Low Tissue Oxygen Tension Research Articles

Targeting Hypoxia‐Adenosinergic Signaling to Enable Effective Anti‐Tumor Responses by Reprogramming the Immunosuppressive Tumor Microenvironment

The hypoxia‐HIF‐1ɑ‐mediated generation of extracellular adenosine (eADO) and associated A2A adenosine receptor (A2AR) signaling represent a critical mechanism for resistance to anti‐tumor immune attack in an immunosuppressive tumor microenvironment (TME). This is supported by earlier clinical and preclinical findings that tumors exhibiting refractory responses to chemotherapeutic and immunotherapeutic interventions are often characterized by low tissue oxygen tension and elevation of intracellular cAMP triggered by the binding of adenosine to the A2AR. The ensuing signaling cascade results in the downregulation of T cell activation and increased production of anti‐inflammatory factors. Several classes of drugs have been proven in preclinical studies and clinical trials to weaken this powerful biochemical mechanism of immunosuppression and enable tumor rejection. Therapeutic approaches targeting the upstream and downstream stages of hypoxia‐adenosinergic negative immune regulation (i.e. A2AR antagonists, oxygenation, inhibition of adenosine generation or adenosine degradation) represent promising co‐adjuvants capable of inducing a more immunopermissive TME. The removal of this biochemical barrier may be the key to unleashing the full therapeutic potential of immunotherapies. For instance, the epithelial‐mesenchymal transition (EMT) program, which confers the ability of cancer cells to engage in metastatic dissemination, is associated with the acquisition of resistance to immune checkpoint blockade (ICB). Recent studies have demonstrated that abrogation of the adenosine‐generating ectoenzyme CD73 sensitizes mice bearing quasi‐mesenchymal (qM) tumors to anti‐CTLA4 ICB through an increase in CD8+ T cell infiltration and cytotoxicity. Furthermore, the present study demonstrates the differential expression of adenosinergic enzymes and EMT transcription factors (EMT‐TFs) in murine breast epithelial (E) and qM carcinoma cell lines cultured in normoxic (21% oxygen) and hypoxic (1% oxygen) conditions in vitro. As hypothesized, the stabilization of HIF‐1ɑ in hypoxic conditions resulted in the upregulation of some adenosine‐generating enzymes and changes in adenosine metabolism. These results elucidate an additional mechanism through which hypoxia can contribute to the assembly of an immunosuppressive TME, while highlighting the categorical differences between the E vs qM states of carcinoma cells.

Analysis of the Association Between Lung Function and Brain Tissue Oxygen Tension in Severe Traumatic Brain Injury.

Low brain tissue oxygen tension (PbtO2) has been shown to be an independent factor associated with unfavourable outcomes in traumatic brain injury (TBI). Although PbtO2 provides clinicians with an understanding of ischaemic and non-ischaemic derangements of brain physiology, the value alone can be the result of several factors, including partial arterial oxygenation pressure (PaO2), haemoglobin levels (Hb) and cerebral perfusion pressure (CPP). This chapter presents a single-centre, retrospective cohort study of 70 adult patients with severe TBI who were admitted to the Neurocritical Care Unit (NCCU) at Addenbrooke's Hospital (Cambridge, UK) between October 2014 and December 2017. A total of 303 simultaneous measurements of different variables that included (but were not limited to) intracranial pressure (ICP), PaO2, PbtO2, CPP and the fraction of inspired oxygen (FiO2) were considered in this work. We conducted a correlation analysis between all of the variables. We also implemented a longitudinal data analysis of the PbtO2 and PaO2/FiO2 ratio (PF ratio). There were strong and independent correlations between PbtO2 and the PF ratio, and between PbtO2 and PaO2, with adjusted p values of <0.001 for both correlations. After adjustment for ICP, age, sex and the Glasgow Coma Scale (GCS) score, a PF ≤ 330 was shown to be an independent risk factor for a compromised PbtO2 value of <20, with an adjusted odds ratio of 1.94 (95% confidence interval 1.12-3.34) and a p value of 0.02. Brain and lung interactions in patients with TBI patients have complex interrelationships. Our results confirm the importance of employing lung-protective strategies to prevent brain hypoxia in patients with TBI.

