The German adaptation of the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR).

BACKGROUND: Individuals with precapillary pulmonary hypertension (PH) experience severely impaired quality of life. A disease-specific outcome measure for PH, the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) was developed and validated in the UK and subsequently adapted for use in additional countries. The aim of this study was to translate and assess the reliability and validity of the CAMPHOR for German-speaking populations. METHODS: Three main adaptation stages involved; translation (employing bilingual and lay panels), cognitive debriefing interviews with patients and validation (assessment of the adaptation's psychometric properties). The psychometric evaluation included 107 patients with precapillary PH (60 females; age mean (standard deviation) 60 (15) years) from 3 centres in Austria, Germany and Switzerland. RESULTS: No major problems were found with the translation process with most items easily rendered into acceptable German. Participants in the cognitive debriefing interviews found the questionnaires relevant, comprehensive and easy to complete. Psychometric analyses showed that the adaptation was successful. The three CAMPHOR scales (symptoms, activity limitations and quality of life) had excellent test-retest reliability correlations (Symptoms = 0.91; Activity limitations = 0.91; QoL = 0.90) and internal consistency (Symptoms = 0.94; Activity limitations = 0.93; QoL = 0.94). Predicted correlations with the Nottingham Health Profile provided evidence of the construct validity of the CAMPHOR scales. The CAMPHOR adaptation also showed known group validity in its ability to distinguish between participants based on perceived general health, perceived disease severity, oxygen use and NYHA classification. CONCLUSIONS: The CAMPHOR has been shown to be valid and reliable in the German population and is recommend for use in clinical practice.

Bronchoscopic performance of bronchoalveolar lavage in germany - a call for standardization.

BACKGROUND: Bronchoalveolar lavage (BAL) is a widely used clinical tool in diagnosing interstitial lung diseases. Although there are recommendations and guidelines, the procedure is not completely standardized. Varying approaches likely influence the conclusiveness of BAL data and may be one reason for the divergent judgement of their value between different centers. OBJECTIVES: To evaluate how BAL is performed in Germany using an electronically based survey. METHODS: We conducted a cross-sectional online survey among all members of the German Respiratory Society. RESULTS: 608 members responded to the survey and of these 500 perform lavages. Most bronchoscopists (344/500) do not use a tube and have no anesthesiologist present during the procedure (405/500). Propofol is used by 76.8% and midazolam by 67.9% (n = 405), often in combination. A major difference was noted regarding the total volume of instillation. Many respondents use a predefined fixed amount of instilled volume (202/500), whereas an almost equal number use variable volumes based on the recovery (196/500). The minimum recovery volume predefined by 217/499 ranged from 3-150 ml (median 30 ml; mean 42.2 ± 55.1 ml). Most respondents did not transport their samples in special medium (61.5%) or on ice (72.8%). The average time between recovery and arrival at the lab was 115.6±267.0 min (n = 323). CONCLUSION: This study shows the broad spectrum of variations in the performance of BAL in Germany, which could have a negative effect on the method's clinical value. There is a need for training and standardization of BAL performance.

Peripheral infusion of rat bone marrow derived endothelial progenitor cells leads to homing in acute lung injury.

BACKGROUND: Bone marrow-derived progenitors for both epithelial and endothelial cells have been observed in the lung. Besides mature endothelial cells (EC) that compose the adult vasculature, endothelial progenitor cells (EPC) are supposed to be released from the bone marrow into the peripheral blood after stimulation by distinct inflammatory injuries. Homing of ex vivo generated bone marrow-derived EPC into the injured lung has not been investigated so far. We therefore tested the hypothesis whether homing of EPC in damaged lung tissue occurs after intravenous administration. METHODS: Ex vivo generated, characterized and cultivated rat bone marrow-derived EPC were investigated for proliferation and vasculogenic properties in vitro. EPC were tested for their homing in a left-sided rat lung transplant model mimicking a severe acute lung injury. EPC were transplanted into the host animal by peripheral administration into the femoral vein (10(6) cells). Rats were sacrificed 1, 4 or 9 days after lung transplantation and homing of EPC was evaluated by fluorescence microscopy. EPC were tested further for their involvement in vasculogenesis processes occurring in subcutaneously applied Matrigel in transplanted animals. RESULTS: We demonstrate the integration of intravenously injected EPC into the tissue of the transplanted left lung suffering from acute lung injury. EPC were localized in vessel walls as well as in destructed lung tissue. Virtually no cells were found in the right lung or in other organs. However, few EPC were found in subcutaneous Matrigel in transplanted rats. CONCLUSION: Transplanted EPC may play an important role in reestablishing the endothelial integrity in vessels after severe injury or at inflammatory sites and might further contribute to vascular repair or wound healing processes in severely damaged tissue. Therapeutic applications of EPC transplantation may ensue.

