Administration of C1 inhibitor reduces neutrophil activation in patients with sepsis

Forty patients with severe sepsis or septic shock recently received C1 inhibitor. In the present study we studied the effect of C1 inhibitor therapy on circulating elastase-alpha(1)-antitrypsin complex (EA) and lactoferrin (LF) levels in these patients to gain further insight about agonists involved in the activation of neutrophils in human sepsis. Elevated levels of EA and LF were found in 65 and 85% of the septic patients, respectively. Patients with elevated EA levels had higher organ dysfunction scores, higher levels of cytokines, and higher levels of complement activation products than patients with normal EA levels. C1 inhibitor therapy reduced EA as well as complement activation and IL-8 release in the patients with elevated EA on admission. We conclude that neutrophil activation in human sepsis correlates with the severity of organ dysfunction and involves complement and interleukin-8 as agonists. The effect of C1 inhibitor therapy on neutrophils may provide an explanation for the beneficial, although mild, effects of this treatment on organ dysfunction in sepsis.

Evidence of impaired microvascular function in pre-eclampsia: a non-invasive study

The clinical presentation of pre-eclampsia suggests that microvascular dysfunction may play a role in the maternal manifestations of the disease. Isovolumetric venous pressure ( P V(i)) is an index of microvascular function, reflecting local plasma colloid osmotic (oncotic) pressure, and is abnormal in clinical conditions with microvascular dysfunction. We hypothesized that, in pre-eclampsia, post-capillary margination of neutrophils would increase post-capillary resistance, and therefore P V(i). A small cumulative step strain-gauge plethysmography protocol was used to compare P V(i) in 18 women with pre-eclampsia, 16 normal pregnant women and 17 non-pregnant controls. Circulating levels of vascular cell-adhesion molecule-1 (VCAM-1), intercellular cell-adhesion molecule-1 (ICAM-1) and E-selectin, and neutrophil elastase, were measured to assess endothelial and neutrophil activation respectively. P V(i) was significantly greater in the pre-eclampsia group, relative to the normal pregnant and non-pregnant controls ( P <0.001, ANOVA, for both comparisons). P V(i) was significantly lower during normal pregnancy compared with the non-pregnant controls ( P =0.001). Plasma levels of neutrophil elastase, VCAM-1, ICAM-1 and E-selectin ( P =0.001) were significantly greater in the pre-eclamptics than the controls. Significant positive correlations were observed between P V(i) and neutrophil elastase ( r =0.71, P =0.001), VCAM-1 ( r =0.52, P =0.03), ICAM-1 ( r =0.67, P =0.002), E-selectin ( r =0.69, P =0.001), uric acid levels ( r =0.54, P =0.02) and haematocrit ( r =0.64, P =0.004) in pre-eclampsia. The relationship with the platelet count was negative ( r =-0.65, P =0.003). No significant correlations were observed between P V(i) and maternal age, gestational age, total protein, albumin, diastolic blood pressures, age, body mass index and infant birth mass in the normal pregnant and non-pregnant controls. These data suggest that microvascular dysfunction occurs in pre-eclampsia, and that it is related to alterations in endothelial cell and neutrophil activation.

[Significance of neutrophil elastase in diagnosis of male genital tract infection]

Neutrophil Elastase(NE) is a kind of neutral proteinase. Its value in the diagnosis of male genital tract infection has attracted increasing attention in recent years. NE has special diagnostic value in screening the typical genital tract infection caused by Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum and Trichomonas, as well as other kinds of genital infection, such as leukocytospermia and periorchitis. NE has been considered as a specific marker of the male genital tract infection.

Serum profiles of E-selectin, interleukin-10, and interleukin-6 and oxidative stress parameters in patients with acute pancreatitis and nonpancreatic acute abdominal pain

INTRODUCTION

Excessive inflammatory response is one of the major causes of early mortality in acute pancreatitis (AP).

AIM

To evaluate the serum profiles of E-selectin, interleukin (IL)-6, and IL-10 along with their correlation to the markers of oxidative stress and neutrophil activation in patients with AP and patients with nonpancreatic acute abdominal pain (NPAAP).

METHODOLOGY

This prospective clinical study included 56 patients with AP (28 with mild AP and 28 with severe AP) as well as 15 patients with NPAAP.

RESULTS

Serum concentrations of E-selectin, IL-10, and IL-6 and plasma concentrations of polymorphonuclear leukocyte elastase (determined on days 1-3, 5, and 10 after admission) were the highest in severe AP during the first 3 days and then declined. At day 10, the E-selectin level in severe AP was still higher than that in mild AP, and the IL-10 concentration increased again. There was no elevation in the E-selectin concentration in NPAAP patients, and IL-10 levels remained unchanged in mild AP. Oxidative stress, measured by serum malondialdehyde and 4-hydroxyalkenals levels, was the most pronounced in severe AP.

