Two Decades of Lung Retransplantation: A Single-Center Experience.

BACKGROUND: Lung retransplantation (ReTx) comprises an increasing share of lung transplants and recently has shown improved outcomes. The aim of this study was to identify risk factors affecting overall survival after pulmonary ReTx. METHODS: The United Network for Organ Sharing database was used to identify patients undergoing lung transplantation at our institution from 1995 to 2014. Of the total 542 lung transplants performed, 87 (16.1%) were ReTxs. The primary outcome was overall survival. Multivariate Cox regression models were used to assess the effect of recipient and donor characteristics on survival. RESULTS: Of the patients who underwent ReTx, median survival was 2 years. Predictors of worse survival include recipient age between 50 and 60 years (relative risk, 4.3; p = 0.02) or older than 60 years (relative risk, 10.2; p < 0.001), and time to ReTx of less than 2 years (relative risk, 3.8; p = 0.01). ReTx for bronchiolitis obliterans syndrome had longer median survival than for restrictive chronic lung allograft dysfunction (2.7 years vs 0.9 years; p = 0.055). Overall survival of ReTx patients after initiation of the lung allocation score was not significantly different (p = 0.21). CONCLUSIONS: Lung ReTx outcomes are significantly worse than for primary transplantation but may be appropriate in well-selected patients with certain diagnoses. Lung ReTx in patients older than 50 years or within 2 years of primary lung transplantation was associated with decreased survival. Further work is warranted to identify patients who benefit most from ReTx.

Helicobacter pylori downregulates expression of human ß-defensin 1 in the gastric mucosa in a type IV secretion-dependent fashion.

Helicobacter pylori establishes a chronic lifelong infection in the human gastric mucosa, which may lead to peptic ulcer disease or gastric adenocarcinoma. The human beta-defensins (hßDs) are antimicrobial peptides, hßD1 being constitutively expressed in the human stomach. We hypothesized that H. pylori may persist, in part, by downregulating gastric hßD1 expression. We measured hßD1 and hßD2 expression in vivo in relation to the presence, density and severity of H. pylori infection, investigated differential effects of H. pylori virulence factors, and studied underlying signalling mechanisms in vitro. Significantly lower hßD1 and higher hßD2 mRNA and protein concentrations were present in gastric biopsies from infected patients. Those patients with higher-level bacterial colonization and inflammation had significantly lower hßD1 expression, but there were no differences in hßD2. H. pylori infection of human gastric epithelial cell lines also downregulated hßD1. Using wild-type strains and isogenic mutants, we showed that a functional cag pathogenicity island-encoded type IV secretion system induced this downregulation. Treatment with chemical inhibitors or siRNA revealed that H. pylori usurped NF-κB signalling to modulate hßD1 expression. These data indicate that H. pylori downregulates hßD1 expression via NF-κB signalling, and suggest that this may promote bacterial survival and persistence in the gastric niche.

NOD2 polymorphisms in clinical phenotypes of common variable immunodeficiency disorders.

Common variable immunodeficiency disorders (CVIDs) are a heterogeneous group of diseases characterized by hypogammaglobulinaemia and consequent susceptibility to infection. CVID patients commonly develop a variety of additional manifestations for which the causative factors are not fully understood. Two such manifestations are granulomatous disease and enteropathy. Because the ability to predict complications would aid clinical management, we continue to search for possible disease modifier genes. NOD2 acts a microbial sensor and is involved in proinflammatory signalling. Particular mutations of the NOD2 gene are associated with Crohn's disease including gly908arg, leu1007finsc and arg702trp polymorphisms. We hypothesized that NOD2 polymorphisms may be a disease modifier gene towards an enteropathic or granulomatous phenotype within CVIDs. Sequence-specific primers returned genotypes for 285 CVID patients from centres across the United Kingdom and Europe. We present the frequencies of the different phenotypes of patients within our international cohort. Arg702trp polymorphisms were significantly less frequent than wild-type (WT) (P = 0·038) among international CVID patients with splenomegaly. Gly908arg polymorphisms were more prevalent than WT in UK patients with autoimmune disorders (P = 0·049) or enteropathy (P = 0·049). NOD2 polymorphisms were not more prevalent than WT in CVID patients with clinical phenotypes of granulomata. UK allele frequencies of 0·014, 0·056 and 0·026 were found for gly908arg, arg702trp and leu1007finsc NOD2 polymorphisms, respectively. These do not differ significantly from UK immunocompetent controls confirming, as expected, that in addition these NOD2 polymorphisms do not confer susceptibility to CVIDs per se.

