Baseline findings of the population-based, randomized, multifaceted Danish cardiovascular screening trial (DANCAVAS) of men aged 65-74 years.

BACKGROUND: The challenge of managing age-related diseases is increasing; routine checks by the general practitioner do not reduce cardiovascular mortality. The aim here was to reduce cardiovascular mortality by advanced population-based cardiovascular screening. The present article reports the organization of the study, the acceptability of the screening offer, and the relevance of multifaceted screening for prevention and management of cardiovascular disease. METHODS: Danish men aged 65-74 years were invited randomly (1 : 2) to a cardiovascular screening examination using low-dose non-contrast CT, ankle and brachial BP measurements, and blood tests. RESULTS: In all, 16 768 of 47 322 men aged 65-74 years were invited and 10 471 attended (uptake 62·4 per cent). Of these, 3481 (33·2 per cent) had a coronary artery calcium score above 400 units. Thoracic aortic aneurysm was diagnosed in the ascending aorta (diameter 45 mm or greater) in 468 men (4·5 per cent), in the arch (at least 40 mm) in 48 (0·5 per cent) and in the descending aorta (35 mm or more) in 233 (2·2 per cent). Abdominal aortic aneurysm (at least 30 mm) and iliac aneurysm (20 mm or greater) were diagnosed in 533 (5·1 per cent) and 239 (2·3 per cent) men respectively. Peripheral artery disease was diagnosed in 1147 men (11·0 per cent), potentially uncontrolled hypertension (at least 160/100 mmHg) in 835 (8·0 per cent), previously unknown atrial fibrillation confirmed by ECG in 50 (0·5 per cent), previously unknown diabetes mellitus in 180 (1·7 per cent) and isolated severe hyperlipidaemia in 48 men (0·5 per cent). In all, 4387 men (41·9 per cent), excluding those with potentially uncontrolled hypertension, were referred for additional cardiovascular prevention. Of these, 3712 (35·5 per cent of all screened men, but 84·6 per cent of those referred) consented and were started on medication. CONCLUSION: Multifaceted cardiovascular screening is feasible and may optimize cardiovascular disease prevention in men aged 65-74 years. Uptake is lower than in aortic aneurysm screening.

The DanCavas Pilot Study of Multifaceted Screening for Subclinical Cardiovascular Disease in Men and Women Aged 65-74 Years.

OBJECTIVE/BACKGROUND: This pilot study of a large population based randomised screening trial investigated feasibility, acceptability, and relevance (prevalence of clinical and subclinical cardiovascular disease [CVD] and proportion receiving insufficient prevention) of a multifaceted screening for CVD. METHODS: In total, 2060 randomly selected Danish men and women aged 65-74 years were offered (i) low dose non-contrast computed tomography to detect coronary artery calcification (CAC) and aortic/iliac aneurysms; (ii) detection of atrial fibrillation (AF); (iii) brachial and ankle blood pressure measurements; and (iv) blood levels of cholesterol and hemoglobin A1c. Web based self booking and data management was used to reduce the administrative burden. RESULTS: Attendance rates were 64.9% (n = 678) and 63.0% (n = 640) for men and women, respectively. In total, 39.7% received a recommendation for medical preventive actions. Prevalence of aneurysms was 12.4% (95% confidence interval [CI] 9.9-14.9) in men and 1.1% (95% CI 0.3-1.9) in women, respectively (p < .001). A CAC score > 400 was found in 37.8% of men and 11.3% of women (p < .001), along with a significant increase in median CAC score with age (p = .03). Peripheral arterial disease was more prevalent in men (18.8%, 95% CI 15.8-21.8) than in women (11.2%, 95% CI 8.7-13.6). No significant differences between the sexes were found with regard to newly discovered AF (men 1.3%, women 0.5%), potential hypertension (men 9.7%, women 11.5%), hypercholesterolemia (men 0.9%, women 1.1%) or diabetes mellitus (men 2.1%, women 1.3%). CONCLUSION: Owing to the higher prevalence of severe conditions, such as aneurysms and CAC ≥ 400, screening for CVD seemed more prudent in men than women. The attendance rates were acceptable compared with other screening programs and the logistical structure of the screening program proved successful.

