Search

Herrington CS, Prekker ME, Arrington AK, Susanto D, Baltzell JW, Studenski LL, Radosevich DM, Kelly RF, Shumway SJ, Hertz MI, Bittner HB, Dahlberg PS. A randomized, placebo-controlled trial of aprotinin to reduce primary graft dysfunction following lung transplantation. Clin Transplant 2011: 25: 90–96. © 2010 John Wiley & Sons A/S. Abstract: Purpose: Severe primary graft dysfunction (PGD) is the major early problem following lung transplantation. Aprotinin, a serine protease inhibitor, has many anti-inflammatory properties that might reduce or prevent lung injury. Our hypothesis was that the incidence of PGD could be reduced by a combination of donor lung perfusion and systemic administration of aprotinin to recipients. Methods and Materials: The study was randomized and placebo controlled. Donor lungs were perfused during procurement with 4 L Perfadex containing aprotinin (280 mg load + 70 mg/hL) or placebo. Aprotinin or placebo was also administered peri-operatively to the recipients. The study was powered to detect a 10% improvement in the primary endpoint of developing ISHLT grade III PGD anytime within 48 hr following the transplant procedure. Results: There were 48 patients randomized. Diagnosis and the use of bypass were different between groups. The study was stopped prematurely at the planned interim analysis point because of published concerns about renal toxicity of aprotinin. There was no difference in the occurrence of the primary endpoint between groups of patients. The median change from the baseline creatinine level at 24, 48, 72 hr; 7 and 30 d following the transplant was not associated with the administration of aprotinin. Conclusions: There was no statistically significant difference in the incidence of the primary endpoint between groups in the study. Excess renal failure related to aprotinin administration in a patient population at high risk for the event was not observed.

Normal growth and development depends upon high fidelity regulation of cap-dependent translation initiation; a process that is usurped and redirected in cancer to mediate acquisition of malignant properties. The epithelial-to-mesenchymal transition (EMT) is a key translationally-regulated step in the development of epithelial cancers as well as pathological tissue fibrosis (1–5). To date, no compounds targeting EMT have been developed. Here we report the synthesis of a novel class of Histidine Triad Nucleotide Binding Protein (HINT)-dependent pronucleotides that interdict EMT by negatively regulating the association of eIF4E with the mRNA cap. Compound eIF4E inhibitor-1 (4Ei-1) potently inhibited cap-dependent translation in a dose-dependent manner in zebrafish embryos without causing developmental abnormalities; and prevented eIF4E from triggering EMT in zebrafish ectoderm explants without toxicity. Metabolism studies with whole cell lysates demonstrated that the prodrug was rapidly converted into 7-Bn-GMP. Thus we have successfully developed the first non-toxic small molecule able to inhibit EMT, a key process in the development of epithelial cancer and tissue fibrosis by targeting the interaction of eIF4E with the mRNA cap; and demonstrate the tractability of zebrafish as a model organism for studying agents that modulate EMT. Our work provides strong motivation for the continued development of compounds designed to normalize cap-dependent translation as novel chemo-preventive agents and therapeutics for cancer and fibrosis.

Background In May 2005 the Organ Procurement Transplant Network (OPTN) and United Network for Organ Sharing (UNOS) implemented the donor lung allocation score (LAS) system to prioritize organ allocation among prospective transplant recipients. The purpose of our study was to determine the impact of LAS implementation on 90-day survival, early complications and incidence of severe primary graft dysfunction (PGD) after the transplant procedure. Methods Early outcomes among 78 patients receiving transplants after the initiation of the scoring system were compared with those of the 78 previous patients. Survival rates at 90 days and 1 year were the primary end-points of the study. Arterial blood-gas measurements were collected for all patients at the time of ICU arrival and at 12, 24 and 48 hours after surgery to determine the distribution of International Society of Heart and Lung Transplant (ISHLT) PGD grade. Major complications within 30 days post-transplant were recorded. Results We found a small but significant 1-year survival advantage among post–LAS implementation patients, which was largely due to decreased early mortality in comparison to the control cohort. The incidence of ISHLT Grade 3 PGD measured within the first 24 hours after transplant did not differ between groups, nor was there an increase in the rate of major post-operative complications. Conclusions Implementation of the LAS system has not been associated with an increase in early mortality, immediate PGD or major complications.

The development of severe primary graft dysfunction (PGD) is a risk factor for perioperative death following lung transplantation. Our goal is to improve the predictive value of the earliest Pao(2)/fraction of inspired oxygen (P/F) measurements that gauge PGD severity.We identified 96 patients with severe PGD (P/F200) at ICU arrival through a retrospective review of 431 lung transplants performed at our institution from 1992 to 2005. The P/F trend, represented as quartiles of the 12-h percentage change in P/F, was analyzed using multivariate logistic regression. Study outcomes were 90-day death and long-term survival.The median percentage change in P/F over 12 h was + 52% (interquartile range, +20 to 90%). We observed the highest early mortality among those in the lowest quartile of the P/F trend (an increase in P/For= 20%). Ninety-day death rates decreased across the quartiles (low quartile, 32%; low-mid quartile, 9%; high-mid quartile, 5%; high quartile, 5%; test for trend, p = 0.007). After adjustment for the use of cardiopulmonary bypass, those in the lowest quartile of P/F trend had 6.8 times the odds of early death vs patients with a more favorable trend (odds ratio, 6.80; 95% confidence interval, 1.73 to 0.51; p = 0.007). In the first 5 years after transplant, there were significantly more deaths within the low quartile group vs those with a more rapidly increasing P/F trend (log-rank test, p = 0.01).Among lung recipients with severe PGD at ICU arrival, an improvement in P/For= 20% in the first 12 h portends a poor outcome.

