Intracellular Pseudomonas aeruginosa within the Airway Epithelium of Cystic Fibrosis Lung Tissues.

Rationale: Pseudomonas aeruginosa is the major bacterial pathogen colonizing the airways of adult patients with cystic fibrosis (CF) and causes chronic infections that persist despite antibiotic therapy. Intracellular bacteria may represent an unrecognized reservoir of bacteria that evade the immune system and antibiotic therapy. Although the ability of P. aeruginosa to invade and survive within epithelial cells has been described in vitro in different epithelial cell models, evidence of this intracellular lifestyle in human lung tissues is currently lacking. Objectives: To detect and characterize intracellular P. aeruginosa in CF airway epithelium from human lung explant tissues. Methods: We sampled lung explant tissues from patients with CF undergoing lung transplantation and non-CF lung donor control tissue. We analyzed lung tissue sections for the presence of intracellular P. aeruginosa using quantitative culture and microscopy, in parallel to histopathology and airway morphometry. Measurements and Main Results: P. aeruginosa was isolated from the lungs of seven patients with CF undergoing lung transplantation. Microscopic assessment revealed the presence of intracellular P. aeruginosa within airway epithelial cells in three of the seven patients analyzed at a varying but low frequency. We observed those events occurring in lung regions with high bacterial burden. Conclusions: This is the first study describing the presence of intracellular P. aeruginosa in CF lung tissues. Although intracellular P. aeruginosa in airway epithelial cells is likely relatively rare, our findings highlight the plausible occurrence of this intracellular bacterial reservoir in chronic CF infections.

Venous air embolism: artefactual air entrapment and autopsy technique.

Venous air embolism (VAE) is a rare cause of death for which special procedures are needed for autopsy diagnosis. The current one of choice was devised by Richter in 1905 to prevent introduction of gas into the right heart while opening the thorax. We could find no published data demonstrating that that this occurs during standard autopsy technique. Two scenarios were investigated. In the first, the study group included cases using the traditional method to open the thoracic cage; in the control group, Richter's method was used. Gas was collected under water and measured in a calibrated tube. The second scenario involved cases in which an intracardiac catheter was present at autopsy. In these, 50 mL of air was injected prior to chest opening and the amount of intracardiac air was measured. The first (non-injected) study and control groups consisted of 28 and 26 cases, respectively. Gas was identified in 3 cases (10%) in the study group and 2 cases (7%) in the control group. In the ten injected cases, there was a significant difference in the amount of the gas recovered (10 mL in the standard cases and 30 mL in the Richter group). No significant artifactual gas entrapment occurs in the right heart using the standard autopsy technique. However, it is possible that this technique may cause loss of intracardiac gas and if there is a clinical suspicion of VAE, Richter's technique should be used.

Radiographic features in investigated for Pneumocystis jirovecii pneumonia: a nested case-control study.

BACKGROUND: Pneumocystis jirovecii pneumonia (PJP) can be challenging to diagnose, often requiring bronchoscopy. Since most patients suspected of PJP undergo imaging, we hypothesized that the findings of these studies could help estimate the probability of disease prior to invasive testing. METHODS: We created a cohort of patients who underwent bronchoscopy specifically to diagnose PJP and conducted a nested case-control study to compare the radiographic features between patients with (n = 72) and without (n = 288) pathologically proven PJP. We used multivariable logistic regression to identify radiographic features independently associated with PJP. RESULTS: Chest x-ray findings poorly predicted the diagnosis of PJP. However, multivariable analysis of CT scan findings found that "increased interstitial markings" (OR 4.3; 95%CI 2.2-8.2), "ground glass opacities" (OR 3.3; 95%CI 1.2-9.1) and the radiologist's impression of PJP being "possible" (OR 2.0; 95%CI 1.0-4.1) or "likely" (OR 9.3; 95%CI 3.4-25.3) were independently associated with the final diagnosis (c-statistic 0.75). CONCLUSIONS: Where there is clinical suspicion of PJP, the use of CT scan can help determine the probability of PJP. Identifying patients at low risk of PJP may enable better use of non-invasive testing to avoid bronchoscopy while higher probability patients could be prioritized.

Evolution of the Immune Response to Chronic Airway Colonization with Aspergillus fumigatus Hyphae.

