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Liu J, Li X, Qu J. Serum IL-31 is related to the severity and 3-month prognosis of patients with Intracerebral hemorrhage. Medicine (Baltimore) 2024; 103:e35760. [PMID: 38306544 PMCID: PMC10843249 DOI: 10.1097/md.0000000000035760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/03/2023] [Indexed: 02/04/2024] Open
Abstract
Interleukin (IL)-31/IL-33 axis has been proved to play an important role in the regulation of inflammation, and serum IL-33 was found to be a novel serum prognostic marker of intracerebral hemorrhage (ICH), while the value of serum IL-31 levels on prognosis in patients with ICH remains unknown. The present study was designed to study the value of serum IL-31 levels on prognosis in ICH patients. A total of 200 ICH patients and 50 healthy people were included in this study. We collected clinical data such as demographic data, laboratory data, admission disease scores and medical histories of these participants. We measured serum IL-31 levels using enzyme-linked immunosorbent assay, and assessed the prognosis of ICH patients 3 months after onset by mRS scale, and mRS > 2 was defined as a 3-month poor outcome. The level of IL-31 in ICH patients were significantly higher than that in healthy control people (211.91 ± 61.61 vs 167.64 ± 27.45 pg/mL, P < .001), and levels of IL-31 in ICH patients with 3-month good outcome were significantly lower than that in ICH patients with 3-month poor outcome (196.09 ± 50.84 vs 248.05 ± 41.41 pg/mL, P < .001). Results of correlation analysis suggested that the level of serum IL-31 was positively related to admission NIHSS score (r = 0.627, P < .001), hematoma volume (r = 0.352, P < .001), mRS score (r = 0.515, P < .001), high-density lipoprotein-cholesterol (r = 0.177, P = .012), serum C-reactive protein levels (r = 0.483, P < .001), and serum tumor necrosis factor α levels (r = 0.389, P < .001) in ICH patients, while the level of serum IL-31 was negatively related to the admission GCS score (r = -0.518, P < .001) and triglycerides (r = -0.147, P = .038). Results of multivariate regression analysis shows that serum IL-31 levels are an independent risk factor affecting NIHSS scores (OR = 1.023, 95% CI = 1.010-2.036) and 3-month prognosis (OR = 1.023, 95% CI = 0.982-1.747) in ICH patients. The receiver operating characteristic curve analysis showed that the sensitivity and specificity of serum IL-31 level in evaluating the prognosis of ICH were 85.2% and 76.7%, respectively. A cutoff value of serum IL-31 level > 185.30 pg/mL may indicate a poor prognosis for ICH. Serum IL-31 levels on admission in ICH patients are associated with patient prognosis, and higher serum IL-31 levels are associated with a higher risk of poor prognosis in ICH patients.
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Affiliation(s)
- Jingfeng Liu
- Emergency Department, Beijing Hepingli Hospital, Beijing, China
| | - Xing Li
- Department of Neurology, Beijing Hepingli Hospital, Beijing, China
| | - Ji Qu
- Department of Neurology, Beijing Hepingli Hospital, Beijing, China
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Zhang A, Liu Y, Wang X, Xu H, Fang C, Yuan L, Wang K, Zheng J, Qi Y, Chen S, Zhang J, Shao A. Clinical Potential of Immunotherapies in Subarachnoid Hemorrhage Treatment: Mechanistic Dissection of Innate and Adaptive Immune Responses. Aging Dis 2023; 14:1533-1554. [PMID: 37196120 PMCID: PMC10529760 DOI: 10.14336/ad.2023.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/26/2023] [Indexed: 05/19/2023] Open
Abstract
Subarachnoid hemorrhage (SAH), classified as a medical emergency, is a devastating and severe subtype of stroke. SAH induces an immune response, which further triggers brain injury; however, the underlying mechanisms need to be further elucidated. The current research is predominantly focused on the production of specific subtypes of immune cells, especially innate immune cells, post-SAH onset. Increasing evidence suggests the critical role of immune responses in SAH pathophysiology; however, studies on the role and clinical significance of adaptive immunity post-SAH are limited. In this present study, we briefly review the mechanistic dissection of innate and adaptive immune responses post-SAH. Additionally, we summarized the experimental studies and clinical trials of immunotherapies for SAH treatment, which may form the basis for the development of improved therapeutic approaches for the clinical management of SAH in the future.