Background Lobectomy for patients with clinical stage I non-small cell lung cancer (NSCLC) can be performed by thoracotomy or by video-assisted thoracoscopic surgery (VATS). We compared the operative characteristics and postoperative course for patients with clinical stage I NSCLC who underwent lobectomy by VATS or thoracotomy. Methods We retrospectively reviewed the charts of all patients undergoing lobectomy for clinical stage I NSCLC from January 1, 1998, through June 30, 2005. Results We performed 147 lobectomies (88 thoracotomy, 59 VATS) in 147 patients with clinical stage I NSCLC. Patient demographics were similar between groups; however, VATS patients had more hypertension ( p = 0.0114), chronic renal insufficiency ( p = 0.0479), and previous malignancies ( p = 0.0086). The two groups did not differ in pathologic stage, tumor size, histologic results, or number of positive nodes. More total nodes were identified in thoracotomy patients ( p = 0.0001), and they had a shorter intensive care unit stay ( p = 0.0224). VATS patients had significantly less postoperative pneumonia ( p = 0.0023). VATS patients trended toward fewer chest tube days and a shorter hospital length of stay. The two groups did not differ in operative time, blood loss, atrial fibrillation, or number of ventilator days. Median survival between the cohorts was similar (>7.9 years thoracotomy versus >4.6 years VATS, log-rank p = 0.6939). Conclusions Patients undergoing VATS lobectomy for clinical stage I NSCLC, despite having more comorbidities, had fewer postoperative complications. The approaches are equivalent in operative time, blood loss, length of stay, and survival rate. Compared with thoracotomy, VATS lobectomy for patients with clinical stage I NSCLC appears to be a less morbid operation.

A scoring system was recently proposed to grade the severity of primary graft dysfunction (PGD), a frequent early complication of lung transplantation. The purposes of this study are to: (1) validate the PGD grading system with respect to patient outcomes; and (2) compare the performance of criteria employing the arterial oxygenation to fraction of inspired oxygen (P/F) ratio to an alternative grading system employing the oxygenation index (OI).We retrospectively reviewed the medical records of 402 patients having undergone lung transplantation at our institution from 1992 through 2004. The ISHLT PGD grading system was modified and grades were assigned up to 48 hours post-transplantation as follows: Grade 1 PGD, P/F300; Grade 2, P/F 200 to 300; and Grade 3, P/F200. A worst score T(0-48) was also assigned, which reflects the highest grade recorded between T0 and T48.The prevalence of severe PGD (P/F Grade 3) declined after transplant, from 25% at T0 to 15% at T48. Grouping patients by P/F grade at T48 demonstrated the clearest differentiation of 90-day death rates (Grade 1, 7%; Grade 2, 12%; Grade 3, 33%) (p = 0.0001). T48 OI grade also differentiates 90-day death rates. There was no difference in longer-term survival between patients with PGD Grades 1 and 2. OI grade at T0 qualitatively improved differential mortality between Grades 1 and 2; however, the differences did not reach statistical significance. Patients with a worst score T(0-48) of Grade 3 PGD did have significantly decreased long-term survival, as well as longer ICU and hospital stay, when compared with Grades 1 and 2 PGD. Significant risk factors for short- and long-term mortality in our multivariate model were P/F Grade 3 [worst score T(0-48) as well as T0 grade], single-lung transplant, use of cardiopulmonary bypass and high pre-operative mean pulmonary artery pressure.There is an increased risk of short- and long-term mortality and length of hospital stay associated with severe (Grade 3) PGD. The proposed ISHLT grading system can rapidly identify patients with poor outcomes who may benefit from early, aggressive treatment. Refinement of the scoring system may further improve patient risk stratification.

Objective: Primary graft dysfunction caused by ischemia—reperfusion injury is one of the most frequent causes of early morbidity and death after lung transplantation. We hypothesized that the perioperative management with aprotinin decreases the incidence of allograft reperfusion injury and dysfunction after clinical lung transplantation. Methods:Lung transplant databases of two transplant centers were used to investigate the incidence of severe post-transplant reperfusion injury (PTRI). We examined data of 142 patients who underwent either single lung (81) or bilateral sequential lung (61) transplantation for COPD, idiopathic pulmonary fibrosis, cystic fibrosis, and miscellaneous lung disorders between 1997 and 2000. Thirty patients were excluded due to heart—lung transplantation or lung transplantation for Eisenmenger’s disease, retransplantation, rejection, or deviation from the standardized triple immunosuppression protocol. The data of remaining 112 patients (control group, 64% single lung, 36% sequential bilateral lung transplants) were compared to the prospectively collected data of 59 lung transplant patients over the last 5 years. All of these 59 patients were managed perioperatively with aprotinin infusion. In addition, Euro-Collins-aprotinin procurement solution (Apt-EC group) was used for 50 donor lungs (58% single lung, 42% sequential bilateral lung transplants). Aprotinin in combination with low-potassium dextran (LPD) flush solution (Apt-LPD group) was used for the procurement of 34 lungs (59% single lung, 41% sequential bilateral lung transplants). The International Society of Heart and Lung Transplantation (ISHLT) grade III injury score was used for the diagnosis of severe PTRI, which is based on a PaO2—FIO2 ratio of less than 200 mmHg. Results: Severe reperfusion injury grade III was observed in 18% of the control group. ECMO support was required in 25% of these patients. The associated mortality rate was 40%. Correlating factors for PTRI were donor age greater than 35 years (45%, p = 0.01, mean age 38 8) and recipient pulmonary artery systolic pressure greater than 60 mmHg (48%, p < 0.05). Lung graft ischemic times (231 14 min) and intraoperative techniques (cardiopulmonary bypass in 12%) were not associated with negative outcomes. Despite longer ischemic times (258 36 min and 317 85 min, respectively) and older donors (42 12 years and 46 12 years, respectively) in the aprotinin patient groups (Apt-EC and Apt-LPD group), the incidence of PTRI was markedly lower (6% and 9%, respectively). There was no mortality in the Apt-EC group and one patient died in the Apt-LPD group due to PTRI-induced graft failure. Conclusions:SeverePTRIincreasedshort-termmorbidityandmortality.Theincidenceofreperfusioninjurywasnotdependentupontheduration of donor organ ischemia. The use of aprotinin in the perioperative patient management in lung transplantation had strong beneficial effects on the patient outcomes and decreased the incidence of post-transplant ischemia—reperfusion injury significantly. # 2005 Elsevier B.V. All rights reserved.

