Expression analysis of candidate genes for chronic subclinical mastitis in Norwegian Red cattle.

Chronic subclinical mastitis (SCM) is characterized by a long-term inflammation in the udder with high somatic cell count (SCC) in milk. Previously, several novel alternative SCM traits for Norwegian Red (NR) cattle have been defined to improve breeding strategies against chronic SCM. Quantitative trait loci and candidate genes affecting chronic SCM in NR have been identified. The aim of this study was to analyze the expression profiles of 14 selected candidate genes (RAD17, ACOT2, ACOT4, FOS, CXCL1, CXCL8, CCNB1, CDK7, TGFB3, SEL1L, STAT4, C6, GLI2, and SLC18A2). Twenty healthy NR cows with official genomic estimated breeding values (GEBV) for lactation average somatic cell scores (LSCS) were selected. Ten cows had high GEBV for LSCS (cows with low probability to have high SCC in milk during lactation) and 10 cows had low GEBV for LSCS (cows with high probability of having high SCC in milk). We isolated RNA from unstimulated peripheral blood mononuclear cells from these. Two out of the 14 analyzed genes showed significantly different results between groups. The group with high GEBV for LSCS displayed significantly higher expression of the CXCL1 gene than the low GEBV group. Grouping by lactation stage revealed significant differential expression of the FOS gene, with higher expression in early lactation (2-3 mo after calving) compared with late lactation (7-8 mo after calving). In addition, flow cytometry was performed on the peripheral blood mononuclear cells samples to analyze if number and type of isolated cells influenced the gene expression in the groups. The results in the current study provide identified genes that can be considered as possible candidate genes for chronic SCM in NR cows.

γδ T cells compose a developmentally regulated intrauterine population and protect against vaginal candidiasis.

This most comprehensive analysis to date of γδ T cells in the murine uterus reveals them to compose a unique local T-cell compartment. Consistent with earlier reports, most cells expressed a canonical Vγ6Vδ1 TCR, and produced interleukin (IL)-17A upon stimulation. Nonetheless, contrasting with earlier reports, uterine γδ T cells were not obviously intraepithelial, being more akin to sub-epithelial Vγ6Vδ1+ T cells at several other anatomical sites. By contrast to other tissues however, the uterine compartment also included non-Vγ6+, IFN-γ-producing cells; was strikingly enriched in young mice; expressed genes hitherto associated with the uterus, including the progesterone receptor; and did not require microbes for development and/or maintenance. This notwithstanding, γδ T-cell deficiency severely impaired resistance to reproductive tract infection by Candida albicans, associated with decreased responses of IL-17-dependent neutrophils. These findings emphasise tissue-specific complexities of different mucosal γδ cell compartments, and their evident importance in lymphoid stress-surveillance against barrier infection.

The role of dead space ventilation in predicting outcome of successful weaning from mechanical ventilation.

BACKGROUND: The exact mechanism by which tracheostomy results in clinical improvement in respiratory function and liberation from mechanical ventilation remains unknown. Physiologic dead space, which includes both normal and abnormal components of non-gas exchange tidal volume, is a clinical measure of the efficiency of ventilation. Theoretically, tracheostomy should reduce dead space ventilation and improve pulmonary mechanics, thereby facilitating weaning from mechanical ventilation. METHODS: This study compares arterial blood gases (ABG), pulmonary mechanics, including minute ventilation (VE) and dead space ventilation (Vd/Vt) within 24 hours before and after tracheostomy in 45 patients admitted to a surgical intensive care unit. RESULTS: There was no difference noted in patients' ABG or VE. Pre- and posttracheostomy change in Vd/Vt was negligible (50.7 and 10 vs. 51.9 and 11; p = NS). On subgroup analysis, those patients that were weaned from mechanical ventilation with 72 hours of tracheostomy (T3) were compared with those patients weaned from mechanical ventilation 5 days or more after tracheostomy (T+5). Again, no difference was found in pulmonary mechanics or Vd/Vt pre- and posttracheostomy. CONCLUSION: There is minimal improvement in pulmonary mechanics after tracheostomy. The change in physiologic dead space posttracheostomy does not predict the outcome of weaning from mechanical ventilation. Tracheostomy does allow better pulmonary toilet, and easier initiation and removal of mechanical ventilation and control of the upper airway.

