Expression and function of Toll-like receptor 9 in severely injured patients prone to sepsis

The purpose of this prospective study was to enumerate Toll-like receptor 9 (TLR9)(+) cells and measure their function using synthetic oligonucleotides enriched in CG dinucleotide motifs (CpG)-induced proliferation within 48 h after trauma in severely injured patients prone to sepsis. Sixteen consecutive trauma patients with an injury severity score (ISS) > 21 and 16 blood donors (controls) were included in this study. Using two-colour flow cytometry, TLR9 expression was detectable intracellularly and also on the surface of B lymphocytes. The surface expression of TLR9 of B lymphocytes from whole blood and peripheral blood mononuclear cells (PBMC) stimulated with CpG was significantly increased in B cells of severely injured patients prone to sepsis compared to controls. No significant differences could be observed between CpG-induced proliferation of PBMC of severely injured patients prone to sepsis and controls. As a measure of immunosuppression, human leucocyte antigen (HLA)-DR expression of monocytes of the trauma patients was significantly diminished compared with controls in PBMC and in whole blood. Immunosuppression in the early phase after trauma seems not to be associated with a disturbed sensing of bacterial DNA.

Outcome and functional capacity after prolonged intensive care unit stay

BACKGROUND

An important proportion of critically ill patients who survives their acute illness remains in a critical state requiring intensive care management for weeks to months. Nevertheless, data on risk factors for in-hospital mortality and especially for long-term mortality and functional capacity are scarce. This study investigated outcome and prognostic factors in long-term critically ill patients.

METHODS

This retrospective observational cohort study was performed at our mixed adult 8-bed cardiologic ICU at a 2200-bed University Hospital. Patient data from our local database connected to an Austrian multicenter program for quality assurance in intensive care were analyzed. Data were collected between March 1(st), 1998 and December 31(st), 2003. Patients with an ICU stay > or =30 days formed the long-term study group. Morbidity and functional capacity were assessed using the Barthel mobility index in telephone interviews.

RESULTS

Patients spending > or =30 days in the ICU numbered 135 (10%) and occupied 5962 bed-days, representing 40.9% of the total bed-days. Compared with patients with an ICU stay <30 days, patients in the long-term group had a significantly higher SAPS II score during the first 24 hours after ICU admission (54 [IQR 41-65] vs. 38 [IQR 27-56], p < 0.001). There was a trend towards male preponderance in the long-term group (98/135 [82.6%] vs. 782/1215 [64.4%], p = 0.05). Differences in ICU and in-hospital mortality were not significant (28/135 (20.7%) vs. 295/1215 (24.3%), p = 0.620 and 46/135 [34.1%] vs. 360/1215 [29.6%], p = 0.285, respectively). After 12 and 48 months, the overall cumulative rates of death in hospital survivors were 14% and 26%, respectively in the short-term ICU group and 31% and 61% in the long-term group. A log-rank test revealed a significantly higher probability of survival in the short-term group after hospital discharge (log rank = 34.3, p < 0.001). Multivariate analysis of hospital survivors and non-survivors in the long-term group showed that the need for renal replacement therapy during the ICU stay was the sole independent predictor for in-hospital death and death within 1 year after ICU discharge (OR = 2.88; 95%CI 1.12-7.41, p = 0.028 and OR = 3.66, 95%CI 1.36-9.83, p = 0.01, respectively). In 28/31 long-term survivors (90%) in the long-term ICU group, the Barthel index indicated no or only moderate disability during daily activities.

CONCLUSION

Hospital mortality rates in critically ill patients with a stay <30 or > or =30 days were comparable. The necessity for renal replacement therapy was the sole independent predictor for in-hospital and 1-year mortality in long-term ICU patients. Critically ill patients with a stay > or =30 days have a high and ongoing risk of death after hospital discharge; however, a substantial number of these patients are long-term survivors with no or only moderate disability during daily activities.

