Tumor necrosis factor and interleukin-1 in the serum of children with severe infectious purpura

Genomic polymorphic profiles in an Irish population with meningococcaemia: is it possible to predict severity and outcome of disease?

Patients with meningococcal disease have increased plasma levels of proinflammatory cytokines IL-6, IL-1beta, and TNF-alpha, with higher levels associated with fatal outcome. This study investigated whether polymorphisms in genes encoding these cytokines, and in those encoding anti-inflammatory IL-10 and IL-1Ra, are associated with the outcome in patients with meningococcal disease. Seven polymorphisms were genotyped in 183 meningococcal disease patients and 389 controls. The IL-6 -174 G/G and IL-10 -1082 A/A genotypes were more frequent in nonsurvivors compared with survivors (P=0.023 IL-6, 0.25 IL-10), and in patients with severe disease compared to those with mild disease (P=0.037 IL-6, 0.0078 IL-10). An association was also found between meningococcal disease and the IL-1RN VNTR polymorphism, but no association was observed with the LTA +252, TNF -308, IL-10 -592, or IL-1B +3953 polymorphisms. We conclude that genetic variability in the IL-6, IL-10, and IL-1RN genes is associated with a poor outcome in meningococcal disease.

Effects of dexmedetomidine on mortality rate and inflammatory responses to endotoxin-induced shock in rats

OBJECTIVES

The aim of this study was to document the effects of a new sedative agent, dexmedetomidine, on the mortality rate and inflammatory responses to endotoxin-induced shock in rats.

DESIGN

Randomized laboratory study.

SETTING

University experimental laboratory.

SUBJECTS

Fifty-seven male rats.

INTERVENTIONS

The animals were randomly assigned to one of four groups. The endotoxemic group (n = 16) received intravenous Escherichia coli endotoxin (15 mg/kg over 2 mins). The saline control group (n = 10) was given saline alone. The dexmedetomidine alone group (n = 15) was treated identically to the control group but also received dexmedetomidine (infusion at 5 microg.kg(-1).hr(-1)) immediately after the injection of 0.9% saline. The dexmedetomidine-endotoxin group (n = 16) was treated identically to the endotoxemic group with the additional administration of dexmedetomidine (infusion at 5 microg.kg(-1).hr(-1)) immediately after endotoxin injection.

MEASUREMENTS AND MAIN RESULTS

Hemodynamics and arterial blood gases were recorded and plasma cytokine concentrations measured during the observation. The mortality rate was assessed up to 8 hrs after endotoxin or saline injection. In addition, microscopic findings of lung tissue for each group were obtained at necropsy. Mortality rates 8 hrs after endotoxin injection were 94%, 10%, 0%, and 44% for the endotoxemic, saline control, dexmedetomidine alone, and dexmedetomidine-endotoxin groups, respectively. Hypotension and increases in plasma cytokine (tumor necrosis factor-alpha and interleukin-6) concentrations and infiltration of neutrophils in the airspace or vessel walls of the lungs were less in the dexmedetomidine-endotoxin group than in the endotoxemic group.

CONCLUSIONS

Dexmedetomidine reduced mortality rate and had an inhibitory effect on inflammatory response during endotoxemia. These findings suggest that dexmedetomidine administration may inhibit the inflammatory response.

Plasma interferon-gamma and interleukin-10 concentrations in systemic meningococcal disease compared with severe systemic Gram-positive septic shock

OBJECTIVE

To analyze plasma interferon-gamma and interleukin-10 concentrations in patients with systemic meningococcal disease and patients with severe Gram-positive septic shock caused by Streptococcus pneumoniae or Staphylococcus aureus. To study the in vitro cytokine (interferon-gamma and interleukin-10) responses in a whole blood model boosted with heat-killed Neisseria meningitidis, S. pneumoniae, and S. aureus before and after treatment with recombinant interleukin-10 or recombinant interferon-gamma.

DESIGN

Experimental study.

SETTING

Laboratory.

SUBJECTS

Plasma samples were collected from patients with systemic meningococcal disease (n = 66) and patients with severe Gram-positive septic shock caused by S. pneumoniae (n = 4) or S. aureus (n = 3).

INTERVENTIONS

Whole blood was boosted with heat-killed N. meningitidis, S. pneumoniae, and S. aureus (1 x 106 colony forming units/mL), and plasmas were analyzed for interleukin-10 or interferon-gamma at 0, 5, 12, and 24 hrs. Furthermore, recombinant interleukin-10 or recombinant interferon-gamma was added before bacteria, and the effect on the secretion of interferon-gamma and interleukin-10, respectively, was analyzed after 24 hrs.

MEASUREMENTS AND MAIN RESULTS

The median concentration of interferon-gamma was 15 pg/mL and of interleukin-10 was 10,269 pg/mL in patients with meningococcal septic shock (n = 24) compared with median interferon-gamma concentration of 3400 pg/mL and interleukin-10 concentration of 465 pg/mL in patients with severe Gram-positive shock (p =.001). Increased interferon-gamma concentrations were associated with case fatality (p =.011). In a whole blood model we demonstrated that 1 x 106 colony forming units/mL of N. meningitidis induced more interleukin-10 but less interferon-gamma than S. pneumoniae. S. aureus induced minimal secretion of both cytokines. Recombinant interleukin-10 efficiently down-regulated the secretion of interferon-gamma, and vice versa, as shown in a whole blood model.

CONCLUSION

We speculate whether high concentrations of interleukin-10 contribute to the low concentrations of interferon-gamma in fulminant meningococcal septicemia. In addition, it appears as if interferon-gamma plays a minor role in the pathophysiology of meningococcal septic shock.

Interleukin-1beta mediates endotoxin- and tumor necrosis factor alpha-induced RGS16 protein expression in cultured cardiac myocytes

Endotoxin (LPS)-induced cardiac failure is associated with an up-regulation of RGS16 protein expression and repression of phospholipase C activity in vivo. Since the release of pro-inflammatory cytokines plays an important role in mediating LPS-induced myocardial dysfunction, we examined the effect of recombinant cytokines on the expression of RGS16 protein in neonatal cardiac myocytes. Myocytes in culture were treated with 50 ng/ml recombinant tumor necrosis factor alpha (TNFalpha), 2 ng/ml interleukin 1beta (IL-1beta), interleukin 6 (IL-6), interferon gamma (IFNgamma) or diluent (NaCl) for 24 h. Before stimulation with LPS (4 micro g/ml for 24 h) cells were treated with 200 ng/ml interleukin 1-receptor antagonist (IL-1ra), 500 ng/ml soluble TNF receptor (sTNFr), or NaCl for 1 h. Isolated membrane proteins were used for Western blot analysis. Cell-associated and secreted IL-1beta and TNFalpha protein content were determined in myocyte protein homogenates and cell culture supernatants by ELISA immunoblotting 3, 6, 24, 48 and 72 h after treatment with LPS. IL-1beta (1.75-fold) and TNFalpha (1.62-fold) but not IL-6 and IFNgamma induced RGS16 protein expression. LPS stimulated intracellular IL-1beta expression within 6 h (847.1+/-172.9 pg/3x10(6) cells) followed by an increase in extracellular secretion up to 70.8+/-8.1 pg/3x10(6) cells after 48 h. In contrast, intracellular protein concentrations of TNFalpha were almost not detectable (0.03+/-0.01 pg/3x10(6) cells), but extracellular secretion was induced by LPS with a maximum at 6 h (653.9+/-36.3 pg/3x10(6) cells). The LPS-induced increase in RGS16 (1.6-fold) was blunted by IL-1ra but not by TNFalpha scavenging. Interestingly, both, the IL-1beta- and TNFalpha-effect could be blocked by IL-1ra, indicating that also the TNFalpha-induced RGS16 expression is mediated by IL-1. We therefore conclude that LPS induces RGS16 protein expression by activation of the cytokine IL-1beta in cardiac myocytes. Our data substantiate the role of IL-1beta as an important mediator in LPS-induced cardiac failure.

