Understanding Misdemeanor Enforcement: The Roles of Calls for Service and Community Characteristics

This study examines the roles of calls for service (i.e., police-related 911 calls) and community characteristics in explaining variation in enforcement rates for low-level, misdemeanor offenses, which make up the large majority of police enforcement activity. The study site is Prince George's County, Maryland, and the unit of analysis is the police department's 65 patrol beats, studied over a 10-year period, during 2006-2015. Overall, misdemeanor enforcement rates vary at the beat level, and that variation can be largely explained using a combination of indicators about community characteristics and calls for service. The findings indicate, though, that the calls for service rate is the most important variable in explaining misdemeanor enforcement variation. These findings inform both future research on police activity, and current policy debates about what drives enforcement rates and the role of discretion in enforcement outcomes.

The contribution of age structure to the international homicide decline

Background

Since 1990, the world’s homicide rate has declined by nearly 20%. While prior research has documented parallel homicide declines across many individual countries, the causes of a shared international homicide decline remain unknown. Drawing on a worldwide process of population ageing, and on research linking age to criminal activity, this study investigates the contribution of global demographic shifts to the international homicide decline.

Methods

We draw from (1) a High Coverage Sample of 126 countries since 1990, and (2) a Long Series Sample of 26 countries since 1960 and utilize fixed-effect regressions to evaluate the impact of age structure on homicide trends. In addition, we use a quantile regression to explore variations in the relationship between age structure and homicide conditional on homicide levels.

Findings

Results using the High Coverage Sample suggest no relationship between age structure and homicide. However, results from the Long Series Sample suggest that changes in the relative size of countries’ youth population is a major predictor of homicide trends since 1960. In exploring this divergence, we find that the influence of age structure on homicide becomes less evident as other risk factors for violence gain prominence. Thus, while high homicide countries had the most to gain from falling homicide rates, the safety benefits of an ageing population have been concentrated among the least violent countries.

Interpretation

While the homicide declines of individual countries have often been attributed to domestic policies, the universality of international homicide trends suggests the influence of broader global phenomenon. We find that countries’ homicide trends are strongly associated with changes in the size of their youth populations, particularly where there are few competing criminogenic forces. Based on these results, we propose an explanation for the international homicide decline, while highlighting the importance of demographic patterns in explaining homicide trends.

A Comparative Assessment of Public Opinion toward Immigrants and Immigration Policies

This article is part of a larger study of public attitudes toward immigration in seven countries that historically and currently have had different policies and practices vis-a-vis immigration. The countries involved are Australia, Canada, France, Germany, Great Britain, Japan and the United States. The time frame for which most of the public opinion data will be reported is from 1970 through 1995. The data have been collected from national surveys that were conducted in each of the countries.

The Prognostic Importance of Bronchoalveolar Lavage Fluid CXCL9 During Minimal Acute Rejection on the Risk of Chronic Lung Allograft Dysfunction

The clinical significance and treatment strategies for minimal acute rejection (grade A1), the most common form of acute rejection (AR), remain controversial. In this retrospective single-center cohort study of 441 lung transplant recipients, we formally evaluate the association between minimal AR and chronic lung allograft dysfunction (CLAD) and test a novel hypothesis using bronchoalveolar lavage (BAL) CXCL9 concentration during minimal AR as a biomarker of subsequent CLAD development. In univariable and multivariable models adjusted for all histopathologic injury patterns, minimal AR was not associated with CLAD development. However, minimal AR with elevated BAL CXCL9 concentrations markedly increased CLAD risk in a dose-response manner. Minimal AR with CXCL9 concentrations greater than the 25th, 50th, and 75th percentile had adjusted hazard ratios (HRs) for CLAD of 1.1 (95% confidence interval [CI] 0.8-1.6), 1.6 (95% CI 1.1-2.3), and 2.2 (95% CI 1.4-3.4), respectively. Thus we demonstrate the utility of BAL CXCL9 measurement as a prognostic biomarker that allows discrimination of recipients at increased risk of CLAD development after minimal AR. BAL CXCL9 measurement during transbronchial biopsies may provide clinically useful prognostic data and guide treatment decisions for this common form of AR, as a possible strategy to minimize CLAD development.

Impact of Allograft Injury Time of Onset on the Development of Chronic Lung Allograft Dysfunction After Lung Transplantation

The impact of allograft injury time of onset on the risk of chronic lung allograft dysfunction (CLAD) remains unknown. We hypothesized that episodes of late-onset (≥6 months) allograft injury would produce an augmented CXCR3/ligand immune response, leading to increased CLAD. In a retrospective single-center study, 1894 transbronchial biopsy samples from 441 lung transplant recipients were reviewed for the presence of acute rejection (AR), lymphocytic bronchiolitis (LB), diffuse alveolar damage (DAD), and organizing pneumonia (OP). The association between the time of onset of each injury pattern and CLAD was assessed by using multivariable Cox models with time-dependent covariates. Bronchoalveolar lavage (BAL) CXCR3 ligand concentrations were compared between early- and late-onset injury patterns using linear mixed-effects models. Late-onset DAD and OP were strongly associated with CLAD: adjusted hazard ratio 2.8 (95% confidence interval 1.5-5.3) and 2.0 (1.1-3.4), respectively. The early-onset form of these injury patterns did not increase CLAD risk. Late-onset LB and acute rejection (AR) predicted CLAD in univariable models but lost significance after multivariable adjustment for late DAD and OP. AR was the only early-onset injury pattern associated with CLAD development. Elevated BAL CXCR3 ligand concentrations during late-onset allograft injury parallel the increase in CLAD risk and support our hypothesis that late allograft injuries result in a more profound CXCR3/ligand immune response.

Impact of axial root growth angles on nitrogen acquisition in maize depends on environmental conditions

BACKGROUNDS AND AIMS

Crops with reduced requirement for nitrogen (N) fertilizer would have substantial benefits in developed nations, while improving food security in developing nations. This study employs the functional structural plant model SimRoot to test the hypothesis that variation in the growth angles of axial roots of maize (Zea mays L.) is an important determinant of N capture.

METHODS

Six phenotypes contrasting in axial root growth angles were modelled for 42 d at seven soil nitrate levels from 10 to 250 kg ha(-1) in a sand and a silt loam, and five precipitation regimes ranging from 0·5× to 1·5× of an ambient rainfall pattern. Model results were compared with soil N measurements of field sites with silt loam and loamy sand textures.

KEY RESULTS

For optimal nitrate uptake, root foraging must coincide with nitrate availability in the soil profile, which depends on soil type and precipitation regime. The benefit of specific root architectures for efficient N uptake increases with decreasing soil N content, while the effect of soil type increases with increasing soil N level. Extreme root architectures are beneficial under extreme environmental conditions. Extremely shallow root systems perform well under reduced precipitation, but perform poorly with ambient and greater precipitation. Dimorphic phenotypes with normal or shallow seminal and very steep nodal roots performed well in all scenarios, and consistently outperformed the steep phenotypes. Nitrate uptake increased under reduced leaching conditions in the silt loam and with low precipitation.

CONCLUSIONS

Results support the hypothesis that root growth angles are primary determinants of N acquisition in maize. With decreasing soil N status, optimal angles resulted in 15-50 % greater N acquisition over 42 d. Optimal root phenotypes for N capture varied with soil and precipitation regimes, suggesting that genetic selection for root phenotypes could be tailored to specific environments.

