51
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Stortz JA, Hollen MK, Nacionales DC, Horiguchi H, Ungaro R, Dirain ML, Wang Z, Wu Q, Wu KK, Kumar A, Foster TC, Stewart BD, Ross JA, Segal M, Bihorac A, Brakenridge S, Moore FA, Wohlgemuth SE, Leeuwenburgh C, Mohr AM, Moldawer LL, Efron PA. Old Mice Demonstrate Organ Dysfunction as well as Prolonged Inflammation, Immunosuppression, and Weight Loss in a Modified Surgical Sepsis Model. Crit Care Med 2020; 47:e919-e929. [PMID: 31389840 DOI: 10.1097/ccm.0000000000003926] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Our goal was to "reverse translate" the human response to surgical sepsis into the mouse by modifying a widely adopted murine intra-abdominal sepsis model to engender a phenotype that conforms to current sepsis definitions and follows the most recent expert recommendations for animal preclinical sepsis research. Furthermore, we aimed to create a model that allows the study of aging on the long-term host response to sepsis. DESIGN Experimental study. SETTING Research laboratory. SUBJECTS Young (3-5 mo) and old (18-22 mo) C57BL/6j mice. INTERVENTIONS Mice received no intervention or were subjected to polymicrobial sepsis with cecal ligation and puncture followed by fluid resuscitation, analgesia, and antibiotics. Subsets of mice received daily chronic stress after cecal ligation and puncture for 14 days. Additionally, modifications were made to ensure that "Minimum Quality Threshold in Pre-Clinical Sepsis Studies" recommendations were followed. MEASUREMENTS AND MAIN RESULTS Old mice exhibited increased mortality following both cecal ligation and puncture and cecal ligation and puncture + daily chronic stress when compared with young mice. Old mice developed marked hepatic and/or renal dysfunction, supported by elevations in plasma aspartate aminotransferase, blood urea nitrogen, and creatinine, 8 and 24 hours following cecal ligation and puncture. Similar to human sepsis, old mice demonstrated low-grade systemic inflammation 14 days after cecal ligation and puncture + daily chronic stress and evidence of immunosuppression, as determined by increased serum concentrations of multiple pro- and anti-inflammatory cytokines and chemokines when compared with young septic mice. In addition, old mice demonstrated expansion of myeloid-derived suppressor cell populations and sustained weight loss following cecal ligation and puncture + daily chronic stress, again similar to the human condition. CONCLUSIONS The results indicate that this murine cecal ligation and puncture + daily chronic stress model of surgical sepsis in old mice adhered to current Minimum Quality Threshold in Pre-Clinical Sepsis Studies guidelines and met Sepsis-3 criteria. In addition, it effectively created a state of persistent inflammation, immunosuppression, and weight loss, thought to be a key aspect of chronic sepsis pathobiology and increasingly more prevalent after human sepsis.
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Affiliation(s)
- Julie A Stortz
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - McKenzie K Hollen
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Dina C Nacionales
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Hiroyuki Horiguchi
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Ricardo Ungaro
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Marvin L Dirain
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Zhongkai Wang
- Department of Biostatistics, University of Florida College of Medicine, Gainesville, FL
| | - Quran Wu
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Kevin K Wu
- Department of Aging and Geriatric Research, University of Florida College of Medicine, Gainesville, FL
| | - Ashok Kumar
- Department of Neuroscience, University of Florida College of Medicine, Gainesville, FL
| | - Thomas C Foster
- Department of Neuroscience, University of Florida College of Medicine, Gainesville, FL
| | - Brian D Stewart
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Julia A Ross
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Marc Segal
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Azra Bihorac
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Scott Brakenridge
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Frederick A Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Stephanie E Wohlgemuth
- Department of Aging and Geriatric Research, University of Florida College of Medicine, Gainesville, FL
| | - Christiaan Leeuwenburgh
- Department of Aging and Geriatric Research, University of Florida College of Medicine, Gainesville, FL
| | - Alicia M Mohr
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Lyle L Moldawer
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
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Cavaillon J, Singer M, Skirecki T. Sepsis therapies: learning from 30 years of failure of translational research to propose new leads. EMBO Mol Med 2020; 12:e10128. [PMID: 32176432 PMCID: PMC7136965 DOI: 10.15252/emmm.201810128] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 12/13/2022] Open
Abstract
Sepsis has been identified by the World Health Organization (WHO) as a global health priority. There has been a tremendous effort to decipher underlying mechanisms responsible for organ failure and death, and to develop new treatments. Despite saving thousands of animals over the last three decades in multiple preclinical studies, no new effective drug has emerged that has clearly improved patient outcomes. In the present review, we analyze the reasons for this failure, focusing on the inclusion of inappropriate patients and the use of irrelevant animal models. We advocate against repeating the same mistakes and propose changes to the research paradigm. We discuss the long-term consequences of surviving sepsis and, finally, list some putative approaches-both old and new-that could help save lives and improve survivorship.
