The molecular interaction pattern of lenvatinib enables inhibition of wild-type or kinase-mutated FGFR2-driven cholangiocarcinoma

Fibroblast growth factor receptor (FGFR)-2 can be inhibited by FGFR-selective or non-selective tyrosine kinase inhibitors (TKIs). Selective TKIs are approved for cholangiocarcinoma (CCA) with FGFR2 fusions; however, their application is limited by a characteristic pattern of adverse events or evocation of kinase domain mutations. A comprehensive characterization of a patient cohort treated with the non-selective TKI lenvatinib reveals promising efficacy in FGFR2-driven CCA. In a bed-to-bench approach, we investigate FGFR2 fusion proteins bearing critical tumor-relevant point mutations. These mutations confer growth advantage of tumor cells and increased resistance to selective TKIs but remain intriguingly sensitive to lenvatinib. In line with clinical observations, in-silico analyses reveal a more favorable interaction pattern of lenvatinib with FGFR2, including an increased flexibility and ligand efficacy, compared to FGFR-selective TKIs. Finally, the treatment of a patient with progressive disease and a newly developed kinase mutation during therapy with a selective inhibitor results in a striking response to lenvatinib. Our in vitro, in silico, and clinical data suggest that lenvatinib is a promising treatment option for FGFR2-driven CCA, especially when insurmountable adverse reactions of selective TKIs or acquired kinase mutations occur.

Novel Adiponectin Receptor Agonist Inhibits Cholangiocarcinoma via Adenosine Monophosphate-activated Protein Kinase

BACKGROUND

Cholangiocarcinoma (CCA) has a poor prognosis and only limited palliative treatment options. The deficiency of adiponectin and adenosine monophosphate-activated protein kinase (AMPK) signaling was reported in several malignancies, but the alteration of these proteins in CCA is still unclear.

OBJECTIVES

This study aimed to assess the role of adiponectin and AMPK signaling in CCA. Furthermore, AdipoRon, a novel adiponectin receptor (AdipoR) agonist, was evaluated in vitro and in vivo as a new anti-tumor therapy for CCA.

METHODS

The expression of AdipoR1 and p-AMPKα in human tissue microarrays (TMAs) was evaluated by immunohistochemistry staining (IHC). The effect of 2-(4-Benzoylphenoxy)-N-[1-(phenylmethyl)- 4-piperidinyl]-acetamide (AdipoRon) was investigated in vitro with proliferation, crystal violet, migration, invasion, colony formation, senescence, cell cycle and apoptosis assays and in vivo using a CCA engineered mouse model (AlbCre/LSL-KRASG12D/p53L/L). RT-qPCR and western blot methods were applied to study molecular alterations in murine tissues.

RESULTS

AdipoR1 and p-AMPKα were impaired in human CCA tissues, compared to adjacent non-tumor tissue. There was a positive correlation between the AdipoR1 and p-AMPKα levels in CCA tissues. Treatment with AdipoRon inhibited proliferation, migration, invasion and colony formation and induced apoptosis in a time- and dose-dependent manner in vitro(p<0.05). In addition, AdipoRon reduced the number of CCA and tumor volume, prolonged survival, and decreased metastasis and ascites in the treated group compared to the control group (p<0.05).

CONCLUSIONS

AdipoR1 and p-AMPKα are impaired in CCA tissues, and AdipoRon effectively inhibits CCA in vitro and in vivo. Thus, AdipoRon may be considered as a potential anti-tumor therapy in CCA.

Adiponectin Receptor Agonist Effectively Suppresses Hepatocellular Carcinoma Growth

Hepatocellular carcinoma (HCC) is the second lethal cancer. Short overall survival, low five-year survival rate, and unimproved treatment efficacy urge the need to improve HCC prognosis. Adiponectin is key protector against cancer and hepatic abnormalities. Hypoadiponectinemia occurs in and promotes carcinogenesis and hepatic diseases. Adiponectin reactivation by different methods showed impressive effect against cancer and hepatic diseases. Recently, AdipoRon, an adiponectin receptor agonist, can interact with both Adiponectin receptors. AdipoRon showed promising anti-cancer effect in some cancers, but no study on HCC yet. The in vitro effect of AdipoRon on HCC was investigated by cell viability, migration, invasion, colony formation and apoptosis assays. The signalling alteration was determined by RT-qPCR and Western blot. The effect of treatment was interpreted by comparison between treatments and control. The difference between two cell lines was relatively compared. Our results showed significant in vitro anti-cancer effect of AdipoRon via AMPK- and dose-dependent manner. Huh7 cells showed a lower level of AdipoR1/2 and a superior proliferation and aggressiveness, compared to Hep3B. In addition, Huh7 cells were more sensitive to AdipoRon treatment (lower IC50, less cell growth, migration, invasion and colonies upon AdipoRon treatment) than Hep3B cells. In conclusion, AdipoRon effectively inhibited HCC growth and invasiveness in vitro. The deficient expression of adiponectin receptors affects efficacy of AdipoRon and aggressiveness of HCC cells.

The diagnostic and prognostic value of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio on gastric cancer patients

Gastric cancer (GC) is the remaining concern of cancer-associated health burden. Valuable predictive and prognostic indicators support the early diagnosis and improve outcome. Immune escape and inflammation are important cancer hallmarks. The prognostic and diagnostic value of platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) was reported in some cancers. But these cheap and convenient indexes are far from clinical use. Thus, investigation the alteration of those index on GC is needed to impose the use of those indexes in clinic. The study recruited seventy-seven hospitalized patients newly diagnosed with GC and 90 healthy individuals. The clinical and preclinical data of participants were collected from Hospital Information Management system. This study were approved by the Ethical Committee, Vietnam Military Medical University. The data were analyzed on STATA version 14.0 and GraphPad Prism 8.0. The alteration of immunological system was reported by significantly higher white blood cell count, neutrophils, platelets, PLR, and NLR as well as decreased lymphocytes on GC, compared to healthy individuals. Those indexes were elevated on advanced stage GC, compared to early stage GC. Our receiver operating characteristic curve analysis showed the significant specificity and sensitivity of PLR (cutoff 135.0) and NLR (cutoff 2.0) on GC diagnosis with respective area under receiver operating characteristic curve of 84.74% and 85.17%, P < .0001. Besides, our results reported the tendency of increased PLR and NLR and short time from clinical signs to being diagnosed. PLR and NLR have significant specificity and sensitivity in diagnosis and prognosis of GC.