Esophagus cancer and radiation exposure due to nuclear test fallout: an analysis based on the data of the Semipalatinsk historical cohort, 1960-1999

This paper describes the Semipalatinsk historical cohort study and, in particular, examines the association between combined external and internal radiation exposure and esophagus cancer. Esophagus cancer is the most frequent single cancer site in the cause of death follow-up for the Semipalatinsk cohort. Set up in the 1960s, this historical cohort included 10 exposed settlements in the vicinity of the Semipalatinsk nuclear test site in East Kazakhstan as well as 6 comparison settlements in a low exposure area of the same region. The external and internal radiation doses to the population of the settlements under study were mainly due to local fallout from atmospheric nuclear testing (1949-1962). The database includes dosimetry and health information for 19.545 inhabitants of exposed and comparison villages in the Semipalatinsk region, comprising a total of 582.750 person-years of follow-up between 1960 and 1999. Cumulative effective dose estimates in this cohort range from 20 mSv to -4 Sv, with a mean dose of 634 mSv in the exposed group. Relative risks were calculated in terms of rate ratios, using a Poisson regression model for grouped person-time data. Esophagus cancer was found substantially elevated, with a statistically significant increase of the relative risk with dose and an ERR/Sv of 2.37 (1.45; 3.28) for the total cohort. If the data set was restricted to the exposed group only, the ERR/Sv was found considerably lower (0.18 (-0.16; 0.52)), whereas the dose-response remained significant only in women. Overall, our results based on the Semipalatinsk historical cohort indicate an association between fallout exposure and the risk of esophagus cancer that should be further investigated.

Fracture of Colvin-Galloway-Future band in a patient with mitral valve annuloplasty

Annuloplasty with various annuloplasty ring systems is a fundamental part of mitral valve repair and has been frequently performed since its introduction by Carpentier in 1969. Due to the different advantages or disadvantages of each system, some controversies exist regarding the best type of ring annuloplasty support. Here we describe, for the first time, the case of a female patient in which a fracture of a semi-rigid open annuloplasty ring occurred, leading to annular deformation and mitral regurgitation.

Evaluation of SRC-family kinases in gastrointestinal stromal tumors

9529

Background: Inhibition of KIT oncoproteins by imatinib mesylate (IM) induces clinical responses in most GIST patients. However, many patients develop IM-resistance and novel KIT-Inhibitors show clinical benefit in only a minority of patients. SRC-family kinases (SFK) are important participants in kinase oncoprotein signaling pathways in ALL and CML, and dual-specificity SRC/ABL-inhibitors show promising activity in IM-resistant CML in vitro. However, little is known about SFK functional roles in IM-resistant GIST. Methods: GIST were analyzed for SFK expression and activation by western blotting. Biological consequences of KIT inhibition alone (IM), SFK inhibition (SU6656) and combined KIT/SFK inhibition (PP1, PP2, SU6656+IM) were determined by immunoblotting for protein activation, and—in GIST cell lines—by luminescence assays for cell proliferation. Results: Primary GIST and GIST cell lines showed weak SFK activation compared to Jurkat (T-cell ALL) controls. Variable expression of the SFK proteins FYN, LYN and SRC (but not BLK and LCK) was shown in the cell lines and primary GIST. Expression of SFK proteins HCK and FGR was found in 2 primary GIST only. KIT and KIT signaling pathways (pAKT, pS6, pSTAT3) were affected by IM and combined KIT inhibitors but not by SU6656 at 1μM in GIST882 (IM-sensitive cell line) and GIST48 (IM-resistant cell line). SRC phosphorylation (Y418) was not affected by IM or SFK-inhibitors at 1μM. IM showed superior inhibition of proliferation compared to PP1 and PP2 (1μM) in GIST882 (IM: 67%, PP1: 1%, PP2: 0%) and comparable inhibition in GIST48 (IM:30%, PP1: 29%, PP2: 29%). No effects on proliferation were seen with SU6656 alone or in combination with IM; no antagonistic effects were observed. Conclusions: Our analysis showed expression and weak activation of several SFK in GIST. Expression of heme-associated SFKs in primary GIST may be explained by lymphocellular infiltration. Biochemical inhibition of SFK alone does not have antiproliferative effects in GIST cell lines, and no synergies or antagonisms were found in combination with IM or with combined KIT/SFK inhibitors. Therefore, targeting of SFK may be of less therapeutic value in GIST than in kinase-driven haematological cancers.

No significant financial relationships to disclose.