CONCLUSIONS

The serum E-selectin concentration is markedly elevated in severe AP and is less in mild AP but not in NPAAP. It may result from stimulation with different inflammatory mediators or indicate vascular endothelium injury mediated by oxidative stress, especially in the severe form of AP.

Influence of two different perfusion systems on inflammatory response in pediatric heart surgery

BACKGROUND

This study tests the hypothesis that a cardiopulmonary bypass system that combines complete heparin-coating, a centrifugal pump, and a closed circuit in comparison with a conventional system (uncoated system, roller pump, and hard shell venous reservoir) attenuates the inflammatory response in pediatric heart surgery.

METHODS

In a prospective randomized controlled clinical study 40 consecutive children weighing 10 kg or less were included and divided into two groups. Concentrations of complement proteins (C3a, sC5b-9, C4d, and Bb), granulocyte degranulation products (polymorphonuclear [PMN] elastase), and proinflammatory cytokines (tumor necrosis factor [TNF]-alpha, interleukin [IL]-6, and IL-8) were measured.

RESULTS

C3a and sC5b-9 concentrations were lower (C3a, p < 0.001; sC5b-9, p = 0.01) in the combined (heparin-coated/centrifugal pump/closed reservoir) group, the peak values being 58% and 37% of conventional group values. The Bb- and C4d-fragment values indicated activation of the complement system through the alternative pathway in both groups. PMN elastase concentrations were lower (p = 0.02) in the combined group, the peak values being 43% of conventional group values. There were no significant intergroup differences regarding TNF-alpha, IL-6, or IL-8 concentrations.

CONCLUSIONS

The use of a fully heparin-coated system, a centrifugal pump, and a closed circuit during CPB in children (10 kg or less) leads to a lower degree of complement activation and PMN elastase release compared with a conventional system.

Effects of portal vein embolization before major hepatectomy

BACKGROUND/AIMS

Major hepatectomy can now be successfully performed after portal vein embolization, but the effects of portal vein embolization have not been clearly delineated. Our objective is to examine whether portal vein embolization really contributes to the success of major hepatectomy.

METHODOLOGY

Thirty-eight patients underwent portal vein embolization and hepatectomy of two subsegments or more. They all belonged to a high-risk group according to a prognostic score. We selected 9 of 38 patients with liver metastases (PE-meta group) and 32 patients who had undergone hepatectomy without portal vein embolization (non-PE-meta group) during the study period to compare the serum levels of total bilirubin after hepatectomy. Fifteen of 38 patients had the levels of polymorphonuclear leukocyte elastase and thrombin-antithrombin complex examined after hepatectomy (PE group) and so did 20 patients without portal vein embolization (non-PE group).

RESULTS

The maximum levels of total bilirubin in non-PE-meta group correlated with the percentage of hepatic parenchyma to be resected. In the patients receiving portal vein embolization, the pre-PE and post-PE levels were both below the regression. Similar shifts were seen in the graphs of polymorphonuclear leukocyte elastase and thrombin-antithrombin complex.

CONCLUSIONS

The effects of preoperative portal vein embolization on safety in major hepatectomy were proved by its suppression of rise in total bilirubin, polymorphonuclear leukocyte elastase and thrombin-antithrombin complex after hepatectomy.

[Changes of urinary tripsin inhibitor in blood and urine, as well as serum cytokines in living related liver transplantation]

BACKGROUND

Living related liver transplantation induces the production of many inflammatory and anti-inflammatory cytokines. Urinary tripsin inhibitor (UTI) is produced in the liver and wellknown as one of the markers of surgical stress.

METHODS

To clarify the significance of UTI in blood and urine and serum cytokines in living related liver transplantation, we examined the changes of UTI, polymorphonuclear elastase (PMNE), interleukin (IL)-6, IL-1 ra and IL-10 perioperatively.

RESULTS

UTI in blood increased gradually after operation. It increased from 5.2 +/- 2.2 U.ml-1 at the end of operation to 19.4 +/- 7.5 U.ml-1 on the 10 th postoperative day (POD). Similarly, UTI in urine increased after operation and the peak was on the 7th POD. Cytokines including IL-6, IL-1 ra and IL-10 showed similar changes in general gastrointestinal surgery, but the peak values in liver transplantation were lower.

CONCLUSION

These results demonstrate that the recovery of the transplanted liver function require certain time after operation and UTI in urine could be an important marker whether the liver is working or not. The immunosuppressive drugs, like steroid, administered during and after operation would suppress the production of cytokines.

