Prolonged Barium-Impaction Ileus in Two Lung Transplant Recipients With Systemic Sclerosis: Case Report

Lung transplantation can be a life-saving measure for people with end-stage lung disease from systemic sclerosis. However, outcomes of lung transplantation may be compromised by gastrointestinal manifestations of systemic sclerosis, which can involve any part of the gastrointestinal tract. Esophageal and gastric disease can be managed by enteral feeding with the use of a gastrojejunal feeding tube. In this report, we describe the clinical courses of 2 lung transplant recipients with systemic sclerosis who experienced severe and prolonged barium-impaction ileus after insertion of a percutaneous gastrojejunal feeding tube.

Scedosporium prolificans pericarditis and mycotic aortic aneurysm in a lung transplant recipient receiving voriconazole prophylaxis

Despite the adoption of antifungal prophylaxis, fungal infections remain a significant concern in lung transplant recipients. Indeed, some concern exists that such prophylaxis may increase the risk of infection with drug-resistant fungal organisms. Here, we describe a case of disseminated Scedosporium prolificans infection, presenting as pericarditis, which developed in a lung transplant patient receiving prophylactic voriconazole for 8 months. The epidemiology and clinical presentation of S. prolificans infections are reviewed, and controversies surrounding antifungal prophylaxis and the development of resistant infections are discussed.

The impact of pretransplant mechanical ventilation on short- and long-term survival after lung transplantation

Lung transplantation in mechanically ventilated (MV) patients has been associated with decreased posttransplant survival. Under the Lung Allocation Score (LAS) system, patients at greatest risk of death on the waiting list, particularly those requiring MV, are prioritized for lung allocation. We evaluated whether pretransplant MV is associated with poorer posttransplant survival in the LAS era. Using a national registry, we analyzed all adults undergoing lung transplantation in the United States from 2005 to 2010. Propensity scoring identified nonventilated matched referents for 419 subjects requiring MV at the time of transplantation. Survival was evaluated using Kaplan-Meier methods. Risk of death was estimated by hazard ratios employing time-dependent covariates. We found that pretransplant MV was associated with decreased overall survival after lung transplantation. In the first 6 months posttransplant, ventilated subjects had a twofold higher risk of death compared to nonventilated subjects. However, after 6 months posttransplant, survival did not differ by MV status. We also found that pretransplant MV was not associated with decreased survival in noncystic fibrosis obstructive lung diseases. These results suggest that under the LAS, pretransplant MV is associated with poorer short-term survival posttransplant. Notably, the increased risk of death appears to be strongest the early posttransplant period and limited to certain pretransplant diagnoses.

Antireflux surgery for patients with end-stage lung disease before and after lung transplantation

BACKGROUND

Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease (ESLD). This disease can lead to microaspiration and may be a risk factor for lung damage before and after transplantation. A fundoplication is the best way to stop reflux, but little is known about the safety of elective antireflux surgery for patients with ESLD. This study aimed to report the safety of laparoscopic fundoplication for patients with ESLD and GERD before or after lung transplantation.

METHODS

Between January 1997 and January 2007, 305 patients were listed for lung transplantation, and 189 patients underwent the procedure. In 2003, routine esophageal studies were added to the pretransplantation evaluation. After the authors' initial experience, gastric emptying studies were added as well.

RESULTS

A total of 35 patients with GERD or delayed gastric emptying were referred for surgical intervention. A laparoscopic fundoplication was performed for 32 patients (27 total and 5 partial). For three patients, a pyloroplasty also was performed. Two patients had a pyloroplasty without fundoplication. Of the 35 operations, 15 were performed before and 20 after transplantation. Gastric emptying of solids or liquids was delayed in 12 (92%) of 13 posttransplantation studies and 3 (60%) of 5 pretransplantation studies. All operations were completed laparoscopically, and 33 patients recovered uneventfully (94%). The median hospital length of stay was 2 days (range, 1-34 days) for the patients admitted to undergo elective operations. Hospitalization was not prolonged for the three patients who had fundoplications immediately after transplantation.

CONCLUSIONS

The results of this study show that laparoscopic antireflux surgery can be performed safely by an experienced multidisciplinary team for selected patients with ESLD before or after lung transplantation, and that gastric emptying is frequently abnormal and should be objectively measured in ESLD patients.

Patient preferences for colorectal cancer screening

BACKGROUND

New guidelines include several options for colorectal cancer screening. The goal of this study was to assess patient preferences for five approaches: no screening, fecal occult blood testing (FOBT), flexible sigmoidoscopy, barium enema, and colonoscopy.

METHODS

Patients from offices of primary care providers listened to a scripted oral presentation while viewing a table describing five screening methods and their outcomes. Immediately following the presentation, the subjects completed a questionnaire assessing their most preferred screening option and their likelihood of undergoing each option.

RESULTS

One hundred subjects aged 50 to 75 years participated. The average age was 64 years; 54 of the subjects were women, and 87 were white. Ninety-six percent of patients preferred to be screened by some method. When asked which test they would choose as their primary method of screening, 38% preferred colonoscopy, 31% preferred FOBT, 14% preferred barium enema, and 13% preferred flexible sigmoidoscopy. When asked how likely they would be to undergo each procedure on a 5-point scale, patients rated FOBT highest with an average score of 4.4, followed by colonoscopy (3.4), barium enema (3.4), flexible sigmoidoscopy (3.4), and no screening (1.5). Acceptance rates for these tests when recommended by their physician were 96% (FOBT), 82% (flexible sigmoidoscopy), 92% (barium enema), and 86% (colonoscopy).

CONCLUSIONS

Patients indicated a strong preference for colorectal cancer screening, but they did not indicate a dominant preference for any single screening test. Physicians need to take into account individual patient preferences when making recommendations regarding colorectal cancer screening.

Ontogeny of photic-induced c-fos mRNA expression in rat suprachiasmatic nuclei

The suprachiasmatic nucleus (SCN) of the hypothalamus contains a circadian pacemaker that controls a variety of physiological and behavioral rhythms. Photic induction of immediate early genes such as c-fos in the SCN occurs in a circadian-phase dependent manner, suggesting that c-fos may be part of the pathway for entrainment of circadian rhythms. The purpose of this study was to determine the point in development when photic stimuli can first activate c-fos mRNA expression in the rat SCN. The results indicate that photic stimulation can induce statistically significant c-fos mRNA expression at circadian time 22 (CT22) on postnatal day 1 (P1), although hybridization above background levels can be detected in the SCN of some rat pups earlier in the subjective night. We infer that a multi-step pathway between visual transduction by the retina and regulation of c-fos transcription in SCN cells must be mature by CT22 on P1.

C-fos mRNA increases in the ground squirrel suprachiasmatic nucleus during arousal from hibernation

During hibernation the body temperature of the golden-mantled ground squirrel, Spermophilus lateralis, may drop below 5 degrees C for a few hours to a week or more. Animals cycle between euthermia and deep hibernation many times over the course of the hibernation season. Expression of the transcription factor c-fos increased in the suprachiasmatic nucleus (SCN) of the hypothalamus, the mammalian circadian clock, during deep hibernation and peaked during the arousal from hibernation. The pattern of increase in c-fos messenger RNA seen in the SCN by in situ hybridization was similar to that seen by Northern blot analysis of total hypothalamic RNA. The induction of c-fos may reflect a wake-up signal, increasing transcription of genes required in the euthermic state.