Airway colonization by the mold Aspergillus fumigatus is common in patients with underlying lung disease and is associated with chronic airway inflammation. Studies probing the inflammatory response to colonization with A. fumigatus hyphae have been hampered by the lack of a model of chronic colonization in immunocompetent mice. By infecting mice intratracheally with conidia embedded in agar beads (Af beads), we have established an in vivo model to study the natural history of airway colonization with live A. fumigatus hyphae. Histopathological examination and galactomannan assay of lung homogenates demonstrated that hyphae exited beads and persisted in the lungs of mice up to 28 days postinfection without invasive disease. Fungal lesions within the airways were surrounded by a robust neutrophilic inflammatory reaction and peribronchial infiltration of lymphocytes. Whole-lung cytokine analysis from Af bead-infected mice revealed an increase in proinflammatory cytokines and chemokines early in infection. Evidence of a Th2 type response was observed only early in the course of colonization, including increased levels of interleukin-4 (IL-4), elevated IgE levels in serum, and a mild increase in airway responsiveness. Pulmonary T cell subset analysis during infection mirrored these results with an initial transient increase in IL-4-producing CD4(+) T cells, followed by a rise in IL-17 and Foxp3(+) cells by day 14. These results provide the first report of the evolution of the immune response to A. fumigatus hyphal colonization.

Review of Thoracic Imaging Findings Unique to Women.

PURPOSE: Traditionally, indications for imaging studies of women are considered to be related to screening for and evaluation of disease of the female breast and pelvis. However, a number of chest diseases and associated intrathoracic imaging findings are unique to women and should be recognized by general radiologists, as well as chest and women-imaging specialists. CONCLUSIONS: The sex-specific findings unique to women include normal anatomical variants, primary lung disease, complications of breast and gynaecological disease, and pregnancy-related conditions. Classification, description, and illustration of gender-specific chest imaging findings are the objective of this article.

Transitioning to Neoadjuvant Therapy for Resectable Non-Small Cell Lung Cancer: Trends and Surgical Outcomes in a Regionalized Pulmonary Oncology Network.

BACKGROUND: Several regulatory agencies have approved the use of the neoadjuvant chemo-immunotherapy for resectable stage II and III of non-small cell lung cancer (NSCLC) and numerous trials investigating novel agents are underway. However, significant concerns exist around the feasibility and safety of offering curative surgery to patients treated within such pathways. The goal in this study was to evaluate the impact of a transition towards a large-scale neoadjuvant therapy program for NSCLC. METHODS: Medical charts of patients with clinical stage II and III NSCLC who underwent resection from January 2015 to December 2020 were reviewed. The primary outcome was perioperative complication rate between neoadjuvant-treated versus upfront surgery patients. Multivariable logistic regression estimated occurrence of postoperative complications and overall survival was assessed as an exploratory secondary outcome by Kaplan-Meier and Cox-regression analyses. RESULTS: Of the 428 patients included, 106 (24.8%) received neoadjuvant therapy and 322 (75.2%) upfront surgery. Frequency of minor and major postoperative complications was similar between groups (P = .22). Occurrence in postoperative complication was similar in both cohort (aOR = 1.31, 95% CI 0.73-2.34). Neoadjuvant therapy administration increased from 10% to 45% with a rise in targeted and immuno-therapies over time, accompanied by a reduced rate of preoperative radiation therapy use. 1-, 2-, and 5-year overall survival was higher in neoadjuvant therapy compared to upfront surgery patients (Log-Rank P = .017). CONCLUSIONS: No significant differences in perioperative outcomes and survival were observed in resectable NSCLC patients treated by neoadjuvant therapy versus upfront surgery. Transition to neoadjuvant therapy among resectable NSCLC patients is safe and feasible from a surgical perspective.

Superiority of systemic bleomycin to intradermal HOCl for the study of interstitial lung disease.

Systemic sclerosis (SSc) is an autoimmune disease characterized by vasculopathy, immune dysregulation, and multi-organ fibrosis. Interstitial lung disease (ILD) is a complication of SSc and a leading cause of SSc-death. The administration of hypochlorous acid (HOCl) intradermally in the mouse (HOCl-SSc) purportedly shows several features typical of SSc. We studied the model by injecting BALB/c mice daily intradermally with HOCl for 6-weeks, an exposure reported to induce lung fibrosis. On day 42, the skinfold thickness and the dermal thickness were two and three times larger respectively in the HOCl group compared to controls. HOCl treatment did not result in histological features of pulmonary fibrosis nor significant changes in lung compliance. Automated image analysis of HOCl mice lungs stained with picrosirius red did not show increased collagen deposition. HOCl injections did not increase pulmonary mRNA expression of pro-fibrotic genes nor induced the production of serum advanced oxidation protein products and anti-topoisomerase 1 antibodies. Immune cells in bronchoalveolar lavage fluid (BALF) and whole lung digests were not increased in HOCl-treated animals. Since lung fibrosis is proposed to be triggered by oxidative stress, we injected HOCl to Nrf2-/- mice, a mouse deficient in many antioxidant proteins. Lung compliance, histology, and BALF leukocyte numbers were comparable between Nrf2-/- mice and wild-type controls. We conclude that the HOCl-SSc model does not manifest SSc-lung disease.