PET hypoxia imaging with FAZA: reproducibility at baseline and during fractionated radiotherapy in tumour-bearing mice.

PURPOSE: Tumour hypoxia is linked to treatment resistance. Positron emission tomography (PET) using hypoxia tracers such as fluoroazomycin arabinoside (FAZA) may allow identification of patients with hypoxic tumours and the monitoring of the efficacy of hypoxia-targeting treatment. Since hypoxia PET is characterized by poor image contrast, and tumour hypoxia undergoes spontaneous changes and is affected by therapy, it remains unclear to what extent PET scans are reproducible. Tumour-bearing mice are valuable in the validation of hypoxia PET, but identification of a reliable reference tissue value (blood sample or image-derived muscle value) for repeated scans may be difficult due to the small size of the animal or absence of anatomical information (pure PET). Here tumour hypoxia was monitored over time using repeated PET scans in individual tumour-bearing mice before and during fractionated radiotherapy. METHODS: Mice bearing human SiHa cervix tumour xenografts underwent a PET scan 3 h following injection of FAZA on two consecutive days before initiation of treatment (baseline) and again following irradiation with four and ten fractions of 2.5 Gy. On the last scan day, mice were given an intraperitoneal injection of pimonidazole (hypoxia marker), tumours were collected and the intratumoral distribution of FAZA (autoradiography) and hypoxia (pimonidazole immunohistology) were determined in cryosections. RESULTS: Tissue section analysis revealed that the intratumoral distribution of FAZA was strongly correlated with the regional density of hypoxic (pimonidazole-positive) cells, even when necrosis was present, suggesting that FAZA PET provides a reliable measure of tumour hypoxia at the time of the scan. PET-based quantification of tumour tracer uptake relative to injected dose showed excellent reproducibility at baseline, whereas normalization using an image-derived nonhypoxic reference tissue (muscle) proved highly unreliable since a valid and reliable reference value could not be determined. The intratumoral distribution of tracer was stable at baseline as shown by a voxel-by-voxel comparison of the two scans (R = 0.82, range 0.72-0.90). During treatment, overall tracer retention changed in individual mice, but there was no evidence of general reoxygenation. CONCLUSION: Hypoxia PET scans are quantitatively correct and highly reproducible in tumour-bearing mice. Preclinical hypoxia PET is therefore a valuable and reliable tool for the development of strategies that target or modify hypoxia.

Therapeutic Modification of Hypoxia.

Regions of reduced oxygenation (hypoxia) are a characteristic feature of virtually all animal and human solid tumours. Numerous preclinical studies, both in vitro and in vivo, have shown that decreasing oxygen concentration induces resistance to radiation. Importantly, hypoxia in human tumours is a negative indicator of radiotherapy outcome. Hypoxia also contributes to resistance to other cancer therapeutics, including immunotherapy, and increases malignant progression as well as cancer cell dissemination. Consequently, substantial effort has been made to detect hypoxia in human tumours and identify realistic approaches to overcome hypoxia and improve cancer therapy outcomes. Hypoxia-targeting strategies include improving oxygen availability, sensitising hypoxic cells to radiation, preferentially killing these cells, locating the hypoxic regions in tumours and increasing the radiation dose to those areas, or applying high energy transfer radiation, which is less affected by hypoxia. Despite numerous clinical studies with each of these hypoxia-modifying approaches, many of which improved both local tumour control and overall survival, hypoxic modification has not been established in routine clinical practice. Here we review the background and significance of hypoxia, how it can be imaged clinically and focus on the various hypoxia-modifying techniques that have undergone, or are currently in, clinical evaluation.

Metabolic arrest and its regulation in anoxic eel hepatocytes.

