Course and treatment of chronic hepatitis E virus infection in lung transplant recipients

OBJECTIVE

Persistent hepatitis E virus (HEV) infections have been described in various transplant cohorts. However, the frequency and the course of HEV infection in lung transplant recipients (Lu-Tr) are not well defined.

METHODS

We retrospectively analyzed serum from 95 Lu-Tr for HEV RNA and anti-HEV immunoglobulin-G (IgG) (with the MP assay). Anti-HEV seroprevalence was compared to that of 537 healthy individuals. Prospective HEV screening was subsequently initiated in Lu-Tr.

RESULTS

Elevated liver enzymes were observed in 44/95 (46.3%) patients. Anti-HEV IgG was present in 5/95 patients (5.3%), revealing a slightly higher prevalence compared to controls (2%, 11/537; P = 0.07). Chronic HEV infection with detectable viral replication was confirmed by polymerase chain reaction in 3 (3.2%) patients, all of whom demonstrated clinical and biochemical features of active liver disease (maximum alanine aminotransferase [ALTmax ] 89, 215, and 270 IU/L, respectively). One patient had died from multi-organ failure in combination with liver cirrhosis before HEV diagnosis. Two additional patients with chronic hepatitis E were identified during prospective screening (ALTmax 359 and 318 IU/L). All patients still alive commenced ribavirin therapy for 5 months, with dose adjustment (400-600 mg/day) according to renal function and hemoglobin level. Sustained resolution of HEV infection occurred in 2 patients. One patient is still under treatment, and the fourth died from graft failure considered unrelated to ribavirin therapy.

CONCLUSION

Chronic hepatitis E should be considered in the differential diagnosis of elevated liver enzymes, which are commonly seen in Lu-Tr. We observed 1 case of end-stage liver cirrhosis and death in an HEV-infected subject, who was not treated with ribavirin. Given this potentially devastating consequence, ribavirin therapy of persistent HEV infection appears to be acceptably safe and effective in Lu-Tr. However, larger prospective studies are warranted.

Abstract P3-08-15: Improving survivors’ quality of care through use of self-reported satisfaction data

Background: Despite numerous initiatives to improve the quality and safety of care for the growing number of cancer survivors, little empirical evidence is available about survivor satisfaction with post-treatment care or whether their information needs are met. Our specific aim was to conduct a comparative evaluation of 2 cohorts of survivors to determine their satisfaction with services provided in a breast survivorship clinic.

Methods: We compared satisfaction in 2 separate cohorts of women who completed their curative treatment. Eligibility criteria for both groups included being a woman diagnosed with breast cancer and transitioned to “long-term survivor” status by their primary oncologist. Women were then grouped into no-visit, those who had never been to a breast survivorship clinic or completed-visit, survivors who had completed a visit to the survivorship clinic. Data was collected for the no-visit group in 2009, when the breast survivorship clinic was initially launched. Data collection for the comparative or completed-visit cohort is ongoing.

The instrument consisted of 6 items reflecting 2 subscales: satisfaction and information needs. The first subscale focused on satisfaction with their visit, time spent with provider, and management of emotional distress. The second sub-scale focused on information received related to disease surveillance, late effects, health promotion, and social services. Survivors in both groups received the questionnaire upon their clinic arrival and completed it during their visit. Descriptive statistics were used to summarize all responses. All data were de-identified.

Results: The no-visit cohort consisted of 81 breast cancer survivors who had never been seen in any type of survivorship clinic. Responses indicating that the survivors strongly agreed with an item were reported as follows: 79.5% satisfied with their visit, 77.3% information received, and 77.8% adequate time with provider. Of survivors who reported they were experiencing emotional distress, 50% strongly agreed that the clinicians in the clinic did all possible to address their distress, such as making referrals to the clinic social worker or to community-based mental health services. Bone health, cancer education, recurrence, and screening were the educational topics most requested. Final data collection and analysis for the comparative cohort, completed-visit, will be concluded by August 2013.

Discussion: The no-visit cohort reported high satisfaction with survivorship care and information before they were seen in any type of institutional survivorship clinic. This finding could be a bias resulting from satisfaction with care received as a patient in active treatment. Results however, also suggest survivors of breast cancer who had not been seen in a survivorship clinic were aware of the type of specialized care or education needed to maintain their health after curative treatment. Further evaluation and research is needed to determine how satisfaction and unmet educational needs can be used to optimize outcomes for our growing population of cancer survivors.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-15.

