Injurious mechanical ventilation and end-organ epithelial cell apoptosis and organ dysfunction in an experimental model of acute respiratory distress syndrome

Context  Recent clinical trials have demonstrated a decrease in multiple organ dysfunction syndrome (MODS) and mortality in patients with acute respiratory distress syndrome (ARDS) treated with a protective ventilatory strategy. Objective  To examine the hypothesis that an injurious ventilatory strategy may lead to end-organ epithelial cell apoptosis and organ dysfunction. Design and Setting  In vivo animals: 24 rabbits with acid-aspiration lung injury were ventilated with injurious or noninjurious ventilatory strategies. In vitro: rabbit epithelial cells were exposed to plasma from in vivo rabbit studies. In vivo human: plasma samples from patients included in a previous randomized controlled trial examining a lung protective strategy were analyzed (lung protection group, n = 9 and controls, n = 11). Main Outcome Measures  In vivo animals: biochemical markers of liver and renal dysfunction; apoptosis in end organs. In vitro: induction of apoptosis in LLC-RK1 renal tubular epithelial cells. In vivo human: correlation of plasma creatinine and soluble Fas ligand. Results  The injurious ventilatory strategy led to increased rates of epithelial cell apoptosis in the kidney (mean [SE]: injurious, 10.9% [0.88%]; noninjurious, 1.86% [0.17%]; P<.001) and small intestine villi (injurious, 6.7% [0.66%]; noninjurious, 0.97% [0.14%]; P<.001), and led to the elevation of biochemical markers indicating renal dysfunction in vivo. Induction of apoptosis was increased in LLC-RK1 cells incubated with plasma from rabbits ventilated with injurious ventilatory strategy at 4 hours (P = .03) and 8 hours (P = .002). The Fas:Ig, a fusion protein that blocks soluble Fas ligand, attenuated induction of apoptosis in vitro. There was a significant correlation between changes in soluble Fas ligand and changes in creatinine in patients with ARDS (R = 0.64, P = .002). Conclusions  Mechanical ventilation can lead to epithelial cell apoptosis in the kidney and small intestine, accompanied by biochemical evidence of organ dysfunction. This may partially explain the high rate of MODS observed in patients with ARDS and the decrease in morbidity and mortality in patients treated with a lung protective strategy.      

Ultrastructural demonstration of neuronal storage in fetal Tay-Sachs disease

This report describes morphologic changes in a 19-week saline-aborted fetus with Tay-Sachs disease (TSD, GM₂ gangliosidosis) diagnosed in utero and subsequently confirmed by biochemical and morphological studies of fetal tissues. Typical membranous cytoplasmic bodies (MCB), comparable to those seen in biopsies from infants with TSD, were demonstrated in neurons of spinal ganglia. The ultrastructure of MCB was well preserved despite the saline abortion, the prolonged interval after death and formalin pre-fixation of tissues.Electron microscopy of spinal ganglion neurons in fetuses with lipid storage disease provides the most conclusive morpholocal findings for confirmation of the prenatal diagnosis. Neurons in fetal spinal ganglia are numerous and well differentiated; this facilitates the search for storage material.     

Pathological features of multiple endocrine neoplasia type IIb in childhood

The features of two patients with multiple endocrine neoplasia type IIb are described. Patient 1, a 9-year-old boy with marfanoid features, presented with chronic constipation and failure to thrive since infancy. Patient 2, a 12-year-old boy with marfanoid features, presented with a five-year history of persistent cervical lymphadenopathy. In patient 1, the myenteric and submucosal nerve plexuses at all levels of the small and large intestines were comprised of diffusely disorganized, hyperplastic, mature ganglion cells and nonmyelinated nerve fibers. Nerve plexus dissection with morphometric analysis showed marked thickening of the myenteric plexus with a quantitative increase in neural tissue. Patient 2 had a submucosal neuroma of the tongue. Both patients had occult medullary thyroid carcinoma, and patient 2 had cervical lymph node metastases. Both neoplasms showed positive staining for cytokeratin, carcinoembryonic antigen, calcitonin, bombesin, chromogranin, serotonin, and Leu 7. Electron microscopy showed membrane-bound, intermediate-sized, dense-core neurosecretory granules in tumor cells. In patient 2, calcitonin-positive amyloid was present with localization of calcitonin by immunoelectron microscopy to cytoplasmic secretory granules and to extracellular amyloid fibrils. These cases illustrate the potential for missed or delayed diagnosis in multiple endocrine neoplasia syndromes.     

Infected thymic cyst: an unusual cause of respiratory distress in a child

A 15-month-old male developed acute respiratory distress following a prolonged upper respiratory tract infection. Laboratory and radiological investigations suggested tracheal compression by a malignant anterior mediastinal mass. Following a short course of steroid therapy, urgent exploration of the mediastinum and resection of the mass was carried out; resolution of the airway obstruction was obtained. Histological and bacteriological examination of the lesion revealed it to be a thymic cyst infected by Haemophilus Influenzae with abscess formation. The causes of tracheal compression in childhood are discussed.     