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Affiliation(s)
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care MedicineUniversity College LondonLondonUK
| | - Tomasz Skirecki
- Laboratory of Flow Cytometry and Department of Anesthesiology and Intensive Care MedicineCentre of Postgraduate Medical EducationWarsawPoland
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53
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Adejumo AC, Akanbi O, Pani L. Protein Energy Malnutrition Is Associated with Worse Outcomes in Sepsis—A Nationwide Analysis. J Acad Nutr Diet 2019; 119:2069-2084. [DOI: 10.1016/j.jand.2019.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 04/14/2019] [Accepted: 04/23/2019] [Indexed: 12/22/2022]
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54
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Yu Y, Zheng S. Research progress on immune aging and its mechanisms affecting geriatric diseases. Aging Med (Milton) 2019; 2:216-222. [PMID: 34553108 PMCID: PMC8445044 DOI: 10.1002/agm2.12089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/21/2019] [Accepted: 10/27/2019] [Indexed: 01/27/2023] Open
Abstract
Immunosenescence, also known as immune aging, refers to the degeneration, compensation, and reconstruction of the immune system with aging. Immune aging is an important factor in the increased susceptibility of the elderly to infectious diseases, malignant tumors, and a variety of chronic diseases and has long been a hotspot in geriatrics and immunology research. In this paper, the characteristics and progression of immune aging are briefly reviewed for clinicians' reference.
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Affiliation(s)
- Yanping Yu
- Department of Geriatric MedicineHua Dong HospitalShanghaiChina
| | - Songbai Zheng
- Department of Geriatric MedicineHua Dong HospitalShanghaiChina
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55
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Grudzinska FS, Brodlie M, Scholefield BR, Jackson T, Scott A, Thickett DR, Sapey E. Neutrophils in community-acquired pneumonia: parallels in dysfunction at the extremes of age. Thorax 2019; 75:164-171. [PMID: 31732687 PMCID: PMC7029227 DOI: 10.1136/thoraxjnl-2018-212826] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 09/16/2019] [Accepted: 09/25/2019] [Indexed: 12/15/2022]
Abstract
"Science means constantly walking a tight rope" Heinrich Rohrer, physicist, 1933. Community-acquired pneumonia (CAP) is the leading cause of death from infectious disease worldwide and disproportionately affects older adults and children. In high-income countries, pneumonia is one of the most common reasons for hospitalisation and (when recurrent) is associated with a risk of developing chronic pulmonary conditions in adulthood. Pneumococcal pneumonia is particularly prevalent in older adults, and here, pneumonia is still associated with significant mortality despite the widespread use of pneumococcal vaccination in middleand high-income countries and a low prevalence of resistant organisms. In older adults, 11% of pneumonia survivors are readmitted within months of discharge, often with a further pneumonia episode and with worse outcomes. In children, recurrent pneumonia occurs in approximately 10% of survivors and therefore is a significant cause of healthcare use. Current antibiotic trials focus on short-term outcomes and increasingly shorter courses of antibiotic therapy. However, the high requirement for further treatment for recurrent pneumonia questions the effectiveness of current strategies, and there is increasing global concern about our reliance on antibiotics to treat infections. Novel therapeutic targets and approaches are needed to improve outcomes. Neutrophils are the most abundant immune cell and among the first responders to infection. Appropriate neutrophil responses are crucial to host defence, as evidenced by the poor outcomes seen in neutropenia. Neutrophils from older adults appear to be dysfunctional, displaying a reduced ability to target infected or inflamed tissue, poor phagocytic responses and a reduced capacity to release neutrophil extracellular traps (NETs); this occurs in health, but responses are further diminished during infection and particularly during sepsis, where a reduced response to granulocyte colony-stimulating factor (G-CSF) inhibits the release of immature neutrophils from the bone marrow. Of note, neutrophil responses are similar in preterm infants. Here, the storage pool is decreased, neutrophils are less able to degranulate, have a reduced migratory capacity and are less able to release NETs. Less is known about neutrophil function from older children, but theoretically, impaired functions might increase susceptibility to infections. Targeting these blunted responses may offer a new paradigm for treating CAP, but modifying neutrophil behaviour is challenging; reducing their numbers or inhibiting their function is associated with poor clinical outcomes from infection. Uncontrolled activation and degranulation can cause significant host tissue damage. Any neutrophil-based intervention must walk the tightrope described by Heinrich Rohrer, facilitating necessary phagocytic functions while preventing bystander host damage, and this is a significant challenge which this review will explore.
