Preformed donor HLA-DP-specific antibodies mediate acute and chronic antibody-mediated rejection following renal transplantation.

Donor-specific HLA alloantibodies may cause acute and chronic antibody-mediated rejection (AMR) and significantly compromise allograft survival. The clinical relevance of antibodies directed against some HLA class II antigens, particularly HLA-DP, is less clear with conflicting reports on their pathogenicity. We report two patients with high levels of pretransplant donor-specific HLA-DP antibodies who subsequently developed recurrent acute AMR and graft failure. In both cases, there were no other donor-specific HLA alloantibodies, suggesting that the HLA-DP-specific antibodies may be directly pathogenic.

Effects of supplemental oxygen during activity in patients with advanced COPD without severe resting hypoxemia.

STUDY OBJECTIVES: To assess oxygen desaturation during activities and to evaluate the short-term effects of supplemental O(2) use in patients with severe COPD who do not qualify for long-term O(2) therapy. DESIGN: A double-blind, randomized, placebo-controlled trial. SETTING: Outpatients from the pulmonary diseases division of a tertiary-care university hospital. PATIENTS: Twenty patients with stable COPD with FEV(1)/FVC ratios of < 50%, FEV(1) levels < 55% of the predicted normal value, and PaO(2) levels of > 60 mm Hg when resting. INTERVENTIONS: Patients were initially evaluated with pulmonary function tests, blood gas analysis, and Doppler echocardiography, and they underwent the following three 6-min walking tests (WTs) in a random sequence: basal WT (BWT); WT while breathing compressed air (CAWT); and WT while breathing O(2) (O(2)WT). MEASUREMENTS AND RESULTS: The distance walked was recorded in meters. Dyspnea was measured by Borg scale measurement before and after the tests, and arterial oxygen saturation measured by pulse oximetry (SpO(2)) was continuously monitored. Results were analyzed by grouping patients in the following manner: desaturators (DSs) (ie, patients with a drop in SpO(2) of at least 5% and < 90% during the WT) vs nondesaturators (NDSs); and O(2) responders (ie, patients with an increase of at least 10% in the distance walked and/or a decrease of at least 3 points in Borg index score) vs nonresponders. During the BWT, 11 of 20 patients (55%) were defined as desaturators. During the O(2)WT, the SpO(2) remained at > 90% in every patient. The distance walked increased by 22% (p < 0.02), and dyspnea decreased 36% (p < 0.01) in DS patients. In NDS patients, O(2) administration reduced dyspnea by 47% (p < 0.001), but the distance walked did not improve. Responses were markedly different from one patient to another. No significant differences were noticed between the results of the BWT and CAWT in any of the groups. Thirteen O(2) responders did not differ from 7 nonresponders either in basal data or in desaturation measure during the BWT, except that all walking responders (five patients) were above the median of basal left ventricle performance. CONCLUSIONS: Most of the studied COPD patients desaturated during the BWT. O(2) administration avoided desaturation and could increase the distance walked and reduce dyspnea, but these effects were not related to walking desaturation in individual cases. Improvements were not a placebo effect. The therapeutic role of O(2) during activities in some patients with severe COPD needs to be individually assessed.

Effect of tracheal dilatation and rupture on mechanical ventilation using a low-pressure cuff tube.

We report the case of a 36-year-old woman who suffered tracheal dilatation and rupture despite careful monitoring of intracuff pressure. Surgical manipulation, postoperative mediastinitis, and bacterial staphylococcal tracheitis may be involved in the development of this complication.

Pulmonary lymphangiomyomatosis associated with tuberous sclerosis. Treatment with tamoxifen and tetracycline-pleurodesis.

