Characteristics and Outcomes Among Patients With Early Venous Thromboembolic Events After Lung Transplant.

BACKGROUND: Despite several previous studies reporting a high frequency of venous thromboembolism (VTE) after lung transplant (LT), few actionable risk factors have been identified. There are limited data regarding the practice patterns of anticoagulation use among patients with LT. METHODS: All adult patients with single or bilateral LT between 2012 and 2016 were included (n = 324; mean age, 56.3 ± 13.3 years; male, 61.1%). Demographic, clinical, and laboratory variables before and after LT were recorded. Follow-up data included survival up to 3 years post-transplant. Development of VTE during the first 30 days after LT was the primary outcome variable. RESULTS: The overall incidence of VTE during the first 30 days after LT was 29.9% (n = 97), among which the majority were upper extremity thromboses. Female sex, personal history of VTE, hospitalization at the time of transplant, and use of 3 or more central venous catheters during index hospitalization were independently associated with VTE. The use of anticoagulants was independently associated with a reduced risk of VTE. Despite increased morbidity, the development of VTE was not associated with worse post-transplant survival. CONCLUSIONS: A significant proportion of patients develop early VTE after LT. Limiting the number of central catheters to < 3 during the post-transplant period, along with the early institution of thromboprophylaxis, may lower the risk of VTE.

Coordination in the unfolded protein response during aging in outbred deer mice.

Endoplasmic reticulum (ER) stress has been linked to various metabolic pathologies, neurodegeneration and aging. Although various mechanistic aspects of the resulting unfolded protein response (UPR) have been elucidated, its regulation in genetically diverse populations remains elusive. In the present study we evaluated the expression of chaperones BiP/GRP78, GRP94 and calnexin (CANX) in the lungs, liver and brain of 7 months old and 2-3 years old outbred deer mice P. maniculatus and P. leucopus. Chaperones' expression was highly variable between species, tissues and ages suggesting that levels of expression of individual chaperones do not change consistently during aging. Despite this variation, a high degree of coordination was maintained between chaperones' expression indicating the tight regulation of the UPR which is consistent with its adaptive activity to maintain homeostasis. In the brain though of older P. maniculatus, at which neurodegenerative changes were detected, loss of coordination was revealed, especially between BiP and either of GRP94 or calnexin which indicates that de-coordination rather than aberrant expression is linked to deregulation of the UPR in aging. These findings underscore the involvement of UPR in the onset of aging-related pathologies and suggest that beyond levels of expression, concerted activation may be of significance to attain homeostasis. These findings emphasize the value of genetically diverse models and suggest that beyond levels of expression of individual targets the coordination of transcriptional networks should be considered when links to pathology are explored.

A CCL8 gradient drives breast cancer cell dissemination.

The migration of cancer cells towards gradients of chemoattractive factors represents a potential, yet elusive, mechanism that may contribute to cancer cell dissemination. Here we provide evidence for the maintenance of a gradient of increasing CCL8 concentration between the epithelium, the stroma and the periphery that is instrumental for breast cancer cells' dissemination. In response to signals elicited by the neoplastic epithelium, CCL8 production is enhanced in stromal fibroblasts at the tumor margins and in tissues at which breast cancer cells tend to metastasize such as the lungs and the brain. Manipulation of CCL8 activity influences the histology of the tumors and promotes major steps of the metastatic process such as invasion to adjacent stroma, intravasation and ultimately extravasation and seeding. These findings exemplify how gradients of chemoattractive factors such as CCL8, drive metastasis and suggest that interference with their operation may provide means for breast cancer management.

Regulation of complement-dependent cytotoxicity by TGF-ß-induced epithelial-mesenchymal transition.

