Impact of maternal social vulnerability and timing of prenatal care on outcome of prenatally detected congenital heart disease

OBJECTIVES

Early prenatal detection of congenital heart disease (CHD) allows mothers to plan for their pregnancy and delivery; however, the effect of certain sociodemographic and fetal factors on prenatal care has not been investigated thoroughly. This study evaluated the impact of maternal and fetal characteristics on the timing of prenatal diagnosis of CHD and fetal and postnatal outcomes.

METHODS

This retrospective multicenter cohort study included women with a fetal echocardiographic diagnosis of CHD between 2010 and 2019. Women were grouped into quartiles of social vulnerability (quartiles 1-4; low-high) using the 2014 social vulnerability index (SVI) provided by the Centers for Disease Control and Prevention. A fetal disease severity score (range, 1-7) was calculated based on a combination of CHD severity (mild = 1; moderate = 2; severe, two ventricles = 3; severe, single ventricle = 4 points) and prenatally diagnosed genetic abnormality, non-cardiac abnormality and fetal hydrops (1 point each). Late diagnosis was defined as a fetal echocardiographic diagnosis of CHD after 24 weeks' gestation. Univariate and multivariable regression analyses were used to identify factors associated with late diagnosis, termination of pregnancy (TOP), postnatal death, prenatal-postnatal discordance in CHD diagnosis and severity and, for liveborn infants, to identify which prenatal variables were associated with postnatal death or heart transplant.

RESULTS

Among 441 pregnancies included, 94 (21%) had a late diagnosis of CHD. Late diagnosis was more common in the most socially vulnerable quartile, 38% of women in this group having diagnosis > 24 weeks, compared with 14-18% in the other three quartile groups. Late diagnosis was also associated with Catholic or other Christian religion vs non-denominational or other religion and with a lower fetal disease severity score. There were 93 (21%) TOP and 26 (6%) in-utero fetal demises. Factors associated with TOP included early diagnosis and greater fetal disease severity. Compared with the other quartiles, the most socially vulnerable quartile had a higher incidence of in-utero fetal demise and a lower incidence of TOP. Among the 322 liveborn infants, 49 (15%) died or underwent heart transplant during the follow-up period (range, 0-16 months). Factors associated with postnatal death or heart transplant included longer delay between obstetric ultrasound examination at which CHD was first suspected and fetal echocardiogram at which CHD was confirmed and greater fetal disease severity.

CONCLUSIONS

High social vulnerability, Catholic or other Christian religion and low fetal disease severity are associated with late prenatal CHD diagnosis. Delays in CHD diagnosis are associated with fewer TOPs and worse postnatal outcome. Therefore, efforts to expedite fetal echocardiography following abnormal obstetric screening, particularly for at-risk women (e.g. those with high SVI), have the potential to impact pregnancy and postnatal outcome among the prenatally diagnosed CHD population. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Experimental demonstration of accurate Bragg peak localization with ionoacoustic tandem phase detection (iTPD)

Accurate knowledge of the exact stopping location of ions inside the patient would allow full exploitation of their ballistic properties for patient treatment. The localized energy deposition of a pulsed particle beam induces a rapid temperature increase of the irradiated volume and leads to the emission of ionoacoustic (IA) waves. Detecting the time-of-flight (ToF) of the IA wave allows inferring information on the Bragg peak location and can henceforth be used forin-vivorange verification. A challenge for IA is the poor signal-to-noise ratio at clinically relevant doses and viable machines. We present a frequency-based measurement technique, labeled as ionoacoustic tandem phase detection (iTPD) utilizing lock-in amplifiers. The phase shift of the IA signal to a reference signal is measured to derive theToF. Experimental IA measurements with a 3.5 MHz lead zirconate titanate (PZT) transducer and lock-in amplifiers were performed in water using 22 MeV proton bursts. A digital iTPD was performedin-silicoat clinical dose levels on experimental data obtained from a clinical facility and secondly, on simulations emulating a heterogeneous geometry. For the experimental setup using 22 MeV protons, a localization accuracy and precision obtained through iTPD deviates from a time-based reference analysis by less than 15μm. Several methodological aspects were investigated experimentally in systematic manner. Lastly, iTPD was evaluatedin-silicofor clinical beam energies indicating that iTPD is in reach of sub-mm accuracy for fractionated doses < 5 Gy. iTPD can be used to accurately measure theToFof IA signals online via its phase shift in frequency domain. An application of iTPD to the clinical scenario using a single pulsed beam is feasible but requires further development to reach <1 Gy detection capabilities.

Deliberating performance targets workshop: Potential paths for emerging PM2.5 and O3 air sensor progress

The United States Environmental Protection Agency held an international two-day workshop in June 2018 to deliberate possible performance targets for non-regulatory fine particulate matter (PM_2.5) and ozone (O₃) air sensors. The need for a workshop arose from the lack of any market-wide manufacturer requirement for Ozone documented sensor performance evaluations, the lack of any independent third party or government-based sensor performance certification program, and uncertainty among all users as to the general usability of air sensor data. A multi-sector subject matter expert panel was assembled to facilitate an open discussion on these issues with multiple stakeholders. This summary provides an overview of the workshop purpose, key findings from the deliberations, and considerations for future actions specific to sensors. Important findings concerning PM_2.5 and O₃ sensors included the lack of consistent performance indicators and statistical metrics as well as highly variable data quality requirements depending on the intended use. While the workshop did not attempt to yield consensus on any topic, a key message was that a number of possible future actions would be beneficial to all stakeholders regarding sensor technologies. These included documentation of best practices, sharing quality assurance results along with sensor data, and the development of a common performance target lexicon, performance targets, and test protocols.