The enigma of sepsis

Sepsis remains a serious cause of morbidity and mortality, and the pathophysiology of the disease is not clear. The definition of the clinical manifestations of sepsis is ever evolving. This review discusses the search for effective therapeutic interventions, hurdles in translational sepsis research, and new therapies in development in current clinical trials.

Pathophysiology of meningococcal meningitis and septicaemia

Neisseria meningitidis is remarkable for the diversity of interactions that the bacterium has with the human host, ranging from asymptomatic nasopharyngeal colonisation affecting virtually all members of the population; through focal infections of the meninges, joints, or eye; to the devastating and often fatal syndrome of meningococcal septic shock and purpura fulminans.

Hypoglycemia in bacterial septicemia

In the emergency department (ED), the typical manifestation of impaired glucose homeostasis seen in patients with severe bacterial infections is hyperglycemia. Severe hypoglycemia is generally not a presenting feature of sepsis in children in the emergency setting, and thus may lead to delayed diagnosis and management. We present a case of a 14-year-old boy who attended the ED with constitutional symptoms and severe hypoglycemia as the initial presentation of overwhelming meningococcal sepsis and discuss the impairment of glucose homeostasis in patients with sepsis.

Regulation of pulmonary and systemic bacterial lipopolysaccharide responses in transgenic mice expressing human elafin

The control of lung inflammation is of paramount importance in a variety of acute pathologies, such as pneumonia, the acute respiratory distress syndrome, and sepsis. It is becoming increasingly apparent that local innate immune responses in the lung are negatively influenced by systemic inflammation. This is thought to be due to a local deficit in cytokine responses by alveolar macrophages and neutrophils following systemic bacterial infection and the development of a septic response. Recently, using an adenovirus-based strategy which overexpresses the human elastase inhibitor elafin locally in the lung, we showed that elafin is able to prime lung innate immune responses. In this study, we generated a novel transgenic mouse strain expressing human elafin and studied its response to bacterial lipopolysaccharide (LPS) when the LPS was administered locally in the lungs and systemically. When LPS was delivered to the lungs, we found that mice expressing elafin had lower serum-to-bronchoalveolar lavage ratios of proinflammatory cytokines, including tumor necrosis factor alpha (TNF-alpha), macrophage inflammatory protein 2, and monocyte chemoattractant protein 1, than wild-type mice. There was a concomitant increase in inflammatory cell influx, showing that there was potential priming of innate responses in the lungs. When LPS was given systemically, the mice expressing elafin had reduced levels of serum TNF-alpha compared to the levels in wild-type mice. These results indicate that elafin may have a dual function, promoting up-regulation of local lung innate immunity while simultaneously down-regulating potentially unwanted systemic inflammatory responses in the circulation.

Patterns of cytokines and soluble cellular receptors in the sera of children with acute chagas' disease

Cytokines and soluble cellular receptors are involved in inflammatory processes and probably in the pathogenesis of parasite and bacterial diseases. In a previous study, we reported increased levels of soluble receptors of interleukin-2 (sIL2-R) in children with acute Chagas' disease, one of the main parasitic infections that is endemic in Latin America. We sought to analyze the pattern of different cytokines and soluble receptors in the sera of children with chagasic infection. Children with acute and indeterminate stages of Chagas' disease, as well as nonchagasic children, were studied. Sera were assayed by enzyme-linked immunosorbent assay to measure the levels of tumor necrosis factor alpha (TNF-alpha), IL-6, IL-2, IL-8, IL-12, sIL-2R, and the soluble receptors of CD8 and CD4 (sCD8 and sCD4). sIL-2R and sCD8 showed the highest levels in serum in acutely infected children, decreasing after specific antiparasite therapy. Chronic children showed a pattern similar to the one of nonchagasic children. Although they were not statistically significant, TNF-alpha, IL-6, and sCD4 showed a tendency to reach high levels in the acutely infected group, whereas IL-2, IL-8, and IL-12 did not reveal changes with respect to the noninfected children. In summary, we report here the patterns of cytokines and soluble receptors in in the sera of children infected with Trypanosoma cruzi; we found significantly increased levels of sIL-2R and sCD8 in acute infection that decreased after therapy, and high levels of TNF-alpha, IL-6, and sCD4 in some of the acute patients. The measurement of sIL-2R and sCD8 may provide a useful tool in the follow-up of children with Chagas' disease.

Clinical chorioamnionitis, elevated cytokines, and brain injury in term infants

OBJECTIVES

To determine the initial inflammatory cytokine response in term infants born to mothers with clinical chorioamnionitis and to assess whether the cytokine response is associated with birth depression, abnormal neurologic examination, and hypoxic-ischemic encephalopathy (HIE).

METHODS

Infants who were exposed to chorioamnionitis and admitted to the neonatal intensive care unit (n = 61) were studied prospectively. Cytokine concentrations were measured from umbilical cord blood and at 6 and 30 hours after birth. Control values (n = 50) were determined from cord blood of healthy term infants. Enzyme-linked immunosorbent assays were performed for interleukin (IL)-1beta; IL-6; IL-8; regulated on activation, normal T-cell expressed and secreted (RANTES); macrophage inflammatory protein-1alpha; and tumor necrosis factor-alpha. Serial blinded neurologic examinations using a modified Dubowitz score were performed simultaneously at 6 and 30 hours.

RESULTS

Cord IL-6 (1071 +/- 1517 vs 65 +/- 46 pg/mL), IL-8 (2580 +/- 9834 vs 66 +/- 57 pg/mL), and RANTES (95 917 +/- 16 518 vs 54 000 +/- 14 306 pg/mL) concentrations only were higher in infants with chorioamnionitis versus control infants. IL-6 increased at 6 hours to 1451 +/- 214 pg/mL, followed by a 5-fold decline at 30 hours in contrast to progressive decreases over time in IL-8 and RANTES. There was no relationship between cytokines and birth depression. Modified Dubowitz score correlated with IL-6 at 6 hours (r = 0.5). Infants with HIE/seizures (n = 5) had significantly higher cytokine concentrations at 6 hours versus infants without either (n = 56): IL-6 (3130 vs 1219 pg/mL), IL-8 (5433 vs 780 pg/mL), and RANTES (97 396 vs 46 914 pg/mL).

CONCLUSIONS

There was a significant association between abnormalities in the neurologic examination and cytokine concentrations, with the highest cytokines concentrations observed in infants who developed HIE/seizures.

