[Some indices of congenital and acquired immunity in patients with endogenous diseases of schizophrenic spectrum disorders]

Indices of congenital leukocyte elastase (LE) activity and adaptive immunity (a level of autoantiboies to nerve growth factor--AabNGF) in blood serum of patients with schizophrenia (attack-like, continuous and slow progressive types) and schizoaffective psychosis have been compared with clinical presentations of the disorders. A patient's state was assessed by clinico-psychopathological methods and with the Positive and Negative Syndromes Scale (PANSS). All schizophrenia types and schizoaffective psychosis were accompanied by LE activity elevation. An increase of AabNGF level was observed only in attack like and continuous schizophrenia. Correlations between AabNGF level and negative symptoms evaluated, using the PANSS, suggest a relation of autoimmune reactions against NGF to the progression of schizophrenic process. Differences in AabNGF level between schizoaffective psychosis and attack-like schizophrenia confirm nosologic independence of schizoaffective psychosis and demand for additional differential laboratory diagnosis of these disorders.

Effect of stress doses of hydrocortisone on S-100B vs. interleukin-8 and polymorphonuclear elastase levels in human septic shock

Stress doses of hydrocortisone are known to have immunomodulatory effects in patients with hyperdynamic septic shock. The prognosis correlates with the presence and severity of septic encephalopathy. However, neurological evaluation is influenced by the use of analgesia sedation during artificial ventilation. The objective of this study was to demonstrate the effect of stress doses of hydrocortisone during the initial phase of human septic shock on the serum values of the neurospecific protein S-100B in comparison to the inflammation markers interleukin (IL)-8 in serum and polymorphonuclear (PMN) elastase in plasma. A total of 24 consecutive patients, who met the American College of Chest Physicians/Society of Critical Care Medicine criteria for septic shock, were enrolled in this prospective, randomized, double-blind, single-center trial. The severity of illness at recruitment was graded using the Acute Physiology and Chronic Health Evaluation II and the Simplified Acute Physiology Score II scoring systems. Multi-organ dysfunction syndrome was described by the Sepsis-related Organ Failure Assessment (SOFA) score. All patients were prospectively randomized to receive either stress doses of hydrocortisone or placebo. Hydrocortisone was started in 12 patients with a loading dose of 100mg and followed by a continuous infusion of 0.18mg/kg/h for 6days. Median S-100B serum levels of the hydrocortisone group decreased from 0.32ng/mL at study entry to 0.07ng/mL 6days later without significant differences compared to the placebo group. Initial IL-8 serum levels were significantly higher in the hydrocortisone group up to 12h after study entry, and significantly decreased from 715 to 17pg/mL at the end of the observation period. Median PMN elastase plasma levels were not affected by hydrocortisone infusion. Patients with initial S-100B serum levels >0.50ng/mL revealed significantly higher SOFA scores up to 30h, IL-8 serum levels up to 12h, and PMN elastase plasma levels up to 36h after study entry than those patients with ≤0.50ng/mL. These effects were independent of the amount of fluid correction for hemodilution. Starting S-100B, IL-8 and PMN elastase values of the hydrocortisone group were within the ranges already known in patients with out-of-hospital cardiac arrest or severe traumatic brain injury. Stress doses of hydrocortisone resulted in a significant reduction in IL-8 serum, but not in S-100B serum and PMN elastase plasma concentrations in patients with hyperdynamic septic shock. For the first time, a similar extent of S-100B increase in serum of septic patients at the time of diagnosis was shown as reported for cardiac arrest or severe traumatic brain injury.

Biosynthetic profiles of neutrophil serine proteases in a human bone marrow-derived cellular myeloid differentiation model

BACKGROUND AND OBJECTIVES

Human leukocyte elastase, proteinase 3 and cathepsin G are neutrophil granule proteins belonging to the hematopoietic serine protease superfamily. In addition to their established roles in inflammation, they have recently been implicated as regulators of granulopoiesis and mediators of apoptosis. We set out to characterize the individual biosynthetic profiles of these proteins in a neutrophil differentiation model.

DESIGN AND METHODS

CD34+CD38+ hematopoietic progenitor cells from 21 healthy human bone marrow donors were cultured in vitro in the presence of recombinant human granulocyte colony-stimulating factor (G-CSF). Biosynthetic radiolabeling was performed in cells from 13 subjects after various periods of differentiation induction. Following protein extraction, the proteins were specifically immunoprecipitated from cell lysates and media and run in gel electrophoresis. Biosynthetic profiles of azurophil granule proteins, in particular members of the neutrophil serine protease family, were examined during myeloid differentiation.

RESULTS

The onset of synthesis of myeloperoxidase, lysozyme, leukocyte elastase, and proteinase 3 occurred early after differentiation induction with G-CSF, while synthesis of cathepsin G, azurocidin, and bactericidal/permeability-increasing protein was detected somewhat later. Cathepsin G and proteinase 3 were retained intracellularly relatively efficiently, while leukocyte elastase and lysozyme were secreted to a greater extent. Cell morphology and positive immunocytochemistry for lactoferrin as well as flow cytometric analysis of selected surface antigens confirmed neutrophil-like maturation.