A 44-year-old woman was seen with the clinical and histologic picture of lymphangiomyomatosis syndrome. She also had dermatologic and neurologic stigmata of tuberous sclerosis. After the development of a recurring chylothorax, she had a downhill course unresponsive to dietary, bronchodilator, corticosteroid and progesterone therapy. In an open lung specimen, the search for steroid receptor for estrogen was positive. The discovery in this case of an estrogen receptor represents important evidence for establishing an association between tuberous sclerosis and lymphangiomyomatosis. Tamoxifen therapy and tetracycline pleurodesis were successful in stopping the progressive course and controlling the chylothorax.

Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.

STUDY OBJECTIVE: To define the impact of BAL data on the selection of antibiotics and the outcomes of patients with ventilator-associated pneumonia (VAP). DESIGN: Prospective observation and bronchoscopy with BAL, performed within 24 h of establishing a clinical diagnosis of a new episode of hospital-acquired VAP or progression of a prior episode of nosocomial pneumonia (NP). SETTING: A 15-bed medical and surgical ICU. PATIENTS: One hundred thirty-two patients hospitalized for more than 72 h, who were mechanically ventilated and had a new or progressive lung infiltrate plus at least two of the following three clinical criteria for VAP: abnormal temperature (> 38 degrees C or < 35 degrees C), abnormal leukocyte count (> 10,000/mm3 or < 3,000/mm3), purulent bronchial secretions. INTERVENTIONS: Bronchoscopy with BAL within 24 h of establishing a clinical diagnosis of VAP or progression of an infiltrate due to prior VAP or NP. All patients received antibiotics, 107 prior to bronchoscopy and 25 immediately after bronchoscopy. RESULTS: Sixty-five of the 132 patients were BAL positive (BAL[+]), satisfying a microbiologic definition of VAP (> 10(4) cfu/mL), while 67 were BAL negative (BAL[-]). The BAL(+) patients had no differences in mortality, prior antibiotic use, and demographic features when compared with the BAL(-) patients. More of the BAL(+) patients (38/65) satisfied all three clinical criteria of VAP than did BAL(-) patients (24/67) (p < 0.05). A total of 50 BAL(+) patients received antibiotic therapy prior to bronchoscopy, and when this prior therapy was adequate (n = 16), as defined by the results of BAL, then mortality was 38%, while if prior therapy was inadequate (n = 34), mortality was 91% (p < 0.001), and if no therapy was given (n = 15), mortality was 60%. When therapy changes were made after bronchoscopy, more patients (n = 42) received adequate therapy, but mortality in this group was comparable to mortality among those who continued to receive inadequate therapy (n = 23). A total of 46 of the 65 BAL(+) patients died, with 23 of these deaths occurring during the 48 h after the bronchoscopy, before BAL results were known. When BAL data became available, 37 of the 42 surviving patients received adequate therapy, but their mortality was comparable to the patients who continued to receive inadequate therapy. CONCLUSIONS: Patients with a strong clinical suspicion of VAP have a high mortality rate, regardless of whether BAL cultures confirm the clinical diagnosis of VAP. When adequate antibiotic therapy is initiated very early (ie, before performing bronchoscopy), mortality rate is reduced if this empiric therapy is adequate, compared to when this therapy is inadequate or no therapy is given. If adequate therapy is delayed until bronchoscopy is performed or until BAL results are known, mortality is higher than if it had been given at the time of first establishing a clinical diagnosis of VAP. When patients were changed from inadequate antibiotic therapy to adequate therapy, based on the results of BAL, mortality was comparable to those who continued to receive inadequate therapy. Thus, even if bronchoscopy can accurately define the microbial etiology of VAP, this information becomes available too late to influence survival.

[Community-acquired pneumonia in adults. Clinical practice guideline for Argentina. Study Group on Community Acquired Pneumonia]. / Neumonía adquirida en la comunidad (NAC) en adultos. Guía de práctica clínica para la Argentina. Grupo de Estudio de las NAC.