Myocardial dysfunction in the patient with sepsis

The nature of myocardial dysfunction during sepsis and septic shock has been investigated for more than half a century. This review traces the evolution of scientific thought regarding this phenomenon during this period with particular emphasis on the current understanding of both the clinical manifestations and the molecular/cellular basis of septic myocardial dysfunction in critically ill patients. Current data suggest, contrary to older literature, that patients with septic shock develop a hyperdynamic circulatory state after fluid resuscitation and maintain this hyperdynamic circulatory state until death or recovery. Overt myocardial depression, as manifested by decreased cardiac output, is decidedly uncommon, even in the preterminal phase. Nonetheless, myocardial depression, as evidenced by biventricular dilation and depression of the ejection fraction, can be demonstrated in most patients with septic shock by using either radionuclide cineangiography or echocardiography. Depression is reversible over the course of 7 to 10 days in survivors. Available evidence suggests that myocardial hypoperfusion is not responsible for septic myocardial depression, because examination of humans with septic shock demonstrates increased myocardial perfusion, and animal models of septic shock appear to maintain myocardial high-energy phosphates. A circulating factor or factors, including the cytokines tumor necrosis factor alpha and interleukin-1beta, appear to have a significant role in the phenomenon. In addition, septic myocardial depression appears to be mediated in part through combinations of nitric oxide-dependent and -independent alterations of basal and catecholamine-stimulated cardiac myocyte contractility.

Cytokine modulation in sepsis and septic shock

Sepsis and septic shock are a major cause of morbidity and mortality in patients admitted to the intensive care unit. Since the introduction of antibiotic therapy, the mortality associated with sepsis has remained within the 30- 50% range. Sepsis constitutes the systemic response to infection. This response encompasses both pro-inflammatory and anti-inflammatory phases that are marked by the sequential generation of pro- and anti-inflammatory cytokines. Among the most important pro-inflammatory cytokines are TNF-alpha and IL-1beta. The pro-inflammatory effects of such cytokines are inhibited by soluble receptors/receptor antagonists and anti-inflammatory cytokines including IL-10 and transforming growth factor-beta. Modulation of the activity of both pro- and anti-inflammatory cytokines to improve outcome in patients with sepsis has been subject of multiple clinical studies. This review will examine clinical trials evaluating several strategies for blocking or attenuating TNF-alpha and IL-1beta activity. This review will also survey the current state of experimental therapies involving IL-10, transforming growth factor-beta, granulocyte colony-stimulating factor and IFN-phi. Finally, newer developments related to less known cytokines such as macrophage migration inhibitory factor and high mobility group 1 protein will be evaluated.

The effect of high dose digoxin on cytokines in healthy dogs

BACKGROUND

Tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta are pro-inflammatory cytokines, causing myocardial dysfunction and a negative inotropic effect. The drugs used to treat heart failure affect the production of cytokines. Digoxin, on which this study was focused, is one of the drugs for the treatment of heart failure.

AIM

The present study was designed to examine the early effects of high doses of digoxin on the production of cytokines in healthy dogs.

METHODS

Digoxin was given parenterally to dogs at 0.15 mg/kg. IL-1beta and TNF-alpha production and levels of digoxin in the serum were measured 0, 12, 24, 48, and 72 h following administration of digoxin.

RESULTS

As the levels of serum digoxin taken at 12, 24, 48, and 72 h of administration were considered significantly high compared with preceding values (p < 0.001), no notable change in serum IL-1beta and TNF-alpha levels was observed.

CONCLUSIONS

These results suggest that high doses of digoxin do not cause a significant cytokine production in heart muscle in the early phase.

Lethality of yeasts with low pathogenicity in mice immunocompromised by cyclophosphamide treatment

One strain each of Arxiozyma telluris, Saccharomyces cerevisiae, and S. kluyveri showed lethal activity in cyclophosphamide (CY)-treated mice. Accumulation of these yeast cells in the kidneys and elevation of the levels of cytokines, tumor necrosis factor-alpha, and interleukin-1alpha in the sera were recognized in the CY-treated infected-debilitated mice.

Systemic endothelial activation is greater in septic than in traumatic-hemorrhagic shock but does not correlate with endothelial activation in skin biopsies

OBJECTIVE

Sepsis and severe trauma result in endothelial activation and damage. The activated endothelium expresses adhesion receptors that control leukocyte trafficking. After activation, some adhesion molecules are also released into plasma as soluble forms. The present study was designed to compare the expression of soluble cell adhesion molecules (sCAMs) in three groups of patients: those with septic shock, severe sepsis, and traumatic-hemorrhagic shock. In addition, the endothelial expression of these adhesive molecules was examined in skin biopsies.

DESIGN

Prospective observational study

SETTING

Intensive care unit at a university hospital

PATIENTS

The study included 15 patients with septic shock (by Bone's definition), 11 patients with severe sepsis (by Bone's definition), and 13 patients with traumatic-hemorrhagic shock. Fifteen healthy blood donors served as controls.

MEASUREMENTS AND MAIN RESULTS

Measurements of sCAMs were performed on days 1, 2, and 3 of the disease. On day 1, when compared with controls, sE-selectin, sP-selectin, soluble vascular cell adhesion molecule (sVCAM)-1, and soluble intercellular adhesion molecule (sICAM)-1 were markedly elevated in septic shock patients, whereas these sCAMs, except for sP-selectin, were within normal ranges in traumatic-hemorrhagic shock patients. In patients with severe sepsis, an earlier stage than septic shock in the sepsis continuum, intermediate values of sCAMs were found. In skin biopsies of septic shock patients, the endothelial cells expressed a bright staining of constitutive endothelial molecules (CD146, CD144, CD131). Inducible molecules (ICAM-1, VCAM-1, and E-selectin) were positively expressed with bright staining. The biopsies from traumatic-hemorrhagic shock patients showed a similar positive expression of endothelial molecules.

CONCLUSION

The patterns of sCAMs indicate that the systemic activation of the endothelium is different in the three clinical entities, maximum in septic shock, intermediate in severe sepsis, and not different from controls in traumatic-hemorrhagic shock. Comparable endothelial activation as evidenced by skin biopsies suggests that caution is required in the interpretation of CAMs in plasma, which does not necessarily reflect the in situ activation state of endothelium.

Evaluation of endotoxin release and cytokine production induced by antibiotics in patients with Gram-negative nosocomial pneumonia

OBJECTIVE

To determine the plasma concentrations of lipopolysaccharide, tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6 in a homogeneous group of septic patients and to evaluate the effect of antibiotic treatment, imipenem or ceftazidime, on the release of lipopolysaccharide and cytokines.

DESIGN

Prospective, randomized study.

SETTING

Sixteen-bed multidisciplinary intensive care unit.

PATIENTS

Twenty-four septic patients with documented Gram-negative nosocomial pneumonia. Controls were 20 patients admitted without sepsis and 20 healthy volunteers.