Increase in rat plasma antioxidant activity after E. coli lipopolysaccharide administration.

It is well recognized that the sensitivity of animals to lipopolysaccharide (LPS) endotoxin varies tremendously. And, it has been recently observed that Sprague-Dawley rats dramatically increase the activity of hepatic endogenous antioxidative enzyme systems after LPS administration. This finding suggests that the relative resistance of rats to LPS may be related to a concomitant increase in the activities of the hepatic antioxidant systems. This study was designed to examine if the above reported hepatic change in rats given LPS could be observed at the systemic level. Male Sprague-Dawley or Wistar rats, weighing 250 - 350 g, were given increasing doses (10 - 100 mg/kg) of LPS i.p. under 1.0% isoflurane anesthesia. Antioxidant capacity (AOC), blood gas analysis, and the cardiovascular parameters of the arterial blood of animals were determined over a 4 hour period following LPS administration. In addition, we studied the effect of pretreatment with the non-specific nitric oxide synthase inhibitor, L-N(G)-Nitroarginine methyl ester hydrochloride (L-NAME), given 50 mg/kg s.c. one and 24 hours before the administration of 20 mg/kg LPS i.p. in Sprague-Dawley rats. Rats given sufficiently high doses of E. coli LPS to produce behavioral effects also showed increased plasma AOCs in the early period after the administration of LPS. Similar changes were noted in Sprague-Dawley and Wistar rat strains, but at different doses that reflect their differential sensitivities to the LPS induced inflammatory response. Also, the resistance of the Sprague-Dawley strain of rats to LPS was not altered by the prior administration of L-NAME, nor was the plasma AOC altered. In conclusion, our study suggests that the rat strains are relatively resistant to develop the toxic signs of LPS in the early period after the administration of LPS, especially in Sprague-Dawley rats. Moreover, endotoxin-induced increases in plasma AOC may contribute to the rats' resistance to LPS intoxication.

Single-breath measurements of pulmonary oxygen uptake and gas flow rates for ventilator management in ARDS.

Monitoring data in critical care and anesthesiology should be displayed to present a rapid and easily comprehensible definition of the patient's clinical status. A graphic computer display of the analog output of gas flow rates and the O(2) and CO(2) concentrations of respiratory gases profiles the expired breath for an estimation of pulmonary function and gas exchange. An estimate of pulmonary perfusion, cardiac output, and the general adequacy of cardiovascular circulation is obtained from the computer calculation of O(2) uptake and CO(2) elimination, dead space, and alveolar ventilation. Adjunctive data from the spirometric measurements of airway pressures, volumes, and compliance, supplemented by hemodynamic monitoring, aids in the diagnosis of physiologic changes. For > 10 years, we have used this system to monitor patients who are anesthetized, sedated, and receiving mechanical ventilation during anesthesia and surgery, and recently have extended the technique to intensive care areas. Our experience has shown good correlation of changes in the computer-assisted expired breath analysis with coinciding clinical events, including upper airway obstruction, bronchospasm, and alveolar volume/pulmonary capillary blood flow impairment. To demonstrate the use of this system, we describe the ventilator management for a patient with severe ARDS. In this patient, changes in ventilator management, including pressure control ventilation, improved pulmonary O(2) uptake (mean, 18.7 vs 8.5 mL/breath), CO(2) elimination (mean, 17 vs 13 mL/breath), and compliance (mean, 29.7 vs 19.0 mL/cm H(2)O), were compared with intermittent mandatory ventilation.

Fluoroquinolone resistance in Bacteroides fragilis following sparfloxacin exposure.

