Medicine Lodge, United States


Medicine Lodge, United States
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Palmer L.B.,Pulmonary
Infectious Disease Clinics of North America | Year: 2017

Multidrug-resistant organisms are creating a challenge for physicians treating the critically ill. As new antibiotics lag behind the emergence of worsening resistance, intensivists in countries with high rates of extensively drug-resistant bacteria are turning to inhaled antibiotics as adjunctive therapy. These drugs can provide high concentrations of drug in the lung that could not be achieved with intravenous antibiotics without significant systemic toxicity. This article summarizes current evidence describing the use of inhaled antibiotics for the treatment of bacterial ventilator-associated pneumonia and ventilator-associated tracheobronchitis. Preliminary data suggest aerosolized antimicrobials may effectively treat resistant pathogens with high minimum inhibitory concentrations. © 2017 Elsevier Inc.

Qing D.Y.,Pulmonary | Conegliano D.,University of Pennsylvania | Shashaty M.G.S.,Pulmonary | Seo J.,University of Pennsylvania | And 5 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2014

Rationale: Red blood cell (RBC) transfusions are associated with increased risk of acute respiratory distress syndrome (ARDS) in the critically ill, yet the mechanisms for enhanced susceptibility to ARDS conferred by RBC transfusions remain unknown. Objectives: To determine the mechanisms of lung endothelial cell (EC) High Mobility Group Box 1 (HMGB1) release following exposure to RBCs and to determine whether RBC transfusion increases susceptibility to lung inflammation in vivo through release of the danger signal HMGB1. Methods: In vitro studies examining human lung EC viability and HMGB1 release following exposure to allogenic RBCs were conducted under static conditions and using a microengineered model of RBC perfusion. The plasma from transfused and nontransfused patients with severe sepsis was examined for markers of cellular injury. A murine model of RBC transfusion followed by LPS administration was used to determine the effects of RBC transfusion and HMGB1 release on LPS-induced lung inflammation. Measurements and Main Results: After incubation with RBCs, lung ECs underwent regulated necrotic cell death (necroptosis) and released the essential mediator of necroptosis, receptor-interacting serine/threonine-protein kinase 3 (RIP3), and HMGB1. RIP3 was detectable in the plasma of patients with severe sepsis, and was increased with blood transfusion and among nonsurvivors of sepsis. RBC transfusion sensitized mice to LPS-induced lung inflammation through release of the danger signal HMGB1. Conclusions: RBC transfusion enhances susceptibility to lung inflammation through release of HMGB1 and induces necroptosis of lung EC. Necroptosis and subsequent danger signal release is a novel mechanism of injury following transfusion that may account for the increased risk of ARDS in critically ill transfused patients. Copyright © 2014 by the American Thoracic Society.

Fritz J.S.,Pulmonary | Fritz J.S.,University of Pennsylvania | Blair C.,Gilead Sciences Inc. | Oudiz R.J.,University of California at Los Angeles | And 7 more authors.
Chest | Year: 2013

Background: Six-minute walk distance (6MWD) and brain natriuretic peptide (BNP) levels at baseline and after initiation of treatment have been associated with survival in patients with pulmonary arterial hypertension. Our objective was to determine the individual and additive ability of pretreatment and posttreatment 6MWD and BNP to discriminate 2-year survival in patients with pulmonary arterial hypertension. Methods: We included patients enrolled in two randomized clinical trials of ambrisentan who had 2-year follow-up (N 5 370). 6MWD and BNP were assessed before and after 12 weeks of treatment. Receiver operating characteristic curve analyses were performed to identify optimal cutoffs that defi ned subgroups with a high 2-year mortality. Classifi cation and regression tree analysis was used to determine the incremental prognostic value of combined assessments. Results: 6MWD at baseline and after 12 weeks of therapy were similarly discriminatory of 2-year survival (c-statistics 5 0.77 [95% CI 0.70-0.84] and 0.82 [95% CI 0.75-0.88], respectively), whereas change in 6MWD from baseline to week 12 was not discriminating. The same observation was true of BNP at baseline and after 12 weeks of therapy (c-statistics 5 0.68 [95% CI 0.60-0.76] and 0.74 [95% CI 0.66-0.82], respectively). After consideration of baseline 6MWD, there was no prognostic information added by the week 12 6MWD or BNP at either time point. Conclusions: 6MWD and BNP values at baseline or week 12 identifi ed a population with an elevated risk of death at 2 years. A repeat assessment of 6MWD or BNP after 12 weeks of ambrisentan therapy did not provide additional prognostic information beyond that obtained from baseline values. © 2013 American College of Chest Physicians.