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Affiliation(s)
- Frances Susanna Grudzinska
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Malcolm Brodlie
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Barnaby R Scholefield
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Thomas Jackson
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Aaron Scott
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - David R Thickett
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
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56
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Nowill AE, Fornazin MC, Spago MC, Dorgan Neto V, Pinheiro VRP, Alexandre SSS, Moraes EO, Souza GHMF, Eberlin MN, Marques LA, Meurer EC, Franchi GC, de Campos-Lima PO. Immune Response Resetting in Ongoing Sepsis. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2019; 203:1298-1312. [PMID: 31358659 PMCID: PMC6697741 DOI: 10.4049/jimmunol.1900104] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 06/28/2019] [Indexed: 01/03/2023]
Abstract
Cure of severe infections, sepsis, and septic shock with antimicrobial drugs is a challenge because morbidity and mortality in these conditions are essentially caused by improper immune response. We have tested the hypothesis that repeated reactivation of established memory to pathogens may reset unfavorable immune responses. We have chosen for this purpose a highly stringent mouse model of polymicrobial sepsis by cecum ligation and puncture. Five weeks after priming with a diverse Ag pool, high-grade sepsis was induced in C57BL/6j mice that was lethal in 24 h if left untreated. Antimicrobial drug (imipenem) alone rescued 9.7% of the animals from death, but >5-fold higher cure rate could be achieved by combining imipenem and two rechallenges with the Ag pool (p < 0.0001). Antigenic stimulation fine-tuned the immune response in sepsis by contracting the total CD3+ T cell compartment in the spleen and disengaging the hyperactivation state in the memory T subsets, most notably CD8+ T cells, while preserving the recovery of naive subsets. Quantitative proteomics/lipidomics analyses revealed that the combined treatment reverted the molecular signature of sepsis for cytokine storm, and deregulated inflammatory reaction and proapoptotic environment, as well as the lysophosphatidylcholine/phosphatidylcholine ratio. Our results showed the feasibility of resetting uncontrolled hyperinflammatory reactions into ordered hypoinflammatory responses by memory reactivation, thereby reducing morbidity and mortality in antibiotic-treated sepsis. This beneficial effect was not dependent on the generation of a pathogen-driven immune response itself but rather on the reactivation of memory to a diverse Ag pool that modulates the ongoing response.
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Affiliation(s)
- Alexandre E Nowill
- Integrated Center for Pediatric OncoHaematological Research, State University of Campinas, Campinas 13083-888, Brazil;
| | - Márcia C Fornazin
- Integrated Center for Pediatric OncoHaematological Research, State University of Campinas, Campinas 13083-888, Brazil
| | - Maria C Spago
- Integrated Center for Pediatric OncoHaematological Research, State University of Campinas, Campinas 13083-888, Brazil
| | - Vicente Dorgan Neto
- Surgery Department, Santa Casa School of Medical Sciences, São Paulo 01221-020, Brazil
| | - Vitória R P Pinheiro
- Integrated Center for Pediatric OncoHaematological Research, State University of Campinas, Campinas 13083-888, Brazil
| | - Simônia S S Alexandre
- Integrated Center for Pediatric OncoHaematological Research, State University of Campinas, Campinas 13083-888, Brazil;
| | - Edgar O Moraes
- School of Engineering, Mackenzie Presbyterian University, São Paulo 01302-907, Brazil
| | - Gustavo H M F Souza
- Mass Spectrometry Research and Development Laboratory, Health Sciences Department, Waters Corporation, Barueri 06455-020, Brazil
| | - Marcos N Eberlin
- School of Engineering, Mackenzie Presbyterian University, São Paulo 01302-907, Brazil
| | - Lygia A Marques
- Thomson Mass Spectrometry Laboratory, Institute of Chemistry, State University of Campinas, Campinas 13083-859, Brazil; and
| | - Eduardo C Meurer
- Thomson Mass Spectrometry Laboratory, Institute of Chemistry, State University of Campinas, Campinas 13083-859, Brazil; and
| | - Gilberto C Franchi
- Integrated Center for Pediatric OncoHaematological Research, State University of Campinas, Campinas 13083-888, Brazil
