[Do corticotherapy and hemodilution decrease postoperative inflammation after maxillofacial surgery?]

OBJECTIVE

To assess the efficiency of corticosteroids and preoperative acute normovolaemic haemodilution (PANHD) in reducing postoperative inflammation after maxillofacial surgery.

STUDY DESIGN

Randomized clinical trial.

PATIENTS

Thirty-two patients scheduled to undergo maxillary osteotomy for facial dysmorphia were randomized into four groups of eight (PANHD or not; corticosteroids or not).

METHODS

PANHD decreased haematocrit to 30%. In the corticosteroid groups, methylprednisolone 1.5 mg.kg-1 was given intravenously at the beginning of surgery (after PANHD in haemodiluted group), and after surgery, 1.5 mg.kg-1 iv daily for three days. Postoperative inflammation was assessed with an X-Ray technique (radiotelemetry) providing data on tissue thickness (extent of facial oedema), and by measurement of plasma concentrations of four acute phase proteins during the first postoperative week.

RESULTS

No change in facial oedema and in acute phase proteins occurred with PANHD. Corticosteroids decreased postoperative oedema and acute phase proteins.

CONCLUSION

Corticosteroids decrease postoperative inflammation after maxillofacial surgery but not PANHD.

sIL-2R levels in rheumatoid arthritis: poor correlation with clinical activity is due in part to disease duration

The serum levels of soluble interleukin-2 receptors (sIL-2R) were measured in an attempt to determine whether they correlated with 'disease activity' in 59 patients suffering from rheumatoid arthritis. Our results indicate that serum levels of sIL-2R do not permit patients to be classified as having active or inactive disease according to standard clinical indices. A correlation between sIL-2R and disease duration could offer one explanation for the current discrepancies found in the literature.

[Methods for studying cytokines in biological media]

Accurate and sensitive methods for the measurement of cytokines in biological fluids are an absolute prerequisite for a proper use of these mediators in clinical practice. The authors describe the numerous molecular forms under which cytokines can possibly circulate. The potential influence of inhibitors (autoantibodies, soluble receptors) on cytokine assays is discussed. Blood collection for cytokines needs a particular attention to prevent a possible contamination by endotoxins which can trigger cytokines cellular production after sampling. If bioassays historically preceded immunoassays, these last techniques are now very popular, but there is an urgent need for standardisation between the different kits commercially available. In addition, in situ detection of cytokines using molecular biology is an helpful complementary technique to the measurement of circulating cytokines.

Acute normovolaemic haemodilution does not reduce the inflammatory process induced by facial surgery

The place of preoperative acute normovolaemic haemodilution (haematocrit = 28%-32%) in reducing postoperative inflammation was evaluated after facial surgery. Thirty-two patients scheduled for mandibular osteotomy were randomized to a nonhaemodiluted group or to a haemodiluted group. The degree of postoperative inflammation was evaluated: first by an x-ray technique (radiotelemetry) providing measurements of the tissue thickness (quantitation of facial oedema), and second by the measurement of four acute phase protein plasma concentrations during the first postoperative week. Throughout the study, no changes in facial oedema or in variation of acute phase proteins were detected after haemodilution. It is concluded that acute normovolaemic haemodilution has no effect on the intensity of facial oedema and the biological inflammation process after facial surgery.

Mechanisms of action of the tumor necrosis factor and lymphotoxin ligand-receptor system