The IL-1 Receptor Is Required to Maintain Neutrophil Viability and Function During Aspergillus fumigatus Airway Infection.

Aspergillus fumigatus airway infections are associated with increased rates of hospitalizations and declining lung function in patients with chronic lung disease. While the pathogenesis of invasive A. fumigatus infections is well studied, little is known about the development and progression of airway infections. Previous studies have demonstrated a critical role for the IL-1 cytokines, IL-1α and IL-1ß in enhancing pulmonary neutrophil recruitment during invasive aspergillosis. Here we use a mouse model of A. fumigatus airway infection to study the role of these IL-1 cytokines in immunocompetent mice. In the absence of IL-1 receptor signaling, mice exhibited reduced numbers of viable pulmonary neutrophils and increased levels of neutrophil apoptosis during fungal airway infection. Impaired neutrophil viability in these mice was associated with reduced pulmonary and systemic levels of G-CSF, and treatment with G-CSF restored both neutrophil viability and resistance to A. fumigatus airway infection. Taken together, these data demonstrate that IL-1 dependent G-CSF production plays a key role for host resistance to A. fumigatus airway infection through suppressing neutrophil apoptosis at the site of infection.

Integrating NGS-derived mutational profiling in the diagnosis of multiple lung adenocarcinomas.

MICROABSTRACT: Integration of Next Generation Sequencing (NGS) information for use in distinguishing between Multiple Primary Lung Cancer and intrapulmonary metastasis was evaluated. We used a probabilistic model, comprehensive histologic assessment and NGS to classify patients. Integrating NGS data confirmed initial diagnosis (n = 41), revised the diagnosis (n = 12), while resulted in non-informative data (n = 8). Accuracy of diagnosis can be significantly improved with integration of NGS data. BACKGROUND: Distinguishing between multiple primary lung cancers (MPLC) and intrapulmonary metastases (IPM) is challenging. The goal of this study was to evaluate how Next Generation Sequencing (NGS) information may be integrated in the diagnostic strategy. PATIENTS AND METHODS: Patients with multiple lung adenocarcinomas were classified using both the comprehensive histologic assessment and NGS. We computed the joint probability of each pair having independent mutations by chance (thus being classified as MPLC). These probabilities were computed using the marginal mutation rates of each mutation, and the known negative dependencies between driver genes and different gene loci. With these NGS-driven data, cases were re-classified as MPLC or IPM. RESULTS: We analyzed 61 patients with a total of 131 tumors. The most frequent mutation was KRAS (57.3%) which occured at a rate higher than expected (p < 0.001) in lung cancer. No mutation was detected in 25/131 tumors (19.1%). Discordant molecular findings between tumor sites were found in 46 patients (75.4%); 11 patients (18.0%) had concordant molecular findings, and 4 patients (6.6%) had concordant molecular findings at 2 of the 3 sites. After integration of the NGS data, the initial diagnosis was confirmed for 41 patients (67.2%), the diagnosis was revised for 12 patients (19.7%) or was considered as non-informative for 8 patients (13.1%). CONCLUSION: Integrating the information of NGS data may significantly improve accuracy of diagnosis and staging.

Promoting physical health in youth mental health services: ensuring routine monitoring of weight and metabolic indices in a first episode psychosis clinic.

OBJECTIVE: Clinicians are increasingly being asked to implement guideline recommendations into their practice, but are given little practical guidance on this complex task. In this paper we outline a promising theory-driven approach we took to implementing guideline recommendations about routine monitoring of weight gain and metabolic disturbance in our first-episode psychosis clinic. While there is significant psychological and physical morbidity associated with weight gain and metabolic disturbance, routine monitoring was not being undertaken according to guideline recommendations. We examined the factors that make it difficult to undertake routine monitoring by interviewing psychiatrists. This barrier analysis allowed us to develop and introduce feasible and acceptable strategies to address these barriers, increasing the likelihood that routine monitoring would take place. CONCLUSION: This paper advocates for undertaking an analysis of the barriers clinicians face to undertaking evidence-based practice in order to develop more sophisticated approaches to address areas where clinical practice and evidence are divergent. Such an approach is more likely to ensure that measures to improve practice are successful, are meaningful for the clinicians involved, and become imbedded in the clinical practice of the service.