Postprandial, but not postabsorptive low-density lipoproteins increase the expression of intercellular adhesion molecule-1 in human aortic endothelial cells.

The magnitude of postprandial lipemia has been identified as independent risk factor for the development of coronary artery disease. To test the effect of postprandial versus postabsorptive low-density lipoproteins (LDL) on the expression of adhesion molecules, LDL were isolated from healthy subjects before and 4h after ingestion of a standardized fatty test meal. We used flow cytometry and Northern blotting to quantify cell adhesion molecules in human aortic endothelial cells (HAEC). The adherence of leukocytes to HAEC was analyzed using a monocyte adhesion assay. Incubation of HAEC with postprandial, but not postabsorptive LDL induced a two-fold increase in the surface expression of intercellular adhesion molecule-1 (ICAM-1), but not of E-selectin or vascular cell adhesion molecule-1. In addition, increased amounts of ICAM-1 transcripts were found in HAEC treated with postprandial LDL. The adhesion of monocytes to HAEC was enhanced after pretreatment with postprandial, but not with postabsorptive LDL. We conclude that postprandial, but not postabsorptive LDL increase the surface expression of ICAM-1 in HAEC apparently by de novo protein synthesis leading to increased adhesion of monocytes. The upregulation of ICAM-1 by postprandial LDL may explain part of the proatherogenic effect of high postprandial lipemia.

Secretoneurin: a new player in angiogenesis and chemotaxis linking nerves, blood vessels and the immune system.

Secretoneurin (SN) represents a 33 amino acid neuropeptide, which is highly conserved between mammals, reptiles, birds, amphibians and fish. It is specifically expressed in endocrine, neuroendocrine and neuronal tissues. In brain, the pattern of SN expression is widespread and unique, partially overlapping with established neurotransmitters. ProSN, the precursor protein, also named secretogranin II, belongs to a class of proteins collectively called chromogranins. Changes in ProSN mRNA, which is significantly regulated by cell depolarisation, represent a useful marker for both rapid and long-lasting changes (positive and negative) of neuronal activity. Under pathophysiological conditions, especially following cellular hypoxia, SN expression can be induced in non-endocrine tissues like muscle cells, pneumocytes or tumor epithelial cells. Several biological effects were attributed to SN. SN releases dopamine from rat striatal slices in a dose dependent manner and influences neurite outgrowth in the developing cerebellum. It potently and specifically attracts monocytes, eosinophils and endothelial cells towards a concentration gradient and acts as an angiogenic cytokine comparable in potency to VEGF. Thus, SN contributes to neurogenic inflammation and might play a role in the (hypoxia-driven) induction of neo-vascularisation in ischemic diseases like peripheral or coronary artery disease, diabetic retinopathia, cerebral ischemia or in solid tumors. The signalling pathways of various biological effects have not been identified in detail, but most data point to a G-protein coupled receptor structure with respective associated intracellular events.

Effects of the neuropeptide secretoneurin on natural killer cell migration and cytokine release.

Secretoneurin has a widespread occurrence in airway mucosal innervation of patients with allergic diseases and may play an important role in the local traffic of immune cells in human airway mucosa. Whether secretoneurin affects natural killer cell migration and cytokine release in vitro was tested. Natural killer cells were obtained from venous blood of healthy donors. Cell migration was studied by micropore filter assays. Signalling mechanisms required for secretoneurin-dependent migration were tested using signalling enzyme blockers. Cytokine release was measured in natural killer cell supernatants by ELISA. Secretoneurin significantly stimulated natural killer cell chemotaxis via activation of phosphatidylinositol 3'-kinase and protein kinase C. IL-2 stimulated natural killer cells showed a stronger response toward secretoneurin than unstimulated cells. Moreover, secretoneurin increased the release of interleukin-5 in a dose-dependent manner but did not affect Th1 cytokine release by natural killer cells. Data suggest that secretoneurin stimulates directed migration of natural killer cells and may modulate Th1/Th2-response via affecting chemokine release. Thus, secretoneurin may play an important role in the early stages of allergic inflammation.

The neuropeptide secretoneurin stimulates adhesion of human monocytes to arterial and venous endothelial cells in vitro.