In vitro pharmacodynamic studies investigating the antimicrobial properties of five fluoroquinolones, (trovafloxacin, sparfloxacin, clinafloxacin, levofloxacin, and ciprofloxacin) against Bacteroides fragilis ATCC 23745 were conducted. The times required to reduce the viable counts by 3 log units were as follows: clinafloxacin, 2.9 h; levofloxacin, 4.6 h; trovafloxacin, 6 h; and sparfloxacin, 10 h. Exposure to ciprofloxacin did not achieve a 3-log decrease in viable counts. The susceptibility of B. fragilis was determined both prior to exposure and following 24 h of exposure to each of the five fluoroquinolones tested. The MICs of clinafloxacin, levofloxacin, trovafloxacin, sparfloxacin, ciprofloxacin, metronidazole, cefoxitin, chloramphenicol, and clindamycin were determined by the broth microdilution method. The MICs for B. fragilis preexposure were as follows: clinafloxacin, 0.25 microg/ml; trovafloxacin, 0.5 microg/ml; sparfloxacin, 2 microg /ml; levofloxacin, 2 microg/ml; and ciprofloxacin, 8 microg/ml. Similar pre- and postexposure MICs were obtained for cultures exposed to trovafloxacin, clinafloxacin, levofloxacin, and ciprofloxacin. However, following 24 h of exposure to sparfloxacin, a fluoroquinolone-resistant strain emerged. The MICs for this strain were as follows: clinafloxacin, 1 microg/ml; trovafloxacin, 4 microg/ml; sparfloxacin, 16 microg/ml; levofloxacin, 16 microg/ml; and ciprofloxacin, 32 microg/ml. No changes in the susceptibility of B. fragilis pre- and postexposure to sparfloxacin were noted for metronidazole (MIC, 1 microg/ml), cefoxitin (MIC, 4 microg /ml), chloramphenicol (MIC, 4 microg/ml), and clindamycin (MIC, 0.06 microg/ml). Resistance remained stable as the organism was passaged on antibiotic-free agar for 10 consecutive days. Mutant B. fragilis strains with decreased susceptibility to clinafloxacin, trovafloxacin, sparfloxacin, levofloxacin, and ciprofloxacin were selected on brucella blood agar containing 8x the MIC of levofloxacin at a frequencies of 6.4 x 10(-9), 4x the MICs of trovafloxacin and sparfloxacin at frequencies of 2.2 x 10(-9) and 3. 3 x 10(-10), respectively, and 2x the MIC of clinafloxacin at a frequency of 5.5 x 10(-11); no mutants were selected with ciprofloxacin. The susceptibilities of strains to trovafloxacin, levofloxacin, clinafloxacin, sparfloxacin, and ciprofloxacin before and after exposure to sparfloxacin were modestly affected by the presence of reserpine (20 microg/ml), an inhibitor of antibiotic efflux. The mechanism of fluoroquinolone resistance is being explored, but it is unlikely to be efflux due to a lack of cross-resistance to unrelated antimicrobial agents and to the fact that the MICs for strains before and after exposure to sparfloxacin are minimally affected by reserpine.

Sedation in the critically ill patient.

The goal of critical care medicine is to support organ function and maintain homeostasis until healing can occur. Sedation and analgesia may blunt the physiologic and psychologic sequelae of intensive care unit stress, and support homeostasis. Although a wide variety of agents have been used empirically, the recognition of analgesia, amnesia, and hypnosis as discrete elements comprising the sedated state has facilitated an individualized approach to therapy. Because intensive care unit patients are a highly heterogeneous population with varying levels of end-organ compromise, the development of specific, easily titratable, parenteral agents has made intensive care unit sedation safer. A trend toward refining dosage regimens in order to minimize the total dose of drug administered and to reduce the occurrence of residual sedation is driven by utilization and cost concerns. The capability for simple bedside electrophysiologic monitoring of the level of sedation is expected to improve the ability to provide optimal therapy.

Lorazepam and midazolam in the intensive care unit: a randomized, prospective, multicenter study of hemodynamics, oxygen transport, efficacy, and cost.

OBJECTIVES: To evaluate and compare the clinical efficacy, impact on hemodynamic and oxygen transport variables, safety profiles, and cost efficiency of sedation and anxiolysis with lorazepam vs. continuous infusion of midazolam in critically ill, intensive care unit patients. DESIGN: Multicenter, prospective, randomized, open-label study. SETTING: Teaching hospitals. PATIENTS: Ninety-five critically ill, mechanically ventilated patients with fiberoptic pulmonary artery catheters in place were randomly assigned to receive short-term (8 hrs) sedation with either intermittent intravenous injection lorazepam (group A, n = 50) or continuous intravenous infusion midazolam (group B, n = 45) titrated to clinical response. MEASUREMENTS AND MAIN RESULTS: The severity of illness, demographic characteristics, levels of anxiety and agitation, hemodynamic parameters, oxygen transport variables, quality of sedation, nursing acceptance, and laboratory chemistries reflecting drug safety were recorded. There were no significant differences with regard to demographic data, hemodynamic and oxygen transport variables, or levels of anxiety/agitation between the two groups at baseline, 5 mins, 30 mins, and 4 and 8 hrs after administration of sedation. There were no significant differences in the quality of sedation or anxiolysis. Midazolam-treated patients used significantly larger amounts of drug for similar levels of sedation and anxiolysis (14.4 +/- 1.2 mg/8 hrs vs. 1.6 +/- 0.1 mg/8 hrs, p = .001). Both drugs were safely administered and patient and nurse satisfaction was similar. CONCLUSIONS: Sedation and anxiolysis with lorazepam and midazolam in critically ill patients is safe and clinically effective. Hemodynamic and oxygen transport variables are similarly affected by both drugs. The dose of midazolam required for sedation is much larger than the dose of lorazepam required for sedation, and midazolam is therefore less cost-efficient.