In the past few years, a number of experimental observations have provided more insight into the mechanisms of action of tumor necrosis factor (TNF)/lymphotoxin (LT) ligand-receptor system. This system consists of three ligands, TNF, LT alpha (LT alpha) and LT beta (LT beta), and three membrane-associated receptors, p55, p75 and LT beta-receptor (LT beta-R). Like TNF, LT alpha is a secreted protein which in solution forms a homotrimer molecule, with a conformation similar to that of TNF. LT beta is a transmembrane protein that provides the membrane anchor for the attachment to the cell surface of the heteromeric complex of LT alpha and LT beta. This complex retains a structure related to TNF and LT alpha homotrimers, with the homology regions interacting in a heterotypic fashion. The LT alpha 1:LT beta 2 heteromer has been found to be a predominant form of surface LT. The biological effects of TNF and LT alpha homotrimers are mediated by p55 and p75 receptors, while the heteromeric complex of LT alpha/LT beta transduces its cellular signal via LT beta-R. Membrane-associated receptor affinities as well as final biological effects of TNF/LT can be modulated by the influence of naturally occurring soluble receptors, derived from the cell surface by proteolytic cleavage. The multimerization of receptor cytoplasmic domains upon TNF/LT ligation is postulated to activate the intracellular signal-transduction pathways. One of them is the activation of phospholipase A2 (PL-A2) resulting in the production of arachidonic acid (AA) and other metabolites, including leukotriens, phosphatidycholine-specific phospholipase C (PC-PLC) with subsequent production of diacylglycerol (DAG) and activation of protein kinase C (PKC). As a third signaling pathway, TNF/LT employ the sphingomyelinase (SMase)-mediated hydrolysis of membrane sphingomyelin (SM) to ceramide. The final link in the TNF/LT signaling is activation of nuclear transcription factors, such as NF-kappa B, AP-1, interferon regulatory factors-1 and -2 (IRF-1, IRF-2), and NF-GMa. Since induction of AP-1, IRF-1 and IRF-2 as well as NF-GMa proceeds through translational event, the posttranslational TNF/LT-driven activation of NF-kappa B remains the only cellular event identified so far that serves as a direct target in their signaling cascade.

IL-3 increases marrow and peripheral erythroid precursors in chronic pure red cell aplasia presenting in childhood

In most patients with Diamond-Blackfan anaemia (DBA) the addition of IL-3 to in vitro cultures increases the number of erythroid progenitors. However, a small proportion of patients show an erythroid response to in vivo administration of IL-3. We treated two adult patients with corticosteroid-refractory DBA, who had shown a clear in vitro erythroid response to IL-3, with increasing doses of IL-3 (from 2.5 to 10 micrograms/kg/d) by subcutaneous injections for 7 and 9 weeks. Monitoring of marrow and circulating progenitors showed a sustained elevation of BFU-E and CFU-E as well as an increase of other progenitors and CD34+ cells during therapy. However, this effect did not translate into a clear clinical response, although transfusion requirements decreased transiently in one patient. This report shows that a sustained elevation of erythroid progenitors induced by in vivo IL-3 administration may not translate into an increase of mature red cells production in DBA patients.

Production of proinflammatory cytokines and cytokines involved in the TH1/TH2 balance is modulated by pentoxifylline

The modulation of cytokine release induced by pentoxifylline (PTX) has recently been demonstrated not to be restricted solely to tumor necrosis factor (TNF)-alpha. This prompted us to study the influence of PTX on a larger spectrum of cytokines with proinflammatory actions [TNF-alpha, interleukin-6, (IL)-6, IL-1 beta, IL-8] or with implied actions in the TH1 (IL-2, IFN-gamma)/TH2 (IL-10) balance. The IL-1RA was also explored. This work was performed using a whole-blood model in which cytokine production is measured after stimulation by lipopolysaccharide (LPS) (25 micrograms/ml) and phytohemagglutinin (PHA) (5 micrograms/ml) in 1:10 diluted whole blood. The stimulation test was performed in blood from healthy controls and from septic patients (without septic shock) in the presence or absence of PTX at 10(-6), 10(-5), 10(-4), or 10(-3) M. In controls and septic patients, at a 10(-4) M PTX concentration the production of IL-2 is strongly diminished (26-32% of the basal level), followed by diminution of IFN-gamma (30-40%). As expected, of the proinflammatory cytokines TNF was the most strongly suppressed (50% of baseline) followed by IL-1 (about 80% of basal production). Finally, IL-10 was also influenced by PTX (65% of baseline). At 10(-4) M, IL-1RA and IL-6 were unaffected by PTX. Taken altogether, our data demonstrate that PTX possesses a much broader spectrum of activity on cytokine production than was initially described, and it appears to be a potential and promising immunotherapeutic agent.