INTERVENTIONS

Septic patients were randomized between imipenem and ceftazidime. Blood samples were collected before (0 hrs) and after (4 and 12 hrs) antibiotic treatment. Concentrations of lipopolysaccharide were measured by using the limulus assay, and cytokine concentrations were measured by enzyme-linked immunosorbent assay. Statistical analyses were performed by Kruskal-Wallis test, Mann-Whitney U test, and Student's t-test.

MEASUREMENTS AND MAIN RESULTS

The mean age was 48.5 +/- 19.5. The mean Acute Physiology and Chronic Health Evaluation II score was 18.4 +/- 4.5. Overall mortality rate was 45.4%. All septic patients showed significant higher concentrations of lipopolysaccharide (p <.001), tumor necrosis factor-alpha (p <.04), and interleukin-6 (p <.001) than the controls, but interleukin-1 beta was never detected. We did not find statistically significant changes in lipopolysaccharide or cytokine plasma concentrations over time within any of the two arms of the study (ceftazidime vs. imipenem). There were no statistically significant differences in lipopolysaccharide and interleukin-6 plasma concentrations between the two antibiotic treatments. Although tumor necrosis factor-alpha plasma concentrations were significantly higher in the group treated with ceftazidime compared with the group treated with imipenem at the baseline and 4 hrs later, these differences were not statistically significant after 12 hrs of initiation of both treatments.

CONCLUSIONS

Patients with Gram-negative nosocomial pneumonia have high plasma concentrations of lipopolysaccharide, interleukin-6, and tumor necrosis factor-alpha, but the antibiotic therapy evaluated did not significantly modify these concentrations.

Paracrine suppression of apoptosis by cytokine-stimulated neutrophils involves divergent regulation of NF-kappaB, Bcl-X(L), and Bak

Dysregulated polymorphonuclear leukocyte (PMN) apoptosis and PMN-mediated organ damage have been associated with several medical conditions such as systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), and ischemia/reperfusion injury. IL-1beta and IL-8 are two cytokines that are elevated under similar conditions. Therefore, we hypothesized that PMN exposed to these cytokines would secrete factors that could affect PMN apoptosis in a cell contact-independent manner. We have previously shown that media conditioned by IL-1beta-stimulated PMN (CM-IL1beta) for 2 h suppressed spontaneous PMN apoptosis. Data presented here demonstrate that media conditioned by IL-8-stimulated PMN (CM-IL8) also have the ability to suppress spontaneous, as well as FasL- and TNF-alpha-induced apoptosis. In contrast, CM-IL1beta was able to suppress FasL-induced, but not TNF-alpha-induced, apoptosis. To elucidate the mechanisms these media use to elicit their effects, we examined the expression and function of several apoptosis-related proteins. Experimental results demonstrate that both CM-IL1beta and CM-IL8 have the ability to delay caspase activation, but have no effect on the expression of their upstream activator, Fas, or its ligand, FasL. Examination of several Bcl-2 family members revealed a selective regulation by each media: CM-IL1beta up-regulated Bcl-X(L), while CM-IL8 down-regulated Bak expression. Additionally, CM-IL1beta, but not CM-IL8, promoted the activation of NF-kappaB, which has anti-apoptotic activity. Together, we can conclude that IL-1beta- and IL-8-stimulated PMN have the ability to suppress PMN apoptosis in a paracrine manner, and that the extent and mechanism of suppression is specific for each.

Cytokine- and endotoxin-enhanced bilirubin cytotoxicity

AIM

To determine the effects of endotoxin and cytokines on the cytotoxic effects of bilirubin.

METHODS

A cell-culture model was developed to simulate the effect of an infection by adding endotoxin from E. coli (LPS) and pro-inflammatory cytokines (TNF-alpha, IL-Ialpha, IL-1beta, and IL-6) to the medium. The cytotoxic effects were measured by a modified MTT method. Four cell lines were tested; they were neuroblastoma, glioblastoma, liver, and endothelial cells.

RESULTS

Both endotoxin and pro-inflammatory cytokines were demonstrated to enhance bilirubin cytotoxicity on all the cell lines tested, as illustrated by endothelial cell from umbilical vein. Endotoxin and TNF-alpha also showed an additive effect. TNF-alpha concentrations at much lower than clinical sepsis levels have been shown to produce significant cytotoxic effects.

CONCLUSION

We speculate that in the jaundiced neonate, infection may increase the risk of tissue damage or kernicterus.

Treatment of systemic inflammatory response syndrome by push-pull powdered sorbent pheresis: a Phase 1 clinical trial

An FDA-approved Phase 1 feasibility study was performed in two centers to determine the safety of the BioLogic-DTPF (detoxifier/plasma filter) system for the treatment of patients with systemic inflammatory response syndrome (SIRS). This device combines hemodiabsorption (dialysis of blood against powdered sorbents with the BioLogic-DT system) with push-pull sorbent-based pheresis (the PF add-on module). Eight adult ICU patients with both SIRS and multiple organ failure participated in the study. One 6 h treatment was planned for each patient with powdered charcoal as sorbent for 4 patients and a combination of charcoal/silica in the PF sorbent bag for 4 patients. The treatments appeared to have no negative effects in 7 patients, but 1 patient died during treatment due to progressive cardiac failure. Sepsis was resolved in 5 of the 8 patients. However, there were only 2 long-term survivors of the group. The addition of the PF module should improve the chemical function of the BioLogic-DT by allowing removal of protein-bound toxins such as cytokines. The selected patients tolerated treatment by the DTPF system well, but proof of benefit of the device remains to be proven in a Phase 2 clinical trial with randomized controls.

Augmented age-associated innate immune responses contribute to negative inotropic and lusitropic effects of lipopolysaccharide and interferon gamma

Innate immunity not only mediates early host defenses to infection, but also contributes to septic hemodynamic compromise through nitric oxide synthase (NOS2) induction and inhibition of cardiovascular adrenergic responses. Because of increased age-related susceptibility to sepsis, we hypothesized that hearts from old (28-29 months) adult rats would exhibit greater beta-adrenergic hyporesponsiveness than young (6-8 months) following lipopolysaccharide (LPS, 6 mg/kg) with and without interferon gamma (INF-gamma, 5000 units). LPS/INF-gamma depressed baseline +dP/dt and isoproterenol-stimulated inotropy in both old and young hearts. beta-adrenergic inotropic (+dP/dt) and lusitropic responses were more depressed in old v young LPS/INF-gamma hearts. Additionally isoproterenol-stimulated cAMP elaboration was less in old (1950+/-160 fmol/min/g) v young (2440+/-170 fmol/min/g, P=0.05) LPS/INF-gamma hearts. LPS alone also depressed basal +dP/dt and prolonged myocardial relaxation in old and young hearts, but suppressed isoproterenol +dP/dt responses only in old hearts. Depressed beta-adrenergic inotropic responses were augmented with the selective NOS2 inhibitor N-iminoethyl-L-lysine. To establish biochemical mechanisms for this, we tested whether induction of NOS2 and innate immune system receptors (CD14 and Toll-like receptor 4, TLR4) were enhanced in old v young hearts. Induction of myocardial NOS2 and CD14 (not present in control) by LPS/INF-gamma was approximately 2-3-fold greater in old compared to young animals. TLR4 was constitutively expressed in old and young hearts and was unaffected by LPS/INF-gamma. These findings indicate that advanced age is associated with augmented cardiac beta-adrenergic depression and enhanced CD14-NOS2 signaling in response to cytokines. Upregulation of cardiovascular innate immunity may have clinical implications for increased mortality in older individuals with systemic inflammatory response syndromes.