[Impulse oscillometry in the diagnosis of the severity of obstructive pulmonary disease]

Impulse oscillometry (IOS) is a computer-supported method for the measurement of complex mechanical airway characteristics. The aim of this study was to evaluate the applicability of IOS in the diagnosis of obstructive airway diseases in comparison to the standard methods of spirometry, pneumotachymetry, and bodyplethysmography. 244 patients (age 61.5 +/- 13.6 years; 61 % men) with bronchial asthma (n = 65) and chronic obstructive pulmonary disease (COPD) (n = 179) were retrospectively analysed. By means of body plethysmography (Srtot < 120%pred) an obstruction was diagnosed in 94%, by pneumotachymetry (FEV1 < 80%pred) in 78 %, and by IOS depending on the parameter chosen in 87-94% of patients. Mild and medium obstructions could be identified by means of all IOS parameters except for R20: severe obstructions, however, were better detected by means of the frequency-dependent resistance FDR and reactance at 5 Hz, X5. The parameters R5, X5, and Zrs, however, showed a tendency to underestimate the degree of obstruction. Bronchial obstruction can reliably be diagnosed by IOS when, in cases of severe obstruction, more complex parameters like FDR and X5 are included. The parameters of the standard methods (body plethysmography and pneumotachymetry) show relatively low correlations due to the different measurement methods not only in comparison to IOS but also to one another. In summary, IOS is a convenient method for patients with a low dependency on cooperation for the evaluation of obstructive airway diseases complementary to the established standard methods and, in addition, is useful as a sensitive screening tool for the early detection of bronchial obstruction.

Treatment of invasive pulmonary aspergillosis in neutropenic patients by additional bronchoscopic amphotericin B instillation

BACKGROUND

Invasive pulmonary aspergillosis (IPA) remains a life-threatening condition despite systemic antifungal therapy.

OBJECTIVES

This retrospective analysis investigated whether additional bronchoscopic instillation of amphotericin B (amB) would improve efficacy of antifungal treatment in patients with haematological malignancies suffering from IPA.

METHODS

Twenty patients (40.6 +/- 14.2 years, 14 male) with preceding chemotherapy, bone marrow or stem cell transplantation complicated by severe IPA who did not respond sufficiently to systemic antifungal therapy were additionally treated by repeated bronchoscopic instillations of amB solution (91 instillations, on average 4.6 +/- 2.2 instillations per patient over a period of 24.1 +/- 21.0 days). Therapeutic response to this combined treatment regimen was monitored by chest X-ray and CT scan.

RESULTS

The mean infiltration sizes during systemic antifungal therapy alone (mean duration 11.9 +/- 9.9 days) did not change significantly. However, after additional bronchoscopic instillation of amB solution infiltration sizes were reduced significantly (p < 0.05). A total resolution of infiltrates was seen in 3 and a partial reduction in 13 of 20 patients. Mean duration of total antifungal treatment was 50.1 +/- 24.0 days. The mean follow-up period was 34.1 +/- 31.2 months. The IPA-related mortality rate was 18.8% (3 of 16 patients).

CONCLUSIONS

Additional bronchoscopic instillation of amB may improve the efficacy of systemic antifungal therapy in patients with haematological malignancies complicated by severe IPA. Bronchoscopic instillation of amB should be considered as an additional treatment option in cases with IPA unresponsive to systemic therapy.

Antenatal Ultrasonographic Appearance of Isolated Fetal Ascites

BACKGROUND

Isolated fetal ascites can be caused by many heterogeneous disorders and is associated with a variety of conditions. Cloacal anomalies are rare abnormalities with a highly variable array of sonographic symptoms, which make them difficult to diagnose antenatally. We present a case with isolated fetal ascites without hydronephrosis caused by a cloacal malformation.

CASE

A 28-year-old woman, gravida 2, para 1, was referred to our unit at 18 weeks gestation with a hyperdense structure in the fetal liver. Cordocentesis revealed a normal karyotype and negative viral titers. Isolated fetal ascites occurred for the first time at 23 weeks gestation. Serial ultrasounds showed progressive fetal ascites with no hydronephrosis at any time and no other malformations apart from the previously diagnosed hyperechogenic liver structure. After the insertion of an abdomino-amniotic shunt, a temporary reduction of the sonographically detectable ascites could be achieved. Cesarean delivery was necessary due to a pathological CTG at 33 weeks of gestation. The baby was born with a markedly distended abdomen. Postnatal radiologic examination showed two fistulae between the cloaca and the notedly dilated vagina and the rectum respectively. At the age of 3 months a vaginoplasty was performed, which involved creating a correctly positioned vaginal opening, reconstruction of the urethra and rectum as well as occlusion of the two fistulae.

CONCLUSION

In view of the examinations, performed before and after delivery, it has to be assumed that fetal urine drained via the cloaca through the fallopian tubes into the abdomen. In contrast to usual appearance of cloacal malformations no hydronephrosis was detected and the kidney function was normal at all times. To our knowledge, this is the first published case of isolated fetal ascites without hydronephrosis caused by a cloacal malformation.

