Current Approaches to Wound Repair in Burns: How far Have we Come From Cover to Close? A Narrative Review

Burn injuries are a significant global health concern, with more than 11 million people requiring medical intervention each year and approximately 180,000 deaths annually. Despite progress in health and social care, burn injuries continue to result in socioeconomic burdens for victims and their families. The management of severe burn injuries involves preventing and treating burn shock and promoting skin repair through a two-step procedure of covering and closing the wound. Currently, split-thickness/full-thickness skin autografts are the gold standard for permanent skin substitution. However, deep burns treated with split-thickness skin autografts may contract, leading to functional and appearance issues. Conversely, defects treated with full-thickness skin autografts often result in more satisfactory function and appearance. The development of tissue-engineered dermal templates has further expanded the scope of wound repair, providing scar reductive and regenerative properties that have extended their use to reconstructive surgical interventions. Although their interactions with the wound microenvironment are not fully understood, these templates have shown potential in local infection control. This narrative review discusses the current state of wound repair in burn injuries, focusing on the progress made from wound cover to wound closure and local infection control. Advancements in technology and therapies hold promise for improving the outcomes for burn injury patients. Understanding the underlying mechanisms of wound repair and tissue regeneration may provide new insights for developing more effective treatments in the future.

The Impact of Switching to a Second Antifibrotic in Patients With Idiopathic Pulmonary Fibrosis: A Retrospective Multicentre Study From the EMPIRE Registry

INTRODUCTION

Most patients with idiopathic pulmonary fibrosis (IPF) treated with antifibrotics (AF) have progressive disease despite treatment. A switch of AF may improve survival, but evidence from randomised controlled trials is missing. We aimed to evaluate the efficacy of an AF switch on survival and FVC decline in patients from the European MultiPartner IPF registry (EMPIRE).

METHODS

The study included 612 patients who discontinued the first antifibrotic therapy. Patients were grouped and analysed from two perspectives: (1) whether they had received a second antifibrotic treatment after the discontinuation of the first therapy, and (2) a reason for discontinuation of the first AF - "lack of efficacy" (LE) and "intolerance" (INT).

RESULTS

While 263 (43%) of 612 patients received no second AF ("non-switched"), 349 (57%) patients switched. Overall survival was higher in patients who received a second AF (median 50 vs. 29 months; adjusted HR 0.64, P=0.023). Similarly, the annual FVC decline was significantly reduced in switched patients: -98ml/y in switched and -172ml/y in non-switched patients (P=0.023), respectively. The switched patients had similar risk for mortality in both LE and INT groups (adjusted HR 0.95, P=0.85). The high impact of switching on survival was demonstrated in LE patients (adjusted HR 0.27, P<0.001).

CONCLUSION

The patients without a second AF had significantly shorter overall survival. Our analysis suggests the importance of switching patients with an ineffective first AF therapy to a second AF therapy.

The effect of nintedanib on lung functions and survival in idiopathic pulmonary fibrosis: real-life analysis of the Czech EMPIRE registry

INTRODUCTION

The antifibrotic drug nintedanib is used for the treatment of idiopathic pulmonary fibrosis (IPF). We analysed the effect of nintedanib on antifibrotic treatment outcome in real-world cohorts of Czech EMPIRE registry.

PATIENTS/METHODS

Data of 611 Czech IPF subjects, 430 (70%) treated with nintedanib (NIN group), 181 (30%) with no-antifibrotic treatment (NAF group) were analysed. The influence of nintedanib on overall survival (OS), pulmonary function parameters as forced vital capacity (FVC) and diffusing lung capacity for carbon monoxide (DLCO), as well as GAP score (gender, age, physiology) and and CPI (composite physiological index) were investigated.

RESULTS

During 2 year follow-up we observed that nintedanib treated patients had longer OS, compared to those treated with no-antifibrotic drugs (p < 0.00001). Nintedanib reduces risk of mortality over no-antifibrotic treatment by 55% (p < 0.001). We have observed no significant difference in the rate of FVC and DLCO decline between the NIN and NAF group. Changes within 24 months from baseline in CPI were not significant between the groups (NAF and NIN).

CONCLUSION

Our real-practice study showed the benefit of nintedanib treatment on survival. There were no significant differences between NIN and NAF groups in changes from baseline in FVC %, DLCO % predicted and CPI.

Germline variant of CTC1 gene in a patient with pulmonary fibrosis and myelodysplastic syndrome

Introduction

Telomeropathies are associated with a wide range of diseases and less common combinations of various pulmonary and extrapulmonary disorders.

Case presentation

In proband with high-risk myelodysplastic syndrome and interstitial pulmonary fibrosis, whole exome sequencing revealed a germline heterozygous variant of CTC1 gene (c.1360delG). This "frameshift" variant results in a premature stop codon and is classified as likely pathogenic/pathogenic. So far, this gene variant has been described in a heterozygous state in adult patients with hematological diseases such as idiopathic aplastic anemia or paroxysmal nocturnal hemoglobinuria, but also in interstitial pulmonary fibrosis. Described CTC1 gene variant affects telomere length and leads to telomeropathies.

Conclusions

In our case report, we describe a rare case of coincidence of pulmonary fibrosis and hematological malignancy caused by a germline gene mutation in CTC1. Lung diseases and hematologic malignancies associated with short telomeres do not respond well to standard treatment.