Sildenafil increases muscle protein synthesis and reduces muscle fatigue

Reductions in skeletal muscle function occur during the course of healthy aging as well as with bed rest or diverse diseases such as cancer, muscular dystrophy, and heart failure. However, there are no accepted pharmacologic therapies to improve impaired skeletal muscle function. Nitric oxide may influence skeletal muscle function through effects on excitation-contraction coupling, myofibrillar function, perfusion, and metabolism. Here we show that augmentation of nitric oxide-cyclic guanosine monophosphate signaling by short-term daily administration of the phosphodiesterase 5 inhibitor sildenafil increases protein synthesis, alters protein expression and nitrosylation, and reduces fatigue in human skeletal muscle. These findings suggest that phosphodiesterase 5 inhibitors represent viable pharmacologic interventions to improve muscle function.

Changes in chemical composition and digestibility of three maize stover components digested by white-rot fungi

Maize stover (total stem and leaves) is not considered a ruminant feed of high nutritive value. Therefore, an improvement in its digestibility may increase the viability of total forage maize production systems in marginal growth regions. The objective of this study was to describe the changes in chemical composition during the storage of contrasting components of maize stover (leaf, upper stem and lower stem) treated with either of two lignin degrading white-rot fungi (WRF; Pleurotus ostreatus, Trametes versicolor). Three components of maize stover (leaf, upper stem and lower stem), harvested at a conventional maturity for silage production, were digested with either of two WRF for one of four digestion durations (1-4 months). Samples taken prior to fungal inoculation were used to benchmark the changes that occurred. The degradation of acid detergent lignin was observed in all sample types digested with P. ostreatus; however, the loss of digestible substrate in all samples inoculated with P. ostreatus was high, and therefore, P. ostreatus-digested samples had a lower dry matter digestibility than samples prior to inoculation. Similarly, T. veriscolor-digested leaf underwent a non-selective degradation of the rumen-digestible components of fibre. The changes in chemical composition of leaf, upper stem and lower stem digested with either P. ostreatus or T. veriscolor were not beneficial to the feed value of the forage, and incurred high DM losses.

Periostitis secondary to prolonged voriconazole therapy in lung transplant recipients

We report five cases of possible drug-induced periostitis associated with long-term use of voriconazole therapy after lung transplantation (LT). The diagnosis of periostitis was made by the documentation of bone pain, elevation of serum alkaline phosphatase and characteristic findings on radionuclide bone imaging in the absence of any identifiable rheumatologic disease. This periostitis appears similar to hypertrophic osteoarthopathy (HOA) but does not meet all criteria for HOA. In all patients, the symptoms resolved rapidly after discontinuation of voriconazole therapy. Awareness of this potential syndrome, which manifests as bone pain, elevated serum alkaline phosphatase and a bone scan suggestive of periostitis, is necessary in LT recipients on long-term voriconazole.

Aspergillus colonization of the lung allograft is a risk factor for bronchiolitis obliterans syndrome

Multiple infections have been linked with the development of bronchiolitis obliterans syndrome (BOS) post-lung transplantation. Lung allograft airway colonization by Aspergillus species is common among lung transplant recipients. We hypothesized that Aspergillus colonization may promote the development of BOS and may decrease survival post-lung transplantation. We reviewed all lung transplant recipients transplanted in our center between January 2000 and June 2006. Bronchoscopy was performed according to a surveillance protocol and when clinically indicated. Aspergillus colonization was defined as a positive culture from bronchoalveolar lavage or two sputum cultures positive for the same Aspergillus species, in the absence of invasive pulmonary Aspergillosis. We found that Aspergillus colonization was strongly associated with BOS and BOS related mortality in Cox regression analyses. Aspergillus colonization typically preceded the development of BOS by a median of 261 days (95% CI 87-520). Furthermore, in a multivariate Cox regression model, Aspergillus colonization was a distinct risk factor for BOS, independent of acute rejection. These data suggest a potential causative role for Aspergillus colonization in the development of BOS post-lung transplantation and raise the possibility that strategies aimed to prevent Aspergillus colonization may help delay or reduce the incidence of BOS.

CXCR3 ligands are augmented during the pathogenesis of pulmonary sarcoidosis

We and other investigators have hypothesised that the CXC chemokine receptor (CXCR)3/CXCR3 ligand biological axis is involved in the formation of sarcoid lung granulomas; however, significant discrepancies in the current literature remain. In an effort to clarify previous conflicting findings, we performed the largest observational study to date of interferon-inducible ELR(-) (lacking the sequence glutamic acid-leucine-arginine) CXC chemokines in sarcoid bronchoalveolar fluid (BALF). BALF chemokine levels from sarcoid patients (n = 72) and healthy controls (n = 8) were measured with the ELISA method. Immunohistochemical staining was performed for CXCR3 and its ligands. BALF CXC chemokine ligand (CXCL)10 levels from sarcoid patients were not significantly increased compared with controls. BALF CXCL11 levels from sarcoid patients demonstrated a trend towards elevation; subgroup analysis by stage showed significant BALF CXCL11 elevation in stage I sarcoid patients compared with controls. BALF CXCL9 levels were elevated from sarcoid patients compared with controls. CXC11, CXCL9 and CXCR3 were expressed from epithelioid histiocytes, multinucleated giant cells and other inflammatory cells forming sarcoid lung granulomas. Our data suggest that CXCL9 and CXCL11 are important mediators in recruiting CXCR3-expressing cells. Importantly, we have made the novel observation that both lymphocytes and cells of monocyte linage express CXCR3 and are involved in the formation of sarcoid lung granulomas.

Using Citizen Surveys to Produce Information on the Police: The Present and Potential Uses of the National Crime Victimization Survey

The National Crime Victimization Survey (NCVS) is a major source of nationally representative data on crime and the response to crime in the United States. The survey's potential to add to our understanding of crime and criminal justice issues has not been fully exploited, however. One of the areas where more effective use could be made of the information gathered by the survey is policing. This paper suggests how the NCVS can more fully realize its potential for informing issues pertaining to the police.

Usual interstitial pneumonia

Usual interstitial pneumonia (UIP) is a distinct histological lesion observed in idiopathic pulmonary fibrosis (IPF), but can be found in other etiologies. The diagnosis of UIP can be established by surgical lung biopsy or by high resolution thin section computed tomographic scans (provided the radiographic features are classical). Historically, patients labeled as "IPF'' encompassed a group of disorders including UIP as well as other idiopathic interstitial pneumonias, which differ from UIP in prognosis and responsiveness to therapy. Current recommendations from international consensus statements restrict the term IPF to patients with idiopathic UIP. The inciting cause(s) and pathogenesis of UIP have not been elucidated, but alveolar epithelial cell injury and dysregulation or altered phenotypic expression of fibroblasts are key elements. Inflammatory cells may play minor roles in initiating or propagating the fibrotic process. The prognosis of UIP is poor. Mean survival following diagnosis approximates 3 years. Current therapies are of unproven value. Corticosteroids or immunosuppressive agents have been most often used, but data affirming benefit are lacking. Single-lung transplantation is a viable option for patients failing medical therapy. Novel therapeutic strategies based upon inhibiting fibroproliferation or enhancing alveolar reepithelialization are desperately needed. In this article, we discuss diagnostic criteria for UIP (both histopathological and radiographic), natural history and clinical course, and therapeutic approaches (both current and future).