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Affiliation(s)
- Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Houshi Xu
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Chaoyou Fang
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Ling Yuan
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - KaiKai Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Jingwei Zheng
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Yangjian Qi
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Anwen Shao
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
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Maity S, Santra A, Vardhan Hebbani A, Pulakuntla S, Chatterjee A, Rao Badri K, Damodara Reddy V. Targeting cytokine storm as the potential anti-viral therapy: Implications in regulating SARS-CoV-2 pathogenicity. Gene 2023:147612. [PMID: 37423400 DOI: 10.1016/j.gene.2023.147612] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/18/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
The latest global pandemic corona virus disease - 2019 (COVID-19) caused by the virus SARS-CoV-2 is still a matter of worrying concern both for the scientific communities and health care organizations. COVID-19 disease is proved to be a highly contagious disease transmitted through respiratory droplets and even close contact with affected individuals. COVID-19 disease is also understood to exhibit diverse symptoms of ranging severities i.e., from mild fatigue to death. Affected individuals' susceptibility to induce immunologic dysregulation phenomena termed 'cytokine storm' seems to be playing the damaging role of escalating the disease manifestation from mild to severe. Cytokine storm in patients with severe symptoms is understood to be characterized by enhanced serum levels of many cytokines including interleukin-1β, interleukin-6, IL-10, TNF, interferon-γ, MIP-1α, MIP-1β and VEGF. Since cytokine production in general is the most important antiviral defense response, understanding the COVID-19 associated cytokine storm in particular and differentiating it from the regular cytokine production response becomes crucial in developing an effective therapeutic strategy.This review focuses on the potential targeting of COVID-19 associated cytokine storm and its challenges.
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Affiliation(s)
- Subashish Maity
- Department of Biotechnology, REVA University, Bengaluru-560064, Karnataka, India
| | - Ayantika Santra
- Department of Biochemistry, Indian Academy Degree College, Bengaluru, 560 043, India
| | | | - Swetha Pulakuntla
- Department of Biotechnology, REVA University, Bengaluru-560064, Karnataka, India
| | - Ankita Chatterjee
- Department of Biotechnology, REVA University, Bengaluru-560064, Karnataka, India
| | - Kameswara Rao Badri
- Department of Pharmacology and Toxicology, Cardiovascular Research Institute, Morehouse School of Medicine, GA, Atlanta-30310, USA; Clinical Analytical Chemistry Laboratory, COVID-19 Testing Laboratory, Morehouse School of Medicine, GA, Atlanta-30310, USA.
| | - Vaddi Damodara Reddy
- Department of Biotechnology, REVA University, Bengaluru-560064, Karnataka, India.
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Wu J, Ma W, Qiu Z, Zhou Z. Roles and mechanism of IL-11 in vascular diseases. Front Cardiovasc Med 2023; 10:1171697. [PMID: 37304948 PMCID: PMC10250654 DOI: 10.3389/fcvm.2023.1171697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/28/2023] [Indexed: 06/13/2023] Open
Abstract
Vascular diseases are the leading cause of morbidity and mortality worldwide. Therefore, effective treatment strategies that can reduce the risk of vascular diseases are urgently needed. The relationship between Interleukin-11 (IL-11) and development of vascular diseases has gained increasing attention. IL-11, a target for therapeutic research, was initially thought to participate in stimulating platelet production. Additional research concluded that IL-11 is effective in treating several vascular diseases. However, the function and mechanism of IL-11 in these diseases remain unknown. This review summarizes IL-11 expression, function, and signal transduction mechanism. This study also focuses on the role of IL-11 in coronary artery disease, hypertension, pulmonary hypertension, cerebrovascular disease, aortic disease, and other vascular diseases and its potential as a therapeutic target. Consequently, this study provides new insight into the clinical diagnosis and treatment of vascular diseases.