[Matrix metalloproteinases and their inhibitors in lung cancer with malignant pleural effusion]

Matrix metalloproteinases (MMP) and tissue inhibitors of metalloproteinases (TIMP) play a crucial role in physiological and pathological matrix turnover. This study aimed to determine the occurrence of MMP and TIMP in lung cancer patients with malignant pleural effusions (CA).

METHODS

MMP-1, MMP-2, MMP-3, MMP-8, MMP-9, TIMP-1, and IMP-2 oncentrations were determined by ELISA and zymography in pleural effusions and plasma of 31 CA and 14 congestive heart failure (CHF) patients and in plasma of 18 healthy controls (CON).

RESULTS

MMP-2, TIMP-1, and TIMP-2 ELISA-concentrations were increased in CA pleural fluid vs. CA plasma (p < 0.005, p < 0.005, p < 0.05), in contrast to MMP-9 being higher in plasma (p < 0.005). Pleural fluid MMP-1 and MMP-8 were increased in CA vs. CHF (p < 0.05, p < 0.005). MMP and TIMP plasma concentrations were not different in CA vs. CHF, but MMP-9, TIMP-1, and TIMP-2 were increased vs. CON (p < 0.005, each). Gelatine zymography MMP-9/MMP-2 ratios were increased in CA plasma vs. effusion fluid (p < 0.005), in CA vs. CHF plasma, CA vs. CHF effusions (p < 0.005 each), and in CA vs. CON plasma (p < 0.05).

CONCLUSIONS

MMP-2, TIMP-1, and TIMP-2 accumulate in the pleural compartment in CA and CHF, probably reflecting an unspecific pleural reaction. MMP-1 and MMP-8 are increased in cellular rich CA pleural effusions only. The determination of MMP-9/MMP-2 ratios in pleural fluid may contribute to differentiate CHF from CA effusions.

Bosentan therapy for portopulmonary hypertension

The dual endothelin receptor antagonist bosentan has been approved in several countries for pulmonary arterial hypertension, and patients with portopulmonary hypertension (PPHTN) have not specifically been excluded. However, no data have been published on the efficacy and safety of bosentan in this patient population. Here, the first clinical experiences with bosentan in patients with Child A cirrhosis and severe PPHTN are reported. In total, 11 consecutive patients with cirrhosis and severe PPHTN in New York Heart Association Functional Classes III and IV were treated for >1 yr with bosentan. After 1 yr of treatment with bosentan, all patients showed improved symptoms and exercise capacity. The 6-min walking distance increased from 310+/-102 m at baseline to 388+/-81 m at 1 yr. Cardiopulmonary exercise testing disclosed a significant increase in peak oxygen uptake, from 12.6+/-3.5 to 16.6+/-2.8 mL.min(-1).kg(-1). Pulmonary vascular resistance fell from 944+/-519 to 635+/-321 dynes.s.L(-1). The medication was well tolerated by all patients, and there was no evidence of drug-related liver injury. In conclusion, bosentan proved to be efficacious and safe in a small number of patients with portopulmonary hypertension.

Vascular endothelial growth factor in pleural effusions of different origin

This study aimed to determine the diagnostic relevance of vascular endothelial growth factor (VEGF) in the pleural fluid and serum of patients with pleural effusions of different aetiology. VEGF was quantified in the pleural effusion fluid and serum of 96 patients with malignancies (58 lung cancers (CA) and 38 tumours with secondaries to the lung (TM)), 45 with congestive heart failure (CHF), 28 with tuberculosis (TB), 45 with acute infections (INF), and in the serum of 20 healthy controls. VEGF pleural effusion concentrations were significantly different in the main diagnostic groups. VEGF was higher in effusions of patients with malignancies (CA as well as TM) in comparison with INF, TB or CHF. In serum, however, high VEGF concentrations indicated CA, TM or INF, but not TB or CHF. Despite significant differences of VEGF levels in different patient groups, receiver-operating characteristic analysis revealed insufficient diagnostic value of VEGF for differential diagnosis of pleural effusions. In conclusion, vascular endothelial growth factor serum concentration is highly suggestive of the presence of lung disease in general, except for tuberculosis. In effusion fluid, the presence of vascular endothelial growth factor clearly indicates inflammatory or malignant origin. However, for diagnostic use, additional parameters besides vascular endothelial growth factor are mandatory.

[Immunohistochemical localization of matrix metalloproteinases (MMP) and tissue inhibitors of metalloproteinases (TIMP) in tuberculous pleuritis]

Matrix metalloproteinases (MMP) and tissue inhibitors of metalloproteinases (TIMP) have been found by ELISA and gelatine zymography in different concentrations in pleural fluid in tuberculous (TB) pleuritis. For further differentiation MMP and TIMP were localized in pleural biopsies by immunhistochemical staining with antibodies directed against MMP-1, MMP-2, MMP-3, MMP-9, TIMP-1, and TIMP-2 using the Labelled-Avidin-Biotin (LAB). Immunohistological reactivity of MMP-1 was found in epitheloidcellular histiocytes, Langhans' giant cells, lymphocytes, macrophages, as well as in fibroblasts of granulomatous reactions. MMP-2 was found in a few epitheloid cellular histiocytes, fibroblasts, and inflammatory cells. MMP-3 was weakly positive in a few lymphocytes only. MMP-9 was found in a few fibroblasts, epitheloid cells, and inflammatory cells, foremost, however, in pleural mesothial cells. A few fibroblasts only showed immunoreactivity of TIMP-1 and TIMP-2. The observed inhomogenous staining pattern could be explained by the different state of activation of individual cellular units. In conclusion, the immunohistochemical demonstration of MMP and TIMP in pleural cells and tissue structures indicates their local involvement in fibrosing reactions in TB-pleuritis.

