The effects of a TNF-alpha inhibitor and HBO combination on the severity of pancreatitis and oxidative response in an experimental model of acute pancreatitis

OBJECTIVES

We aimed to investigate the effects of infliximab and HBO (hyperbaric oxygen) used alone or in combination on oxidative stress and the severity of pancreatitis in an experimental model of AP (acute pancreatitis).

MATERIAL AND METHODS

A total of 60 rats were randomly divided into five groups. Group 1 underwent laparotomy; Group 2 underwent experimental AP; Group 3 was given an infliximab infusion and underwent AP; Group 4 was subjected to HBO therapy after AP; and Group 5 was given infliximab infusion before AP and subjected to HBO therapy. Serum amylase, superoxide dismutase (SOD), malondialdehyde (MDA), and glutathione peroxidase (GPX) levels in the pancreas tissues were measured. The pancreatic tissue samples were scored.

RESULTS

There were statistically significant differences in the histopathological scores and amylase levels between non-treated AP and all the three treatment groups. Group 5 had the closest histopathological scores to the sham group. MDA levels were significantly different between non-treated AP and all the three treatment groups, but the SOD levels and GPX values were not.

CONCLUSIONS

Combination of HBO therapy and Infliximab showed a synergistic effect on the reduction of histopathological severity and mortality in acute pancreatitis. All treatment modalities reduced the pathological findings by decreasing lipid peroxidation and partly increasing the antioxidant capacity in early period (Tab. 1, Fig. 3, Ref. 28).

Lymphoid pneumonitis as an immune reconstitution inflammatory syndrome in a patient with CD4 cell recovery after HAART initiation

In the era of highly active antiretroviral therapy (HAART), immune reconstitution inflammatory syndrome (IRIS) has come to present a significant clinical challenge. Following the recovery of memory T cells, latent infections may lead to clinical and laboratory deterioration despite immunological and virological reconvalescence. However, many other forms of complications after induction of HAART, which are not entirely understood, must be included in the entity of IRIS. Here we report a case of a patient complaining of respiratory distress and fever 10 days after initiating HAART. Radiologically and clinically, his findings mimicked Pneumocystis jiroveci pneumonia. However, no infectious agent could be detected, and bronchoalveolary lavage showed a high cell count (90% lymphocytes and 4% eosinophils) consistent with interstitial pneumonitis. He improved dramatically after treatment with oral steroids.

Sleep apnoea in heart failure

Studies from the USA have reported that sleep apnoea is common in congestive heart failure (CHF), with Cheyne-Stokes respiration (CSR) being the most frequent type of sleep-disordered breathing (SDB) in these patients. Within the present study, the authors sought to assess the prevalence and type of SDB among CHF patients in Germany. A total of 203 CHF patients participated in this prospective multicentre study. All patients were stable in New York Heart Association classes II and III and had a left ventricular ejection fraction (LVEF)<40%. The patients were investigated by polygraphy and all data were centrally analysed. Patient enrolment was irrespective of sleep-related symptoms. The majority of patients were male with a mean age of 65 yrs and hospitalised. Of the 203 patients, 145 (71%) had an apnoea/hypopnoea index>10.h(-1), obstructive sleep apnoea (OSA) occurred in 43% (n=88) and CSR in 28% (n=57) of patients. The prevalence of sleep-disordered breathing is high in patients with stable severe congestive heart failure from a European population. As sleep-disordered breathing may have a negative impact on the prognosis of congestive heart failure, a sleep study should be performed in every patient with congestive heart failure and a left ventricular ejection fraction of <40%. This diagnostic approach should probably be adopted for all of these patients irrespective of the presence of sleep-related symptoms.

NT-pro-BNP in obstructive sleep apnea syndrome is decreased by nasal continuous positive airway pressure

OBJECTIVE

The aim of this study was to evaluate the impact of obstructive sleep apnea syndrome (OSAS) on B-type natriuretic peptide (BNP) and to determine the effect of nasal continuous positive airway pressure (nCPAP) treatment on BNP levels.

BACKGROUND

Increased sympathetic activity, repetitive rises in blood pressure, and apnea-induced wall stress may contribute as a trigger to release BNP in OSAS. However, there is uncertainty about whether OSAS affects BNP and whether application of nasal continuous positive airway pressure (nCPAP) ventilation affects release of BNP.

PATIENTS AND METHODS

A prospective study in 69 consecutive patients with suspected sleep disordered breathing referred to our sleep laboratory was conducted. OSAS was confirmed in 26 normotensive and 34 hypertensive patients and ruled out in nine normotensive patients (controls) by polysomnography (PSG).