Influence of PMEA-coated bypass circuits on perioperative inflammatory response

BACKGROUND

Poly(2-methoxyethylacrylate) (PMEA) is a new coating material, and several experimental studies have revealed excellent biocompatibility of PMEA-coated cardiopulmonary bypass circuits. The clinical utility of the PMEA-coated circuits was compared with that of uncoated circuits, focusing on perioperative inflammatory response.

METHODS

Twenty-two patients were randomized to PMEA-coated (group P; Capiox RX25; n = 11) or uncoated (group U; Capiox SX10; n = 11) circuit group, and underwent coronary artery bypass grafting and/or valve operations. The following markers, as well as clinical outcomes, were analyzed perioperatively: (a) complement activation by C3a (including C3a-desArg) concentrations; (b) leukocyte activation by polymorphonuclear-elastase concentrations; (c) acute phase inflammatory response by interleukin-6 concentrations; and (d) platelet preservation by number of platelets.

RESULTS

The maximal values of C3a and polymorphonuclear-elastase were significantly lower in group P than in group U. The intergroup difference of interleukin-6 was not significant. Although preservation of platelets was significantly better in group P until 1 hour after initiating cardiopulmonary bypass, no significant intergroup difference was observed thereafter. The duration of postoperative mechanical ventilation revealed no significant intergroup difference.

CONCLUSIONS

The PMEA-coated circuits exhibited better suppression of perioperative complement and leukocyte activation than the uncoated circuits. In addition, the price of the PMEA-coated circuits is the same as that of the uncoated circuits. Therefore, we judged that the clinical utility of the PMEA-coated circuits is superior to those of the uncoated circuits.

Biocompatibility of poly2methoxyethylacrylate coating for cardiopulmonary bypass

The systemic inflammatory response to cardiopulmonary bypass (CPB) may contribute to the development of postoperative complications. Heparin-coated circuits and poly2methoxyethylacrylate (PMEA)-coated circuits have been developed to reduce the risk of such complications. We compared the biocompatibility of these circuits. Twelve patients scheduled to undergo elective coronary artery bypass grafting (CABG) with CPB were assigned to CPB with a PMEA-coated circuit (PMEA-coated group, n=6) or a heparin-coated circuit (heparin-coated group, n=6). The plasma concentrations of the following inflammatory markers were measured before CPB and just after, 4 hours after, and 24 hours after the termination of CPB: cytokines (interleukin [IL]-6, IL-8, IL-10), complement factor (C3a), polymorphonuclear elastase (PMNE), and coagulofibrinolytic factors (thrombin-antithrombin III complex [TAT], D-dimer). Postoperative clinical response was evaluated on the basis of respiratory index, blood loss, and the postoperative and preoperative body-weight percent ratio. There were no significant differences between the groups in the plasma concentrations of IL-6, IL-10, C3a, PMNE, TAT, or D-dimer. Plasma IL-8 concentrations were below the assay detection limits at all time points in both groups. Clinical variables did not differ significantly between the groups. In conclusion, PMEA-coated CPB circuits are as biocompatible as heparin-coated CPB circuits and prevent postoperative organ dysfunction in patients undergoing elective CABG with CPB.

Comparison of surgical stress between laparoscopic and open colonic resections

BACKGROUND

The magnitude of surgical trauma after laparoscopic and open colonic resection was evaluated by examining postoperative serum values of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and granulocyte elastase (GE) for further evidence of the benefit realized with minimally invasive approaches in colonic surgery.

METHODS

Altogether, 42 patients with Crohn's disease (n = 20) or colon carcinomas/adenomas (n = 22) were matched by age, gender, body mass index (BMI), and Crohn's Disease Activity Index for either a laparoscopic (n = 21) or an open colonic resection (n = 21). In both groups the postoperative serum levels of IL-6, IL-10, C-RP, and granulocyte elastase were determined, as indicators of surgical stress.

RESULTS

Laparoscopic and open colonic resection caused a significant increase in serum IL-6, IL-10, CRP, and granulocyte elastase levels. The comparison between laparoscopic and open colonic resections, however, showed significantly lower serum IL-6, IL-10, CRP, and granulocyte elastase levels after laparoscopic colonic resection, which was most evident for IL-6 and granulocyte elastase.

CONCLUSIONS

Our study demonstrated that IL-6 and granulocyte elastase may be appropriated particularly to monitor surgical stress. By using these parameters, we found a significant reduction in surgical trauma after laparoscopic surgery, was compared with the open procedure. This supports the clinical findings of a clear benefit for patients undergoing laparoscopic colonic surgery.