The safety of CAR-T cells and PD-1 antibody combination on an experimental model

Chimeric antigen receptor (CAR) T cells and PD-1 antibodies (PD-1 Ab) are emergent immunotherapies with unprecedented efficacy. The presence of PD-1 on T cells contributes to hypofunction of CAR-T therapy and inhibition of PD-1 enhances anti-cancer effect of CAR-T cells. Therefore, the combination of CAR-T cells and PD-1 antibody is a promissing strategy for cancer treatment. This study aims to establish our in-house CAR-T cells and evaluate the safety of CAR-T cells in combination with PD-1 antibody in animals. The toxicity of CD19-CAR-T cells was examined using Swiss Webster mice. Four mouse groups were treated with control, CAR-T, PD-1 antibody or CAR-T + PD-1 antibody. Mice's overall status was monitored and recorded. At the end-point, hematological and biochemical indices were quantified, histopathology of liver and kidney was evaluated by pathologists. The relative abnormal ratio and absolute values were compared between groups. We generated our in-house CAR-T cells and used them for safety evaluation in mice. The increase in mouse weight was observed in all groups after treatment and the weight was comparable between groups. The hematological, biochemical and histopathological parameters were equivalent between groups, except for liver grain degeneration occurred in treatment groups. Thus, CAR-T cells, PD-1 Ab and their combination were safe in mice. We successfully produced our in-house CAR-T cells and the combination of our CAR-T cells and PD-1 antibody was safe in mice with comparable values of hematopoietic indices, liver and kidney functions. Longer follow-up might be necessary to evaluate their effect on the liver.

Cholangiocarcinoma Therapeutics: An Update

BACKGROUND

Cholangiocarcinoma (CCA) is the second most common hepatobiliary cancer and associated with a poor prognosis. Only one-third of CCA cases are diagnosed at operable stages. However, a high rate of relapse has been observed postoperatively. Besides screening for operable individuals, efficacious therapeutic for recurrent and advanced CCA is urgently needed. The treatment outcome of available therapeutics is important to clarify clinical indication and facilitate the development of treatment strategies.

OBJECTIVE

This review aims to compare the treatment outcome of different therapeutics based on both overall survival and progression-free survival.

METHODS

Over one hundred peer-reviewed articles were examined. We compared the treatment outcome between different treatment methods, including tumor resection with or without postoperative systematic therapy, chemotherapies including FOFLOX, and targeted therapies, such as IDH1, K-RAS, and FGFR inhibitors. Notably, the scientific basis and outcome of available treatment methods were compared with the standard first-line therapy.

RESULTS

CCAs at early stages should firstly undergo tumor resection surgery, followed by postoperative treatment with Capecitabine. Chemotherapy can be considered as a preoperative option for unresectable CCAs. Inoperable CCAs with genetic aberrances like FGFR alterations, IDH1, and KRAS mutations should be considered with targeted therapies. Fluoropyrimidine prodrug (S-1)/Gemcitabine/Cisplatin and nab-Paclitaxel/Gemcitabine/Cisplatin show favorable outcome which hints at the triplet regimen to be superior to Gemcitabine/Cisplatin on CCA. The triplet chemotherapeutic should be tested further compared to Gemcitabine/Cisplatin among CCAs without genetic alterations. Gemcitabine plus S-1 was recently suggested as the convenient and equivalent standard first-line for advanced/recurrent biliary tract cancer.

CONCLUSION

This review provides a comparative outcome between novel targeted therapies and currently available therapeutics.

Targeting interleukin 6 signaling by monoclonal antibody siltuximab on cholangiocarcinoma

BACKGROUND AND AIM

Cholangiocarcinoma has an unimproved prognosis. Interleukin 6 (IL-6) has an oncogenic potential in some cancer diseases. However, the role of IL-6 in cholangiocarcinoma carcinogenesis is not well understood. The current study investigated the role of IL-6 signaling in cholangiocarcinoma carcinogenesis and efficacy of siltuximab treatment on cholangiocarcinoma in vitro and in vivo.

METHODS

The expression of IL-6 was analyzed on human cholangiocarcinoma cell lines and murine and human cholangiocarcinoma tissues, using reverse transcription real-time polymerase chain reaction and immunohistochemistry. In addition, the effect of anti-IL-6 chimeric monoclonal antibody, siltuximab, was investigated in vitro by proliferation, migration, and two-dimensional and three-dimensional invasion assays and in vivo by xenograft mouse model. Western blot was applied to study the molecular alteration.

RESULTS

Our result shows high expression of IL-6 in human cholangiocarcinoma cells, and IL-6 stimulants enhance cholangiocarcinoma cell proliferation. In addition, murine and human cholangiocarcinoma tissues express significantly higher levels of IL-6, compared with adjacent non-tumor tissues. On the cholangiocarcinoma engineered mouse model, IL-6 level is associated with tumor volume. Taken together, our data indicate an oncogenic potential of IL-6 in cholangiocarcinoma carcinogenesis. Siltuximab sufficiently abrogates IL-6 signaling and inhibits cholangiocarcinoma progression in vitro and in vivo. The results additionally indicate a relative alteration of IL-6 signaling and its molecular targets, such as STAT3, Wnt/β-catenin, and mesenchymal markers.

CONCLUSIONS

Interleukin 6 plays an essential role in cholangiocarcinoma carcinogenesis, and siltuximab has the potential to be considered as a new treatment option for cholangiocarcinoma patients.

Hypoxia induced Sonic Hedgehog signaling regulates cancer stemness, epithelial-to-mesenchymal transition and invasion in cholangiocarcinoma

Aberrant activation of Sonic Hedgehog (SHH) pathway has been implicated in a variety of cancers including cholangiocarcinoma (CC); however, the influencing factors are still unknown. Additionally, intratumoral hypoxia is known to contribute towards therapeutic resistance through modulatory effects on various pathways. In this study, we investigated the relationship between hypoxia and SHH pathway activation and the effect of this interplay on cancer stemness and epithelial-to- mesenchymal transition (EMT) during cholangiocarcinogenesis. Hypoxia promoted SHH pathway activation, evidenced by upregulated SHH and SMO levels, and enhanced glioma-associated oncogene homolog 1 (GLI1) nuclear translocation; whereas silencing of HIF-1α impaired SHH upregulation. Hypoxia also enhanced the expression of cancer stem cell (CSC) transcription factors (NANOG, Oct4, SOX2), CD133 and EMT markers (N-cadherin, Vimentin), thereby supporting invasion. Cyclopamine treatment suppressed hypoxia induced SHH pathway activation, consequently reducing invasiveness by downregulating the expression of CSC transcription factors, CD133 and EMT. Cyclopamine induced apoptosis in CC cells under hypoxia, suggesting that hypoxia induced activation of SHH pathway has modulatory effects on CC progression. Therefore, SHH signaling is proposed as a target for CC treatment, which is refractory to standard chemotherapy.

Silencing of Kangai 1 C-terminal interacting tetraspanin suppresses progression of cholangiocarcinoma

Cholangiocarcinoma (CC) is the second most common primary hepatic malignancy. CC treatment options are very limited especially for patients with distant metastasis. Kangai 1 C-terminal interacting tetraspanin (KITENIN) is highly expressed in numerous cancers, but the role of KITENIN in CC remains unknown. Here, we have investigated for the first time the function of KITENIN in human CC cell lines (TFK-1, SZ-1), tissues and a CC mouse model (Alb-Cre/LSL-KRAS^G12D/p53^L/L). KITENIN was expressed in 92.2% of human CC tissues, in murine CC samples and also in human CC cell lines. Knockdown of KITENIN by small interfering RNA (siRNA) effectively reduced proliferation, migration, invasion and colony formation in both intra- and extra-hepatic CC cells. The expression of epithelial-mesenchymal transition (EMT) markers like N-cadherin, Vimentin, Snail and Slug were suppressed in KITENIN knockdown CC cells. Our results indicate that KITENIN is crucial for cholangiocarcinogenesis and it might become a potential therapeutic target for human CC treatment.

