 D were treated with PRK using an ablation-zone diameter of 6 mm. Subsequently, 40 consecutive eyes were treated with LASIK under a hinged flap using an ablation-zone diameter of 5 mm. All procedures used a Summit OmniMed laser and were done by the same surgeon.

RESULTS

Preoperatively, 24 eyes (60%) undergoing PRK had 20/20 spectacle-corrected visual acuity; 1 year postoperatively, 20 (50%) had 20/20 vision uncorrected. Preoperatively, 13 eyes (33%) undergoing LASIK had 20/20 spectacle-corrected visual acuity; 1 year postoperatively, 24 (60%) could see 20/20 uncorrected. Sixteen (39%) PRK eyes had a spherical equivalent refraction within +/-1.00 D at 1 year; 20 (60%) eyes undergoing LASIK had a refraction within +/-1.00 D at that point. None of the eyes treated with LASIK developed corneal haze, while after PRK, 36 eyes (90%) developed haze (23 eyes [57%] +2 to +3).

CONCLUSION

LASIK under a hinged flap proved superior to PRK in treating myopia between -6.00 D and -10.00 D.

Faciometrics: a new syntax for facial feature analysis

A little neglect appears to exist in current cephalometric soft tissue analysis. Specifically, some areas of the facial integument are not accessible to cephalometric analysis. Further, no method of frontal cephalometric soft tissue analysis has been described. Faciometrics, a new cephalometric, nonradiographic system for facial feature analysis, may carry professional diagnostic capacity to another dimension by providing an evaluation for previously inaccessible facial areas and by supplying a beginning for frontal cephalometric soft tissue analysis. The reliability and the validity of the proposed system were tested on a random sample of 20 subjects. The system was found to be reliable and valid. A method for rapid checking of facial symmetry is also described, and some equations for facial proportions are presented as guidelines for good facial esthetics. The faciometric system is proposed as a complement to, rather than a replacement for, available soft tissue cephalometric analysis.