Immunodeficiency in ataxia telangiectasia is correlated strongly with the presence of two null mutations in the ataxia telangiectasia mutated gene.

Immunodeficiency affects over half of all patients with ataxia telangiectasia (A-T) and when present can contribute significantly to morbidity and mortality. A retrospective review of clinical history, immunological findings, ataxia telangiectasia mutated (ATM) enzyme activity and ATM mutation type was conducted on 80 consecutive patients attending the National Clinic for Ataxia Telangiectasia, Nottingham, UK between 1994 and 2006. The aim was to characterize the immunodeficiency in A-T and determine its relationship to the ATM mutations present. Sixty-one patients had mutations resulting in complete loss of ATM kinase activity (group A) and 19 patients had leaky splice or missense mutations resulting in residual kinase activity (group B). There was a significantly higher proportion of patients with recurrent sinopulmonary infections in group A compared with group B (31 of 61 versus four of 19 P = 0.03) and a greater need for prophylactic antibiotics (30 of 61 versus one of 19 P = 0.001). Comparing group A with group B patients, 25 of 46 had undetectable/low immunoglobulin A (IgA) levels compared with none of 19; T cell lymphopenia was found in 28 of 56 compared with one of 18 and B cell lymphopenia in 35 of 55 compared with four of 18 patients (P = 0.00004, 0.001 and 0.003 respectively). Low IgG2 subclass levels and low levels of antibodies to pneumococcal polysaccharide were more common in group A than group B (16 of 27 versus one of 11 P = 0.01; 34/43 versus six of 17 P = 0.002) patients. Ig replacement therapy was required in 10 (12.5%) of the whole cohort, all in group A. In conclusion, A-T patients with no ATM kinase activity had a markedly more severe immunological phenotype than those expressing low levels of ATM activity.

Cytokine profile after lung transplantation: correlation with allograft injury.

BACKGROUND: Post-lung transplant reperfusion edema (PLTRE) and its more severe form, primary graft failure (PGF), occur in 10% to 60% of lung transplant recipients. We hypothesized that PLTRE and PGF would be associated with an elevated proinflammatory cascade and that the allograft would be the source of cytokine appearance in the circulation. METHODS: Pulmonary arterial and systemic arterial samples were obtained at baseline and at 4, 8, and 24 hours after reperfusion. Post-lung transplant reperfusion-edema and PGF were defined as PaO2/FiO2 less than 300 with a mild or moderate infiltrate, or less than 200 with a severe infiltrate and ventilator dependence after 72 hours, respectively. Tumor necrosis factor alpha (TNFalpha), interleukin (IL)-6, IL-8, and IL-10 concentrations were determined by immunoassay. RESULTS: Fifteen single and 6 bilateral lung recipients were studied. Six (29%) had PLTRE and 4 (19%) had PGF; these patients had an overall elevation in plasma IL-6, IL-8, and IL-10 concentrations (all p < 0.05). Subgroup analysis revealed a significantly greater elevation in IL-6, IL-8, and IL-10 levels in PGF patients (all p < 0.01) versus PLTRE. In the PGF group, TNFalpha and IL-10 concentrations were significantly greater in the systemic versus the pulmonary arterial samples (p < 0.05). CONCLUSIONS: Patients with PLTRE and PGF exhibited graded increases in IL-6, IL-8, and IL-10 concentrations. The PGF patients had higher TNFalpha and IL-10 systemic arterial concentrations overall, consistent with the allograft being a source of this cytokine production.

Elongational flow induced ordering in surfactant micelles and mesophases.