Unerwartete Ursache einer Fußwurzeldestruktion bei einem Diabetiker

HISTORY

A 56-year-old male patient has suffered from increasing pain in the left foot which limited the ability of walking since 18 months. There was a soft and painful swelling below the left inner ankle. In addition the patient reported back pain, but no neurological symptoms. Insulin dependent diabetes type II was known for 20 years, and a diabetic foot syndrome was suspected. 6 months prior the patient consulted his physician because of repeated acute bronchitis with expectoration and no improvement following antibiotic therapy.

INVESTIGATIONS

Osteolytic destruction of the left middle foot and the tarsal with soft tissue infiltration according to MR, a spondylodiscitis of the lumbar vertebra I and II (MR) and mixed interstitial/alveolar infiltrates throughout the lung with a predominance in both upper lobes were found. The microbiological examination of sputum and biopsy of inflamed soft tissue of the left ankle revealed infection with mycobacterium tuberculosis.

DIAGNOSIS

Open lung tuberculosis with concomitant bone tuberculosis and tuberculous arthritis of the left middle foot and spondylodiscitis.

THERAPY AND CLINICAL COURSE

The antibiotic therapy consisted of a combination of five antibiotic drugs for 2 weeks and of a four drug combination for further 3.5 months. After that there will be a consolidation therapy with a two drug regime for 6 months. An orthopaedist is also involved. Surgical procedures with respect to the left foot will not be considered as long as the antibiotic therapy has not been finished.

CONCLUSION

A combination of symptoms resulting from inflammatory bone processes and pulmonary symptoms is always suspicious for a hematogenic dissemination of a pulmonary tuberculosis.

Lungeninfiltrat, Pleuraerguss und IgM-Makroglobulinämie

We report a 71-year-old mam with known IgM- Macroglobulinemia, who developed infiltrative pulmonary changes and a pleural effusion. Both, the pleural effusion and bronchoalveolar lavage revealed monoclonal IgM positive B-lymphocytoes. Transbronchial biopsies showed tissue infiltrates of lymphoplasmocytic cells, consistent with a pleuropulmonary manifestation of Morbus Waldenstroem. Bone marrow and gastrointestinal involvement could be excluded, and the diagnosis of a primary pulmonary immunocytoma was made. The patient underwent partial lung resection with removal of the affected lung tissue. Pleuropulmonary changes in patients with IgM-Macroglobulinaemia or Morbus Waldenstroem may be due to pulmonary involvement by the hematological disease.

[62-year-old patient with progressive dyspnea and positional left-sided thoracic pain]

A 62-year-old male patient presented with left-sided chest pain experienced in a lying position and progressive dyspnea. He had a history of thyroid carcinoma treated 22 years ago and a nodular shadow in the left lung first identified 9 years ago. He refused any further diagnostic and therapeutic measures for the nodular shadow as he had been free of symptoms. The clinical findings at presentation included labial and acral cyanosis. Breathing sounds over the lower left lung were diminished. A chest X-ray revealed a 9 x 8-cm cloudiness lateral to the left border of the heart, which was confirmed in a contrast thoracic CT evidencing a smooth surface and a wall absorbing contrast medium. Staging diagnostics indicated no further tumor manifestations. Needle biopsy showed fibrous tissue. Thoracotomy with tumor extirpation exhibited a solitary fibrous tumor of the pleura. Solitary fibrous tumor of the pleura is a rare cause for a nodular shadow of the lung. Clinical findings are rather nonspecific. Complete resection is the therapy of choice. Resection of functional lung tissue has to be avoided because the tumor often is pediculated.

[Miflonide/Foradil via Aerolizer compared with other anti-inflammatory and anti-obstructive therapeutic regimens]

Standard therapy of asthma consists of combined, antiinflammatory (steroids) and anti-obstructive (long acting/short acting beta-agonist) treatment via inhalation using two separate or a single inhalation device. Here, we report the results of using Miflonide (Budesonide 400 - 800 microg per day) and Foradil (Formoterol 24 - 48 microg per day) in cases of moderate and severe asthma previously treated insufficiently with another combination therapy. 80 patients with asthma previously treated insufficiently with any other combination therapy of steroid and long acting beta-agonist were included. Instead of their previous therapy all were switched to therapy with Miflonide and Foradil for eight weeks (two office visits at 4 and 8 weeks). Lung function (peak flow [l/min], FEV1 [I], FVC [I], R(tot) [kPa*s/l]) was performed at every visit. Doctors' and patients' estimation of disease severity, physical examination, drug related side-effects and the use of short acting beta-agonist aerosols were registered. Lung function parameters improved significantly compared to the run in phase prior to the change in medication (peak flow: + 18.4 %, FEV 1 : + 10.7 %, FVC: + 6.8 %, R(tot) : -18.0 %). Use of additional short acting inhalative beta-agonists was reduced. Subjectively, patients judged their general condition as improved, effectiveness as greater compared to previous medication and side effects as tolerable. The use of a combination of Miflonide/Foradil lead to an improvement in subjective and objective parameters in asthma patients that had previously been treated with a variety of other antiinflammatory and anti-obstructive therapy regimens. Reasons for this observation are beside change in medication, patients training in asthma therapy, change of application system, and increase of patients compliance.