[Development of intensive care for pediatric infectious diseases over the last 20 years]

Intensive care and especially pediatric intensive care originated in connection with fatal forms of infectious diseases, some forty years ago. It has come a long way during the last quarter of the past century. Several infectious diseases have disappeared in France during this period such as poliomyelitis, dipteria and tetanus. Many other are receding. Nevertheless problems remain: serious infections by pneumococcus or staphylococcus, maternofoetal infections, whooping cough in very young infant. Now, thanks to liver transplantations and intensive care, the fatal forms of infectious hepatitis can be overcome in more than 50% of the cases. Meanwhile HIV appeared involving intensivists participation. Toxic shock, and especially the purpura fulminans, remains a major difficulty. Great advances in understanding its mechanisms have been made and it seems today like the result of excessive and unsuitable defence reactions. In addition, intensive care takes charge of more and more vulnerable ill persons: immunosuppressed, extreme premature babies, children who had to undergo heavy operations. In those cases, intensive care faces superinfections, nosocomial infections, multi-resistant germs, related in part to the particular working and environmental conditions and an unsuitable use of antibiotics. To conclude, it is necessary to optimize the technical and working conditions in intensive care units, to strictly observe the well established regulations of hygienics and to develop vaccinations.

Metabolic and nutritional disorders in cardiac cachexia

Cardiac cachexia is divided into two types, i.e., the classic type, which occurs in patients with severe heart failure, and the nosocomial type, which develops in the postoperative state. Cardiac cachexia is due both to a decrease in nutrient intake (anorexia, malabsorption) and to specific metabolic alterations (hypercatabolism with increased energy expenditure, response to hypoxia, inflammatory status, etc). Among the various mechanisms involved in the pathogenesis of cachexia, cellular hypoxia has long been recognized. The chronic activation of the endogenous neurohormonal system is another specific feature of such patients; a striking relationship was found between cardiac cachexia and hormonal levels which correlate better than the classical parameters of cardiac failure severity. Finally, inflammatory syndrome has been known to occur frequently in patients with cardiac cachexia. Several studies have shown that tumor necrosis factor-alpha was significantly increased in cachectic patients and that chronic activation of the systemic immune response might be a common and unifying factor.

Cytokines, growth factors, and plastic surgery

Numerous inflammatory cytokines and growth factors have been identified and are known to be essential for normal wound healing and host defense, and many have been implicated in disease states treated by plastic surgeons. Cytokines and growth factors are members of a large functional group of polypeptide regulatory molecules secreted by different cell lines. These peptides exert their influence through autocrine and paracrine fashions within sites of injury and repair. Although cytokines and growth factors are crucial in initiating, sustaining, and regulating the postinjury response, these same molecules have been implicated in impaired wound healing, abnormal scarring, and chronic cutaneous diseases. Therapeutic manipulation of inflammatory mediators in normal and impaired wounds has been performed, with mixed clinical results, but evolving strategies such as gene therapy, as well as further characterization of the cellular-mechanism cytokines and growth-factor triggers, will further add to our therapeutic options. This article discusses the current understanding of important cytokines and growth factors involved in the normal injury response and then addresses pathological states associated with an inappropriate expression of these mediators. Finally, a summary of various cytokine and growth factor-directed strategies being used in impaired wound healing states is presented.

Increased distribution and expression of CD64 on blood polymorphonuclear cells from patients with the systemic inflammatory response syndrome (SIRS)

Evidence is growing to suggest that the multiple organ damage of the systemic inflammatory response syndrome (SIRS) arises from the untoward activity of blood polymorphonuclear cells (PMNs), which upon activation acquire the IgG high affinity receptor, CD64. In the current study, flow cytometry was used to assess the prevalence of CD64-bearing PMNs and the intensity of expression of CD64 in whole blood samples from 32 SIRS patients, 11 healthy normal subjects and from eight non-SIRS patients in the intensive care unit (ICU). The percentage of PMNs expressing CD64 was higher in SIRS patients (mean 65%) than in non-SIRS patients (mean 42%; P < 0.02) and in healthy controls (mean 19%; P < 0.001) and was particularly evident in patients with SIRS and sepsis (mean 71%; P < 0.02) as opposed to SIRS alone (mean 55%). There were more CD64 molecules expressed on PMNs from patients with SIRS (median 1331 molecules/cell) in comparison with PMNs from healthy subjects (median 678 molecules/cell; P < 0.01). The highest intensity of CD64 expression was associated with PMNs from patients with both SIRS and sepsis. Functional studies revealed that the supranormal binding of PMNs from patients with SIRS to endothelial monolayers treated with TNFalpha was impeded by anti-CD64 antibodies (mean 24% inhibition; P < 0.01). Monitoring the distribution of CD64+ PMNs and their level of CD64 expression could be of assistance in the rapid discrimination of patients with SIRS from other ICU patients and in the identification of PMNs which are likely to participate in the pathological manifestations of the disease.

[Meningococcal purpura fulminans: untoward result of genetic polymorphism?]

Despite significant progress in intensive care medicine, the mortality of septic shock has not changed in recent years. Early recognition of subtle signs in favor of meningococcal sepsis, early antibiotic treatment, and aggressive hemodynamic support remains the cornerstone of therapy of severe meningococcal shock in children. Recent work has emphasized the role of genetic polymorphisms in various systems to explain the most severe cases: anti-inflammatory cytokine profile IL-10/TNF-alpha, elevated levels of plasminogen activator inhibitor type-1, variants of the gene for mannose-binding lectin complement pathway. This may explain the disillusionment of pediatric intensivists, and the general failure of immunotherapy for sepsis. Reasonable hope lies upon new meningococcal vaccines.

Prognostic factors in intensive care

Predicting the outcome of critical illness remains an evolving art despite many recent advances. This review article describes the tools currently employed, appraising each in turn. The subject is viewed from the perspective that physiological reserve and inflammatory response are the essential elements in assessing prognosis in patients with multi-organ dysfunction/failure, the most commonly encountered syndrome in intensive care practice.

Pathogenic Neisseria trigger expression of their carcinoembryonic antigen-related cellular adhesion molecule 1 (CEACAM1; previously CD66a) receptor on primary endothelial cells by activating the immediate early response transcription factor, nuclear factor-kappaB

Neisseria gonorrhoeae express opacity-associated (Opa) protein adhesins that mediate binding to various members of the carcinoembryonic antigen-related cellular adhesion molecule (CEACAM; previously CD66) receptor family. Although human umbilical vein endothelial cells express little CEACAM receptor in vitro, we found neisserial infection to induce expression of CEACAM1, CEACAM1-3L, and CECAM1-4L splice variants. This mediates an increased Opa(52)-dependent binding of gonococci by these cells. The induced receptor expression did not require bacterial Opa expression, but it was more rapid with adherent bacteria. Because the time course of induction was similar to that seen for induced proinflammatory cytokines, we tested whether CEACAM1 expression could be controlled by a similar mechanism. Gonococcal infection activated a nuclear factor-kappaB (NF-kappaB) heterodimer consisting of p50 and p65, and inhibitors that prevent the nuclear translocation of activated NF-kappaB complex inhibited CEACAM1 transcript expression. Each of these effects could be mimicked by using culture filtrates or purified lipopolysaccharide instead of intact bacteria. Together, our results support a model whereby the outer membrane "blebs" that are actively released by gonococci trigger a Toll-like receptor-4-dependent activation of NF-kappaB, which up-regulates the expression of CEACAM1 to allow Opa(52)-mediated neisserial binding. The regulation of CEACAM1 expression by NF-kappaB also implies a broader role for this receptor in the general inflammatory response to infection.

