Possible Role of Chest Ultrasound in the Assessment of Costo-Phrenic Angle Lesions Prior to Medical Thoracoscopy: A Retrospective Pilot Case Series.

Background: Pleural malignancy (PM) and malignant pleural effusion (MPE) represent an increasing burden of diseases. Costo-phrenic angle (CPA) could be involved by malignant small nodularities or thickenings in the case of MPE. The aim of this study was to evaluate whether lung ultrasound (LUS), performed prior to medical thoracoscopy (MT), could detect pleural abnormalities in CPA not easily detectable by chest computed tomography scan (CCT). Methods: Patients suspected for PM and MPE were retrospectively recruited. Patients underwent both LUS examination with a linear array and CCT prior to diagnostic medical thoracoscopy. LUS pathological findings in CPA were compared with pathological findings detected by CCT. Findings were confirmed by subsequent MT, the gold standard for PMs. Results: Twenty-eight patients were recruited. LUS detected 23 cases of pleural abnormalities in CPA. CCT was detected 12 pleural abnormalities. Inter-rater agreement between the two techniques was minimal (Cohen's Kappa: 0.28). MT detected PMs in CPA in 22 patients. LUS had a sensitivity of 100% and specificity of 83%. CCT had a sensitivity of 54% and specificity of 100%. A better sensitivity for CCT was reached analysing only all abnormalities > 5 mm (64.3%). Conclusions: LUS examination, in the case of PMs, could change and speed up diagnostic workup.

Air bronchogram integrated lung ultrasound score to monitor community-acquired pneumonia in a pilot pediatric population.

AIMS: Chest ultrasound is a non-invasive method for evaluating children with suspected community-acquired pneumonia (CAP). We evaluated the prognostic role of change of ultrasonographic (US) air bronchogram in management of CAP in terms of: rate of complicated CAP, change of empiric antibiotic therapy, relationship to defervescence time, and length of hospitalization. METHODS: Patients with CAP and radiographic evidence of lung consolidation were prospectively enrolled. Chest US examinations were performed within 12 h from admission and after 48 h. A new grading system (USINCHILD score) based on presence and features of air bronchogram was adopted. RESULTS: Thirty six patients were stratified into two groups according to the presence of an increase of at least 1 grade of US score (Δ US grade), expression of an improvement of lung consolidation. Δ US grade after 48 h ≥ 1 was associated with an increased risk of complicated CAP (p value 0.027) and a longer defervescence time (p value 0.036). Moreover, Δ US grade ≥ 1 was predictive of a short hospitalization (p value 0.008). CONCLUSIONS: USINCHILD score could be an innovative biotechnology tool for the management of pediatric CAP. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION: NCT03556488, June 14, 2018.

Does transbronchial lung cryobiopsy give useful information in asthmatic patients?

INTRODUCTION: Lung biopsy in asthmatic patients is justified in case of atypical presentations of asthma, when other differential diagnoses, such as hypersensitivity pneumonitis or eosinophilic granulomatosis with polyangiitis, could be possible or for research purposes. AIM: We aim to describe the utility and the safety of TBLC (transbronchial lung cryobiopsy) in asthmatic patients, providing data on the pathological changes occurring in the airways and in the lung parenchyma. METHODS: We reviewed asthmatic patients that underwent TBLC, that eventually had only a final diagnosis of asthma. RESULTS: Three patients were detected. TBLC described pathological abnormalities in peribronchiolar and alveolar spaces already well identified with SLB (surgical lung biopsy); the pathological information provided could be useful to better understand the pathobiology of the disease. Finally, we had no complications, confirming a satisfactory safety profile of TBLC. CONCLUSION: We suggest the potential role of TBLC in asthmatic patients: its safety and its acceptable diagnostic accuracy lead to consider this procedure instead of SLB when histological changes in lung parenchyma are needed for the differential diagnosis. Furthermore, TLBC could be useful for research in the pathobiology of asthma and severe asthma.