[Febrile respiratory infection and erythema in a 25-year-old man]

HISTORY AND CLINICAL FINDINGS

A 26-year-old man fell acutely ill with fever (39 degrees C), rigor, dry cough, headache and pain in the neck and limbs. Ambulant treatment with amoxycillin, later cefuroximaxetil, worsened his general condition. At admission to hospital he had, over his trunk and limbs, cocarde-like, erythematous efflorescences up to 2 cm in diameter with central elevations and blisters. Additional acute bronchitis, pharyngitis, stomatitis, tonsillitis, conjunctivitis and urethritis indicated extensive mucosal involvement.

INVESTIGATIONS

Significant findings were: 9900/microl WBC, ESR 57 mm at one hour, C-reactive protein 160 mg/l, capillary pO2 6.4 kPa, pCO2 4.2 kPa. Mycoplasma serology (days 1, 8, 15) took a typical course. Chest radiogram showed an interstitial infiltrate on day 5.

DIAGNOSIS

Respiratory Mycoplasma infection with interstitial pneumonia and exudative erythema multiforme.

TREATMENT AND COURSE

Because infection with an atypical pathogen was suspected, antibiotic treatment was changed to erythromycin and, at the suggestion of the dermatologist and ophthalmologist, local treatment (erythromycin, dexamethasone and dexpanthenol) was begun. Mycoplasma serology was first positive on day 3. The fever had disappeared on day 6 and the rash had regressed. Blood gases and blood picture were normal by day 8. The patient was discharged on day 18, after marked improvement of the skin and mucosal changes.

CONCLUSION

The occurrence of a rare dermatological complication of a relatively common respiratory Mycoplasma infection can, when the erythema precedes positive Mycoplasma serology, aid in the differential diagnosis.

[Nosocomial pneumonias in haematological malignancies in the medical intensive care unit]

30 patients with malignant haematological disorders and nosocomial pneumonia, treated during a three-year period in the medical intensive care unit (ICU) of a university hospital, were studied in retrospect. Twelve patients had received bone marrow or peripheral stem cell transplantations 90 +/- 143 (10 - 546) days prior to ICU admission. Six of these received cyclosporin A. 19 of 30 patients were on corticosteroids and 20 had received courses of chemotherapy within a period of one month prior to ICU admission. Patients presented with signs of pulmonary infection and respiratory failure. In 24 patients the likely causative pathogen for pneumonia could be identified. Gram-negative bacteria (n = 17) were in the majority, lead by Pseudomonas, Enterobacter, and Klebsiella species. Gram-positive bacteria (n = 5) were Streptococcus and Staphylococcus species. Infections with Chlamydiae species were diagnosed in two cases. Fungal infections were caused by Candida (n = 8) or Aspergillus species (n = 3) and viral infections by Cytomegalovirus (n = 6). Infections with more than one pathogen were common. Ten patients had pneumonia associated with signs of diffuse pulmonary parenchymal damage of varying degree. 26 patients received mechanical ventilation for 7 +/- 9 (1 - 32) days. The duration of stay in the ICU was 11 +/- 10 (1 - 43) days. 26 of the 30 patients (87 %) died. Patients with haematological malignancies and nosocomial pneumonias have despite medical intensive care treatment a poor prognosis with substantial mortality.

BALF N-acetylglucosaminidase and beta-galactosidase activities in idiopathic pulmonary fibrosis

The lysosomal enzymes N-acetylglucosaminidase (N-ACGA) and beta-galactosidase (beta-gal) are involved in cellular collagen metabolism and may, therefore, be markers of fibrosis in idiopathic interstitial pneumonias, such as idiopathic pulmonary fibrosis (IPF). N-ACGA and beta-gal were analyzed in the bronchoalveolar lavage fluid (BALF) of patients with the histologic pattern of usual interstitial pneumonia (UIP, n=10) and controls (n=9). Cellular distribution in BALF as well as the concentration of TGF-beta a well-known mediator of fibroblast matrix deposition were correlated to the enzyme activities in both groups of patients. We found that both, N-ACGA (UIP: 25.2 nmol/l s +/- 3.4; controls: 73 nmol/l s +/- 1.3) and beta-gal (UIP: 4.7 nmol/l s +/- 0.5; controls: 2.4 nmol/l s +/- 0.3) were elevated significantly in BALF of patients with IPF compared to that of control patients (P<0.003). This increase was paralleled by an increase in neutrophils (IPF: 17.9% +/- 21.8; controls: 5.4% +/- 6.3; P=0.03) and eosinophils (IPF: 2.0% +/- 1.5; controls: 0.2% +/- 0.45; P=0.002) in BALF fluid. In addition, N-ACGA activity correlated closely with lung function (FVC, TLC, and DLCO), transforming growth factor-beta (TGF-beta) in BALF (r=0.77, P=0.008) and activated lymphocytes (r=0.66, P=0.0021). Our findings suggest that measurement of lysosomal enzymes such as N-ACGA may represent a useful indicator of fibrotic activity in IPF.