Thalidomide dose proportionality assessment following single doses to healthy subjects

Thalidomide is approved in the United States for treating erythema nodosum leprosum, a complication of leprosy. The present study determined the single-dose oral pharmacokinetics and dose proportionality from 50 to 400 mg of Celgene's commercial Thalomid thalidomide formulation in an open-label, single-dose, three-way crossover study. Fifteen healthy subjects were given 50, 200, and 400 mg of thalidomide on three occasions, and blood samples were collected over 48 hours. Pharmacokinetic parameters were determined using noncompartmental methods, and dose proportionality was assessed by linear regression of dose-normalized Cmax and AUC0-infinity. No serious or unexpected adverse events occurred. The most common adverse events were dizziness, somnolence, headache, and nausea. One patient was discontinued because of pharyngitis. There was a significant deviation from proportionality for Cmax with increases being less than proportional than changes in dose. AUC0-infinity increased proportionally with dose, suggesting that the overall amount of thalidomide absorbed, as well as its clearance, is independent of dose over the range used. V/F was found to increase with dose. This was most likely due to the terminal rate constant, which is used to calculate V/F, actually representing the absorption process rather than elimination (i.e., flip-flop phenomenon). The terminal rate constant (absorption rate constant) for the highest dose was 50% less than for the other two lower doses. The less than proportional increases in Cmax were most likely due to thalidomide's low aqueous solubility. Thalidomide shows reasonable dose proportionality with respect to AUC from 50 to 400 mg.

Interferon-gamma in healthy subjects: selective modulation of inflammatory mediators

BACKGROUND

It is suggested that interferon-gamma (IFN-gamma), like other cytokines, is a mediator in the host inflammatory response, which could be of importance in the pathophysiology of sepsis. The role of IFN-gamma in human host inflammatory responses, however, has not been studied.

DESIGN

In a placebo-controlled trial we studied the acute effects of IFN-gamma administration on host inflammatory mediators in healthy men: i.e. the cytokine/chemokine cascade system, acute-phase proteins, activation markers of the innate cellular immunity and coagulation/fibrinolysis parameters.

RESULTS

IFN-gamma increased plasma levels of interleukin-6 (IL-6), IL-8 and IFN-gamma-inducible protein-10 (IP-10) (P < 0.05), but did not affect plasma levels of other cytokines (IL-4, IL-10, tumour necrosis factor-alpha, IL-12p40/p70). Plasma concentrations of C-reactive protein and secretory phospholipase A2 both increased (P < 0.05). Plasma levels of the leucocyte activation marker elastase-alpha1-antitrypsin complexes increased after IFN-gamma administration (P < 0.05), IFN-gamma increased the percentage of high-affinity Fcgamma-receptor (FcgammaRI) -positive neutrophils (P < 0.05), but did not affect the mean fluorescence intensity of FcgammaRI on neutrophils. Procoagulant and profibrinolytic effects of IFN-gamma were evidenced by increased plasma levels of prothrombin fragment F1 + F2, tissue-plasminogen activator and plasmin-alpha2-antiplasmin complexes (P < 0.05).

CONCLUSION

We conclude that IFN-gamma selectively affects host inflammatory mediators in humans.

Can generic scores (Pediatric Risk of Mortality and Pediatric Index of Mortality) replace specific scores in predicting the outcome of presumed meningococcal septic shock in children?

OBJECTIVE

To compare, in children with septic shock and purpura, the accuracy in predicting death of two specific scores (the MenOPP bedside clinical [MOC] score of Gedde Dahl and the score of Groupe Francophone de Réanimation Pédiatrique [GFRP]), the C-reactive protein (CRP) level, and the two pediatric generic scores (the Pediatric Risk of Mortality [PRISM] and Pediatric Index of Mortality [PIM] scores).

DESIGN

Prospective, population-based study with analysis of previous comparative studies.

SETTING

A 14-bed pediatric intensive care unit in a university hospital.

PATIENTS

All children admitted consecutively to the pediatric intensive care unit with septic shock and purpura (n = 58, with 16 deaths [27.6%]) from January 1993 to May 2000.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The MOC and GFRP scores and the CRP level were prospectively determined at admission. The PRISM score was prospectively calculated within 24 hrs of admission or at the time of death, and the PIM score was calculated retrospectively between 1993 and 1997 and then prospectively from admission data. The nonparametric estimate of the area under the receiver operating characteristic curves (AUC) was calculated from the raw data using the Wilcoxon-Mann-Whitney two-sample statistic, and the standard error of the AUCs was calculated with DeLong's method. All the scores had an AUC >0.80, the PRISM probability of death having the best one (0.96 +/- 0.02). The PRISM value, which is easier to calculate, had an AUC of 0.95 +/- 0.02. The PRISM score performed significantly better than the PIM score (AUC, 0.83 +/- 0.06; p <.01) and the CRP level (AUC, 0.80 +/- 0.06; p <.01); however, there was no significant difference between the MOC (AUC, 0.91 +/- 0.04) and GFRP scores (AUC, 0.87 +/- 0.05). Analyzing literature and calculating AUCs from original data of previous studies, we observed that the superiority of the PRISM score had never been demonstrated in meningococcal diseases.

CONCLUSIONS

The PRISM score performed better than the PIM score, and was not surpassed by specific scores. Thus, we propose its use for outcome prediction in children with septic shock and purpura. However, if the PRISM score is to be used as inclusion criterion for clinical trials, it should be evaluated within a few hours after admission.

Outer membrane vesicles from Neisseria meningitidis: effects on cytokine production in human whole blood

The Norwegian group B meningococcal outer membrane vesicle (OMV) vaccine consists of outer membrane proteins (OMPs) as main antigens with significant amounts of lipopolysaccharide (LPS; 5-9% relative to protein). We have studied the ability of this OMV vaccine preparation to induce secretion of pro-inflammatory cytokines, tumour necrosis factor alpha (TNF-alpha), interleukin 1beta (IL-1beta), interleukin 6 (IL-6), interleukin 8 (IL-8) and anti-inflammatory cytokines, interleukin 4 (IL-4), interleukin 10 (IL-10) and interleukin 13 (IL-13) in a human whole blood model. Plasma levels of TNF-alpha, IL-1beta, IL-6 and IL-8 were massively increased; mean peak levels of TNF-alpha 44 696+/-7764, IL-1beta 38 043+/-5411, IL-6 10 057+/-1619 and IL-8 30 449+/-5397 pg/ml were obtained with an OMV-LPS concentration of 1 microg/ml; corresponding levels in control plasmas were below the detection limit of the assay. Mean maximal level of IL-10 (2540+/-144 pg/ml) was obtained at OMV-LPS concentration of 10 microg/ml, after 24 h; while the level in control plasma was below detection limit. OMV-LPS did not induce release of IL-4 and IL-13 in doses from 0.001-10 microg/ml. The present results show that OMVs from meningococci have potent pro-inflammatory properties and are likely to contribute to the observed local and systemic inflammatory effects.