News in respiratory medicine

Pneumology and phthisiology (respiratory medicine) has undergone dynamic development in the last two decades. The main focus of pulmonology in the past was care for patients with tuberculosis and pneumonia. Since then, respiratory medicine evolved and the current focus is on chronic pulmonary diseases, including chronic obstructive pulmonary disease, bronchial asthma, interstitial lung diseases, but also on acute lung conditions (e.g., pneumonia, pleural diseases, respiratory failure), pneumooncology or highly specialized care for rare lung diseases (e.g., cystic fibrosis, rare interstitial diseases). Bronchology, interventional pneumology and pulmonary function testing are also important components of respiratory medicine. The importance of respiratory medicine was apparent during the COVID-19 pandemic. In this article, we provide a brief overview of the most important news to the field of respiratory medicine in the year 2022, addressing the thematic areas of bronchology, cystic fibrosis, chronic obstructive pulmonary disease, asthma, interstitial lung diseases, pleural diseases, pneumooncology, tuberculosis and non-tuberculous mycobacteria.

Langerhans cell histiocytosis (LCH). Overview of symptoms of LCH, which may lead the patients to any of these medical specialists

Langerhans cell histiocytosis (LCH) is a rare condition with incidence in adults 1-2/1 million, wherein Langerhans cells proliferate abnormally, adversely impacting organs including most frequently bones, skin, lungs, pituitary gland, lymph nodes, gums and other organs. The LCH course varies widely among patients from a self-limiting condition, to one that progresses. But LCH only very rarely culminates in death. To aim of this text is to review all possible symptoms and manifestations of this disease.

Antifibrotic therapy and its indications for interstitial pulmonary fibrosis

Idiopathic pulmonary fibrosis and chronic fibrotic interstitial lung disease with progressive phenotype are characterized by fibrotic lung parenchyma. Current antifibrotic treatment does not affect pre-existing lung parenchyma fibrosis, but prevents fibrosis progression and reduces mortality by reducing fibrotization. This work summarizes fibrotic lung processes and their treatment options.

Therapy of immunoglonuline IgG4 related disease (IgG4-RD)

Immunoglobulin IgG4 related disease (IgG4-RD) is a heterogeneous disorder with multi-organ involvement recognised as a separate entity at the beginning of this century only. Evolving therapy is reviewed in this paper. Glucocorticoids are first choice drug but long administration of glucocorticoids is connected with many adverse effects. In case of combination glucocorticoids and immunosuppressive agents lower doses of glucocorticoids are needed, the response rate is higher and therapy is better tolerated. Rituximab is drug, that is possible use as monotherapy or in combination with glucocorticoids and immunosuppressive drugs. Only one study compared two immunosuporessive drugs, mycophenolate mofetil and cyclophosphamide. The response rated was similar but remissions were longer after glucocorticoids with cyclophosphamide then glucocorticoids with mycofenolat mofetil. No other comparative study of combination of various imunossupressive drugs with glucocorticoids was published. Rituximab has high number (90 %) of response rate in monotherapy, but can be used in combination with glucocorticoids and immunosuppressives. Rituximab is now preferred and recommended for maintenance therapy administered in 6-month interval. In case of advanced disease, we prefer therefore combination of rituximab, cyclofosphamide and dexamethasone for initial therapy followed by maintenance with rituximab in 6 months interval. There are two new drugs under investigation abatacept and dupilimab with promising results. Although we have very intensive therapies for good results of therapy early diagnosis before irreversible fibrotic changes in IgG4-RD involved organs is still needed.

IgG4-related disease. Clinical manifestation differential diagnosis and recent International Diagnostic Criteria for IgG4-related disease

Immunoglobulin G4- related disease (IgG4-RD) is a rare systemic fibro-inflammatory disorder. Autoimmune pancreatitis is the most frequent manifestation of IgG4-RD. However, IgG4-RD can affect any organ such as salivary glands, orbits, retroperitoneum, prostate and many others. Recent research enabled a clear clinical and histopathological description of IgG4-RD and in 2019 four Clinical phenotypes of IgG4-related disease were described. Diagnosis is based on morphological examination with typical findings of lymphoplasmocellular inflammation, storiform fibrosis and obliterative phlebitis in IgG4-RD biopsies and the tissue invading plasma cells largely produce IgG4. Elevated serum IgG4 levels are found in many but not all patients. New diagnostic criteria for IgG4-RD have been published recently in 2019 and 2021. This review summarizes current knowledge on pathophysiology, clinical manifestations, diagnosis and differential diagnosis of IgG4-RD from the point of view 2022 and in next article brings overview of the IgG4-RD therapy.

Left ventricular myocardial deformation assessment in asymptomatic patients with recently diagnosed sarcoidosis of the respiratory tract and/or extrapulmonary sarcoidosis

BACKGROUND

Sarcoidosis is a systemic granulomatous disease affecting different organs including the heart. Myocardial strain analysis could potentially detect the early stages of cardiac dysfunction in sarcoidosis patients. The present study aims to assess the use of cardiac magnetic resonance (CMR) strain analysis using feature tracking (FT) in the detection of early cardiac involvement in asymptomatic patients with sarcoidosis.

METHODS

One hundred and thirteen CMR studies of patients with sarcoidosis of the respiratory tract and/or extrapulmonary sarcoidosis without pre-existing known cardiovascular disease were included in the study and analysed using FT and compared to 22 age and gender-matched controls. Global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS) of the left ventricle (LV) were measured.