We have used small angle neutron scattering, SANS, to investigate the elongational flow induced ordering in surfactant micelles and mesophases. Spatially resolved SANS measurements have been used to determine the distribution of orientational ordering over the flow velocity pattern in an elongational flow cell, and comparison with the effects of shear flow are made. Two different surfactant systems have been studied, the charged wormlike mixed micelles of hexaethylene monododecyl ether, C16E6/hexadecyl trimethylammonium bromide, C16TAB (3% C16E(6)/5 mol% C16TAB), and the Lalpha lamellar phase of C16E6 (50.6 wt% C16E6 at 55 degrees C), and a substantially different response is observed. The orientational distribution of the Lalpha lamellar phase of C16E6 reflects the flow velocity pattern distribution within the cell, whereas for the wormlike mixed micelles of C16E6/C16TAB this is not the case, and this is associated with the shear thinning behavior of that system.

Structure of mixed anionic/nonionic surfactant micelles: experimental observations relating to the role of headgroup electrostatic and steric effects and the effects of added electrolyte.

The structures of the mixed anionic/nonionic surfactant micelles of SDS/C12E6 and SDS/C12E8 have been measured by small angle neutron scattering (SANS). The variations in the micelle aggregation number and surface charge with composition, measured in D2O and in dilute electrolyte, 0.01 and 0.05 M NaCl, provide data on the relative roles of the surfactant headgroup steric and electrostatic interactions and their contributions to the free energy of micellization. For the SDS/C12E8 mixture, solutions increasingly rich in C12E8 show a modest micellar growth and an increase in the surface charge. The changes with increasing electrolyte concentration are similarly modest. In contrast, for the SDS/C12E6 mixture, solutions rich in C12E6 show a more significant increase in aggregation number. Furthermore, electrolyte has a more substantial effect on the aggregation for the nonionic (C12E6) rich mixtures. The experimental results are discussed in the context of estimates of the steric and electrostatic contributions to the free energy of micellization, calculated from the molecular thermodynamic approach. The variation in micelle surface charge is discussed in the context of the "dressed micelle" theory for micelle ionization, and other related data.

The microstructure of di-alkyl chain cationic/nonionic surfactant mixtures: observation of coexisting lamellar and micellar phases and depletion induced phase separation.

The evolution of the microstructure and composition occurring in the aqueous solutions of di-alkyl chain cationic/nonionic surfactant mixtures has been studied in detail using small angle neutron scattering, SANS. For all the systems studied we observe an evolution from a predominantly lamellar phase, for solutions rich in di-alkyl chain cationic surfactant, to mixed cationic/nonionic micelles, for solutions rich in the nonionic surfactant. At intermediate solution compositions there is a region of coexistence of lamellar and micellar phases, where the relative amounts change with solution composition. A number of different di-alkyl chain cationic surfactants, DHDAB, 2HT, DHTAC, DHTA methyl sulfate, and DISDA methyl sulfate, and nonionic surfactants, C12E12 and C12E23, are investigated. For these systems the differences in phase behavior is discussed, and for the mixture DHDAB/C12E12 a direct comparison with theoretical predictions of phase behavior is made. It is shown that the phase separation that can occur in these mixed systems is induced by a depletion force arising from the micellar component, and that the size and volume fraction of the micelles are critical factors.

Adsorption of aromatic counterions at the surfactant/water interface: a neutron reflectivity study of hydroxybenzoate and chlorobenzoate counterions at the hexadecyl trimethylammonium surfactant/water interface.

Specular neutron reflectivity has been used to investigate the adsorption of the aromatic counterions hydroxybenzoate and chlorobenzoate at the hexadecyl trimethylammonium bromide surfactant monolayer/water interface. The degree of counterion binding and the location of the counterions at the interface are shown to depend on the isomeric form of the counterion. For hydroxybenzoate, the para-substituted counterion is located within the headgroup region of the surfactant monolayer, and there is of order one counterion for every two surfactant ions. For the ortho-substituted counterion, the degree of counterion binding is higher. There is of order 0.85 counterions for each surfactant ion, and the counterion is located within the hydrophobic region of the monolayer, some 5 A from the center of the headgroup distribution. Similar results were found for the chlorobenzoate counterion, but in that case it was the para-substituted counterion that was more tightly bound and located within the hydrophobic region of the surfactant monolayer. The results for the ortho-substituted hydroxybenzoate and for the para-substituted chlorobenzoate are consistent with those previously reported for the para-tosylate. The results are discussed in the context of the ability of the specific aromatic counterion isomer to promote massive micellar growth, and the results shed light on that mechanism.