Effect of AdipoR agonist in cholangiocarcinoma

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Background: Adiponectin is the key adipokine, which plays an important role in health and disease such as obesity, diabetes, and cancer. Adiponectin is reduced in different tumor types, especially in obesity-related cancer, and recent studies showed that Adiponectin had a potential anti-cancer effect. Obesity is a risk factor for various tumor diseases including cholangiocarcinoma (CC), the second most common primary hepatic cancer. The aim of this study is to investigate for the first time the anti-cancer effect of AdipoR agonist in CC cell lines and a CC engineered mouse model. Methods: Human CC cell lines (TFK-1 and SZ-1) and CC engineered mice (Alb-Cre/KRASG12D/p53L/L) were used to investigate the anti-cancer effects of an AdipoR agonist (2-(4-Benzoylphenoxy)-N-[1-(phenylmethyl)-4-piperidinyl]-acetamide). Cell proliferation, migration, invasion, colony formation, apoptosis assay were applied to evaluate the effect of AdipoR agonist in vitro. In addition, important cancer signalling pathways and targets were analysed by Western Blot. Mice (n = 12) were treated with AdipoR or verhicle and tumor burden and survival were monitored. Results: AdipoR agonist suppressed proliferation, migration, invasion, colony formation and apoptosis in CC cells. AdipoR agonist regulated the expression of different proteins such as EMT markers, pAMPK, pSTAT3, and PARP, which have pivotal functions in cholangiocarcinogenesis. AdipoR agonist also prolonged survival time in a CC engineered mouse model. Conclusions: Our data revealed that AdipoR agonist inhibited successfully cell proliferation, migration, invasion, colony formation and apoptosis in vitro, and prolonged mice survival in vivo through regulation of crucial signaling pathways in cholangiocarcinogenesis. These results suggested that AdipoR agonist might become a new potential candidate for CC treatment in the future.

Gamma-Secretase Inhibitor IX (GSI) Impairs Concomitant Activation of Notch and Wnt-Beta-Catenin Pathways in CD44+ Gastric Cancer Stem Cells

Cancer stem cells (CSC) are associated with tumor resistance and are characterized in gastric cancer (GC). Studies have indicated that Notch and wnt-beta-catenin pathways are crucial for CSC development. Using CD44⁺ CSCs, we investigated the role of these pathways in GC carcinogenesis. We performed cell proliferation, wound healing, invasion, tumorsphere, and apoptosis assays. Immunoblot analysis of downstream signaling targets of Notch and wnt-beta-catenin were tested after gamma-secretase inhibitor IX (GSI) treatment. Immunohistochemistry, immunofluorescence, and Fluorescence activated cell sorting (FACS) were used to determine CD44 and Hairy enhancer of split-1 (Hes1) expression in human GC tissues. CD44⁺ CSCs were subcutaneously injected into NMR-nu/nu mice and treated with vehicle or GSI. GC patients with expression of CD44 and Hes1 showed overall reduced survival. CD44⁺ CSCs showed high expression of Hes1. GSI treatment showed effective inhibition of cell proliferation, migration, invasion, tumor sphere formation of CD44⁺ CSCs, and induced apoptosis. Importanly, Notch1 was found to be important in mediating a crosstalk between Notch and wnt-beta-catenin in CD44⁺ CSCs. Our study highlights a crosstalk between Notch and wnt-beta-catenin in gastric CD44⁺ CSCs. Expression of CD44 and Hes1 is associated with patient overall survival. GSI could be an alternative drug to treat GC. Stem Cells Translational Medicine 2017;6:819-829.

Telomerase in alveolar epithelial development and repair

Telomerase expression and activity were examined in the developing lung and in the adult lung during repair after injury. Both whole lung tissue and primary cultures of type 2 alveolar epithelial cells (AEC2) isolated from fetal and adult rodents were analyzed for 1) telomerase expression by immunohistochemistry and 2) telomerase activity with a telomerase repeat amplification protocol. We found that telomerase was expressed in a temporally regulated manner in fetal lung through the late stages of gestation, with peak expression just before birth. Expression persisted for a brief period in neonates, then decreased to nearly undetectable levels by postnatal day 9. Telomerase expression and activity were reinduced in normally quiescent adult lung by in vivo treatment with hyperoxia. In populations of AEC2 isolated from both developing and repairing lungs, telomerase expression and activity showed a strong correlation with the proliferation marker proliferating cell nuclear antigen. It has been suggested that telomerase expression and activity are hallmarks of stem or progenitor cells. Our observations suggest that a telomerase-positive subpopulation is present within the general AEC2 population. Telomerase may act as a marker for the proliferative status of this subpopulation.

Extracorporeal membrane oxygenation for cardiac support in pediatric patients

Extracorporeal membrane oxygenation (ECMO) has been used for pediatric cardiac support in settings of expected mortality due to severe myocardial dysfunction. We reviewed the records of 34 children (<18 years) placed on ECMO between March 1995 and May 1999. Demographic, cardiac, noncardiac, and outcome variables were recorded. Data were subjected to univariate analysis to define predictors of outcome. Eighteen patients were placed on ECMO after cardiac surgery (Group A); seven of 18 were weaned off ECMO, and four survived to discharge (22%). Thirteen patients were placed on ECMO as a bridge to cardiac transplantation (Group B), six of 13 received a heart transplant, one recovered spontaneously, and six survived to discharge (46%). Three patients were placed on ECMO for failed cardiac transplantation while awaiting a second transplant (Group C); one recovered graft function, two received a second heart transplant, and two of three survived (66%). The primary cause of death was multiorgan system failure (68%). Group A patients supported on ECMO for more than 6 days did not survive. Mediastinal bleeding complications and renal failure requiring dialysis were associated with nonsurvival. We conclude that ECMO as a bridge to cardiac transplant was more successful than ECMO support after cardiotomy. Mediastinal bleeding and renal failure were associated with poor outcome. Recovery of cardiac function occurred within the first week of ECMO support if at all. Longer support did not result in survival without transplantation.

Comparison of intratracheal pulmonary ventilation and hybrid intratracheal pulmonary ventilation with conventional mechanical ventilation in a rabbit model of acute respiratory distress syndrome by saline lavage

OBJECTIVES

To study changes in PaCO2 and PaO2 during intratracheal pulmonary ventilation (ITPV) and hybrid intratracheal pulmonary ventilation (h-ITPV) compared with conventional mechanical ventilation (CMV) in a rabbit model of respiratory failure, and to define the technique of h-ITPV that combines conventional mechanical ventilation and ITPV.