RESULTS

The sarcoidosis patients did not significantly differ from the controls in basic demographic data and had normal global and regional systolic LV function-LV ejection fraction (EF) 66 ± 7% vs 65 ± 5% in the controls (p = NS). No statistically significant differences were found in all strain parameters between patients and controls: GLS (- 13.9 ± 3.1 vs. - 14.2 ± 2.5), GCS (- 23.4 ± 4.0 vs. - 22.2 ± 2.9) and GRS (53.4 ± 13.5 vs. 51.2 ± 13.6%) (p = NS).

CONCLUSION

Patients with sarcoidosis of the respiratory tract and/or extrapulmonary sarcoidosis had normal myocardial deformation measured by CMR-FT derived global strain.

Amiodarone induced pulmonary toxicity

Amiodarone is one of the more frequently used drugs in the treatment of supraventricular and ventricular arrhythmias. Many adverse effects, more or less serious, are associated with its administration. Amiodaron-induced pulmonary toxicity (AIPT) is quite rare but represents one of the most severe adverse effects with high mortality. We present an 80 years old patient, who used amidorane due to paroxysmal atrial fibrillation for several years. Within 3 months, he was repeatedly hospitalized for a bilateral pneumonia. Eventually, AIPT was diagnosed. Early diagnosis, proper therapy of AIPT and changed antiarrhythmic therapy has significantly improved the clinical status of our patient. In this case we demonstrate typical clinical presentations of AIPT as well as the most common diagnostic procedures and recommended treatment methods. Finally, some other commonly used therapeutical options for supraventricular arrhythmias are mentioned. Future options are outlined.

Myocardial T1 mapping using SMART1 Map and MOLLI mapping in asymptomatic patients with recent extracardiac sarcoidosis

INTRODUCTION

Sarcoidosis is a systemic granulomatous disease affecting in particular the respiratory tract. Cardiac magnetic resonance (CMR), including a measurement of T₁ relaxation time, could potentially detect early stadia of sarcoidosis of the heart. The study aims to assess T₁ mapping in the detection of early cardiac involvement in asymptomatic patients with sarcoidosis.

METHODS

One hundred and twenty patients with extracardiac sarcoidosis and without any heart disease history were included. One hundred and thirteen of them underwent a CMR examination. The mean time from the diagnosis of sarcoidosis was 0.8 (0.2-3.3) years. Cine images for the assessment of left ventricular (LV) functional parameters and pre- and post-contrast saturation method using adaptive recovery times for cardiac T₁ mapping (SMART₁ Map) and modified Look-Locker inversion recovery (MOLLI) images were acquired for the assessment of native T₁ relaxation time and extracellular volume (ECV). The measured parameters were compared between sarcoidosis patients and 22 controls.

RESULTS

The sarcoidosis patients had normal global and regional systolic LV function-LV ejection fraction 65 ± 5% versus 66 ± 7% (p NS). The mean native T₁ relaxation times were not prolonged-1465 ± 93 ms versus 1480 ± 88 ms (p NS) measured by SMART₁ Map and 1317 ± 60 ms versus 1313 ± 83 ms (p NS) measured using a MOLLI sequence. Similarly, the mean ECV values did not increase-16.9 ± 3.9% versus 17.9 ± 3.7% (p NS) measured by SMART₁ Map and 30.9 ± 2.9% versus 31.6 ± 8.3% (p NS) measured using a MOLLI sequence.

CONCLUSION

Myocardial native T₁ relaxation times were not prolonged and ECV was not increased in asymptomatic patients with extracardiac sarcoidosis.

Diagnosis of Bloom Syndrome in a Patient with Short Stature, Recurrence of Malignant Lymphoma, and Consanguineous Origin

Bloom syndrome is an autosomal recessive disorder characterized by prenatal and postnatal growth deficiency, photosensitive skin changes, immune deficiency, insulin resistance, and a greatly increased risk of early-onset cancer and development of multiple malignancies. Loss-of-function variants of the BLM gene, which codes for a RecQ helicase, cause Bloom syndrome. We report a consanguineous family, with 2 siblings showing clinical signs of suspected chromosome breakage disorder. One of them developed recurrent malignant lymphoma during lifetime. We performed next-generation sequencing analysis, focusing on cancer predisposition syndromes. We identified a homozygous pathogenic nonsense variant c.1642C>T (p.Gln548*) in the BLM gene in the proband, associated with Bloom syndrome. Sanger sequencing validated the presence of a homozygous pathogenic variant in the proband and also in the brother with short stature. In this article, we will focus on the clinical presentation of the syndrome in this particular family as well as the characteristics of malignancies found in the proband.

Necrotising sarcoid granulomatosis. A rare granulomatous disease

Introduction: Necrotizing sarcoid granulomatosis (NSG) is a very rare disease of unknown etiology characterized by sarcoid-like granulomas, vasculitis and necrosis in pulmonary and extrapulmonary localizations. Case report: We describe a case of a 34-year-old Caucasian male with fever, pleural pain, and nodular pulmonary opacities on chest radiograph. Histological examination of the lung tissue confirmed NSG. Diagnostically, infectious causes, vasculitis, and malignancy were excluded. A tendency to partial regression was observed, without the need for corticosteroid treatment. Conclusion: NSG is a rare disease which must be distinguished from other systemic diseases including vasculitides. The key to diagnosis, emphasized in our paper, is the histopathological finding. The course of NSG is similar to sarcoidosis. Corticosteroids are considered the treatment of choice, but the disease exhibits a tendency towards spontaneous regression. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 395-398)