Diagnosis and therapy of necrotizing tracheobronchitis in ventilated neonates

From January 1983 to September 1984 our neonatal ICU (NICU) treated eight endotracheally intubated infants who had suspected airway obstruction characterized by hypercarbia dissonant with severity of lung disease and difficulty in ventilation with lack of chest movement, both on conventional intermittent mandatory ventilation and high-frequency oscillation. Bronchoscopic removal of necrotic tissue was possible in six infants, two of whom survived. Bronchoscopy showed desquamation of epithelial surfaces, leaving encrusted exudations considered to be characteristic of necrotizing tracheobronchitis (NTB). The four nonsurvivors of bronchoscopy and one of the infants not submitted to bronchoscopy had NTB confirmed at autopsy. NTB was not associated with any specific lung disease, humidifier, or ventilator. The autopsy frequency of NTB during this period was 5 per 160 NICU admissions. A separate chart review of unselected autopsied cases in 1981 and 1982 showed that 12 of 284 neonates admitted to the NICU had NTB. NTB appears to be a rediscovered condition related to endotracheal intubation and mechanical ventilation using high mean airway pressures.     

Complications of parenteral nutrition

There have been no controlled studies that clearly document a beneficial effect of TPN on neonatal mortality and morbidity. Beneficial effects such as reducing the time required to achieve some targeted weight and enhancing positive nitrogen balance are used in support of TPN. The positive opinion about TPN is strongly supported by the experience in surgical patients with GI disorders. It is not surprising that use of TPN is a complex therapy in newborn patients. It is an essential therapy in many patients if nutrition is to be maintained that permits growth and promotes resolution of other chronic problems. Accurate determination of the requirements for TPN is difficult, while complications are not always preventable by simply monitoring blood chemistries. Because of the acute or long-term and potentially lethal complications, there is need for further understanding in parenteral nutrition.     

Cell biology of pulmonary neuroepithelial bodies—validation of an in vitro model. I. Effects of hypoxia and Ca2+ ionophore on serotonin content and exocytosis of dense core vesicles

Pulmonary neuroendocrine (NE) cells including the innervated clusters of NE cells—neuroepithelial bodies (NEB)—are difficult to study because of their small numbers and diffuse distribution within the airway mucosa of the lung. We have previously reported a method for isolation and culture of NE cells from rabbit fetal lung using a combination of mechanical and enzymatic dissociation followed by gradient centrifugation. This method provides single cell suspension of mixed lung cells enriched in NE cells, particularly those originating from NEB. This study further validates our in vitro model by detailed morphologic characterization of cultured NEB cells using high resolution light microscopy, transmission and scanning electron microscopy, HPLC for detection of serotonin (5-HT), and molecular (Northern blot) analysis of mRNA encoding for 5-HT synthesizing enzymes, tryptophane hydroxylase, and aromatic L-amino acid decarboxylase. In addition to effects of hypoxia on NEB cells in vitro were investigated to define the role of these cells as possible airway chemoreceptors. Exposure of NEB cultures to hypoxia resulted in decreased intracellular content of 5-HT accompanied by increased exocytosis of dense core vesicles (DCV). The amount of 5-HT release correlated with the degree of hypoxia, suggesting modulation by ambient pO₂ levels. The role of Ca²⁺ ions in exocytosis of DCV and 5-HT release from NEB cells was tested in experiments with Ca²⁺ ionophore (A23187). Exposure of cultures to 5 μg/ml of ionophore resulted in up to 40% reduction in 5-HT content of NEB cultures as well as increased exocytosis of DCV. Our overall findings are consistent with a view that NEB cells are chemosensory in nature and that Ca²⁺ signaling pathway is involved in stimulus-secretion coupling. Further refinements in cell separation and culture methodology are required before more detailed investigation of NEB cell membrane properties, signal transduction mechanisms, and intracellular signaling pathways can be carried out. © 1993 Wiley-Liss, Inc.     

Campylobacter pyloridis-associated primary gastritis in children

Campylobacter pyloridis are spiral-shaped Gram-negative bacteria that have recently been associated with gastritis and peptic ulcer diseases in adults. The organisms have been identified in biopsy specimens of the gastric antrum by staining sections with silver stain. To determine the frequency of colonization of the antral mucosa with C pyloridis in association with gastritis in childhood, we retrospectively reviewed 53 cases in patients (mean age 11.9 years) in whom upper endoscopy with antral biopsy was performed for the evaluation of symptoms referable to the upper gastrointestinal tract. A silver impregnation method was used to detect the presence of C pyloridis. Nineteen of 53 antral biopsy specimens showed evidence of mucosal inflammation. Ten of these 19 patients had no apparent predisposing etiology for gastritis, and six of these ten had C pyloridis identified on antral biopsies. Nine of the 19 patients had secondary causes of gastric inflammation (two gastroduodenal Crohn disease, two eosinophilic gastroenteritis, four drug related, and one dys-gamma-globulinemia and lymphonodular hyperplasia). In contrast, none of these nine patients had C pyloridis demonstrated on antral biopsies. Silver stain for C pyloridis was negative in all 34 of the 53 children who had normal antral histologic findings. C pyloridis was not demonstrated by silver stain on any of the duodenal sections, although eight of the 19 children with gastritis and nine of the 34 children with normal antral histologic findings had histologic evidence of duodenal inflammation. We conclude that C pyloridis is associated with primary antral gastritis but not with secondary gastritis in the pediatric population.