The process of epithelial-mesenchymal transition (EMT), in addition to being an initiating event for tumor metastasis, is implicated in conferring several clinically relevant properties to disseminating cancer cells. These include stem cell-like properties, resistance to targeted therapies and ability to evade immune surveillance. Enrichment analysis of gene expression changes during transforming growth factor-ß (TGF-ß)-induced EMT in lung cancer cells identified complement cascade as one of the significantly enriched pathway. Further analysis of the genes in the complement pathway revealed an increase in the expression of complement inhibitors and a decrease in the expression of proteins essential for complement activity. In this study, we tested whether EMT confers resistance to complement-dependent cytotoxicity (CDC) in lung cancer cells and promotes tumor progression. CD59 is a potent inhibitor of membrane attack complex that mediates complement-dependent cell lysis. We observed a significant increase in the CD59 expression on the surface of cells after TGF-ß-induced EMT. Furthermore, CD59 knockdown restored susceptibility of cells undergoing EMT to cetuximab-mediated CDC. TGF-ß-induced CD59 expression during EMT is dependent on Smad3 but not on Smad2. Chromatin immunoprecipitation analysis confirmed that Smad3 directly binds to the CD59 promoter. Stable knockdown of CD59 in A549 cells inhibited experimental metastasis. These results demonstrate that TGF-ß-induced EMT and CD59 expression confers an immune-evasive mechanism to disseminating tumor cells facilitating tumor progression. Together, our data demonstrates that CD59 inhibition may serve as an adjuvant to enhance the efficacy of antibody-mediated therapies, as well as to inhibit metastasis in lung cancer.

Left Ventricular Dysfunction After Lung Transplantation for Pulmonary Arterial Hypertension.

BACKGROUND: Lung transplantation (LT) is the final treatment option for patients with pulmonary arterial hypertension (PAH). Perioperative challenges after LT are unique and commonly include excessive bleeding, arrhythmias, and primary graft dysfunction. Transient left ventricular dysfunction (LVD) is a known postoperative complication, but not fully explored. We describe our experiences at a single institution. METHODS: We reviewed our database for patients with PAH who underwent LT from July 2008 to July 2012. The data were analyzed for preoperative inotrope use, intravenous prostacyclin, cardiac catheterization, and imaging. Also measured were perioperative ischemic time, bypass time, primary graft dysfunction, ventilator days, length of stay, and mortality. LVD is defined as acute cardiopulmonary compromise (acute worsening of hypoxia with new bilateral infiltrates on imaging) with a drop in LV systolic function of 15% from baseline. We compared data between patients with LVD and without LVD. RESULTS: Sixteen patients met the criteria, the majority of patients (10) with World Health Organization (WHO) group 1 PAH. Thirteen received intravenous prostacyclin therapy, and 6 required inotropes before surgery. Five patients (31%) developed LVD after transplantation. Average time to onset of LVD was 4.2 days. Preoperative vasopressors were required in 60% of those developing LVD. Patients with LVD had lower right and left ventricular ejection fraction with higher left ventricular end diastolic volume before surgery. All patients recovered from LVD within 4 months after LT. CONCLUSIONS: LVD is a phenomenon observed mostly in patients with WHO group 1 PAH receiving LT. Prompt recognition and treatment of this condition reduced morbidity.

Effect of pulmonary hypertension in patients with end-stage lung disease on posttransplantation outcomes.

A subgroup of patients with end-stage lung disease develop secondary pulmonary hypertension (PH). PH results in worse prognosis in these patients. However, it is unclear if this effect prevails in the immediate- and long-term outcomes of these patients after lung transplantation (LT). The objective of this study was to evaluate the effect of pretransplantation PH on immediate- or long-term posttransplantation outcomes. A retrospective chart review of post-LT patients at Henry Ford Hospital from January 1995 through January 2008 was done. Patients were grouped by presence or absence of PH and were compared using chi-square or Fisher exact tests for categorical variables and t tests or Wilcoxon rank sum tests for continuous variables. Kaplan-Meier estimation was used to evaluate primary and secondary outcomes. Among the patients included in the study, 25 had PH. This group consisted mostly of females (68%). There was no difference in the indication or type of LT in the 2 groups. There was no statistically significant difference in freedom from bronchiolitis obliterans syndrome (BOS; P = .42), time to onset of BOS (P = .82), grade of BOS (P = .21), or cummulative acute rejection (CAR) score (P = .66). There was no difference in overall mortality at 3 and 5 years (P = .57) or time to death (P = .25). Number of A1 rejection episodes was the only significant predictor for BOS (P = .001). In conclusion, PH due to end-stage lung disease does not have any effect on early or late posttransplantation outcomes. There is predisposition for females with end-stage lung disease to develop secondary PH more so than males. The number of A1 rejections increases the likelihood of development of BOS. A larger multicenter study is needed to confirm the results of this pilot study.

