Differences in vitamin D nutritional status between newly diagnosed cancer patients from rural or urban settings in Kentucky

Although poor nutritional status and weight loss in cancer patients is known to affect outcomes, little is known about malnutrition differences based on geographic location. We investigated nutritional and inflammatory status of 220 newly diagnosed adults with solid tumors at the University of Kentucky's Markey Cancer Center during December 2008 through October 2011. Chi-square tests were used to determine any associations between suboptimal nutritional levels and rural-urban areas of residence. Out of the 13 lab values collected, the only significant difference between rural and urban participants was found for vitamin D resulting in more rural subjects (67.4%) having a suboptimal vitamin D status as compared to those residing in urban areas (53.3%, P = 0.04). Controlling for baseline demographics including age, race, sex, body mass index, nutritional status, and type of cancer, logistic regression analyses concluded those in rural areas had nearly a twofold increase in the odds of having a suboptimal vitamin D level compared to those in urban areas (odd's ratio = 1.97; 95% confidence interval = 1.04, 3.74). Further investigation into the rural-urban differences in vitamin D needs to be investigated in order to improve outcomes during cancer treatment.

Preliminary observations of transtracheal augmented ventilation for chronic severe respiratory disease

OBJECTIVE

Evaluate the potential safety and efficacy of transtracheal augmented ventilation (TTAV), which is the transtracheal delivery of high flows of a humidified air-oxygen blend.

METHODS

The first of 2 observational studies evaluated patients before and after a 3-month intervention with the nocturnal (Noc) administration of TTAV at 10 L/min. Resting physiologic studies evaluated standard low-flow transtracheal oxygen (LFTTO), TTAV, and breathing without transtracheal flow via mouthpiece (MP). Patients also underwent nocturnal polysomnography, bronchoscopy, ventilatory drive evaluation, and treadmill exercise. The second study assessed the safety of Noc TTAV for up to 60 months. Each study evaluated 15 different transtracheal patients with severe lung disease.

RESULTS

Pleural pressure-time index and respiratory duty cycle were significantly lower (p < 0.05) when comparing MP to TTAV. TTAV contributed more (p < 0.05) than LFTTO to the total volume delivered to the lung (V(L)). Arterial blood gases and (V(L)) were unaltered by TTAV. Sleep quality and nocturnal oxygenation with TTAV were similar to LFTTO, and Noc TTAV had no effect on ventilatory drive. Bronchoscopy showed no evidence of substantial injury. Treadmill exercise tests showed a longer exercise time (p < 0.005) and greater total work (p < 0.05) following Noc TTAV. During exercise, the changes in slope for heart rate and pH were less steep (p < 0.05) following Noc TTAV. The 3-month study and a long-term evaluation showed that Noc TTAV was well-tolerated and safe, with a reported high compliance.

CONCLUSIONS

Patients with chronic hypoxemia and severe respiratory insufficiency may benefit from Noc TTAV.