Imbalances between the levels of tissue factor and tissue factor pathway inhibitor in ARDS patients

INTRODUCTION

To evaluate the pathogenetic role of tissue factor (TF), tissue factor pathway inhibitor (TFPI), and neutrophil elastase in acute respiratory distress syndrome (ARDS), as well as to test the hypothesis that TFPI levels modified by neutrophil activation are not sufficient to prevent TF-dependent intravascular coagulation, leading to sustained systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), which determine the prognosis of these patients.

MATERIALS AND METHODS

The study subjects consisted of 55 patients with trauma and sepsis who were divided into three groups according to the Lung Injury Score. Ten normal healthy volunteers served as control. Plasma levels of TF, TFPI, and neutrophil elastase were measured on the day of injury or the day of diagnosis of sepsis (day 0) and days 1 through 4. The number of SIRS criteria that the patient met and the disseminated intravascular coagulation (DIC) score is determined daily.

RESULTS

Patients (15) developed ARDS, 23 were at risk for but did not develop the syndrome, and 17 patients were without risk for ARDS. TF and neutrophil elastase levels in ARDS patients were persistently higher than those in other two groups and control subjects. However, the TFPI levels showed no difference among the three groups, which retained normal or slightly elevated levels compared to the control subjects. DIC scores did not improve and SIRS continued during the study period in patients with ARDS. The ARDS patients showed higher numbers of dysfunctioning organs and associated with poorer outcome than the other two groups.

CONCLUSION

Systemic activation of the TF-dependent pathway not adequately balanced by TFPI is one of the aggravating factors of ARDS. High levels of neutrophil elastase released from activated neutrophils may explain the imbalance of TF and TFPI. Persistent DIC and sustained SIRS contribute to MODS, determining the prognosis of ARDS patients.

Serum neutrophil elastase levels predict initial clinical condition but do not correlate with the progression of interstitial lung disease

BACKGROUND

Recent publications have suggested that neutrophil elastase (NE) may have a role in evaluating the clinical condition of patients with interstitial lung diseases (ILD). This study aims to evaluate the role of serum NE levels in the follow-up of patients with ILD.

MATERIAL/METHODS

A group of 100 consecutive patients diagnosed with various ILDs were prospectively studied on two successive visits. On the first visit, the clinical condition of each patient was assessed, and blood count, pulmonary function tests, chest x-ray and serum NE levels (by latex agglutination assay) were performed on all patients. On the second visit, 8 months later, the patients were classified in two groups: those with unfavorable progression and those who were either in the same clinical status or showed good progression.

RESULTS

There was a weak correlation between NE and age (r= -0.383; p < 0.0005). Sex, age, NE and the treatment received were found to be independent predictors of the initial clinical condition. Multivariate analysis including these variables demonstrated that higher levels of serum NE predicted the worst clinical presentation (odds ratio: 4.392; 95% CI: 1.665 - 11.586; p = 0.003). However, none of the variables were found to be significantly different when the progression of the disease was assessed.

CONCLUSIONS

Although NE seems to be a good marker for the initial clinical condition in this group of diseases, its role as a prognostic factor could not be proven

Combined activation of coagulation and inflammation has an important role in multiple organ dysfunction and poor outcome after severe trauma

We tested the hypothesis that activated neutrophil-endothelial cell interaction in DIC can cause endothelial injury contributing to multiple organ dysfunction syndrome (MODS) and a poor outcome after trauma. Fifty-eight severe trauma patients, 29 with DIC and 29 without DIC were studied. Serial levels of soluble L-, P-, and E-selectins, ICAM-1, VCAM-1, thrombomodulin, and neutrophil elastase were measured on days 0-4 after trauma. The numbers of systemic inflammatory response syndrome (SIRS) criteria that patients met were determined, simultaneously. In the DIC patients, higher DIC scores, lower platelet counts, and a longer duration of SIRS were found compared with the non-DIC patients. The incidence of ARDS and MODS were higher in patients with DIC than in those patients without DIC, and the DIC patients had poor outcome. Soluble L-selectin (sL-selectin) level on Day 1 in the DIC patients who died was markedly lower than those in the non-DIC patients. The levels of sP- and sE-selectins, sICAM-1, and sVCAM-1 were more elevated in the patients with DIC than in those without DIC on days 2 to 4. Neutrophil elastase and sThrombomodulin levels in the DIC patients persistently increased during the study period compared to those in the non-DIC patients. Maximum DIC scores in the DIC group showed good correlations with peak levels of sICAM-1, sVCAM-1, neutrophil elastase, sThrombomodulin, and the number of dysfunctioning organs. Highly activated and sustained inflammation caused by neutrophil-endothelium interaction in DIC gives rise to MODS and poor outcome in patients with severe trauma. These results suggest a close relationship between inflammation and thrombosis in posttrauma DIC.