Some vertebrates depress overall metabolism in an abrupt and reversible fashion when challenged with anoxia, ensuring stabilization of cellular [ATP] and long-term survival, but little is known about the eliciting stimuli (e.g., change in O2, adenylates) and downstream effectors responsible for metabolic arrest. Accordingly, eel (Anguilla anguilla) hepatocytes were treated with inhibitors of putative components of the oxygen/metabolite-sensing pathway(s) and exposed to anoxia (Po2=0 mmHg). Anoxia in untreated cells caused a remarkable 85-fold decrease in ATP production rate, but cellular ATP levels stabilized following an initial steep drop. Reoxygenation of cells after 4 h of anoxia caused a fast metabolization of accumulated lactate and reestablishment of preanoxic ATP levels. Unlike physiological anoxia, pharmacological inhibition of the electron transport chain in the presence of oxygen caused extensive cellular ATP depletion, though no loss in viability. In contrast, cellular lactate (i.e., ATP) production rate was affected similarly by either treatment, suggesting that anaerobic glycolysis is regulated by a stimulus other than oxygen tension per se, whereas the continuous matching of ATP consumption and a rapidly ceasing mitochondrial ATP supply require a physiological relevant change in oxygen tension. Protein kinases, notably kinase C (PKC) and A (PKA), have been proposed as key downstream regulators of stress-induced defense mechanisms, but anoxic cell viability, metabolic rate, and [ATP] were not significantly affected by inhibitors of PKC and PKA. Likewise, inhibition of the upstream PKC-activating enzymes phospholipase C (PLC) and phosphatidylinositol 3-kinase (PI 3-K) had no effect on recorded parameters. Anoxic cell survival in complex organisms may, in vivo, also depend on stress hormones released from distant oxygen-sensing cells. Accordingly, adrenaline elevated anaerobic energy production but, apparently, also elevated ATP consumption because cellular ATP levels during oxygen deprivation were slightly lowered by adrenergic stimulation.

Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction.

Cryotherapy is used for endoscopic management of tracheobronchial obstruction (TBO). This study describes the use of a flexible cryoprobe for cryotherapy using nitrous oxide as a cryogen through a fiberoptic bronchoscope. The study group consisted of 22 patients, ages ranging from 28 to 82 years. Twenty patients had malignant TBO and two had bronchial obstruction (BO) following lung transplantation. Benign BO was first dilated with a balloon and followed with cryotherapy. Eighteen of the 20 malignant endobronchial lesions were completely removed. In three of these patients, the airway remained occluded due to extrinsic compression. Cryotherapy offers an alternative to Nd:YAG laser in the management of TBO. Cryotherapy offers other advantages such as being inexpensive, safe for the operator, and safe for other members of the team. Similarly for the patient, there is no danger of bronchial wall perforation or endobronchial fires, cryotherapy can be done under local anesthesia with conscious sedation, and it can be performed in an endoscopy suite.

Relevance of hypoxia in radiation oncology: pathophysiology, tumor biology and implications for treatment.

Tumors are characterized by an inefficient and disorganized vasculature which leads to tumor regions that are transiently or chronically undersupplied with oxygen (hypoxia) and nutrients (e.g., glucose). These adverse conditions are linked to treatment resistant and metastasizing disease with poor prognosis. Radiation sensitivity is dramatically lowered in hypoxic, yet viable and clonogenic, cells since oxygen is involved in the fixation of radiation-induced DNA damage (radiobiological hypoxia), and loco-regional tumor control is adversely affected in patients with hypoxic tumors. Hypoxia also leads to reduced sensitivity towards chemotherapeutics since drug delivery is reduced in hypoperfused hypoxic areas and hypoxic cells are quiescent, making drugs that target dividing cells ineffective. Fortunately, clinical attractive imaging and gene-expression based technologies that allows pre- and during treatment assessment of tumor hypoxia are now available. These technologies may identify patients suitable for established or emerging hypoxia-targeting treatments and, equally important; they allow us to monitor the efficacy of such intervention and may thus pave the way for effective individualized treatment. In the current review, we address 1) the causes and consequences of tumor hypoxia, 2) technologies that allow assessment of tumor hypoxia in individual patients and 3) current status of hypoxia-targeting treatments.

Vascular targeting therapy: potential benefit depends on tumor and host related effects.

