Pediatric Pulmonology 2022 year in review: Rare and diffuse lung disease

The field of rare and diffuse pediatric lung disease continues to evolve and expand rapidly as clinicians and researchers make advancements in the diagnosis and treatment of children's interstitial and diffuse lung disease, non-cystic fibrosis bronchiectasis, and primary ciliary dyskinesia. Papers published on these topics in Pediatric Pulmonology and other journals in 2022 describe newly recognized disorders, elucidate disease mechanisms and courses, explore potential biomarkers, and assess novel treatments. In this review, we will discuss these important advancements and place them in the context of existing literature.

Acute vaping in a golden Syrian hamster causes inflammatory response transcriptomic changes

E-cigarette vaping is a major aspect of nicotine consumption, especially for children and young adults. Although it is branded as a safer alternative to cigarette smoking, murine and rat models of subacute and chronic e-cigarette vaping exposure have shown many proinflammatory changes in the respiratory tract. An acute vaping exposure paradigm has not been demonstrated in the golden Syrian hamster, and the hamster is a readily available small animal model that has the unique benefit of becoming infected with and transmitting respiratory viruses, including SARS-CoV-2, without genetic alteration of the animal or virus. Using a 2-day, whole body vaping exposure protocol in male golden Syrian hamsters, we evaluated serum cotinine, bronchoalveolar lavage cells, lung, and nasal histopathology, and gene expression in the nasopharynx and lung through reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Depending on the presence of nonnormality or outliers, statistical analysis was performed by ANOVA or Kruskal-Wallis tests. For tests that were statistically significant (P < 0.05), post hoc Tukey-Kramer and Dunn's tests, respectively, were performed to make pairwise comparisons between groups. In nasal tissue, RT-qPCR analysis revealed nicotine-dependent increases in gene expression associated with type 1 inflammation (CCL-5 and CXCL-10), fibrosis [transforming growth factor-β (TGF-β)], nicotine-independent increase oxidative stress response (SOD-2), and a nicotine-independent decrease in vasculogenesis/angiogenesis (VEGF-A). In the lung, nicotine-dependent increases in the expression of genes involved in the renin-angiotensin pathway [angiotensin-converting enzyme (ACE), ACE2], coagulation (tissue factor, Serpine-1), extracellular matrix remodeling (MMP-2, MMP-9), type 1 inflammation (IL-1β, TNF-α, and CXCL-10), fibrosis (TGF-β and Serpine-1), oxidative stress response (SOD-2), neutrophil extracellular traps release (ELANE), and vasculogenesis and angiogenesis (VEGF-A) were identified. To our knowledge, this is the first demonstration that the Syrian hamster is a viable model of e-cigarette vaping. In addition, this is the first report that e-cigarette vaping with nicotine can increase tissue factor gene expression in the lung. Our results show that even an acute exposure to e-cigarette vaping causes significant upregulation of mRNAs in the respiratory tract from pathways involving the renin-angiotensin system, coagulation, extracellular matrix remodeling, type 1 inflammation, fibrosis, oxidative stress response, neutrophil extracellular trap release (NETosis), vasculogenesis, and angiogenesis.

Vaping and diffuse alveolar hemorrhage: All EVALI is not created equal

E-cigarette, or vaping product, use associated lung injury (EVALI) refers to respiratory illness in patients with recent vaping and no signs of infection or underlying illness. EVALI can cause severe acute respiratory distress syndrome and death. A spectrum of diagnoses can fit the description of EVALI since it relies heavily on nonspecific, radiographic findings. We present a rare case of EVALI in which a patient with a history of vaping presented with acute hypoxemia and was diagnosed with diffuse alveolar hemorrhage (DAH). The mechanism of injury of DAH due to vaping is unknown, and further research into the topic is required.

Oral antibiotic prescribing patterns for treatment of pulmonary exacerbations in two large pediatric CF centers

INTRODUCTION

Oral antibiotics are frequently prescribed for outpatient pulmonary exacerbations (PEx) in children with cystic fibrosis (CF). This study aimed to characterize oral antibiotic use for PEx and treatment outcomes at two large US CF centers.