Adenovirus-mediated E2F-1 gene transfer in nonsmall-cell lung cancer induces cell growth arrest and apoptosis

Since overexpression of E2F-1 has been shown to induce apoptosis, the ability of adenovirus-mediated transfer of E2F-1 to inhibit tumour growth in nonsmall-cell lung cancer cell lines was investigated. Three cell lines with various genomic status were infected with AdE2F. Cell proliferation and viability were determined by trypan blue exclusion. Apoptosis induction was assessed by flow cytometry and poly-adenosine diphosphate-ribose-polymerase cleavage assay. In vivo, the effect of E2F-1 on tumour growth was determined in severe combined immunodeficiency (SCID) mice. The current experiments showed that overexpression of E2F-1 suppressed tumour cell growth. The population of apoptotic cells was dramatically increased 96 h after infection with AdE2F. Inhibition of cell growth and induction of apoptosis was not dependent on genomic status. Moreover, treatment of implanted tumours in SCID mice with AdE2F inhibited tumour growth. These data suggest that adenovirus-mediated E2F-1 gene therapy may be effective in the treatment of nonsmall-cell lung cancer.

Different expression of endothelin in the bronchoalveolar lavage in patients with pulmonary diseases

Endothelin (ET) is a broncho- and vasoconstrictive cytokine, but it also possesses proinflammatory and mitogenic activity. It is suggested to be involved in the pathogenesis of fibrotic lung diseases. We analyzed the concentration of ET 1 in the bronchoalveolar lavage (BAL) fluid in 95 patients with different lung diseases, among them 41 patients with interstitial lung diseases (13 fibrosing alveolitis in systemic sclerosis (FASS), 9 idiopathic pulmonary fibrosis (IFP), 8 sarcoidosis (S), 6 occupational lung disease (OLD), 5 other alveolitidies A), 27 patients with pneumonia, and 8 patients with chronic obstructive pulmonary disease (COPD). A heterogeneous group of 19 patients served as controls. The median ET concentration was 3.3 pg/ml. Significantly higher concentration was found in patients with FASS (5.8 pg/ml), IPF (5.0 pg/ml), and S (5.1 pg/ml) compared with OLD (2.8 pg/ml), A (1.9 pg/ml), COPD (1.5 pg/ml), and the control group (2.5 pg/ml). In pneumonia, the elevated ET concentration (4.1 pg/ml) was accompanied by a high alveolocapillary leakage. When normalized to BAL albumin concentration, only FASS presented with significantly elevated ET/albumin in the BAL compared with the control group (134.5 vs. 56.l pg/mg, p < 0.05). There were no correlations between ET and BAL differential cell count or pulmonary function tests. In current smokers, ET in BALF was significantly higher compared with non- or ex-smokers (3.9 vs. 2.0 pg/ml, p < 0.01), but not so the ET/albumin ratio (65.0 vs. 62.5 pg/mg). In summary, ET in the BAL is differentially expressed in distinct inflammatory and interstitial lung disease. Consistently high concentrations are found in FASS and elevated ET concentration could be discussed in IPF, sarcoidosis, and pneumonia. ET concentration in BAL is influenced by current smoking habits.

BAX and p16INK4A are independent positive prognostic markers for advanced tumour stage of nonsmall cell lung cancer

Clinical studies suggest prognostic relevance of p16INK4A in nonsmall cell lung cancer (NSCLC) while conflicting results for p53 have been published. However, the importance of the apoptosis regulating gene BAX, a downstream regulator of p53, on the prognosis of NSCLC is unknown. The present study investigated the prognostic relevance of BAX with respect to the status of p53 and P16INK4A in 61 patients with advanced NSCLC. Protein expression of BAX, p53 and p16INK4A was investigated retrospectively by immunohistochemistry. Tumour deoxyribonucleic acid (DNA) was screened for p53 mutations by single strand-conformation polymorphism polymerase chain reaction (PCR) and BAX frameshift mutations by fragment length analysis. Patients with positive BAX protein expression had a significantly longer median survival (14 months) than those patients without BAX expression (6 months, p=0.0004). In contrast, p53 status did not influence prognosis. Patients with p161NK4A negative tumours had a significantly shorter survival (4 months) than those with p16INK41 protein expression (15 months, p=0.0001). Furthermore, the loss of p16INK4A protein expression correlated strongly with the pressure of distant and advanced lymph-node metastases. The best survival was seen in a subgroup of 20 patients with positive p16INK4A expression and intact BAX (p=0.0002). The results of the present study suggest that the loss of BAX and p16INK4A expression are independent markers for poor prognosis in nonsmall cell lung cancer. The study suggests that multimarker analysis of genes involved in apoptosis may be useful for determining individual therapy and for identifying targets for gene-replacement therapy. This should be assessed in a prospective study with a larger cohort of patients.

Aspergillus detection in bronchoscopically acquired material. Significance and interpretation

Pulmonary invasive aspergillosis is frequently difficult to diagnose. In particular, the value of the cultivation of Aspergillus and the Aspergillus galactomannan antigen detection (Pastorex) in bronchoscopically acquired material (bronchoalveolar lavage = BAL, bronchial lavage = BL) in the course of diagnosing this mycosis is viewed controversially. Between January 1996 and September 1999, we obtained 114 positive results in 100 bronchoscopically aquired specimens from a total of 69 patients. 59 of the 69 patients were immunosuppressed, 42 suffered from pulmonary aspergillosis and 38 suffered from invasive pulmonary aspergillosis. The positive prediction rate for a positive result with regard to pulmonary aspergillosis in bronchoscopically acquired material was approximately 61%. Cultivation of Aspergillus was more successful in BAL, and the Aspergillus antigen detection was more successful in BL.