Nonspecific interstitial pneumonia (NSIP)

Nonspecific interstitial pneumonia (NSIP) represents one histologic subtype of idiopathic interstitial pneumonia (IIP). NSIP is typified by temporal homogeneity and less profusion of fibroblastic foci than is seen with usual interstitial pneumonia (UIP), the most common IIP. Clinically patients with NSIP present with similar symptoms (cough and dyspnea) when compared to patients with UIP. The duration of these symptoms prior to presentation is variable. The finding of fever may be more common in NSIP and clubbing may be more common in UIP; however, both findings can be seen in either UIP or NSIP. Physiological findings typically demonstrate a restrictive ventilatory defect with decreased gas transfer; little difference exists between UIP and NSIP. High resolution computed tomography (HRCT) scans are more likely to show honeycombing with UIP and a ground-glass pattern with NSIP, however, either of these findings can be seen with UIP or NSIP. The most striking differential feature between NSIP and UIP is the markedly better prognosis for patients with NSIP, a finding that cannot be explained by baseline differences in physiology or radiographic features. In this article we explore the clinical, physiological, and radiographic features of NSIP. We also review available information regarding response to therapy and prognosis.

The effect of premedication with OTFC, with or without ondansetron, on postoperative agitation, and nausea and vomiting in pediatric ambulatory patients

BACKGROUND

The purpose of this study was to evaluate, in the pediatric ambulatory surgical population, the efficacy of: (i) oral transmucosal fentanyl citrate (OTFC), when given preoperatively, to reduce postoperative excitement associated with sevoflurane, and (ii) intravenous ondansetron to reduce postoperative nausea and vomiting (PONV) associated with OTFC.

METHODS

This randomized, double-blinded, placebo controlled study evaluated the efficacy of OTFC [normal dose (ND) = 10-15 microg x kg(-1) or low dose = 100 microg] compared with placebo in the prevention of postoperative agitation; and the efficacy of ondansetron (0.1 mg x kg(-1) to 4 mg) compared with placebo to reduce PONV associated with OTFC.

RESULTS

There were 125 patients evaluated (2-10 years old, ASA class I or II and weight 10-40 kg). Preoperatively OTFC was associated with an increased likelihood of cooperation at baseline (P = 0.018). Postoperatively there was a higher incidence of vomiting in children that received OTFC. The anxiety/agitation of patients entering the PACU was significantly less in children who received OTFC ND (P < 0.001). This effect decreased over time. Patients with respiratory adverse events related to the study drug were significantly higher in groups who received OTFC, however, they were not of clinical significance. OTFC was associated with delays in time for eligibility to PACU discharge (P = 0.003).

CONCLUSIONS

Even though OTFC reduced early postoperative agitation the increase in side effects, namely PONV and prolonged recovery times, limits its clinical usefulness. The study demonstrates the tradeoffs between anxiety and agitation vs vomiting, respiratory events and prolonged recovery times. Ambulatory pediatric patients undergoing procedures in which opioids would be routinely used might benefit the most from OTFC combined with ondansetron as part of the anesthetic technique.

Thiotepa and fractionated TBI conditioning prior to allogeneic stem cell transplantation for advanced hematologic malignancies: a phase II single institution trial

Relapse of hematologic malignancies after allogeneic stem cell transplantation remains a common problem, in particular for patients who have advanced disease at the time of transplantation. Thiotepa has excellent antileukemic and immunosuppressive activity, and could therefore be a useful drug in the conditioning regimen for patients with advanced hematologic neoplasms. We retrospectively analyzed toxicity, engraftment and survival data of 41 patients who received a conditioning regimen of thiotepa (600 mg/m2) and hyperfractionated TBI (10 Gy) prior to matched related (n = 25) or matched unrelated (n = 16) allogeneic stem cell transplantation. The mean age at transplantation was 37.8 years (range 20-59), all but five patients had advanced hematologic malignancies at the time of transplantation. GVHD prophylaxis was with standard cyclosporine and methotrexate. Engraftment was excellent, but the regimen was associated with a high incidence of grade III renal (41%) and hepatic (15%) toxicity, and high transplant-related mortality (44% at day +90). The 3-year event-free survival was 13% and overall survival 14%. We conclude that this regimen requires modification to reduce toxicity.

Radiological versus histological diagnosis in UIP and NSIP: survival implications

BACKGROUND

High resolution computed tomography (HRCT) has an important diagnostic role in idiopathic interstitial pneumonia (IIP). We hypothesised that the HRCT appearance would have an impact on survival in patients with IIP.

METHODS

HRCT scans from patients with histological usual interstitial pneumonia (UIP; n=73) or histological non-specific interstitial pneumonia (NSIP; n=23) were characterised as definite UIP, probable UIP, indeterminate, probable NSIP, or definite NSIP. Cox regression analysis examined the relationships between histopathological and radiological diagnoses and mortality, controlling for patient age, sex, and smoking status.

RESULTS

All 27 patients with definite or probable UIP on HRCT had histological UIP; 18 of 44 patients with probable or definite NSIP on HRCT had histological NSIP. Patients with HRCT diagnosed definite or probable UIP had a shorter survival than those with indeterminate CT (hazards ratio (HR) 2.43, 95% CI 1.06 to 5.58; median survival 2.08 v 5.76 years) or HRCT diagnosed definite or probable NSIP (HR 3.47, 95% CI 1.58 to 7.63; median survival 2.08 v 5.81 years). Patients with histological UIP with no HRCT diagnosis of probable or definite UIP fared better than patients with histological UIP and an HRCT diagnosis of definite or probable UIP (HR 0.49, 95% CI 0.25 to 0.98; median survival 5.76 v 2.08 years) and worse than those with a histological diagnosis of NSIP (HR 5.42, 95% CI 1.25 to 23.5; median survival 5.76 v >9 years).

CONCLUSIONS

Patients with a typical HRCT appearance of UIP experience the highest mortality. A surgical lung biopsy is indicated for patients without an HRCT appearance of UIP to differentiate between histological UIP and NSIP.

Difficult treatment issues in sarcoidosis

The management of sarcoidosis includes several crucial decisions. Not all patients with sarcoidosis need treatment. At least a third of patients will never be treated. It is unclear whether asymptomatic patients ever need therapy, even if they have extensive lung disease. One reason that clinicians are reluctant to start therapy is that many patients who are started on corticosteroids have a difficult time getting off therapy, even after 2 years. In the chronic patient, alternatives to corticosteroids have been developed. These include drugs such as methotrexate, azathioprine and hydroxychloroquine. These agents have been the standard second line of therapy for patients with chronic disease. However, these drugs do not always work. In addition, they are associated with their own toxicities. Another group of sarcoidosis patients have also emerged. These are the refractory patients, who have progressive disease whilst on therapy. For these patients, new agents such as thalidomide and the monoclonal antibodies to tumour necrosis factor have been occasionally helpful. This paper reviews several important issues in the management of sarcoidosis.

A comparative assessment of public opinion toward immigrants and immigration policies

"This article is part of a larger study of public attitudes toward immigration in seven countries that historically and currently have had different policies and practices vis-a-vis immigration. The countries involved are Australia, Canada, France, Germany, Great Britain, Japan and the United States. The time frame for which most of the public opinion data will be reported is from 1970 through 1995. The data have been collected from national surveys that were conducted in each of the countries."