Manipulation of the adsorption of ionic surfactants onto hydrophilic silica using polyelectrolytes.

This paper demonstrates the use of polyelectrolytes to modify and manipulate the adsorption of ionic surfactants onto the hydrophilic surface of silica. We have demonstrated that the cationic polyelectrolyte poly(dimethyl diallylammonium chloride), poly-dmdaac, modifies the adsorption of cationic and anionic surfactants to the hydrophilic surface of silica. A thin robust polymer layer is adsorbed from a dilute polymer/surfactant solution. The resulting surface layer is cationic and changes the relative affinity of the cationic surfactant hexadecyl trimethylammonium bromide, C16TAB, and the anionic surfactant sodium dodecyl sulfate, SDS, to adsorb. The adsorption of C16TAB is dramatically reduced. In contrast, strong adsorption of SDS was observed, in situations where SDS would normally have a low affinity for the surface of silica. We have further shown that subsequent adsorption of the anionic polyelectrolyte sodium poly(styrene sulfonate), Na-PSS, onto the poly-dmdaac coated surface results in a change back to an anionic surface and a further change in the relative affinities of the cationic and anionic surfactants for the surface. The relative amounts of C16TAB and SDS adsorption depend on the coverage of the polyelectrolyte, and these preliminary measurements show that this can be manipulated.

Surface ordering in dilute dihexadecyl dimethyl ammonium bromide solutions at the air-water interface.

At elevated temperatures and in dilute solution, we have observed lamellar surface ordering at the air-water interface of dihexadecyl dimethylammonium bromide, DHDAB, in the presence of electrolyte. With increasing temperature, the onset in ordering is observed between 35 and 40 degrees C. At 40 degrees C, there is an abrupt change in the lamellar spacing, from approximately 33 to approximately 40 A. Furthermore, in the presence of the cosurfactant benzyl alcohol, the ordering occurs at a lower temperature, between 20 and 25 degrees C. The change in lamellar spacing with temperature is attributed to a surface-induced transition, similar to the Lbeta to Lalpha phase transition observed in bulk lamellar dispersions.

Surface and solution behavior of the mixed dialkyl chain cationic and nonionic surfactants.

The surface and solution behavior of the mixed dialkyl chain cationic and nonionic surfactant mixture of dihexadecyldimethylammonium bromide, DHDAB, and hexaethylene monododecyl ether, C12E6, has been investigated, using primarily the scattering techniques of small-angle neutron scattering and neutron reflectivity. Within the time scale of the measurements, the adsorption of the pure component C12E6 at the air-solution interface shows no time dependence. In contrast, the adsorption of the DHDAB/C12E6 mixture and pure DHDAB has a pronounced time dependence. The characteristic time for adsorption varies with surfactant concentration, composition, and temperature. It is approximately 2-3 h for the DHDAB/C12E6 mixture, dependent upon concentration and composition, and approximately 50 min for DHDAB. At the air-solution interface, the equilibrium composition of the adsorbed layer shows a marked departure from ideal mixing, which is dependent upon both the solution concentration and the concentration of added electrolyte. In contrast, the composition of the aggregates in the bulk solution that are in equilibrium with the surface is close to ideal mixing, as expected for solution concentrations well in excess of the critical micellar concentration. The structure of the mixed adsorbed layer has been measured and compared with the structure of the equivalent pure surfactant monolayer, and no substantial changes in structure or conformation are observed. The extreme departure from ideal mixing in the adsorption behavior of the DHDAB/C12E6 mixture is discussed in the context of the structure of the adsorbed layer, changes in the underlying solution structures, and the failure of regular solution theory to predict such behavior.

An exploratory randomised controlled trial of a support programme for carers of patients with a psychosis.