DESIGN

Prospective, interventional study.

SUBJECTS

Twelve adult New Zealand White rabbits.

INTERVENTIONS

Surfactant deficiency was induced by saline lavage, and rabbits were randomized to either ITPV or h-ITPV. The study consisted of four phases: phase 0, CMV after saline lavage, ventilator rate 30 breaths/min; phase I, ITPV or h-ITPV initiated at the same pressure and rate as in phase 0; phase II, ITPV or 1.0 L/min h-ITPV bias flow, with peak inspiratory pressure (PIP) decreased and ventilator rate increased to achieve the lowest tidal volume while maintaining adequate gas exchange; and phase III, animals returned to CMV.

MEASUREMENTS AND MAIN RESULTS

In phase I, no difference in PaCO2 was observed between ITPV, h-ITPV, or CMV. There was a decrease in PaO2 when switching from CMV to ITPV but not to h-ITPV. In phase II, it was possible to decrease PIP (average of 37% for ITPV and 36% for h-ITPV) and tidal volume (average of 64% for ITPV and 53% for h-ITPV) without compromising gas exchange (p < .05). Oxygenation tended to improve from phase 0 to the end of phase II. In phase III, PaCO2 increased (average of 71% for ITPV and 79% for h-ITPV) and pH decreased (p < .05). Normocapnia was achieved using significantly higher PIP and tidal volume, compared with phase 0 (p < .05).

CONCLUSIONS

ITPV and h-ITPV can effectively ventilate and oxygenate rabbits with surfactant-deficient lungs at tidal volumes and therefore pressures lower than required with CMV. Maximum benefit appears to occur at high ventilator rates. These findings suggest that both modes of ventilation may represent powerful new tools in the management of patients with acute respiratory failure. (Crit Care Med 2000; 28:774-781)

Comparison of intratracheal pulmonary ventilation with hybrid intratracheal pulmonary ventilation in a rabbit model of acute respiratory distress syndrome by saline lavage

We compared different hybrid mode ITPV (h-ITPV) flow rates, and h-ITPV with intratracheal pulmonary ventilation (ITPV) with respect to CO2 clearance and oxygenation. Surfactant deficiency was induced in six adult rabbits with saline lavage. The study consisted of three phases. Phase 0: Stabilization on conventional mechanical ventilation (CMV). Phase I: Bias flow initiated at same pressure and respiratory rate as Phase 0. Flow rates of 25%, 50%, 75% h-ITPV, and ITPV were initiated. Animals were transitioned from CMV to 25% h-ITPV proceeding sequentially to ITPV or vice versa. Phase II: Animals were returned to CMV. Statistical analysis included the two-way analysis of variance (ANOVA) and repeated measures ANOVA with Tuckey's test. No difference in PaCO2 was observed among all h-ITPV flow rates or between h-ITPV and ITPV. After bias flow was introduced (transition from Phase 0 to Phase I), PaCO2 decreased by 37%. PaCO2 increased by 119% during Phase II. Oxygenation improved in all animals, particularly in those transitioned to 25% h-ITPV and proceeding to ITPV. No difference in CO2 clearance between ITPV and h-ITPV was observed. Even at low bias flows, excellent CO2 clearance was achieved. Oxygenation was superior when animals were transitioned from CMV to h-ITPV. Hybrid-ITPV offers some advantages over ITPV and may represent a powerful tool in the management of acute respiratory distress syndrome (ARDS).

Reduction of respiratory system resistance of rabbits with surfactant deficiency using a novel ultra thin walled endotracheal tube

The ultra thin walled, two-stage endotracheal tube (UTW-TS-ETT) is very flexible, nonkinking, and has a widened extralaryngeal portion. The UTW-TS-ETT has a greater ID/OD (internal diameter/outer diameter) ratio than a comparable standard endotracheal tube (ST-ETT) because of its thinner wall: 0.2-0.25 mm in UTW-TS-ETT, compared to 0.55-0.8 mm in ST-ETT. The authors hypothesized that in an animal model of lung disease, significant reductions in respiratory system resistance (Rrs) of 30-40% would be achieved using the UTW-TS-ETT, compared to Rrs achieved with the comparable ST-ETT. This study compared the pulmonary mechanics of rabbits (N = 17, body weight 3.4-4.7 kg) before and after induction of surfactant deficiency, using either ST-ETT (OD 4.9 mm, ID 3.5 mm) or UTW-TS-ETT (OD 5.0 mm, ID 4.6 mm). Animals were sedated, paralyzed, and ventilated by an ETT placed through a tracheotomy incision. Surfactant deficiency was induced by lavaging the lungs with normal saline (10 ml/kg). Pulmonary mechanics were measured on identical ventilator settings for each ETT used at baseline and at 45 min after lavage. Compared to ST-ETT, UTW-TS-ETT reduced Rrs by 50.6 +/- 8.7% in normal lungs (significantly more than 40%; p < 0.01), and by 41.47 +/- 16.2% in surfactant deficient lungs (significantly more than 30%; p < 0.05). Tidal volume increased with UTW-TS-ETT in all animals but did not achieve statistical significance. The UTW-TS-ETT did not induce significant changes in respiratory system compliance, PaO2, PaCO2, or pH. It is concluded that UTW-TS-ETT significantly reduces Rrs in rabbits with either normal lungs or with surfactant deficient lungs. This novel ETT may be beneficial for ventilated patients with increased Rrs, by effecting a decrease in Rrs and thus reducing the work of breathing and improving ventilation efficiency.

Dynamics of TGF-beta 3 peptide activity during rat alveolar epithelial cell proliferative recovery from acute hyperoxia

Hyperoxia causes a reproducible pattern of lung injury and recovery, characterized by proliferation of type II alveolar epithelial cells (AEC2) during the recovery phase. We measured TGF-beta peptide production by AEC2 and macrophages from lungs of adult male rats exposed to 100% oxygen for 48 h and then allowed to recover for up to 72 h in room air. TGF-beta peptide activity levels were measured using the PAI-1 promoter-luciferase mink lung epithelial cell assay and characterized with peptide specific inhibitory antibodies. Control AEC2 produced 997 +/- 54 pg active TGF-beta x 10(6) cells-1.24h-1 (mean +/- SD), of which > 70% was TGF-beta 3, while cultured macrophages produced 58 +/- 17 pg active TGF-beta x 10(6) macrophages-1.24 h-1, > 80% of which was TGF-beta 1. During hyperoxia and recovery, active TGF-beta 3 production by AEC2 decreased by 75%, with a nadir at 24 h recovery (P < 0.005). In contrast, TGF-beta peptide activity increased from undetectable levels in lung lavage from control rats to a peak of 1,470 +/- 743 pg/rat after 48 h oxygen exposure and 24 h recovery, while lavaged macrophage TGF-beta production in culture also increased threefold to a peak of 150 +/- 5 pg. 10(6) cells-1. 24 h-1 after 48 h oxygen exposure (P < 0.005). The nadir of active TGF-beta 3 production by AEC2 coincided with the peak of the AEC2 proliferative phase of repair as determined by BrdU incorporation and FACS analysis of freshly isolated AEC2. We conclude that active TGF-beta 3 production by AEC2 is dynamically downregulated during the proliferative phase of recovery from acute hyperoxic injury in rat. We speculate that decreased autocrine negative regulation of AEC2 proliferation by TGF-beta 3 may facilitate AEC2 proliferation during recovery from acute hyperoxic injury.