Objective The International Society for Heart and Lung Transplantation has proposed a new grading system for primary graft dysfunction based on the ratio of arterial oxygen to fraction of inspired oxygen measured within 48 hours after lung transplantation. Worsening primary graft dysfunction grade is associated with increased operative mortality rates and decreased long-term survival. This study evaluated donor and recipient risk factors for postoperative International Society for Heart and Lung Transplantation grade 3 primary graft dysfunction. Methods We reviewed donor and recipient medical records of 402 consecutive lung transplantations performed between 1992 and 2004. We calculated a worst International Society for Heart and Lung Transplantation primary graft dysfunction grade in the first 48 hours postoperatively. Severe primary graft dysfunction (International Society for Heart and Lung Transplantation grade 3) was defined by a ratio of arterial oxygen to fraction of inspired oxygen of less than 200. Associations of potential risk factors with grade 3 primary graft dysfunction in the first 48 hours postoperatively were examined through bivariate and multivariate analysis. Results The 90-day mortality rate associated with the development of International Society for Heart and Lung Transplantation grade 3 primary graft dysfunction in the first 48 hours postoperatively was 17% versus 9% in the group without grade 3 primary graft dysfunction. Significant bivariate risk factors associated with this end point were increasing donor age, donor smoking history of more than 10 pack-years, early transplantation era (1992-1998), increasing preoperative recipient pulmonary artery pressure, and recipient diagnosis. In the multivariate analysis only recipient pulmonary artery pressure, donor age, and transplantation era were associated with grade 3 primary graft dysfunction in the first 48 hours postoperatively at a P value of less than .05. Conclusions Our analysis of donor and recipient risk factors for severe primary graft dysfunction identified patient groups at high risk for poor outcomes after lung transplantation that might benefit from treatments aimed at reducing reperfusion injury.

Background The use of a low-potassium–based preservation solution improves gas exchange in experimental models of lung transplantation. However, its efficacy in reducing the incidence of primary graft dysfunction (PGD) and improving patient outcomes in the clinical setting is controversial. Methods In this study we measured: oxygenation index (OI); International Society of Heart and Lung Transplantation (ISHLT) PGD grades; extubation times; intensive care unit (ICU) and hospital length of stay; 30-day, 90-day and 1-year survival rates; and bronchiolitis obliterans syndrome (BOS)-free survival. We compared 115 consecutive (2001 to 2004) lung recipients who received allografts preserved with Perfadex, a low-potassium dextran (LPD) solution, and compared the results with the previous 116 consecutive (1999 to 2001) lung recipients who received allografts preserved with modified Euro-Collins (MEC) solution. Recipients were classified as having severe PGD (ISHLT Grade III) if the lowest arterial oxygenation (P) to fraction of inspired oxygen (F) (P/F ratio) within 48 hours post-transplantation was Results Baseline characteristics of the 2 cohorts were similar except for recipient age (LPD 53.5 vs MEC 49.9 years; p = 0.03). There were no differences in donor age, gender, category of transplant, indication for transplant, use of cardiopulmonary bypass or pre-operative pulmonary artery pressures. When gas-exchange parameters were measured upon arrival to the ICU (T0), at 24 hours post-transplant (T24) and at 48 hours post-transplant (T48), the only significant finding was that the incidence of ISHLT Grade III PGD at T24 was lower in the LPD group compared with the MEC group (8% vs 20%, p = 0.03). The incidence of severe PGD at other timepoints was not statistically different (LPD vs MEC: T0, 17% vs 26%; T0 to T48, 25% vs 31%). Both groups had similar extubation rates at 48 hours post-transplant (LPD 64% vs MEC 67%). The 30-day survival (LPD 93% vs MEC 95%), 90-day survival (LPD 89% vs MEC 89%), 1-year patient survival (LPD 80% vs MEC 77%) and 1-year BOS-free survival (LPD 70% vs MEC 74%) were not statistically different. Conclusions Lung preservation with LPD as compared with MEC does not improve early gas exchange or impact 90-day and 1-year mortality. Continued investigation into lung preservation solution composition is necessary to reduce the incidence of PGD.

Background Idiopathic pulmonary fibrosis (IPF) is the second largest indication for lung transplantation worldwide. Average 90-day mortality rates for this procedure are 22%. It is unclear what factors predispose patients with IPF to this increased early posttransplant mortality. Pulmonary hypertension may increase the risk of development of early posttransplant complications through several mechanisms. We examined the effect of secondary pulmonary hypertension on 90-day mortality after lung transplantation for IPF. Methods An International Society for Heart and Lung Transplant Registry cohort study of 830 patients with IPF transplanted from January 1995 to June 2002 was undertaken. Risk factors were assessed individually and adjusted for confounding by a multivariable logistic regression model. Results In the univariate analysis, pulmonary hypertension and bilateral-lung transplantation were significant risk factors for increased 90-day mortality. Multivariate analysis confirmed that mean pulmonary artery pressure and bilateral procedure remain independent risk factors after adjustment for potential confounders. Recipient age, ischemia time, cytomegalovirus status mismatch, and donor age were not independent risk factors for early mortality. Conclusions Bilateral-lung transplantation carries a greater risk of early mortality than single-lung transplantation for IPF. Increasing pulmonary artery pressure is a risk factor for death after single-lung transplantation in IPF. Mean pulmonary artery pressure should be included in the overall risk assessment of patients with IPF evaluated for lung transplantation.

Extracorporeal membrane oxygenation (ECMO) has been used successfully for early, severe reperfusion injury after lung transplantation. The purposes of this study are to: (1) document the medium-term survival of patients treated with ECMO; and (2) assess the extent of recovery of their pulmonary function.We retrospectively reviewed charts of 172 patients having lung transplants at our institution from 1997 through 2002. The group included 16 patients (9% of total; 10 bilateral, 5 single, 1 living lobar) treated with ECMO for primary allograft failure after single or bilateral single-lung transplantation. Survival and bronchiolitis obliterans syndrome (BOS)-free survival rates were calculated. Pulmonary function was assessed at 2 months, 1 year and 2 years post-transplant.Median hospital stay was 48 days for the ECMO group and 16 days for the overall group (p0.05). The 90-day survival was 60% in the ECMO group, and 90% in the overall group. The 2-year survival was 46% in the ECMO group, and 69% in the overall group. Mean forced expiratory volume in 1 second (FEV(1)) in the ECMO group at 1 year was 59 +/- 13% of predicted, and at 2 years 60 +/- 15% of predicted; it was not significantly different for the overall group.Patients treated with ECMO for primary allograft failure after lung transplantation showed acceptable medium-term survival and pulmonary function.

