Indoor Air Quality.

Many health care providers are concerned with the role environmental exposures play in the development of respiratory disease. While most individuals understand that outdoor air quality is important to their health status, many are unaware of the detrimental effects indoor air pollution can potentially have on them. The Environmental Protection Agency (EPA) regulates both outdoor and indoor air quality. According to the EPA, indoor levels of pollutants may be up to 100 times higher than outdoor pollutant levels and have been ranked among the top 5 environmental risks to the public. There has been a strong correlation between air quality and health, which is why it is crucial to obtain a complete environmental exposure history from a patient. This article focuses on the effects indoor air quality has on the respiratory system. Specifically, this article will address secondhand smoke, radon, carbon monoxide, nitrogen dioxide, formaldehyde, house cleaning agents, indoor mold, animal dander, and dust mites. These are common agents that may lead to hazardous exposures among individuals living in the United States. It is important for health care providers to be educated on the potential risks of indoor air pollution and the effects it may have on patient outcomes. Health problems resulting from poor indoor air quality are not easily recognized and may affect a patient's health years after the onset of exposure.

Donors with cardiac arrest: improved organ recovery but no preconditioning benefit in liver allografts.

BACKGROUND: Historically, organ recovery rates in donors with cardiac arrest (CA) have been low, presumably from hemodynamic instability. We hypothesized that donor resuscitation has improved hemodynamic stability and organ recovery in CA donors, and that CA triggers ischemic preconditioning (IP) in liver grafts. METHODS: A total of 131 donor pairs with and without CA were matched in age, gender, and year of recovery. Hemodynamic stability was determined by vasopressor use. Abdominal and thoracic organs recovered and livers transplanted were compared between the groups. Liver graft function, injury, and IP benefit were examined by comparing liver chemistries after transplantation and postperfusion biopsies between recipients of grafts from both groups (n=40 each). RESULTS: Hemodynamic stability was similar in both groups, but recovery of thoracic organs was significantly lower in CA versus non-CA donors (35 vs. 53%, P<0.01). On the other hand, recovery rates of three or more abdominal organs from CA donors approached those of non-CA donors (77 vs. 87%, not significant). Although significantly fewer livers were transplanted from CA donors (69 vs. 85%, P<0.01), posttransplantation graft function and injury parameters were similar between the two groups, and CA did not appear to trigger IP. CONCLUSION: Compared with historical data, cardiovascular stability and abdominal organ recovery rates have improved considerably in CA donors. Liver grafts from CA donors function similarly to grafts from non-CA donors with no IP from CA. Our data support the increased use of livers and other organs from donors with CA.

Primary non-Hodgkin's lymphoma of the bile ducts mimicking cholangiocarcinoma.

BACKGROUND: Primary non-Hodgkin's lymphoma (NHL) of the liver and bile duct mimicking cholangiocarcinoma is rare. METHODS: The clinical and radiologic features and the treatment of 2 patients with primary NHL of the bile ducts are presented and analyzed together with cases collected from a review of the English literature between 1966 and 2003. RESULTS: Fifteen patients with primary NHL, including our 2 patients, presented with clinical features mimicking cholangiocarcinoma. All had jaundice; 9 had systemic symptoms; 7 had abdominal pain; and 5 had mass lesions. All had biliary strictures as shown on cholangiography. Two patients were infected with human immunodeficiency virus-1. In only 1 patient was the diagnosis established without surgery. Immunophenotyping in 10 patients showed 9 B-cell tumors and 1 T-cell tumor. Twelve patients underwent resection. Seven received chemotherapy immediately after the diagnosis was made. Only 3 patients have survived more than 3 years, with the longest survival being 68 months. CONCLUSIONS: Non-Hodgkin's lymphoma of the liver and bile duct must be considered in the differential diagnosis of patients with obstructive jaundice. If the correct diagnosis is made before surgery, current protocols of chemotherapy may be the primary modality of therapy. Surgical resection should be reserved to address complications of biliary obstruction or the failure of chemotherapy to eradicate localized disease.

Diffuse pulmonary infiltrates in an old man with chronic lymphocytic leukemia.

An 82-year-old man known case of chronic lymphocytic leukemia (CLL) presented with fever and weakness. He had never received any treatment for his CLL in the past. On admission he was found to be in mild respiratory distress with bilateral crackles and had markedly elevated white blood count (WBC) (137 K/uL with 93% lymphocytes). His respiratory status deteriorated necessitating non-invasive ventilatory support. Chest computed tomography (CT) scan revealed bilateral diffuse ground glass opacities, so broad spectrum antibiotic therapy was initiated. Despite that, he remained febrile and cultures were all negative. Chest x-rays showed progressive worsening of diffuse alveolar opacities. Bronchoalveolar lavage (BAL) was negative for infectious etiologies, however flow cytometry of the fluid was consistent with CLL. Chemotherapy with chlorambucil was started. Although most of the pulmonary infiltrates in CLL patients are due to infectious causes, leukemic cells infiltration should be considered as well in CLL patients with respiratory symptoms who do not respond appropriately to standard antimicrobial regimen.

De novo diagnosis of portopulmonary hypertension following liver transplantation.

Portopulmonary hypertension occurs in 2-8% of liver recipients. However, new onset of pulmonary hypertension following liver transplantation has been reported only once. We report de novo occurrences of portopulmonary hypertension in two liver recipients following successful liver transplantation. Although both patients had recurrent hepatitis C after the transplant, both had excellent clinical graft function. In one patient, upper endoscopy and aortogram showed evidence of persistent venous collaterals in the abdomen. Both patients presented with shortness of breath. Portopulmonary hypertension was diagnosed late, thus contributing directly to their deaths. Autopsy in one patient confirmed the absence of significant liver pathology and failed to demonstrate any source of deep venous thrombosis. This, and our earlier case report, highlights the potential for the occurrence of pulmonary hypertension following liver transplantation. Further studies are needed to determine the scope of the problem and identify patients at risk for this complication.

Effect of sirolimus on infection incidence in liver transplant recipients.

Sirolimus is a new immunosuppressive agent that lacks the nephrotoxicity and neurotoxicity associated with calcineurin inhibitors. The addition of sirolimus to immunosuppressive protocols may thus allow sparing of calcineurin inhibitors and reduction or elimination of associated toxicities. Between January 2000 and July 2001, sirolimus was administered to 55 of 116 consecutive liver recipients. The remaining 61 patients served as the comparison group in the retrospective analysis. In the sirolimus group, perioperative steroids were reduced, and calcineurin inhibitor initiation was delayed. All infectious episodes that occurred within 60 days of liver transplantation were evaluated but were limited to 1 per patient for statistical analysis of sepsis. Demographic variables were comparable between groups. Patients receiving sirolimus experienced more infection (47.2% vs. 18.03%, P<0.001), and this effect persisted across high and low dosage ranges and sirolimus levels. A trend toward increased length of stay was noted (P=0.07). No difference between groups was found in acute rejection rates (17.5% vs. 22.5%), 1-year graft (81% vs. 89%), patient survival (86% vs. 89%), or hepatic artery thrombosis. In conclusion, despite reduction of other immunosuppressants, patients receiving even low doses of sirolimus experienced increased sepsis rates. This agent may have greater usefulness for patients with threatened renal function or patients with chronic rejection after wound healing has occurred.