BACKGROUND: Despite an acknowledgement of the impact of serious mental disorders on informal caregivers, we still know little about how to best help them. The aim of the study was to evaluate the effectiveness of a two-phased carers' intervention comprising family sessions followed by relatives' groups. This intervention was designed to be of 'intermediate' intensity, that is,one lying between brief educational programmes and long-term family psychoeducational treatments. METHODS: An exploratory randomised controlled trial was conducted comparing the experimental support programme with 'standard' care. All carers of patients with a psychotic disorder from a defined population were approached. Outcome measures were based on a 'stress-appraisal-coping' model of caregiving. RESULTS: Despite concerted attempts to engage carers, only 42% participated in the study. The carers' programme did not offer any significant advantage on any of the outcome measures: psychological morbidity, negative appraisal, coping or social support. The severity of caregiving difficulties decreased over the study period for the group as a whole. CONCLUSIONS: There is still uncertainty about the most effective interventions for carers. Meeting 'needs' may not improve caregiver distress.

Evaluating a model of caregiving for people with psychosis.

BACKGROUND: The caregiving experience has been conceptualised as distress or satisfaction attributed to various factors in the carer's external and internal world. AIMS: The aim of this study was to test how such factors relate to one another in the framework of a 'stress-coping' model using data from a group of carers of people with psychosis. METHOD: Standard univariate analyses and graphical modelling techniques were applied to baseline and follow-up interview data available from a clinical trial of a support package offered to 77 carers in contact with a community psychiatric service. RESULTS: Results at baseline were consistent with a stress-coping model. Carer distress was most strongly associated with coping. In turn, coping was associated with two sets of factors - one related to appraisal and caregiving difficulty, the other to social support. Using a small sample of longitudinal data (n = 38), most individual measures were predictable from baseline. However, there was again a strong association between carer distress and current coping. Support from confidants assumed an important relationship to effective coping. The level of effective coping increased over time while caregiving difficulty decreased, but carer appraisal and distress did not change. CONCLUSIONS: The findings provide some support for an interactive, stress-coping model of caregiving in psychosis. Effective coping in caregivers may improve with support from confidants. Carer distress may not change while caregiving continues.

The structure of mixed nonionic surfactant monolayers at the air-water interface: the effects of different alkyl chain lengths.

The structure of mixed nonionic surfactant monolayers of monodecyl hexaethylene glycol (C10E6) and monotetradecyl hexaethylene glycol (C14E6) adsorbed at the air-water interface has been determined by specular neutron reflectivity. Using partial isotopic labeling (deuterium for hydrogen) of the alkyl and ethylene oxide chains of each surfactant, the distribution and relative positions of the chains at the interface have been obtained. The packing of the two different alkyl chain lengths results in structural changes compared to the pure surfactant monolayers. This results in changes in the relative positions of the alkyl chains and of the ethylene oxide chains at the interface. The role of the alkyl chain length is contrasted with that of the ethylene oxide chain length, determined from results reported previously on the nonionic surfactant mixture of monododecyl triethylene glycol (C12E3) and monododecyl octaethylene glycol (C12E8).

Oxidized low-density lipoprotein receptor LOX-1 and apoptosis in human atherosclerotic lesions.

BACKGROUND: Lectin-like oxidized LDL receptor-1 (LOX-1), a novel receptor for oxidized low-density lipoprotein, mediates oxidized low-density lipoprotein-induced apoptosis of endothelial cells, monocyte adhesion to endothelium, and phagocytosis of aged cells. The present study examined the role of LOX-1 and apoptosis in human atherosclerotic lesions. METHODS AND RESULTS: Grafted vein (n = 8), human carotid artery endarterectomy (n = 11), and normal human internal mammary artery (n = 8) specimens were used to study the expression of LOX-1 and apoptosis. LOX-1 expression was determined by reverse transcriptase-polymerase chain reaction, Western analysis, and immunostaining. Presence of apoptosis was determined by fluorescent in situ nick end-labeling staining and by the presence of poly (ADP-ribose) polymerase protein (an apoptotic marker). Expression of LOX-1 was significantly increased in atherosclerotic grafted vein and carotid artery specimens compared with that in normal arteries. LOX-1 was expressed in endothelial cells, macrophages, and smooth muscle cells. LOX-1 was extensively expressed in the new blood vessels in the core of advanced atherosclerotic lesions. Double immunostaining showed LOX-1 expression to be colocalized with apoptotic cells. Fluorescent in situ nick end-labeling staining showed that the apoptotic cells were present mostly in the rupture-prone regions of the atherosclerotic plaque. CONCLUSION: These observations indicate that LOX-1 is extensively expressed in the proliferated intima of grafted veins and in advanced atherosclerotic carotid arteries. Further, LOX-1 is colocalized with apoptotic cells. These observations may relate to the phenomenon of plaque rupture, and provide targets for developing new therapies.