Familial pulmonary fibrosis - guidelines for diagnostics and treatment

Familial pulmonary fibrosis (FPF) is defined as interstitial lung involvement in at least two members of the same biological family. Pathogenesis of FPF involves background of genetic risk factors further modified by environmental exposures and aging. Manifesta tion of FPF mirrors manifestation of interstitial lung diseases generally. Patients may present also with involvement of other organs, as seen usually in those affected by complex syndromes or telomeropaties. Described mutations concern telomeres homeostasis genes (TERT, TERC, RTEL1, PARN, DKC1, TINF, NAF1), surfactant genes (SFTPC, ABCA3, NFKX21) or genes associated with complex syndromes (COPA, TMEM173, HPS18, NF1, FAM111B, NDUFAF6, GATA 2). Genetic tests are indicated by specialist in clinical genetics, optimaly after consultation with respiratory specialist involved in interstitial lung diseases. Treatment of FPF is currently unknown. In patients with multiorgan involvement growing number of organs may be affected in time and sometimes dysfunction of mostly severe affected organ may manifest before interstitial lung involvement.

Lung diseases and autoimmune hemolytic anemia associted with IgG4 disease

IgG4 related disease (IgG4-RD) is a rare and relatively new group of systemic inflammatory diseases characterized by inflammatory, fibrotic or sclerotic involvement of one or more organs accompanied by increased IgG4plasma cells tissue infiltration andusually elevated serum IgG4(IgG4 &gt; 1.35g/l, normal range 0.08-1.40 g/l) level. Histopathological findings are crucial for the diagnostics of this disease. The authors present a case report of a patient with IgG4 associated disease manifested by a rare combination of autoimmune hemolytic anemia and pulmonary involvement.

Novel genetic variant of HPS1 gene in Hermansky-Pudlak syndrome with fulminant progression of pulmonary fibrosis: a case report

Background

Hermansky-Pudlak syndrome (HPS) is an autosomal recessive disorder that is associated with oculocutaneous albinism, bleeding diathesis, granulomatous colitis, and highly penetrant pulmonary fibrosis in some subtypes. Homozygous or compound heterozygous pathological variants in HPS1, HPS3, HPS4, and several other genes lead to clinical manifestation of the disease.

Case presentation

A 57-year-old female was admitted with congenital oculocutaneous albinism, thrombocytopathy and late-onset accelerated pulmonary fibrosis (first symptoms from age 50 onwards). Chest high-resolution computed tomography identified thickening of peribronchovascular interstitium, bronchiectasis, reticulations, honeycombing, ground glass opacities and lung parenchyma consolidations. HPS was clinically suspected. We performed whole exome sequencing (WES), a form of massive parallel sequencing, of proband-parents trio. Whole exome libraries were processed using KAPA Hyper Prep Kit, SeqCap EZ MedExome Enrichment Kit and HyperCap Bead Kit according to the SeqCap EZ HyperCap Workflow. The paired-end 2 × 75 bp sequencing was performed on the Illumina NextSeq 500 Sequencer (Illumina Inc., USA). Furthermore, obtained variants by WES were evaluated using a virtual panel of genes: HPS1, AP3B1, HPS3, HPS4, HPS5, HPS6, DTNBP1, BLOC1S3, and PLDN. We identified a compound heterozygous genotype in HPS1 gene in the proband. We identified a pathogenic frameshift variant c.1189delC; p.(Gln397Serfs*2), resulting in a premature stop codon. This variant has been previously associated with HPS. Furthermore, we characterized previously undescribed nonsense variant c.1507C > T; p.(Gln503*), resulting in a premature stop codon and mRNA degradation through nonsense-mediated decay. Sanger sequencing validated the presence of both variants and simultaneously confirmed the heterozygous carrier status of parents. Unfortunately, the patient died due to fulminant progression of pulmonary fibrosis 2 months after diagnostics.

Conclusions

Compound heterozygous mutations in HPS1 in the proband lead to disruption of HPS1 gene and clinical manifestation of HPS with severe pulmonary fibrosis. This case illustrates the need to consider HPS in differential diagnostics of pulmonary fibrosis. Pulmonary fibrosis is a common cause of death in HPS patients. Earlier diagnosis may enable better treatment for these patients.

A novel germline mutation of the SFTPA1 gene in familial interstitial pneumonia

Different genes related to alveolar stability have been associated with familial interstitial pneumonia (FIP). Here, we report a novel, rare SFTPA1 variant in a family with idiopathic interstitial pneumonia (IIP). We performed whole-exome sequencing on germline DNA samples from four members of one family; three of them showed signs of pulmonary fibrosis (idiopathic interstitial pneumonia) with autosomal-dominant inheritance. A heterozygous single nucleotide variant c.532 G > A in the SFTPA1 gene has been identified. This variant encodes the substitution p.(Val178Met), localized within the carbohydrate recognition domain of surfactant protein A and segregates with the genes causing idiopathic interstitial pneumonia. This rare variant has not been previously reported. We also analyzed the detected sequence variant in the protein structure in silico. The replacement of valine by the larger methionine inside the protein may cause a disruption in the protein structure. The c.532 G > A variant was further validated using Sanger sequencing of the amplicons, confirming the diagnosis in all symptomatic family members. Moreover, this variant was also found by Sanger sequencing in one other symptomatic family member and one young asymptomatic family member. The autosomal-dominant inheritance, the family history of IIP, and the evidence of a mutation occurring in part of the SFTPA1 gene all suggest a novel variant that causes FIP.