Otolaryngologist's role in transtracheal oxygen therapy: the minitrach procedure

The modified Seldinger technique for transtracheal oxygen catheter insertion is relatively straightforward, but tract problems during subsequent oxygen therapy are not uncommon. With the modified Seldinger technique method, transtracheal oxygen is not initiated until 1 week after the procedure. Six to 8 weeks are required for tract epithelialization, which allows routine catheter removal and cleaning by the patient. Without removal, mucus tends to collect and form balls on the catheter tip, creating a management problem. Previous studies suggest a significant incidence of tracheal chondritis, keloid formation, and inadvertent catheter dislodgment. In 7% to 10% of patients, the epithelial tract cannot be recovered by medical personnel, and complete closure occurs. We have developed a surgical technique for the creation of a controlled tracheocutaneous tract. Highlights of the minitrach include skin flap elevation, cervical lipectomy, resection of a small window of tracheal cartilage, and approximation of the skin flaps to the window. We evaluated 33 patients who underwent the minitrach procedure as an access method for receiving transtracheal oxygen. When compared with results from 64 patients followed up for a similar period with the modified Seldinger technique, results with minitrach showed that transtracheal oxygen could be instituted sooner (<24 hours), and symptomatic mucus balls were reduced because the tract matured more quickly (approximately 14 days). With the minitrach there were no inadvertent catheter dislodgments, as compared with 41% of modified Seldinger technique patients who had one or more episodes of catheter dislodgment. Twelve percent of minitrach patients had a single episode of chondritis, as compared with 25% of the modified Seldinger technique patients, who had one or more episodes. The minitrach was well tolerated in this group of patients with severe pulmonary and/or cardiovascular disease. In 12 of these patients, a minitrach revision of their previous modified Seldinger technique tracts resolved recurrent problems with chondritis, lost tracts, and keloids. We conclude that the minitrach promotes early institution of transtracheal oxygen, simplifies an intense postprocedure educational and management process, facilitates tract maturation, and reduces the incidence of problems related to mucus balls, lost tracts, chondritis, and keloids. The minitrach can be used as a revision procedure to resolve tract problems encountered with modified Seldinger technique. We are now using the minitrach as the preferred procedure for the institution of transtracheal oxygen. The minitrach greatly improves and simplifies the transtracheal oxygen program, and the otolaryngologist becomes an important member of the transtracheal oxygen team.

Effects of hyperoxia and caffeine on the expression of fragile site at Xq27.3

To enhance the cytogenetic expression of the fragile X chromosome, we studied the effects of hyperoxia and caffeine on the induction of fragile Xq27.3. A lymphoblastoid cell line (GM 06912) derived from a fragile X male proband was cultured in RPMI 1640 containing 16% dialyzed fetal calf serum. The cells were synchronously subjected to one of 3 different atmospheric oxygen tensions (21%, 21.3 kPa, normoxic; 40%, 40.5 kPa, hyperoxic; or 60%, 60.8 kPa, hyperoxic) during the last 24 hours of the 72 hour culture, immediately after the addition of 2'-deoxy-5-fluorouridine (FUdR) at 25 ng/ml. To study the enhancing effect of caffeine, with or without hyperoxia, a second set of cultures was additionally subjected to caffeine (2.5 mM) during the last 6 hours of the culture. When the fragility of hyperoxic cells (38.1 kPa dissolved oxygen) was compared to that of normoxic control cells (13.3 kPa dissolved oxygen), the difference was significant (P < 0.05). These data suggest that there is a mean increase in the fragile Xq27.3 expressivity as the dissolved oxygen tension increases. Additionally, we observed that caffeine, with or without hyperoxia, significantly (P < 0.05) suppressed the expression of the fragile X site in this lymphoblastoid cell line.

Constitutional heteromorphism of 9q13 --> q21 in a patient with chronic myelogenous leukemia

Cytogenetic studies were carried out in a 44-year-old white male because of newly diagnosed chronic myelogenous leukemia. His initial bone marrow study revealed 46,XY, var(9)(q13 -->q21)/46,XY,var(9) (q13-->q21), t(9;22)(q34;q11) karyotypes and later he also acquired a 47,XY,+8,var(9)(q13-->q21), t(9;22)(q34;q11) clone. The var(9)(q13-->q21) heteromorphism was observed in the normal 9 homolog, in 200 GTG-banded bone marrow metaphases in seven cytogenetic studies (1988-90). This heteromorphism was observed in the normal cell line, in the two chronic myelogenous leukemia-related clones, as well as in 100 mitogen-induced peripheral blood lymphocytes, indicating its constitutional nature. This seems to be the first report of var(9)(q13 --> q21) heteromorphism, involving GTG-positive euchromatic band, in a chronic myelogenous leukemia proband.