Community-acquired pneumonia (CAP) affects approximately 1% of the population annually. Initial antimicrobial therapy is most often empirical. Guidelines designed in other countries for the empirical management of CAP are not recommended for use in Argentina. Studies from other countries were considered together with unpublished local data to define the potential etiologic microorganisms and their antimicrobial susceptibility. Recommended diagnostic tests, groups of patients for different therapies and hospitalization criteria were defined. Severe CAP requiring intensive care was distinguished from the rest because of its distinct spectrum of etiologic agents and its high mortality, requiring a more focused therapy. Age, coexisting conditions and severity of illness were taken into account in the election of therapy.

Riesgo del cateterismo Swan-Ganz en la hipertensión pulmonar primaria / Risk of the Swan-Ganz catheterization in primary pulmonary hypertension

Se describen 2 pacientes portadores de hipertensión pulmonar primaria, comprobada por autopsia. Ambas presentaron un colapso hemodinámico, en un caso fatal, después del enclavamiento espontáneo de un catéter de Swan-Ganz en ramas periféricas de arterias pulmonares. En la paciente que falleció pocas horas después de ocurrida la complicación, no se apreciaron alteraciones morfológicas que explicaran el trastorno hemofinámico observado. La migración y enclavamiento espontáneos del catéter parecerían constituir una complicación más frecuente y sus consecuencias particularmente peligrosas (a diferencia de lo que ocurre habitualmente) en estos pacientes, por lo cual sería recomendable retirar el dispositivo en cuestión a una posición bien proximal en el tronco de la arteria pulmonar luego de registrar en forma basal y por única vez la presión capilar pulmonar mediante el inflado del balón, ya que en enfermedades cuya terapéutica es de eficacia discutida es preferible no ahondar el estudio cuando éste importa un riesgo para el enfermo

Linfangiomiomatosis pulmonar asociada con esclerosis tuberosa / Lung lyphangiomyomatosis associated with tuberous sclerosis

Se comunica el caso de una mujer de 44 años con cuadro clínico-histopatológico de una linfangiomiomatosis. Presentaba además lesiones cutáneas y estigmas neurológicos de esclerosis tuberosa. Desarrolló quilotorax recurrente y peoría progresiva que no pudieron ser controladas mediante tratamiento con dieta, broncodilatadores, corticoides y progesterona. La búsqueda de receptores estrogénicos en una biopsia pulmonar a cielo abierto fue positiva. Tal hallazgo representa una evidencia importante para establecer una asociación entre esclerosis tuberosa y linfangiomiomatosis. El tratamiento con tamoxifeno y la pleurodesis con tetraciclina fueron medidas terapéuticas satisfactorias para detener el curso progresivo de la enfermedad y controlar el quilotorax

Predictive capacity of risk indices in pulmonary resections

Pulmonary and cardiac complications are known to be the most frequent causes of morbidity and mortality after thoracic surgery. We attempted to correlate the relationship between the complications with preoperatively cardiac, pulmonary and cardiopulmonary risk indices in patients undergoing pulmonary resections. Complicatiosn in 15 consecutive patients with high cardiac (GoldmanÝs index); pulmonary (TorringtonÝs index) or cardiopulmonary (exercise capacity less than 3 METS) risk indices were compared with 31 consecutive patients without that risk factores. Nineteen complications developed in 15 patients in the high risk group and 4 complications occurred in 31 patients in the low risk group (p<0.0001). Death occurred in 8 patients in the high risk group, there were no deaths in the low risk group. Causes of death were: Pneumonia 4; Contralateral bronchial obstruction 1; Cardiac death 1; Pulmonary Embolism 1 and Sepsis 1 patient. Patients assigned to Goldman cardiac index = 3 or 4; Torrington pulmonary index = 3 and maximal exercise capacity tower than 3 METS correlated well with high morbidity and mortality. Using together the three indices, sensitivity was similar but specificity was better: all the patients who eventually died postoperatively had been preoperatively assigned to the high risk group. Our findings suggest that outcome and severity of complications after resective pulmonary surgery correlate with high risk cardiac, pulmonary and/or cardiopulmonary predictive indices.