INTERPRETATION AND CONCLUSIONS

We demonstrate that azurophil granule proteins, including proforms of human leukocyte elastase, proteinase 3 and cathepsin G, are constitutively secreted to various degrees during in vitro myeloid differentiation of human hematopoietic progenitor cells, in addition to being stored intracellularly in active forms. These findings suggest protein-specific sorting mechanisms and may have implications for the regulation of granulopoiesis.

Elevated plasma levels of fibrin degradation products by granulocyte-derived elastase in patients with deep vein thrombosis

Plasma levels of granulocyte-derived elastase (GE-XDP), D-dimer and soluble fibrin (SF) were examined in 53 patients with deep vein thrombosis (DVT) and in 100 healthy volunteers. The mean plasma level of D-dimer was 0.92+/-0.81 microg/ml (+/-S.D.) in healthy volunteers and the mean+2 S.D. value (cutoff value for DVT) was 2.53 microg/ml, which was higher than that used in Europe and North America. Plasma levels of GE-XDP, D-dimer and SF were significantly higher in patients with DVT than in healthy volunteers, and diminished after 1 week of treatment with heparin, urokinase or tissue type plasminogen activator, though were still higher than those of the control subjects. The sensitivity of GE-XDP, D-dimer and SF for DVT was 81.1%, 75.5% and 79.2%, respectively. GE-XDP levels correlated with those of D-dimer and SF. Our results indicate that GE-XDP is a potentially useful marker for the diagnosis of DVT, suggesting that granulocytes are activated in patients with DVT. In our system, the cutoff value of D-dimer for the diagnosis of DVT is higher than in western countries, probably due to the use of different analytical assays.

[Recent advances in biochemical diagnosis and assessment of severity in acute pancreatitis]

Serum amylase is most commonly used as a biochemical marker of acute pancreatitis (AP). But it lacks specificity. The serum lipase level is more accurate and a better marker. Serum elastase -1 level is specific and remains elevated longer, but its radioimmunoassay is not routinely used. Recently, it can be rapidly measured by latex turbidometric immunoassay with automatic analyzer. Biochemically, only CRP test is available and useful to assess severity, but its sensitivity is unacceptably low in the early course of the disease. Urinary trypsinogen activation peptide (TAP) or trypsinogen-2 is an earlier marker. Increasing knowledge of the inflammatory process in AP has led to possibly useful biochemical indicators of severity, such as cytokines, nonpancreatic synovial type group II PLA2 or granulocyte elastase.

Recurrence of Pulmonary Emphysema in an α-1 Proteinase Inhibitor-deficient Lung Transplant Recipient

Several types of primary disease may recur after lung transplantation, but recurrence of pulmonary emphysema has so far never been published. We report the case of a 49-year-old white male who underwent single lung transplantation for emphysema related to alpha-1 antitrypsin deficiency and to superimposed smoking. The postoperative course was complicated by several rejection episodes. Subsequently, the patient remained stable without evidence of graft dysfunction for more than 10 years, but he resumed light smoking at 8 years after transplant. At 11 years after transplant, although the patient was still asymptomatic and had a stable lung function, recurrence of emphysema on the grafted side was diagnosed on computerized tomography of the thorax. One year later, the patient began to experience a moderate decline in lung function. Two separate bronchoalveolar lavages performed after the onset of the recurrence disclosed a significant elastolytic activity related to neutrophil serine-elastase in lavage fluid. In summary, we describe a case of recurrence of pulmonary emphysema in a patient with alpha-1 antitrypsin deficiency. The resumption of smoking has probably played a central role in the presence of elastolytic activity in lavage fluid and in the recurrence of emphysema.

Temporal changes in factors associated with neutrophil elastase and coagulation in intensive care patients with a biphasic waveform and disseminated intravascular coagulation

Summary. The biphasic waveform is an early marker of disseminated intravascular coagulation (DIC). Neutrophil elastase (NE) cleaves coagulation factors; thus, elevated elastase levels or its dysregulation by alpha-1-protease inhibitor (Alpha1PI) may be linked to DIC. Time courses over a period were determined for factors associated with NE and coagulation in 14 Intensive Care Unit patients with a biphasic waveform who developed DIC. The data were analyzed using a random coefficient linear regression model to predict the variables' mean values on day 0 and their mean rates of change over the period in which the biphasic waveform appeared. The biphasic waveform was normal on day 0, maximized on day 1, and approached normal again by day 4. Alpha1PI/NE complex levels were 2.5-fold greater than normal for the entire period. The A1PI activity, antigen, and specific activity levels were normal on day 0 and increased thereafter by 21.0, 10.5, and 8.9% of normal per day, respectively. Factor II, V, VII, IX, and X activity levels were, respectively, 57, 46, 46, 77, and 46% of normal on day 0, whereas factor VIII and fibrinogen levels were normal. All coagulation factor levels trended upward with time but not significantly. The prothrombin time, but not the activated partial thromboplastin time, was prolonged, and the platelet counts and hematocrits were below normal on day 0 and remained so thereafter. We conclude that events associated with neutrophil activation, elastase release, and perturbations of coagulation precede both the appearance of the biphasic waveform and the diagnosis of DIC in these patients.