Improvement of bypass circuit biocompatibility: comparison and combination of heparin-coated circuit and nitric oxide gas infusion

OBJECTIVES

Nitric oxide (NO) gas infusion to the oxygenator, as well as heparin-coated bypass circuits, have been reported to attenuate blood activation induced by the interaction with the artificial surfaces of an extracorporeal bypass circuit. Using a mock circulation model, we compared the effect of each and also evaluated the effect of their combination on attenuating bypass-induced blood activation.

METHODS

A miniature closed bypass circuit was primed with diluted fresh human blood and perfused for 180 minutes using a centrifugal pump. NO gas (0, 50, or 100 ppm) was infused to the oxygenator sweep gas of either a non-heparin-coated or a heparin-coated circuit. Platelet counts, beta-thromboglobulin, platelet factor 4, complement-3 activation products and granulocyte elastase were measured at 0, 30, 60, 120, and 180 minutes after starting the perfusion.

RESULTS

One hundred ppm of NO was statistically equivalent to the heparin-coated circuit for attenuating bypass-induced blood activation, and a combination of the two significantly surpassed the results of either modification alone. Fifty ppm of NO alone provided only a slight attenuation of blood activation as compared with the non-heparin-coated circuit, though the difference was not significant. A combination of 50 ppm NO and the heparin-coated circuit did not significantly enhance the effects of the heparin-coated circuit alone.

CONCLUSIONS

The combination of NO gas infusion and heparin-coated circuits appears to be a useful and promising modification for enhancing the attenuation of bypass-induced blood activation, though the optimal dose of NO infusion in terms of effectiveness and adverse effects to the whole body remains to be established.

Marked activation of complement and leukocytes and an increase in the concentrations of soluble endothelial adhesion molecules during cardiopulmonary resuscitation and early reperfusion after cardiac arrest in humans

OBJECTIVE

Animal studies have demonstrated that reperfusion disorders occurring after cardiac arrest affect outcome. Reperfusion injury can be caused by activation of complement, polymorphonuclear leukocytes (PMN), and PMN-endothelial interaction. We studied different specific markers of these processes during and after cardiopulmonary resuscitation in humans.

DESIGN

Prospective clinical trial.

SETTING

University hospital.

PATIENTS

A total of 55 patients who underwent out-of-hospital cardiopulmonary resuscitation for nontraumatic causes.

INTERVENTIONS

Blood samples were drawn immediately, 15 mins, and 30 mins after initiation of cardiopulmonary resuscitation. In the case of restoration of spontaneous circulation, additional blood samples were taken at serial time points until 7 days after cardiac arrest.

MEASUREMENTS AND MAIN RESULTS

A marked activation of complement and PMN was found in all patients investigated. Serum concentrations of specific activation markers of the complement system, anaphylatoxin C3a and the soluble membrane attack complex SC5b-9, and PMN elastase were increased during cardiopulmonary resuscitation and for </=48 hrs after restoration of spontaneous circulation. Compared with controls at 30 mins after initiation of cardiac massage, concentrations of C3a, SC5b-9, and PMN elastase were increased in patients without and in those with restoration of spontaneous circulation. PMN elastase concentrations were significantly greater in patients without restoration of spontaneous circulation than in those who could be stabilized. In addition, the plasma concentrations of the soluble P-selectin were significantly increased between 15 mins and 24 hrs after the start of cardiopulmonary resuscitation. The concentrations of soluble intercellular adhesion molecule-1 were increased between 2 hrs and 72 hrs.

CONCLUSIONS

Our data clearly demonstrate a marked activation of complement and PMN and an increased PMN-endothelial interaction during cardiopulmonary resuscitation and early reperfusion after cardiac arrest in humans. These changes are known to induce reperfusion disorders and tissue injury and point to new therapeutic options to improve outcome after cardiac arrest.

[Reliability of polymorphonuclear elastase for the diagnosis of neonatal sepsis]

Infections are a major problem in neonatal intensive care units throughout the world, and early diagnosis and therapy would certainly reduce associated morbidity and mortality as well as decrease unnecessary antibiotic treatment.

OBJECTIVES

To evaluate the usefulness of polymorphonuclear elastase (PMN-E) serum concentration as an early indicator of neonatal sepsis in comparison with routinely used infection markers.

METHODS

PMN-E was measured in 74 newborns with suspicion of systemic bacterial infection treated in a tertiary intensive care unit. The measurements were performed with commercially available enzyme immunoassay (Milenia).