Transcutaneous electrical acupoint stimulation potentiates analgesic effect of morphine

Pain is the major complaint of patients who choose acupuncture treatment. Transcutaneous electrical acupoint stimulation (TEAS) provides a safe, standardized technique without needle insertion. TEAS can be tested with the cold-pressor test, a simple, reliable, and widely used model in humansfor the induction of tonic pain. In this controlled study, the effects of TEAS on cold-pressor-induced pain were evaluated in 20 healthy human subjects. Electrical stimulation electrodes were applied to He-Gu (LI 4) and Nui-Guan (P 6) acupoints. The effects of saline plus no TEAS, 15-minute TEAS alone, 0.05 mg/kg morphine alone, and 15-minute TEAS plus morphine were assessed. Pain score ratings were evaluated at four time points from 30 to 170 seconds during the cold-pressor test. The authors observed analgesic effects in both TEAS-alone and morphine-alone sessions, and pain score rating reductions were statistically significant compared to unstimulated control (both p < 0.01). The degree of TEAS analgesia combined with 0.05 mg/kg morphine was significantly higher than TEAS alone (p < 0.01). The results support the efficacy of TEAS analgesia and suggest that combination of TEAS with low-dose morphine can achieve better pain control in a variety of clinical settings.

Clinical significance of histological classification of idiopathic interstitial pneumonia

Patients with idiopathic interstitial pneumonias (IIPs) can be subdivided into groups based on the histological appearance of lung tissue obtained by surgical biopsy. The quantitative impact of histological diagnosis, baseline factors and response to therapy on survival has not been evaluated. Surgical lung biopsy specimens from 168 patients with suspected IIP were reviewed according to the latest diagnostic criteria. The impact of baseline clinical, physiological, radiographic and histological features on survival was evaluated using Cox regression analysis. The predictive value of honeycombing on high-resolution computed tomography (HRCT) as a surrogate marker for usual interstitial pneumonia (UIP) was examined. The response to therapy and survival of 39 patients treated prospectively with high-dose prednisone was evaluated. The presence of UIP was the most important factor influencing mortality. The risk ratio of mortality when UIP was present was 28.46 (95% confidence interval (CI) 5.5-148.0; p=0.0001) after controlling for patient age, duration of symptoms, radiographic appearance, pulmonary physiology, smoking history and sex. Honeycombing on HRCT indicated the presence of UIP with a sensitivity of 90% and specificity of 86%. Patients with nonspecific interstitial pneumonia were more likely to respond or remain stable (9 of 10) compared to patients with UIP (14 of 29) after treatment with prednisone. Patients remaining stable had the best prognosis. The risk ratio of mortality for stable patients compared to nonresponders was 0.32 (95% CI 0.11-0.93; p=0.04) in all patients and 0.33 (95% CI 0.12-0.96; p=0.04) in patients with UIP. The histological diagnosis of usual interstitial pneumonia is the most important factor determining survival in patients with suspected idiopathic interstitial pneumonia. The presence of honeycombing on high-resolution computed tomography is a good surrogate for usual interstitial pneumonia and could be utilized in patients unable to undergo surgical lung biopsy. Patients with nonspecific interstitial pneumonia are more likely to respond or remain stable following a course of prednisone. Patients remaining stable following prednisone therapy have the best prognosis.

Use of the BIS monitor to detect onset of naturally occurring sleep

OBJECTIVES

Inadvertent sleep episodes are a recognized complication of sleep deprivation. Although such events can be life threatening, no system currently exists to detect and prevent sleep onset. Because sleep shares electroencephalographic similarities with the anesthetized state, we hypothesized that the BIS monitor, a currently available EEG-based monitor of anesthetic depth, would detect the onset of physiologic sleep. To test our hypothesis, we monitored volunteers during the transition from waking to sleep.

METHODS

Non-medicated volunteers were asked to lie down in a dark room for 30-minutes and fall asleep while attached to a BIS monitor located outside the room. A laptop computer was used to generate an audio tone inside the room. Speaker volume was adjusted to the lowest level detectable by the awake subject. Testing was begun by activating a computer to play a tone at random intervals. The subject was instructed to click a mouse connected to the computer upon hearing the tone to verify wakefulness. The session was terminated upon loss of response to three consecutive tones or after 30 minutes. Subjects were questioned afterwards regarding their perceptions of sleep during testing.

RESULTS

11 out of 28 self-described good sleepers could not sleep under testing conditions. BIS values for the remaining 17 fell from 96.4 +/- 2.1 to 86.5 +/- 0.79 (p < 0.01) upon sleep onset. All subjects responded to audio stimuli at BIS values >90, and were asleep either by subjective or objective report at BIS values <80. Three subjects retained the mouse-click response despite low BIS scores and subjective descriptions of sleep.

CONCLUSION

Although variability in the BIS value marking sleep onset was noted, the BIS monitor detected all episodes of sleep onset in our testing regimen. We conclude that a threshold BIS value can be defined to allow the BIS monitor to detect sleep onset.

ENA-78 is an important angiogenic factor in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic and often fatal disorder. Fibroplasia and deposition of extracellular matrix are dependent, in part, on angiogenesis and vascular remodeling. We obtained open lung biopsies from patients undergoing thoracic surgery for reasons other than interstitial lung disease (control) (n = 78) and from patients with IPF (n = 91). We found that levels of epithelial neutrophil-activating peptide 78 (ENA-78) were greater from tissue specimens of IPF patients, as compared with control subjects. When ENA-78 was depleted from IPF tissue specimens, tissue-derived angiogenic activity was markedly reduced. Immunolocalization of ENA-78 demonstrated that hyperplastic Type II pneumocytes and macrophages were the predominant cellular sources of ENA-78. These findings support the notion that ENA-78 may be an important additional factor that regulates angiogenic activity in IPF.

Pulmonary function tests in interstitial lung disease: what role do they have?

Pulmonary function tests have been widely accepted and utilized in the management of interstitial lung diseases. Although the tests performed have changed little over the past several decades, extensive literature has been published highlighting their clinical role in the diagnosis, staging, prognostication, and follow-up of patients with a wide variety of interstitial lung diseases.

Histopathologic variability in usual and nonspecific interstitial pneumonias

Findings of surgical lung biopsy (SLB) are important in categorizing patients with idiopathic interstitial pneumonia (IIP). We investigated whether histologic variability would be evident in SLB specimens from multiple lobes in patients with IIP. SLBs from 168 patients, 109 of whom had multiple lobes biopsied, were reviewed by three pathologists. A diagnosis was assigned to each lobe. A different diagnosis was found between lobes in 26% of the patients. Patients with usual interstitial pneumonia (UIP) in all lobes were categorized as concordant for UIP (n = 51) and those with UIP in at least one lobe were categorized as discordant for UIP (n = 28). Patients with nonspecific interstitial pneumonia (NSIP) in all lobes were categorized as having fibrotic (n = 25) or cellular NSIP (n = 5). No consistent distribution of lobar histology was noted. Patients concordant for UIP were older (63 +/- 9 [mean +/- SD] yr; p < 0.05 as compared with all other groups) than those discordant for UIP (57 +/- 12 yr) or with fibrotic NSIP (56 +/- 11 yr) or cellular NSIP (50 +/- 9 yr). Semiquantitative high-resolution computed tomography demonstrated a varied profusion of fibrosis (p < 0.05 for all group comparisons), with more fibrosis in concordant UIP (2.13 +/- 0.62) than in discordant UIP (1.42 +/- 0.73), fibrotic NSIP (0.83 +/- 0.58), or cellular NSIP (0.44 +/- 0.42). Survival was better for patients with NSIP than for those in both UIP groups (p < 0.001), although survival in the two UIP groups was comparable (p = 0.16). Lobar histologic variability is frequent in patients with IIP, patients with a histologic pattern of UIP in any lobe should be classified as having UIP.