Responses of cytokines and coagulation-fibrinolytic states to surgical stress following esophagectomy

BACKGROUND/AIMS

Surgery for esophageal cancer is one of the most invasive treatments in gastrointestinal surgery. The aim of this study was to analyze perioperative kinetics of coagulation-fibrinolytic states in comparison with cytokines in order to investigate biological responses to surgical stress in patients undergoing esophagectomy.

METHODOLOGY

Serum or plasma samples of 20 patients with esophageal cancer who had undergone esophagectomy were collected during the perioperative period. Serial concentrations of cytokines (IL-6, IL-8, IL-10), PMN-E, and coagulation-fibrinolytic agents (TAT and PIC) were measured and analyzed.

RESULTS

There were significant increases in concentrations of both inflammatory and anti-inflammatory cytokines during the operative and postoperative courses. TAT and PIC levels also increased significantly intra- and postoperatively. The TAT/PIC ratio was elevated simultaneously with a predominance of inflammatory cytokines over anti-inflammatory ones.

CONCLUSIONS

In addition to the profile of cytokines, the TAT/PIC ratio seems to be a sensitive and useful indicator in evaluating biological responses to surgical stress.

Impaired fibrinolytic potential related to elevated ?1-proteinase inhibitor levels in patients with pulmonary thromboembolism

The contribution of neutrophil leukocyte elastase (NE) to in vivo thrombolysis is still an open question. The present study examines the impact of variable levels of alpha1-proteinase inhibitor (alpha1-PI) (the major plasma inhibitor of NE) on fibrinolysis within the setting of thromboembolic diseases. Blood samples were taken from 56 patients with pulmonary thromboembolism prior to treatment. alpha1-PI and alpha1-PI-NE complex were measured in the serum and plasma with immunoturbidimetric and enzyme-linked immunosorbent assay (ELISA) methods, respectively. The fibrinolytic potential [spontaneous, tissue-type plasminogen activator (tPA) induced, and plasmin induced] of the plasma was evaluated in vitro with turbidimetric clot lysis assay. Correlation analysis (Pearson product-moment correlation coefficient, r) of the turbidimetric lysis parameters and the blood levels of alpha1-PI and alpha1-PI-NE complex was carried out. Fibrinolysis is slower in clots prepared from plasma containing elevated levels of alpha1-PI and alpha1-PI-NE complex. The maximal turbidity of the plasma clots shows significant correlation with the alpha1-PI level (r=0.39, p=0.003) and the correlation of the maximal turbidity and the tPA-induced lysis time is also significant (r=0.77, p<0.001). The lysis time correlates with the plasma level of alpha1-PI-NE complex, if fibrinolysis is induced with tPA (r=0.37, p=0.02), but not with plasmin (r=0.19, p=0.4). Our study shows that in pulmonary thromboembolism elevated levels of alpha1-PI are associated with suppressed plasma fibrinolytic potential. This effect can be at least partially explained by the coarse fibrin network structure and retarded plasminogen activator-dependent fibrinolysis.

Influence of molecule CD 11b blockade on the course of acute ceruleine pancreatitis in rats

Polymorphonuclear cells (PMN) activation is an essential step in acute pancreatitis (AP). We investigated the activation status of PMN, oxidative stress and pancreatic damage in early stage of experimental ceruleine pancreatitis in rats. The PMN action was modulated by monoclonal antibody CD 11b administration. The circulating WBC and polymorphonuclear cells count was reduced after AP induction. Chemiluminescence of whole blood PMN was remarkably reduced in AP group and increased after MoAb CD 11b administration. The CD 11b blockade significantly reduced the WBC infiltration and malondialdehyde (MDA) concentration within pancreatic gland. These data suggest that activated PMN are an important factor in early AP pathogenesis. Neutrophil aggregation within pancreatic gland modulated by monoclonal antibody CD11b contribute to the extent of injury during the early stage of ceruleine experimental pancreatitis in rats.

Neutrophil elastase inhibition in acute lung injury: Results of the STRIVE study

OBJECTIVE

Neutrophil elastase is believed to be an important mediator of acute lung injury. Sivelestat (ONO-5046, Elaspol) is a small molecular weight inhibitor of neutrophil elastase. The primary objectives of this study were to determine whether sivelestat would reduce 28-day all-cause mortality or increase the number of ventilator-free days (days alive and free from mechanical ventilation from day 1 to day 28) compared with placebo in mechanically ventilated patients with acute lung injury.