Lung Injury Is a Predictor of Cerebral Hypoxia and Mortality in Traumatic Brain Injury

Background: A major contributor to unfavorable outcome after traumatic brain injury (TBI) is secondary brain injury. Low brain tissue oxygen tension (PbtO2) has shown to be an independent predictor of unfavorable outcome. Although PbtO2 provides clinicians with an understanding of the ischemic and non-ischemic derangements of brain physiology, its value does not take into consideration systemic oxygenation that can influence patients' outcomes. This study analyses brain and systemic oxygenation and a number of related indices in TBI patients: PbtO2, partial arterial oxygenation pressure (PaO2), PbtO2/PaO2, ratio of PbtO2 to fraction of inspired oxygen (FiO2), and PaO2/FiO2. The primary aim of this study was to identify independent risk factors for cerebral hypoxia. Secondary goal was to determine whether any of these indices are predictors of mortality outcome in TBI patients.Materials and Methods: A single-centre retrospective cohort study of 70 TBI patients admitted to the Neurocritical Care Unit (NCCU) at Cambridge University Hospital in 2014–2018 and undergoing advanced neuromonitoring including invasive PbtO2 was conducted. Three hundred and three simultaneous measurements of PbtO2, PaO2, PbtO2/PaO2, PbtO2/FiO2, PaO2/FiO2 were collected and mortality at discharge from NCCU was considered as outcome. Generalized estimating equations were used to analyse the longitudinal data.Results: Our results showed PbtO2 of 28 mmHg as threshold to define cerebral hypoxia. PaO2/FiO2 found to be a strong and independent risk factor for cerebral hypoxia when adjusting for confounding factor of intracranial pressure (ICP) with adjusted odds ratio of 1.78, 95% confidence interval of (1.10–2.87) and p-value = 0.019. With respect to TBI outcome, compromised values of PbtO2, PbtO2/PaO2, PbtO2/FiO2, and PaO2/FiO2 were all independent predictors of mortality while considered individually and adjusting for confounding factors of ICP, age, gender, and cerebral perfusion pressure (CPP). However, when considering all the compromised values together, only PaO2/FiO2 became an independent predictor of mortality with adjusted odds ratio of 3.47 (1.20–10.04) and p-value = 0.022.Conclusions: Brain and Lung interaction in TBI patients is a complex interrelationship. PaO2/FiO2 seems to be a major determinant of cerebral hypoxia and mortality. These results confirm the importance of employing ventilator strategies to prevent cerebral hypoxia and improve the outcome in TBI patients.

In Silico Model of Critical Cerebral Oxygenation after Traumatic Brain Injury: Implications for Rescuing Hypoxic Tissue.

Cerebral oxygen delivery is central to the modern intensive care of patients with severe traumatic brain injury. Low brain tissue oxygen tension (PbtO2) results from microvascular collapse and diffusion limitation and is associated with adverse outcome. A number of therapies to improve oxygen delivery are known to be effective in improving PbtO2. Their relative effectiveness and microscopic regions of hypoxia, however, may exist/persist even in the presence of normal PbtO2. Unfortunately, there are no methods currently for assessing this quantitatively. We used an in silico (computational) simulation approach to understand the effect of common interventions on the microscopic distribution of brain tissue oxygen tension. We constructed a non-linear mathematical model of cerebral oxygen supply, diffusion, and consumption for a simplified geometry. Model parameters were chosen to agree with clinical parameters. We found that it was possible to create a plausible diffusion-limited scenario with a significant hypoxic fraction by increasing the mean diffusion distance. We found that increasing cerebral blood flow/blood oxygen content or suppressing the cerebral metabolic rate were most effective at improving PbtO2 and reduced the hypoxic fraction. Within the limitations of our modeling assumptions, increasing the arterial oxygen partial pressure was less effective and only improved PbtO2 by creating a region of hyperoxic tissue with no improvement in hypoxic fraction. The in silico simulations can be useful in understanding the likely physiological effect of complex treatments for which measurement techniques do not exist.