Drug-induced pneumonitis: the role of methotrexate

Methotrexate (MTX) is a folate antagonist used in several chronic inflammatory and neoplastic conditions. Pulmonary toxicity occurs in 0.5% to 14% of patients receiving low-dose MTX. Manifestations of pulmonary toxicity are protean and include parenchymal inflammation, pneumonia, airway hyperreactivity, air trapping and possibly neoplasm. We performed an exhaustive review of the English literature and identified 189 cases of methotrexate-induced pneumonitis (MIP). Rheumatoid arthritis (RA) was the most frequent underlying disease. In most patients, symptoms present subacutely with progression over several weeks. Most patients present with dyspnea, dry cough, fever, and bibasilar crackles. Peripheral eosinophilia has been cited in one third of cases. The chest radiograph may be normal, but more commonly reveals bilateral interstitial or mixed, interstitial and alveolar infiltrates with a predilection for the bases. Chest computed tomography (CT) scans demonstrate ground-glass opacities, interstitial infiltrates, septal lines or widespread consolidation. Pulmonary function studies reveal a restrictive ventilatory defect and/or impaired gas exchange. Bronchoalveolar lavage (BAL) may be helpful in ruling out an infectious etiology and in supporting the diagnosis of MIP. Cellular interstitial infiltrates, granulomas, fibrosis, atypical epithelial cells, and diffuse alveolar damage (DAD) are the main histologic features. Once MIP is suspected, the MTX should be withdrawn. Corticosteroids may accelerate resolution and are recommended in severe or fulminant cases. The prognosis of MIP is usually favorable, but occasionally the outcome may be fatal.

Lymphoproliferative disease after lung transplantation: comparison of presentation and outcome of early and late cases

BACKGROUND

Post-transplantation lymphoproliferative disease (PTLD) after lung transplantation has not been fully characterized. In previous studies, the incidence has varied substantially, and most cases have been reported during the first year after transplantation. The purpose of this study was to review our center's experience with PTLD and to analyze the pattern of disease and determinants of outcome.

METHODS

Among 494 adult lung (n = 491) or heart-lung (n = 3) recipients, 30 cases of PTLD were retrospectively identified. The cases were classified by site(s) of involvement, histology and time of onset (early, < or =1 year, and late, >1 year after transplantation). The outcome of each case was ascertained, and risk factors for death were analyzed in a multivariate model.

RESULTS

PTLD was identified in 30 (6.1%) of the recipients during 1,687 patient-years (median 2.8 years) of follow-up. The incidence density was 1.8 cases per 100 patient-years. Fourteen cases were diagnosed during the first year after transplantation, and 16 cases in subsequent years. The incidence density was significantly higher in the first year than in later years (3.3 cases/100 patient-years versus 1.3 cases/100 patient years; p <.008). Presentation in the thorax and involvement of the allograft were significantly more common in the early cases (thorax: 12 of 14, 86%; allograft: 9 of 14, 64%) than in the late cases (thorax: 2 of 16, 12%; allograft: 2 of 16, 12%). There was no difference in survival after the diagnosis of PTLD between the early and late cases, but survival time after diagnosis was significantly longer in cases with, than those without, allograft involvement (median 2.6 years vs 0.2 year, respectively; log rank p = 0.007). The presentation and pattern of organ involvement of PTLD after lung transplantation is related to the time of onset.

CONCLUSIONS

Disease in the thorax and involvement of the allograft are common in the first year after transplantation, but other sites, especially the gastrointestinal tract, predominate later. PTLD that is confined to the allograft appears to have a somewhat better prognosis than disease that involves other sites.

Corticosteroids in idiopathic pulmonary fibrosis

Corticosteroids were the mainstay of therapy for idiopathic pulmonary fibrosis (IPF) for more than four decades, but their efficacy is unproven and toxicities are substantial. The course of IPF is characterized by progressive respiratory insufficiency, leading to death within 3 to 8 years from the onset of symptoms. Although a subset (10-20%) of patients survives more than 10 years, there is no evidence that any form of therapy alters the natural history of the disease. Nonetheless, given the poor prognosis, a trial of corticosteroids is often given. Because of the rarity of IPF, randomized, placebo-controlled therapeutic trials have not been done. Further, no studies have compared differing dosages or duration of corticosteroid in matched patients. Interpretation of therapy efficacy is obscured by several factors including heterogeneous patient populations, inclusion of patients with histologic entities other than usual interstitial pneumonia, lack of objective, validated endpoints, different criteria for "response." We review published data regarding corticosteroid therapy for IPF and present a rationale for stratifying therapy based on host, demographic, and clinical factors that influence prognosis as well as risk for corticosteroid complications.

Relationship of cytomegalovirus viral load in blood to pneumonitis in lung transplant recipients

We developed a multiplex, quantitative, real-time, polymerase chain reaction assay for cytomegalovirus (CMV) and used it to measure the CMV viral load in weekly blood specimens from 43 lung transplant recipients. The median viral load in blood samples immediately preceding bronchoscopy was 1150 copies/microg human DNA for 12 subjects with pneumonitis compared to 91 copies for 31 subjects without (P=0.02, Mann-Whitney U test). Each log10 increase in CMV viral load resulted in an increase of 1.92 in the odds ratio for CMV pneumonitis (95% confidence interval 1.03-3.56). CMV viral load was elevated (>100 copies/microg human DNA) for a median of 21 days before bronchoscopy in those subjects with pneumonitis versus 0 days in those without (P=0.004). We conclude that the risk of CMV pneumonitis after lung transplantation is related to the level of CMV DNA in blood. Quantitative PCR should be evaluated prospectively for the preemptive management of CMV in lung transplant recipients.

Critical role for the chemokine MCP-1/CCR2 in the pathogenesis of bronchiolitis obliterans syndrome

Bronchiolitis obliterans syndrome (BOS) is the major limitation to survival after lung transplantation. Acute rejection, its main risk factor, is characterized by perivascular/bronchiolar leukocyte infiltration. BOS is characterized by persistent peribronchiolar leukocyte recruitment leading to airway fibrosis and obliteration. The specific mechanism(s) by which these leukocytes are recruited are unknown. Because MCP-1, acting through its receptor CCR2, is a potent mononuclear cell chemoattractant, we hypothesized that expression of this chemokine during an allogeneic-response promotes persistent recruitment of leukocytes and, ultimately, rejection. We found that elevated levels of biologically active MCP-1 in human bronchial lavage fluid (BALF) were associated with the continuum from acute to chronic allograft rejection. Translational studies in a murine model of BOS demonstrated increased MCP-1 expression paralleling mononuclear cell recruitment and CCR2 expression. Loss of MCP-1/CCR2 signaling, as seen in CCR2(-/-) mice or in WT mice treated with neutralizing antibodies to MCP-1, significantly reduced recruitment of mononuclear phagocytes following tracheal transplantation and led to attenuation of BOS. Lymphocyte infiltration was not reduced under these conditions. We suggest that MCP-1/CCR2 signaling plays an important role in recruitment of mononuclear phagocytes, a pivotal event in the pathogenesis of BOS.