The development of 3-D, in vitro, endothelial culture models for the study of coronary artery disease.

The response of the vascular endothelium to wall shear stress plays a central role in the development and progression of atherosclerosis. Current studies have investigated endothelial response using idealized in vitro flow chambers. Such cell culture models are unable to accurately replicate the complex in vivo wall shear stress patterns arising from anatomical geometries. To better understand this implication, we have created both simplified/tubular and anatomically realistic in vitro endothelial flow models of the human right coronary artery. A post-mortem vascular cast of the human left ventricular outflow tract was used to create geometrically accurate silicone elastomer models. Straight, tubular models were created using a custom made mold. Following the culture of human abdominal aortic endothelial cells within the inner lumen, cells were exposed to steady flow (Re = 233) for varying time periods. The resulting cell morphology was analyzed in terms of shape index and angle of orientation relative to the flow direction. In both models a progressive elongation and alignment of the endothelium in the flow direction was observed following 8, 12, and 24 hours. This change, however, was significantly less pronounced in the anatomical model (as observed from morphological variations indicative of localized flow features). Differences were also observed between the inner and outer walls at the disease-prone proximal region. Since morphological adaptation is a visual indication of endothelial shear stress activation, the use of anatomical models in endothelial genetic and biochemical studies may offer better insight into the disease process.

Maude Abbott and the Origin and Mysterious Disappearance of the Canadian Medical War Museum.

CONTEXT.­: In the early 1900s, it was common practice to retain, prepare, and display instructive pathologic specimens to teach pathology to medical trainees and practitioners; these collections were called medical museums. Maude Abbott, MD, established her reputation by developing expertise in all aspects of medical museum work. She was a founder of the International Association of Medical Museums (later renamed the International Academy of Pathology) and became an internationally renowned expert on congenital heart disease. Her involvement in the Canadian Medical War Museum (CMWM) is less well known. OBJECTIVE.­: To explore Abbott's role in the development of the CMWM during and after World War I and to trace its history. DESIGN.­: Available primary and secondary historical sources were reviewed. RESULTS.­: Instructive pathologic specimens derived from Canadian soldiers dying during World War I were shipped to the Royal College of Surgeons in London, which served as a clearinghouse for museum specimens from Dominion forces. The Canadian specimens were repatriated to Canada, prepared by Abbott, and displayed at several medical meetings. Abbott, because she was a woman, could not enlist and so she reported to a series of enlisted physicians with no expertise in museology. Plans for a permanent CMWM building in Ottawa eventually failed and Abbott maintained the collection at McGill (Montreal, Quebec, Canada) until her death in 1940. We trace the CMWM after her death. CONCLUSIONS.­: Sadly, after Abbott had meticulously prepared these precious teaching specimens so that their previous owners' ultimate sacrifice would continue to help their military brethren, the relics were bureaucratically lost.

Response to stereotactic ablative radiotherapy in a novel orthotopic model of non-small cell lung cancer.

Stereotactic ablative radiotherapy (SABR) is the main treatment for inoperable early-stage non-small cell lung cancer (NSCLC). Despite the widespread use of SABR, the biological determinants of response to SABR remain poorly investigated. We developed an orthotopic NSCLC animal model to study the response to clinically-relevant doses of SABR. Image-guided intra-thoracic injection of NSCLC cells was performed in the right lung of nude rats. A highly conformal dose of 34 Gy was delivered in a single fraction using clinical photon energies. Animals were sacrificed 10-60 days post treatment. Lung tumors were assessed for tumor differentiation, proliferation and invasiveness. An analysis of 770 cancer-related genes was performed on tumor-derived cell lines from treated animals at early and late time points after SABR. The majority of animals receiving SABR demonstrated complete response (67%), while 33% demonstrated local failure. 50% of animals with complete response failed distantly. Analysis of cancer-related genes revealed significant differences between tumors treated with SABR and untreated tumors. SABR significantly modulated expression of genes involved in adhesion, migration and angiogenesis. In particular, interleukin-8 (IL8) which plays a critical role in promoting tumor invasion was found to be secreted at high levels after SABR. In vitro invasion assays confirmed SABR-induced invasion and demonstrated induction of IL-8 secretion in multiple NSCLC cell lines. Our findings underscore the importance of developing targeted therapies that can circumvent the pro-invasive effects of SABR in NSCLC.

Emerging psychosis in young people - Part 2 - key issues for acute management.