DESIGN

Multiple-center, double-blind, placebo-controlled trial administering a continuous infusion of sivelestat at a dose of 0.16 mg.kg(-1)hr(-1).

SETTING

One hundred and five institutions in the United States, Canada, Belgium, Spain, Australia, and New Zealand.

PATIENTS

A total of 492 mechanically ventilated patients with acute lung injury.

INTERVENTIONS

Patients were randomized in a 1:1 fashion to sivelestat or placebo. Study drug was administered as a continuous infusion for the duration of mechanical ventilation plus 24 hrs for a maximum of 14 days. All patients were managed using low tidal volume mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

The study was stopped prematurely at the recommendation of an external Data and Safety Monitoring Board, which noted a negative trend in long-term mortality rate. Final analysis revealed no effect of sivelestat on the primary end points of ventilator-free days (day 1-day 28) or 28-day all-cause mortality. There were 64 deaths in each treatment group within the 28-day study period, and the mean number of ventilator-free days was 11.4 and 11.9 in the sivelestat and placebo treatment groups, respectively (p =.536). There was no evidence of effect on measures of pulmonary function, including Pao2/Fio2, static lung compliance, and time to meeting weaning criteria. There was no difference in adverse events or serious adverse events between treatment groups. A comparison of the Kaplan-Meier 180-day survival curves showed no difference between treatment groups (p =.102), but there was an increase in 180-day all-cause mortality in the sivelestat treatment group compared with the placebo group (p =.006).

CONCLUSIONS

Intravenous sivelestat had no effect on 28-day all-cause mortality or ventilator-free days in a heterogeneous acute lung injury patient population managed with low tidal volume mechanical ventilation.

Neutrophil elastase and interleukin-8 as inflammatory mediators in mechanically ventilated children

BACKGROUND

Neutrophil elastase is a proteolytic enzyme which can have a destructive effect on respiratory tract structures. Interleukin-8 (IL-8), a proinflammatory cytokine, is an important chemoattractant for neutrophils. The aim of our study was to assess inflammatory states by determining elastase in complex with alpha1-proteinase inhibitor (E-alpha1PI) and IL-8 in children requiring mechanical ventilation.

MATERIAL/METHODS

Plasma and respiratory tract lavage fluid (RTLF) levels of E-a1PI and IL-8 were measured (ELISA) in 31 children with (group I) and 22 without (group II) respiratory tract infection. Plasma results were compared with a group of healthy controls. Results are given as medians and ranges. Additionally, the percentage content of neutrophils in RTLF was determined.

RESULTS

Significantly higher (p<0.00004) plasma levels of E-alpha1PI were found in group I than in group II. In group II, there were significantly higher (p<0.002) RTLF levels of E-alpha1PI and IL-8 than in group I. In both groups, the percentage content of neutrophils in RTLF exceeded 60%. A negative correlation was found between the plasma and RTLF levels of E-alpha1PI (r=-0.69; p<0.0004), between E-alpha1PI and percentage neutrophil content (r=-0.6; p<0.006), and between IL-8 and percentage neutrophil content (r=-0.5; p<0.04) in RTLF in group II.

CONCLUSIONS

The determination of E-alpha1PI and IL-8 may be useful in the assessment of the inflammatory state in children requiring mechanical ventilation.

Inflammatory response in an immunosuppressed patient with Wegener's granulomatosis

BACKGROUND

The use of cardiopulmonary bypass (CPB) triggers a systemic inflammatory response (IR), but it is not known if a similar response occurs in an immunosuppressed patient with autoimmune disease.

METHODS AND RESULTS

Observational study in a 56-year-old man receiving immunosuppressive therapy for Wegener's granulomatosis (WG) who underwent aortic valve replacement on CPB. The following markers for IR were studied in the perioperative period: C3a, C5a, neutrophil elastase (NE), interleukin eight (IL-8), white cell count (WCC) and C-reactive protein (CRP). Results were compared with published literature on the IR in patients undergoing coronary revascularisation with and without the use of CPB. All inflammatory markers increased in the perioperative period. The intensity of IR was markedly reduced compared to published literature for patients undergoing coronary revascularisation on CPB and the temporal patients and extend resembled that for off-pump.

CONCLUSION

In a patient with WG on immunosuppressive therapy the CPB-related IR is reduced.