Increased cortical capillary transit time heterogeneity in Alzheimer's disease: a DSC-MRI perfusion study

Alzheimer's disease (AD) is characterized by the accumulation of hyperphosphorylated tau and neurotoxic Aβ in the brain parenchyma. Hypoxia caused by microvascular changes and disturbed capillary flows could stimulate this build-up of AD–specific proteins in the brain. In this study, we compared cerebral microcirculation in a cohort of AD and mild cognitive impairment (MCI) patients with that of age-matched controls, all without a history of diabetes or of hypertension for more than 2 years, using dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI). Vascular flow disturbances were quantified using a parametric model and mapped to the mid-cortical surface for group-wise statistical analysis. We found widespread hypoperfusion in patients compared with controls and identified areas of increased relative capillary transit time heterogeneity (RTH), consistent with low tissue oxygen tension. Notably, RTH was positively correlated with white matter hyperintensities and positively correlated with symptom severity in the patient cohort. These correlations extended over large parts of the temporal, parietal, and frontal cortices. The results support the hypothesis of disturbed capillary flow patterns in AD and suggest that DSC-MRI may provide imaging biomarkers of impaired cerebral microcirculation in AD.

Modeling Glucose Metabolism in the Kidney.

The mammalian kidney consumes a large amount of energy to support the reabsorptive work it needs to excrete metabolic wastes and to maintain homeostasis. Part of that energy is supplied via the metabolism of glucose. To gain insights into the transport and metabolic processes in the kidney, we have developed a detailed model of the renal medulla of the rat kidney. The model represents water and solute flows, transmural fluxes, and biochemical reactions in the luminal fluid of the nephrons and vessels. In particular, the model simulates the metabolism of oxygen and glucose. Using that model, we have identified parameters concerning glucose transport and basal metabolism that yield predicted blood glucose concentrations that are consistent with experimental measurements. The model predicts substantial axial gradients in blood glucose levels along various medullary structures. Furthermore, the model predicts that in the inner medulla, owing to the relatively limited blood flow and low tissue oxygen tension, anaerobic metabolism of glucose dominates.

Ameliorative effect of VIP family members on blood retinal barrier breakdown in diabetic macular edema

Diabetic macular edema (DME) is one of the main complications of diabetic retinopathy [1]. This pathology is owed to impairment of the blood-retinal barrier (BRB) [2]. Many factors, such as hypoxia, contribute to barrier dysfunction and progression of the disease. Low oxygen tension is one of the main events involved in the formation of new blood vessels that characterize the typical uncontrolled angiogenesis in proliferative stage of diabetic retinopathy. In the last decades, various studies have focused their attention on the role of pituitary adenylate cyclase-activating polypeptide (PACAP) and vasoactive intestinal peptide (VIP) in the pathophysiology of DME. However, the effects of these peptides in maintaining the integrity of the BRB exposed to hypoxia remains to be elucidated. In the present work we have studied, for the first time, the effect of these peptides on outer BRB integrity following hypoxic insult in an experimental model of DME. To this end, we have used the human retinal pigment epithelial cells (ARPE-19) to test the effect of both peptides on cellular permeability, transepithelial electrical resistance, tight junctions expression and hypoxia-induced apoptosis. Results have demonstrated that both PACAP and VIP are able to rescue the integrity of cell monolayer during the hypoxic event, minimizing apoptotic damages induced by low tissue oxygen tension through the activation of phosphoinositide 3 kinase /Akt and mammalian mitogen activated protein kinase/Erk kinase signaling pathways. Furthermore, these peptides modulate the expression of vascular endothelial growth factor which is one of the downstream transcription factor activated during the hypoxic process. In conclusion, we have demonstrated that PACAP and VIP are able to counteract the damage induced by hypoxia on BRB through the modulation of hypoxia inducible factors expression.

Prolonged triglyceride storage in macrophages: pHo trumps pO2 and TLR4.

Lipid-laden macrophages contribute to pathologies as diverse as atherosclerosis and tuberculosis. Three common stimuli are known to promote macrophage lipid storage: low tissue oxygen tension (pO2), low extracellular pH (pHo), and exposure to agonists such as bacterial LPS. Noting that cells responding to low pO2 or agonistic bacterial molecules often decrease pHo by secreting lactic and other carboxylic acids, we studied how pHo influences the stimulation of triacylglycerol (TAG) storage by low pO2 and LPS. We found that TAG retention after incubation for 48-72 h was inversely related to pHo when primary macrophages were cultured in 21% oxygen, 4% oxygen, or with LPS at either oxygen concentration. Maintaining pHo at ~7.4 was sufficient to prevent the increase in prolonged TAG storage induced by either low pO2 or LPS. The strong influence of pHo on TAG retention may explain why lipid-laden macrophages are found in some tissue environments and not in others. It is also possible that other long-term cellular changes currently attributed to low pO2 or bacterial agonists may be promoted, at least in part, by the decrease in pHo that these stimuli induce.