Leukocyte activation study during occlusive arterial disease of the lower limb: effect of pentoxifylline infusion

Granulocytes play a significant role in vascular diseases. The mechanisms of neutrophil-mediated vascular injury include their increased endothelial adhesion and activation with release of inflammatory mediators. Pentoxifylline (PTX) has a well-demonstrated ability to act on the activated neutrophils. It increases chemotaxis and decreases their adherence to endothelial cells, oxidative burst, and enzyme release. In this preliminary study, we investigated the effects of PTX on ischemia-induced changes in polymorphonuclear neutrophils (PMN) activation and cytokine release. A double-blind, randomized, placebo-controlled trial was carried out in 14 patients (age range 46-86 years) suffering from critical ischemia, as defined by the European Consensus Document, or subacute ischemia due to occlusive arterial disease of the lower limb. Femoral and antecubital venous blood samples on the side of the ischemic leg were obtained from patients immediately before (TO) and after infusion (T24) of PTX or placebo. PMN activation was evaluated by study of cell migration, beta 2 integrin expression (CD11b/ CD18), oxidative burst, and elastase release. Inflammation proteins were analyzed, such as tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1), interleukin-6 (IL-6), C-reactive protein (CRP), and fibrinogen. Before treatment, our results demonstrate an important activation in both femoral and antecubital venous blood. PMN activation markers, cytokine release, and other inflammation proteins were significantly increased compared with normal subjects. In the experimental group there was no significant difference between femoral and antecubital venous blood. Six patients received PTX infusion and seven patients were in the placebo group. The effect of PTX was evaluated after 24 h of treatment (1,200 mg). In the PTX group the following variables were improved compared with the placebo group: CD11b expression on PMNs, elastase released from PMNs, fibrinogen, CRP, TNF-alpha, and IL6 in plasma. These preliminary results should be interpreted with caution because of the small sample size. Further trials may contribute to more complete understanding.

Implication of cytokines in the aggravation of malnutrition and hypercatabolism in elderly patients with severe pressure sores

The objectives of this work were to study the production of the cytokines Interleukin 1 (IL-1), Interleukin 6 (IL-6), and tumour necrosis factor (TNF) in elderly patients with severe pressure sores and to assess their potential contribution to the aggravation of malnutrition. Nineteen bedridden patients with stage III or IV pressure sores, 12 bedridden patients free from pressure sores, but at risk of them, and 12 control patients without risk of pressure sores were studied. Nutritional status was evaluated using anthropometry, serum albumin, prealbumin, retinol-binding protein analyses, and delayed hypersensitivity skin tests. Acute-phase proteins (APP), cortisol, and cytokines blood levels together with cytokine production were measured. Nutritional status was poor in patients with sores and their APP, and IL-6 blood levels were significantly increased; IL-1 and TNF serum concentrations were not elevated in these patients. A significant difference in cortisol levels was observed between patients with stage III and IV sores. A local cytokine origin (especially IL-6, and also IL-1) was demonstrated. Thus cytokines, mainly IL-6, produced by tissue cells in damaged areas together with cortisol may aggravate malnutrition and hypercatabolism in patients with sores.

New international reference preparation for proteins in human serum (RPPHS)

Quality-control surveys in recent years, in various parts of the world, have shown poor between-laboratory agreement for measurements of plasma proteins. Despite the existence of international reference materials distributed by the World Health Organization, standards produced by diagnostics manufacturers and professional organizations differ significantly in their ascribed values. The reasons for this are complex but include poor availability of the primary materials, confusion about their use, and the fact that their turbidity on reconstitution precludes their use in modern optical immunoassays. This unfortunate situation led to an important initiative to produce sufficient quantities of a widely available, optically clear secondary reference material for plasma proteins that could be used worldwide by manufacturers, professional organizations, and laboratories. Here we present an overview on how the laboratory community, including manufacturers, clinical laboratories, professional societies, and regulators, has reached what we consider is a successful conclusion to a difficult problem.