Intrapulmonary TNF gene therapy reverses sepsis-induced suppression of lung antibacterial host defense

Sepsis syndrome is frequently complicated by the development of nosocomial infections, particularly Gram-negative pneumonia. Although TNF-alpha (TNF) has been shown to mediate many of the pathophysiologic events in sepsis, this cytokine is a critical component of innate immune response within the lung. Therefore, we hypothesized that the transient transgenic expression of TNF within the lung during the postseptic period could augment host immunity against nosocomial pathogens. To test this, mice underwent 26-gauge cecal ligation and puncture (CLP) as a model of abdominal sepsis, followed 24 h later by intratracheal (i.t.) administration of Pseudomonas aeruginosa. In animals undergoing sham surgery followed by bacterial challenge, Pseudomonas were nearly completely cleared from the lungs by 24 h. In contrast, mice undergoing CLP were unable to clear P. aeruginosa and rapidly developed bacteremia. Alveolar macrophages (AM) recovered from mice 24 h after CLP produced significantly less TNF ex vivo, as compared with AM from sham animals. Furthermore, the adenoviral mediated transgenic expression of TNF within the lung increased survival in CLP animals challenged with Pseudomonas from 25% in animals receiving control vector to 91% in animals administered recombinant murine TNF adenoviral vector. Improved survival in recombinant murine TNF adenoviral vector-treated mice was associated with enhanced lung bacterial clearance and proinflammatory cytokine expression, as well as enhanced AM phagocytic activity and cytokine expression when cultured ex vivo. These observations suggest that intrapulmonary immunostimulation with TNF can reverse sepsis-induced impairment in antibacterial host defense.

Intrinsic capacity of monocytes to produce cytokines ex vivo in patients with acute lymphoblastic leukaemia

Monocytic cytokine profiles of fifteen children with acute lymphoblastic leukaemia (ALL) were included to determine whether malignancy per se contributes to impaired cytokine profiles in vivo and ex vivo. The ex vivo tumour necrosis factor-alpha (TNF-alpha) and interleukin 1beta (IL-1beta) production was positively correlated with the monocyte number and with the number of intracellular TNF-alpha or IL-1beta positive cells in lipopolysaccharide (LPS)-stimulated MNC cultures. The mean ex vivo TNF-alpha and IL-1beta production per 1x10(4)monocytes in these cultures was not significantly different in children at diagnosis of ALL, at remission or in controls. High IL-10 plasma levels at diagnosis of ALL had no effect on the ex vivo TNF-alpha and IL-1beta production of monocytes in LPS stimulated MNC cultures. These results show that monocytes of ALL patients have a normal intrinsic capacity to produce cytokines ex vivo. However, the decreased monocyte number is responsible for the lower TNF-alpha and IL-1beta concentrations ex vivo upon LPS stimulation.

Microspheres containing neutralizing antibodies to tumor necrosis factor-alpha and interleukin-1 beta protect rats from Staphylococcus aureus-induced peritonitis

Previous studies using microencapsulated neutralizing antibodies (NA) to tumor necrosis factor (TNF) and interleukin-1 (IL-1) in combination with gentamicin have demonstrated improved survival in a peritonitis model of gram-negative septic shock. Microencapsulation has been shown to improve the effectiveness of NA by delivering them intracellularly, taking advantage of the natural phagocytic activity of the macrophage. It is the purpose of this study to see if microencapsulated NA to TNF and IL-1 in combination with vancomycin can improve survival compared with NA in solution in Staphlococcus aureus-induced septic shock. Groups of 10 rats received the following treatments: (1) S. aureus plus no treatment, (2) S. aureus plus blank microspheres, (3) S. aureus plus vancomycin, (4) S. aureus plus a microsphere form of NA and vancomycin, (5) S. aureus plus a solution form of NA and vancomycin, (6) S. aureus plus a microsphere form of NA, and (7) S. aureus plus a solution form of NA. Survival was monitored for 5 days, and plasma TNF and IL-1 levels were measured for 48 h after S. aureus administration. All (100%) animals that received the microsphere form of NA plus vancomycin, 20%-70% of the animals that received the microsphere form of NA alone, and 20% of the animals that received antibiotics alone survived for 5 days or more. None of the animals in the no treatment group or blank microsphere treatment group and only 10% of the animals in the solution form of NA plus or minus vancomycin group survived for more than 5 days. Plasma TNF and IL-1 levels were significantly increased after S. aureus treatment. Simultaneous and delayed treatment with the microsphere form of NA plus or minus vancomycin significantly reduced TNF and IL-1 levels, and the solution form of NA significantly reduced only TNF levels after immediate treatment. The survival rate was higher in animals with lower TNF levels and IL-1 levels. The results demonstrate that the microsphere form of cytokine NA is 100% effective in combination with vancomycin in protecting rats from S. aureus-induced peritonitis. The microsphere form was also more efficient in attenuating both TNF and IL-1 levels.

Ventricular cerebrospinal fluid and serum concentrations of sTNFR-I, IL-1ra, and IL-6 after aneurysmal subarachnoid hemorrhage

Postsubarachnoid hemorrhage, systemic inflammatory response syndrome and associated organ system failure are more frequently found in patients in poor neurologic condition. Since subarachnoid hemorrhage causes a profound intrathecal inflammatory response with production of proinflammatory cytokines TNFalpha, IL-1beta, and IL-6, a possible explanation for this association is that brain-derived cytokines may enter the systemic circulation in the presence of postsubarachnoid hemorrhage blood brain barrier disruption to systemically activate inflammatory cascades and thereby contribute to the development of postsubarachnoid hemorrhage systemic inflammatory response syndrome and extracerebral organ system failures. In 44 patients with aneurysmal subarachnoid hemorrhage admitted within 3 days of the initial bleed, extracerebral organ system functions were assessed individually and in aggregate using the modified Multiple Organ Dysfunction Score. Serum and cerebrospinal fluid concentrations of soluble tumor necrosis factor-alpha receptor-I, interleukin-1beta receptor antagonist, and IL-6 were determined during the first 2 weeks after subarachnoid hemorrhage and tested for correlation with (1) admission Hunt-Hess grade, (2) development of systemic inflammatory response syndrome and extracerebral organ system failures, and (3) neurologic outcome. The development of postsubarachnoid hemorrhage systemic inflammatory response syndrome and extracerebral organ system failures was paralleled by a significant increase in serum but not in cerebrospinal fluid levels of soluble tumor necrosis factor-alpha receptor-I and IL-1ra, that is, patients with and without extracerebral organ system failures did not differ in pattern and time course of cerebrospinal fluid cytokine concentrations. In contrast, increasing soluble tumor necrosis factor-alpha receptor-I and interleukin-1beta receptor antagonist serum levels correlated with a higher Multiple Organ Dysfunction score and with individual organ system dysfunctions. Postsubarachnoid hemorrhage, systemic inflammatory response syndrome and extracerebral organ system failures could therefore not be linked to changes in cerebrospinal fluid cytokine concentration profiles.