Relationship between inflammation and tissue hypoxia in a mouse model of chronic colitis

Hypoxia has been reported to be associated with the colonic inflammation observed in a chemically induced mouse model of self-limiting colitis, suggesting that low tissue oxygen tension may play a role in the pathophysiology of inflammatory tissue injury. However, no studies have been reported evaluating whether tissue hypoxia is associated with chronic gut inflammation. Therefore, the objective of the present study was to determine whether hypoxia is produced within the colon during the development of chronic gut inflammation. Adoptive transfer of CD4(+) T cells obtained from interleukin-10-deficient (IL-10(-/-)) mice into lymphopenic recombinase-activating gene-1-deficient (RAG(-/-)) mice induces chronic colonic inflammation, with the inflammation ranging from mild to severe as determined by blinded histological analyses. Colonic blood flow, hematocrit, and vascular density were determined using standard protocols, whereas tissue hypoxia was determined using the oxygen-dependent probe pimonidazole. Adoptive transfer of IL-10(-/-) CD4(+) T cells into RAG(-/-) recipients induced chronic colonic inflammation that ranged from mild to severe at 8 weeks following T-cell transfer. The colitis was characterized by bowel wall thickening, goblet cell dropout, and inflammatory infiltrate. Surprisingly, we found that animals exhibiting mild colonic inflammation had increased hypoxia and decreased systemic hematocrit, whereas mice with severe colitis exhibited levels of hypoxia and hematocrit similar to healthy controls. In addition, we observed that the extent of hypoxia correlated inversely with hematocrit and vascular density. Changes in hematocrit, vascular density, and inflammatory state appear to influence the extent of tissue oxygenation in the T-cell-mediated model of chronic gut inflammation.

Blood p50 evaluation enhances diagnostic definition of isolated erythrocytosis

High oxygen-affinity haemoglobin variants and 2,3-diphosphoglycerate (2,3-DPG) deficiency are inherited diseases generating low tissue oxygen tension and erythropoietin-driven erythrocytosis, that characterizes the clinical phenotype of patients. Level of blood p50 (the oxygen tension at which haemoglobin is 50% saturated) is used to recognize these conditions. To define the clinical utility of blood p50 measurement in the diagnosis of isolated erythrocytosis. Venous blood p50 measurement was included in the diagnostic work-up of 102 consecutive patients with isolated erythrocytosis besides blood cell count, arterial oxygen saturation, serum erythropoietin measurement and screening for JAK2 mutations. Haematological Outpatient Section at University Hospital. Seven patients had relative erythrocytosis. Among 95 patients with absolute erythrocytosis, 4 (4.2%) had decreased p50 level. The extended study of family members revealed a familial inheritance. Two families had haemoglobin variants already described as Haemoglobin Malmö and Haemoglobin San Diego. In one family, the proband had a new high oxygen-affinity haemoglobin variant (Haemoglobin Safi) resulting from the transversion C-->A at codon 81 of the alpha2-globin gene. In the last family, a deficiency of 2,3-DPG was found. Within the 91 patients with normal p50 values, 46 (51%) had secondary erythrocytosis, 13 (14%) polycythemia vera and 32 (35%) idiopathic erythrocytosis. This study suggests that the investigation of blood p50 level may be useful to define diagnosis in patients with isolated erythrocytosis.

Brain tissue oxygen tension is more indicative of oxygen diffusion than oxygen delivery and metabolism in patients with traumatic brain injury*