RESULTS

Baseline N-terminal fragment of BNP prohormone (NT-pro-BNP) did not differ significantly between OSAS patients (hypertensive: mean +/-SEM 60.8+/-9.9 pg/ml, normotensive: 43.2+/-6.8 pg/ml) and controls (36.5+/-8.5 pg/ml). Application of CPAP resulted in a significant decrease of NT-pro-BNP in hypertensive (60.8+/-9.9 pg/ml to 47.6+/-7.4 pg/ml, p=0.023) and normotensive OSAS (43.2+/-6.8 pg/ml to 29.6+/-5.3 pg/ml, p=0.0002). In contrast, controls showed no significant differences in NT-pro-BNP after a second PSG (36.5+/-8.5 pg/ml to 40.7+/-12.3 pg/ml, p=0.597).

CONCLUSIONS

Normotensive and hypertensive OSAS was not associated with a significant elevation of NT-pro-BNP. Application of nCPAP decreased NT-pro-BNP levels significantly in normotensive and, in particular, hypertensive OSAS. These findings may provide further evidence of the potential for nCPAP to improve cardiovascular comorbidity and co-mortality in OSAS and sleep disordered breathing, in general.

Influence of obstructive sleep apnea on heart rate turbulence

BACKGROUND

Patients with obstructive sleep apnea (OSA) are at increased risk for cardiovascular disease. Increased sympathetic drive is considered as one of the underlying mechanisms. Both heart rate turbulence (HRT) and heart rate variability (HRV) are parameters to describe autonomic regulation. We investigated the influence of sleep-disordered breathing (SDB) on HRT and HRV in patients with OSA.

METHODS

Sixty-five patients underwent overnight polysomnography for clinically suspected SDB and simultaneous Holter monitoring (11 p.m.-6 a.m.). Patients with diabetes mellitus, a history of cardiac disease, left ventricular dysfunction, periodic breathing pattern, and those on beta-blockers or theophylline were excluded. According to the apnea-hypopnea index (AHI), the patients were assigned to group A (AHI <20, n = 31) or group B (AHI > or =20, n = 34). HRV (time domain, frequency domain) and HRT (onset, slope) were then related to the severity of SDB.

RESULTS

Nighttime turbulence slope (TS) correlated inversely with the AHI (r = -0.45, p = 0.01) and was significantly lower in group B (8.9 +/- 1.6 ms/R-R interval) compared with that in group A (19.8 +/- 4.0 ms/R-R interval, P = 0.01). This relationship remained stable after adjusting TS for the number of ventricular premature contractions. No significant differences in turbulence onset or parameters of nighttime HRV were observed.

CONCLUSIONS

Alterations in nighttime HRT correlate with the severity of SDB, indicating abnormalities in cardiac autonomic activity in moderate-to-severe OSA even in the absence of overt cardiac disease. These changes may be associated with the subsequent development of cardiovascular disease.

[Progressive upper lobe consolidation in a 73-year old healthy woman]

A 73-year old healthy woman presented for pacemaker replacement. Chest X-ray showed an right upper lobe consolidation. CT-scan and bronchoscopy with bronchoalveolar lavage could not yield a specific diagnosis. Due to progression of the consolidation in a CT scan after 10 weeks another bronchoscopy with transbronchial biopsy was performed and yielded bronchiolo-alveolar carcinoma. The patient underwent resection of the right upper lobe and middle lobe with curative intent.

Obstructive sleep apnea as a risk marker in coronary artery disease

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is associated with a range of cardiovascular sequelae and increased cardiovascular mortality. The aim of our study was to assess the prevalence of OSA in patients with symptomatic angina and angiographically verified coronary artery disease (CAD). In addition, we analyzed the association of OSA and other coronary risk factors with CAD and myocardial infarction.

METHODS

Overnight non-laboratory-monitoring-system recordings for detection of OSA was performed in 223 male patients with angiographically verified CAD and in 66 male patients with exclusion of CAD. A logistic regression analysis was performed to assess associations between risk factors and CAD and myocardial infarction.

RESULTS

CAD patients were found to have OSA in 30.5%, whereas OSA was found in control subjects in 19.7%. The mean apnea/hypopnea index (AHI) was significantly higher (p < 0.01) in CAD patients (9.9 +/- 11.8) than in control subjects (6.7 +/- 7.3). Body-mass-index (BMI) was significantly higher in patients with CAD and OSA than in patients with CAD without OSA (28. 1 vs. 26.7 kg/m(2); p < 0.001). No significant difference was found with regard to other risk factors and left ventricular ejection fraction (LVEF) between both groups. Hyperlipidemia (OR 2.3; CI 1. 3-3.9; p < 0.005) and OSA defined as AHI >/=20 (OR 2.0; CI 1.0-3.8, p < 0.05) were independently associated with myocardial infarction.