Effect of phosphorus availability on basal root shallowness in common bean

Root gravitropism may be an important element of plant response to phosphorus availability because it determines root foraging in fertile topsoil horizons, and thereby phosphorus acquisition. In this study we seek to test this hypothesis in both two dimensional paper growth pouch and three-dimensional solid media of sand and soil cultures. Five common bean ( Phaseolus vulgaris L.) genotypes with contrasting adaptation to low phosphorus availability were evaluated in growth pouches over 6 days of growth, and in sand culture and soil culture over 4 weeks of growth. In all three media, phosphorus availability regulated the gravitropic response of basal roots in a genotype-dependent manner. In pouches, sand, and soil, the phosphorus-inefficient genotype DOR 364 had deeper roots with phosphorus stress, whereas the phosphorus-efficient genotype G19833 responded to phosphorus stress by producing shallower roots. Genotypes were most responsive to phosphorus stress in sand culture, where relative root allocation to the 0-3- and 3-6-cm horizons increased 50% with phosphorus stress, and varied 300% (3-6 cm) to 500% (0-3 cm) among genotypes. Our results indicate that (1) phosphorus availability regulates root gravitropic growth in both paper and solid media, (2) responses observed in young seedlings continue throughout vegetative growth, (3) the response of root gravitropism to phosphorus availability varies among genotypes, and (4) genotypic adaptation to low phosphorus availability is correlated with the ability to allocate roots to shallow soil horizons under phosphorus stress.

Prolonged sedation with propofol in the rat does not result in sleep deprivation

The use of propofol provides sedation without prolonging emergence in patients in the Intensive Care Unit. When prolonged, however, continuous sedation may overlap with naturally occurring sleep periods and potentially increase the risk of sleep deprivation. We modified an established rat model of sleep to determine whether prolonged, continuous sedation results in sleep deprivation. Rats were continuously sedated for a 12-h period overlapping completely with their normal sleep phase. Electroencephalogram (EEG) and movement data were collected before and after the sedation period. Rats were evaluated for EEG and movement evidence of sleep deprivation after sedation. When compared with baseline, the time spent in rapid eye movement (REM) and non-REM sleep was decreased during the first 4 h after sedation. The duration of non-REM sleep bouts was not altered. Power in the delta band (0.5-4 Hz) during non-REM sleep was diminished during the first 2 h only. Movements were reduced during the first hour after emergence from sedation only. In summary, no EEG or behavioral evidence of sleep deprivation was observed on emergence from sedation. These results imply that sedation is associated with a restorative process reversing the natural accumulation of sleep need that occurs during wakefulness.

IMPLICATIONS

Prolonged sedation in the Intensive Care Unit may alter the restorative effects of naturally occurring sleep. We sedated rats during their sleep phase to determine whether sedation interferes with sleep. Upon emergence, no evidence of sleep deprivation was observed. Sedation may thus be associated with a restorative effect similar to sleep.

Induction of a major leaf acid phosphatase does not confer adaptation to low phosphorus availability in common bean

Acid phosphatase is believed to be important for phosphorus scavenging and remobilization in plants, but its role in plant adaptation to low phosphorus availability has not been critically evaluated. To address this issue, we compared acid phosphatase activity (APA) in leaves of common bean (Phaseolus vulgaris) in a phosphorus-inefficient genotype (DOR364), a phosphorus-efficient genotype (G19833), and their F(5.10) recombinant inbred lines (RILs). Phosphorus deficiency substantially increased leaf APA, but APA was much higher and more responsive to phosphorus availability in DOR364 than in G19833. Leaf APA segregated in the RILs, with two discrete groups having either high (mean = 1.71 micromol/mg protein/min) or low (0.36 micromol/mg protein/min) activity. A chi-square test indicated that the observed difference might be controlled by a single gene. Non-denaturing protein electrophoresis revealed that there are four visible isoforms responsible for total APA in common bean, and that the difference in APA between contrasting genotypes could be attributed to the existence of a single major isoform. Qualitative mapping of the APA trait and quantitative trait loci analysis with molecular markers indicated that a major gene contributing to APA is located on linkage group B03 of the unified common bean map. This locus was not associated with loci conferring phosphorus acquisition efficiency or phosphorus use efficiency. RILs contrasting for APA had similar phosphorus pools in old and young leaves under phosphorus stress, arguing against a role for APA in phosphorus remobilization. Our results do not support a major role for leaf APA induction in regulating plant adaptation to phosphorus deficiency.

Systemic lupus during pregnancy with refractory alveolar haemorrhage: recovery following termination of pregnancy

A case of refractory pulmonary hemorrhage in a pregnant 22-year-old with systemic lupus is presented. The clinical difficulty of management of pulmonary haemorrhage and lupus flare during pregnancy are discussed.

Steroids in idiopathic pulmonary fibrosis: a prospective assessment of adverse reactions, response to therapy, and survival

PURPOSE

We evaluated the risk and potential benefit of high-dose corticosteroid therapy in patients with idiopathic pulmonary fibrosis.

SUBJECTS AND METHODS

We prospectively studied 41 patients with previously untreated, biopsy-proven idiopathic pulmonary fibrosis. Before treatment, we calculated clinical, radiographic, and physiologic severity-of-illness scores for each patient. We scored high-resolution computerized tomographic (CT) scans for ground glass and interstitial opacity. We determined the extent of cellular infiltration, interstitial fibrosis, desquamation, and granulation in open lung biopsy samples. Patients were monitored monthly for steroid-related side effects, response to therapy at 3 months, and mortality.

RESULTS

All patients experienced at least one steroid-induced side effect. Eleven (27%) patients were nonresponders, 11 (27%) were responders, and 19 (46%) remained stable. Of the 19 patients who died during a mean (+/- SD) follow-up of 3.3 +/- 2.3 years, 8 (42%) lost weight during the initial 3 months of steroid therapy; only 3 (14%) of the 22 patients still living (P = 0.08) experienced weight loss. In a multivariate analysis, greater fibrosis (hazard ratio [HR] = 1.4 per unit increase; 95% confidence interval [CI]: 1.0 to 1.9; P = 0.03) and cellularity (RR = 1.9 per unit increase; 95% CI: 1.3 to 2.8; 3, P <0.001) in the biopsy sample and whether a patient was classified as a responder (RR = 0.4 versus nonresponder; 95% CI: 0.2 to 1.0; P = 0.05) or stable (RR = 0.2 versus nonresponder; 95% CI: 0.1 to 0.6, P <0.001) after steroid therapy were associated with mortality.

CONCLUSION

Corticosteroid treatment for idiopathic pulmonary fibrosis is associated with substantial morbidity. Patients who remain stable or respond to corticosteroid therapy have better survival than those who fail to respond. Whether this difference reflects an effect of treatment or less severe disease can be determined only in a randomized trial.