Factors influencing breath condensate volume

Analysis of breath condensate (BC) has received interest recently due to the need for easy and repetitive monitoring or airway and pulmonary disease. While many authors have used custom built systems, commercial systems are now available and will probably be used more widely. Early studies of markers and mediators in BC have reported concentrations following varying periods of sampling time. However, factors that influence the generation of BC have not been analysed and it is unclear whether breathing rate, tidal volume, lung function, body weight, height or age influence the amount of BC collected. We therefore studied the influence of these factors on breath condensate volume and breath condensate urea and protein concentrations in 22 healthy volunteers and 23 COPD patients. A strong correlation of total respired volume and breath condensate volume was observed for both groups (volunteers: r=0.952, p < 0.0001, COPD: r=0.883, p < 0.001) while no significant correlation existed for breath condensate volume and TLC, RV, Vc, FEV1, R(tot), height or body weight, As long as ventilation remained fairly constant, breath condensate volume increased linearly with time. The fraction of breath condensate extracted from total vapour contained in the exhalate was estimated by measuring relative atmospheric humidity before and after the collecting tube. The amount calculated by the change in temperature and saturation corresponded closely to the amount actually collected. We conclude from these results that breath condensate volume is primarily dependent on V(E), and does not seem to depend on lung function parameters. For standardisation it is suggested to report breath condensate measurements per volume respired. Both, urea and protein are present in measurable quantities in breath condensate and protein as well as BCV may be helpful denominators for comparison with e.g. cytokines in lung disease.

Occurrence of matrix metalloproteinases and tissue inhibitors of metalloproteinases in tuberculous pleuritis

OBJECTIVE

Matrix metalloproteinases (MMP) and tissue inhibitors of metalloproteinases (TIMP) have been found in high concentrations in pleural effusions. Because MMP and TIMP may play a part in the causation of the fibrosis seen in tuberculous (TB) pleuritis their occurrence was examined.

DESIGN

Pleural effusion fluid and plasma concentrations of MMP-1, MMP-2, MMP-3, MMP-8, MMP-9, TIMP-1 and TIMP-2 were determined by ELISA in 21 patients with TB pleuritis. To adjust for the total protein content, respective ratios were calculated. Activities of MMP-2 and MMP-9 were measured by gelatine zymography and the MMP-9/MMP-2 ratios calculated. Pleural effusions and plasma of 15 patients with congestive heat failure (CHF) and plasma of 15 healthy persons (CON) served as controls.

RESULTS

Immunoreactive pleural fluid concentrations of MMP-1, MMP-2, MMP-8, and MMP-9 were higher in TB compared to CHF, but plasma concentrations were not different between the groups. TB pleural fluid concentrations of MMP-1, MMP-2, TIMP-1, and TIMP-2 were higher compared to TB plasma. MMP-3 was found in trace amounts only. The MMP-9/total protein ratios in pleural fluid were higher in TB compared to CHF (0.4492+/-0.1633 vs 0.0364+/-0.0145, P<0.005) but the TIMP-1 ratios were lower (139.0+/-28.7 vs 517.8+/-183.7, P<0.0005). In TB pleural fluid vs TB plasma, the respective MMP-1, MMP-2, TIMP-1, and TIMP-2 ratios were increased (0.46+/-0.10 vs 0.17+/-0.02; 25.2+/-2.8 vs 4.2+/-0.9; 139.0+/-28.7 vs 27.8+/-8.2; 0.67+/-0.13 vs 0.18+/-0.04, P<0.0005 each). Gelatine zymography demonstrated MMP-2 and MMP-9 bands of different brightness in TB effusions but in CHF effusions the MMP-9 band was barely visible. The MMP-9/MMP-2 effusion ratios were therefore higher in TB compared to CHF (0.46+/-0.15 vs 0.05+/-0.04, P<0.0005).

CONCLUSION

Compartmentalized MMP-1, MMP-2, TIMP-1, and TIMP-2 and, compared to CHF, a surplus of MMP-1, MMP-2, MMP-8, and MMP-9 in the pleural space obviously contribute to the fibrotic reactions in TB pleuritis.

Proinflammatory cytokine levels in patients with lung cancer and carcinomatous pleurisy

Increased levels of interleukin-6 (IL-6) and interleukin-8 (IL-8) have been reported in various diseases, including lung cancer. The role of the soluble form of the IL-6 receptor (sIL-6R) remains to be explored. We therefore measured IL-6, IL-8 and sIL-6R in effusion fluid and blood serum of 10 lung cancer patients with carcinomatous pleurisy (5 men, 5 women, age 64.3 +/- 4.4 years) by enzyme-linked immunosorbent assays. Serum levels of healthy individuals served as control. Concentrations of sIL-6R were much higher in serum compared to pleural effusion fluids of tumor patients (25,698 +/- 1,993 vs. 9,438 +/- 1,407 pg/ml: p < 0.0001). In contrast, IL-6 and IL-8 were found at high concentrations in carcinomatous pleural effusions in comparison to serum (IL-6: 964 +/- 176 vs. 10.2 +/- 1.3 pg/ml, p < 0.0001; IL-8: 319 +/- 85 vs. 9.6 +/- 9.6 pg/ml, p < 0.0001). The serum concentrations of IL-6 were not significantly increased in lung cancer patients (10.2 +/- 1.3 pg/ml) in comparison to controls (7.3 +/- 1.0 pg/ml). IL-8 was detected in the serum of only 1 patient and in low levels in the serum of controls (8.0 +/- 1.5 pg/ml; all values are mean +/- SEM). We conclude from this study that decreased levels of sIL-6R, but increased levels of IL-6 and IL-8, are found in pleural effusion fluid of patients with lung cancer and carcinomatous pleurisy. The low sIL-6R levels in the presence of high IL-6 levels in pleural effusions and the high sIL-6R levels in the presence of low IL-6 levels in serum may suggest a downregulation of sIL-6R expression of sIL-6R shedding in the presence of excessive amounts of IL-6.