BACKGROUND: To optimise the management of emerging psychotic disorders in young people, close collaboration between the general practitioner and youth friendly specialist mental health services is favourable. Ideally, a multidisciplinary team including individual case management with expertise in early intervention should treat these patients for the initial 2-5 years. However, only a few areas across Australia currently provide this type of specialised service. Most GPs will at some point be faced with the reality of personally managing young patients with emerging psychotic disorders on their own, sometimes with very limited support. OBJECTIVE: This article summarises key issues for the optimal management of emerging psychotic disorders, with a particular focus on the role of the GP. DISCUSSION: Once an emerging psychotic disorder is confirmed, the engagement of the young person into therapy is the primary target. Ideally therapy integrates not only the patient, but also their family, carers and friends. General practitioners need to inform patients about the nature of the emerging psychotic illness, manage related comorbidities such as substance abuse, and initiate antipsychotic medication to avoid any unnecessary delay in resolution of symptoms. It is important to monitor the patient on a regular basis even after symptom recovery as up to 80% of cases that cease medication will relapse within 5 years.

Emerging psychosis in young people - Part 1 - key issues for detection and assessment.

BACKGROUND: A delay in the recognition of first episode psychosis is common and is often associated with psychological distress, social decline, and as recent evidence suggests, lasting brain changes. It is increasingly evident that early intervention potentially alters the course of these serious mental illnesses. General practitioners are ideally placed to identify early changes that may herald an emergent psychotic illness and to bridge the existing gap between patients, their families and specialist mental health services. OBJECTIVE: This article summarises the rationale and importance of early detection of emerging psychotic illness in young people, and provides practical tips regarding its assessment and detection. DISCUSSION: Early warning signs of emerging psychotic illnesses include behavioural, emotional and cognitive disturbances. Risk factors include a combination of a family history of a psychotic illness coupled with a decline in functioning, or a history of a brief self limiting psychotic episode (even if triggered by drugs such as cannabis or amphetamines). It is important that those working in primary care recognise these features in order to facilitate a speedy referral to specialist youth friendly mental health services, or if such services are not available, to initiate treatment and provide appropriate ongoing management.

Emerging psychosis in young people - Part 3 - key issues for prolonged recovery.

BACKGROUND: After 18 months of specialist care only about half of all first episode psychosis patients achieve functional recovery, and about 10-20% patients will not respond to initial treatment and have persistent psychotic symptoms. These patients need special attention in order to minimise the burden of disease and prolonged disability. OBJECTIVE: This article reviews the management of young first episode psychosis patients with incomplete recovery, and focuses on the general practitioner's role, how to deal with treatment resistance, vocational rehabilitation, and other aspects of patient care. DISCUSSION: Once the acute episode has been treated, it is important to avoid complacency and address other aspects contributing to a patient's wellbeing including social welfare, physical health and vocational rehabilitation. The prevention of relapse and the psychosocial development of the individual are key in fostering and promoting a healthy lifestyle, leading to improved quality of life. Treatment refractory patients need specialist care.

Diagnostic concordance of non-small cell lung carcinoma subtypes between biopsy and cytology specimens obtained during the same procedure.

BACKGROUND: The objectives of this study were: 1) to determine the diagnostic concordance of non-small cell lung carcinoma (NSCLC) subtypes in cytology and biopsy specimens taken during the same procedure and evaluate the causes of discordance; and 2) to determine the frequency of immunohistochemistry (IHC) use for subtyping NSCLC. METHODS: Biopsy and cytology specimens that were obtained at the same procedure and diagnosed as NSCLC between January 2011 and December 2014 at the McGill University Health Center were identified (n = 226 pairs). The diagnostic concordance between the 2 methods was evaluated. The slides from discordant cases were reviewed, and final diagnoses were made based on IHC, resection specimens, or pathologist discussion. RESULTS: Concordance in subtype diagnosis was perfect (adeno-adeno or squamous-squamous) in 66.2% of cases and was partial (adeno or squamous vs non-small cell) in 23%; discordance (adeno vs squamous) was observed in 7.8%. Although subtyping was not possible (ie, the final diagnosis was NSCLC, not otherwise specified) in 12.8% of biopsy specimens and 16.3% of cytology specimens, specific subtyping was not achieved in only 3% of cases when both modalities were considered. IHC was used in 47% of biopsy cases and 13% of cytology cases. CONCLUSIONS: Subtyping of NSCLC can be achieved in most cases (97%) by considering findings in both biopsy and cytology specimens, and concordance in subtyping between cytology and biopsy specimens can be reached in a high percentage of cases (89.2%). Cancer Cytopathol 2016;124:737-43. © 2016 American Cancer Society.