METHODS

Retrospective, descriptive study of oral antibiotic prescribing practices among children with CF ages 6-17 years over 1 year. The care setting for antibiotic initiation (clinic or phone encounter) was determined and outcomes were compared.

RESULTS

A total of 763 oral antibiotic courses were prescribed to 312 patients aged 6-17 years (77% of 403 eligible patients) with a median of two courses per year (range: 1-10). Fifty-eight percent of prescriptions were provided over the phone. Penicillin was the most commonly prescribed antibiotic class (36% of prescriptions) but differences in antibiotic class prescriptions were noted between the two centers. Hospitalizations occurred within 3 months following 19% of oral antibiotic courses. Forced expiratory volume in 1 s (FEV₁ ) recovered to within 90% of prior baseline within 6 months in 87% of encounters; the mean (SD) % recovery was 99.6% (12.1%) of baseline. Outcomes did not differ between phone and clinic prescriptions.

CONCLUSIONS

Phone prescriptions, commonly excluded in studies of PEx, made up more than half of all oral antibiotic courses. Heterogeneity in prescribing patterns was observed between the two centers. Most patients had improvement in FEV₁ returning to near their prior baseline, but hospitalizations occurred in one-fifth following oral antibiotic treatment. Efforts to optimize PEx treatment must consider care that occurs over the phone; this is particularly important as the use of telemedicine increases.

Neurofibromin-deficient myeloid cells are critical mediators of aneurysm formation in vivo

BACKGROUND

Neurofibromatosis type 1 (NF1) is a genetic disorder resulting from mutations in the NF1 tumor suppressor gene. Neurofibromin, the protein product of NF1, functions as a negative regulator of Ras activity in circulating hematopoietic and vascular wall cells, which are critical for maintaining vessel wall homeostasis. NF1 patients have evidence of chronic inflammation resulting in the development of premature cardiovascular disease, including arterial aneurysms, which may manifest as sudden death. However, the molecular pathogenesis of NF1 aneurysm formation is unknown.

METHOD AND RESULTS

With the use of an angiotensin II-induced aneurysm model, we demonstrate that heterozygous inactivation of Nf1 (Nf1(+/-)) enhanced aneurysm formation with myeloid cell infiltration and increased oxidative stress in the vessel wall. Using lineage-restricted transgenic mice, we show that loss of a single Nf1 allele in myeloid cells is sufficient to recapitulate the Nf1(+/-) aneurysm phenotype in vivo. Finally, oral administration of simvastatin or the antioxidant apocynin reduced aneurysm formation in Nf1(+/-) mice.

CONCLUSION

These data provide genetic and pharmacological evidence that Nf1(+/-) myeloid cells are the cellular triggers for aneurysm formation in a novel model of NF1 vasculopathy and provide a potential therapeutic target.

Ultrastructural mucosal injury after experimental ischemia of the ascending colon in horses

The ultrastructural injury that develops sequentially in the ascending colon during experimentally induced ischemia was examined in 6 halothane-anesthetized horses. Colonic ischemia was created by 2 types of vascular occlusion 24 cm proximal and distal to the pelvic flexure. In all horses, transmural vascular compression was created. The colonic venous circulation was obstructed in 3 horses, whereas in the other 3 horses, arterial and venous circulation was obstructed. Two additional horses were anesthetized as controls for determination of any morphologic alterations associated with the experimental protocol. Full-thickness colonic biopsy specimens were obtained from the antimesenteric border of the pelvic flexure at 0, 0.25, 0.5, 1, 1.5, 1.75, 2, 2.25, 2.5, 3, 3.5, 4, 4.5, and 5 hours during occlusion, and were studied by light and transmission electron microscopy. Morphologic alterations did not develop in the colon of control horses. Mucosal congestion was observed by light microscopy in the colon of horses with experimentally induced ischemia, but congestion developed early in those with obstructed colonic venous circulation, compared with those having arterial and venous obstruction. Inter- and intracellular vacuolation and loss of staining initially resulted in groups of 3 to 5 superficial luminal epithelial cells. Alterations in the glandular epithelium lagged behind those in the superficial epithelium, but were observed in both groups by 2 hours of obstruction. These changes progressed to 100% sloughing of all epithelium by 4.5 to 5 hours. The initial cellular alterations, which were observed by transmission electron microscopy, developed at 0.25 hour in horses with colonic venous obstruction and was characterized by inter- and intracellular edema.(ABSTRACT TRUNCATED AT 250 WORDS)