RESULTS

Mean PMN-E value in non-infected newborns was 38.85 ng/ml, and for infected 184.12 ng/ml (p < 0.05) (t-student test). The sensitivity to the diagnosis of culture--proven bacterial systemic infection was 76% for PMN-E, 60% for C-reactive protein, 59% for the immature to total neutrophil ratio and 56% for the total white blood cell count. The corresponding specificity amounted to 81%, 86%, 100% and 80% respectively.

CONCLUSION

Serum PMN-E level determination yields diagnostic advantages in comparison with infection markers routinely used in sepsis screen and may serve as a valuable early indicator of neonatal systemic bacterial infection.

Coagulation/fibrinolysis abnormality and vascular endothelial damage in the pathogenesis of thrombocytopenic multiple organ failure

OBJECTIVE

Until recently, attention has been directed to disseminated intravascular coagulation as a cause of multiple organ failure (MOF). On the other hand, it has now become clear that humoral mediators play important roles in the pathogenesis of MOF. Therefore, we performed the present study in patients with thrombocytopenic MOF to investigate the relationship between various humoral mediators and vascular endothelial damage reported to be triggered by such humoral mediators in the pathogenesis of MOF.

DESIGN

A retrospective clinical study.

SETTING

Intensive care unit of a university hospital.

PATIENTS

The study included 18 thrombocytopenic patients whose conditions progressed to septic MOF (MOF group) and 20 others who did not progress to MOF (non-MOF group). The MOF group and non-MOF group were also presented with infection and with platelet counts of <100,000/mm3.

MEASUREMENTS AND MAIN RESULTS

The MOF group had fibrinolysis abnormality, as indicated by increased plasminogen activator inhibitor-1 level. On the other hand, the MOF group had increased polymorphonuclear elastase and polymorphonuclear-mediated fibrinogen degradation product levels with consequent prolonged elevation of thrombomodulin. In addition, both polymorphonuclear elastase and polymorphonuclear-fibrinogen degradation products were significantly positively correlated with thrombomodulin in the MOF group, but no such positive correlation was observed between interleukin-6 or plasminogen activator inhibitor-1 and thrombomodulin. In the non-MOF group, on the other hand, thrombomodulin exhibited no significant positive correlation with polymorphonuclear elastase, polymorphonuclear-fibrinogen degradation products, interleukin-6, or plasminogen activator inhibitor-1.

CONCLUSIONS

Our study provided evidence that vascular endothelial damage was the primary cause of organ failures in patients with thrombocytopenic MOF and that humoral mediators played a major role in the development of vascular endothelial damage in such patients. These results suggest that it is important to treat thrombocytopenic MOF as a condition of vascular endothelial damage, with weight placed on countermeasures against disorders of humoral mediators.

Reduction of the inflammatory response following coronary bypass grafting with total minimal extracorporeal circulation

OBJECTIVE

Cardiopulmonary bypass (CPB) is known to cause part of the systemic inflammatory reaction after cardiac surgery that can be responsible for organ failure. A novel technique based on a minimal extracorporeal circulation (MECC(R)) system has been evaluated with regard to the inflammatory response in a prospective study involving patients undergoing coronary artery bypass grafting.

METHODS

Sixty consecutive patients were randomly assigned to either standard normothermic CPB (n=30) or the MECC system, with a reduced priming volume, no aortic venting and no venous reservoir, excluding the blood-air interface (n=30). Specific evaluation of cytokine release (IL-1beta, IL-6, TNF-alpha), as well as neutrophil elastase secretion and beta-thromboglobulin release from platelets and S100 protein assay were performed. Serial blood samples were taken prior to the onset, after initiation, at the end and after weaning of the CPB; further samples were collected 6 and 24h after the end of the CPB.

RESULTS

All patients were similar with regards to pre- and intra-operative characteristics and clinical outcomes were comparable for both groups. MECC system allowed a reduced hemodilution with a mean drop of the hematocrit of 8.5 vs. 15.3% (P<0.05). Mononuclear phagocytes dropped in a more important manner under standard CPB conditions (247+/-151 vs. 419+/-168, P=0.002), but both groups demonstrated a rise in monocyte count at the end of the CBP. No significant release of IL-1beta was observed in either group. By the end of CPB, IL-6 levels were significantly lower in the MECC group (38.8+/-19.6 vs. 87.9+/-78.9, P=0.04), despite a higher monocyte count. Plasma levels of TNF-alpha rised significantly more during standard CPB than with the MECC system (17.8+/-15.4 vs. 10.1+/-5.6, P=0.002). With MECC, the neutrophil elastase release was reduced (72.7+/-47.9 vs. 219.6+/-103.4, P=0.001). Platelet count remained at higher values with the minimal compared to standard CPB. It is noteworthy to consider that beta-thromboglobulin levels showed slightly lower platelet activation in the MECC group at all times of CPB (110.5+/-55.6 vs. 134.7+/-46.8, P=0.10). The pattern of release of S100 protein showed higher values in patients undergoing standard CPB than after MECC.