Researchers have identified a novel mutation that causes inheritable and ultimately deadly scarring of the tiny air sacs in the lungs, the alveoli. In familial interstitial pneumonia (FIP), alveoli are scarred and stiffened by inflammation, not by bacterial infection as the word ‘pneumonia’ usually indicates. Michael Doubek at University Hospital and Central European Institute of Technology, Brno, Czech Republic and co-workers investigated a suspected case of FIP following the early death of one family member. Sequencing the genomes of other family members revealed that they shared a mutation in a protein that keeps alveoli moist, aiding oxygen absorption. Computer analysis showed that the mutation probably changed the protein’s shape, preventing it from functioning. Identifying mutations that cause FIP will help provide proactive treatment for family members who are at risk but not yet showing symptoms.

Immunodeficiency in the differential diagnosis of interstitial lung diseases

Interstitial lung processes (IPP), or diffuse parenchymal lung diseases, are a broad group of diseases characterized by varying degrees of pulmonary fibrosis and inflammation affecting predominantly, but not exclusively, pulmonary interstitium. IPP mostly occur in adulthood with maximum manifestation between 40 and 70 years of age. Although IPP mostly present as a primary diagnosis, they also belong to the portfolio of pulmonary disorders in patients with primary immunodeficiencies. The authors present case reports of patients with interstitial lung involvement and primary immunodeficiencies [particularly those manifesting also in adulthood, such as common variable immunodeficiency (CVID), and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) deficiency]. In addition, we report the case of silico-sis patient with severe lymphopenia. Therefore, in patients with newly diagnosed interstitial lung disease, congenital immune system disorder should be considered. Basic immunological laboratory examination of humoral and cellular immunity should be an essential part of the differential diagnosis algorithm for interstitial lung disease.

Capillary Electrophoretic Analysis of Exhaled Breath Condensate in the Diagnosis of Gastroesophageal Reflux Disease

In this work, capillary electrophoresis with contactless conductometric detection (CCD) was used for the analysis of the ionic content of exhaled breath condensate (EBC) to differentiate between healthy individuals and patients with gastroesophageal reflux disease (GERD). The exhaled breath condensate was collected using a miniature sample collection device and the content analyzed using a separation electrolyte composed of 20 mM 2-(N-morpholino)ethanesulfonic acid, 20 mM L-histidine, 2 mM 18-Crown-6 and 30 M cetyltrimethylammonium bromide. The separation of anions took less than 2.5 minutes, while the cations were separated in less than 1.5 minutes. The most significantly elevated ions in the group of patients suffering from gastroesophageal reflux disease were chloride, nitrate, propionate and butyrate. Although the number of subjects was too small to draw definite conclusions with regard to the discriminatory power of these ions, the pilot data are promising for EBC as a useful non-invasive alternative for other methods used in the diagnosis of gastroesophageal reflux disease

Laser-synthesized nanocrystalline, ferroelectric, bioactive BaTiO3/Pt/FS for bone implants

The goal of our study is to design BaTiO₃ ferroelectric layers that will cover metal implants and provide improved osseointegration. We synthesized ferroelectric BaTiO₃ layers on Pt/fused silica substrates, and we studied their physical and bio-properties. BaTiO₃ and Pt layers were prepared using KrF excimer laser ablation at substrate temperature T_s in the range from 200°C to 750°C in vacuum or under oxygen pressure of 10 Pa, 15 Pa, and 20 Pa. The BaTiO₃/Pt and Pt layers adhered well to the substrates. BaTiO₃ films of crystallite size 60-140 nm were fabricated. Ferroelectric loops were measured and ferroelectricity was also confirmed using Raman scattering measurements. Results of atomic force microscopy topology and the X-ray diffraction structure of the BaTiO₃/Pt/fused silica multilayers are presented. The adhesion, viability, growth, and osteogenic differentiation of human osteoblast-like Saos-2 cells were also studied. On days 1, 3, and 7 after seeding, the lowest cell numbers were found on non-ferroelectric BaTiO₃, while the values on ferroelectric BaTiO₃, on non-annealed and annealed Pt interlayers, and on the control tissue culture polystyrene dishes and microscopic glass slides were similar, and were usually significantly higher than on non-ferroelectric BaTiO₃. A similar trend was observed for the intensity of the fluorescence of alkaline phosphatase, a medium-term marker of osteogenic differentiation, and of osteocalcin, a late marker of osteogenic differentiation. At the same time, the cell viability, tested on day 1 after seeding, was very high on all tested samples, reaching 93-99%. Ferroelectric BaTiO₃ films deposited on metallic bone implants through a Pt interlayer can therefore markedly improve the osseointegration of these implants in comparison with non-ferroelectric BaTiO₃ films.

How to diagnose cardiac sarcoidosis?

Sarcoidosis is a systemic granulomatous disease of unknown etiology that can affect any organ including the heart. Clinical manifestations of heart disease are seen in about 5 % of patients, but histology shows a higher rate of heart involvement by sarcoidosis. Therefore, heart sarcoidosis is underdiagnosed because of clinically non-symptomatic course in some patients or physicians simply do not think about this heart involvement. Echocardiography, Holter monitoring, magnetic resonance imaging, positron emission tomography/computed tomography, thallium scintigraphy, and endomyocardial biopsy are methods of investigation when suspected of heart involvement by sarcoidosis. In particular, magnetic resonance has gained importance recently in the diagnosis of cardiac sarcoidosis. Key words: cardiac sarcoidosis - diagnostics - therapy.