Formation of Ascorbate Radicals as a Measure of Oxidative Stress: An In Vitro Electron Spin Resonance-Study Using 2,2–Azobis (2-Amidinopropane) Dihydrochloride as a Radical Generator

Reactive oxygen species (ROS) are continuously formed in biological systems. Any increase in radical production or decrease in the defense against ROS induces oxidative stress. This imbalance between ROS formation and ROS detoxification is believed to be involved in a variety of pathogenic processes, including ischemia-reperfusion injury. Various markers indicating oxidative stress has been used in experimental and clinical studies. One of them is ascorbate free radical (AFR), electron spin resonance intensity of which correlates with the severity of radical formation. We investigated the impact of alkyl peroxyl radicals produced by 2,2-Azobis (2-amidinopropane) dihydrochloride decomposition on the magnitude of the AFR signal. Our data confirmed the principal applicability of AFR as a nontoxic marker of radical generation.

In vitro-Generated Viral Double-Stranded RNA in Contrast to Polyinosinic : Polycytidylic Acid Induces Interferon-alpha in Human Plasmacytoid Dendritic Cells

Double-stranded RNA (dsRNA) arises in the cytoplasm during viral replication and was shown to participate in the interferon (IFN)-alpha induction process. Besides the intracellular recognition, released dsRNA from dying, infected cells can function as a pathogen-associated molecular pattern (PAMP) for the innate immune system. In the present study, in vitro-generated dsRNA fragments of genomic sequences of Newcastle disease virus were used to induce IFN-alpha release in human peripheral blood mononuclear cells (PBMC), in immature myeloid dendritic cells (mDC) and in immature plasmacytoid DC (pDC). The extracellular administration of dsRNA fragments but not the application of the corresponding single-stranded RNA (ssRNA) strands led to an IFN-alpha production in PBMC. The synthetic dsRNA analogue polyinosinic acid : polycytidylic acid [Poly(I : C)] could only stimulate IFN-alpha production in enriched mDC but not in pDC. In contrast, dsRNA fragments induced IFN-alpha only in pDC. Complexation of dsRNA fragments with transfection reagents increased the efficiency of IFN-alpha induction and commuted ssRNA molecules into IFN-alpha inducers. However, stimulation of in vitro-generated murine Toll-like receptor 7 (TLR7) knockout DC and human TLR-transfected HEK293 cells with dsRNA fragments gave no evidences for the involvement of pDC-specific TLR7 or TLR9 in the observed IFN-alpha induction.

TNFalpha-mediated induction of PAI-1 restricts invasion of HTR-8/SVneo trophoblast cells

The pro-inflammatory cytokine TNFalpha has numerous effects on placental trophoblasts. Here, we investigated the effects of the cytokine on gene expression and function of the extravillous trophoblast cell line HTR-8/SVneo. Wound healing and Matrigel invasion assays demonstrate that TNFalpha impairs motility and invasiveness. In contrast, counting of cumulative cell numbers and FACS analyses revealed that the cytokine did neither affect proliferation nor distribution of cell cycle phases. Immunocytochemistry of the cytokeratin 18 neo-epitope suggests that TNFalpha did not induce apoptosis in HTR-8/SVneo cells. Gelatine zymography and enzyme activity assays of supernatants of TNFalpha-treated cells demonstrate elevation of the pro- and active form of MMP-9 suggesting that increased expression of the protease cannot overcome the TNFalpha-inhibitory effect on cell invasion. Semi-quantitative RT-PCR analyses suggest that the cytokine may not alter mRNA levels of uPA and tPA. However, elevated expression of PAI-1 was detected by RT-PCR, as well as by Northern and Western blot analyses. Supplementation of PAI-1-blocking antibodies restored invasion of TNF-alpha-incubated HTR-8/SVneo cells through Matrigel-coated transwells. In addition, immunocytochemistry revealed nuclear accumulation of the p65 subunit of NFkappaB in the presence of the cytokine. EMSA indicated TNFalpha-induced binding of the inflammatory transcription factor to an NFkappaB consensus sequence and to the NFkappaB recognition site located in the PAI-1 promoter. The data suggest that TNFalpha restricts trophoblast invasion mainly by increasing the expression of PAI-1. Induction of the inhibitor may involve TNFalpha-stimulated activation of NFkappaB.

Erfahrungen mit Diabetikern in der Koronarchirurgie—

BACKGROUND

The objective of this paper was to analyze demographic and clinical characteristics of diabetic patients undergoing coronary artery bypass grafting on the basis of a significant number of cases.