Background The incidence of esophageal adenocarcinoma (EAC) has risen dramatically in the last two decades. As with other malignancies, changes in gene expression play a key role in the development and progression of these tumors. Methods Microarray analysis was used to study gene expression of 12,000 genes in EAC specimens. Adenocarcinoma tissue samples (n = 10) and controls of normal stomach (n = 6) and esophageal (n = 7) mucosa were collected fresh, then rapidly frozen in liquid nitrogen. The messenger ribonucleic acid (mRNA) from the samples was isolated, reverse transcribed, and used to generate biotin-labeled mRNA fragments, which were hybridized to Affymetrix U95 gene chips (AME Bioscience, Norway) for analysis. Additional samples analyzed included tissue containing dysplastic Barrett's epithelium from three patients, metastatic lymph nodes from two patients with EAC, one squamous carcinoma, and two esophageal cancer cell lines. Samples were segregated into groups with similar patterns of gene expression using clustering algorithms and gene sets that differentiated tumors from normal tissue were generated. Results There were 150 genes that were fourfold up regulated and 183 genes that were fourfold down regulated in the esophageal adenocarcinoma specimens, as compared to normal esophageal mucosa tissue controls. Using paired specimens (n = 5) and the paired t -test ( p Value of 0.05) as a filter, only 64 genes were fourfold up regulated and 110 were fourfold down regulated. These groups included cytoskeletal, cell adhesion, tumor suppressor, and signal transduction genes. Hierarchical clustering segregated the samples into the expected divisions. The esophageal cancer cell lines, OE19 and OE33, clustered separately from the EAC specimens. Extremely high gene expression levels of the ERBB2 gene, seen in the microarray analysis of the 2 cell lines, correlated with amplification of the gene determined by Southern blotting. Conclusions Gene expression patterns from a small subset of genes distinguish EAC specimens from normal controls. This technique can rapidly identify genes for targeted chemotherapeutic approaches to cancer treatment.

Background We plan to determine whether the cause of mitral valve regurgitation, ischemic or degenerative, affects survival after combined mitral valve repair or replacement and coronary artery bypass grafting (CABG) surgery and to assess the influence of residual mitral regurgitation on late outcome. Methods A retrospective study was made of 302 patients having mitral valve repair or replacement and CABG from January 1987 through December 1996. Risk factors for death, for development of New York Heart Association class III or IV congestive heart failure (CHF), and recurrent mitral valve regurgitation were identified by proportional hazards analysis. Results The cause of mitral regurgitation was ischemic in 137 patients (45%) and degenerative in 165 patients (55%). Valve replacement was performed in 51 patients (17%) and valve repair in 251 patients (83%). Median follow-up was 64 months. Ten-year actuarial survival rates were 33% (95% confidence interval: 22% to 47%) in the ischemic group and 52% (95% confidence interval: 42% to 64%) in the degenerative group. Univariate predictors of death, were entered into a multivariate model. Older age, ejection fraction of 35% or less, three-vessel coronary artery disease, replacement of the mitral valve, and residual mitral regurgitation at dismissal were independent risk factors for death. The cause of mitral valve regurgitation (ischemic or degenerative) was not an independent predictor of long-term survival, class III or IV CHF, or recurrent regurgitation. Conclusions Survival after mitral valve surgery and CABG is determined by the extent of coronary disease and ventricular dysfunction and by the success of the valve procedure; etiology of mitral valve regurgitation has relatively little impact on late outcome.

Background . The objective of this study was to analyze our initial results after laparoscopic repair of large paraesophageal hiatal hernias. Methods . Between October 1997 and May 2000, 37 patients (23 women, 14 men) underwent laparoscopic repair of a large type II (pure paraesophageal) or type III (combined sliding and paraesophageal) hiatal hernia with more than 50% of the stomach herniated into the chest. Median age was 72 years (range 52 to 92 years). Data related to patient demographics, esophageal function, operative techniques, postoperative symptomatology, and complications were analyzed. Results . Laparoscopic hernia repair and Nissen fundoplication was possible in 35 of 37 patients (95.0%). Median hospitalization was 4 days (range 2 to 20 days). Intraoperative complications occurred in 6 patients (16.2%) and included pneumothorax in 3 patients, splenic injury in 2, and crural tear in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating in 2, and a small bowel obstruction in 1. Two patients died within 30 days (5.4%), 1 from delayed splenic bleeding and 1 from adult respiratory distress syndrome secondary to a recurrent strangulated hiatal hernia. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Twenty-seven patients (87.1%) were improved. Four patients (12.9%) required early postoperative dilatation. Recurrent paraesophageal hiatal hernia occurred in 4 patients (12.9%). Functional results were classified as excellent in 17 patients (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%). Conclusions . Laparoscopic repair of large paraesophageal hiatal hernias is a challenging operation associated with significant morbidity and mortality. More experience, longer follow-up, and further refinement of the operative technique is indicated before it can be recommended as the standard approach.