CONCLUSIONS

The MECC system is suitable to maintain total extracorporeal circulation and demonstrates a lower inflammatory reaction when compared to standard CPB.

Lung protection during total cardiopulmonary bypass by isolated lung perfusion: preliminary results of a novel perfusion strategy

BACKGROUND

The present pilot study was conducted to evaluate the effect of isolated short-term lung perfusion during cardiopulmonary bypass (CPB) on inflammatory response and oxygenation.

METHODS

A total of 24 patients undergoing elective cardiac surgery with routine CPB were prospectively assigned to three groups. Group I (n = 7), control subjects receiving neither lung perfusion nor ultrafiltration; group II (n = 9), patients undergoing lung perfusion; and group III (n = 8), patients undergoing lung perfusion plus ultrafiltration. Lung perfusion consisted of single-shot hypothermic pulmonary artery perfusion with oxygenated blood. Proteins indicative of leukocyte activation and lung injury were measured in plasma and bronchoalveolar lavage fluid (BALF). The alveolar-arterial oxygen gradient (A-aDO2) and the oxygenation index (PO2/FiO2) were also determined.

RESULTS

Oxygenation values were best preserved in group III, followed by group II. After CPB, elastase-alpha1-proteinase inhibitor complex had increased in plasma in all groups; in BALF it increased in groups I and II, but not in group III. Alpha2-macroglobulin increased significantly in BALF in group I but not in groups II and III.

CONCLUSIONS

These preliminary results provide some evidence that single-shot hypothermic lung perfusion with oxygenated blood at the beginning of CPB may have a protective effect on the lungs, especially when combined with ultrafiltration.

Leukocyte activation and phagocytotic activity in cardiac surgery and infection

BACKGROUND

Cardiac surgery (CS) using cardiopulmonary bypass (CPB) is associated with cellular and humoral defense reactions termed the systemic inflammatory response syndrome. Leukocyte activation is one of its causative mechanisms which may be aggravated by additional infection.

METHODS AND RESULTS

Eighty-five patients undergoing CS with CPB were prospectively investigated. Leukocyte counts, elastase, and phagocytotic activity were measured from 24 h preoperatively up to 7 days postoperatively. Seventy-nine patients had an uneventful course (group 1) while six patients developed a systemic infection (group 2). Leukocytes and elastase levels increased postoperatively (p<0.01) and were significantly higher in group 2 (p<0.01). In both groups a decrease of leukocyte/elastase ratio occurred (p<0.002), no differences between groups were observed. The phagocytotic activity, representing the circulating cells of the reticuloendothelial system (RES), dropped on day 1 (p<0.05), and increased thereafter above baseline levels (p<0.001). No differences of RES function between groups was observed, the initial drop on day 1 in both groups was compensated by the quality of phagocytotic ability of each cells.

CONCLUSION

Leukocyte activation after CS with CPB occurs. It is associated with a regular RES function and similarly leukocyte/elastase ratios in both groups, suggesting an adequate immune response. Therapeutic interventions resulting in depletion of leukocytes to alleviate reperfusion injury might impair the immune response of those patients acquiring perioperative infection and should be approached with caution. Leukocyte depletion maybe effective in patients for whom an extended period of CPB was required. Further investigations to prove this hypothesis awaits confirmation.

Domain structure of erythrocyte membranes in psoriasis: an EPR study

Membrane fluidity of erythrocytes from psoriatic patients in active and inactive period of the disease was studied by electron paramagnetic resonance (EPR). Comparison of simulated and experimental EPR spectra of erythrocyte membranes from controls and psoriatics showed that they are essentially superimposition of three components; two regions with a high degree of order of the lipid acyl chains and one region with poor alignments of hydrocarbon chains (with a small order parameter). In psoriatic erythrocytes not only the portion of the most rigid domain was enlarged, but also the order parameter of this domain was increased, while the order parameters of two other domains were the same than in normal erythrocytes. Results obtained in this article showed that the portion of the most rigid domain (W(A)) better correlated with polymorphonuclear elastase (PMN elastase) than with PASI score. Additionally, correlation between PMN elastase and W(A) in the active period of the disease was observed to be higher than in the inactive period. Therefore, portion of the most ordered domain (W(A)) seems to be a good marker for evaluation of the disease activity in psoriatic patients.