The growth and development of most solid tumors require that they form their own functional vascular supply, which they do from the host normal vascular network by the process of angiogenesis. The significance of this neo-vasculature makes it an excellent target and two forms of vascular targeting agents (VTAs) have evolved; those that inhibit the angiogenesis process (angiogenesis inhibitors, AIs) and those that damage the already established vessels (vascular disrupting agents, VDAs). Although both AIs and VDAs can have substantial anti-tumor activity, neither induce tumor control, thus for their full clinical potential to be achieved they will need to be combined with more conventional cancer therapies. Numerous pre-clinical studies have demonstrated the efficacy of combining AIs and VDAs with radio- and chemo-therapy and many of these approaches are now under clinical evaluation. Although the tumor is the target for VTA therapy the normal host cells play an important role in VTA efficacy. Host cells such as infiltrating macrophages, neutrophils, mast cells, platelets, endothelial cells, and stromal fibroblasts can all produce the important growth factors that initiate angiogenesis. Many of these host cells also actively participate in the physical steps of angiogenesis including destabilization of existing vessels, blood vessel sprouting, endothelial cell migration and proliferation, and vessel stabilization. There is some evidence that these host cells can also influence VTA treatment, either by helping to normalize tumor vessels when AIs are administered or stimulate tumor angiogenesis after treatment with VDAs. The host itself also plays a critical role. Cancer patients undergoing therapy are normally treated to tolerance, thus the normal tissue side effects actually control the effective dose given to the tumor. All VTAs currently in clinical development induce some form of systemic side effects, which range from being rather mild and tolerable to more severe and even life threatening. For more localised therapies there is also the issue of possible VTA-enhanced local tissue reactions. A few pre-clinical studies have investigated this with radiation, but failed to show any enhancement of radiation-induced normal tissue damage by VTAs. Clearly, the therapeutic benefit of VTA treatment will depend on a balance between tumor and host related effects, and in this review we will consider the contribution of each.

Specific demonstration of drug-induced tumour cell apoptosis in human xenografts models using a plasma biomarker.

Pharmacodynamic (PD) assays should be used before advancing new drugs to clinical trials. Most PD assays measure the response to drugs in tissue, a procedure which requires tissue biopsies. The M30-Apoptosense ELISA is a PD biomarker assay for the quantitative determination of caspase-cleaved cytokeratin 18 (CK18) released from apoptotic carcinoma cells into blood. We here demonstrate that whereas the M30-Apoptosense ELISA assay detects human caspase-cleaved CK18, the mouse and rat CK18 caspase cleavage products are detected with low affinity. The M30-Apoptosense ELISA therefore facilitates the determination of drug-induced apoptosis in human tumour xenografts in rodents using plasma samples, largely independently from host toxicity. Increases of caspase-cleaved CK18 were observed in plasma from different carcinoma xenograft models in response to anticancer drugs. The appearance caspase-cleaved CK18 in plasma was found to reflect formation of the caspase-cleaved epitope in FaDu head-neck carcinomas and in cultured cells. The M30-Apoptosense assay allows determination of tumour response in blood from xenograft models and from patients, providing a powerful tool for translational studies of anticancer drugs.

Characterization of the integrin alpha v beta 6 as a fibronectin-binding protein.

Integrins are a complex family of divalent cation-dependent cell adhesion receptors composed of one alpha and one beta subunit noncovalently bound to one another. A subset of integrins contains the alpha v subunit in association with one of several beta subunits (e.g. beta 3, beta 5, beta 1). We have recently identified a novel integrin beta subunit, beta 6, that is present in a number of epithelial cell lines. Using a polyclonal antibody raised against the carboxyl-terminal peptide of beta 6, we have now identified the integrin heterodimer, alpha v beta 6, on the surface of two human carcinoma cell lines. Using affinity chromatography of lysates from the pancreatic carcinoma cell line, FG-2, we demonstrate that alpha v beta 6 binds to fibronectin, but not to vitronectin or collagen I. In contrast, the alpha v beta 5 integrin, which is also expressed on FG-2 cells, binds exclusively to vitronectin. Immobilized collagen I does not interact with alpha v integrins, but binds beta 1-containing integrins. Both alpha v beta 6 and alpha v beta 5 are eluted from their respective immobilized ligands by a hexa-peptide containing the sequence Arg-Gly-Asp (RGD). RGD is highly effective in the presence of Ca2+, somewhat less effective in Mg2+, and virtually inactive in Mn2+. These results suggest that alpha v beta 6 functions as an RGD-dependent fibronectin receptor in FG-2 carcinoma cells. In agreement with this notion, cell adhesion assays show that FG-2 cell attachment to fibronectin is only partially inhibited by anti-beta 1 integrin antibodies, implying that other fibronectin receptors may be involved. Taken together with recent reports on the vitronectin receptor function of alpha v beta 5, our results suggest that the previously described carcinoma cell integrin, alpha v beta x (Cheresh, D. A., Smith, J. W., Cooper, H. M., and Quaranta, V. (1989) Cell 57, 59-69), is a mixture of at least two different receptors: alpha v beta 5, mediating adhesion to vitronectin, and alpha v beta 6, mediating adhesion to fibronectin.