Cell cycle arrest in G0/G1 phase by contact inhibition and TGF-beta 1 in mink Mv1Lu lung epithelial cells

We postulated that contact inhibition and transforming growth factor (TGF)-beta 1 may target the same molecules to negatively regulate the Mv1Lu cell cycle in G0/G1. Both contact inhibition and TGF-beta 1 suppressed the expression of a 45-kDa protein (p45); cyclins D2 and B1; cyclin-dependent protein kinase (Cdk)-4, Cdc-2, and Cdc-2-associated activity; and the phosphorylation of retinoblastoma tumor-suppressor protein (pRb) but did not affect the expression of cyclins D1, E, and A or the expression of Cdk-2 and Cdk-5. Expression of p45 reappeared 12 h after release from contact inhibition and 6-8 h after release from TGF-beta 1, while TGF-beta 1 prevented release from contact inhibition and maintained suppression of both p45 and cyclin D2. Additionally, cyclin D2 phosphorylation and its associated kinase activity were strongly inhibited by contact inhibition and TGF-beta 1. Thus suppression of p45, cyclin D2/Cdk-4, and cyclin B1/Cdc-2 expression and/or activities is targeted both by contact inhibition and by TGF-beta 1 and may define common mechanisms through which these negative growth signals are integrated.

Intratracheal pulmonary ventilation versus conventional mechanical ventilation in a rabbit model of surfactant deficiency

Intratracheal pulmonary ventilation (ITPV) enhances the clearance of CO2 from dead space and lungs by a bias flow of gas administered in the distal trachea. ITPV flow is continuously administered through a separate catheter placed within an endotracheal tube (ETT). After exiting from catheter's tip in the distal trachea, the flow of gas is redirected outward away from the lungs. We hypothesized that, compared with conventional mechanical ventilation (CMV), ITPV may increase minute CO2 clearance (VCO2), reduce the partial pressure of CO2 dioxide in arterial gas (PaCO2), and reduce distal tracheal peak inspiratory pressure (dPIP). We induced surfactant deficiency in 15 adult rabbits by lung lavage with 10 mL/kg normal saline. Animals were ventilated through a double-lumen 4.0 ETT, inserted through a tracheotomy incision. dPIP, distal positive end expiratory pressure, and distal mean airway pressure were monitored, and the mean exhaled CO2 concentration was measured. For ventilator rates (respiratory rate) of 30, 45, and 70 breaths/min, the study included two phases: phase I compared CO2 clearance and PaCO2 between ITPV and CMV using similar ventilatory pressures; phase II evaluated the effectiveness of ITPV in reducing dPIP and tidal volume (Vt), compared with CMV, while maintaining eucapnea. When comparing ITPV and CMV, the following results (mean +/- SD) were achieved at respiratory rate of 30, 45, and 70 breaths/min, respectively. Phase I ITPV resulted in mean percent reduction of PaCO2 by 31.4 +/- 10%, 37.1 +/- 9.7% and 38.3 +/- 9%; mean percent increase in VCO2 by 61.3 +/- 29%, 56 +/- 23, and 98 +/- 40%, compared with CMV. Phase II ITPV resulted in mean percent reduction of dPIP by 35.5 +/- 14%, 38 +/- 10.8%, and 37.2 +/- 13.7%, and mean percent reduction in Vt by 34.7 +/- 12.9%, 36.4 +/- 15%, and 52.7 +/- 10.7%, compared with CMV. The changes in PaCO2, VCO2 (phase I), and dPIP and Vt (phase II) were all significantly more than 25% (p < 0.05). Oxygenation and pH were not significantly different between ITPV and CMV. We conclude that, in a surfactant deficiency rabbit model, ITPV is an efficient mode of assisted ventilation that increases CO2 clearance and reduces ventilator pressures required for adequate ventilation. We speculate that ITPV can minimize lung barotrauma associated with mechanical ventilation.

Induction of A- and D-type cyclins and cdc2 kinase activity during recovery from short-term hyperoxic lung injury

Hyperoxia causes a reproducible pattern of lung injury and repair in rodents, in which proliferation of alveolar epithelial cells (AEC) and fibroblasts is observed during recovery. We postulated that if quiescent cells are stimulated to reenter the cell cycle, then cyclin expression and cyclin-dependent protein kinase activity would be reactivated in AEC during the repair process after hyperoxic lung injury. To test this hypothesis, we exposed adult rats to short-term hyperoxia, followed by recovery for various times in room air. Cellular proliferation in vivo was confirmed by 1) flow cytometric analysis of DNA content (FACS) of freshly isolated AEC and 2) immunohistochemistry of proliferating cell nuclear antigen (PCNA) and bromodeoxyuridine (BrdU) incorporation into DNA on lung sections. The percentage of freshly isolated AEC in S phase and G2/M phase on FACS analysis increased twofold to a maximum of 16.5%, after 48 h in 100% oxygen and 48 h recovery in air. Cyclins A and D and p34cdc2 protein expression were also increased during the recovery period; while p33cdk2 and p34cdk4 increased only slightly. p34cdc2 histone H1 kinase activity, both in whole lung and in AEC, decreased initially after 48 h in oxygen. However, a marked increase in p34cdc2 kinase activity was observed at 48 h recovery in whole lung and returned to baseline by 72 h. In isolated and cultured AEC, p34cdc2 kinase activity was maximal at 24 h of recovery in air. We conclude that cyclins A and D and p34cdc2 protein expression and p34cdc2 kinase activity are increased in vivo during recovery from hyperoxic lung injury in both adult rat lungs and in AEC isolated from these lungs. We speculate that the induction of cyclin-dependent protein kinase activity is a key event in mediating the proliferative cellular repair response to lung injury.