Finkel B.B.,Pulmonary | Khalsa S.S.,Medical Informatics Group | Lanken P.N.,Pulmonary | Prasad M.,Pulmonary | And 2 more authors.
Critical Care Medicine | Year: 2011

Objective: Lung protective ventilation reduces mortality in patients with acute lung injury, but underrecognition of acute lung injury has limited its use. We recently validated an automated electronic acute lung injury surveillance system in patients with major trauma in a single intensive care unit. In this study, we assessed the system's performance as a prospective acute lung injury screening tool in a diverse population of intensive care unit patients. Design: Patients were screened prospectively for acute lung injury over 21 wks by the automated system and by an experienced research coordinator who manually screened subjects for enrollment in Acute Respiratory Distress Syndrome Clinical Trials Network (ARDSNet) trials. Performance of the automated system was assessed by comparing its results with the manual screening process. Discordant results were adjudicated blindly by two physician reviewers. In addition, a sensitivity analysis using a range of assumptions was conducted to better estimate the system's performance. Setting: The Hospital of the University of Pennsylvania, an academic medical center and ARDSNet center (1994-2006). Patients: Intubated patients in medical and surgical intensive care units. Interventions: None. Measurements and main results: Of 1270 patients screened, 84 were identified with acute lung injury (incidence of 6.6%). The automated screening system had a sensitivity of 97.6% (95% confidence interval, 96.8-98.4%) and a specificity of 97.6% (95% confidence interval, 96.8-98.4%). The manual screening algorithm had a sensitivity of 57.1% (95% confidence interval, 54.5-59.8%) and a specificity of 99.7% (95% confidence interval, 99.4-100%). Sensitivity analysis demonstrated a range for sensitivity of 75.0-97.6% of the automated system under varying assumptions. Under all assumptions, the automated system demonstrated higher sensitivity than and comparable specificity to the manual screening method. Conclusions: An automated electronic system identified patients with acute lung injury with high sensitivity and specificity in diverse intensive care units of a large academic medical center. Further studies are needed to evaluate the effect of automated prompts that such a system can initiate on the use of lung protective ventilation in patients with acute lung injury. Copyright © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.

Mace T.A.,Divisions of Medical Oncology | Ameen Z.,Divisions of Medical Oncology | Mair M.,Divisions of Medical Oncology | Young G.S.,Arthur G James Cancer Hospital And Richard J Solove Research Institute | And 4 more authors.
Cancer Research | Year: 2013