Microvascular circulation of the small intestine in horses

The microvascular anatomic features of the small intestine was described by correlating results of microangiography, light microscopy, gross studies, and scanning electron microscopy of vascular replicas in 14 horses. After heparinization, the horses were euthanatized, a length of jejunum was transected, and blood was flushed free of the circulation, using isotonic NaCl solution. In six horses, the circulatory system was perfused with a modified radiopaque medium and evaluated radiographically. These sections were then evaluated by standard histologic methods. Sections from 8 horses were perfused with 1 of 2 types of plastics and studied grossly or by scanning electron microscopy. The marginal arterial arcade gives rise to vessels that enter the jejunum at the mesenteric angle. These vessels penetrated either directly, by branching and entering on both sides of the mesenteric angle, or supplying only 1 side of the mesenteric angle. All these vessels continued in the submucosa branching extensively, forming a submucosal plexus. This submucosal plexus supplied the tunica muscularis, tunica serosa, and the mucosa. Vessels within the 2 muscle layers ran parallel to the muscle fibers and, consequently, perpendicular to each other. The arterial supply to the mucosa penetrated the muscularis mucosae and branched to supply 2 mucosal capillary networks. An eccentrically placed arteriole penetrated the base of the villus and spiralled to the tip where it "fountained" into a mesh-like capillary network, which descended peripherally in the villus to drain via 1 to 3, but most commonly 2 venules. Venules from adjacent villi united and drained via the submucosal veins.(ABSTRACT TRUNCATED AT 250 WORDS)

Microvascular circulation of the cecum in horses

The microvascular circulation of the cecum was studied in 15 adult horses, using microangiography and light microscopy combined with gross studies and scanning electron microscopy of vascular replicas. After heparinization, the horses were euthanatized and the cecum was transected at the cecocolic junction. Blood was flushed free of the circulation with isotonic NaCl and the cecal lumen was slightly distended. In 6 horses, the vascular system was injected with a modified radiopaque medium and evaluated radiographically. Sections evaluated radiographically were also prepared for histologic examination by standard methods. Eight horses were injected with 1 of 2 types of plastics and studied grossly or by scanning electron microscopy. In 1 additional horse, the lateral and medial arteries were injected with different colored plastic for gross studies. The lateral and medial cecal arteries appear to supply the respective areas of the cecum with minimal mixing of the 2 circulations. The major vascular supply to the cecal apex appeared to be through the medial cecal artery. Both the lateral and medial cecal arteries gave rise to cecal retia, which formed a mesh-like network around the respective veins. Vessels from these retia supplied the cecal tissue and the cecal lymph nodes. The continuation of the retia was through long terminal arteries that coursed around the circumference in the submucosa, forming an extensive submucosal plexus. This plexus supplied both the mucosa, and the tunica muscularis and serosa. Vessels within the longitudinal and circular muscle layers of the muscularis externa ran parallel to the muscle fibers, and consequently, perpendicular to each other.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of three techniques for closure of pelvic flexure enterotomies in normal equine colon

Six enterotomies 3 cm long, spaced at 3 cm intervals, were made in the antimesenteric border of the pelvic flexure of the ascending colon in five adult horses. Ten incisions each were sutured with a Utrecht pattern (single layer), a full-thickness simple continuous oversewn with a Cushing pattern (two layer), and a mucosal simple continuous with a seromuscular simple continuous oversewn with a Cushing pattern (three layer). In all horses, chromic gut and polyglactin 910 were each used once for each pattern. On day 6, the pelvic flexure was excised and the colonic vessels were injected with a radio-opaque mass. Sections of each enterotomy were studied by light microscopy and high detail radiography. The single-layer closure led to serosa-to-mucosa healing and a thin bowel wall, and the three-layer closure resulted in distortion of the bowel wall by hematoma formation and submucosal contamination with ingesta. The two-layer closure resulted in good alignment and improved healing. There was less inflammatory reaction with polyglactin 910 than with chromic gut.