Differential expression of cyclin D2 and cdc2 genes in proliferating and nonproliferating alveolar epithelial cells

Alveolar epithelial cells (AEC) proliferate during embryonic and fetal life, while in the adult lung AEC form a highly differentiated population that does not usually divide. Herein, we tested the hypothesis that differential expression of specific cell cycle control genes may occur during AEC development and transformation. We compared normal rat AEC in primary culture with transformed AEC for the expression of D-type G1 cyclins and cyclin-dependent protein kinases (cdc2 and cdk2). Cyclin D1 mRNA and protein were expressed at comparable levels in both normal rat AEC and in transformed AEC. In contrast, high levels of cyclin D2 mRNA and protein expression were only observed in normal 19-day fetal rat AEC and in transformed mink Mv1Lu cells derived from fetal mink lung epithelium. Moreover, treatment either with antisense oligodeoxynucleotides directed against cyclin D2 mRNA or with genistein (a tyrosine kinase inhibitor) caused significant inhibition of [3H]thymidine incorporation into DNA as well as inhibition of cyclin D2 expression in normal 19-day fetal rat AEC. p34cdc2 (but not p33cdk2 or p34cdk4) was expressed at progressively decreasing levels with corresponding histone H1 kinase activities during rat AEC development (19-day fetal > 21-day fetal > 13-day postnatal > adult rat AEC). The levels of p34cdc2 histone H1 kinase activity were significantly up-regulated or amplified in adult rat type 2 AEC following hyperoxic injury and repair and in transformed AEC. Collectively, these data support an important functional role for cyclin D2 and cdc2 genes in determining the proliferative versus nonproliferative phenotype of AEC during lung development, injury and repair, and transformation.

Cell cycle-dependent expression of cyclin D1 and a 45 kD protein in human A549 lung carcinoma cells

Cyclin D1, which is suggested to have a role in G1 control during the cell cycle, is genetically linked to BCL-1 and is widely overexpressed in parathyroid, breast, and squamous cancer cells. We postulated that cyclin D1 regulation may also be important in lung cancer. Therefore, we characterized the cell cycle-dependent expression of cyclin D1 at both mRNA and protein levels in synchronized human A549 lung carcinoma cells. Monospecific anti-cyclin D1 C-terminal peptide antibodies recognized both p36cyclinD1 and an as-yet uncharacterized 45 kD protein (p45). A549 cells were synchronized with well-studied drugs. Cyclin D1 mRNA expression remained relatively constant, with less than a twofold fluctuation during the cell cycle and with a minor peak at M phase. However, the p36cyclinD1 protein fluctuated during the A549 cell cycle and was expressed at very low levels in late G1 and at the G1/S boundary, but then increased in S phase and peaked at M phase. In contrast, p45 protein was expressed at relatively high levels in late G1 and reached maximal levels at the G1/S boundary, was expressed at decreased levels in S phase, and then had disappeared by M phase. Moreover, p45 was highly expressed only in transformed alveolar epithelial cells, but not in normal rat alveolar epithelial cells or fetal rat lung fibroblasts in primary cultures. In mink Mv1Lu cells, the expression of p45 was totally blocked by transforming growth factor-beta 1 treatment or contact inhibition. p45 protein was phosphorylated on serine, threonine, and tyrosine residues in A549 cells in culture. The phosphorylation of the p45 protein was cell cycle-regulated and reached its maximal levels at G2/M phase. The p45 protein had a different peptide map from p36cyclinD1 after cleavage with N-chlorosuccinimide. Immunoprecipitation studies showed that p45 was also anti-ubiquitin immunoreactive during the cell cycle. We conclude that p36cyclinD1 and the p45 protein are differentially regulated in a cell cycle-dependent manner in A549 cells. Although p45 is antigenically related to p36cyclinD1, it is probably not a closely cyclin-related protein. We speculate that p45 may be associated with malignant transformation and may play a distinct role from p36cyclinD1 in regulation of the cell cycle in A549 cells.

Predictors of Neonatal Mortality in 1,500–1,999 g Premature Infants with Respiratory Failure

Despite the introduction of new ventilation techniques and surfactant therapy, some premature infants still experience severe respiratory failure and either die or survive with severe bronchopulmonary dysplasia. Extracorporeal membrane oxygenation is currently not offered for preterm infants with a birth weight less than 2,000 g, mainly because of the potential high risk for intracranial hemorrhage. The aim of this study was to determine risk predictors for mortality alone and for mortality or major lung morbidity in 1,500-1,999 g premature infants with respiratory failure. We reviewed the medical records of all preterm infants (n = 459) with respiratory failure and a birth weight of 1,500-1,999 g treated at five medical centers from 1989 to 1991. Of those infants, 23 (5%) had severe respiratory failure, defined as a requirement for ventilatory support with the fraction of inspired oxygen > or = 0.8 or peak inspiratory pressure > or = 30 cmH2O for > or = 3 hr in the 1st week of life. A mortality of > or = 75% was associated with a single arterial/alveolar oxygen ratio < or = 0.04; pulmonary air leak alone or pulmonary air leak with a mean airway pressure > or = 12 cmH2O; and arterial oxygen tension < or = 50 mmHg. These risk predictors may provide a basis for the selection of patients for future clinical trials of extracorporeal membrane oxygenation in this high-risk group of 1,500-1,999 g premature infants with severe respiratory failure.

Predictors of neonatal mortality in 1,500-1,999 g premature infants with respiratory failure. Basis for ECMO Therapeutic Trial

Despite the introduction of new ventilation techniques and surfactant therapy, some premature infants still experience severe respiratory failure and either die or survive with severe bronchopulmonary dysplasia. Extracorporeal membrane oxygenation is currently not offered for preterm infants with a birth weight less than 2,000 g, mainly because of the potential high risk for intracranial hemorrhage. The aim of this study was to determine risk predictors for mortality alone and for mortality or major lung morbidity in 1,500-1,999 g premature infants with respiratory failure. We reviewed the medical records of all preterm infants (n = 459) with respiratory failure and a birth weight of 1,500-1,999 g treated at five medical centers from 1989 to 1991. Of those infants, 23 (5%) had severe respiratory failure, defined as a requirement for ventilatory support with the fraction of inspired oxygen > or = 0.8 or peak inspiratory pressure > or = 30 cmH2O for > or = 3 hr in the 1st week of life. A mortality of > or = 75% was associated with a single arterial/alveolar oxygen ratio < or = 0.04; pulmonary air leak alone or pulmonary air leak with a mean airway pressure > or = 12 cmH2O; and arterial oxygen tension < or = 50 mmHg. These risk predictors may provide a basis for the selection of patients for future clinical trials of extracorporeal membrane oxygenation in this high-risk group of 1,500-1,999 g premature infants with severe respiratory failure.