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Laurence M, Benito-León J, Calon F. Malassezia and Parkinson's Disease. Front Neurol 2019; 10:758. [PMID: 31396143 PMCID: PMC6667642 DOI: 10.3389/fneur.2019.00758] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 07/01/2019] [Indexed: 12/14/2022] Open
Abstract
Parkinson's disease (PD) is a common debilitating neurodegenerative disease caused by a loss of dopamine neurons in the substantia nigra within the central nervous system (CNS). The process leading to this neuronal loss is poorly understood. Seborrheic dermatitis (SD) is a common benign inflammatory condition of the skin which mainly affects lipid-rich regions of the head and trunk. SD is caused by over proliferation of the lipophilic fungus Malassezia. PD and SD are strongly associated. The increased PD risk following an SD diagnosis (OR = 1.69, 95% CI 1.36, 2.1; p < 0.001) reported by Tanner and colleagues remains unexplained. Malassezia were historically considered commensals confined to the skin. However, many recent studies report finding Malassezia in internal organs, including the CNS. This raises the possibility that Malassezia might be directly contributing to PD. Several lines of evidence support this hypothesis. AIDS is causally associated with both parkinsonism and SD, suggesting that weak T cell-mediated control of commensal microbes such as Malassezia might contribute to both. Genetic polymorphisms associated with PD (LRRK2, GBA, PINK1, SPG11, SNCA) increase availability of lipids within human cells, providing a suitable environment for Malassezia. Four LRRK2 polymorphisms which increase PD risk also increase Crohn's disease risk; Crohn's disease is strongly associated with an immune response against fungi, particularly Malassezia. Finally, Malassezia hypha formation and melanin synthesis are stimulated by L-DOPA, which could promote Malassezia invasiveness of dopamine neurons, and contribute to the accumulation of melanin in these neurons. Although Malassezia's presence in the substantia nigra remains to be confirmed, if Malassezia play a role in PD etiology, antifungal drugs should be tested as a possible therapeutic intervention.
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Affiliation(s)
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain.,Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain.,Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas, Madrid, Spain
| | - Frédéric Calon
- Faculty of Pharmacy, Université Laval, Quebec City, QC, Canada.,Neurosciences Unit, CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
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58
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Age and Sex Influence the Hippocampal Response and Recovery Following Sepsis. Mol Neurobiol 2019; 56:8557-8572. [PMID: 31278440 PMCID: PMC6834928 DOI: 10.1007/s12035-019-01681-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/14/2019] [Indexed: 01/03/2023]
Abstract
Although in-hospital mortality rates for sepsis have decreased, survivors often experience lasting physical and cognitive deficits. Moreover, older adults are more vulnerable to long-term complications associated with sepsis. We employed a murine model to examine the influence of age and sex on the brain’s response and recovery following sepsis. Young (~ 4 months) and old (~ 20 months) mice (C57BL/6) of both sexes underwent cecal ligation and puncture (CLP) with restraint stress. The hippocampal transcriptome was examined in age- and sex-matched controls at 1 and 4 days post-CLP. In general, immune- and stress-related genes increased, while neuronal, synaptic, and glial genes decreased 1 day after CLP-induced sepsis. However, specific age and sex differences were observed for the initial responsiveness to sepsis as well as the rate of recovery examined on day 4. Young females exhibited a muted transcriptional response relative to young males and old females. Old females exhibited a robust shift in gene transcription on day 1, and while most genes recovered, genes linked to neurogenesis and myelination continued to be downregulated by day 4. In contrast, old males exhibited a more delayed or prolonged response to sepsis, such that neuronal and synaptic genes continued to decrease while immune response genes continued to increase on day 4. These results suggest that aging is associated with delayed recovery from sepsis, which is particularly evident in males.