Pancreatic stellate cells (PSC) are a subset of pancreatic cancer-associated fibroblasts. These cells provide prosurvival signals to tumors; however, little is known regarding their interactions with immune cells within the tumor microenvironment. We hypothesized that factors produced by human PSC could enhance myeloid-derived suppressor cell (MDSC) differentiation and function, which promotes an immunosuppressive microenvironment. Primary PSC cell lines (n 1/4 7) were generated from human specimens and phenotypically confirmed via expression of vimentin, a-smooth muscle actin (a-SMA), and glial fibrillary acidic protein (GFAP). Luminex analysis indicated that PSC but not human fetal primary pancreatic fibroblast cells (HPF; negative controls) produced MDSC-promoting cytokines [interleukin (IL-6), VEGF, macrophage colony-stimulating factor (M-CSF) ] and chemokines (SDF-1, MCP-1). Culture of peripheral blood mononuclear cells [peripheral blood mononuclear cell (PBMC), n 1/4 3 donors] with PSC supernatants or IL-6/granulocyte macrophage colony-stimulating factor (GM-CSF; positive control) for 7 days promoted PBMC differentiation into an MDSC (CD11b+CD33+) phenotype and a subpopulation of polymorphonuclear CD11b+CD33+CD15+ cells. The resulting CD11b+CD33+ cells functionally suppressed autologous T-lymphocyte proliferation. In contrast, supernatants from HPF did not induce an MDSC phenotype in PBMCs. Culture of normal PBMCs with PSC supernatants led to STAT3 but not STAT1 or STAT5 phosphorylation. IL-6 was an important mediator as its neutralization inhibited PSC supernatant-mediated STAT3 phosphorylation and MDSC differentiation. Finally, the FLLL32 STAT3 inhibitor abrogated PSC supernatant-mediated MDSC differentiation, PSC viability, and reduced autocrine IL-6 production indicating these processes are STAT3 dependent. These results identify a novel role for PSC in driving immune escape in pancreatic cancer and extend the evidence that STAT3 acts as a driver of stromal immunosuppression to enhance its interest as a therapeutic target. Cancer Res; 73(10); 3007-18. © 2013 AACR.

Diamond J.M.,Pulmonary | Christie J.D.,Pulmonary | Christie J.D.,University of Pennsylvania
Current Opinion in Organ Transplantation | Year: 2010

Purpose Of Review: Primary graft dysfunction (PGD) is the primary obstacle to short-term survival for post-lung transplant patients. PGD is a form of acute lung injury secondary to donor brain death and ischemia-reperfusion damage to the allograft affecting 10-25% of all lung transplant recipients. This article reviews the significant role of allograft ischemia in the phenotypic presentation of PGD and the evidence for activation and disruption of normal cellular pathways for the development and long-term sequelae. Recent Findings: Pathways implicated in the pathogenesis of PGD resultant from tissue ischemia include abnormalities in coagulation and fibrinolysis, epithelial cell injury, endothelial cell dysfunction, chemotaxis, and alterations in cell adhesion. Blood and bronchoalveolar lavage fluid biomarkers from these pathways have been increasingly identified as useful for diagnosing and predicting the development of severe PGD. Summary: Future efforts at preventing and treating severe PGD should focus on techniques for altering the pathways involved in PGD pathogenesis. Ex-vivo lung perfusion and transduction with interleukin-10 are promising modalities for preventing PGD and expanding the available lung transplant donor pool. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Goncharov D.A.,Pulmonary | Goncharov D.A.,University of Pittsburgh | Kudryashova T.V.,Pulmonary | Kudryashova T.V.,University of Pittsburgh | And 9 more authors.
Circulation | Year: 2014

BACKGROUND- : Enhanced proliferation, resistance to apoptosis, and metabolic shift to glycolysis of pulmonary arterial vascular smooth muscle cells (PAVSMCs) are key pathophysiological components of pulmonary vascular remodeling in idiopathic pulmonary arterial hypertension (PAH). The role of the distinct mammalian target of rapamycin (mTOR) complexes mTORC1 (mTOR-Raptor) and mTORC2 (mTOR-Rictor) in PAVSMC proliferation and survival in PAH and their therapeutic relevance are unknown. METHODS AND RESULTS- : Immunohistochemical and immunoblot analyses revealed that mTORC1 and mTORC2 pathways are markedly upregulated in small remodeled pulmonary arteries and isolated distal PAVSMCs from subjects with idiopathic PAH that have increased ATP levels, proliferation, and survival that depend on glycolytic metabolism. Small interfering RNA- and pharmacology-based analysis showed that although both mTORC1 and mTORC2 contribute to proliferation, only mTORC2 is required for ATP generation and survival of idiopathic PAH PAVSMCs. mTORC2 downregulated the energy sensor AMP-activated protein kinase, which led to activation of mTORC1-S6 and increased proliferation, as well as a deficiency of the proapoptotic protein Bim and idiopathic PAH PAVSMC survival. NADPH oxidase 4 (Nox4) protein levels were increased in idiopathic PAH PAVSMCs, which was necessary for mTORC2 activation, proliferation, and survival. Nox4 levels and mTORC2 signaling were significantly upregulated in small pulmonary arteries from hypoxia-exposed rats at days 2 to 28 of hypoxia. Treatment with the mTOR kinase inhibitor PP242 at days 15 to 28 suppressed mTORC2 but not Nox4, induced smooth muscle-specific apoptosis in small pulmonary arteries, and reversed hypoxia-induced pulmonary vascular remodeling in rats. CONCLUSIONS- : These data provide a novel mechanistic link of Nox4-dependent activation of mTORC2 via the energy sensor AMP-activated protein kinase to increased proliferation and survival of PAVSMCs in PAH, which suggests a new potential pathway for therapeutic interventions. © 2013 American Heart Association, Inc.