METHODS

The data of 8,195 patients who have undergone coronary bypass operations between 1996 and 2003 were analyzed. Non-diabetic patients (no DM), oral treated diabetics (DM oral) and insulin-treated diabetics (DM insulin) were compared in terms of their pre-operative, intra-operative and post-operative characteristics. The statistical analyses were performed with the support of SPSS 11.5 under application of chi-square and student-t tests.

RESULTS

In cardiosurgery, diabetics differ in various ways from non-diabetic patients. They show a significantly higher prevalence of the known cardiovascular risk factors such as raised body mass index, age and hypertension. Furthermore they present a higher prevalence of vascular comorbidity such as peripheral vascular disease and carotid disease. At the postoperative stage, cerebral dysfunction occurred more often among the diabetic patients (no DM 5.2% vs. DM oral 7.3% vs. DM insulin 10.5%; p < 0.05), they suffered from apoplexies more frequently (no DM 1.9% vs. DM oral 2.1% vs. DM insulin 3.2%; p < 0.05), and they required re-intubation more frequently (no DM 2.6% vs. DM oral 3.1% vs. DM insulin 5.6%; p < 0.05). Peri-operative mortality was highest in the group of insulin-treated diabetics (no DM 1.1% vs. DM oral 1.6% vs. DM insulin 1.8%; p < 0.05).

CONCLUSION

In coronary surgery, diabetic patients represent an especially challenging patient group with an independent risk profile, who require specific consideration as far as the selection of the operative approach, on, one hand, and the post-operative follow-up, on the other hand, are concerned.

Occupational Health Survey of Farm Workers by Camp Health Aides

Little is known about the magnitude of occupational health problems among migrant farm workers. A community-based cross-sectional survey was conducted in two migrant farm worker communities: Homestead, Florida, and Kankakee, Illinois. Camp Health Aides (CHAs) interviewed 425 workers about job tasks, personal protective equipment (PPE), field sanitation, work exposures, and selected health conditions. Limited provision of personal protective equipment was reported among those reporting early re-entry tasks: 35% in Kankakee and 42% in Homestead were provided gloves, and 22% in Homestead and 0% in Kankakee were provided protective clothing. About two-thirds were provided toilet facilities and water for hand-washing. Workers reported high prevalences of health conditions consistent with exposure to ergonomic hazards and pesticides. The prevalence of back pain in the past 12 months was 39% in Homestead and 24% in Kankakee. Among Homestead participants, 35% experienced eye symptoms, while 31% reported skin symptoms. These symptoms were less prevalent among Kankakee participants (16% for both eye and skin symptoms). Specific areas of concern included back pain associated with heavy lifting and ladder work; eye and skin irritation associated with fertilizer application tasks and with working in fields during or after spraying of chemicals, especially early re-entry of sprayed fields; and skin irritation associated with a lack of access to hand-washing facilities. In both Kankakee and Homestead, better adherence to safety standards is needed, as well as greater efforts to implement solutions that are available to help prevent work-related musculoskeletal problems.

[The structurizing effect of minimum quantitative requirements for inpatient care]

PURPOSE

German social law ( section sign 137 SGB V) authorized the partners in health care to establish and develop a catalogue of procedures for which quality is associated with volume. There is lack of evidence regarding the volume limits. Other aspects need to be taken into account, first of all by consultation of performance data analysis.

METHODS

Inpatient-data of hospitals in Baden-Wurttemberg were studied to make out possible effects of volume standard codes on health care provision. For each procedure studied an ICPM- tracer was defined and a volume limit fixed.

RESULTS

If a limit affects many hospitals but a small portion of health care to be changed, it means, that only very low volume providers would be excluded. An adequate network of care can be achieved by joining volumes from neighbouring regions. The analysis showed that 39 % of the regions offering pancreatectomy come to a minimum volume of ten operations per year. A volume below 5 procedures per year is performed in 12 regions. If these small amounts are brought together, about two thirds of the regions involved in this segment of care could continue with a local offer corresponding to that defined standard. For certain high-risk conditions or procedures centralisation has already taken place (e. g. coronary bypass surgery).

CONCLUSIONS

Based on appropriate analysis of the data of all partners in health care concepts can be tailored to the needs of the statutory health care system and accompanying activities involved from the very beginning. Risks have to be taken into consideration, including rarefaction of health care offers, disparities in care and on the other hand economically motivated decentralization, where risk adapted centralisation was necessary.