Despite the growing clinical use of brain tissue oxygen monitoring, the specific determinants of low brain tissue oxygen tension (P(bt)O2) following severe traumatic brain injury (TBI) remain poorly defined. The objective of this study was to evaluate whether P(bt)O2 more closely reflects variables related to cerebral oxygen diffusion or reflects cerebral oxygen delivery and metabolism. Prospective observational study. Level I trauma center. Fourteen TBI patients with advanced neuromonitoring underwent an oxygen challenge (increase in FiO2 to 1.0) to assess tissue oxygen reactivity, pressure challenge (increase in mean arterial pressure) to assess autoregulation, and CO2 challenge (hyperventilation) to assess cerebral vasoreactivity. None. P(bt)O2 was measured directly with a parenchymal probe in the least-injured hemisphere. Local cerebral blood flow (CBF) was measured with a parenchymal thermal diffusion probe. Cerebral venous blood gases were drawn from a jugular bulb venous catheter. We performed 119 measurements of PaO2, arterial oxygen content (CaO2), jugular bulb venous oxygen tension (PVO2), venous oxygen content (CVO2), arteriovenous oxygen content difference (AVDO2), and local cerebral metabolic rate of oxygen (locCMRO2). In multivariable analysis adjusting for various variables of cerebral oxygen delivery and metabolism, the only statistically significant relationship was that between P(bt)O2 and the product of CBF and cerebral arteriovenous oxygen tension difference (AVTO2), suggesting a strong association between brain tissue oxygen tension and diffusion of dissolved plasma oxygen across the blood-brain barrier. Measurements of P(bt)O2 represent the product of CBF and the cerebral AVTO2 rather than a direct measurement of total oxygen delivery or cerebral oxygen metabolism. This improved understanding of the cerebral physiology of P(bt)O2 should enhance the clinical utility of brain tissue oxygen monitoring in patients with TBI.

The role of lung function in brain tissue oxygenation following traumatic brain injury

Previous studies have demonstrated that periods of low brain tissue oxygen tension (PbtO2) are associated with poor outcome after head trauma but have primarily focused on cerebral and hemodynamic factors as causes of low PbtO2. The purpose of this study was to investigate the influence of lung function on PbtO2 with an oxygen challenge (increase in fraction of inspired oxygen [FiO2] concentration to 1.0). This prospective observational cohort study was performed in the neurointensive care unit of the Level 1 trauma center at San Francisco General Hospital. Thirty-seven patients with severe traumatic brain injury (TBI) undergoing brain tissue oxygen monitoring as part of regular care underwent an oxygen challenge, consisting of an increase in FiO2 concentration from baseline to 1.0 for 20 minutes. Partial pressure of arterial oxygen (PaO2), PbtO2, and the ratio of PaO2 to FiO2 (the PF ratio) were determined before and after oxygen challenge. Patients with higher PF ratios achieved greater PbtO2 during oxygen challenge than those with a low PF ratio because they achieved a higher PaO2 after an oxygen challenge. Lung function, specifically the PF ratio, is a major determinant of the maximal PbtO2 attained during an oxygen challenge. Given that patients with TBI are at risk for pulmonary complications such as pneumonia, severe atelectasis, and adult respiratory distress syndrome, lung function must be considered when interpreting brain tissue oxygenation.

Supplemental Oxygen, but Not Supplemental Crystalloid Fluid, Increases Tissue Oxygen Tension in Healthy and Anastomotic Colon in Pigs

Low tissue oxygen tension is an important factor leading to the development of wound dehiscence and anastomotic leakage after colon surgery. We tested whether supplemental fluid and supplemental oxygen can increase tissue oxygen tension in healthy and injured, perianastomotic, and anastomotic colon in an acutely instrumented pig model of anastomosis surgery. Sixteen Swiss Landrace pigs were anesthetized (isoflurane 0.8%-1%) and their lungs ventilated. The animals were randomly assigned to low fluid treatment ("low" group, 3 mL x kg(-1) x h(-1) lactated Ringer's solution) or high fluid treatment ("high" group, 10 mL/kg bolus, 18 mL x kg(-1) x h(-1) lactated Ringer's solution) during colon anastomosis surgery and a subsequent measurement period (4 h). Two-and-half hours after surgery, tissue oxygen tension was recorded for 30 min during ventilation with 30% oxygen. Three hours after surgery, the animals' lungs were ventilated with 100% oxygen for 60 min. Tissue oxygen tension was recorded in the last 30 min. Tissue oxygen tension was measured with polarographic Clark-type electrodes, positioned in healthy colonic wall, close (2 cm) to the anastomosis, and in the anastomosis. In every group, tissue oxygen tension during ventilation with 100% oxygen was approximately twice as high as during ventilation with 30% oxygen, a statistically significant result. High or low volume crystalloid fluid treatment had no effect on colon tissue oxygen tension. Supplemental oxygen, but not supplemental crystalloid fluid, increased tissue oxygen tension in healthy, perianastomotic, and anastomotic colon tissue.