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Affiliation(s)
- Jiacheng Wu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Engineering Research Center for Immunological Diagnosis and Therapy of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenrui Ma
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Engineering Research Center for Immunological Diagnosis and Therapy of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Radiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Wuhan, China
| | - Zhihua Qiu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Engineering Research Center for Immunological Diagnosis and Therapy of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zihua Zhou
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Engineering Research Center for Immunological Diagnosis and Therapy of Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Datta A, Udhaya Kumar S, D'costa M, Bothe A, Thirumal Kumar D, Zayed H, George Priya Doss C. Identification of dysregulated canonical pathways associated with pathogenesis and progression of Amyotrophic Lateral Sclerosis-An integrated bioinformatics approach. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2023; 134:21-52. [PMID: 36858735 DOI: 10.1016/bs.apcsb.2022.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The mechanisms responsible for the pathogenesis and progression of Amyotrophic Lateral Sclerosis (ALS) remain poorly understood, making the diagnosis of ALS challenging. We aimed to find the novel gene biomarkers via computationally analyzing microarray expression studies, in three different cell lineages, namely myotube cells, astrocyte cells and oligodendrocyte cells. Microarray gene expression profiles were obtained and analyzed for three cell types: myotube cell lineage (GSE122261), astrocyte, and oligodendrocyte cell lineage (GSE87385). A comprehensive computational pipeline, tailored explicitly for microarray gene expression profiling studies, was devised to analyze the sample groups, wherein the myotube sample group comprised of six control (GSM3462697, GSM3462698, GSM3462699, GSM3462700, GSM3462701, GSM3462702) & six diseased (GSM3462691, GSM3462692, GSM3462693, GSM3462694, GSM3462695, GSM3462696) samples were considered. Similarly, for the astrocyte sample group two samples each for the control (GSM2330040, GSM2330042) and the diseased (GSM2330039, GSM2330041), and for the oligodendrocyte sample group, 2 control (GSM2330043, GSM2330045) samples and two diseased (GSM2330044, GSM2330046) samples were considered for the current study. The in-depth interaction of these DEGs was studied using MCODE and subjected to preliminary functional analysis using ClueGO/CluePedia plug-in. Qiagen's IPA software was employed for enrichment analysis, which generated the key canonical pathways and a list of potential biomarker molecules specific to each sample group. The preliminary analysis yielded 512 DEGs across all 3-sample groups, wherein 139 DEGs belonged to the myotube sample group, 216 DEGs for the astrocyte sample group, and 157 DEGs for the oligodendrocytes sample group. The data suggests growth hormone signaling and its activity, ErbB signaling pathway, and JAK/STAT signaling pathway are some of the pathways that are significantly dysregulated and play a crucial role in the development and progression of ALS. KISS1R and CSHL1 are potential genes that could act as diagnostic biomarkers in myotube cell types. Also, KRAS, TGFB2, JUN, and SMAD6 genes may be used as prognostic biomarkers to differentiate between early and late-stage ALS-diseased patients.
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Affiliation(s)
- Ankur Datta
- Laboratory of Integrative Genomics, Department of Integrative Biology, School of Biosciences and Technology, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - S Udhaya Kumar
- Laboratory of Integrative Genomics, Department of Integrative Biology, School of Biosciences and Technology, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - Maria D'costa
- Laboratory of Integrative Genomics, Department of Integrative Biology, School of Biosciences and Technology, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - Anusha Bothe
- Laboratory of Integrative Genomics, Department of Integrative Biology, School of Biosciences and Technology, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - D Thirumal Kumar
- Faculty of Allied Health Sciences, Meenakshi Academy of Higher Education and Research (Deemed to be University), Chennai, India
| | - Hatem Zayed
- Department of Biomedical Sciences, College of Health and Sciences, QU Health, Qatar University, Doha, Qatar
| | - C George Priya Doss
- Laboratory of Integrative Genomics, Department of Integrative Biology, School of Biosciences and Technology, Vellore Institute of Technology, Vellore, Tamil Nadu, India.