CONCLUSIONS

There is a high prevalence of OSA among patients with angiographically proven CAD. OSA of moderate severity (AHI >/=20) is independently associated with myocardial infarction. Thus, in the care of patients with CAD, particular vigilance for OSA is important.

[Successful treatment of chronic necrotizing pulmonary aspergillosis with oral itraconazole long-term therapy]

HISTORY AND ADMISSION FINDINGS

A 66-year-old man with bullous pulmonary emphysema, was being treated with oral prednisone, had over the previous two month experienced dyspnoea, productive cough and an 8 kg weight loss. Physical examination revealed inspiratory rales over the right middle lobe, with faint vesicular breathing in the other lobes.

INVESTIGATIONS

Inflammation parameters were markedly elevated (WBC 24,800/microliter, C-reactive protein 28.6 mg/dl), while the chest radiograph showed liquid infiltrates in the right upper and middle lobes. Despite administration of antibiotics the infiltrates persisted. Aspergillus fumigatus was demonstrated in bronchial secretion.

TREATMENT AND COURSE

Antifungal treatment with itraconazole (400 mg/d) was started and resulted in marked subjective improvement, normalization of the inflammation parameters and slow regression of the pulmonary infiltrates. Thoracic computed tomography one year later merely revealed residual post-inflammatory changes.

CONCLUSION

An insidious course and treatment-resistant lung infiltrates in patients with steroid treatment should suggest chronic necrotizing pulmonary aspergillosis and this pathogen should be looked for in bronchial secretions. Antifungal treatment with itraconazole is essential and efficacious.

Atrial natriuretic peptide levels and pulmonary artery pressure awake, at exercise and asleep in obstructive sleep apnoea syndrome

Elevated nocturnal plasma atrial natriuretic peptide (ANP) levels were found in patients with obstructive sleep apnoea (OSA). The purpose of our study was to examine the secretion of ANP during the night and to measure changes in oxygen saturation, pulmonary artery pressure and intrathoracic pressure swings in patients with OSA. Moreover, we analysed the secretion of ANP and the pulmonary artery pressure in different behavioural states, e.g. awake, at exercise and asleep. Consecutive apnoeas in non-rapid eye movement (NREM) sleep at the beginning, middle and end of the sleep study were analysed in six patients with obstructive sleep apnoea. In addition, we measured the plasma levels of ANP. The apnoea duration was significantly longer (P< 0.05) at the middle of the sleep study than at the beginning or end. Correspondingly, the end-apnoeic oxygen saturation and end-apnoeic oesophageal pressure were both significantly lower (P< 0.05) in the middle of the sleep study than at the beginning or end. No significant differences were found in the end-apnoeic systolic transmural pulmonary artery pressure (P(PATM)) and the levels of ANP. Evaluation of the ANP levels during different behavioural states revealed that the asleep levels were slightly, but not significantly, higher than the awake levels (0.235+/-0.088 vs. 0.207+/-0.057 nmol/L). However, the highest levels were found during exercise (0.334+/-0.170 nmol/L) with a significant difference compared with the awake and asleep levels. These data suggest that volume effects may be a potent factor in liberating ANP during exercise, but the role of OSA in ANP secretion when asleep is questionable.

Microbiologic analysis of aqueous humor in phacoemulsification

PURPOSE

This study was designed as a microbiologic survey of the fluids aspirated from the anterior chamber at the end of cataract extraction performed by phacoemulsification, and to correlate the contamination rate of the anterior chamber to the surgical technique used.

METHODS

One hundred and one consecutive patients (126 eyes) who underwent cataract extraction by phacoemulsification and posterior chamber intraocular lens implantation were included in the study. Microscopical examination, culture, and determination of the number of colonies were carried out on the bacteria and fungi in the anterior chamber fluids aspirated at the end of surgery, before final suture placement.

RESULTS

Anterior chamber fluids yielded positive cultures in nine specimens (8.14%), six of which were identified as coagulase-negative staphylococci. Quantification disclosed colony counts ranging between 2-10 and 10-40 per mL.

CONCLUSIONS

Preliminary results in a small population show that the contamination of the aqueous humor is significantly less frequent if the cataract extraction is performed by phacoemulsification.

[Pulmonary aspergillosis in patients without pre-existing pulmonary disease after brain edema prevention with dexamethasone]

Pulmonary aspergillosis (PA) is a well-described complication in severely immunocompromised hosts. We report on one case of invasive PA and one case of PA following oral dexamethasone prophylaxis for cerebral oedema. Steroids were administered in a dosage of 14 mg and 16 mg, daily respectively for 21 and 15 days. Both patients died despite antifungal treatment. We conclude that PA must be considered as a cause for pulmonary complications in non-immunosuppressed, non-neutropenic patients during oral dexamethasone prophylaxis for neurological disease.