[Autoantibodies in systemic connective tissue disease and ANCA-associated vasculitis, their relationship to interstitial lung diseases and prognosis]

Lung disease, including interstitial lung disease (ILD), is a frequent complication of systemic connective tissue disorders (CTD) and ANCA (anti-neutrophil cytoplasmic antibody) associated vasculitis (AAV). Pulmonary manifestations are prognostic factor of CTDs and vasculitis. Autoantibodies assessment is a part of differential diagnosis algorithm of lung diseases. Autoantibodies importance is mainly clinical-diagnostic. Using detection of some autoantibodies it is possible to determine prognosis of lung involvement, especially in CTDs.Key words: autoantibodies - connective tissue disease - interstitial lung diseases - prognosis - vasculitis.

Prognostic significance of surfactant protein A, surfactant protein D, Clara cell protein 16, S100 protein, trefoil factor 3, and prostatic secretory protein 94 in idiopathic pulmonary fibrosis, sarcoidosis, and chronic pulmonary obstructive disease

BACKGROUND

Identification of serum and bronchoalveolar lavage fluid (BALF) biomarkers may facilitate diagnosis and prognostication in various lung disorders.

OBJECTIVE

Serum and BALF levels of surfactant protein A (SP-A), surfactant protein D (SP-D), Clara cell protein 16 (CC16), S100 protein, trefoil factor 3 (TFF3), and prostatic secretory protein 94 (PSP94) were evaluated in 94 consecutive patients (idiopathic pulmonary fibrosis (IPF; n=18), sarcoidosis (n=25), chronic obstructive pulmonary disease (COPD; n=51)), and in 155 healthy controls.

METHODS

Biomarkers were measured at diagnosis and compared with disease characteristics. Both uniparametric and multiparametric analyses were used.

RESULTS

Seven significant correlations were found: 1) BALF PSP94 level correlated with prognosis of sarcoidosis (P=0.035); 2) BALF SP-D level with pulmonary functions in IPF (P=0.032); 3) BALF SP-D and TFF3 with IPF mortality (P=0.049 and 0.017, respectively); 4) serum TFF3 level with COPD mortality (P=0.006,); 5) serum SP-A with pulmonary functions impairment in IPF (P=0.011); 6) serum SP-D level was associated with HRCT interstitial score in IPF (P=0.0346); and 7) serum SP-A was associated with staging of COPD according to spirometry (P<0.001). Moreover, our analysis showed that some biomarker levels differed significantly among the diseases: 1) BALF SP-D level differed between sarcoidosis and IPF; 2) serum SP-A level differed among IPF, sarcoidosis, COPD and was also different from healthy controls; 3) serum S100A6, S100A11 levels differed among IPF, sarcoidosis, COPD from healthy controls 4) serum SP-D, CC16, TFF-3 levels distinguished IPF patients from healthy controls; and 5) serum CC16, TFF3, PSP94 distinguished COPD patients from healthy controls. Our study shows that some of selected biomarkers should have prognostic value in the analysed lung disorders. On the other hand, these biomarkers do not appear to be unequivocally suitable for differential diagnosis of these disorders.

[Hypercalcemia, symptoms, differential diagnostics and treatment, or importance of calcium investigation]

The concentration of calcium is carefully maintained under physiological conditions with parathormone, calcitonin and 1,25-dihydroxyvitamin D at appropriate levels. There are multiple causes that may bring about increased concentrations of calcium which exceed physiological values. Increased production of parathormone in parathyroid glands is only one of the possible causes. Malignant diseases are a very frequent cause of hypercalcemia, due to their creating mediators which stimulate osteoclasts and thereby osteolysis. A less frequent cause is represented by granulomatous processes, a typical example of which is sarcoidosis, whose cells increasingly (independently of parathormone) hydroxylate 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D. However there are also hereditary forms of hypercalcemia. One of the causes of the hereditary form of hypercalcemia is mutations of the calcium sensing receptor. In order to locate the adenoma of parathyroid glands, essential apart from sonographic imaging is scintigraphy 99mTc-methoxyisobutylisonitrile (MIBI) and even more exact is PET-CT examination with a radio-pharmaceutical 18F-fluorocholine. PET-CT examinations are beneficial with regard to detecting a malignant cause of hypercalcemia in until then undetected malignancy or an undetected granulomatous process. The essential treatment procedures for malignant hypercalcemia include appropriate hydratation of ionic solutions without calcium, administering of bisphosphonates or denosumab. The text describes in detail the symptoms of hypercalcemia and diagnostics of causes of hypercalcemia.

KEY WORDS

bisphosphonates - cinacalcet - denosumab - granulomatous diseases - hereditary hypercalcemia - hypercalcemia - hypercalciuria - hyperparathyreosis - calcimimetics - calcitonin - multiple myeloma - malignant hypercalcemia - parathormone - sarcoidosis - 1,25-dihydroxyvitamin D.