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Rehabilitation Training Can Significantly Increase the Serum IL-11 Levels and Improve the Prognosis in Ischemic Stroke Patients. Mediators Inflamm 2023; 2023:1865760. [PMID: 36875689 PMCID: PMC9977548 DOI: 10.1155/2023/1865760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/26/2022] [Accepted: 11/24/2022] [Indexed: 02/24/2023] Open
Abstract
We aimed to explore the expression of IL-11 in ischemic stroke patients and its correlation with rehabilitation training and prognosis. The present randomized control study recruited ischemic stroke patients who were admitted during March 2014 to November 2020. All patients underwent computer tomography (CT) and magnetic resonance imaging (MRI) examination. All patients were randomly divided into two groups, including rehabilitation training (RT) group and control group. The patients in the RT group were received rehabilitation training within 2 days after the vital signs were stable while control group received routine nursing. The serum interleukin- (IL-) 11 levels were measured by enzyme-linked immunosorbent assay (ELISA) when patients were just hospitalized and 6 h, 24 h, 48 h, 72 h, and 90 h after treatment. Demographic, clinical statistics, imaging data, and the National Institutes of Health Stroke Scores (NIHSS) were recorded. The modified Rankin Scale (mRS) scores were measured after 90 days treatment to assess the prognosis of ischemic patients. The serum IL-11 levels of the RT group elevated more quickly during the study time compared with the control group. In addition, the NIHSS and mRS scores of ischemic stroke patients in the RT group were significantly lower than that in the control group. The NIHSS score, the proportion receiving rehabilitation training, and the levels of IL-11, triglyceride (TG), and high-density leptin cholesterol (HDLC) of ischemic stroke patients in the mRS score ≥ 3 group were remarkably elevated than that in the mRS score ≤ 2 group. However, the serum IL-11 levels of ischemic stroke patients were obviously decreased in the mRS score ≥ 3 group. IL-11 could be a potential diagnostic biomarker of poor prognosis of ischemic stroke patients. Furthermore, IL-11, NIHSS score, and rehabilitation training were the risk factors for poor prognosis of ischemic stroke patients. This study demonstrated that the ischemic stroke patients in the RT group had higher serum IL-11 levels and better prognosis. This study might provide a new approach to improve the prognosis of patients with ischemic stroke. This trial is registered with ChiCTR-PNR-16007706.
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Yeshi K, Ruscher R, Miles K, Crayn D, Liddell M, Wangchuk P. Antioxidant and Anti-Inflammatory Activities of Endemic Plants of the Australian Wet Tropics. PLANTS 2022; 11:plants11192519. [PMID: 36235388 PMCID: PMC9571949 DOI: 10.3390/plants11192519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/03/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022]
Abstract
Plants have been a vital source of natural antioxidants since ancient times. Plants growing under various abiotic stress conditions often produce more defensive secondary metabolites such as phenolics, flavonoids, and terpenoids during adaptation to the environment. Many of these secondary metabolites are known to possess antioxidant and anti-inflammatory properties. This study tested seven plants sourced from the mountaintop areas (above 1000 m elevation) of Mount Lewis National Park (falls under the Wet Tropics of Queensland), Australia, for their antioxidant and anti-inflammatory activities. Of the seven studied plants, hydroethanolic extracts of six plants (Leptospermum wooroonooran, Ceratopetalum hylandii, Linospadix apetiolatus, Garcinia brassii, Litsea granitica, and Polyscias willmottii) showed high 2,2-diphenyl-1-picrylhydrazyl (DPPH)-free radical scavenging activity in a dose-dependent (25–1000 μg/mL) manner. At the highest concentration of 1 mg/mL, the DPPH free radical scavenged percentage varied between 75.4% and 92.3%. Only the species Alyxia orophila was inactive in the DPPH free radical scavenging assay. Pseudo-IC50 values of the extracts’ ferric reducing antioxidant power (FRAP) based on dose-response curves showed a significant positive correlation with total phenolic content. Five out of the seven plants, namely G. brassii, C. hylandii, L. apetiolatus, L. wooroonooran, and A. orophila, showed inhibitory effects on the secretion of proinflammatory cytokines, tumour necrosis factor (TNF), and interleukins (IL)-23 in a lipopolysaccharide (LPS)-stimulated human peripheral blood mononuclear cells (PBMCs) assay. The results of this study demonstrate the value of tropical mountaintop plants in the biodiscovery of antioxidant and anti-inflammatory lead compounds.