Monocytes appear to play a central role in inflammatory processes like atherogenesis or lung inflammation both as the progenitors of foam cells and as a potential source of factors mediating further inflammatory processes. However, signals mediating the influx of monocytes into the inflammatory focus remain partly unknown. Secretoneurin (SN) is a more recently characterised 33-amino acid neuropeptide that is co-released from afferent nerve endings together with substance P (SP) and calcitonin gene-related peptide (CGRP). Furthermore, SN has been shown to affect human fibroblast, endothelial, smooth muscle, eosinophil and monocyte functions in vitro. An activity of SN on monocyte adhesion to the vascular wall has not yet been reported. The aim of this study was to investigate whether the adhesion properties of human monocytes (U937 and Mono Mac-6) to endothelial cells could be influenced by SN. In an in vitro model of the vascular wall, incubation of arterial (rat aortic endothelial cells) and venous endothelial cells (immortalised human umbilical vein endothelial line: EA.hy 926) with SN resulted in a time- and concentration-dependent increase in monocyte adhesion with a maximal effect seen after 4-6 h at a concentration of 10(-8) M SN. Increased monocyte adhesion seems not to be tissue-specific as SN-induced adhesion was observed on both arterial and venous endothelial cells. A specific antibody preparation against SN completely abolished increased monocyte adhesion toward SN-stimulated endothelium. Since adhesion was enhanced to a similar degree and with similar time kinetics as responses evoked by interleukin-1 (IL-1, 1 ng/ml) or lipopolysaccharide (LPS, 100 ng/ml), involvement of identical adhesion molecules can be suggested. Our observations provide substantial evidence that in inflammatory processes, SN might play a role in recruitment of monocytes to inflamed tissue.

Natural killer cell functions mediated by the neuropeptide substance P.

The neuropeptide substance P (SP) can modulate a number of immunological functions in vitro and in vivo. Here, we investigated if SP boosts migration and cytotoxicity of natural killer cells, thus providing a further link between "innate immunity" and neurogenic inflammatory processes like asthma bronchiale. We demonstrate a dose-dependent effect of SP on natural killer cell migration with a maximal response at 10(-8) M SP. SP was shown to stimulate unstimulated as well as interleukin-2 (IL-2)-activated natural killer cells. Stimulation of natural killer cell migration was neurokinin-1 receptor dependent. Furthermore, mRNA encoding the neurokinin-1 receptor was demonstrated as being present in natural killer cells using RT-PCR while mRNA of the neurokinin-2 receptor was not detectable. Additionally, SP seems to influence specific cytotoxicity against Raji and K567 effector cells by a receptor-independent mechanism. In conclusion, our data indicate that functionally active neurokinin-1 receptors can be expressed by human natural killer cells. Substance P might therefore be a novel link between neural structures and innate immunity.

Transendothelial migration of leukocytes and signalling mechanisms in response to the neuropeptide secretoneurin.

Secretoneurin (SN), a newly discovered neuropeptide, may be implicated in inflammatory responses as it was shown to modulate leukocyte, endothelial and mesenchymal cell functions. Neutrophils placed above pulmonary arterial or venous endothelial monolayers migrated through this cellular barrier in response to apical or basal stimulation with SN in a dose-dependent manner. At optimal concentrations of 10(-6) to 10(-8) M, SN was nearly equally effective in stimulating neutrophil transmigration as was tumor necrosis factor-alpha at 10 ng/ml or a chemotactic gradient of formyl-Met-Leu-Phe (10(-8) M). Stimulation of transendothelial migration appears to be specific, since a trypsin digest of SN was ineffective and excess concentrations of anti-SN antibodies completely abolished the effect. Inhibition of cyclooxygenase or nitric oxide synthase did not affect the action of SN. Preincubation of endothelial cells with pertussistoxin (PTx) or choleratoxin (CTx), and the presence of staurosporine significantly inhibited transmigration, suggesting that SN uses a signalling pathway that is coupled to G-proteins and protein kinase C in endothelium. Moreover, SN treatment resulted in transient elevation of cytoplasmatic calcium concentration in endothelial cells. These data support the hypothesis that SN might contribute to neurogenic inflammation in vivo and reveal signalling mechanisms of SN in endothelial cells.

Successful switch from inhalative iloprost to oral bosentan in portopulmonary hypertension associated with liver cirrhosis.