Perioperative management of the thoracotomy patient.

The perioperative management of the thoracotomy patient must be both specific and flexible. The assessment of preoperative information yields information as to operability and resectability. Once anesthesia is administered for operative procedures, however, techniques and methods must be changed to accommodate additional information obtained during the surgical procedure. The preoperative and intraoperative management is focused on improving pulmonary function during the postoperative period and improving outcome. Significant advances in pain management techniques have evolved within the last 10 to 15 years. Relieving the intense pain associated with a thoracotomy incision not only improves patient well-being, but improves breathing patterns and pulmonary function, resulting in a more comfortable and ambulatory patient. Epidural analgesia, intrathecal analgesia, intrapleural installation of local anesthetics, and PCA are but a few of the techniques that enhance the therapeutic armamentarium and improve the postoperative course. Inasmuch as surgical extirpation of lung cancers remains the best hope of survival for many patients, a detailed and aggressive management plan is necessary to achieve the desired result.

Pressure support and flow-cycled, assisted mechanical ventilation in acute lung injury.

Pressure support is a ventilatory mode, available with many microprocessor ventilators, which is patient-triggered, pressure-limited, and flow-cycled. This study compared the respiratory and hemodynamic effects of PS used as a stand-alone mode of ventilation with those of conventional patient-triggered, flow-cycled, assisted mechanical ventilation. Instruments for hemodynamic and respiratory measurements were placed in ten spontaneously breathing, anesthetized sheep. In each animal, baseline measurements were made during PS and flow-cycled AMV. Acute lung injury was then instituted by instilling hydrochloric acid in the endotracheal tube, and after 60 minutes, measurements were repeated. No hemodynamic or respiratory variables differed, either before or after ALI, between PS and AMV. This study demonstrates that PS, when used as a stand-alone mode of ventilation, has similar hemodynamic and respiratory effects as flow-cycled AMV.

Graded exercise testing and postthoracotomy complications.

A controversy exists over whether or not preoperative exercise testing can predict postthoracotomy complications. This study was designed to evaluate the usefulness of a presurgical exercise protocol in patients with lung disease, but no evidence of cardiac disease. Seventy patients underwent baseline pulmonary function testing and split function perfusion studies, when indicated, to calculate predicted postoperative pulmonary function. Noninvasive data were incrementally collected from 17 patients by using a treadmill exercise tolerance test that was designed to elicit maximal performance. Inhaled and exhaled gas flow and volume, the partial pressure of O2 and CO2, maximal O2 consumption (VO2max), and maximal minute ventilation (VE max) were measured. The breathing and heart rate reserves were calculated by standard formulae in an attempt to separate cardiac from pulmonary exercise limitation. Two patients had postoperative cardiopulmonary complications after thoracotomy and lung resection, and six patients had noncardiopulmonary complications. There was no significant prognostic relationship among VO2max, VE max, maximum O2 pulse, and the incidence of postoperative cardiopulmonary complications. The percentages of predicted VE max and predicted maximum heart rate were related to the occurrence of total complications, but not specifically to cardiopulmonary complications. The results emphasize the difficulty in attempting to exercise thoracotomy candidates with chronic lung disease to maximal performance. Excluding patients from further surgical consideration because of exercise limitation is not feasible based on these data.

Accurate determination of end-tidal carbon dioxide during administration of oxygen by nasal cannulae.