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59
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Salminen A, Kaarniranta K, Kauppinen A. Immunosenescence: the potential role of myeloid-derived suppressor cells (MDSC) in age-related immune deficiency. Cell Mol Life Sci 2019; 76:1901-1918. [PMID: 30788516 PMCID: PMC6478639 DOI: 10.1007/s00018-019-03048-x] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/25/2019] [Accepted: 02/14/2019] [Indexed: 12/17/2022]
Abstract
The aging process is associated with chronic low-grade inflammation in both humans and rodents, commonly called inflammaging. At the same time, there is a gradual decline in the functional capacity of adaptive and innate immune systems, i.e., immunosenescence, a process not only linked to the aging process, but also encountered in several pathological conditions involving chronic inflammation. The hallmarks of immunosenescence include a decline in the numbers of naïve CD4+ and CD8+ T cells, an imbalance in the T cell subsets, and a decrease in T cell receptor (TCR) repertoire and signaling. Correspondingly, there is a decline in B cell lymphopoiesis and a reduction in antibody production. The age-related changes are not as profound in innate immunity as they are in adaptive immunity. However, there are distinct functional deficiencies in dendritic cells, natural killer cells, and monocytes/macrophages with aging. Interestingly, the immunosuppression induced by myeloid-derived suppressor cells (MDSC) in diverse inflammatory conditions also targets mainly the T and B cell compartments, i.e., inducing very similar alterations to those present in immunosenescence. Here, we will compare the immune profiles induced by immunosenescence and the MDSC-driven immunosuppression. Given that the appearance of MDSCs significantly increases with aging and MDSCs are the enhancers of other immunosuppressive cells, e.g., regulatory T cells (Tregs) and B cells (Bregs), it seems likely that MDSCs might remodel the immune system, thus preventing excessive inflammation with aging. We propose that MDSCs are potent inducers of immunosenescence.
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Affiliation(s)
- Antero Salminen
- Department of Neurology, Institute of Clinical Medicine, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland.
| | - Kai Kaarniranta
- Department of Ophthalmology, Institute of Clinical Medicine, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
- Department of Ophthalmology, Kuopio University Hospital, KYS, P.O. Box 100, 70029, Kuopio, Finland
| | - Anu Kauppinen
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
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61
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Arnau-Barrés I, Güerri-Fernández R, Luque S, Sorli L, Vázquez O, Miralles R. Serum albumin is a strong predictor of sepsis outcome in elderly patients. Eur J Clin Microbiol Infect Dis 2019; 38:743-746. [PMID: 30680575 DOI: 10.1007/s10096-019-03478-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/02/2019] [Indexed: 11/25/2022]
Abstract
The incidence of sepsis is disproportionately higher in elderly adults, and age is an independent predictor of mortality. Retrospective analysis was conducted among patients admitted to the emergency department in a tertiary teaching hospital from January 2016 to June 2017. To study the prognosis determinants of sepsis among elderly patients attended in the emergency room of a tertiary care hospital. As secondary objectives, we aimed to describe the causes of sepsis, the general outcome, and the general characteristics of these patients. Two hundred thirty-five episodes data of patients admitted throughout the 15-month study period who were diagnosed with sepsis, severe sepsis or septic shock, were included. Throughout the study cohort, 51 patients (21.7%) fulfilled the criteria of severe sepsis or septic shock. All-cause mortality was 11 patients (4.7%) on day 14 and 27 (11.5%) on day 30. Prognosis factors associated with 30-day mortality were the following: albumin level < 2.6 g/dl (first quartile of the overall population), odds ratio (OR 3.26, 95% CI 12-9.41; p = 0.029), Charlson comorbidity index (OR 1.23, 95% CI 1.04-1.45; p = 0.012), C-reactive protein on admission (OR 1.04, 95% CI 0.99-1.08; p = 0.062), and non-adequacy of the initial antimicrobial therapy (OR 3.3, 95% CI 1.06-10.4; p = 0.039). Among elderly patients with sepsis, strong predictors of mortality such as albumin could be considered as part of prognosis and future potential interventions. Adequacy of antimicrobial therapy at admission must be one of the objectives in the treatment of sepsis, also in the elderly, since it is an independent predictor of mortality.
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Affiliation(s)
- Isabel Arnau-Barrés
- Geriatrics Department, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Robert Güerri-Fernández
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain. .,Infectious Diseases, Hospital del Mar Medical Research Institute, IMIM, Barcelona, Spain.
| | - Sonia Luque
- Pharmacy, Hospital del Mar Medical Research Insitute, IMIM, Barcelona, Spain
| | - Luisa Sorli
- Infectious Diseases, Hospital del Mar Medical Research Institute, IMIM, Barcelona, Spain
| | | | - Ramón Miralles
- Geriatrics Department, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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62
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Timsit JF, Bassetti M, Cremer O, Daikos G, de Waele J, Kallil A, Kipnis E, Kollef M, Laupland K, Paiva JA, Rodríguez-Baño J, Ruppé É, Salluh J, Taccone FS, Weiss E, Barbier F. Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med 2019; 45:172-189. [PMID: 30659311 DOI: 10.1007/s00134-019-05520-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.