Palmer L.B.,Pulmonary
Current Respiratory Medicine Reviews | Year: 2010

Purpose of Review: This review focuses on the pathophysiology of proximal airway infection in the ventilated patient. Ventilator-associated tracheobronchitis (VAT) is increasingly recognized as an important entity not only as an essential step in the pathway from oral colonization to deep lung infection but also as an infection associated with its own morbidity. Recent Findings: Multiple recent clinical trials have focused on the effects of new devices and treatment protocols on the morbidity associated with the progression of airway colonization to VAT or with the progression of VAT to VAP. Continuous subglottic secretion suctioning (CASS), innovative types of endotracheal tubes, and targeted therapy for VAT in recent investigations have shown promise in improving clinical outcomes in the critically ill patient. However, even with diligent attention to all the modifiable risk factors for respiratory infection, complete elimination of VAT and VAP remains unlikely. As long as a patient requires an endotracheal tube which disturbs airway integrity, host defenses will be impaired, and resistant virulent organisms which result from our liberal use of systemic antibiotics will continue to challenge critical care specialists. Summary: This review will focus on: 1) the current understanding of the pathogenesis of VAT, 2) modifiable risk factors, and 3) new approaches to treatment and bacterial resistance challenges. © 2010 Bentham Science Publishers Ltd.

Palmer L.B.,Pulmonary
Clinics in Chest Medicine | Year: 2011

This review summarizes recent clinical data examining the use of aerosolized antimicrobial therapy for the treatment of respiratory tract infections in mechanically ventilated patients in the intensive care unit. Aerosolized antibiotics provide high concentrations of drug in the lung without the systemic toxicity associated with the intravenous antibiotics. First introduced in the 1960s as a treatment of tracheobronchitis and bronchopneumonia caused by Pseudomonas aeruginosa, now, more than 40 years later, there is a resurgence of interest in using this mode of delivery as a primary therapy for ventilator-associated tracheobronchitis and an adjunctive therapy for ventilator-associated pneumonia. © 2011 Elsevier Inc.

Haczku A.,Pulmonary | Panettieri Jr. R.A.,Pulmonary
Journal of Allergy and Clinical Immunology | Year: 2010

Psychosocial stress alters susceptibility to infectious and systemic illnesses and may enhance airway inflammation in asthma by modulating immune cell function through neural and hormonal pathways. Stress activates the hypothalamic-pituitary-adrenal axis. Release of endogenous glucocorticoids, as a consequence, may play a prominent role in altering the airway immune homeostasis. Despite substantial corticosteroid and catecholamine plasma levels, chronic psychosocial stress evokes asthma exacerbations. Animal studies suggest that social stress induces corticosteroid insensitivity that in part may be a result of impaired glucocorticoid receptor expression and/or function. Such mechanisms likely promote and amplify airway inflammation in response to infections, allergen, or irritant exposure. This review discusses evidence of an altered corticosteroid responsive state as a consequence of chronic psychosocial stress. Elucidation of the mechanisms of stress-induced impairment of glucocorticoid responsiveness and immune homeostasis may identify novel therapeutic targets that could improve asthma management. © 2010 American Academy of Allergy, Asthma & Immunology.

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