Oxygen therapy using pulse and continuous flow with a transtracheal catheter and a nasal cannula

Pulse delivery (PD) of oxygen was compared with continuous flow (CF) utilizing transtracheal oxygen catheter (TTO) and nasal cannula (NC) in 20 stable patients with chronic hypoxemia. Oxygen saturation, respiratory rate, and accuracy of pulsed oxygen delivery were measured during sleep studies and these parameters, as well as arterial blood gases, were evaluated during rest and exercise. Additionally, bulk liquid oxygen use was measured under each condition, for a period of 1 month. Pulse delivery NC was evaluated in six subjects, CF NC in 14 subjects, and PD and CF TTO in 20 subjects over the 1-month period. Results showed that, as a group, patients were adequately oxygenated when utilizing the PD with both NC and TTO as assessed by arterial blood gases, oximetry, and hematocrit. However, four subjects could not be adequately oxygenated on PD NC during exercise even at the maximum liter per minute setting and could not be studied with this mode of therapy. The PD settings in the remaining subjects were equivalent to continuous flow settings for TTO and NC as assessed by PaO2 for rest and SaO2 for exercise and sleep. Compared with standard CF NC, the daily bulk oxygen use was decreased by 29.4 percent with CF TTO, by 48.2 percent with PD NC, and by 49.9 percent with PD TTO. We conclude that, compared with CF NC, PD of oxygen via TTO or NC by this method appears to be a safe, reliable, effective, and cost-effective method of oxygen delivery in the majority of subjects when used with proper screening.

The effects of transtracheal gas delivery on central inspiratory neuromuscular drive

Previous studies have shown transtracheal delivery of low-flow oxygen (TTO) decreases inspired minute ventilation (Veinsp) and have postulated that this would result in a decrease in the work of breathing (WOB). We hypothesized that a fall in central inspiratory neuromuscular drive (CIND) with TTO would reflect a fall in WOB. We measured resting ventilatory parameters (RVP) and CIND by the mouth occlusion pressure technique (MOP) at different gas flow rates through the catheter in 21 subjects (13 men, 8 women; mean age, 60 +/- 10.6 years) with severe COPD with a mature intratracheal oxygen catheter (ITOC). We also constructed a lung/chest wall analog (LCA) to determine if flow through the catheter would alter pressure changes during inspiration. Inspiratory tidal volume (Vtinsp) and minute ventilation (Veinsp) decreased proportionally to the gas flow rate through the catheter. However, with increasing flow through the catheter, P0.1 increased in the LCA, presumably due to the Bernoulli effect. The lack of a similar change in the subject group suggests that CIND does, in fact, fall, and that possibly there is a decrease in WOB. This effect may be of benefit to patients with severe COPD.

Pulsed nasal and transtracheal oxygen delivery

Oxygen conserving devices, the TTO catheters, electronic pulsed DODS and reservoir cannulas, increase efficacy of oxygen delivery; TTO also improves cosmetic appearance, comfort and compliance. We speculated that pulsing of oxygen transtracheally can increase efficiency of TTO. We modified the DODS to include settable delays and a rapid pre-inspiratory trigger. The first part of the study was performed with nasal oxygen on seven subjects and the second part, with TTO on 17 subjects. Nasal oxygen results indicate improved delivery efficiency with more rapid response. The TTO results indicate no significant change for each delay setting, but there was improvement in delivery efficiency when DODS was combined with TTO vs continuous flow TTO. Thus, early inspiratory delivery increases efficiency of oxygen therapy. Small delays in response time are critical in nasal delivery but not important in TTO. Pulsed TTO is more efficient than continuous flow TTO and merits long-term studies.

A program for transtracheal oxygen delivery. Assessment of safety and efficacy

Over a 2-year period, the safety and efficacy of a program specifically designed for transtracheal oxygen therapy were evaluated in 100 patients with chronic hypoxemia. The four clinically defined phases of the program included patient orientation, evaluation, and selection (phase I); a new needle-wire guide-dilator transtracheal procedure and stent week (phase II); transtracheal oxygen delivery with an immature tract (phase III); and transtracheal oxygen delivery with a mature tract (phase IV). Sequelae and complications were minor, and patient acceptance was high. As compared with the nasal cannula, the transtracheal catheter was associated with a significant reduction in oxygen flow requirement during both rest and exercise. Adequate oxygenation was maintained over time, and erythrocythemia was alleviated with transtracheal delivery. We conclude that transtracheal oxygenation by this method has a low, acceptable morbidity; it is more efficient than nasal cannula delivery and may be more effective in some patients.