The relationship between visceral ischemia, proinflammatory cytokines, and organ injury in patients undergoing thoracoabdominal aortic aneurysm repair

OBJECTIVES

Plasma proinflammatory, anti-inflammatory cytokine, and soluble tumor necrosis factor (TNF) receptor concentrations were examined in hospitalized patients after abdominal and thoracoabdominal aortic aneurysm (TAAA) repair, with and without left atrial femoral bypass. Changes in plasma cytokine concentrations were related to the duration of visceral ischemia and the frequency rate of postoperative, single, or multiple system organ dysfunction (MSOD).

DESIGN

Prospective, observational study.

SETTING

Two academic referral centers in the United States and The Netherlands.

PATIENTS

We included 16 patients undergoing TAAA repair without left atrial femoral bypass, 12 patients undergoing TAAA repair with left atrial femoral bypass, and nine patients undergoing infrarenal aortic aneurysm repair.

MEASUREMENTS AND MAIN RESULTS

Timed, arterial blood sampling for proinflammatory and anti-inflammatory cytokine and soluble TNF receptor concentrations (p55 and p75), and prospective assessment of postoperative single and MSOD. Plasma appearance of TNF-alpha, interleukin (IL)-6, IL-8, and IL-10 peaked 1 to 4 hrs after TAAA repair, and concentrations were significantly elevated compared with infrarenal abdominal aortic aneurysm repair (p < .05). Left atrial femoral bypass significantly reduced the duration of visceral ischemia (p < .05) and the systemic TNF-alpha, p75, and IL-10 responses (p < .05). Plasma TNF-alpha concentrations >150 pg/mL were more common in patients with extended visceral ischemia times (>40 mins). Additionally, patients with early peak TNF-alpha concentrations >150 pg/mL and IL-6 levels >1,000 pg/mL developed MSOD more frequently than patients without these elevated plasma cytokine levels (both p < .05).

CONCLUSIONS

Thoracoabdominal aortic aneurysm repair results in the increased plasma appearance of TNF-alpha, IL-6, IL-8, IL-10, and shed TNF receptors. The frequency and magnitude of postoperative organ dysfunction after TAAA repair is associated with an increased concentration of the cytokines, TNF-alpha, and IL-6 and the increased plasma levels of these cytokines appear to require extended visceral ischemia times.

Meningococcal disease as a model to evaluate novel anti-sepsis strategies

OBJECTIVE

To consider the appropriateness of meningococcemia as a clinical entity for the evaluation of anti-endotoxin agents.

DATA SOURCES

English language published literature concerning meningococcemia, sepsis, and endotoxin.

STUDY SELECTION

The purpose of this work is to consider some of the practical and scientific issues that arise in designing clinical trials to evaluate anti-endotoxin agents. A selected review of recently published articles was undertaken.

DATA EXTRACTION AND SYNTHESIS

Relevant literature has been cited to support factual statements in the text.

CONCLUSION

Meningococcemia as a paradigm of endotoxin-mediated Gram-negative sepsis has many advantages. It is a homogeneous population, and it represents a single, measurable, bacterial target that is unequivocally implicated in the pathogenesis of the disease. However, it is an uncommon disease that may develop so quickly that attempts to intervene may be too late to have an effect. There is considerable morbidity, but how best to measure the outcome and the extent to which the results can be extrapolated to adult populations with sepsis secondary to nosocomial infection remain unclear.

Comparison of the performance of two general and three specific scoring systems for meningococcal septic shock in children

OBJECTIVE

To evaluate the performance at admission to the pediatric intensive care unit (PICU) of five severity scores, two general (the Pediatric Risk of Mortality [PRISM] II and III scores) and three specific for meningococcal septic shock (Leclerc, Glasgow Meningococcal Septicemia Prognostic Score [GMSPS], and Gedde-Dahl's MOC score) in children with this condition.

DESIGN

Multicenter, retrospective, cohort study.

SETTING

The PICUs from four tertiary centers.

PATIENTS

Patients were 192 children ranging in age from 1 month to 14 yrs consecutively admitted to the participating PICUs during a period of 12 yrs and 6 months (January 1983 to June 1995), who were diagnosed with presumed or confirmed meningococcal septic shock. Patients with a length of stay <2 hrs were excluded from the study.

INTERVENTIONS

Clinical and laboratory data gathered during the first 2 hrs after admission were used to compute the scoring systems tested.

MEASUREMENTS AND MAIN RESULTS

There were 66 deaths (34%). Neisseria meningitidis was cultured from 142 (74%) children. GMSPS and PRISM II provided the best discriminative capability, as measured by the area under the receiver operating characteristic curve (SEM): 0.816 (0.036) and 0.803 (0.041), respectively. The other three scores gave lower receiver operating characteristic areas: PRISM III = 0.777 (0.043), MOC = 0.775 (0.037), and Leclerc = 0.661 (0.045). There was a statistically significant difference between the areas under the receiver operating characteristic curve of GMSPS and Leclerc (p < .01) but not between the GMSPS and the remaining three scores. All five scores presented good calibration with no significant differences between observed and predicted mortality (Hosmer-Lemeshow goodness-of-fit test).

CONCLUSIONS

The specific GMSPS and the general pediatric severity system PRISM II performed better than the other three scores, being appropriate tools to assess severity of illness at admission to the PICU in children with presumed meningococcal septic shock.

A role for TNF in bone resorption of deciduous molars in human beings

In this study, tumor necrosis-alpha was sampled from the gingival crevice of human deciduous molars; this was compared with values measured from the crevice of those deciduous molars missing a permanent successor, and from the crevice of deciduous ankylosed molars. Tumor necrosis-alpha was harvested from the gingival crevice with magnetic microspheres coated with tumor necrosis-alpha antibodies. The amount of bead-bound tumor necrosis-alpha was quantified with the use of an enzyme-linked immunosorbent assay. One hundred seven sites (from 41 patients) were sampled; for each patient, the normal value was compared with either the molars missing a permanent successor or ankylosed value. The tumor necrosis-alpha levels were 1.6 times higher from the crevice of ankylosed deciduous molars when compared with normal deciduous molars and 2.6 times higher from the crevice of sites with a molar missing a permanent successor. The mean and standard error mean distribution of tumor necrosis-alpha expressed as picograms was: normal molars 91 pg (standard error mean +/- 20), ankylosed molars 150 pg (standard error mean +/- 31), and missing permanent successor 236 pg (standard error mean +/- 67). Analysis of variance showed the difference among the 3 means was close to attaining significant difference (F [2.104] = 2.7905, P =.066). Multiple comparison procedures indicated that the mean for molars missing a permanent successor and the normal groups were significantly different, P =.05. The results of this study suggest tumor necrosis-alpha values are elevated in the gingival crevice of deciduous molars with ankylosis and where the permanent tooth bud is congenitally missing.