A Mini-ISY100 Transposon Delivery System Effective in γ Proteobacteria.

Transposons are invaluable biological tools for the genetic manipulation of microorganisms. ISY100 from Synechocystis sp. PCC6803 is a member of the Tc1/mariner/IS630 superfamily, and is characterized by high transposition efficiency and a strong preference for TA target sequences. In this paper, we describe the design and application of a mini-ISY100 suicide vector for the in vivo creation of stable random transposon insertion libraries. The system was successfully applied in seven species belonging to four different orders of γ proteobacteria. In all cases, delivery using conjugation consistently showed the highest transposition efficiency compared to chemical transformation or electroporation. We determined the frequency of transposon insertions in all the species and proved the utility of the system by identifying genes involved in colony coloration in Shewanella oneidensis. The ease and the efficiency of the protocol developed here allow the creation of complete knock-out libraries in an extensive range of host microorganisms in less than a week with no requirement for preparatory modification.

Impulse oscillometry and nitrogen washout test in the assessment of small airway dysfunction in asthma: Correlation with quantitative computed tomography.

OBJECTIVE: Small airway dysfunction (SAD) and airway remodeling influence the disease control and progression in asthma. We investigated whether impulse oscillometry (IOS) and single breath nitrogen washout (SBN2W) could be reliable tests in evaluating SAD and airway remodeling by correlating their data with radiological parameters derived from quantitative chest multidetector computed tomography (MDCT) imaging. METHODS: Lung function tests were performed before and after bronchodilator. The MDCT lung scans were acquired at full inspiration and expiration using a portable spirometer to control the respiratory manoeuvres. Symptom control was assessed using the Asthma Control Test (ACT) questionnaire. RESULTS: Twenty six patients were enrolled. The bronchial lumen area (LA) measured with MDCT lung scan, correlated inversely with airway resistance (Raw, p < 0.001) and with total and large airway oscillometric resistance (R5, p = 0.002 and R20, p = 0.006, respectively). However these two last correlations became non-significant after Bonferroni correction for multiple comparisons. The radiological quantification of air trapping correlated with Raw (p < 0.001), residual volume (RV, p < 0.001), and the slope of phase III of SBN2W (DeltaN2, p < 0.001) whereas the correlation with small airway oscillometric resistance (R5-20) was non-significant after Bonferroni adjustment. Finally, air trapping was significantly higher in patients with a fixed bronchial obstruction in comparison to patients with reversible obstruction. CONCLUSIONS: Plethysmographic method remains the main tool to investigate SAD and airway remodeling in asthmatic patients. The integration with the SBN2W test proved useful to better evaluate the small airway involvement whereas IOS showed a weaker correlation with both radiological and clinical data.

Competence in thoracic ultrasound.

Ultrasound examination is traditionally considered a safe and repeatable exam, but its use is highly operator-dependent. Because of this, lack of sufficient operator skills could lead to diagnostic errors and damage to patient safety related to unnecessary tests or interventional procedures. The indications for lung ultrasound include: diagnosis, quantification, and follow-up of different conditions for which acute respiratory failure or chest pain are the main clinical presentation. Clinicians should have theoretical and practical knowledge on: physics and technology of ultrasound, indications and methodology of ultrasound examination, normal thoracic anatomy identification by echography, and detection of signs of pleuro-pulmonary pathology. Consequently, according to international recommendations, core basic skills and minimum training recommendations for the practice of medical ultrasound and image acquisition are needed to ensure competence of clinicians using ultrasound.

Competence in pleural procedures.