Portopulmonary hypertension (PPHTN) is a rare complication of liver cirrhosis. Prostanoids have been shown to be effective in the treatment of PPHTN and have been used as a bridge to orthotopic liver transplantation. However, inhibition of platelet aggregation might be a limitation of prostacyclin therapy in patients with end-stage liver disease having an increased risk of bleeding from esophageal varices. The effect of oral bosentan, a dual endothelin-receptor antagonist in the reversal of PPHTN, is still unclear. We report a case of PPHTN (mean pulmonary artery pressure [mPAP] of 51 mmHg) that was successfully switched from inhalative iloprost to oral bosentan therapy. Hemodynamic and symptomatic improvements were maintained after a 12-month long-term treatment with inhalative iloprost as well as after single oral bosentan therapy. This is the first reported case of a successful switch from therapy with an inhalative prostacyclin analogue to oral bosentan in a patient suffering from PPHTN. Thus, oral bosentan therapy might be a promising new option for patients suffering from PPHTN.

Management of respiratory deterioration in a pregnant patient with severe kyphoscoliosis by non-invasive positive pressure ventilation.

The problem of kyphoscoliosis in combination with pregnancy is uncommon and published cases are rare. Until now, little and controversial information on the outcome, optimal management and course of pregnancy in patients with kyphoscoliosis has been available. The majority of maternal deaths seem to be attributed to cardiorespiratory failure, while obstetric complications account for relatively few complications. We present the case of a 34-year old pregnant woman with congenital kyphoscoliosis and a forced vital capacity (FVC) of about one liter. A further deterioration of lung function was expected. In fact, severe limitations in exercise capacity (bed rest), fatigue and hypersomnolence, as well as a severe increase in pulmonary hypertension occurred during the second and third trimester. Nasal intermittent positive pressure ventilation (NIP-PV) with bilevel positive airway pressure (BiPAP) was started in the 20th week of gestation and adapted throughout pregnancy. Nasal BiPAP was well-tolerated and corrected exercise tolerance, fatigue and nocturnal oxygen desaturations. At 32 weeks of gestation, the patient was admitted for an elective Caesarean section under combined spinal-epidural anaesthesia with ongoing NIPPV, and delivered a healthy baby. Home nocturnal ventilatory support was continued as nocturnal episodic desaturations were also assessed during the postpartum period. At time of discharge, the patient's exercise capacity and lung function were nearly equal to levels before pregnancy. We conclude that pregnancy in selected kyphoscoliotic patients with severe limitations in lung function is relatively safe for both the mother and the child when NIPPV is used for overcoming respiratory deterioration and for preventing further cardiorespiratory failure.

Quantification of recent smoking behaviour using proton transfer reaction-mass spectrometry (PTR-MS).

Smoking is the most important single risk factor in current public health. Surveillance of exposure to tobacco smoke may be accomplished using environmental monitoring or in-vivo tests for smoking biomarkers. Acetonitrile exhaled in human breath has been described as a potential marker mirroring recent smoking behavior. The aim of this study was to determine exhaled acetonitrile levels in a sample of 268 volunteers (48 smokers, 220 non-smokers) attending a local health fair. Breath specimens were collected into inert sample bags, with parallel collection of ambient air. Subsequently, all samples were analysed using proton transfer reaction-mass spectrometry (PTR-MS). Smokers had elevated levels of exhaled acetonitrile compared with non-smokers (p<0.001). Analysis using the receiver-operating-characteristic curve demonstrated that smoking can be predicted with a sensitivity of 79% and a specificity of 91%, using a cut-off concentration of 20.31 parts per billion of acetonitrile. This first field survey of exhaled acetonitrile in a large group of test persons demonstrates the feasibility of a rapid and non-invasive test for recent exposure to tobacco. We conclude that analysis of exhaled-breath acetonitrile may serve as a method of determining recent active smoking behaviour.

Subcutaneous implantation of a new intravenous pump system for prostacyclin treatment in patients with pulmonary arterial hypertension.

BACKGROUND: Intravenous prostacyclin treatment is a well recognized option in patients suffering from pulmonary arterial hypertension (PAH), and remains the gold standard of treatment. However, intravenous prostacyclin treatment involves several limitations, because the available battery-driven pump systems carry the risk of line infections, catheter-related embolisms, thrombosis, and delivery system malfunctions. CASE REPORT: We report for the first time, to the best of our knowledge, on the safe transition procedure from subcutaneous to intravenous treprostinil in a 74-year-old woman suffering from severe PAH (New York Heart Association functional class III), using a new implantable, gas-driven, intravenous pump device (LenusPro, Tricumed/OMT, Frittlingen, Germany). CONCLUSIONS: This implantable pump system may overcome the well-known limitations and risks of commonly used delivery systems, and thus may provide a new option for continuous intravenous prostacyclin treatment in patients with PAH.

Endothelial progenitor cells: current issues on characterization and challenging clinical applications.