The respiratory consequences of feeding in amphibians and reptiles.

Many ectothermic vertebrates ingest very large meals at infrequent intervals. The digestive processes associated with these meals, often coupled with an extensive hypertrophy of the gastrointestinal organs, are energetically expensive and metabolic rate, therefore, increases substantially after feeding (specific dynamic action, SDA). Here, we review the cardio-respiratory consequences of SDA in amphibians and reptiles. For some snakes, the increased oxygen uptake during SDA is of similar magnitude to that of muscular exercise, and the two physiological states, therefore, exert similar and profound demands on oxygen transport by the cardiorespiratory systems. In several species, SDA is attended by increases in heart rate and overall systemic blood flows, but changes in blood flow distribution remain to be investigated. In snakes, the regulation of heart rate appears to involve a non-adrenergic-non-cholinergic mechanism, which may be a regulatory peptide released from the gastrointestinal system during digestion. Digestion is also associated with a net acid secretion to the stomach that causes an increase in plasma HCO3- concentration (the 'alkaline tide'). Experiments on chronically cannulated amphibians and reptiles, show that this metabolic alkalosis is countered by an increased P(CO2), so that the change in arterial pH is reduced. This respiratory compensation of arterial pH is accomplished through a reduction in ventilation relative to metabolism, but the estimated reductions in lung P(O2) are relatively small. The SDA response is also associated with haematological changes, but large interspecific differences exist. The studies on cardiorespiratory responses to digestion may allow for a further understanding of the physiological and structural constraints that limits the ability of reptiles and amphibians to sustain high metabolic rates.

Effects of feeding on metabolism, gas transport, and acid-base balance in the bullfrog Rana catesbeiana.

Massive feeding in ectothermic vertebrates causes changes in metabolism and acid-base and respiratory parameters. Most investigations have focused on only one aspect of these complex changes, and different species have been used, making comparison among studies difficult. The purpose of the present study was, therefore, to provide an integrative study of the multiple physiological changes taking place after feeding. Bullfrogs (Rana catesbeiana) partly submerged in water were fed meals (mice or rats) amounting to approximately (1)/(10) of their body weight. Oxygen consumption increased and peaked at a value three times the predigestive level 72-96 h after feeding. Arterial PO(2) decreased slightly during digestion, whereas hemoglobin-bound oxygen saturation was unaffected. Yet, arterial blood oxygen content was pronouncedly elevated because of a 60% increase in hematocrit, which appeared mediated via release of red blood cells from the spleen. Gastric acid secretion was associated with a 60% increase in plasma HCO3(-) concentration ([HCO3(-)]) 48 h after feeding. Arterial pH only increased from 7.86 to 7.94, because the metabolic alkalosis was countered by an increase in PCO(2) from 10.8 to 13.7 mm Hg. Feeding also induced a small intracellular alkalosis in the sartorius muscle. Arterial pH and HCO3(-) returned to control values 96-120 h after feeding. There was no sign of anaerobic energy production during digestion as plasma and tissue lactate levels remained low and intracellular ATP concentration stayed high. However, phosphocreatine was reduced in the sartorius muscle and ventricle 48 h after feeding.

Transforming growth factor beta differentially regulates expression of integrin subunits in guinea pig airway epithelial cells.