New international reference preparation for proteins in human serum (RPPHS)

Quality-control surveys in recent years, in various parts of the world, have shown poor between-laboratory agreement for measurements of plasma proteins. Despite the existence of international reference materials distributed by the World Health Organization, standards produced by diagnostics manufacturers and professional organizations differ significantly in their ascribed values. The reasons for this are complex but include poor availability of the primary materials, confusion about their use, and the fact that their turbidity on reconstitution precludes their use in modern optical immunoassays. This unfortunate situation led to an important initiative to produce sufficient quantities of a widely available, optically clear secondary reference material for plasma proteins that could be used worldwide by manufacturers, professional organizations, and laboratories. Here we present an overview on how the laboratory community, including manufacturers, clinical laboratories, professional societies, and regulators, has reached what we consider is a successful conclusion to a difficult problem.

Inhibition of immune cell proliferation and cytokine production by lipoprotein-bound gangliosides

We have analyzed the immunomodulatory effect of human melanoma gangliosides bound to serum lipoprotein fractions on normal human immune-competent cells in vitro. Total melanoma gangliosides in micelles inhibited proliferation of peripheral blood mononuclear cells stimulated by various mitogens, modulated lymphocyte surface molecules CD2, CD3, CD4, CD5 and CD8 and inhibited the production of interleukin-1 beta (IL-1 beta), tumor necrosis factor alpha (TNF alpha) and IL-6 by stimulated adherent cells. Most of these effects were abrogated in the presence of serum. Purified serum lipoprotein fractions were tested for their ability to allow or inhibit the immunomodulatory effects of gangliosides. Melanoma gangliosides bound to very-low-density lipoproteins (VLDL) were shown to be as potent modulators of the immune response in vitro as when they were presented to cells in the form of micelles. Gangliosides bound to low-density lipoproteins were less active and gangliosides bound to high-density lipoproteins or the lipoprotein-free fraction had no immunomodulatory effects. Given the fact that gangliosides are predominantly bound to lipoproteins in serum, we conclude that lipoproteins are important determinants of the immunomodulating potential of tumor gangliosides, and that the immunomodulatory effects of melanoma gangliosides observed in vitro may also occur in vivo.

Regional chemotherapy (with mitomycin C) and intra-operative hyperthermia for digestive cancers with peritoneal carcinomatosis

Intraperitoneal chemo-hyperthermia with mitomycin C was used to treat 28 patients with far advanced digestive adenocarcinoma and histologically confirmed peritoneal carcinomatosis. Surgical resection of the primary tumor was possible in 17 cases. After closure of the abdominal wall, intraperitoneal chemo-hyperthermia was performed for 90 to 120 minutes under general anesthesia and 32 degrees C hypothermia, through 3 intraperitoneal drains forming a closed circuit, using 10 mg/l of mitomycin C in 6 liters of peritoneal dialysate heated to an inflow temperature of 46-49 degrees C. No mortality occurred, and there were 2 post-operative complications, with transitory biological side effects. In 9 out of 10 patients with preoperative malignant ascites, the ascites cleared after treatment. One-year survival rate was 54.2%. These encouraging preliminary results show that intraperitoneal chemohyperthermia with mitomycin C is a safe and reliable treatment for peritoneal carcinomatosis in far advanced digestive cancers.

Coagulation/fibrinolysis balance in septic shock related to cytokines and clinical state

This study explored the relationship between cytokines (TNF, IL-1, IL-6), coagulation and fibrinolytic factors in the early stage of sepsis syndrome and the relation between these factors with the severity of inflammatory illness as measured by the Simplified Acute Physiology Score (SAPS). Twenty-one normal controls were compared to 34 patients divided into three categories ranging from uncomplicated postoperative patients, to patients with severe infectious conditions including septic shock. A major hemostatic imbalance was demonstrated with particularly marked reduction in fibrinolytic activity [drop of antithrombin III (ATIII) and protein C with an increase of plasminogen activator inhibitor (PAI-1) levels] which were directly correlated with the severity of the inflammatory state. Both ATIII and PAI-1 levels were correlated with the levels of TNF and IL-6 and the severity of illness as measured by SAPS. We established an index, ATIII/PAI-1 antigen that is significantly different among the four groups (p < 0.001) and strongly correlated with the SAPS (p < 0.001). As PAI-1 could be secreted not only by TNF activating endothelial cells but also by hepatocytes activated by insulinemia, treatment of sepsis with cytokine-specific agents might be of limited effect.