Measurement of end-tidal carbon dioxide tension (PETCO2) by mass spectrometry or infrared capnometry provides a clinically useful approximation of arterial carbon dioxide tension (PaCO2) in intubated patients. Although several devices have been proposed to sample PETCO2 during spontaneous breathing (i.e., unintubated patients receiving supplemental oxygen), thus far no reports have documented their efficacy. This article reports the use of an easily constructed modification of simple nasal cannulae that permits accurate sampling of PETCO2 during oxygen administration to unintubated patients. After amputation of the closed tip, a cap from a syringe was inserted via a slit made at the base into one prong of a pair of nasal cannulae. A capnometer was connected to the syringe cap, and PETCO2 and PaCO2 were determined simultaneously during the administration of 3 L/min oxygen via nasal cannulae to 21 normocapnic patients. The PaCO2 - PETCO2 gradients were calculated and compared with values obtained in the same patients after intubation and mechanical ventilation. No significant difference was found between the calculated gradients with nasal cannulae (2.09 +/- 2.18 mm Hg) versus intubation (2.87 +/- 2.82 mm Hg). Simultaneous oxygen administration and accurate sampling of PETCO2 may be achieved in unintubated patients by using this easily constructed modification of nasal cannulae.

High-frequency percussive ventilation compared with conventional mechanical ventilation.

In seven patients with severe respiratory distress, conventional mechanical ventilation and PEEP were used initially for respiratory support, which was changed to high-frequency percussive ventilation (HFPV) at the same level of airway pressure and FIO2. During both modes of ventilation, patients could breathe spontaneously via a low-threshold demand valve. With HFPV, PaO2 improved significantly (p less than .01) compared with PaO2 during conventional methods. Cardiac output was unaffected by the change to HFPV.

Noninvasive monitoring of lung function during mechanical ventilation.

Noninvasive monitoring can greatly enhance decision-making and clinical approaches to the respiratory failure patient. Newer microprocessor systems will calculate, present, and trend derived data such as airway resistance and lung-thorax compliance. These changes characterize the degree of lung dysfunction and parallel abnormalities in gas exchange.

Effects of expiratory flow resistance on inspiratory work of breathing.

To minimize work of breathing, airway pressure should not fluctuate during spontaneous breathing with continuous positive airway pressure (CPAP). However, flow resistance in the inspiratory limb of the breathing circuit and an inadequate continuous gas flow rate result in airway pressure fluctuation and increased work of breathing. Flow resistance of the expiratory pressure/exhalation valve also directly affects the level of airway pressure during spontaneous inhalation with CPAP (the greater the resistance of the valve, the greater the decrease in airway pressure and work of breathing). We compared this effect with three types of expiratory pressure valves: a threshold resistor with low resistance to flow, an inflatable balloon (mushroom) valve with moderate resistance to flow, and a variable-orifice flow resistor with a high resistance to flow. Work increased up to threefold with the balloon valve and more than tenfold with the flow resistor compared with the threshold resistor. To apply CPAP, expiratory pressure valves with low resistance to flow should be used to minimize fluctuations in airway pressure and, thus, in the work of spontaneous breathing.

Flow resistance of expiratory positive-pressure valve systems.

The flow-resistive characteristics of a variety of commercially available expiratory positive-pressure valve systems used to provide continuous positive airway pressure (CPAP) and positive end-expiratory pressure were evaluated. One flow-resistor and seven threshold-resistor expiratory pressure valve systems were set at 5, 10, 15, 20, and 25 cm H2O of expiratory pressure, and sinusoidal exhaled flows peaking at 50,100, and 200 L/min were directed through each valve at each level of expiratory pressure. The Siemens flow-resistor valve demonstrated the greatest deviation in pressure above set CPAP levels at peak flow rates of 100 and 200 L/min, which suggests high resistance to exhaled flow. The Vital Signs threshold-resistor valve demonstrated the least deviation in pressure from set CPAP levels at all rates of exhaled flow, which suggests low flow resistance. The Emerson and IMV Bird threshold-resistor systems resisted flow less than the BEAR-2 and the Puritan-Bennett MA-2 and 7200 inflatable-balloon threshold-resistor-like valve systems. These data suggest that threshold resistors may be classified as low-resistance or high-resistance types. Using only low-resistance threshold resistors for CPAP may minimize the incidence of barotrauma and other deleterious effects related to airway pressure.