Increased serum concentration of urinary trypsin inhibitor with asthma exacerbation

The aim of the study was to determine whether the amount of urinary trypsin inhibitor (UTI) in serum, a degenerate induced by neutrophil elastase (NE), reflects the degree of bronchial inflammation in children with acute asthma exacerbation. The involvement of neutrophil-mediated inflammation plays as important a role as eosinophil-mediated inflammation in the pathogenesis of acute asthma exacerbation. However, no measurable marker is sensitive enough to assess neutrophil-mediated inflammation in the airways. The pre-alpha-/inter-alpha-trypsin inhibitors are assumed to be precursors of UTI. NE degrades pre-alpha-/inter-alpha-trypsin inhibitors to liberate UTI. UTI concentrations in 25 childhood patients admitted with asthma exacerbation and 15 control subjects were measured by means of one-step sandwich-type enzyme immunoassay. Serum UTI concentrations in the patients at admission were significantly higher than control values (10.597+/-0.649 and 6.136+/-0.303 U x mL(-1), respectively (mean+/-SEM)). These levels returned to baseline values with improvement in the asthmatic symptoms. However, serum NE and alpha1 antitrypsin concentrations were not significantly different between patients and controls, even during acute exacerbation in the former. The findings suggest that neutrophil-mediated inflammatory events are involved in exacerbation of childhood asthma. The monitoring of urinary trypsin inhibitor concentrations might be useful for evaluating the neutrophil-mediated inflammation in childhood asthma attack.

Effects of nafamostat mesilate and minimal-dose aprotinin on blood-foreign surface interactions in cardiopulmonary bypass

BACKGROUND

The pharmacological inhibition of blood-foreign surface interactions is an attractive strategy for reducing the morbidity associated with cardiopulmonary bypass. We compared the inhibitory effects of nafamostat mesilate (a broad-spectrum synthetic protease inhibitor) and minimal-dose aprotinin on blood-surface interactions in clinical cardiopulmonary bypass.

METHODS

Eighteen patients undergoing coronary surgery were divided into three groups: (1) the control group (heparin, 4 mg/kg; n = 6), (2) the nafamostat mesilate group (heparin plus nafamostat, 0.2 mg/kg bolus followed by 2.0 mg/kg/h during cardiopulmonary bypass; n = 6), and (3) the aprotinin group (heparin plus aprotinin, 2.0 x 10(4) KIU/kg; n = 6). Platelet count, platelet aggregation, beta-thromboglobulin, prothrombin fragment F1.2, thrombin-antithrombin complex, plasminogen activator inhibitor-1, alpha2-plasmin inhibitor-plasmin complex, D-dimer, neutrophil elastase, and interleukin-6 were measured before, during, and after bypass. Bleeding times and blood loss were recorded.

RESULTS

There were no significant differences between groups in platelet count, beta-thromboglobulin, plasminogen activator inhibitor-1, interleukin-6, bleeding times, or blood loss. Platelet aggregation was better preserved at 12 hours after surgery in the nafamostat and aprotinin groups than in the control group. Prothrombin fragment F1.2, thrombin-antithrombin complex and neutrophil elastase levels were significantly reduced by aprotinin, but not by nafamostat as compared with the control group. The alpha2-plasmin inhibitor-plasmin complex and D-dimer were significantly lower with either of the drugs. Aprotinin showed better control of D-dimer than did nafamostat.

CONCLUSIONS

Nafamostat mesilate fails to reduce thrombin formation and neutrophil elastase release, whereas minimal-dose aprotinin inhibits both. Neither nafamostat nor aprotinin inhibits platelet activation. Nafamostat reduces fibrinolysis during cardiopulmonary bypass, although its effect is not as potent as aprotinin.

Plasma neutrophil lipocalin, elastase-alpha1-antitrypsin complex and neutrophil protease 4 in preterm infants with respiratory distress syndrome

Respiratory distress syndrome (RDS) and chronic lung disease of prematurity (CLD) are associated with inflammation of the airways and interstitial tissue of the lung. It is hypothesized that RDS severity and the risk of developing CLD may be correlated with neutrophil gelatinase-associated lipocalin (NGAL), a marker of leucocyte activity, human elastase-alpha1-antitrypsin complex (HEAT) or free and complexed neutrophil protease 4 (NP4), markers of proteolytic enzyme secretion from granulocytes. Thirty-three preterm infants with RDS were enrolled in the study and plasma sampled between 3 and 14 days of life. NGAL, HEAT and NP4 concentrations varied widely in infants with RDS. Significant correlations between subsequent development of CLD and plasma concentrations of HEAT and NP4, respectively, were found on days 3-4 of life, p=0.006 and p=0.02, respectively.

Leukocyte-depleted terminal blood cardioplegia provides superior myocardial protective effects in association with myocardium-derived nitric oxide and peroxynitrite production for patients undergoing prolonged aortic crossclamping for more than 120 minutes

OBJECTIVES

This study was designed to examine the myocardial protective effect of leukocyte-depleted terminal blood cardioplegia in association with nitric oxide and peroxynitrite production, especially for patients undergoing prolonged aortic crossclamping.

METHODS

Fifty-four patients (34 men, 20 women, mean age 56.7 +/- 12.7 years) undergoing aortic valve replacement were randomly allocated to one of two groups; group LDTC (n = 27) received 10 minutes of leukocyte-depleted terminal blood cardioplegic solution, and group CONT (n = 27) served as controls. Each group was subdivided into 2 groups: aortic crossclamping for less than 120 minutes in groups LDTC-S (n = 13) and CONT-S (n = 14); aortic crossclamping for 120 minutes or more in groups LDTC-L (n = 14) and CONT-L (n = 13).