Diseases of the pleura and pleural space are common and present a significant contribution to the workload of respiratory physicians, with most cases resulting from congestive heart failure, pneumonia, and cancer. Although the radiographic and ultrasonographic detection of pleural abnormalities may be obvious, the determination of a specific diagnosis can often represent a challenge. Invasive procedures such as pleural drainage, ultrasound/CT-guided pleural biopsy or medical thoracoscopy can be useful in determining specific diagnosis of pleural diseases. Management of primary and secondary spontaneous pneumothorax is mandatory in an interventional pulmonology training program, while the medical or surgical treatment of the recurrence is still a matter of discussion. Pleural drainage is a diagnostic and therapeutic procedure used in the treatment of pneumothorax and pleural effusions of different etiologies and even in palliation of symptomatic in malignant pleural effusion. Medical thoracoscopy (MT) is a minimally invasive procedure aimed at inspecting the pleural space. It could be a diagnostic procedure in pleural effusions (suspected malignant pleural effusion, infective pleural disease such as empyema or tuberculosis) or therapeutic procedure (chemical pleurodesis or opening of loculation in empyema). Diagnostic yield is 95% in patients with pleural malignancies and higher in pleural tuberculosis. In parapneumonic complex effusion, MT obviates the need for surgery in most cases. Thoracoscopy training should be considered being as important as bronchoscopy training for interventional pulmonology, although prior acquisition of ultrasonography and chest tube insertion skills is essential.

Investigational drugs for idiopathic pulmonary fibrosis.

INTRODUCTION: IPF is a specific form of chronic fibrosing interstitial pneumonia of unknown cause, characterized by progressive worsening in lung function and an unfavorable prognosis. Current concepts on IPF pathogenesis are based on a dysregulated wound healing response, leading to an over production of extracellular matrix. Based on recent research however, several other mechanisms are now proposed as potential targets for novel therapeutic strategies. Areas covered: This review analyzes the current investigational strategies targeting extracellular matrix deposition, tyrosine-kinase antagonism, immune and autoimmune response, and cell-based therapy. A description of the pathogenic rationale implied in each novel therapeutic approach is summarized. Expert opinion: New IPF drugs are being evaluated in the context of phase 1 and 2 clinical trials. Nevertheless, many drugs that have shown efficacy in preclinical studies, failed to exhibit the same positive effect when translated to humans. A possible explanation for these failures might be related to the known limitations of animal models of the disease. The recent development of 3D systems composed of cells from individual patients that recreate an ex-vivo model of IPF, could lead to significant improvements in disease pathogenesis and treatment. New drugs could be tested on more genuine models and clinicians could tailor therapy based on patient's response.

The expression of the Cuphea palustris thioesterase CpFatB2 in Yarrowia lipolytica triggers oleic acid accumulation.

The conversion of industrial by-products into high-value added compounds is a challenging issue. Crude glycerol, a by-product of the biodiesel production chain, could represent an alternative carbon source for the cultivation of oleaginous yeasts. Here, we developed five minimal synthetic glycerol-based media, with different C/N ratios, and we analyzed the production of biomass and fatty acids by Yarrowia lipolytica Po1g strain. We identified two media at the expense of which Y. lipolytica was able to accumulate ∼5 g L(-1) of biomass and 0.8 g L(-1) of fatty acids (0.16 g of fatty acids per g of dry weight). These optimized media contained 0.5 g L(-1) of urea or ammonium sulfate and 20 g L(-1) of glycerol, and were devoid of yeast extract. Moreover, Y. lipolytica was engineered by inserting the FatB2 gene, coding for the CpFatB2 thioesterase from Cuphea palustris, in order to modify the fatty acid composition towards the accumulation of medium-chain fatty acids. Contrary to the expected, the expression of the heterologous gene increased the production of oleic acid, and concomitantly decreased the level of saturated fatty acids.

The multifaceted benefits of protein co-expression in Escherichia coli.

