A Test to Detect Chest Tube Kinking

Objectives: To determine whether the Mac‐technique test can detect kinking of the chest tube upon thoracostomy tube placement. Methods: This was a prospective observational study that was conducted October 2000 through October 2001 in an urban Level 1 trauma center. There were 103 consecutive nonrandomized adult trauma patients who required immediate tube thoracostomy during their initial resuscitation who were entered into the study. The Mac‐technique test was performed during standard tube thoracostomy insertion to the appropriate depth. The test involved grasping the external portion of the thoracostomy tube, turning it clockwise 180°, and then releasing the tube. If the tube spontaneously spun back to its original position, the test was considered positive, and the tube was considered kinked. If the tube did not spontaneously spin back and stayed in position upon release, the test was considered negative. Regardless of the results of this test, the tube was secured, and a postprocedure chest radiograph was obtained. The criterion standard for determining a kinked chest tube was its appearance on this chest radiograph. Results: A total of 103 chest tubes were placed by using the Mac‐technique test. The test was positive in eight placements; four tubes were kinked on chest radiograph. The Mac‐technique test was negative in 95 placements; four tubes were kinked on chest radiograph. The Mac technique had a sensitivity of 50% (95% confidence interval [CI] = 15.7% to 84.3%), a specificity of 95.8% (95% CI = 89.6% to 98.8%), a positive likelihood ratio of 11.9, a negative likelihood ratio of 0.52, and an odds ratio using Yates correction of 20.3 (95% CI = 4.1 to 102.1). Conclusions: On the basis of this study, a positive Mac‐technique test is useful to detect chest tubes that are likely to be kinked after insertion and before securing.     

Obesity and non-alcoholic steatohepatitis

Obesity is the most important risk factor associated with non-alcoholic steatohepatitis, which is caused by to impaired insulin activity, overflow of portal triglycerides, and production of inflammatory cytokines; all of these are deleterious to hepatocytes. These phenomena facilitate disruptions in hepatic physiology, as observed in alcoholic hepatitis; however, consumption of this substance is absent. Non-alcoholic steatohepatitis has had a great impact due to the fact that previously, main cases of cryptogenic cirrhosis actually were attributed to this disease. Despite advances in understanding the pathophysiologic process of the disease, there is no better treatment than weight reduction (a combination of diet and exercise). In this issue, we describe the most important topics with regard to non-alcoholic steatohepatitis and the obesity-related process.     

Constitutive expression of endothelin gene in cultured human mesangial cells and its modulation by transforming growth factor-beta, thrombin, and a thromboxane A2 analogue.

The present study was designed to assess whether human glomerular mesangial cells in culture express preproendothelin gene and whether endothelin gene expression in the mesangium is regulated by factors potentially released by inflammatory cells and platelets infiltrating the glomerular tuft during the course of various types of glomerulonephritis. For this purpose mesangial cells were incubated for 6 hours in the presence of absence of interleukin 1 beta (IL-1 beta), transforming growth factor-beta (TBF-beta), the thromboxane A2 analogue U-46619, and thrombin. Resting mesangial cells expressed a 2.3-kilobase mRNA on blot hybridization analysis with a human cDNA preproendothelin probe, indicating that this type of cells, in addition to glomerular endothelial cells, constitutively expresses endothelin gene. IL-1 beta did not change endothelin mRNA levels in respect to unstimulated mesangial cells. At variance, TGF-beta, U-46619, and thrombin had a marked effect on endothelin mRNA, stimulating a 3- to 8-fold increase over basal levels. Quantification of actin mRNA and analysis of the autoradiographic signals provided validation of the difference in the endothelin mRNA levels. Expression of preproendothelin mRNA in either resting or stimulated mesangial cells was associated with synthesis and release of the corresponding peptide in the cell supernatant as determined by a specific radioimmunoassay for endothelin. Endothelin production from IL-1 beta stimulated mesangial cells was not different from that of unstimulated cells, whereas a significant (p less than 0.01) increase in endothelin production was observed after cell stimulation with TGF-beta, U-46619, and thrombin. The demonstration that mesangial cells constitutively express mRNA for preproendothelin and release endothelin into culture medium, together with the finding that endothelin gene expression and production in mesangial cells are regulated by molecules potentially released at glomerular level during an inflammatory reaction may suggest that endothelin participates in the complex process of glomerular disease progression.     

L-arginine, the precursor of nitric oxide, abolishes the effect of estrogens on bleeding time in experimental uremia.

We have reported previously that conjugated estrogens that are effective in shortening the prolonged bleeding time in uremic patients are also effective on bleeding time in a rat model of uremia. Using such a rat model we have recently demonstrated that nitric oxide (NO), an endothelium-derived vasodilator, is involved in mediating the bleeding tendency of uremia. With the present study we wanted to investigate whether conjugated estrogen mixture or its active component, 17 beta-estradiol, reduce uremic bleeding by interfering with the NO pathway. Our results showed that the shortening effect of conjugated estrogen and 17 beta-estradiol on bleeding time of uremic rats was completely reversed by giving the animals the NO precursor L-arginine, but not D-arginine, which is not a precursor of NO. Dexamethasone which at variance to progesterone inhibits the process of induction of NO-forming enzyme, shortened the prolonged bleeding time of uremic rats within 4 hours from injection. This effect was eliminated by L-arginine but not D-arginine administration. The glucocorticoid receptor antagonist cortexolone prevented the shortening of bleeding time induced by dexamethasone, suggesting that a receptor-mediated mechanism is involved in the hemostatic effect of dexamethasone as previously reported for estrogens. Unlike conjugated estrogens and dexamethasone, progesterone had no effect on bleeding time. All these findings would indicate that the effect of estrogens and dexamethasone on primary hemostasis in uremia might be mediated by changes in NO synthetic pathway.