[Cardiovascular morbidity in patients with obstructive sleep apnea in relation to the severity of respiratory disorder]

BASIC PROBLEM AND OBJECTIVE

Untreated patients with obstructive sleep apnoea (OSA) have an increased risk of death from cardiovascular (cv) disease. This study was undertaken to determine the disease spectrum in patients with sonographically proven OSA (apnoea-hypopnoea index > or = 5), with special reference to cv risk factors and accompanying diseases in relation to the severity of their respiratory abnormalities. The study's aim was to clarify what risk factors and accompanying diseases were associated with different degrees of OSA.

PATIENTS AND METHODS

A systematic recording of cv risk factors and accompanying diseases as well as their association to the severity of nocturnal respiratory disorders was made for 175 patients (165 men, 10 women, mean age 54 +/- 10.2 years) with sonographically proven OSA (mean apnoea-hypopnoea index 37 +/- 24.4).

RESULTS

The body mass index (BMI) was significantly related to the severity of the respiratory disorder (apnoea-hypopnoea index, AHI, P < 0.05, odds ratio [OR]: 1.95; 95% confidence interval [CI]: 1.15-3.31). In a multivariate analysis, nocturnal breathing pause (P < 0.05; OR: 3.8; 95% CI: 1.3-11.1), left ventricular hypertrophy (P < 0.01; OR: 3.9; 95% CI: 1.5-10.3) and diabetes mellitus (P < 0.05; OR: 4.2, 95% CI: 1.2-14.7) were independently associated with a high-grade breathing disorder (AHI > or = 20). The incidence of left ventricular hypertrophy rose with an increasing severity of nocturnal OSA.

CONCLUSION

These data indicate that in patients with high-grade OSA (AHI > or = 20) there is a further grouping together of cardiovascular risk factors, namely increasing body weight, diabetes mellitus, arterial hypertension and left ventricular hypertrophy; they explain the increased mortality rate among these patients from vascular complications.

Pulmonary haemodynamics in obstructive sleep apnoea: time course and associated factors

Changes in pulmonary artery pressure within an obstructive apnoea and elevations of transmural pulmonary artery pressure (Ppa,tm) towards the end of apnoea are well known. The purpose of our study was to examine which factors contribute to the increase of Ppa,tm in an apnoea. In addition, the time course of Ppa,tm and associated factors during a sleep study was investigated. We analysed the association of changes in arterial oxygen saturation (Sa,O2), oesophageal pressure (Poes) to estimate intrathoracic pressure, systolic blood pressure (BPsys) to estimate left ventricular afterload, apnoea duration and the change in Ppa,tm (deltaPpa,tm) during the course of obstructive apnoeas. Consecutive apnoeas in nonrapid eye movement (NREM)-sleep at the beginning, the middle and the end of the sleep study were analysed in six patients with obstructive sleep apnoea. The mean systolic Ppa,tm was 28.0+/-12.1 mmHg at the beginning of apnoea and 38.6+/-15.5 mmHg at the end (deltaPpa,tm 10.5+/-7.4 mmHg; p<0.0001). DeltaSa,O2 (p<0.0001; odds ratio (OR) 1.45; confidence interval (CI) 1.20-1.76) and deltaPoes (p<0.0001; OR 1.22; CI 1.11-1.34) were independently associated with deltaPpa,tm in a multiple regression analysis. Apnoea duration as well as deltaPoes, deltaPpa,tm and deltaSa,O2 were all significantly higher (p<0.05) in apnoeas at the middle of the sleep study than at the beginning or the end. In conclusion, hypoxaemia and mechanical factors as an increase in negative thoracic pressure contribute to elevations of the transmural pulmonary artery pressure during an obstructive apnoea. The time course of pulmonary haemodynamics within a steep study reveals that the highest transmural pulmonary artery pressure occurs in the middle of the night with no progressive increase towards the end of the sleep study.

[Nosocomial ventilator-associated pneumonias caused by Aspergillus fumigatus in non-immunosuppressed, non-neutropenic patients]

We observed three cases of severe ventilator-associated pneumonia due to Aspergillus fumigatus in non-immunosuppressed, non-neutropenic patients. Autopsy confirmed an angioinvasive pattern of spreading with septic foci. In all cases conditions associated with temporary immunodysfunction like underlying diseases, antecedent sepsis or pneumonia, coinfections or steroid therapy were present. Although Aspergillus fumigatus was isolated in all cases in cultures of tracheobronchial secretions, the correct diagnosis was not obtained during lifetime. Our cases demonstrate that pneumonia due to Aspergillus fumigatus must be taken into account also in this patient population.