We report here that the expression of protein complexes in vivo in Escherichia coli can be more convenient than traditional reconstitution experiments in vitro. In particular, we show that the poor solubility of Escherichia coli DNA polymerase III ε subunit (featuring 3'-5' exonuclease activity) is highly improved when the same protein is co-expressed with the α and θ subunits (featuring DNA polymerase activity and stabilizing ε, respectively). We also show that protein co-expression in E. coli can be used to efficiently test the competence of subunits from different bacterial species to associate in a functional protein complex. We indeed show that the α subunit of Deinococcus radiodurans DNA polymerase III can be co-expressed in vivo with the ε subunit of E. coli. In addition, we report on the use of protein co-expression to modulate mutation frequency in E. coli. By expressing the wild-type ε subunit under the control of the araBAD promoter (arabinose-inducible), and co-expressing the mutagenic D12A variant of the same protein, under the control of the lac promoter (inducible by isopropyl-thio-ß-D-galactopyranoside, IPTG), we were able to alter the E. coli mutation frequency using appropriate concentrations of the inducers arabinose and IPTG. Finally, we discuss recent advances and future challenges of protein co-expression in E. coli.

Decline of the lung function and quality of glycemic control in type 2 diabetes mellitus.

OBJECTIVE: The aim of this study was to verify to which extent in type 2 diabetes mellitus respiratory function and respiratory muscle efficiency decline over time in relation to the quality of glycemic control (GC). METHODS: Forty-five non-smoker diabetic patients without pulmonary diseases performed a complete respiratory function assessment at baseline and after a follow-up of 4.9±0.6 years. The respiratory muscle efficiency was assessed by maximal inspiratory pressure (MIP) and maximum voluntary ventilation (MVV). Patients with an average yearly value of glycosylated hemoglobin≥7.5% at least in two years during follow-up were considered to have a poor GC. RESULTS: Residual volume and pulmonary diffusing capacity significantly declined over time in the whole sample of patients (p=0.049 and 0.025, respectively), but without difference between patients with poor (n. 12) and good (n. 33) GC. MIP declined in patients with poor GC (from 83.75±32.42 to 71.16±30.43% pred), and increased in those with good GC (from 76.22±26.00 to 82.42±30.34% pred), but the difference between groups was not significant (p=0.091). Finally, MVV significantly declined in patients with poor GC (from 70.60±25.49 to 68.10±18.82% pred) and increased in those with good GC (from 66.40±20.39 to 84.00±23.09% pred) with a significant difference between the two groups (p=0.003). CONCLUSION: These results show that, in type 2 diabetic patients, respiratory muscle efficiency, but not lung volumes and diffusing capacity, might suffer from a poor GC over time.

Continuous enzyme-coupled assay of phosphate- or pyrophosphate-releasing enzymes.

A coupled enzyme assay able to monitor the kinetics of reactions catalyzed by phosphate- or pyrophosphate-releasing enzymes is presented here. The assay is based on the concerted action of inorganic pyrophosphatase (PPase), purine nucleoside phosphorylase (PNPase), and xanthine oxidase (XOD). In the presence of phosphate, PNPase catalyzes the phosphorolysis of inosine, generating hypoxanthine, which is oxidized to uric acid by XOD. The uric acid accordingly formed can be spectrophotometrically monitored at 293 nm, taking advantage of a molar extinction coefficient which is independent of pH between 6 and 9. The coupled assay was tested using DNA polymerases as a model system. The activity of Klenow enzyme was quantitatively determined, and it was found in agreement with the corresponding activity determined by traditional methods. Moreover, the continuous coupled assay was used to determine Km and Vmax of Klenow enzyme, yielding values in good agreement with previous observations. Finally, the coupled assay was also used to determine the activity of partially purified DNA polymerases, revealing its potential use to monitor purification of phosphate- or pyrophosphate-releasing enzymes.

The diabetic lung--a new target organ?

Several abnormalities of the respiratory function have been reported in patients with type 1 and type 2 diabetes. These abnormalities concern lung volume, pulmonary diffusing capacity, control of ventilation, bronchomotor tone, and neuroadrenergic bronchial innervation. Many hypotheses have emerged, and characteristic histological changes have been described in the "diabetic lung", which could explain this abnormal respiratory function. Given the specific abnormalities in diabetic patients, the lung could thus be considered as a target organ in diabetes. Although the practical implications of these functional changes are mild, the presence of an associated acute or chronic pulmonary and/or cardiac disease could determine severe respiratory derangements in diabetic patients. Another clinical consequence of the pulmonary involvement in diabetes is the accelerated decline in respiratory function. The rate of decline in respiratory function in diabetics has been found to be two-to-three times faster than in normal non-smoking subjects, as reported in longitudinal studies. This finding, together with the presence of anatomical and biological changes similar to those described in the aging lung, indicates that the "diabetic lung" could even be considered a model of accelerated aging. This review describes and analyses the current insight into the relationship of diabetes and lung disease, and suggests intensifying research into the lung as a possible target organ in diabetes.

