BackgroundGlutamine (GLN) attenuates acute lung injury (ALI) but its effect on alveolar macrophages is unknown. We hypothesized that GLN pretreatment would induce the anti-inflammatory CD163/heme oxygenase (HO)-1/p38-MAPK dephosphorylation pathway in alveolar macrophages and reduce ALI in rats insufflated with interleukin-1 (IL-1) and lipopolysaccharide (LPS).MethodsMale Sprague-Dawley rats were randomized to the following groups: GLN-IL-1/LPS-, GLN+IL-1/LPS-, GLN-IL-1/LPS+, and GLN+IL-1/LPS+. GLN pretreatment was given via gavage (1g/kg L-alanyl-L-glutamine) daily for 2 days. ALI was subsequently induced by insufflating 50ng IL-1 followed by 5mg/kg E.coli LPS. After 24h, bronchoalveolar lavage (BAL) protein, lactate dehydrogenase (LDH) and neutrophil concentrations were analyzed. BAL alveolar macrophage CD163+ expression, HO-1 and p38-MAPK concentrations were measured, as well as alveolar macrophage tumor necrosis factor (TNF)-α and interleukin (IL)-10 concentrations. Histology and immunofluorescence studies were also performed.ResultsFollowing IL-1/LPS insufflation, GLN pretreated rats had significantly decreased BAL protein and LDH concentrations, but not BAL neutrophil counts, compared to non-GLN pretreated rats. The number of alveolar macrophages and the number of CD163+ macrophages were significantly increased in GLN pretreated IL-1/LPS-insufflated rats compared to non-GLN pretreated, IL-1/LPS-insufflated rats. GLN pretreatment before IL-1/LPS also significantly increased HO-1 concentrations and dephosphorylated p38-MAPK levels but not cytokine levels in alveolar macrophages. Immunofluorescence localized CD163 and HO-1 in alveolar macrophages.ConclusionShort-term GLN pretreatment activates the anti-inflammatory CD163/HO-1/p38-MAPK dephosphorylation pathway of alveolar macrophages and decreases capillary damage but not neutrophil recruitment in IL-1/LPS-insufflated rats.
Here a case of catamenial pneumothorax and its diagnostic challenges is discussed. CASE PRESENTATION: A 39F G1P1001 with a PMH of endometriosis stage 4 with prior laparoscopic endometrial ablation presents with dyspnea and right sided chest pain. After successful delivery of her first child 7 months prior, and resumption of regular menses, she developed 6 months of non-productive cough, intermittent recurrent dyspnea, and chest pain that coincided temporally with menses. On the AM of presentation she began her menses, and while at the gym had sudden onset worsening of her chest pain and significant exertional dyspnea. She presented to pulmonary clinic acutely where she was satting at 100% in no acute distress. CXR was obtained and noted a moderate right sided pneumothorax (Fig 1). A right 14F pigtail chest tube was placed in the immediate term and a video-assisted thoracoscopic surgery (VATS) and mechanical pleurodesis for definitive treatment was performed on HD#1 with tissue suspicious for endometrium visualized (Fig 2). Mechanical pleurodesis was performed using a Bovie scratch pad. She was started on prophylactic progesterone therapy with improvement of her sx. Four days after the birth of her second child she experienced recurrence of her R sided chest pain similar to the episode described above. No pneumothorax was seen on CXR at that time but small right pleural effusion was seen (Fig 3). DISCUSSION: Catamenial PTX can be a difficult illness to diagnose given its rarity (2-6%), and requires a high level of clinical suspicion to diagnose. In this case, the patient had a clinical course classic for catamenial pneumothorax including dyspnea and chest pain occurring temporally with menses and a positive response to initial hormonal therapy. The gold standard for diagnosis involves video laparoscopy (VL) and VATS with visualization and biopsy of the suspected lesions. Treatment requires consideration of the endometrial implants, separate treatment of the endometriosis, and consideration of a pleural symphysis procedure to prevent potential recurrence. In this case the patient underwent removal of the diaphragmatic lesions and mechanical pleurodesis with additional hormonal treatment. It is interesting that she developed recurrent post-partum chest pain without development of pneumothorax, suggesting that pleurodesis may have prevented recurrence of pneumothorax though development of right sided pleural effusion could indicate persistence of endometrium in the thoracic cavity. CONCLUSIONS: Catamenial PTX can be a challenging diagnosis. Even in cases where the gold standard of VL/VATS is performed there can still remain uncertainty. Symptoms consistent with catamenial PTX despite a negative tissue diagnosis should still prompt hormonal treatment and the clinician should have a low threshold for evaluation for recurrent PTX.
Background: Endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) has become standard for the diagnosis of lung cancer, and there is an increasing need for procedural competence in trainees. We evaluate a low-cost, gelatin-based EBUS-TBNA training simulator to assess pulmonary fellows’ baseline skills and facilitate procedural development. Methods: A low-cost ($30) gelatin-based, high-fidelity simulator was created to represent the airways, major vessels, and lymph node stations essential to identify for EBUS-TBNA. Trainees had a baseline skills assessment using the simulator and were then provided a 1-hour didactic session on EBUS-TBNA and additional practice time with the simulator. Trainees then underwent a postsimulation skills assessment using a modified endobronchial ultrasound (EBUS)-Skills and Tasks Assessment Tool (STAT) performance assessment tool. Simulator fidelity and trainee procedural confidence was assessed using a 10-point scale. Results: Ten fellows received training on the EBUS-TBNA simulator. First-year trainees scored the lowest on the 18-point performance scale with a mean score of 9, while third-year trainees scored highest with a mean score of 17.5. Mean 18-point performance score improvement after simulator training and didactics was 4.31 points for all trainees with the largest change in first-year trainees amounting to 8.25 points. First-year trainees experienced the greatest improvement in EBUS procedural confidence by a mean of 2.5 points on a 10-point confidence survey. Conclusion: A low-cost EBUS simulator effectively differentiated early and advanced learners based on graded procedural performance scores. Simulation-based practice significantly improved learners’ procedural performance, and the degree of improvement correlated with learner inexperience. The simulation significantly increased early learner confidence in EBUS-TBNA technique.
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