Physiologic responses following gonadotropin-releasing hormone immunization in intact male dogs

We investigated the use of a commercial gonadotropin-releasing hormone (GnRH) vaccine as a method of temporary and reversible immunocastration in intact male dogs. Four privately owned dogs were vaccinated twice at 4-week intervals. Blood samples were collected at 0, 4, 12 and 20 weeks following the initial vaccination. These samples were analysed for GnRH antibody titres, luteinizing hormone (LH) and testosterone concentrations. Scrotal measurements were made at the time of sample collection, and testicular volume was calculated using the formula of an ellipsoid. As a result of vaccination, dogs displayed an elevated GnRH antibody titre, decreased LH and testosterone concentrations and decreased testicular volume, which reversed by the end of the study period. Therefore, these results suggest that immunizing against GnRH may be a possible choice for temporary and reversible immunocastration.

Phenotyping established chronic lung allograft dysfunction predicts extracorporeal photopheresis response in lung transplant patients

Chronic lung allograft dysfunction (CLAD) remains the leading cause of mortality in lung transplant recipients after the first year. Treatment remains limited and unpredictable. Existing data suggests extracorporeal photopheresis (ECP) may be beneficial. This study aimed to identify factors predicting treatment response and the prognostic implications. A single center retrospective analysis of all patients commencing ECP for CLAD between November 1, 2007 and September 1, 2011 was performed. In total 65 patients were included, 64 of whom had deteriorated under azithromycin. Median follow-up after commencing ECP was 503 days. Upon commencing ECP, all patients were classified using proposed criteria for emerging clinical phenotypes, including "restrictive allograft syndrome (RAS)", "neutrophilic CLAD (nCLAD)" and "rapid decliners". At follow-up, 8 patients demonstrated ≥10% improvement in FEV1 , 27 patients had stabilized and 30 patients exhibited ≥10% decline in FEV1 . Patients fulfilling criteria for "rapid decliners" (n=21, p=0.005), RAS (n=22, p=0.002) and those not exhibiting neutrophilia in bronchoalveolar lavage (n=44, p=0.01) exhibited poorer outcomes. ECP appears an effective second line treatment in CLAD patients progressing under azithromycin. ECP responders demonstrated improved progression-free survival (median 401 vs. 133 days). Proposed CLAD phenotypes require refinement, but appear to predict the likelihood of ECP response.

Do semantic categories activate distinct cortical regions? Evidence for a distributed neural semantic system

A key issue in cognitive neuroscience concerns the neural representation of conceptual knowledge. Currently, debate focuses around the issue of whether there are neural regions specialised for the processing of specific semantic attributes or categories, or whether concepts are represented in an undifferentiated neural system. Neuropsychological studies of patients with selective semantic deficits and previous neuroimaging studies do not unequivocally support either account. We carried out a PET study to determine whether there is any regional specialisation for the processing of concepts from different semantic categories using picture stimuli and a semantic categorisation task. We found robust activation of a large semantic network extending from left inferior frontal cortex into the inferior temporal lobe and including occipital cortex and the fusiform gyrus. The only category effect that we found was additional activation for animals in the right occipital cortex, which we interpret as being due to the extra visual processing demands required in order to differentiate one animal from another. We also carried out analyses in specific cortical regions that have been claimed to be preferentially activated for various categories, but found no evidence of any differential activation as a function of category. We interpret these data within the framework of cognitive accounts in which conceptual knowledge is represented within a nondifferentiated distributed system.

Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation

RATIONALE

The use of extracorporeal membrane oxygenation (ECMO) in patients who are awake and spontaneously breathing may represent a novel bridging strategy toward lung transplantation (LuTx).

OBJECTIVES

To evaluate the outcomes of patients treated with the "awake ECMO" concept as bridge to transplantation.

METHODS

We performed a retrospective, single-center, intention-to-treat analysis of consecutive LuTx candidates with terminal respiratory or cardiopulmonary failure receiving awake ECMO support. The outcomes were compared with a historical control group of patients treated with conventional mechanical ventilation (MV group) as bridge to transplant.

MEASUREMENTS AND MAIN RESULTS

Twenty-six patients (58% female; median age, 44 yr; range, 23-62) were included in the awake ECMO group and 34 patients (59% female; median age, 36 yr; range, 18-59) in the MV group. The duration of ECMO support or MV, respectively, was comparable in both groups (awake ECMO: median, 9 d; range, 1-45. MV: median, 15 d; range, 1-71; P = 0.25). Six (23%) of 26 patients in the awake ECMO group and 10 (29%) of 34 patients in the MV group died before a donor organ was available (P = 0.20). Survival at 6 months after LuTx was 80% in the awake ECMO group versus 50% in the MV group (P = 0.02). Patients in the awake ECMO group required shorter postoperative MV (P = 0.04) and showed a trend toward a shorter postoperative hospital stay (P = 0.06).