The effect of phosphorus availability on the carbon economy of contrasting common bean (Phaseolus vulgaris L.) genotypes

A common response to low phosphorus availability is increased relative biomass allocation to roots. The resulting increase in root:shoot ratio presumably enhances phosphorus acquisition, but may also reduce growth rates by diverting carbon to the production of heterotrophic rather than photosynthetic tissues. To assess the importance of increased carbon allocation to roots for the adaptation of plants to low P availability, carbon budgets were constructed for four common bean genotypes with contrasting adaptation to low phosphorus availability in the field ("phosphorus efficiency"). Solid-phase-buffered silica sand provided low (1 microM), medium (10 microM), and high (30 microM) phosphorus availability. Compared to the high phosphorus treatment, plant growth was reduced by 20% by medium phosphorus availability and by more than 90% by low phosphorus availability. Low phosphorus plants utilized a significantly larger fraction of their daytime net carbon assimilation on root respiration (c. 40%) compared to medium and high phosphorus plants (c. 20%). No significant difference was found among genotypes in this respect. Genotypes also had similar rates of P absorption per unit root weight and plant growth per unit of P absorbed. However, P-efficient genotypes allocated a larger fraction of their biomass to root growth, especially under low P conditions. Efficient genotypes had lower rates of root respiration than inefficient genotypes, which enabled them to maintain greater root biomass allocation than inefficient genotypes without increasing overall root carbon costs.

Hospital-acquired pneumonia: risk factors, microbiology, and treatment

Pneumonia complicates hospitalization in 0.5 to 2.0% of patients and is associated with considerable morbidity and mortality. Risk factors for hospital-acquired pneumonia (HAP) include mechanical ventilation for > 48 h, residence in an ICU, duration of ICU or hospital stay, severity of underlying illness, and presence of comorbidities. Pseudomonas aeruginosa, Staphylococcus aureus, and Enterobacter are the most common causes of HAP. Nearly half of HAP cases are polymicrobial. In patients receiving mechanical ventilation, P aeruginosa, Acinetobacter, methicillin-resistant S aureus, and other antibiotic-resistant bacteria assume increasing importance. Optimal therapy for HAP should take into account severity of illness, demographics, specific pathogens involved, and risk factors for antimicrobial resistance. When P aeruginosa is implicated, monotherapy, even with broad-spectrum antibiotics, is associated with rapid evolution of resistance and a high rate of clinical failures. For pseudomonal HAP, we advise combination therapy with an antipseudomonal beta-lactam plus an aminoglycoside or a fluoroquinolone (eg, ciprofloxacin).

The effect of phosphorus availability on the carbon economy of contrasting common bean (Phaseolus vulgaris L.) genotypes

A common response to low phosphorus availability is increased relative biomass allocation to roots. The resulting increase in root:shoot ratio presumably enhances phosphorus acquisition, but may also reduce growth rates by diverting carbon to the production of heterotrophic rather than photosynthetic tissues. To assess the importance of increased carbon allocation to roots for the adaptation of plants to low P availability, carbon budgets were constructed for four common bean genotypes with contrasting adaptation to low phosphorus availability in the field ("phosphorus efficiency"). Solid-phase-buffered silica sand provided low (1 microM), medium (10 microM), and high (30 microM) phosphorus availability. Compared to the high phosphorus treatment, plant growth was reduced by 20% by medium phosphorus availability and by more than 90% by low phosphorus availability. Low phosphorus plants utilized a significantly larger fraction of their daytime net carbon assimilation on root respiration (c. 40%) compared to medium and high phosphorus plants (c. 20%). No significant difference was found among genotypes in this respect. Genotypes also had similar rates of P absorption per unit root weight and plant growth per unit of P absorbed. However, P-efficient genotypes allocated a larger fraction of their biomass to root growth, especially under low P conditions. Efficient genotypes had lower rates of root respiration than inefficient genotypes, which enabled them to maintain greater root biomass allocation than inefficient genotypes without increasing overall root carbon costs.

Spectrum of Aspergillus infection in lung transplant recipients: case series and review of the literature

STUDY OBJECTIVES

(1) To define the incidence and natural history of Aspergillus colonization and infection in lung transplant recipients, and (2) to assess the impact of prophylaxis, surveillance, and therapy on the incidence and outcome of the disease.

DESIGN

Retrospective review of 133 consecutive single or bilateral lung transplantations performed at a single institution, and review of the published literature.

RESULTS

Airway colonization, isolated tracheobronchitis, and invasive pneumonia due to Aspergillus species occurred in 29%, 5%, and 8% of our series, and in 26%, 4%, and 5% of the pooled published data (all series, including ours), respectively. Greater than 50% of all diagnoses were made in the first 6 months after transplantation in both our series and the published literature. Incidence of progression from airway colonization to invasive disease was 1 in 38 in our series and 3 of 97 (3%) in the pooled published data. In patients with isolated tracheobronchitis, all 6 patients in our series and 41 of 50 patients (82%) in all published series, including ours, responded to antifungal therapy and/or surgical debridement. Among patients with invasive pneumonia or disseminated disease, however, 5 of 10 patients in our series and 26 of 64 patients (41%) in the pooled series survived their infection.

CONCLUSIONS

The role of antifungal therapy in Aspergillus airway colonization in lung transplant recipients is unclear. Data support a strategy of scheduled screening bronchoscopy followed by aggressive treatment for isolated Aspergillus tracheobronchitis in lung transplant recipients.

Timing of Lung Transplantation for Patients with Fibrotic Lung Diseases

Idiopathic pulmonary fibrosis (IPF) is typically a fatal disease that fails to respond to medical therapy. For these patients lung transplantation offers the promise of improved quality and duration of life. The initial reports of successful transplantation for IPF date back to the mid-1980s although recent data suggest IPF patients make up nearly 20% of all single lung transplants. The survival rates following lung transplantation for IPF are estimated at 67% for 1 year, 52% for 3 years, and 35% for 5 years. Mortality rates following lung transplantation for IPF are higher than emphysema, but are generally comparable to primary pulmonary hypertension. Given the relatively high mortality following transplant the decision of when to transplant a patient is of paramount importance. Although individual patients differ, generalizations predicting a poor prognosis include the diagnosis of usual interstitial pneumonia (UIP), a forced vital capacity or total lung capacity of less than 65% predicted, a diffusion capacity for carbon monoxide (DL(CO)) less than 45% of predicted, and the presence of extensive honeycombing on high-resolution computed tomographic scans. The presence of any of these features should prompt the patient and physician to consider lung transplantation as a potential therapeutic modality. Patients with interstitial lung disease related to collagen vascular diseases or other causes need to be considered on an individual basis; their prognosis is usually better than patients with IPF, and the potential for systemic involvement may preclude listing for lung transplantation.

Antimicrobial resistance in Streptococcus pneumoniae: implications for patients with community-acquired pneumonia

Streptococcus pneumoniae is the leading cause of community-acquired pneumonia. During the past decade, the prevalence of penicillin resistance in S pneumoniae has increased dramatically, with resistance rates approaching 45% in some areas of the United States. Streptococcus pneumoniae has also acquired resistance to other commonly used antimicrobials, including cephalosporins, macrolides, and trimethoprim-sulfamethoxazole. While vancomycin and the newer quinolones are currently highly active against most strains of S pneumoniae, reduced susceptibilities to these agents have been identified in some strains. Prior use of antimicrobial agents is the major risk factor for colonization and infection with antibiotic-resistant strains. beta-Lactam antibiotics remain the treatment of choice for infections caused by susceptible S pneumoniae. The optimum therapy for penicillin-resistant strains remains unclear. Appropriate empirical therapy for patients with community-acquired pneumonia depends in part on the community-specific resistance patterns of S pneumoniae to various antibiotics. In this article, we provide an overview of the development of S pneumoniae resistance to commonly used antibiotics and discuss the implications of the development of resistance on treatment decisions.