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Affiliation(s)
- Jean-François Timsit
- Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard Hospital, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Olaf Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George Daikos
- Scool of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andre Kallil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Kipnis
- Surgical Critical Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Lille, Lille, France
| | - Marin Kollef
- Critical Care Research, Washington University School of Medicine and Respiratory Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Kevin Laupland
- Department of Medicine, Royal Inland Hospital, Kamloops, Canada
| | - Jose-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jesús Rodríguez-Baño
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, Departament of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Étienne Ruppé
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
- Bacteriology Laboratory, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, IDOR, Rio De Janeiro, Brazil
| | | | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, AP-HP, Clichy, France
- INSERM, CRI, UMR 1149, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
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Abstract
INTRODUCTION Sepsis is a life-threatening organ dysfunction caused by host immune response to infection. In this regard, modifying host immune response may help to eliminate systemic infection and restore organ function. Thymosin alpha 1 (Tα1), acting as an immune modulator, exerts great biological influence in activating and restoring the dysregulated immune response for patients with sepsis. AREAS COVERED In this review, we summarize the clinical studies of Tα1 treatment alone and in combination with anti-inflammatory for patients with sepsis or septic shock. Clinical studies were collected from available English and Chinese databases. EXPERT OPINION In previous studies, single or combined treatment with Tα1 reduced the mortality rate of sepsis, improved the expression of HLA-DR on monocyte, and diminished the incidence of secondary infection. Based on the existing studies, Tα1 seems to be a promising alternative adjuvant therapy for sepsis. However, sepsis is a remarkably heterogeneous clinical syndrome, so much so that it is impossible to generalize the clinical results to all septic patients. Also, the present studies on Tα1 treatment are not able to focus on the immunosuppressive individuals. We believe that selecting septic patients with immunosuppression will be more likely to reveal the efficacy of Tα1 in future trials.
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Affiliation(s)
- Fei Pei
- a Department of Critical Care Medicine , The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , Guangdong , China
| | - Xiangdong Guan
- a Department of Critical Care Medicine , The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , Guangdong , China
| | - Jianfeng Wu
- a Department of Critical Care Medicine , The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , Guangdong , China
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64
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Chronic Infections: A Possible Scenario for Autophagy and Senescence Cross-Talk. Cells 2018; 7:cells7100162. [PMID: 30308990 PMCID: PMC6210027 DOI: 10.3390/cells7100162] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 02/07/2023] Open
Abstract
Multiple tissues and systems in the organism undergo modifications during aging due to an accumulation of damaged proteins, lipids, and genetic material. To counteract this process, the cells are equipped with specific mechanisms, such as autophagy and senescence. Particularly, the immune system undergoes a process called immunosenescence, giving rise to a chronic inflammatory status of the organism, with a decreased ability to counteract antigens. The obvious result of this process is a reduced defence capacity. Currently, there is evidence that some pathogens are able to accelerate the immunosenescence process for their own benefit. Although to date numerous reports show the autophagy–senescence relationship, or the connection between pathogens with autophagy or senescence, the link between the three actors remains unexplored. In this review, we have summarized current knowledge about important issues related to aging, senescence, and autophagy.
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65
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Lin GL, McGinley JP, Drysdale SB, Pollard AJ. Epidemiology and Immune Pathogenesis of Viral Sepsis. Front Immunol 2018; 9:2147. [PMID: 30319615 PMCID: PMC6170629 DOI: 10.3389/fimmu.2018.02147] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/30/2018] [Indexed: 12/11/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis can be caused by a broad range of pathogens; however, bacterial infections represent the majority of sepsis cases. Up to 42% of sepsis presentations are culture negative, suggesting a non-bacterial cause. Despite this, diagnosis of viral sepsis remains very rare. Almost any virus can cause sepsis in vulnerable patients (e.g., neonates, infants, and other immunosuppressed groups). The prevalence of viral sepsis is not known, nor is there enough information to make an accurate estimate. The initial standard of care for all cases of sepsis, even those that are subsequently proven to be culture negative, is the immediate use of broad-spectrum antibiotics. In the absence of definite diagnostic criteria for viral sepsis, or at least to exclude bacterial sepsis, this inevitably leads to unnecessary antimicrobial use, with associated consequences for antimicrobial resistance, effects on the host microbiome and excess healthcare costs. It is important to understand non-bacterial causes of sepsis so that inappropriate treatment can be minimised, and appropriate treatments can be developed to improve outcomes. In this review, we summarise what is known about viral sepsis, its most common causes, and how the immune responses to severe viral infections can contribute to sepsis. We also discuss strategies to improve our understanding of viral sepsis, and ways we can integrate this new information into effective treatment.