INTRARENAL OXYGEN AND HYPERTENSION

The kidney has a unique environment that results in relatively low tissue oxygen tension (Po2). However, recent studies have shown that renal hypoxia is more severe during hypertension and may reflect changes in the way O2 is used. The present review summarizes studies that explore the relationship between renal oxygen tension (Po2), oxygen consumption and hypertension. More recent studies suggest that oxidative stress accompanying hypertension, rather than the elevated blood pressure per se reduces Po2. The Po2 in various sections of the kidney often reflects the level of oxygen consumption, which varies depending on the sites of Na+ reabsorption, a process that consumes nearly 90% of total renal oxygen. The efficient use of oxygen for the transport of Na+ in the kidney is reduced during hypertension, which may contribute to the resulting hypoxia. Conversely, the defect in renal oxygen usage due to oxidative stress may exacerbate hypertension in animal models. The goal of many of these studies is to determine the impact of renal hypoxia in the generation of hypertension.

Oxygen transport to muscle tissue where regions of low oxygen tension exist

Most studies devoted to mathematical modelling of oxygen transport to tissue have assumed a constant oxygen consumption, independent of oxygen tension, whilst oxygen concentration remains positive. However, it is more physiologically realistic to allow the oxygen consumption to fall continuously to zero as the oxygen tension falls towards zero for low oxygen tensions. We show that using this more physiologically realistic oxygen consumption in a mathematical model of oxygen transport to tissue gives a significantly different solution to the governing equations when areas of low oxygen tension exist. We then use this method of modelling oxygen consumption to compare the location of regions of low tissue oxygen tension predicted by two previously published mathematical models of oxygen transport. The two models are a partial differential equation (PDE) model, and an ordinary differential equation (ODE) model that is a simplification of the PDE model. We show that most of the predictions of the ODE model are almost identical to those of the PDE model, but there are some significant differences.

Interruption of bronchial circulation leads to a severe decrease in peribronchial oxygen tension in standard lung transplantation technique.

In clinical practice lung transplantation is the only procedure where the transplanted organ is left without its own arterial perfusion. With the interruption of the bronchial arteries the nutritive support is dependent on collateral flow by the pulmonary artery and the oxygen tension of desaturated central venous blood, representing an abnormal physiology. To analyze this problem systematically, we used a standard single left lung transplantation model in the pig (n = 12). In accordance with the clinical standard, lung preservation was performed with modified Euro-Collins solution with addition of prostacycline. The duration of ischemia was set to 4 h. Before and after single left lung transplantation tissue oxygen tension in the peribronchial tissue was measured with Licox tissue pO2 microprobes. For validation, the myocardial tissue oxygen tension was recorded simultaneously. The hemodynamic assessment included continuous flow measurement of the left and right pulmonary artery using Transsonic ultrasound flow probes. After transplantation the animals were observed for 4 h. For hypothetic augmentation of collateral blood flow to the peribronchial tissue we administered Nitric oxide (10 ppm) to the ventilation in six pigs (group B). Six pigs (group A) served as a control without the addition of nitric oxide (NO). All pigs were ventilated with a FiO2 of 0.5 resulting in paO2 values between 160 and 200 mmHg. In both groups single lung transplantation led to a significant decrease in peribronchial tissue oxygen tension throughout the observation period. Pre-Tx values of peribronchial tissue oxygen tension (38.31 +/- 6.56 mmHg) decreased to 9.72 +/- 2.55 mmHg in group A and 10.3 +/- 3.61 mmHg in group B after 4 h, which could not be altered by a FiO2 of 1.0 (P < 0.0001). The addition of NO in group B led to a significantly augmented flow in the left pulmonary artery (0.63 +/- 0.31 l/min in group B vs. 0.46 +/- 0.26 l/min group A, P < 0.001) representing 67 vs. 49% of the pre-Tx flow in groups B and A, respectively, but the peribronchial tissue oxygen tension was not influenced (P > 0.05). In both groups A and B, the central venous pO2 did not differ in the postoperative period (41.83 +/- 3.27 mmHg group A vs. 43.26 +/- 2.98 mmHg group B) and was kept in a comparable range to the pretransplantation values (45.23 +/- 3.41 mmHg pre-Tx). The persistence of a very low peribronchial tissue oxygen tension in the early phase after lung transplantation cannot be influenced by improved pulmonary artery flow and solely relates to the central venous pO2, which cannot be augmented by the addition of NO. This mechanism might be a trigger for anastomotic healing problems, infectious complications and later development of obliterative bronchiolitis (OB).