CONCLUSIONS

ECMO support in patients who are awake and nonintubated represents a promising bridging strategy, which should be further evaluated to determine its role in patients with end-stage lung disease awaiting LuTx.

The prognostic impact of follow-up assessments in patients with idiopathic pulmonary arterial hypertension

Current guidelines for the treatment of patients with idiopathic pulmonary arterial hypertension (IPAH) recommend basing therapeutic decision-making on haemodynamic, functional and biochemical variables. Most of these parameters have been evaluated as risk predictors at the time of diagnosis. The aim of the present study was to assess the prognostic impact of changes in these parameters after initiation of targeted therapy. A cohort of 109 patients with IPAH who had undergone haemodynamic, functional and biochemical assessments at baseline and 3-12 months after initiation of pulmonary arterial hypertension (PAH)-targeted therapy, were followed for a median 38 months in order to determine predictors of mortality at baseline and during the course of their disease. Within the observation period, 53 (48.6%) patients died and four (3.7%) underwent lung transplantation. Kaplan-Meier estimates for transplantation-free survival were 92%, 67%, and 51% at 1, 3, and 5 yrs, respectively. Among baseline variables, 6-min walk distance, right atrial pressure, cardiac index, mixed-venous oxygen saturation (S(v,O(2))) and N-terminal-pro brain natriuretic peptide (NT-proBNP) were independent predictors of survival. During follow-up, changes in World Health Organization functional class, cardiac index, S(v,O(2)) and NT-proBNP proved significant predictors of outcome. When assigned to prognostic groups, improvements as well as deteriorations in these parameters after initiation of PAH-targeted therapy had a strong impact on survival. Measurements obtained at follow-up had a higher predictive value than variables obtained at baseline. Changes in established predictors of outcome during the course of the disease provide important prognostic information in patients with IPAH.

GDF-15 is abundantly expressed in plexiform lesions in patients with pulmonary arterial hypertension and affects proliferation and apoptosis of pulmonary endothelial cells

BACKGROUND

Growth-differentiation factor-15 (GDF-15) is a stress-responsive, transforming growth factor-β-related cytokine, which has recently been reported to be elevated in serum of patients with idiopathic pulmonary arterial hypertension (IPAH). The aim of the study was to examine the expression and biological roles of GDF-15 in the lung of patients with pulmonary arterial hypertension (PAH).

METHODS

GDF-15 expression in normal lungs and lung specimens of PAH patients were studied by real-time RT-PCR and immunohistochemistry. Using laser-assisted micro-dissection, GDF-15 expression was further analyzed within vascular compartments of PAH lungs. To elucidate the role of GDF-15 on endothelial cells, human pulmonary microvascular endothelial cells (HPMEC) were exposed to hypoxia and laminar shear stress. The effects of GDF-15 on the proliferation and cell death of HPMEC were studied using recombinant GDF-15 protein.

RESULTS

GDF-15 expression was found to be increased in lung specimens from PAH patients, compared to normal lungs. GDF-15 was abundantly expressed in pulmonary vascular endothelial cells with a strong signal in the core of plexiform lesions. HPMEC responded with marked upregulation of GDF-15 to hypoxia and laminar shear stress. Apoptotic cell death of HPMEC was diminished, whereas HPMEC proliferation was either increased or decreased depending of the concentration of recombinant GDF-15 protein.

CONCLUSIONS

GDF-15 expression is increased in PAH lungs and appears predominantly located in vascular endothelial cells. The expression pattern as well as the observed effects on proliferation and apoptosis of pulmonary endothelial cells suggest a role of GDF-15 in the homeostasis of endothelial cells in PAH patients.

Catheter fragmentation and local lysis in two lung transplant patients with pulmonary embolism

In conjunction with the rising number of lung transplant operations in the past decade, an increased predisposition to venous thrombosis (VT), particularly within the first year posttransplantation has been observed. Previous studies have revealed that between 8.6% and 12% of patients develop VT, which can ultimately result in pulmonary emboli (PE).Transplanted lungs pose a much greater infarction risk due to their lack of collateral vascularisation, relying entirely on the vasa publica--the pulmonary artery--in the absence of vasa privata. Such losses in viable lung parenchyma are always serious, but carry still greater risks for single-lung transplant recipients, an early diagnosis and treatment remain critical. Here we report on two cases of PE after lung transplantation, both of whom were managed with catheter fragmentation and local thrombolysis. In our opinion, this approach represents a viable treatment for symptomatic PE in lung transplant recipients. The benefits and risks of the alternative treatment options in these special cases will be reviewed and the definitive therapy was described. In the patients treated, catheter fragmentation with localized thrombolysis resulted in short term improvements in graft function, but could not prevent later lung infarction in one case.