We developed 9H1.B11, an anti-idiotypic anti-deep core/lipid A (DCLA), murine monoclonal antibody (mAb) that mimics the conserved DCLA region of lipopolysaccharide (LPS). It recognizes an epitope in the variable region of an DCLA mAb, binds to the murine macrophage cell surface, and inhibits LPS-induced macrophage cytokine secretion. We hypothesized that (1) active immunization with mAb 9H1.B11 would be associated with the development of anti-DCLA antibodies and (2) immunization would protect against subsequent gram negative bacterial challenge. Mice were immunized for 8 weeks before intraperitoneal (ip) challenge with Escherichia coli O111:B4 bacteria. Control animals were immunized with an irrelevant IgM antibody 8133 (negative control) or with LPS derived from Salmonella minnesota Re bacteria (positive control). Sera from immunized mice were collected, and titers against the core region of LPS (Re) and against LPS derived from the infecting E. coli strain were determined. Mice immunized with mAb 9H1.B11 developed measurable titers against S. minnesota Re LPS but not against the challenge strain of E. coli. However, immunization with 9H1.B11 on S. minnesota Re LPS protected against subsequent infection due to E. coli O111:B4 (100% survival). The group of mice immunized with IgM 8133 exhibited only 25% survival. The development of an anti-S. minnesota Re LPS titer after immunization with 9H1.B11 provides further evidence that a portion of 9H1.B11 mimics the conserved DCLA region of LPS. We believe that this approach holds considerable promise and plan further studies to define the mechanism by which protective capacity occurs.

Severe primary graft dysfunction (PGD) is the major early problem following lung transplantation. Aprotinin, a serine protease inhibitor, has many anti-inflammatory properties that might reduce or prevent lung injury. Our hypothesis was that the incidence of PGD could be reduced by a combination of donor lung perfusion and systemic administration of aprotinin to recipients.The study was randomized and placebo controlled. Donor lungs were perfused during procurement with 4 L Perfadex containing aprotinin (280 mg load + 70 mg/hL) or placebo. Aprotinin or placebo was also administered peri-operatively to the recipients. The study was powered to detect a 10% improvement in the primary endpoint of developing ISHLT grade III PGD anytime within 48 hr following the transplant procedure.There were 48 patients randomized. Diagnosis and the use of bypass were different between groups. The study was stopped prematurely at the planned interim analysis point because of published concerns about renal toxicity of aprotinin. There was no difference in the occurrence of the primary endpoint between groups of patients. The median change from the baseline creatinine level at 24, 48, 72 hr; 7 and 30 d following the transplant was not associated with the administration of aprotinin.There was no statistically significant difference in the incidence of the primary endpoint between groups in the study. Excess renal failure related to aprotinin administration in a patient population at high risk for the event was not observed.

Reduced lung perfusion and subsequent pulmonary ischemia can cause increased pulmonary vascular resistance, decreased oxygenation capacity, worsened compliance, and edema formation.

Background Although the incidence of adenocarcinoma of the esophageal and gastroesophageal junction has increased at an alarming rate in the past 30 years, little improvement has been made in treatment strategies. Previous studies have demonstrated that many upper gastrointestinal (GI) adenocarcinomas exhibit ERBB2 amplification. In cancers proven to have similar amplification, such as breast, ERBB2–targeted therapies have dramatically improved overall survival and disease-free rates of survival. This study uses siRNA to knockdown ERBB2 in GI adenocarcinoma cell lines to evaluate cell viability, apoptosis, and changes in cell cycle. Methods A cell line with a baseline amount of ERBB2 (Seg-1) and 2 upper GI adenocarcinoma cell lines with known amplification of ERBB2 (esophageal [OE19] and gastric [MKN45]) were treated with 120 pmol of 1 of 2 independent ERBB2 siRNAs or control siRNA for 6 hours. Results We demonstrate that knockdown of ERBB2 in esophageal and gastric cancer cell lines with known ERBB2 amplification effectively decreases ERBB2 protein levels and decreases cell viability mainly via apoptotic pathways. Conclusion ERBB–directed therapy may be of benefit in the subset of patients with GI adenocarcinomas exhibiting amplification of ERBB2.

We have measured the microsecond rotational motions of myosin heads in contracting rabbit psoas muscle fibers by detecting the transient phosphorescence anisotropy of eosin-5-maleimide attached specifically to the myosin head. Experiments were performed on small bundles (10-20 fibers) of glycerinated rabbit psoas muscle fibers at 4 OC. The isometric tension and physiological ATPase activity of activated fibers were unaffected by labeling 6040% of the heads. Following excitation of the probes by a 10-ns laser pulse polarized parallel to the fiber axis, the time-resolved emission anisotropy of muscle fibers in rigor (no ATP) showed no decay from 1 ps to 1 ms (r, = 0.095), indicating that all heads are rigidly attached to actin on this time scale. In relaxation (5 mM MgATP but no Ca2+), the anisotropy decayed substantially over the microsecond time range, from an initial anisotropy (ro) of 0.066 to a final anisotropy (r,) of 0.034, indicating large-amplitude rotational motions with correlation times of about 10 and 150 ps and an overall angular range of 40-50'. In isometric contraction (MgATP plus saturating Ca2+), the amplitude of the anisotropy decay (and thus the amplitude of the microsecond motion) is slightly less than in relaxation, and the rotational correlation times are about twice as long, indicating slower motions than those observed in relaxation. While the residual anisotropy (at 1 ms) in contraction is much closer to that in relaxation than in rigor, the initial anisotropy (at 1 ps) is approximately equidistant between those of rigor and relaxation. Therefore, the anisotropy decay in contraction is not a simple linear combination of those in rigor and relaxation, implying that there are myosin head rotations in contraction that are distinct from those in both rigor and relaxation. Fiber stiffness in isometric contraction is about 70% of the rigor value, suggesting that a majority of cross-bridges are attached to actin. Therefore, much of the rotational motion observed in contraction probably occurs in the attached phase of the cross-bridge cycle.

Background Severe hyperhidrosis is treated by thoracic sympathetic chain interrupting through chain transection or clipping. Our study compared the efficacy of these 2 methods. Methods Retrospectively, patients who underwent thoracoscopic sympathectomy from 1999 to 2005 had demographic, operative, and postoperative data analyzed. Results Fifty-four operations were performed for refractory sweating of the palm (72%), axilla (66%), foot (53%), and head/neck (19%). Thirty-seven (69%) underwent clipping; 17 (31%) underwent chain transection. There was no difference in age, sex, or blood loss. One ganglion level was interrupted in 24.1% and 2 levels in 75.4%. Bothersome compensatory hyperhidrosis occurred in 13% (5-clipping and 2-transection). One patient underwent clip removal for debilitating symptoms. Three small pneumothoraces occurred (all in the transection group); all treated expectantly. Conclusions Thoracoscopic sympathectomy is a safe outpatient procedure. Both methods yield excellent results with minimal compensatory hyperhidrosis. Thoracoscopic sympathetic chain clipping and transection are equivalent.