Serum profiles of interleukin-18 in different severity forms of human acute pancreatitis

BACKGROUND

Interleukin 18 (IL-18) is a new mediator and modulator of the immune response; its role in acute pancreatitis (AP), however, has not yet been fully explained. The aim of our study was to evaluate the profile IL-18 serum concentrations in the course of acute pancreatitis.

METHODS

The prospective study involves 30 patients with AP (n = 15 with mild AP and n = 15 with severe AP) as well as 10 healthy subjects. AP severity was defined according to Ranson's and Balthazar's criteria, supplemented by serum CRP concentration measurements. In the course of hospitalization, 2 patients with severe AP died. Serum IL-18 and plasma polymorphonuclear leukocyte elastase (PMN-E) concentrations were measured at admission (day 1) and on days 2, 3, 5 and 10.

RESULTS

In both the mild and the severe forms of AP, serum IL-18 concentration was significantly higher than in the healthy controls. In severe AP, serum IL-18 reached the highest levels in all observed periods compared to that in patients with mild AP. Significant correlations, calculated for day 1, were found between serum IL-18 and plasma PMN-E (Rs = 0.514. P < 0.001) and between IL-18 and CRP (Rs = 0.463, P < 0.001) levels.

CONCLUSIONS

Serum profile IL-18 during AP indicates that this cytokine was released early after AP onset and may play the key role in inflammatory and immune response. Positive correlation between serum IL-18 and commonly known early prognostic markers of AP severity suggest that serum IL-18 concentrations may represent another early marker indicating severe course of AP.

Discovery of further pyrrolidine trans-lactams as inhibitors of human neutrophil elastase (HNE) with potential as development candidates and the crystal structure of HNE complexed with an inhibitor (GW475151)

Described herein is a modern approach to the rapid preparation and evaluation of compounds as potential back-up drug candidates. GW311616A, 1, a derivative of pyrrolidine trans-lactams, has previously been described as a potent, orally active inhibitor of human neutrophil elastase (HNE) for the treatment of respiratory disease. These properties made it a suitable candidate for development. Described here is the discovery of three further derivatives of pyrrolidine trans-lactams, which fulfill the criteria required for back-up candidates 28, 29, and 32. These include increased activity in inhibiting HNE in human whole blood (HWB) and comparable pharmacokinetic properties, in particular clearance, in two species. To provide a rapid assessment of clearance, cassette dosing in dog was used. Modern array techniques, including the synthesis of mixtures, were used to synthesize compounds rapidly. Having selected three potential compounds as back-up candidates, they were prepared as single enantiomers and profiled in in vitro and in vivo assays and evaluated pharmacokinetically in rat and dog. These compounds are highly potent and selective HNE inhibitors, with a prolonged pharmacodynamic action. Pharmacokinetically, these compounds are comparable with 1 while they are more potent in HWB. Compound 28, however, has a higher clearance. One of these compounds, 32, was cocrystallized with HNE, and features of this structure are described and compared with the cocrystal structure of 1 in porcine pancreatic elastase.

Oxidative stress in critically ill patients with systemic inflammatory response syndrome

OBJECTIVE

To evaluate whether critically ill patients with systemic inflammatory response syndrome, on admission to an intensive care unit, had more severe oxidative stress than those without this syndrome.

DESIGN

A prospective, cohort study.

SETTING

A mixed medical and surgical adult intensive care unit with 12 beds.

PATIENTS

A total of 68 consecutive patients admitted to the intensive care unit.

INTERVENTIONS

Venous blood samples were routinely obtained within 24 hrs of admission.

MEASUREMENTS AND MAIN RESULTS

Patients' plasma total antioxidant capacity, the lipid peroxidation products malondialdehyde and 4-hydroxynonenal, reduced sulfhydryl groups, and nitrites/nitrates were measured by spectrophotometric technique at admission to the intensive care unit. Myeloperoxidase (enzyme-linked immunosorbent assay) and polymorphonuclear elastase (immuno-activation assay) were also measured on admission to the intensive care unit. The patients with criteria of systemic inflammatory response syndrome (n = 20) had higher Acute Physiology and Chronic health Evaluation III scores (determined by collecting the worst value within 24 hrs after admission to the intensive care unit) and plasma concentrations of lipid peroxidation products and nitrites/nitrates and lower plasma concentration of reduced sulfhydryl groups and plasma total antioxidant capacity than patients without the syndrome (n = 48). Moreover, the markers for leukocyte activation, myeloperoxidase and polymorphonuclear elastase, presented higher concentrations in the plasma of patients with systemic inflammatory response syndrome.

CONCLUSIONS

Patients admitted to the intensive care unit with criteria of systemic inflammatory response syndrome had a more severe oxidative stress than patients without this syndrome.