RESULTS

After aortic unclamping, group LDTC-L showed higher incidence of spontaneous defibrillation (78.6% vs 30.8%, P =.0213), higher plasma nitrate + nitrite in the coronary sinus effluent (32.5 +/- 4.1 vs 28.7 +/- 3.0 micromol/L, P =.0013), lower differences between coronary sinus effluent and arterial blood in the percentage ratio of nitrotyrosine to tyrosine (myocardium-derived peroxynitrite; 2.987% +/- 0.576% vs 3.951% +/- 0.952%, P =.0036), and plasma polymorphonuclear-elastase (113.9 +/- 21.3 vs 155.5 +/- 41.6 microg/L, P =.0029) and malondialdehyde (2.75 +/- 0.67 vs 4.02 +/- 0.96 micromol/L, P =.0005) than group CONT did. Postoperatively, group LDTC-L showed lower human-heart fatty acid-binding protein (111.4 +/- 25.2 vs 156.4 +/- 38.6 IU/L, P =.0013), lower creatine kinase-muscle and brain (19.2 +/- 4.7 vs 24.8 +/- 6.5 IU/L, P =.0120), and smaller requirement of catecholamine (5.44 +/- 2.29 vs 8.45 +/- 3.42 microg x kg(-1) x min(-1), P =.0122). There were no significant differences in these parameters between groups LDTC-S and CONT-S.

CONCLUSIONS

This study demonstrated that leukocyte-depleted terminal blood cardioplegia provided superior myocardial protective effects and regulated myocardial-derived nitric oxide and peroxynitrite production only for patients undergoing aortic crossclamping for more than 120 minutes. The results suggest that prolonged aortic crossclamping deteriorates the tolerance to leukocyte-mediated myocardial injury accompanied by endothelial dysfunction associated with nitric oxide and peroxynitrite production.

Pentoxifylline is as effective as leukocyte depletion for modulating pulmonary reperfusion injury

OBJECTIVE

Previous studies have suggested the amelioration of lung reperfusion injury when initial reperfusion is undertaken with leukocyte-depleted blood. Pharmacologic agents, such as pentoxifylline, are also effective, but no previous studies have demonstrated which is superior. We investigated these agents in a porcine model of left single-lung transplantation.

METHODS

Donor lungs were preserved with modified Euro-Collins solution for a mean ischemic time of 18.6 hours. Gas exchange, pulmonary vascular resistance, neutrophil elastase level, and free radical release (measured on the basis of malonaldehyde levels) were assessed over a 12-hour period. Group A (n = 5) was a control group with no interventions added. Group B was reperfused through an extracorporeal circuit incorporating a leukocyte-depleting filter for 30 minutes before conventional blood flow was restored. Group C was reperfused with the addition of intravenous pentoxifylline (2 mg x kg(-1) x h(-1)).

RESULTS

Groups B and C were similar in terms of oxygenation, pulmonary vascular resistance, and free radical release. Group B displayed increased levels of neutrophil elastase. Both groups were superior with regard to these outcome measures compared with control group A.

CONCLUSIONS

Pentoxifylline, when administered to recipient animals, attenuates reperfusion injury to a degree similar to that seen with leukocyte-depleted reperfusion. This technique is simple, safe, and as effective as using a more complex extracorporeal circuit incorporating a leukocyte-depleting filter to ameliorate acute lung injury.

Pathological uterine perfusion in the second trimester is not associated with neutrophil activation

OBJECTIVE

Preeclampsia and intrauterine growth retardation (IUGR) are associated with elevated concentrations of myeloperoxidase (MPO) and polymorphonuclear (PMN) elastase, which indicate maternal neutrophil activation. The aim of the study was to measure maternal MPO and PMN elastase plasma concentrations in second trimester pregnancies with pathological uterine perfusion that are a high risk group for preeclampsia and IUGR, and compare them to normal controls.

METHODS

The study includes 25 pregnancies with normal and 25 pregnancies with pathological uterine perfusion. In both groups, doppler-sonographic measurement of uterine perfusion was performed in the twenty-first week of gestation. Maternal plasma concentrations of MPO and PMN elastase were measured using a specific ELISA for both enzymes.

RESULTS

The plasma MPO concentration of pregnant women with normal perfusion did not differ significantly from that of the group with pathological perfusion (27.4 +/- 3.3 vs. 23.7 +/- 2.0 ng/mL). Likewise, the plasma PMN elastase-concentration also did not show a significant difference between the groups (5.7 +/- 0.5 ng/mL normal vs. 8.0 +/- 1.0 ng/mL pathological). Patients with pathological perfusion that later developed preeclampsia or IUGR (9/25) showed unchanged MPO and PMN elastase values in the second trimenon compared to those with pathological perfusion and normal outcome.