Comparison of the coadsorption of benzyl alcohol and phenyl ethanol with the cationic surfactant, hexadecyl trimethyl ammonium bromide, at the air-water interface.

A comparison of the coadsorption of benzyl alcohol and phenyl ethanol with the cationic surfactant, hexadecyl trimethyl ammonium bromide, C16TAB, at the air-water interface is made using the specular reflection of neutrons. The phenyl ethanol is more surface active than the benzyl alcohol, and competes more effectively with the C16TAB for the interface. The structure of the C16TAB component in the mixed monolayer is compared with the structure of the pure C16TAB monolayer at an equivalent area per molecule. The addition of the aromatic alcohol subtly alters the conformation of the C16TAB and draws it closer to the aqueous subphase. The center of the alcohol distribution is located in the interface adjacent to the C6 group of the C16TAB alkyl chain closest to the headgroup. Compared to the benzyl alcohol, the more hydrophobic phenyl ethanol is slightly farther away from the headgroup, and has a greater impact on the conformation of the alkyl chain of the C16TAB.

Adsorption of nonionic mixtures at the air-water interface: effects of temperature and electrolyte.

Specular neutron reflection has been used to investigate the effects of temperature and added electrolyte on the adsorption of nonionic surfactants and nonionic surfactant mixtures at the air-water interface. For the alkyl poly-oxyethylene oxide nonionic surfactants, C(n)EO(m), the adsorption at the air-water interface is independent of temperature for surfactants with shorter ethylene oxide groups, whereas there is an increasing tendency for increased adsorption with temperature for surfactants with longer ethylene oxide groups. The addition of "salting in" (sodium thiocyanate, NaSCN) and "salting out" (sodium chloride, NaCl, sodium sulphate, Na2SO4) electrolyte results in reduced and enhanced adsorption, respectively, for C12EO8, whereas both types of electrolyte result in enhanced adsorption for C12EO12. The addition of electrolyte does not substantially alter the temperature dependence of the adsorption of the pure monolayers. For the nonionic mixtures of C12EO3/C12EO8 increasing temperature results in a surface richer in the least surface-active component, C12EO8. For the same nonionic mixture, the addition of "salting in" and "salting out" electrolyte results in an reduced and increased adsorption, respectively. The addition of "salting in" electrolyte results in a surface more rich in C12EO3, whereas for the addition of both "salting in" and "salting out" electrolyte the surface composition is essentially unaltered.

Unilateral vs. bilateral ultrasound in the monitoring of cerebral microemboli.

We used bilateral transcranial Doppler to monitor the number of microembolic events (ME) in the left and right middle cerebral arteries of 29 patients during cardiac surgery that required extracorporeal circulation. Based on a previously published study, we hypothesized that the commonly used method of doubling unilateral ME counts to obtain an estimated bihemispheric load would result in significant errors of estimation. In our sample, estimated bihemispheric counts were inaccurate by an average of 18% (range 0--80%). Despite this large range of error, calculation of Cronbach's alpha revealed that actual error due to unreliability (4%) was small relative to the large variation in ME counts across subjects in this patient series. These findings suggest that unilateral monitoring is sufficient when the goal is to characterize a given subject's ME load within the context of the other subjects in the sample. However, when precise ME counts are required, bilateral monitoring is essential.