Lung transplantation is warranted for stable, ventilator-dependent recipients

BACKGROUND

Lung transplantation for patients on ventilators is a controversial use of scarce donor lungs. We have performed 500 lung transplants in 12 years and 21 of these have been in ventilator-dependent patients.

METHODS

A retrospective review of patient records and computerized database was performed. Living patients were contacted to confirm their health and functional status.

RESULTS

Patients included 13 men and 8 women with a mean age of 43 years. Sixteen patients were considered stable awaiting lung transplant, whereas 5 patients were unstable with acute graft failure after prior lung transplantation. Stable patients had been ventilated for a mean of 57 +/- 46 days whereas unstable patients had been supported for 10 +/- 9 days. Half of the patients required cardiopulmonary bypass support during the transplant, and there was no statistical difference in the frequency of CPB in stable and unstable patients (p = 0.61). Three hospital deaths included 0 of 16 of the stable patients and 3 of 5 of the unstable patients (p = 0.01). Long-term actuarial survival was significantly better in stable versus unstable patients (p = 0.02), with 5-year survival 40% for stable patients and 0% for unstable patients.

CONCLUSIONS

Lung transplantation can be successfully conducted in stable patients who have become ventilator dependent after listing for transplantation. Acute retransplantation for early lung dysfunction is high risk and has produced poor long-term results.

Leptin reduces body weight gain in neonatal rats

Leptin (OB protein) elicits a neuroendocrine response to starvation and states of nutritional abundance to stabilize the proportion of body fat. Leptin has dramatic effects on food intake and energy expenditure in adult and juvenile rodents. However, whether the neonatal period is associated with the development of an effective leptin feedback system is still not known. In this study, we evaluated the effects of peripherally administered leptin on body weight changes in neonatal rats during the early suckling period (from birth to 10 d). Our results show that daily i.p. injections of leptin (0.3 microg/g and 1.0 microg/g) to neonatal rats led to a significant reduction in weight gain over 10 d compared with the control group (p < 0.01 and p < 0.01, respectively). Concomitant with a reduction in weight gain, retroperitoneal fat pad weight also significantly decreased in the leptin-treated group. Our data indicate that the potential for energy balance regulation by leptin occurs in the first day after birth. In addition, we also observed that 3 d after discontinuing leptin treatment, the body weight as well as the fat pad weight of leptin-treated pups returned to the control level. Our results demonstrate that leptin reduces body weight gain in neonatal rats.

Outcome of patients with cystic fibrosis awaiting lung transplantation

Cystic fibrosis is a common indication for lung transplantation. Under the current organ allocation system, donor lungs are distributed to patients based solely on their accrued waiting time, and the death rate on the waiting list has been high. Physiologic parameters have been used to guide the referral, but risk factors for death while awaiting transplantation have not been well defined. This study aimed to identify factors at the time of evaluation that were associated with death on the waiting list. A consecutive cohort of 146 patients with cystic fibrosis who were listed for lung transplantation was retrospectively reviewed. Characteristics of patients who died awaiting transplantation were compared with those of patients who survived until transplantation or the end of the study. Thirty-seven patients died while waiting, 76 underwent transplantation, and 33 were alive and still waiting. Actuarial survival rates for the entire cohort were 81% at 1 yr, 67% at 2 yr, and 59% at 3 yr. Although a multivariate Cox proportional hazards model (chi(2) = 29.6; p < 0.001) identified shorter six-minute walk distance (50 m increments; RR, 0.69; 95% CI, 0.57 to 0.84), higher systolic pulmonary artery pressure (5 mm Hg increments; RR, 1.41; 95% CI, 1.11 to 1.80), and diabetes mellitus (RR, 1.57; 95% CI, 1.06 to 2.32) as significant risk factors for death on the waiting list, these factors and other features overlapped considerably between the group of patients who died waiting and the group who lived until transplantation or the end of the study. The transplant evaluation selects a rather homogeneous cohort of patients for the waiting list. Unless outcome on the waiting list can be reliably predicted, establishing criteria to allocate donor lungs according to medical urgency may not be feasible.

Increased expression of inflammatory cytokines and adhesion molecules by alveolar macrophages of human lung allograft recipients with acute rejection: decline with resolution of rejection

BACKGROUND

Alveolar macrophages (AM) are the major population in bronchoalveolar lavage (BAL) cells; we assessed their role in human lung allograft recipients by correlating the expression of adhesion molecules and inflammatory cytokines with clinical outcome of allograft.

METHODS

We obtained BAL samples from patients and enriched them for AM in plastic petri dish for 2 hours at 37 degrees C in 5% CO(2). Expression of intercellular adhesion molecule-1 (ICAM-1, CD54), platelet endothelial cell adhesion molecule-1 (PECAM-1, CD31), and CD11c was assessed by flow cytometry using monoclonal antibodies. We assessed cytokine profile using Multi-Probe RNase protection assay.

RESULTS

Alveolar macrophages that express CD11c, CD31 and CD54 were increased in patients with either rejection or infection compared with those without rejection and infection. The difference in the percentage of AM expressing CD11c and CD31 between the rejection group and patients without rejection and infection group was statistically significant (CD11c, p < 0.01; CD31, p < 0.03). Interleukin (IL)-1 alpha, IL-1 beta, IL-1 receptor antagonist (IL-1Ra), and IL-6 expression was higher in the rejection group than in patients without rejection. Five out of 9 patients in the rejection group expressed high levels of IL-15 and tumor necrosis factor-alpha compared with patients without rejection and infection. The increased number of AM expressing adhesion molecules and elevated expression of cytokines observed during acute rejection declined to basal levels after successful treatment and resolution of rejection. This study demonstrates that lung allograft rejection is associated with increased expression of adhesion molecules and inflammatory cytokines by AM, which could facilitate mononuclear cell adhesion and extravasation contributing to the allograft injury in lung transplant recipients.

Plant growth and phosphorus accumulation of wild type and two root hair mutants of Arabidopsis thaliana (Brassicaceae)

Arabidopsis thaliana root hairs grow longer and denser in response to low-phosphorus availability. We tested the hypothesis that wild-type Arabidopsis would acquire more phosphorus under phosphorus-limiting conditions than mutants that do not have the root hair response. The growth and phosphorus acquisition of wild-type Arabidopsis (WS) were compared to two root hair mutants (rhd6 and rhd2) under eight phosphorus treatments ranging from 0.4 mmol/m to 54 mmol/m phosphorus. At the lowest phosphorus treatment, all plants were small and showed severe phosphorus stress symptoms. At 1.5 mmol/m phosphorus, WS plants had greater shoot biomass, absolute growth rate, total phosphorus, and specific phosphorus absorption than the two root hair mutants. At the highest phosphorus treatment, there was no difference between genotypes in any of the parameters measured. We conclude that the response of increased root hair growth under low phosphorus availability in Arabidopsis is important in increasing phosphorus acquisition under phosphorus-limiting conditions.