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Affiliation(s)
- Gu-Lung Lin
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Joseph P McGinley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Simon B Drysdale
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom.,Department of Paediatrics, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
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66
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Current etiology, clinical features and outcomes of bacteremia in older patients with solid tumors. J Geriatr Oncol 2018; 10:246-251. [PMID: 30005979 DOI: 10.1016/j.jgo.2018.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/02/2018] [Accepted: 06/26/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the etiology, clinical features and outcomes of bacteremia in older patients with solid tumors. METHODS All episodes of bacteremia in hospitalized patients with solid tumors were prospectively collected. Patients aged ≥70 years were compared to patients aged <70 years. Risk factors for case-fatality rates in older patients were identified. RESULTS We compared 217 episodes of bacteremia involving older patients and 525 occurring in younger patients. Older patients had more frequently other comorbidities, but were less commonly neutropenic and carried less frequently central venous catheters. Bacteremia from an abdominal source was more common in patients ≥70, whereas an endogenous source and catheter-related infection were less frequently observed. Streptococcus bovis group (3.7% vs. 0.8%, p = .01) and Listeria monocytogenes (4.6% vs. 1.9%, p = .04) were more common in older patients, whereas coagulase-negative staphylococci were less frequently found (1.4% vs. 5.3% p = .01). Infection due to multi-drug resistant (MDR) strains was significantly higher in older patients (17.1% vs. 10.9%, p = .02), who in addition, presented higher overall mortality (35.4% vs 27.7%, p = .04). In older patients, lung tumor, neutropenia, and low grade fever were associated with early mortality, whereas comorbidities, corticosteroids, septic shock and inadequate empirical antibiotic therapy were associated with overall mortality. CONCLUSIONS We identified remarkable differences in the etiology and sources of bacteremia between older and younger cancer patients with bacteremia. Older patients had more frequent infection due to MDR organisms and presented a higher overall mortality. Corticosteroids and inadequate empirical antibiotic therapy are modifiable factors associated with mortality.
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67
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Zhang Y, Cui X, Ning L, Wei D. The effects of tumor necrosis factor-α (TNF-α) rs1800629 and rs361525 polymorphisms on sepsis risk. Oncotarget 2017; 8:111456-111469. [PMID: 29340067 PMCID: PMC5762335 DOI: 10.18632/oncotarget.22824] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 11/13/2017] [Indexed: 01/20/2023] Open
Abstract
This meta-analysis of 23 eligible articles comprehensively and quantitatively evaluated the effects of tumor necrosis factor-α (TNF-α) rs1800629 and rs361525 polymorphisms on sepsis risk. We found that TNF-α rs1800629 was associated with increased sepsis risk in the overall population in four genetic models, including A vs. G (P<0.001, odds ratio (OR)=1.32), GA vs. GG (P<0.001, OR=1.46), GA+AA vs. GG (P<0.001, OR=1.46), and carrier A vs. carrier G (P<0.001, OR=1.32). Subgroup analyses showed a similar result for Asian patients (all P<0.05, OR>1). TNF-α rs361525 was also associated with increased sepsis risk in Asian patients in the four genetic models (all P<0.05, OR>1). Begg's and Egger's tests excluded large publication bias, and sensitivity analysis indicated stable results. Our results suggest that the G/A genotype of TNF-α rs1800629 and rs361525 increases sepsis risk in an Asian population.