CONCLUSIONS

Pathological uterine perfusion in the second trimester was not associated with maternal neutrophil activation. The measurement of the MPO and PMN elastase concentration suggested that neutrophil activation in preeclampsia or IUGR is a secondary effect of the disease rather than a primary pathophysiological factor.

ONO-6818, a novel, potent neutrophil elastase inhibitor, reduces inflammatory mediators during simulated extracorporeal circulation

BACKGROUND

Among the serine proteases, neutrophil elastase is a powerful cytotoxic enzyme and plays a pivotal role in the inflammatory response associated with cardiopulmonary bypass. This study assesses the effects of the specific inhibition of neutrophil elastase by a novel, potent, low-molecular-weight neutrophil elastase inhibitor, ONO-6818. We hypothesized that ONO-6818 reduces inflammatory mediators and modulates adhesion molecules and the deformability of neutrophils during simulated extracorporeal circulation.

METHODS

Simulated extracorporeal circulation was established by recirculating fresh heparinized (3.75 U/mL) human blood for 120 minutes in a membrane oxygenator and a roller pump with and without 1.0 micromol/L of ONO-6818 (n = 9 for control group, n = 7 for ONO-6818 group). The neutrophil adhesion molecules, CD11b and L-selectin, and the cytoplasmic F-actin of neutrophils were measured by flow cytometry. Neutrophil deformability was evaluated using simulated silicon microcapillaries. Neutrophil elastase, interleukin 8, and C5b-9 were measured using enzyme immunoassay.

RESULTS

Neutrophil elastase levels were significantly lower in the ONO-6818 group. ONO-6818 significantly reduced interleukin 8 and C5b-9 production. ONO-6818 did not modulate changes of CD11b and L-selectin during recirculation. Cytoplasmic F-actin content and changes of neutrophil deformability did not significantly differ between the groups.

CONCLUSIONS

Inhibition of neutrophil elastase activity with ONO-6818 reduces further interleukin 8 production and the formation of the complement membrane attack complex, and this results in a reduction of neutrophil elastase levels during simulated extracorporeal circulation. This study suggests that specific neutrophil elastase inhibition with ONO-6818 is a feasible therapeutic option to attenuate the exaggerated inflammatory response associated with cardiopulmonary bypass.

Association between inflammatory mediators and the fibrinolysis system in infectious pleural effusions

The response of the fibrinolytic system to inflammatory mediators in empyema and complicated parapneumonic pleural effusions is still uncertain. We prospectively analysed 100 patients with pleural effusion: 25 with empyema or complicated parapneumonic effusion, 22 with tuberculous effusion, 28 with malignant effusion and 25 with transudate effusion. Inflammatory mediators, tumour necrosis factor-alpha (TNF-alpha), interleukin-8 (IL-8) and polymorphonuclear elastase, were measured in serum and pleural fluid. Fibrinolytic system parameters, plasminogen, tissue-type plasminogen activator (t-PA) and urokinase PA, PA inhibitor type 1 (PAI 1) and PAI type 2 concentrations and PAI 1 activity, were quantified in plasma and pleural fluid. The Wilcoxon signed-rank test was used to compare plasma and pleural values and to compare pleural values according to the aetiology of the effusion. The Pearson correlation coefficient was used to assess the relationship between fibrinolytic and inflammatory markers in pleural fluid. Significant differences were found between pleural and plasma fibrinolytic system levels. Pleural fluid exudates had higher fibrinolytic levels than transudates. Among exudates, tuberculous, empyema and complicated parapneumonic effusions demonstrated higher pleural PAI levels than malignant effusions, whereas t-PA was lowest in empyema and complicated parapneumonic pleural effusions. PAI concentrations correlated with TNF-alpha, IL-8 and polymorphonuclear elastase when all exudative effusions were analysed, but the association was not maintained in empyema and complicated parapneumonic effusions. A negative association found between t-PA and both IL-8 and polymorphonuclear elastase in exudative effusions was strongest in empyema and complicated parapneumonic effusions. Blockage of fibrin clearance in empyema and complicated parapneumonic effusions was associated with both enhanced levels of PAIs and decreased levels of t-PA.

[Immune status in children with psychomotor development disturbances]

Leukocyte elastase (LE) activity and autoantibodies to nerve growth factor (NGF) level as indexes of innate and adaptive immunity have been studied in children with psychomotor development disturbances of cerebral organic origin. LE activity was elevated in mild and moderate degrees of psychomotor disturbances caused by perinatal encephalopathy. In psychomotor disturbances of cerebral organic origin, higher LE activity was accompanied by a significant increase of autoantibodies to NGF titers. Correlations between immunological parameters and some clinical symptoms were found. The results obtained suggest involvement of innate and adaptive immune system links in pathophysiology of psychomotor development disturbances in children.