Successful liver transplantation following medical management of portopulmonary hypertension: a single-center series.

Severe portopulmonary hypertension (POPH) is an absolute contraindication to orthotopic liver transplantation (OLT). Vasodilators have been used, but the safety of subsequent transplantation and the reversibility of pulmonary hypertension after transplantation are uncertain. This study examined the feasibility and post-transplant effects of liver transplantation following medical control of POPH. Eight consecutive patients (three females and five males, ages 39-51) with POPH as their only contraindication to transplantation were treated with continuous intravenous epoprostenol. Liver transplantation was considered if the mean pulmonary artery pressure (PAM) was lowered to <35 mmHg. Epoprostenol 2-8 ng/kg/min successfully improved hemodynamics in seven of eight patients, usually within 6.5 months of initiating therapy. PAM declined from an average of 43-33 mmHg (p=0.03); mean pulmonary vascular resistance declined from 410 to 192 dyn s cm-5 (p=0.01) and cardiac output increased from 6.6 to 10 L/min (p=0.02). Six of the seven responders were actively listed for liver transplantation. Two died on the waiting list; the remaining four were transplanted and remain alive and well 9-18 months post-OLT-two without vasodilators, and two on oral medication. We conclude that pulmonary vasodilators permit safe liver transplantation in some cases, and that POPH may be reversible after transplantation.

A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium.

PURPOSE: To determine the rate of recurrence and complications after bare sclera excision of primary pterygia followed by low-dose mitomycin C (0.2 mg/ml twice daily for five days), placebo (balanced saline solution), or conjunctival autograft. METHODS: We performed a prospective, double-masked clinical trial of 64 patients (60 Hispanic) randomly assigned to a treatment group. Twenty-four patients received mitomycin C, 23 conjunctival autograft, and 17 placebo. Recurrence was defined as fibrovascular tissue over the corneoscleral limbus onto clear cornea in the area of previous pterygium excision. RESULTS: The recurrence rate after mitomycin C and conjunctival autograft was 38% and 39% of eyes, respectively, after mean follow-up (in recurrence-free patients) of 12.3 and 13.5 months, respectively. The recurrence rate after placebo treatment was significantly higher (P = .002), 88%, after mean follow-up (in recurrence-free patients) of 9.3 months. Increasing age was associated with significantly fewer recurrences (P = .006) after controlling for pterygium type (atrophic, noninflamed, or inflamed) and treatment group. The mean time to recurrence varied from 3.7 to 4.8 months; only 6% of recurrences were noted after the sixth postoperative month. Major complications included symblepharon (two), loose autograft (one), and pyogenic granuloma (two). No group had significantly more complications. CONCLUSIONS: Conjunctival autograft and low-dose topical mitomycin C are equally effective as adjunctive treatment after excision of primary pterygia in this young, southern California, predominantly Hispanic population. Both methods have significantly lower rates of recurrence than bare sclera excision alone, and neither is associated with severe complications after one year of follow-up. Increasing patient age is associated with significantly less risk of recurrence.

Photoinactivation of herpes simplex virus by rose bengal and fluorescein. In vitro and in vivo studies.

Rose bengal and fluorescein are photosensitive dyes in widespread use in the evaluation of ocular surface diseases, including herpes simplex virus (HSV) keratitis. These dyes have recently been shown to penetrate living cells, and rose bengal was previously reported to possess antiviral activity. Several experiments reported herein suggest that these dyes do possess the potential for potent antiviral activity against extracellular virus, but only in the presence of light. Rose bengal is substantially more effective in vitro than fluorescein, and the effect is greater with increasing concentration of dye and duration of light exposure. Electron microscopic evaluation of treated virus showed no structural difference from untreated virus, in spite of 4- to 5-log decreases in virus titer. Intracellular virus was found to be markedly resistant to photoinactivation. In a rabbit model of acute primary HSV keratitis, daily application of topical rose bengal followed by light exposure had no therapeutic effect, although an adverse effect on culture sensitivity testing was seen.