The integrin family is composed of a large number of heterodimers, each one mediating distinct interactions with extracellular matrix and/or cell surface ligands. The expression of integrins appears to be tightly regulated in vivo, but the mechanisms by which cells control the formation and surface expression of specific pairs of subunits have not been well characterized. Two integrin subunits, the alpha subunit alpha v, and the beta subunit beta 1, could pose special problems in regulation because of their capacity to associate with multiple partners. In the present study, we have examined the effects of the cytokine transforming growth factor beta 1 (TGF-beta 1) on the expression of alpha v- and beta 1-containing integrins in primary cultures of guinea pig airway epithelial cells, e.g. cells that we have previously found to express multiple potential partners for both alpha v and beta 1. TGF-beta 1 increased the surface expression of both alpha v- and beta 1-containing heterodimers after periods of stimulation from 24 to 72 h. These increases in surface expression were associated with significant increases in the concentrations of mRNA encoding each of the partners of alpha v and beta 1, but with only minimal increases in mRNA encoding alpha v and beta 1 themselves. Airway epithelial cells metabolically labeled with [35S]methionine during stimulation with TGF-beta 1 demonstrated only a minimal increase in the synthesis of new alpha v protein at a time when synthesis of alpha v's beta subunit partners and surface expression of alpha v-containing heterodimers were dramatically increased. These data suggest that, at least in some cells, promiscuous integrin subunits (both alpha and beta) may normally be synthesized in excess. Thus, the surface expression of specific integrin heterodimers can be regulated primarily through regulation of the synthesis of the specific partners of these subunits.

Effects of the methyl xanthine S 9795 on isolated bronchi of the dog.

The xanthine derivative 1-methyl 3-isobutyl 8-(2-ethyl[1-(4-diphenylmethyl piperazinyl)])3, 7-dihydro (1H) purine 2, 6-dione (S 9795) is a potent inhibitor of bronchoconstriction in vivo. The aim of the present study was to analyze the effects of S 9795 in vitro and determine whether S 9795 affects the autonomic nerves, the epithelium or the smooth muscle of the bronchial wall. S 9795 had an inhibitory effect on the contractile responses evoked by acetylcholine and by electrical stimulation of the cholinergic nerves. S 9795 appeared more potent against contractions evoked by nerve stimulation. In addition, S 9795 caused the release of [3H]norepinephrine from the adrenergic nerve endings but did not affect neuronal uptake of the catecholamine. At low concentrations, S 9795 acted as a competitive serotonergic antagonist; at higher concentrations, the compound inhibited noncompetitively the contractions evoked by histamine and acetylcholine. In both second and fourth order bronchi, S 9795 (and theophylline) produced concentration-dependent relaxations that were significantly greater in rings with, compared with rings without, epithelium. The compound also facilitated the epithelium-dependent component of the relaxation response to beta-adrenergic activation. These results suggest that S 9795: 1) causes prejunctional inhibition of the release of acetylcholine, 2) evokes the displacement of stored norepinephrine, 3) exerts a differential inhibitory effect on airway contractions induced by various bronchoconstrictors and 4) augments the release or facilitates the effect of the epithelium-derived relaxing factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Acid-base regulation in tadpoles of Rana catesbeiana exposed to environmental hypercapnia.

Tadpoles of Rana catesbeiana were exposed to different levels of environmental hypercapnia. The acid-base regulatory response differed from that in adult amphibians in showing a high degree of pH compensation in the extracellular fluid (65-85%) and complete compensation in the intracellular fluid (tail muscle and liver) within 24 h. Hypercapnia induced a massive transfer of HCO3- equivalents and Ca2+ from the tadpoles to the environment, which lasted some 4-6 h. Bicarbonate accumulated in the body fluids came mainly from internal buffer sources (probably CaCO3 in lime sacs and/or skin deposits). It is suggested that the large bicarbonate efflux from the animal is a consequence of the dissolution of CaCO3 stores and the delayed adjustment of bicarbonate-retaining mechanisms. Re-exposure of tadpoles to hypercapnia after 1-3 weeks of normocapnic recovery only affected transepithelial fluxes of acid-base equivalents marginally, suggesting that mobilisable CaCO3 stores were depleted during the first exposure to hypercapnia and that they were not refilled. The CaCO3 stores may normally be mobilised during the slowly developing internal hypercapnia that occurs during metamorphosis.