[Usefulness of determination of granulocyte elastase plasma level, c-reactive protein and white blood cell count in prediction in intrauterine infection in pregnant women after PROM]

The main markers of intrauterine infection: C-reactive protein and white blood cell count are dependent on medical management as steroids or antibiotics therapy. Granulocyte elastase is independent variable from influence of tocolysis, steroids, antibiotics, chemiotherapeutics, hours since PROM. The aim of the study was to evaluate and compare the usefulness of determination granulocyte elastase, (EG) C-reactive protein (CRP) and white blood cell count (WBC) in prediction of chorioamninitis in pregnant women after premature rupture of fetal membranes.

MATERIALS AND METHODS

67 women with single pregnancy between 24-36 week of gestation after PPROM were included into the study group. All women were managed expectantly (tocolysis, antibiotics, steroids, intravaginal chemiotherapeutics, bed rest), maternal and fetal (KTG, USG) vital signs were monitored every day. EG, CRP and WBC blood test were performed every day. Histopathologic examinations of all placentas were performed for chorioamnionitis confirmation or exclusion. Normal range for EG--88 micrograms/l, CRP--15 micrograms/l, WBC--15 x 10(9).

RESULTS

The usefulness of granulocyte elastase plasma serial determination as biochemical marker of chorioamnionitis in cases of PPROM was confirmed: sensitivity--100%, specificity--33%, PPV--64.9%, NPV--100% in comparison with CRP: sensitivity--27%, specificity--80%, PPV--62.5%, NPV--47% and white blood cell count: sensitivity--27%, specificity--66.7%, PPV--50%, NPV-42.5%.

CONCLUSIONS

We confirmed statistical correlation (p < 0.001) between granulocyte elastase plasma level > 88 micrograms/l and histological signs of intrauterine infection in pregnant women after PPROM. Granulocyte elastase determination in plasma is most sensitive indicator of histologic confirmed chorioamnionitis.

Effect of prolonged exercise and carbohydrate on total neutrophil elastase content

PURPOSE

The purpose of the present study was twofold: first, to assess the effect of prolonged intense exercise on total neutrophil elastase content in endurance-trained cyclists and to determine whether this is associated with postexercise falls in lipopolysaccharide (LPS)-stimulated neutrophil elastase release; and second, to determine the effect of carbohydrate (CHO) ingestion during exercise on these responses.

METHODS

In a randomized design, nine trained male cyclists cycled for 2 h at 75% VO(2max) on two occasions with either CHO (6.4%, i.e., 64 g x L-1) or placebo (PLA) beverage ingestion before (5 mL x kg-1), during (2 mL x kg-1), and after (5 mL x kg-1) the exercise. Venous blood samples were obtained at rest, immediately postexercise, and at 1 h postexercise.

RESULTS

After exercise, CHO ingestion was associated with a higher plasma glucose concentration (P < 0.05) and fewer numbers of circulating neutrophils compared with the PLA trial (P < 0.01). Neither exercise nor CHO ingestion affected total neutrophil elastase content, yet LPS-stimulated neutrophil elastase release fell postexercise by approximately 47% on the PLA trial (P < 0.01). Values did not change significantly from preexercise on the CHO trial.

CONCLUSIONS

These findings suggest that neither exercise nor CHO-beverage ingestion influences the total elastase content of neutrophils. Therefore, changes in neutrophil elastase content cannot account for the fall in LPS-stimulated neutrophil elastase release after prolonged intense exercise or for the blunting of this response with CHO ingestion.

Treatment of relapsed B-cell non-Hodgkin's lymphoma with a combination of chimeric anti-CD20 monoclonal antibodies (rituximab) and G-CSF: final report on safety and efficacy

Antibody-dependent cellular cytotoxicity (ADCC) is one of the possible mechanisms of action of the chimeric CD20 monoclonal antibody IDEC-C2B8 (rituximab). As granulocyte-colony stimulating factor (G-CSF) greatly enhances the cytotoxicity of neutrophils in ADCC, the efficacy of rituximab might be enhanced by the addition of G-CSF. In a phase I/II clinical trial, we investigated the safety and efficacy of the combination of rituximab and G-CSF (5 microg/kg/day, administered for 3 days, starting 2 days before each infusion) in 26 relapsed low-grade lymphoma patients. Adverse events occurred in 25/26 patients and mainly consisted of (grade I/II) fever (29%) and allergic reactions (19%). In phases I and II (375 mg/m(2) rituximab+G-CSF), 19 patients were evaluable for efficacy. The response rate was 42% (8/19; 95% CI 20-67%), with 16% (3/19) complete remissions and 26% (5/19) partial remissions. The median duration of response was 18 months, the median time to progression was 24 months. We conclude that the combination of rituximab and G-CSF is well tolerated. Although the overall response rate seems comparable to that reported for rituximab monotherapy, remission duration in this pilot phase II study is remarkably long. Randomized comparison with rituximab monotherapy should substantiate this promising finding.