The efficacy of extracorporeal life support in premature and low birth weight newborns

Based on data obtained early in the development of neonatal extracorporeal life support (ECLS), contraindications to the use of ECLS have included low estimated gestational age (EGA) and low birth weight (BW). However, multiple improvements in the technical and management aspects of neonatal ECLS have been implemented since those early data were evaluated. The purpose of this study, therefore, is to assess in the "modern era" the efficacy of prolonged extracorporeal support in premature and low birth weight newborns. Examination of the Extracorporeal Life Support Organization (ELSO) Registry showed that between 1988 and 1991 ECLS was utilized in 158 premature (PREM, EGA < or = 34 weeks), 4,128 full-term (FT, EGA > or = 35 weeks), 26 low birth weight (LBW, BW < 2.0 kg), and 4,333 normal birth weight (NBW, BW > or = 2.0 kg) patients with respiratory failure. Data were evaluated for variables thought to be associated with a decrease in survival or an increase in the incidence of intracranial hemorrhage (ICH). A logistic regression model was developed to evaluate the ability of EGA and BW to predict survival. The incidence of survival (SURV) was decreased (63% v 84%) and ICH increased (37% v 14%) significantly in PREM when compared with FT newborns (P < .001). However, respectable survival rates in PREM patients with EGA > 32 weeks were documented. In addition, both survival and ICH in PREM patients have improved substantially when compared with past reports (Past: SURV = 25% and ICH = 100%; current: SURV = 63% and ICH = 37%; ICH P < .001; SURV P = .056). Survival was significantly decreased in LBW when compared to NBW neonates (65% v 83%, P < .05), but there was no significant difference in ICH.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclin A expression in normal and transformed alveolar epithelial cells

The mature adult alveolar epithelial cell (AEC) is a highly differentiated phenotype that does not readily divide and exhibits numerous specialized functions. Yet, transformed AEC proliferate aggressively in certain forms of lung cancer. Normal AEC also proliferate but in a coordinated manner during embryonic growth and fetal development as well as during lung repair. Therefore, biochemical mechanisms regulating the cell cycle in AEC are clearly of fundamental significance for understanding lung development, lung injury, and cancer. Cyclin A is a protein that varies in abundance during the cell cycle and regulates critical transition points through its association with cyclin-dependent protein kinase subunits. We postulated that high expression of cyclin A might be associated with rapid proliferation in transformed AEC. We compared the expression of cyclin A mRNA and protein in primary cultures of fetal and adult rat AEC, in the E1A-T2 neonatal rat AEC, and in the malignant A549 human AEC. We used pharmacologic blockades with mimosine, aphidicolin, and nocodazole for cell cycle synchronization, which was verified by fluorescence-activated cell sorter (FACS) analysis of cellular DNA content. Transformed cells (A549 and E1A-T2) exhibited a much higher level of expression for both cyclin A mRNA and protein than did normal rat AEC. Induction of cyclin A mRNA expression in A549 human AEC and E1A-T2 rat AEC occurred in late G1, prior to the onset of S phase. Fetal and adult rat AEC and rat E1A-T2 AEC expressed two cyclin A mRNA transcripts, whereas human A549 cells in S phase and M phase expressed three cyclin A mRNA transcripts. We conclude that transformed AEC overexpress cyclin A in comparison with primary AEC cultures, while retaining cell cycle-dependent differences in cyclin A expression. We speculate that cyclin A expression is regulated both at the transcriptional and post-transcriptional levels, and that cyclin A may play a key role in the increased proliferation of transformed AEC that is associated with the pathogenesis of lung cancer.

Ocular findings in neonates after extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is a modified, prolonged cardiopulmonary bypass procedure used to treat newborns who have reversible cardiac or respiratory failure. The venoarterial bypass technique requires cannulation of both the right carotid artery and the internal jugular vein, and after decannulation these vessels are permanently ligated. Left-sided retinal vascular changes after ECMO have been reported, and were attributed to ligation of these vessels. A retrospective review of the results of ocular examinations of 86 infants who had undergone ECMO therapy at Childrens Hospital in Los Angeles between March, 1987 and May, 1991 was conducted. Normal findings were noted in 73 infants. One infant had bilateral retinal vascular tortuosity, and 12 infants had incidental ocular findings, but there was no evidence of left-sided retinal hemorrhage, venous congestion, or tortuosity. Our results suggest that left-sided retinal vascular changes after ECMO do not occur, occur only rarely, or clear rapidly and result in no permanent retinal damage. To unequivocally rule out the possibility that ECMO can cause transitory retinal vascular changes, we recommend further prospective studies, with ocular examinations performed before, during, and after ECMO.

Phospholipid and surfactant protein A concentrations in tracheal aspirates from infants requiring extracorporeal membrane oxygenation

To test the hypothesis that infants with severe respiratory failure and the need for extracorporeal membrane oxygenation (ECMO) are surfactant deficient, we measured the amount of surfactant phospholipids, disaturated phosphatidylcholine, surfactant protein A, and protein in tracheal aspirates from 22 infants, who received ECMO therapy for respiratory failure with meconium aspiration syndrome (n = 18) or pneumonia (n = 4). Tracheal suction material was obtained in a standardized way every 4 hours during the period of ECMO treatment and pooled for 24-hour periods. During ECMO, mean total phospholipid, disaturated phosphatidylcholine, and surfactant protein A values in tracheal aspirates increased and protein values decreased significantly, predominantly during the 72-hour period before infants were weaned from ECMO. Of the 22 infants, 14 had an increase in tracheal aspirate phospholipid values of more than 200% and were found to need a shorter period of ECMO support (p less than 0.005) and post-ECMO ventilatory support (p less than 0.025) than did the eight infants with stationary or only moderate increases in tracheal aspirate phospholipid values, three of whom had pneumonia. We conclude that infants with respiratory failure who require ECMO treatment often have surfactant deficiency. We speculate that surfactant treatment might decrease the need for or the duration of ECMO support.

Plasma thromboxane and pulmonary artery pressure in neonates treated with extracorporeal membrane oxygenation

To examine whether neonates with persistent pulmonary hypertension are subject to a thromboxane-mediated exacerbation of their pulmonary hypertension during extracorporeal membrane oxygenator therapy (a form of partial cardiopulmonary bypass), we performed serial measurements of plasma thromboxane B2 and pulmonary artery pressure before, during, and after extracorporeal membrane oxygenation. Pulmonary artery pressure was high before extracorporeal membrane oxygenation, did not increase after the start of this therapy, but began to decrease after 48 hours of extracorporeal membrane oxygenation. During the course of extracorporeal membrane oxygenation, mean pulmonary artery pressure decreased by 50% and mean plasma thromboxane B2 levels decreased by 70%. In addition, serial plasma thromboxane B2 levels were significantly correlated with pulmonary artery pressures in individual infants with a primary diagnosis of meconium aspiration (r = 0.965 to 0.723). We speculate that the decrease in pulmonary artery pressure and plasma thromboxane B2 levels over time may reflect resolution of acute lung injury and that thromboxane B2 may play a role in regulating pulmonary artery pressure in infants with meconium aspiration.

Extracorporeal membrane oxygenation in lambs through umbilical vessel perfusion: cardiac and hepatic complications

Twin lambs were delivered by ceasarean section near term, aralyzed, sedated and randomly assigned to either mechanical ventilation or umbilical arteriovenous ECMO for 48 hours. Umbilical arteriovenous ECMO provided adequate gas exchange with minimal or no ventilation of the native lungs. However, at autopsy, animals treated with umbilical ECMO showed right heart dilation and liver necrosis or hemorrhage compared to their twins treated with mechanical ventilation.