[Idiopathic pulmonary fibrosis prognostic factors - analysis of the Czech registry]

Idiopathic pulmonary fibrosis (IPF) is a rare, progressive and usually fatal form of idiopathic interstitial pneumonia. IPF is characterized by failure of alveolar re-epithelization, persistence of fibroblasts, deposition of extracellular matrix, and distortion of lung architecture, which ultimately results in respiratory failure.We analysed 202 consecutive patients with IPF diagnosed at the Departments of Pulmonary Diseases and Tuberculosis in the Czech Republic, who they were included in the nationwide Czech IPF registry. Our aim was to determine prognostic factors of IPF and outcome of the disease.There were 129 males and 73 females who were the median age 67 years. IPF was biopsy-proven in 66 (33 %) of patients. Median time from the first symptom to diagnosis was 12 months. Diagnosis was made in 57 patients (28.3 %) within 6 months from the onset of respiratory symptoms. 8 (4 %) patients had an acute exacerbation during the course of the disease.In uniparametric (univariate) analysis as prognostic factors associated with poorer survival were found: higher age, higher degree dyspnea scores, clubbing fingers, comorbidities (arterial hypertension, osteoporosis), patients without histology biopsy, and bronchoalveolar increased neutrophil count. We found these positive prognostic factors: higher levels of VC (vital capacity), TLC (total lung capacity) and DLCO (diffusing capacity for carbon monooxide).In multiparametric (multivariate) analysis as prognostic factors associated with mortality were found: higher age, higher degree of dyspnoe score. Increased lymphocytes in bronchoalveolar fluid, higher level of VC a DLCO were associated with better survival. There was no difference in survival of patients by sex, by smoking status. No significant difference in survival rates was found between IPF with and without emphysema, between the extent of fibrosis on HRCT (high resolution computed tomography) of thorax and mortality. Median survival was 51.6 months. 58 (28.7 %) patients died. The most frequent reason of dead was IPF progression with respiratory failure.

KEY WORDS

Idiopathic pulmonary fibrosis; prognosis; treatment.

Monitoring the ionic content of exhaled breath condensate in various respiratory diseases by capillary electrophoresis with contactless conductivity detection

The analysis of an ionic profile of exhaled breath condensate (EBC) by capillary electrophoresis with contactless conductivity detection and double opposite end injection, is demonstrated. A miniature sampler made from a 2 ml syringe and an aluminium cooling cylinder was used for the fast collection of EBC (under one minute). Analysis of the collected EBC was performed in a 60 mM 2-(N-morpholino)ethanesulfonic acid, 60 mM L-histidine background electrolyte with 30 µM cetyltrimethylammonium bromide and 2 mM 18-crown-6 at pH 6, and excellent repeatability of migration times (RSD  <1.3% (n = 7)) and peak areas (RSD  <  7% (n = 7)) of 14 ions (inorganic anions, cations and organic acids) was obtained. It is demonstrated that the analysis of EBC samples obtained from patients with various respiratory diseases (chronic obstructive pulmonary disease, asthma, pulmonary fibrosis, sarcoidosis, cystic fibrosis) is possible in less than five minutes and the ionic profile can be compared with the group of healthy individuals. The analysis of the ionic profile of EBC samples provides a set of data in which statistically significant differences among the groups of patients could be observed for several clinically relevant anions (nitrite, nitrate, acetate, lactate). The developed collection system and method provides a highly reproducible and fast way of collecting and analyzing EBC, with future applicability in point-of-care diagnostics.

[Interstitial lung diseases and granulomatoses associated common variable immunodeficiency]

Common variable immunodeficiency disorder belongs to the most common primary human immunodeficiencies and it is characterized by primary defective immunoglobulin production. Hypogammaglobulinemia manifests in every age, usually in adult people. There is no gender predisposition. The prevalence is 1 : 25 000-1 : 50 000. The ethiopathogenesis of the majority of CVIDs is unknown. The main clinical respiratory symptoms include recurrent respiratory infects, especially bacterial etiology, sinusitis, bronchitis, pneumonia, leading to bronchiectasis and lung fibrosis. Interstitial lung fibrosis and granulomatosis often manifest at diagnosis of CVID and they are negative prognostic factors of the disease.

Exogenous lipoid pneumonia caused by chronic improper use of baby body oil in adult patient

INTRODUCTION

Exogenous lipoid pneumonia (ELP) is an uncommon condition resulting from aspirating or inhaling fatlike material. These substances elicit a foreign body reaction and proliferative fibrosis in the lung.

CASE REPORT

We report a case of a 38-year-old woman with bilateral pulmonary infiltration. There were no clinical symptoms of this infiltration at diagnosis. The infiltration was found coincidentally during the pre-operation examination before surgery. A chest computed tomography scan revealed bilateral lung consolidation, particularly in the S6 area on the right side. The transthoracic lung biopsy led to suspicion of ELP. Precise anamnesis confirms the diagnosis of ELP caused by chronic improper use of baby body oil. Two years after discontinuing "baby body oil therapy", a chest CT scan revealed partial regression of pulmonary infiltration.

CONCLUSION

The diagnosis of exogenous lipoid pneumonia is often difficult as symptoms, signs, and radiographic findings are all rather non-specific. We would like to emphasize the role of precise case history in better identification of ELP.