Invasive procedures in the diagnosis of pneumonia.

The etiology of respiratory infections can be elusive despite the recent advances in diagnostic technology. Thereby, the clinician needs a systematic approach for a definitive early diagnosis. This review presents the pros and cons of various invasive procedures in order to select the most appropriate diagnostic method. Expectorated sputum, the important initial step in community-acquired pneumonia, is unreliable in complex pneumonias, mainly because of colonization of the oropharynx. Even though blood cultures are frequently negative, they provide a precise diagnosis and should be obtained in undiagnosed pneumonias. Transtracheal needle aspiration has few false-negative results. However, its use has decreased because of the high frequency of false-positive cultures and risk of serious complications. Bronchoscopy provides direct access to both the bronchi and parenchyma for visualization and sampling. Plugged telescoping catheter brush, used safely in different clinical settings, has good sensitivity in identifying the pathogen, but the specificity varies with the underlying status of the patient. Because of upper airway contamination, bronchial washings are only slightly better than expectorated sputum. A newer technique, transbronchial needle aspiration, is, thus far, no improvement over the plugged telescoping catheter brush. In the immunosuppressed patient, bronchoalveolar lavage has excellent diagnostic accuracy for opportunistic infections. The accuracy increases with the addition of transbronchial biopsy. Transthoracic needle aspiration gives decisive information with low false-positive results. With the ultrathin needle, the complications decrease. Renewed interest in thoracoscopy-guided biopsy has demonstrated a high diagnostic accuracy with low complication rate. One procedure, a combination, or improvements of these procedures may reduce the need for open lung biopsy. Nevertheless, an open lung biopsy furnishes the best specimen for making a histological and microbiological diagnosis, although controversy exists regarding any improvement in survival rates.

Effects of feeding on arterial blood gases in the American alligator Alligator mississippiensis.

Reptiles habitually ingest large meals at infrequent intervals, leading to changes in acid-base status as the net secretion of acid to the stomach causes a metabolic alkalosis (the alkaline tide). In chronically cannulated and undisturbed amphibians and reptiles, the pH changes in arterial blood are, nevertheless, reduced by a concomitant respiratory acidosis (increased P(CO2) caused by a relative hypoventilation). Alligators (Alligator mississippiensis) have been reported to exhibit exceptionally large increases in plasma [HCO3(-)] following feeding, but these studies were based on blood samples obtained by cardiac puncture, so stress and disturbance may have affected the blood gas levels. Furthermore, crocodilian haemoglobin is characterised by a unique binding of HCO3(-) that act to reduce blood oxygen-affinity, and it has been proposed that this feature safeguards oxygen offloading by counteracting pH effects on blood oxygen-affinity. Therefore, to study acid-base regulation and the interaction between the alkaline tide and oxygen transport in more detail, we describe the arterial blood gas composition of chronically cannulated and undisturbed alligators before and after voluntary feeding (meal size 7.5+/-1% of body mass). Digestion was associated with an approximately fourfold increase in metabolic rate (from 0.63+/-0.04 to 2.32+/-0.24 ml O(2) min(-1)kg(-1)) and was accompanied by a small increase in the respiratory gas exchange ratio. The arterial P(O2) of fasting alligators was 60.3+/-6.8 mmHg (1 mmHg = 0.133 kPa) and reached a maximum of 81.3+/-2.7 mmHg at 96 h following feeding; there was only a small increase in lactate levels, so the increased metabolic rate seems to be entirely aerobic. Plasma [HCO3(-)] increased from 24.4+/-1.1 to 36.9+/-1.7 mmol l(-1) (at 24 h), but since arterial P(CO2) increased from 29.0+/-1.1 to 36.8+/-1.3 mmHg, arterial pH remained virtually unaffected (changing from 7.51+/-0.01 to 7.58+/-0.01 at 24 h). The changes in plasma [HCO3(-)] were mirrored by equimolar reductions in plasma [Cl(-)]. The in vitro blood oxygen-affinity was reduced during the post-prandial period, whereas the estimated in vivo blood oxygen-affinity remained virtually constant. This supports the view that the specific HCO3(-) effect prevents an increased blood oxygen-affinity during digestion in alligators.