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Affiliation(s)
- Yixin Zhang
- Department of Clinical Laboratory, The Second Hospital of Tianjin Medical University, Tianjin 300211, PR China.,School of Medical Laboratory, Tianjin Medical University, Tianjin 300070, PR China
| | - Xiaoteng Cui
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin 300070, PR China
| | - Li Ning
- Department of Clinical Laboratory, The Second Hospital of Tianjin Medical University, Tianjin 300211, PR China
| | - Dianjun Wei
- Department of Clinical Laboratory, The Second Hospital of Tianjin Medical University, Tianjin 300211, PR China
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68
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Huang SY, Huang WC, Chen YC, Tsai CY, Lee IK. Increased Mortality in Seasonal H3N2 Patients Compared with those with Pandemic 2009 H1N1 in Taiwan, 2009-2010. Am J Trop Med Hyg 2017; 97:1945-1951. [PMID: 29016325 DOI: 10.4269/ajtmh.17-0172] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We conducted a retrospective study to compare clinical and laboratory findings between 1) severe influenza A and mild influenza A and 2) pandemic 2009 H1N1 (pdm09 A/H1) and seasonal H3N2 (A/H3) from 2009 to 2010. A total of 526 (mean age, 13.6 years; 447 pdm09 A/H1, 79 seasonal A/H3) patients were included, 41 (7.8%) with severe influenza (mean age, 28.1 years; 26 pdm09 A/H1, 15 seasonal A/H3). Influenza-associated complications were pneumonia (75.6%), meningoencephalitis (14.6%), acute kidney injury (14.6%), and acute respiratory distress syndrome (12.2%). Patients with seasonal A/H3 were significantly less likely to experience sore throat (P < 0.001), malaise (P < 0.001), and muscle pain (P < 0.001); they were significantly more likely to have hypertension (P < 0.001), diabetes mellitus (P = 0.001), and chronic obstructive pulmonary disease (P < 0.001), delayed hospital presentation (P = 0.001), delayed oseltamivir treatment (P < 0.001), and higher in-hospital mortality (P = 0.02) than patients with pdm09 A/H1. Further comparison between severe pdm09 A/H1 and severe seasonal A/H3 revealed that severe seasonal A/H3 patients (median age, 71 years) were significantly older than patients with severe pdm09 A/H1 (median age, 7 years) (P < 0.001). Comparison between severe influenza and mild influenza, regardless of influenza A subtypes, by multivariate analysis, found that tachypnea (odds ratio [OR] = 44.3, 95% confidence interval [CI] = 15.7-124.6) and delayed oseltamivir therapy ≧ 48 hours after illness onset (OR = 3.7, 95% CI = 1.3-10.5) were independent risk factors for severe influenza. The findings of this study will improve the understanding of the clinical differences between pdm09 A/H1 and seasonal A/H3, and of influenza-associated complications and predictors for severe outcomes that can help to direct clinicians toward the most effective management of influenza patients to reduce the preventable mortality and morbidity.
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Affiliation(s)
- Shi-Yu Huang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wen-Chi Huang
- Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yi-Chun Chen
- Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ching-Yen Tsai
- Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ing-Kit Lee
- Chang Gung University College of Medicine, Tao-Yuan, Taiwan.,Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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69
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Miller EJ, Linge HM. Age-Related Changes in Immunological and Physiological Responses Following Pulmonary Challenge. Int J Mol Sci 2017; 18:E1294. [PMID: 28629122 PMCID: PMC5486115 DOI: 10.3390/ijms18061294] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/08/2017] [Accepted: 06/14/2017] [Indexed: 01/07/2023] Open
Abstract
This review examines the current status of knowledge of sepsis and pneumonia in the elderly population and how the dynamics of the pulmonary challenge affects outcome and consequences. Led by an unprecedented shift in demographics, where a larger proportion of the population will reach an older age, clinical and experimental research shows that aging is associated with certain pulmonary changes, but it is during infectious insult of the lungs, as in the case of pneumonia, that the age-related differences in responsiveness and endurance become obvious and lead to a worse outcome than in the younger population. This review points to the neutrophil, and the endothelium as important players in understanding age-associated changes in responsiveness to infectious challenge of the lung. It also addresses how the immunological set-point influences injury-repair phases, remote organ damage and how intake of drugs may alter the state of responsiveness in the users. Further, it points out the importance of considering age as a factor in inclusion criteria in clinical trials, in vitro/ex vivo experimental designs and overall interpretation of results.
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Affiliation(s)
- Edmund J Miller
- The Center for Heart and Lung Research, The Feinstein Institute for Medical Research Manhasset, New York, NY 11030, USA.
- The Elmezzi Graduate School of Molecular Medicine, Manhasset, New York, NY 11030, USA.
- Hofstra Northwell School of Medicine, Hempstead, New York, NY 11549, USA.
| | - Helena M Linge
- The Center for Heart and Lung Research, The Feinstein Institute for Medical Research Manhasset, New York, NY 11030, USA.
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, 221 00 Lund, Sweden.
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