Plasma prostanoids in neonates with pulmonary hypertension treated with conventional therapy and with extracorporeal membrane oxygenation

Thromboxane may be a mediator of pulmonary hypertension in the neonate. Acute thromboxane-mediated pulmonary hypertension has been described in sheep receiving extracorporeal membrane oxygenation, which raises concerns about a potential thromboxane-mediated exacerbation of pulmonary hypertension in human neonates with severe pulmonary hypertension who are treated with extracorporeal membrane oxygenation. We measured plasma levels of thromboxane, prostaglandin F2 alpha, and 6-keto-prostaglandin F1 alpha in infants with pulmonary hypertension, some of whom were treated medically and some of whom were treated with extracorporeal membrane oxygenation. Plasma levels of all three prostanoids were elevated in infants with pulmonary hypertension and decreased with time, whether the neonates were treated with extracorporeal membrane oxygenation or with medical management alone. In infants treated with extracorporeal membrane oxygenation, we collected samples simultaneously from preoxygenator sites, postoxygenator sites, and umbilical artery catheter. We could demonstrate no significant difference in plasma prostanoid levels across the oxygenator. In two patients, plasma thromboxane and prostaglandin F2 alpha levels measured shortly after a platelet transfusion were distinctly higher in the umbilical artery catheter than in venous samples.

Plasma prostanoids in neonatal extracorporeal membrane oxygenation. Influence of meconium aspiration

Thromboxane B2 may be a mediator of neonatal persistent pulmonary hypertension. Elevated levels of plasma thromboxane and prostacyclin have been described previously in hypoxic newborn infants with neonatal pulmonary hypertension. We measured serial plasma levels of thromboxane B2 and 6-keto-prostaglandin F1 alpha (stable metabolite of prostacyclin) in 21 newborn infants with severe respiratory failure and pulmonary hypertension who required extracorporeal membrane oxygenation support. We sought to study (1) the evolution of plasma prostanoids in pulmonary hypertensive infants treated with extracorporeal membrane oxygenation and (2) whether different pulmonary hypertensive diagnostic subgroups have distinctive prostanoid profiles. Our data indicated that infants with meconium aspiration had significantly lower levels of plasma thromboxane B2 and 6-keto-prostaglandin F1 alpha while receiving extracorporeal membrane oxygenation than did infants with persistent pulmonary hypertension but no meconium aspiration. Levels of all infants decreased progressively as extracorporeal membrane oxygenation support continued.

Variations in local PGE levels: a potential factor in therapeutic responsiveness?

It was hypothesized that it is the concentration of PGE in the plasma which actually reaches the ductus arteriosus which determines ductal response to PGE administration. Therefore, site specific PGE levels were studied in two infants with ductus dependent congenital heart lesions who were receiving PGE1 infusions. PGE levels were found to vary in a fashion related to the infusion site and the specific cardiac anatomy and hemodynamics of each patient. One of our patients, for instance, had a double outlet right ventricle with high pulmonary vascular resistance and right to left ductal shunting. This infant was given an intraarterial infusion of PGE. The plasma concentrations of PGE in the ductal blood of the infant were negligible. Assuming that ductal site specific PGE levels are critical in mediating the therapeutic response, hemodynamics and infusion site are factors that should be considered when initiating a PGE infusion, or in evaluating a therapeutic failure of PGE.

ECMO in premature infants. Review of factors associated with mortality

During the first few years of clinical research on neonatal extracorporeal membrane oxygenation (ECMO), 16 premature infants of less than 35 weeks gestational age were treated by the authors (RHB), and only four (25%) survived. Intracranial hemorrhage was common, prompting the authors to recommend that ECMO not be used in premature infants with respiratory failure. Since diagnostic methods, indications, and techniques of extracorporeal support have improved considerably, the records of these previous cases were reviewed in detail to determine if there was reason to believe that results might be better in the modern era. Of the 16 patients, four had pre-ECMO conditions that would now be considered contraindications and five of the remaining patients had major technical complications that are now rare. Anticoagulation and fluid management of these patients also would be handled much differently. Based on this review and on current experience with extracorporeal support in near-term infants, it is reasonable to expect that survival of moribund premature infants might be 50% or greater with extracorporeal support. New phase I trials using improved indications and technology are suggested.

Extracorporeal membrane oxygenation in neonatal respiratory failure. A brief overview

Extracorporeal membrane oxygenation has been used for over 15 years to salvage neonates with severe respiratory failure. This article briefly reviews the indications, cannulation procedures, management on bypass, possible complications, and available neurodevelopmental follow-up data of the survivors.

Persistent pulmonary hypertension of the newborn. Managing the unmanageable?

Persistent pulmonary hypertension of the newborn is a complex syndrome with multiple causes, which retains a high morbidity and mortality. This article presents pathophysiologic and diagnostic foundations and then focuses the discussion on management issues.

Metoclopramide promotes enteral feeding in preterm infants with feeding intolerance

We hypothesized that the feeding difficulties experienced by premature infants are related to immature peristaltic activity and that a bowel accelerant might promote feeding in prematures. We administered metoclopramide (Meto) to 14 infants admitted to the Intensive Care Nursery at The University of Chicago between January 1, 1984, and January 1, 1987. Each infant had failed enteral feeding on at least two separate occasions. At the time of initiation of Meto, the group of infants tolerated only 11.7 +/- (SEM) 3.6 cm3/kg/day enterally. Feeding tolerance improved steadily after Meto was initiated, and by 29 days the infants tolerated 134 +/- 12.6 cm3/kg/day enterally. The average slope of the post-Meto feeding regression lines was +4.21 +/- 0.94 cm3/kg/day/day, significantly greater than -0.67 +/- 0.59 cm3/kg/day/day pre-Meto. The percentage of feedings followed by significant gastric residual volumes was 33.1 +/- 4.6% pre-Meto, compared to 6.9 +/- 2.5% post-Meto. No child receiving Meto developed any extrapyramidal neurologic symptoms, worsening of hepatic function, or necrotizing enterocolitis. Meto may have a role in the treatment of premature infants with enteral feeding intolerance.

Endogenous dilator prostaglandins in congenital heart disease

Maintaining patency of the ductus arteriosus pending surgical intervention can be critical to the survival of the neonate with ductal dependent congenital heart disease. Spontaneously delayed ductal closure has been observed clinically and experimentally in newborns with critical pulmonic stenosis. Infants with ductal dependent congenital heart lesions were therefore studied to ascertain whether there was an endogenous increase in dilator prostaglandins prolonging ductal patency. Six neonates with cyanotic lesions (group 1) and six with left ventricular obstructive lesions (group 2) were studied. Circulating PGE2 was not increased in either group. The levels of plasma 6 keto PGF1 alpha, a stable hydrolysis product of prostacyclin, were found to be elevated, but only in the cyanotic group (3143 +/- 1844 vs 404 +/- 250 pg/ml; p less than 0.05; normal less than 500 pg/ml). As expected, PaO2's were also different (36 +/- 15 vs 72 +/- 34 mmHg; p less than 0.05). It is speculated, therefore, that increased synthesis and/or release of prostacyclin, possibly mediated by the hypoxia of the cyanotic ductal dependent lesion, contributes to persistent patency of the ductus arteriosus.