Objective Acute graft dysfunction secondary to ischemia–reperfusion injury (IRI) continues to be the most common cause of early mortality after lung transplantation. The perioperative management with aprotinin could decrease the incidence of severe IRI. Methods A retrospective analysis was conducted of the data from 180 patients who underwent either single lung (56%) or bilateral sequential lung transplantation for similar end-stage lung disease between 1997 and 2005. The most recent 68 patients were managed perioperatively with the high-dose aprotinin infusion regimen (aprotinin group). The ISHLT grade III injury score was used for the diagnosis of severe IRI, which is based on a Pa o 2 –FI o 2 ratio of less than 200 mmHg. Results Grade III injury was observed in 18% of the patients who were not managed with aprotinin (control group, 152 grafts, 64% single transplants, 68% male, 54 ± 8 years of age). Early ECMO support was required in 25% of these patients. The associated mortality rate was 40%. Despite significantly longer cold ischemic times (290 ± 14 minutes vs 231 ± 14 minutes), older donors (42 ± 12 years of age), and more frequently observed severely elevated systolic PAP of greater than 60 mmHg (60% vs 48%) as well as more frequently required extracorporeal circulatory support (24%* vs 12%) in the aprotinin group, the incidence of severe IRI (8%) and associated mortality (9%) was markedly reduced. Conclusions The use of aprotinin in LTX surgery, which had strong beneficial effects on patient outcomes, significantly decreased the incidence of severe posttransplant IRI.

Background Severe primary graft dysfunction (PGD) is associated with poor early outcomes after lung transplantation (LTx). Less is known about lingering effects of severe PGD on pulmonary function. The study’s aim was to determine whether development of severe primary graft dysfunction in the perioperative period was associated with reduced long term rates of survival or with diminished long term pulmonary function. Methods A retrospective review was performed on LTx recipients who received their transplant during the period from 1992 through 2005. PGD severity over the first 48 hours post-transplant was graded using International Society for Heart Lung Transplantation criteria. Pulmonary function was evaluated yearly, and bronchiolitis obliterans syndrome (BOS) was determined from measurements of forced expiratory volume in 1 second (FEV1). Results A total of 374 patients survived at least 90 days post-transplant. Overall survival rates were worse in patients with Grade 3 PGD: 51% at 5 years and 11% at 10 years for patients with Grade 3 PGD; 64% at 5 years and 35% at 10 years for those with Grade 2 PGD; and 66% at 5 years and 38% at 10 years for Grade 0 to 1 PGD (p = 0.001). BOS-free survival rate for patients with Grade 3 PGD was lower compared to those with Grade 0 to 2 for bilateral lung recipients, but not for single-lung recipients. Bilateral lung recipients who developed Grade 3 PGD had a significantly worse mean FEV1 than those who did not. For single-lung recipients, PGD grade did not correlate with post-transplant pulmonary function. Conclusions Development of Grade 3 PGD in the early post-operative period negatively affects long-term survival, BOS-free survival and pulmonary function of bilateral lung transplant recipients who survive the peri-operative period.

Background ERBB2 (v-erb-b2 erythroblastic leukemia viral oncogene homolog 2, Her-2-neu) gene amplification and overexpression has been reported in several types of cancer. The purpose of this study was to (1) determine the frequency of ERBB2 amplification (in comparison to other proto-oncogenes) in tumors from patients with esophageal adenocarcinoma, (2) characterize structural details of an ERBB2 amplicon in the esophageal adenocarcinoma cell line OE19 (contains a 100-fold ERBB2 amplification), and (3) test whether growth of the OE19 cell line is sensitive to the ERBB2 inhibitor trastuzumab (Herceptin; Genetech, Inc, San Francisco, CA). Methods First, we determined the frequency, by Southern blotting techniques, of amplification of ERBB2 and 13 other proto-oncogenes in a panel of 25 esophageal adenocarcinoma tumors. Then, in a second panel of 10 tumor specimens, expression levels of the ERBB2 gene and of several other genes that flank ERBB2 on chromosome 17 were determined by microarray analysis. Next we characterized the ERBB2 amplicon in the esophageal adenocarcinoma cell line OE19 using cytogenetic methods and a Rec-A protein assisted restriction endonuclease mapping technique. Finally, an in vitro growth inhibition assay was used to measure the sensitivity of OE19 and OE33 cells to treatment with trastuzumab (humanized antibody to ERBB2). Results ERBB2 was the most frequently amplified proto-oncogene among 25 esophageal adenocarcinoma tumors tested (greater than 10-fold amplification in 3 of 25 (12%) tumors tested). The OE19 cell line contains a 100-fold amplification of the ERBB2 gene, and highly expresses its messenger ribonucleic acid. Transcripts from genes that flank ERBB2 including GRB7, a protein linked to metastasis in esophageal cancer, also showed high levels of expression. In OE19 cells, the ERBB2 amplicon was localized to a homogeneously staining region of chromosome 14. Southern blots from the Rec-A protein assisted restriction endonuclease cleavage mapping experiments in OE19 showed a strong band of 210 kilobases in size, demonstrating that the main amplicon was a tandem repeat. In the in vitro growth inhibition assay, trastuzumab inhibited the OE19 and OE33 cells growth by 49% and 20%, respectively, at a saturating concentration of 20 μg/mL. Conclusions ERBB2 is the most frequently amplified proto-oncogene in esophageal adenocarcinoma among the genes that we tested. In the OE19 esophageal adenocarcinoma cell line, the ERBB2 amplicon is translocated onto chromosome 14, is amplified 100-fold at the deoxyribonucleic acid level, and is highly overexpressed at the messenger ribonucleic acid level. Finally, the growth of this cell line was inhibited by incubation with trastuzumab. These results demonstrate that a substantial number of esophageal adenocarcinomas have amplified copies of the ERBB2 gene, and that they may be responsive to ERBB2 targeted therapies such as trastuzumab.