Respiratory consequences of feeding in the snake Python molorus.

Snakes can ingest large meals and exhibit marked increases in metabolic rate during digestion. Because postprandial oxygen consumption in some snakes may surpass that attained during exercise, studies of digestion offers an alternative avenue to understand the cardio-respiratory responses to elevated metabolic rate in reptiles. The effects of feeding on metabolic rate, arterial oxygen levels, and arterial acid-base status in the snake Python molorus are described. Four snakes (180-250 g) were cannulated in the dorsal aorta and blood samples were obtained during 72 h following ingestion of a meal (rat pups) exceeding 20% of body weight. Oxygen consumption increased from a fasting value of 1.71 +/- 0.08 to 5.54 +/- 0.42 ml kg-1 min-1 at 48 h following feeding, and the respiratory gas exchange ratio increased from 0.67 +/- 0.02 to a maximum of 0.92 +/- 0.03 at 32 h. Plasma lactate was always less than 0.5 mM, so the postprandial increase in metabolic rate was met by aerobic respiration. In fasting animals, arterial PO2 was 66 +/- 4 mmHg and haemoglobin-O2 saturation was 92 +/- 3%; similar values were recorded during digestion, but haematocrit decreased from 15.8 +/- 1.0 to 9.8 +/- 0.8 due to repeated blood sampling. Plasma [HCO3-] increased from a fasting level of 19.3 +/- 0.8 to 25.8 +/- 1.0 mmol l-1 at 24 h after feeding. However, because arterial PCO2 increased from 21.1 +/- 0.5 to 27.9 +/- 1.4 mmHg, there was no significant change in arterial pH from the fasting value of 7.52 +/- 0.01. Acid-base status returned to pre-feeding levels at 72 h following feeding. The increased arterial PCO2 is most likely explained by a reduction in ventilation relative to metabolism, but we predict that lung PO2 does not decrease below 115 mmHg. Although ingestion of large meals is associated with large metabolic changes in pythons, the attendant changes in blood gases are relatively small. In particular, the small changes in plasma [HCO3-] and stable pH show that pythons respond very differently to digestion than alligators where very large alkaline tides have been observed. It is unclear why pythons and alligators differ in the magnitude of their responses, but given these interspecific differences it seems worthwhile to describe arterial blood gases during digestion in other species of ectothermic vertebrates.

Copper exposure impairs intra- and extracellular acid-base regulation during hypercapnia in the fresh water rainbow trout (Oncorhynchus mykiss).

In order to evaluate the impact of water-borne copper on acid-base regulation in fresh water rainbow trout, chronically cannulated fish were exposed to copper (0.6 mg 1(-1)), hypercapnia (water PCO2 of 6 mmHg) or a combination of copper and hypercapnia, while a fourth untreated group served as the control. Blood samples obtained at 0 h, 4 h and 24 h were analysed for acid-base status, ion concentrations and respiratory parameters. Tissue samples from caudal skeletal muscle, liver and gill filaments were examined for intracellular acid-base status, ion- and water contents, and copper concentration. Exposure to copper alone elicited a small extracellular metabolic alkalosis, no changes in arterial PO2, and a minor decrease in plasma ion concentrations. Hypercapnia alone increased arterial PCO2 from approximately 2 mmHg to 7.2 mmHg, but the extracellular respiratory acidosis present at 4 h was almost completely compensated at 24 h due to an increase in plasma bicarbonate concentration [HCO3-] from 8.1 mM to 24.4 mM. Combined exposure to hypercapnia and copper resulted in a slightly larger acidosis at 4 h, and the fish failed to restore extracellular pH at 24 h, because plasma [HCO3-] only increased to 16.3 mM. Fish exposed to hypercapnia and copper also showed a delayed recovery of intracellular pH in skeletal muscle, compared to fish exposure to hypercapnia only. Thus, copper exposure impaired both extracellular and intracellular acid-base regulation during hypercapnia. When seen in connection with only minor effects of copper on osmoregulatory and respiratory parameters, the reduced ability to regulate acid-base suggests that acid-base regulation may be one of the most copper-sensitive branchial functions.