[Sarcoidosis--diagnostics, prognosis and therapy. A retrospective analysis]

Sarcoidosis is systematic granulomatous disease of unknown etiology which can affect any organ. Sarcoidosis belongs to diseases called interstitial lung diseases. Our study is a retrospective analysis of 169 patients (100 females and 69 males), whom we diagnosed sarcoidosis at our pulmonary department in years 2005-2010. Aim of the analysis was to find out prognostic factors and to describe the course of disease. Median age of sarcoidosis patients was 48 years (20-79). Females : males ratio was 1.5 : 1. Non smoker : smoker (or former smoker) ratio was 2.2 : 1. Familial occurrence was observed in 4 patients (2.4%). At diagnosis, stage 0 was present in 6 (3.5%) patients, stage I in 58 (34%) patients, stage II in 84 (49.5%) patients, stage III in 18 (11%) patients, and stage IV in 3 (2%) patients. Diagnosis was confirmed by histology in 111 patients. In 76 patients there was extrapulmonary sarcoidosis. The coincidence of sarcoidosis with autoimmune diseases was observed in 10 patients; 6 patients developed trombembolic disease. One patient suffered from sarcoidosis with cystic fibrosis. Spontaneous resolution was seen in 65 (38.5%) patients; 37 (64%) stage I patients, 26 (31%) stage II patients, and 2 (11%) stage III patients. One hundred one patients (60%) received corticosteroids. Adverse events of corticosteroid therapy were observed in 28 (26%) patients. In sarcoidosis patients with spontaneous resolution, no relapse of disease was observed. On the other hand, eleven (11%) patients treated with glucocorticosteroids relapsed. Median time to sarcoidosis relapse was 6 months (2-34). The age under 40 years, the X-ray stage I or II, the high CD4/CD8 ratio in bronchoalveolar fluid, pulmonary involvement, and therapy need for a period shorter than 2 years were assessed as a significant good prognostic factors. Observed lethality of our patient cohort was 1.2% (2 patients; both deaths related to sarcoidosis).

[Hidden cystic fibrosis in patient suffering from sarcoidosis]

We describe a case of an adult patient, whom sarcoidosis was diagnosed at first and cystic fibrosis was also discovered 2 years later on. Cystic fibrosis and sarcoidosis are uncommon diseases that only rarely occur together. On the other hand, the coincidence of sarcoidosis and cystic fibrosis is possible, and, moreover, one of the diseases can remain undiagnosed long time. Relationship between sarcoidosis and cystic fibrosis seems not to be probable, in accordance with recent medical reports, and the coincidence of both conditions appears as sporadic.

[Pulmonary Langerhans cell histiocytosis--evaluation of the disease activity and treatment response using PET-CT (SUV(max) Pulmo/SUV(max) Hepar index). Description of own experience and literature review]

Pulmonary Langerhans cell histiocytosis (LCH) manifests with dyspnoea and a cough with no significant expectoration, with spontaneous pneumothorax being the first symptom in some patients. The disease is caused by multiple granulomas in terminal bronchioles, visible on high resolution CT (HRCT) as nodules. During the further course of the disease, these nodules progress through cavitating nodules into thick-walled and, subsequently, thin-walled cysts. LCH may affect the lungs only or multiple organs simultaneously. Pulmonary LCH may continually progress or remit spontaneously. Treatment is indicated in patients in whom pulmonary involvement is associated with multi-system involvement or when a progression of the pulmonary lesions has been confirmed. To document the disease progression, examination of the lungs using HRCT is routinely applied. Increasing number of nodules suggests disease progression. However, determining the number of nodules is extremely difficult. Measuring radioactivity of the individual small pulmonary loci (nodules) using PET is not possible due to the high number and small size of the nodules. Our centre has a register of 23 patients with LCH; the pulmonary form had been diagnosed in 7 patients. A total of 19 PET and PET-CT examinations were performed in 6 of these patients. PET-CT was performed using the technique of maximum fluorodeoxyglucose accumulation in a defined volume of the right lung--SUV(max) Pulmo. In order to compare the results of examinations performed using the same and different machines over time as well as in order to evaluate pulmonary activity, the maximum fluorodeoxyglucose accumulation in a defined volume of the right lung (SUV(max) Pulmo) to maximum fluorodeoxyglucose accumulation in a defined volume of the liver tissue (SUV(max) Hepar) ratio (index) was used. The disease progression was evaluated using the SUV(max) Pulmo/SUV(max) Hepar index in the six patients with pulmonary LCH. The index value was compared to other parameters characterising the disease activity (HRCT of the lungs, examination of pulmonary function and clinical picture). The SUV(max) Pulmo/SUV(max) Hepar index correlated closely with other disease activity parameters. The traditional PET-CT examination is useful in detecting the LCH loci in the bone, nodes and other tissue but not in the presence of diffuse involvement of pulmonary parenchyma. Measuring the maximum fluorodeoxyglucose accumulation in a defined volume of the right lung and expressing this activity as the SUV(max) Pulmo/SUV(max) Hepar index appears to be a promising approach. Our initial experience suggests that the results obtained using this method correlate well with other parameters that characterise activity of pulmonary LCH. However, this is a pilot study and further verification is required.

[Idiopathic pulmonary fibrosis]

Idiopathic pulmonary fibrosis (IPF), known in Europe as cryptogenic fibrosing alveolitis, is a rare, progressive and usually fatal form of idiopathic interstitial pneumonia. IPF is characterized by failure of alveolar re-epithelization, persistence of fibroblasts, deposition of extracellular matrix, and distortion of lung architecture which ultimately results in respiratory failure. Current consensus statements reserve the term IPF to refer to a specific clinical entity associated with the histopatological pattern of usual interstitial pneumonia (UIP). UIP is characterized by temporal heterogeneity, with alternating areas of interstitial fibrosis, fibroblastic foci (areas of proliferating fibroblasts and myofibroblasts), inflammation, honeycomb lung, and normal parenchyma. Fibroblastic foci are associated with progressive disease. Treatment of IPF remains clinical problem. Currently, there is no conservative therapy improving the survival of patients. Lung transplantation, however, improves survival. Identification of pathways crucial to fibrogenesis might offer potentially novel therapeutic targets to slow or halt progression of IPF.