Vascular injury associated with naturally occurring strangulating obstructions of the equine large colon

Ten horses were euthanatized before, during, or after surgery to correct severe volvulus of the large colon. At surgery, the colonic serosa changed from blue-gray, blue or purple toward a more normal pink in seven horses after the volvulus was corrected. The mucosa consistently remained black or dark red. Results of postmortem colonic microangiography revealed perfusion of the serosa and the circular and longitudinal muscle layers, but mucosal perfusion was limited by thrombosis in the muscularis mucosae and submucosa. There was evidence of thrombosis of the mesenteric colic vessels in six horses. Damage to the colonic vascular system, especially thromboembolism in the submucosa, may be an important limitation to colonic viability after surgical correction of volvulus of the large colon.

Microvascular circulation of the ascending colon in horses

Microvascular circulation of the ascending colon in healthy horses was studied using microangiography, light microscopy, and scanning electron microscopy. The pelvic flexure with 30 cm of ventral and dorsal colon attached was removed from 14 adult horses immediately after horses were euthanatized. The lumen was flushed with warm water, and this section of the ascending colon was placed in a 37-C bath of isotonic NaCl. In sections from 8 horses, colic vessels were perfused with a radio-opaque medium for microangiography. After angiographic evaluation, tissue sections were prepared for light microscopic observation, using standard histologic methods. In sections from 6 horses, injection replicas were made by perfusing the vessels with 2 types of plastics. The results of microangiography, light microscopy, and scanning electron microscopy of vascular replicas were correlated, providing a comprehensive documentation of the microvasculature of the ascending colon at the pelvic flexure. Arteries branched from mesenteric colic vessels approximately every 2 cm toward the colonic tissue. Immediately after branching, arterial vessels formed an anastomotic plexus, the colonic rete. However, each branch from the colic vessel eventually continued into the colonic tissue. A second set of vessels originated from the colonic tissue. A second set of vessels originated from the colonic rete and supplied the mesenteric lymph nodes. Arterial vessels penetrated the tunica muscularis into the submucosa 3 to 4 cm toward the antimesenteric border forming a submucosal vascular network. From the submucosal arterioles, branching took place at right angles to supply the mucosal capillaries. Capillaries surrounded the colonic glands and anastomosed at the luminal surface, forming a superficial luminal honeycomb-appearing vascular plexus.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of ozone on lung and somatic growth. Pair fed rats after ozone exposure and recovery periods

Minor differences in lung growth and development during childhood have been considered as a potential cause of rapid decline in pulmonary function in adulthood. Inhalation of ozone commonly causes changes in both body weight and lung volumes, which complicates interpretation of any changes in lung growth. The effects of ozone on lung growth were studied in rats which were pair fed. This technique permitted comparison of ozone-exposed and filtered-air control rats of the same body weight and body size as well as age and sex. Exposure was to filtered air or to 0.64 or 0.96 ppm ozone (UV standard) 8 h/night for 42 nights. A second control group was fed ad libitum and exposed to only filtered air. Half the rats were studied at the end of the 42-night exposures, the rest after a 42-day post-exposure period during which all rats were fed ab libitum and breathed filtered air. Rats examined at the end of the exposure period had larger saline and fixed lung volumes. These larger lungs had greater volumes of parenchyma, alveoli and respiratory bronchioles. Some of these changes persisted throughout a 42-day post-exposure period. Ozone inhalation by young rats alters lung growth and development in ways likely to be detrimental and those changes persist after ozone inhalation stops.