The number of transplants performed at our center continues to grow--partly as a result of the use of expanded donors and partly as a result of referrals from programs that have closed. We also anticipate having a more active living-donor lobar transplant program. The major acute problems that we encounter after transplantation are reperfusion injury and pneumonia. Improvements in perioperative mortality and morbidity will come with better lung preservation techniques and with an improved understanding of and an ability to modify the reperfusion process. BOS continues to be a major long-term problem for lung transplant patients. Although we do not understand the underlying pathogenesis of BOS, we are optimistic that BOS-free survival rates will increase with improvements in our ability to detect acute rejection as well as by avoidance of chronic injury to the lung from processes like GERD. Ongoing genetic analysis being conducted at our center will likely provide information about important biomarkers that define these processes.

Background. Bactericidal permeability increasing protein (BPI) binds to and neutralizes lipopolysaccharide (LPS, endotoxin). Small synthetic peptides based on the amino add sequence of the LPS binding domain of BPI neutralize LPS, albeit inefficiently. Although the LPS binding domain of native BPI possesses a β-turn secondary structure, this structure is not present in small derivative peptides. The purpose of this study was to determine whether the addition of a β-turn to a BPI-derived peptide is associated with more potent endotoxin antagonism. Methods. We generated a hybrid peptide (BU3) on the basis of (1) a portion of the LPS binding domain from BPI and (2) amino acids known to initiate a β-turn. BU3 folds with a β-turn, and we tested its effects on LPS neutralization and LPS-induced tumor necrosis factor-α secretion, comparing it with BPI-derived peptide BG22 that lacks a β-turn and to an irrelevant peptide (BG16). Results. Compared with BG22, BU3 demonstrated enhanced LPS neutralization and inhibition of LPS-induced tumor necrosis factor-α secretion in vitro and a similar diminution of endotoxemia and tumor necrosis factor-α secretion in a murine model of endotoxemia. Conclusions. These data demonstrate the potential for enhancing the biologic activity of a BPI-derived peptide endotoxin antagonist via manipulation of its conformational structure.

Candida albicans has been isolated with increasing frequency during intraabdominal infection; yet its role as a pathogen or copathogen remains controversial. A recent experimental study of its effect during polymicrobial peritonitis indicated that it did not enhance mortality when added to an Escherichia coli challenge, but that study used fecal or mucin-based adjuvants which are known to markedly potentiate the lethality of intraperitoneal bacteria. Therefore, we sought to examine the hypothesis that C. albicans and E. coli are synergistic copathogens that act in concert to increase mortality rates in experimental models of polymicrobial peritonitis, irrespective of the presence of growth adjuvant. To test this hypothesis, we assessed the mortality rates of previously healthy Swiss-Webster mice (20 g) that were challenged intraperitoneally (i.p.) with E. coli, C. albicans, or both, in either the presence or the absence of hemoglobin-mucin. In the absence of hemoglobin-mucin, E. coli plus C. albicans resulted in 83.3% mortality (P0.02) compared to either E. coli (0%) or C. albicans (0%) alone. In the presence of hemoglobin-mucin, the synergistic effect was not observed, lower numbers of E. coli alone (62.5%), C. albicans alone (75%), or both organisms together (100%, P0.05) provoked high lethality. These data demonstrate that in the absence of adjuvant, E. coli plus C. albicans provoked synergistic lethality. However, in the presence of hemoglobin-mucin the synergistic effect was no longer observed. Therefore, this study provides support for the contention that C. albicans is capable of acting as a copathogen during experimental peritonitis, but that this effect may be obscured by the presence of an adjuvant substance that itself markedly potentiates microbial growth.

Objectives: To generate a recombinant fusion protein (FP) based on the endotoxin-binding domain of bactericidal/permeability-increasing protein (BPI) and the constant domain of IgG and to test its ability to inhibit lipopolysaccharide (LPS)-induced macrophage tumor necrosis factor α (TNF-α) secretion. Design: A murine macrophage cell line, RAW 264.7, was transfected with a BPI-IgG FP before incubation with LPS. The amount of LPS-induced TNF-α protein secreted was measured and compared with that secreted by cells transfected with a control construct. Setting: Basic science research laboratory. Main Outcome Measure: Secreted TNF-α protein concentration. Results: After transfection, RAW 264.7–cell FP expression was detected in cell lysates and supernatants. At each LPS dose tested, cells transfected with the FP gene secreted less TNF-α than did cells transfected with a control construct. Conclusions: The FP possesses substantial antiendotoxin activity, as delineated by inhibition of LPS-induced TNF-α secretion by murine macrophages transfected with the fusion gene construct. In the future, such FP may be used as a clinical reagent to reduce the morbidity and mortality associated with serious gram-negative bacterial infections in surgical patients. Arch Surg. 1996;131:1173-1178

Twenty-seven amino acid peptides with sequences corresponding to a proposed endotoxin binding region of bactericidal permeability increasing protein (BPI):1) inhibit lipopolysaccharide induced macrophage tumor necrosis factor-alpha (TNF-alpha) secretion, 2) have bactericidal activity against gram-negative bacteria, and 3) protect mice from a lethal lipopolysaccharide (LPS) challenge. Unfortunately, peptides have a short halflife in vivo. Therefore, we have chemically conjugated the BPI based peptide, BG38, to a larger carrier protein, keyhole limpet hemocyanin (KLH), and characterized its ability: 1) to inhibit LPS induced macrophage TNF-alpha secretion and 2) to decrease plasma endotoxin and TNF-alpha levels following an i.v. injection of E. coli 0111:B4 LPS. BG38-KLH inhibited cultured macrophage TNF-alpha secretion in response to LPS derived from four pathogenic strains of gram-negative bacteria in a dose dependent manner (90% inhibition at 50 microgram/ml, P0.05 Student's t test). BG38-KLH also decreased serum endotoxin (90%, P0.05 Student's t test) and peak TNF-alpha levels (30% inhibition, P0.05 Student's t test) following E. coli LPS challenge in a murine gram-negative bacterial sepsis model. Novel endotoxin antagonists based upon a small domain of BPI represent promising reagents for the treatment of serious gram-negative bacterial infections.