Since their discovery about a decade ago, endothelial precursor cells (EPC) have been subjected to intensive investigation. The vision to stimulate respectively suppress a key player of vasculogenesis opened a plethora of clinical applications. However, as research opened deeper insights into EPC biology, the enthusiasm of the pioneer era has been damped in favour of a more critical view. Recent research is focused on three major questions: The fact that the number of EPC in peripheral blood is exceedingly low has consistently raised suspicion whether these cells can plausibly have an impact on physiological or pathophysiological processes. Secondly, whereas the key role of EPC in tumourigenesis has been strongly emphasized by various groups in the past, recent publications are challenging this hypothesis. Thirdly, the lack of consensus on EPC-defining markers and standardized protocols for their detection have repeatedly led to difficulties concerning comparability between papers. In this current review, an overview on recent findings on EPC biology is given, their challenging clinical implications are discussed and the perplexity underlying the current controversial debate is illustrated.

Diagnostic and therapeutic challenges of a large pleural inflammatory myofibroblastic tumor.

We report a 48-year-old woman with a pleural pseudoneoplasm requiring different diagnostic and therapeutic strategies. After initial presentation with increasing dyspnoea, temperature, dry cough, and interscapular pain diagnostic processing showed a large mediastinal mass with marked pleural effusion and high metabolic activity in the 18F-FDG-PET/CT. Extensive CT-guided biopsy of the tumor reaching from the visceral pleura into the right upper lobe revealed no malignancy, but a marked inflammatory tissue reaction containing foam cells. Initial empiric antibiotic therapy was temporarily successful. However, in the further course the mass relapsed and was resistant to antibiotics and a corticosteroid trial. With the working hypothesis of an inflammatory myofibroblastic tumor the patient underwent surgical tumor resection, finally confirming the suspected diagnosis. Due to residual disease intravenous immunoglobulins were administered leading to sustained response. This case with a pleural localisation of a large inflammatory pseudotumor with responsiveness to immunomodulation after incomplete resection extends the reported spectrum of thoracopulmonary manifestations of this rare entity.

Successful treatment of portopulmonary hypertension with the selective endothelin receptor antagonist Sitaxentan.

Portopulmonary hypertension (POPH) is a rare complication of portal hypertension. Prostanoids have been shown to be effective in the treatment of POPH and have been used as a bridge to liver transplantation. More recently, case series revealed beneficial effects of both the dual endothelin receptor antagonist bosentan and the phosphodiesterase-5 inhibitor sildenafil. The efficacy of sitaxentan, a selective endothelin receptor A (ERA) antagonist in the reversal of POPH, is still unclear. We report a case of POPH that was successfully treated with oral sitaxentan. Haemodynamic and symptomatic improvements were maintained after a 12-week long-term treatment period. Additionally, hepatic vein pressure gradient significantly decreased from 12 mmHg to 8 mm after treatment with sitaxentan. This is the first reported case of a successful therapy with a selective ERA antagonist in a patient suffering from POPH. Oral sitaxentan therapy might be a promising new option for patients suffering from POPH.

Treatment of pulmonary arterial hypertension (PAH): updated Recommendations of the Cologne Consensus Conference 2011.

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. The guidelines contain detailed recommendations on the diagnosis of pulmonary hypertension (PH). However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the treatment of pulmonary arterial hypertension (PAH). This commentary describes in detail the results and recommendations of the working group on treatment of PAH which were last updated in October 2011.

Sensory neuropeptides are potent chemoattractants for human basophils in vitro.

The sensory neuropeptides secretoneurin (SN) and substance P (SP) are involved in "neurogenic" inflammatory processes as they occur in bronchial asthma or allergic rhinitis. A possible interaction with basophils has not been reported to date. Basophils were isolated from healthy donors by magnetic cell sorting technique and migration was explored using Boyden microchemotaxis chambers. SN [10(-8)M] and SP [10(-6) to 10(-8)M] proved to be chemoattractants equally potent to FMLP [10(-8)M] or LPS [10 pg/ml]. Specific anti-SN antibodies and a trypsinization preparation of SN were used to determine the specificity of the SN effect on basophils. The preincubation of basophils with neurokinin-1 (NK-1) or -2 (NK-2) receptor antagonists revealed the SP effect to act via NK-1 receptors in basophils. In addition, we were able to show phosphodiesterases and phosphoinositide-3 kinases to be engaged in the downstream signalling pathway. Our observations reveal for the first time a link between basophils, which are engaged in allergic processes, and the neuropeptides SN and SP. Furthermore, our data might suggest phosphodiesterases or phosphoinositide-3 kinases to be new therapeutic targets for the treatment of allergic diseases such as asthma or allergic rhinitis.