Analytical performances of commercial ELISA-kits for IL-2, IL-6 and TNF-alpha. A WHO study

The determination of cytokine levels in biological fluids by accurate and sensitive methods is an absolute need to be able to define the involvement of these mediators in various clinical situations. To test if this goal was achieved with ELISA kits, a comparative study was undertaken using various commercial kits (6 for IL-2, 8 for IL-6 and 9 for TNF-alpha). The major aims of the work were to critically analyze the analytical performances of the kits and to illustrate some of the pitfalls the users may face. Substantial differences were noted in terms of sensitivity and behaviour of commercial standards versus international reference preparations. These results clearly illustrate the urgent need for a real standardization of immunoassays for cytokine quantitation.

Study of the pharmacokinetics of mitomycin C in humans during intraperitoneal chemohyperthermia with special mention of the concentration in local tissues

The aim of this work is to estimate the 24-hour distribution and elimination of mitomycin C (MMC) during and after intraperitoneal chemohyperthermia (IPCH) in 18 patients (13 gastric adenocarcinoma, 3 pancreatic adenocarcinoma, 2 malignant mesothelioma) who received 60 mg MMC during 90-120 min in 6 liters of heating solution HS; (42 degrees C) or HS flowing at 0.4 liters/min in a closed circuit. MMC assay in the serum, urine, HS and in local biopsies were performed by high performance liquid chromatography. The amount of MMC in HS decreased by 54.1 +/- 13.6% during IPCH. The maximum MMC levels in serum reached 0.4 +/- 0.18 mg/l 45 min after the start of IPCH, then rapidly decreased. Only 1.77 +/- 0.93 mg were recovered in urine in 24 h. These data are consistent with a large and rapid absorption, mostly in local tissue, demonstrated by the level in 7 post-IPCH biopsies (8.3 +/- 7.6 mg/kg).

Is there a relationship between malnutrition, inflammation, and post-vaccinal antibody response to influenza viruses in the elderly?

This study was designed to explore the relationship between malnutrition, inflammation, and the specific antibody response after influenza vaccination in the elderly. Eighty-two aged subjects, immunized annually against influenza with a trivalent inactivated vaccine, were evaluated for 9 protein markers (albumin, thyroxin-binding prealbumin, transferrin, immunoglobulins (Ig) G, M, and A, orosomucoid, haptoglobin, and C reactive protein) and for their antibody response to influenza viruses in comparison to 29 younger adults who received the same vaccine and 21 unvaccinated adults. IgM and nutritional markers were significantly reduced in the aged as compared to controls, while the opposite pattern was seen for IgA and inflammatory markers. No difference was observed between the elderly and the controls with regard to the antibody response to influenza virus after vaccination. Reciprocally, influenza immunization had no influence on the levels of the protein variables. These results suggest that the protein status does not play an important role in the antibody response to influenza vaccination in the elderly, a fact which could be related to the slight involvement of cellular immunity in the defense against influenza reinfection.

Cytokine production during intraperitoneal chemohyperthermia

The aim of the present work is to investigate in vivo cytokine production during chemohyperthermia. 11 patients suffering from gastric adenocarcinoma (n = 6), ovarian adenocarcinoma (n = 4) or malignant mesothelioma (n = 1) were studied. Patients received 60 mg mitomycin or 100 mg cisplatin per square meter during 2 h in 6 liters of a heating solution (temperature 42 degrees C, flow rate 200 ml/min in a closed circuit) after previous surgical resection. Tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) were measured at 0, 30, 45, 60 and 90 min, both in the blood stream and in the heating solution circulating intraperitoneally. We observed a slight increase in plasma IL-6 occurring as soon as 30 min, a dramatic rise in IL-6 in the heating solution. TNF-alpha values were only slightly augmented. In addition, the importance of various factors in the induction of IL-6 and TNF-alpha production during chemohyperthermia (temperature, mitomycin C, cisplatin) were studied using a whole blood ex vivo model.