Transtracheal oxygen therapy for refractory hypoxemia

Eight patients with chronic severe and refractory hypoxemia were treated with a new transtracheal oxygen catheter. All patients demonstrated an arterial oxygen partial pressure of less than 55 mm Hg on high-flow nasal cannula therapy. Refractory hypoxemia was successfully treated in all eight patients following initiation of transtracheal oxygen therapy at 2.5 to 6.0 L/min. Arterial oxygen partial pressure was 50% greater and oxygen flow requirements were 72% less with transtracheal oxygen. There were no complications related to the procedure and oxygen flow rates up to 6 L/min were well tolerated. Although four patients died, four remain clinically stable with adequate oxygenation at up to 20 months' follow-up. All eight patients experienced an improvement in quality of life with transtracheal oxygen.

Bronchoalveolar lavage fluid neutrophils increase after corticosteroid therapy in smokers with idiopathic pulmonary fibrosis

Patients with idiopathic pulmonary fibrosis (IPF) are often cigarette smokers and are often being treated with corticosteroids at the time of bronchoalveolar lavage. We addressed the question of whether or not the bronchoalveolar lavage fluid (BALF) neutrophil content of patients with IPF undergoes changes in smokers different from those in nonsmokers after institution of corticosteroids. Eighteen patients were studied (10 smokers and 8 nonsmokers). Fourteen patients (6 smokers and 8 nonsmokers) were treated orally with prednisone. The histologic assessment of alveolar inflammation and inflammatory small airways disease was no different in smokers than in nonsmokers. None of the smokers treated with prednisone had pathologic evidence of emphysema in addition to IPF. Five of 6 smokers showed an increase in BALF neutrophils after 3 months of prednisone (p less than 0.05), whereas the nonsmokers' BALF neutrophils decreased or remained unchanged. This increase in BALF neutrophils in smokers was not associated with concomitant or subsequent clinical deterioration but, in fact, with clinical improvement after 3 months of therapy. These data indicate that the combination of cigarette smoking and corticosteroid therapy influences the BALF neutrophil content in patients with IPF and suggest that interval changes in BALF neutrophil content may not reflect the status of the inflammatory process or structural derangements in the lungs of some patients with IPF.

Demand and continuous flow intermittent mandatory ventilation systems

A mechanical lung was used to evaluate the pressure and flow characteristics of four demand and two continuous flow intermittent mandatory ventilation (IMV) systems. The amount of negative pressure required to initiate inspiratory flow and peak expiratory resistance were measured. The inspiratory pressure required to initiate flow in the demand mode was also compared to pressures generated in the assist mode. In addition, the peak expiratory resistance was measured with four commercially available exhalation valves. Results showed that the ventilator manometer measuring internal machine pressures significantly underestimated the amount of negative pressure required to open the demand valve (p less than 0.01). There are major differences in the flow and pressure characteristics among demand and continuous flow IMV systems. Systems that impose high inspiratory elastic threshold loads and expiratory flow resistive loads may have a deleterious effect on the mechanics of breathing, and thereby limit weaning success and eventually impair the recovery of certain patients in respiratory failure. The basic methodology, especially the simple technique of inserting an aneroid manometer in line next to a patient's ET tube, for measuring proximal negative inspiratory force (NIF test) can be easily applied to any and all ventilators at any practitioner's individual institution.