Rat brain adaptation to chronic hypobaric hypoxia.

The normal function of the brain is entirely dependent on an adequate supply of oxygen for the provision of ATP via oxidative energy metabolism. But, the presence of oxygen in excess of metabolic needs can be toxic, with especially drastic consequences for an organ such as the brain in which neurons cannot be regenerated once lost. Thus, there are mechanisms that have evolved, apparently in response to these opposing requirements, which control oxygen delivery to the brain so that it is tightly coupled to tissue oxygen consumption, such that energy demand is satisfied but brain oxygen exposure is minimized. This principle of just sufficient oxygen implies that under normal ambient oxygen pressures and normal physiological conditions, regional brain blood flow is relatively low and brain tissue oxygen tension is also low (Sick et al., 1982). Increases in functional energy demand would have to be accompanied by at least transient increases in local oxygen delivery (LaManna et al., 1987).

On the etiology of clubbing of the fingers

Clubbing of the fingers and toes, and the more severe “pulmonary” osteoarthropathies and periostitides, occur when there is arterial anoxia due to congenital or acquired lesions or residence at high altitude. It occurs in many disorders in which the erythrocyte sedimentation rate is rapid, but arterial oxygen saturation normal. In all these cases the vascular bed is wide, blood flow rapid, and the tissue warmer than normal. That rapid sedimentation rates, with intravascular rouleaux formation, interfered with oxygenation of the tissues by decreasing the diffusion surface per unit of hemoglobin had long ago been suggested by Fahraeus. In this review it is suggested that with escape of rouleaux through the arteriovenous anastomoses so numerous in the fingers and toes, rapid blood flow and high levels of arterial and venous oxygen saturation may be present simultaneously with low oxygen tension in the digital tissues. Thus, rapid rates of blood flow and low tissue oxygen tension would provide the same mechanism for clubbing in chronic infections, neoplasms, or metabolic defects leading to abnormal fibrinogen and globulin levels, as in the classical cases of arterial anoxia. The most rapidly evolving and the most severe types of osteoarthropathy are seen in cases of mediastinal and lung tumors where the sedimentation rates are rapid and arterial anoxia is present. Here the two types of anoxia may coexist. In rheumatoid arthritis, in Raynaud's disease, and in Buerger's disease clubbing is rare, although tissue anoxia is severe in the latter two and rapid sedimentation rates are characteristic of the former. But in all of these, blood flow and tissue temperatures are low in the tips of the extremities. It is thereby concluded that for the development of clubbing low oxygen tensions must occur in tissues which are warm and in which the blood flow is greater than normal.

On the Etiology of Clubbing of the Fingers

Abstract Clubbing of the fingers and toes, and the more severe “pulmonary” osteoarthropathies and periostitides, occur when there is arterial anoxia due to congenital or acquired lesions or residence at high altitude. It occurs in many disorders in which the erythrocyte sedimentation rate is rapid, but arterial oxygen saturation normal. In all these cases the vascular bed is wide, blood flow rapid, and the tissue warmer than normal. That rapid sedimentation rates, with intravascular rouleaux formation, interfered with oxygenation of the tissues by decreasing the diffusion surface per unit of hemoglobin had long ago been suggested by Fahraeus. In this review it is suggested that with escape of rouleaux through the arteriovenous anastomoses so numerous in the fingers and toes, rapid blood flow and high levels of arterial and venous oxygen saturation may be present simultaneously with low oxygen tension in the digital tissues. Thus, rapid rates of blood flow and low tissue oxygen tension would provide the same mechanism for clubbing in chronic infections, neoplasms, or metabolic defects leading to abnormal fibrinogen and globulin levels, as in the classical cases of arterial anoxia. The most rapidly evolving and the most severe types of osteoarthropathy are seen in cases of mediastinal and lung tumors where the sedimentation rates are rapid and arterial anoxia is present. Here the two types of anoxia may coexist. In rheumatoid arthritis, in Raynaud's disease, and in Buerger's disease clubbing is rare, although tissue anoxia is severe in the latter two and rapid sedimentation rates are characteristic of the former. But in all of these, blood flow and tissue temperatures are low in the tips of the extremities. It is thereby concluded that for the development of clubbing low oxygen tensions must occur in tissues which are warm and in which the blood flow is greater than normal.