Treatment of malignant peritoneal effusion in digestive and ovarian cancer

Intra Peritoneal Chemo Hyperthermia (IPCH) with Mitomycin C (MMC) or Cisplatinum (CP) was used to treat 32 patients with far advanced digestive or ovarian cancers and peritoneal carcinomatosis. Surgical resection of the primary tumor has been possible in 18 cases. After closure of the abdominal wall, a 90 minutes IPCH as performed under general anaesthesia and 32 degrees C general hypothermia, through 3 intraperitoneal drainages realizing a closed circuit, using 10 mg/l of MMC or 15 to 25 mg/l of CP in 6 l of peritoneal dialysate heated at the inflow temperature of 46 to 49 degrees C. The mortality rate was 3% and the morbidity rate was 3%. In 11 out of 12 patients with preoperative malignant ascites, no more ascites could be found after IPCH. For peritoneal carcinomatosis from digestive origin, median survival was 11.2 months and 1 year survival rate was 46.9%. These encouraging preliminary results show that IPCH is a safe and reliable treatment for peritoneal carcinomatosis in far advanced digestive or ovarian cancers.

Study of six antisera used for the immunonephelometric assay of human IgG

The composition and performance of six commercial antisera for the immunonephelometric assay of IgG were studied. The analysis of the protein content of these reagents revealed significant differences in composition: the total protein contents ranged from 41 to over 130 g/l and gamma-globulins were twice to thirteen times higher than in a normal serum of the species. The antibodies found in these reagents were mostly IgG, with traces of IgM, and no IgA. Precipitation curves yielded by these antisera with a standard nephelometer showed a great diversity of performance. The very different shapes, the span of antigen concentrations and antibody dilutions necessary to obtain comparable quantities of precipitates further demonstrated the wide differences between these reagents. A method previously proposed by other authors was found to be inadequate. The failure of this method is attributed to the different conditions for the antigen-antibody reaction, as determined by the instrumentation used. It is concluded that the fundamental and classical criteria for testing antisera remain valid: specificity and the study of the precipitation curve to define the quantitative limits of the reaction. A simple universal method is inapplicable.

Use of immunoglobulin heavy-chain and light-chain measurements in a multicenter trial to investigate monoclonal components: I. Detection

We assessed the combined use of serum protein electrophoresis (SPE) and nephelometric measurement of immunoglobulin heavy- and light-chain components for detecting serum monoclonal immunoglobulins (monoclonal components, MC) in 4788 unselected samples from 4173 patients. MC were detected in 514 samples from 390 patients. In 356 these were detected by SPE; the other 34 had a normal SPE pattern but an abnormal kappa:lambda light-chain ratio (KLR). Only 208 of the 356 (58%) samples with bands by SPE had abnormal KLRs. Samples with MC concentrations greater than 5 g/L had a higher proportion of abnormal KLRs (75%) than those with concentrations less than 5 g/L (42%). The KLR was abnormal in 13% of samples in which no MC were visible by SPE or immunofixation electrophoresis (IFE). Compared with quantitative measurements of immunoglobulin heavy and light chains, high-quality SPE remains the method of choice for the detection of MC. Quantitative methods, however, are able to detect additional MC, especially those containing free light chains, and in the absence of SPE and IFE will detect about 75% of MC present at greater than 5 g/L.

Use of immunoglobulin heavy-chain and light-chain measurements in a multicenter trial to investigate monoclonal components: I. Detection

We assessed the combined use of serum protein electrophoresis (SPE) and nephelometric measurement of immunoglobulin heavy- and light-chain components for detecting serum monoclonal immunoglobulins (monoclonal components, MC) in 4788 unselected samples from 4173 patients. MC were detected in 514 samples from 390 patients. In 356 these were detected by SPE; the other 34 had a normal SPE pattern but an abnormal kappa:lambda light-chain ratio (KLR). Only 208 of the 356 (58%) samples with bands by SPE had abnormal KLRs. Samples with MC concentrations greater than 5 g/L had a higher proportion of abnormal KLRs (75%) than those with concentrations less than 5 g/L (42%). The KLR was abnormal in 13% of samples in which no MC were visible by SPE or immunofixation electrophoresis (IFE). Compared with quantitative measurements of immunoglobulin heavy and light chains, high-quality SPE remains the method of choice for the detection of MC. Quantitative methods, however, are able to detect additional MC, especially those containing free light chains, and in the absence of SPE and IFE will detect about 75% of MC present at greater than 5 g/L.