The potential role of respiratory therapy equipment in cross infection. A study using a canine model for pneumonia

Experimental Pseudomonas aeruginosa pneumonia was induced in 8 dogs that had radiation-induced leukopenia. Three dogs were supported by mechanical ventilation (MV), 3 received continuous heated aerosol therapy (CHAT), and 2 did not receive respiratory therapy and served as control animals. The animals were studied in a carefully controlled environment until they succumbed to infection or they were killed at 24 h. An air sampler was used to collect exhaled P. aeruginosa aerosols at distances as far as 15 feet from the dogs at multiple time intervals. Water condensate in the tubing of MV and CHAT equipment was collected and cultured at the same intervals. Results showed that all dogs had multilobar P. aeruginosa pneumonia at necropsy. Control dogs did not exhale aerosols containing P. aeruginosa. Animals that were supported by MV, exhaled contaminated aerosols, but organisms could not be recovered at distances greater than 2 feet. In contrast, aerosols containing P. aeruginosa were recovered at distances as far as 15 feet from the animals receiving CHAT. Furthermore, as much as 1L of water condensate was collected in a 24-h period from tubing associated with MV and CHAT. Although the nebulizers and humidifiers remained sterile, tubing condensate was contaminated with as much as 10(7) colony-forming units per ml of P. aeruginosa in 5 of the 6 animals receiving either MV or CHAT. Contamination of tubing by P. aeruginosa was present as early as 8 to 12 h. This study identifies potential sources for cross infection through an airborne route for CHAT or from direct contact with contaminated tubing.

Vocal-cord dysfunction presenting as asthma

We identified five patients with a functional disorder of the vocal cords that mimicked attacks of bronchial asthma. Paroxysms of wheezing and dyspnea were refractory to standard therapy for asthma. During episodes of wheezing, the maximal expiratory and inspiratory flow-volume relationship was consistent with a variable extrathoracic obstruction. Laryngoscopy confirmed that wheezing was due to adduction of the true and false vocal cords throughout the respiratory cycle. During asymptomatic periods the maximal flow-volume relationship and laryngoscopic examination were normal. Provocation tests for bronchial asthma were negative. A variety of personality styles and psychiatric diagnoses were represented; patients were not aware of the vocal-cord dysfunction, which uniformly and dramatically responded to speech therapy and psychotherapy. This syndrome may be a form of conversion reaction.

Breathing He-O2 shifts the lung pressure-volume curve of the dog

To determine whether breathing a mixture of 80% He-20% O2 affects the lung pressure-volume (PV) curve, eight anesthetized paralyzed dogs were studied in a volume-displacement plethysmograph. Static PV curves on air were compared with PV curves obtained after equilibration with He-O2. The He-O2 PV curves were significantly shifted upward by an average of 5% total lung capacity. There was no change in compliance, indicating that the shift was due to lung expansion rather than a change in elasticity. Pretreatment of the dogs with cyclooxygenase inhibitors abolished the PV shift with He-O2. Four dogs had PV curves recorded on air and a mixture of O2, SF6, and Ne, a gas mixture with the same density as air but with 45% greater viscosity. The PV curve shift was even greater than observed with He-O2 and could again be virtually abolished with a cyclooxygenase inhibitor. These results suggest that breathing a high-viscosity gas mixture results in alveolar duct dilatation due to the release of a prostaglandin bronchodilator. This may need to be taken into account in the analysis of flow augmentation with He-O2.

The effect of positive end-expiratory pressure on functional residual capacity: role of prostaglandin production

It has been shown that lung distension can generate prostaglandins. To test the hypothesis that there may be a prostaglandin-mediated peripheral (alveolar duct) bronchodilator effect contributing to the increase in functional residual capacity (FRC) observed with positive end-expiratory pressure (PEEP), we applied PEEP to 8 beagle dogs at 2, 5, 5, 7.5, and 10 cm H2O, and measured FRC at each level and immediately after cessation of PEEP. This experiment was then repeated after the intravenous administration of indomethacin 10 mg/kg. The results indicate a significant reduction of FRC (p less than 0.05) at 5, 7.5, and 10 cm PEEP after the administration of indomethacin. Furthermore, FRC initially failed to return to baseline immediately after cessation of PEEP but did so after indomethacin. We conclude that endogenous prostaglandin production of PEEP but did so after indomethacin. We conclude that endogenous prostaglandin production may be partially responsible for the elevation of FRC with PEEP.