Prolonged oral L-carnitine substitution increases bicycle ergometer performance in patients with severe, ischemically induced cardiac insufficiency

Acute and chronic L-carnitine application exerts protective effects in a number of cardiac diseases. These favourable effects are attributed to improvements of the energy metabolism and have been found both in animal experiments and in man. In order to investigate the effect of long-time oral L-carnitine substitution on physical performance, 41 patients suffering from class NYHA II or III cardiac insufficiency were recruited for a clinical study. Following the double-blind, randomized, placebo-controlled design of the study, 20 patients were given 3 x 1 g L-carnitine daily for 120 days whereas the control group (21 patients) received placebo. Bicycle ergometer tests were used to determine maximum performance, systolic and diastolic blood pressure, heart rate, and ST changes. Four series of tests were carried out: on day 0 (before the first substrate application), on the 60th and the 120th day (during L-carnitine or placebo application), and on the 180th day (60 days after the end of substitution). A significant improvement in performance (significantly higher maximum performance during bicycle ergometry) could be found within the carnitine group on the 60th and 120th day of L-carnitine application; and haemodynamical parameters showed a tendency to improve, too. These effects, which were attributed to L-carnitine, could be detected even 60 days after the end of substitution. No corresponding changes were found in the placebo group. The findings presented in this paper support suggestions of other authors that L-carnitine in combination with the usual medication (digitalis, beta-blockers, calcium antagonists, nitrates) improves performance and effort tolerance in patients with cardiac insufficiency. Moreover, the findings suggest a favourable long-term effect, which lasts beyond the actual L-carnitine application, on the performance of patients with advanced cardiac insufficiency.

[The solitary echinococcal cyst--a rare cause of a round pulmonary focus]

HISTORY AND ADMISSION FINDINGS

A 29-year-old man from Kazakhstan presented with right-sided chest pain, cough, whitish sputum and a temperature up to 38.5 degrees C. He had been working in an animal farm for the previous two years.

INVESTIGATIONS

Laboratory tests showed increased inflammatory parameters (WBC 15.9 gpt/l with an increased proportion of band and segmented granulocytes, C-reactive protein (242.3 mg/dl). Chest radiogram showed an infiltration and effusion in the right base judged to be due to pneumonia. In addition there was a round homogeneous mass, 2.5 cm in diameter, at the lateral thoracic wall in the 8th lower lobe segment. Computed tomography (CT) of the lung and mediastinum confirmed these findings. Bronchoscopy, echocardiography, upper abdominal sonography and CT of the skull revealed no other space-occupying lesion.

DIAGNOSIS, TREATMENT AND COURSE

The right-sided pneumonia was successfully treated, at first with ceftriaxone (i.v.), later with ofloxacin (by mouth). An echinococcal cyst was considered especially because of the patient's profession in Kazakhstan in the differential diagnosis of the right-sided round mass and confirmed by an indirect haemagglutination test giving an antibody titre of 1:1024. In response a thoracotomy was performed and the mass, histologically an echinococcal cyst (E. granulosa), resected. There were no other cysts. There was no explanation for the right-sided pneumonia.

CONCLUSIONS

Even though Echinococcosis is rare in Central Europe, it should be included in the differential diagnosis of a round pulmonary mass. A detailed history, especially with regard to occupation and country of origin, is essential. Serological tests for specific Echinococcus antibodies, together with usual imaging procedures, will usually and quickly provide the diagnosis.

Compartmentalization of pro-inflammatory cytokines in tuberculous pleurisy

Increased levels of interleukin-6 (IL-6) and IL-8 are found in various immunologically mediated inflammatory disorders. Concentrations of IL-6, IL-8 and the soluble form of the IL-6 receptor (sIL-6R) were determined in serum and effusion fluid of 25 patients with tuberculous pleurisy utilizing enzyme linked immunosorbent assays (EIA). Serum IL-6 levels were only slightly increased in patients with tuberculous pleurisy in comparison to controls (11.1 +/- 2.1 vs 7.3 +/- 1.0 pg ml-1). IL-8 could not be detected in the serum of tuberculosis patients, but it was detected in the serum of healthy controls (8.0 +/- 1.5 pg ml-1). In comparison to serum, IL-6 and IL-8 were found in high concentrations in pleural effusions (IL-6: 932 +/- 70 vs 11.1 +/- 2.1 pg ml-1, P < 0.0001; IL-8: 450 +/- 85 vs 0 +/- 0 pg ml-1). In contrast, sIL-6R concentrations were much higher in serum compared to pleural effusion levels [30,477 +/- 1905 vs 9881 +/- 1177 pg ml-1, P < 0.0001 (mean +/- SEM)]. The authors conclude that elevated levels of IL-6 and IL-8 in pleural effusions are compartmentalized at the site of active disease. The low levels of sIL-6R in the presence of high levels of IL-6 in pleural effusions, and the high levels of sIL-6R in the presence of low levels of IL-6 in serum suggest that the expression or shedding of sIL-6R may be downregulated in the presence of excessive amounts of IL-6.