Stabilization of the Escherichia coli DNA polymerase III ε subunit by the θ subunit favors in vivo assembly of the Pol III catalytic core.

Escherichia coli DNA polymerase III holoenzyme (HE) contains a core polymerase consisting of three subunits: α (polymerase), ε (3'-5' exonuclease), and θ. Genetic experiments suggested that θ subunit stabilizes the intrinsically labile ε subunit and, furthermore, that θ might affect the cellular amounts of Pol III core and HE. Here, we provide biochemical evidence supporting this model by analyzing the amounts of the relevant proteins. First, we show that a ΔholE strain (lacking θ subunit) displays reduced amounts of free ε. We also demonstrate the existence of a dimer of ε, which may be involved in the stabilization of the protein. Second, θ, when overexpressed, dissociates the ε dimer and significantly increases the amount of Pol III core. The stability of ε also depends on cellular chaperones, including DnaK. Here, we report that: (i) temperature shift-up of ΔdnaK strains leads to rapid depletion of ε, and (ii) overproduction of θ overcomes both the depletion of ε and the temperature sensitivity of the strain. Overall, our data suggest that ε is a critical factor in the assembly of Pol III core, and that this is role is strongly influenced by the θ subunit through its prevention of ε degradation.

pGOODs: new plasmids for the co-expression of proteins in Escherichia coli.

Two systems for the co-expression of proteins in Escherichia coli were designed and constructed. The first system relies on the new vector, pGOOD, which is compatible with ColE1-type plasmids and sustains efficient co-expression of soluble protein complexes. The second system is based on the pGOOD1 vector (a derivative of pGOOD), useful for the production of toxic proteins, whose synthesis can be regulated by the co-expressed LacI repressor.

Bevacizumab compared with macular laser grid photocoagulation for cystoid macular edema in branch retinal vein occlusion.

INTRODUCTION: To evaluate the outcome of cystoid macular edema treated with intravitreal injections of bevacizumab and macular grid laser photocoagulation (GLP), in patients with perfused branch retinal vein occlusion. METHODS: Thirty eyes of 30 consecutive patients with cystoid macular edema secondary to nonischemic branch retinal vein occlusion were assigned to either GLP group or to intravitreal bevacizumab (IB) group. Complete ophthalmologic examinations were performed just before GLP and IB injection at 1, 3, 6, and 12 months after treatment. Changes in logarithm of minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA), central macular thickness (CMT) shown by optical coherence tomography-3 were evaluated. RESULTS: Baseline BCVA (logMAR) and CMT were, respectively, 0.89 +/- 0.13 and 650 +/- 140 microm for the GLP group, 0.87 +/- 0.16 and 690 +/- 120 microm for the IB group. After the treatment, at 1, 3, 6, and 12 months in the GLP group, BCVA had improved by 0.19, 0.22, 0.21, and 0.20 logMAR, CMT had decreased by 40%, 41.3%, 40.5%, and 42%. In the IB group, BCVA had improved by 0.31, 0.32, 0.30, and 0.31 logMAR and CMT had decreased by 59.5%, 59%, 60%, and 60.3%. The group receiving bevacizumab had better BCVA and lower CMT values at all time points (P < 0.05). CONCLUSION: Intravitreal bevacizumab injection improves BCVA and reduces CMT more than GLP. Intravitreal bevacizumab injection was well tolerated and could be used as primary treatment in patients with cystoid macular edema secondary to perfused branch retinal vein occlusion.