Hypothesis We hypothesized that the recent reduction in procedure volume for coronary artery bypass grafting (CABG) has led to an increase in the in-hospital mortality rate. Design Hospital discharge data from the Nationwide Inpatient Sample from January 1, 1988, through December 31, 2003. Setting A 20% random sample of patients admitted to US hospitals. Patients All patients who underwent CABG or percutaneous transluminal coronary interventions. Facilities performing CABG were assigned to standard volume cutoffs. Main Outcome Measures Rates of cardiac procedures and the proportion of hospitals meeting standard volume cutoffs, as well as the CABG mortality rate. Results During our 16-year study period, the rate of CABG increased from 7.2 cases per 1000 discharges in 1988 to 12.2 cases in 1997 but then decreased to 9.1 cases in 2003, while the rate of percutaneous interventions tripled. For CABG, the proportion of high-volume hospitals declined from 32.5% in 1997 to 15.5% in 2003. Despite shifts between high- and low-volume hospitals, the CABG mortality rate steadily declined from 5.4% in 1988 to 3.3% in 2003. Hospitals performing the lowest volume of CABG experienced the largest decrease in the in-hospital mortality rate. Conclusions Since 1997, CABG volume has declined in the setting of a decrease in in-hospital mortality. A lower mortality rate in the setting of reduced CABG volume is a counterintuitive finding, suggesting that procedure volume is an insufficient predictor of outcome on which to base regionalization strategies.

Objective Laparoscopic repair of a giant hiatal hernia (>50% of the stomach above the diaphragm) is associated with short-term recurrence rates of 12% to 42%. Recurrent hiatal hernias often have significantly altered anatomy, making laparoscopic repair challenging. We hypothesized that increasing intra-abdominal esophageal length by means of Collis wedge gastroplasty, complete fat-pad dissection, hernia-sac excision, and primary reinforced crural repair would minimize short-term recurrence and provide adequate symptomatic relief. Methods From January 1, 2001, though May 1, 2005, 61 patients underwent laparoscopic repair of a giant or recurrent hiatal hernia with a Collis wedge gastroplasty and Nissen fundoplication. Symptomatic outcomes were assessed with a validated questionnaire (Gastroesophageal Reflux Disease Health-Related Quality of Life). We obtained postoperative radiographic imaging to objectively assess anatomic results at a median of 1.13 years. Results Of the 61 patients, 12 (20%) were referred to our institution after previous repairs. Operating time averaged 308 ± 103 minutes. The median hospital stay was 4 days. Postoperative complications occurred in 5 (8.2%) patients. One (1.6%) patient died of cardiac complications. Postoperatively, 52 (85%) patients completed the questionnaire with mean a Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire score of 1.15 ± 2.78 (scale, 0-45; 0=asymptomatic). Overall, 51 (98%) of the 52 respondents were satisfied with their surgical outcome. Postoperative radiographic data were available for 54 (89%) patients. We identified no recurrences at 1-month follow-up, and only 4.7% (2/42) had evidence of radiographic recurrence at 1 year or more. Conclusions Consistent use of a Collis wedge gastroplasty with reinforced crural repair minimizes short-term recurrence after minimally invasive giant hiatal hernia repair. Symptomatic results are excellent in most patients.

Introduction: Primary graft dysfunction (PGD) is a frequent early complication of lung transplantation. A grading system has been proposed by the ISHLT for PGD based on arterial oxygenation to fraction of inspired oxygen (P/F) ratios at ICU arrival (T0), 24 hours (T24), and 48 hours (T48) post-transplantation. Our objective was to determine if this PGD grading system is predictive of short-term outcomes. Methods: We reviewed donor and recipient medical records for 369 consecutive lung transplants performed between 1992 and 2003. Grade 0-I recipients had P/F ratios 300, grade II 299–200, and grade III 200. Results: During the study period 237 single (SLT), and 132 bilateral single (BSL) lung transplants were performed. The incidence of severe PGD (grade III) was 25% at T0, 5.4% at T24, and 14% at T48. Grouping recipients by the lowest P/F ratio recorded within 48 (T0-48) hours yielded evenly distributed groups: 130 grade 0-I (35%), 107 grade II (29%), and 132 grade III (35%). Grade III T0-48 recipients had an increased 90 day mortality (18%) versus recipients in grades 0-I (10%) and II (7.5%) (p 0.03). Overall survival (Figure), mean length of ICU and hospital stay also increased in grade III patients (12 and 25 days) versus grades 0-I (4.5 and 15) and II (5.5 and 17 days) (p 0.0001). Conclusions: There is an increased risk of mortality and length of hospital stay associated with grade III PGD. The proposed system can rapidly identify recipients with poor outcomes who may benefit from early aggressive treatment. Refinement of the scoring system may further improve patient risk-stratification.

Introduction. Proto-oncogene activation can occur by amplification of a large tract of DNA: the purpose of this study was to determine the structure of the FGFR2 amplicon in the gastric cancer cell line SNU-16. Methods. FGFR2 amplification was confirmed by Southern blotting. Fluorescence in situ hybridization was used to visualize the locations of the SNU-16 amplicons, which then were mapped using RecA protein-assisted restriction endonuclease (RARE) cleavage techniques. Results. Results of RARE mapping studies were consistent with two structures that contain the FGFR2 gene (Figure). The dominant structure is a 660-kb double minute (DM) chromosome that has two full copies of the FGFR2 gene and a third truncated copy. There are about 160 copies of the DM per cell, and it is likely that the circular DM evolved from a precursor linear head-to-tail repeat. A second amplicon is a chromosomal head-to-tail repeat that contains the FGFR2 gene and an adjacent pseudogene. Sequences from the joint region (J2) of the DM contain Alu repeats and chi-like elements suggesting that homologous recombination played a role in generating the amplicons. Conclusions. FGFR2 amplification in SNU-16 is complex. However, RARE cleavage and mapping was effective in resolving the various amplicons. It appears that, once created, FGFR2 amplicons are dynamic structures that evolve. Detailed knowledge of the structure of amplified oncogenes in tumors may be useful for developing novel treatment strategies for upper gastrointestinal tract cancers. Download : Download full-size image