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Affiliation(s)
- Karma Yeshi
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Building E4 and E5, McGregor Rd, Smithfield, QLD 4878, Australia
- Correspondence: (K.Y.); (P.W.)
| | - Roland Ruscher
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Building E4 and E5, McGregor Rd, Smithfield, QLD 4878, Australia
| | - Kim Miles
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Building E4 and E5, McGregor Rd, Smithfield, QLD 4878, Australia
| | - Darren Crayn
- Australian Tropical Herbarium, James Cook University, Building E2, McGregor Rd, Smithfield, QLD 4878, Australia
| | - Michael Liddell
- College of Science and Engineering, Centre for Tropical Environmental and Sustainability Science, Building E1, McGregor Rd, Smithfield, QLD 4878, Australia
| | - Phurpa Wangchuk
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Building E4 and E5, McGregor Rd, Smithfield, QLD 4878, Australia
- Correspondence: (K.Y.); (P.W.)
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Wang S, Xu X, Yu Q, Hu H, Han C, Wang R. Combining modified Graeb score and intracerebral hemorrhage score to predict poor outcome in patients with spontaneous intracerebral hemorrhage undergoing surgical treatment. Front Neurol 2022; 13:915370. [PMID: 35968295 PMCID: PMC9373905 DOI: 10.3389/fneur.2022.915370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/11/2022] [Indexed: 12/02/2022] Open
Abstract
Objective Spontaneous intracerebral hemorrhage (sICH) is a frequently encountered neurosurgical disease. The purpose of this study was to evaluate the relationship between modified Graeb Score (mGS) at admission and clinical outcomes of sICH and to investigate whether the combination of ICH score could improve the accuracy of outcome prediction. Methods We retrospectively reviewed the medical records of 511 patients who underwent surgery for sICH between January 2017 and June 2021. Patient outcome was evaluated by the Glasgow Outcome Scale (GOS) score at 3 months following sICH, where a GOS score of 1–3 was defined as a poor prognosis. Univariate and multivariate logistic regression analyses were conducted to determine risk factors for unfavorable clinical outcomes. Receiver operating characteristic (ROC) curve analysis was performed to detect the optimal cutoff value of mGS for predicting clinical outcomes. An ICH score combining mGS was created, and the performance of the ICH score combining mGS was assessed for discriminative ability. Results Multivariate analysis demonstrated that a higher mGS score was an independent predictor for poor prognosis (odds ratio [OR] 1.207, 95% confidence interval [CI], 1.130–1.290, p < 0.001). In ROC analysis, an optimal cutoff value of mGS to predict the clinical outcome at 3 months after sICH was 11 (p < 0.001). An increasing ICH-mGS score was associated with increased poor functional outcome. Combining ICH score with mGS resulted in an area under the curve (AUC) of 0.790, p < 0.001. Conclusion mGS was an independent risk factor for poor outcome and it had an additive predictive value for outcome in patients with sICH. Compared with the ICH score and mGS alone, the ICH score combined with mGS revealed a significantly higher discriminative ability for predicting postoperative outcome.
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Affiliation(s)
- Shen Wang
- Department of Neurosurgery, Shanghai University of Medicine and Health Sciences Affiliated Jia Ding Hospital, Shanghai, China
| | - Xuxu Xu
- Department of Neurosurgery, Shanghai Minhang District Central Hospital, Shanghai, China
| | - Qiang Yu
- Department of Neurosurgery, Fuyang Fifth People's Hospital, Anhui, China
| | - Haicheng Hu
- Department of Neurosurgery, Fuyang Fifth People's Hospital, Anhui, China
| | - Chao Han
- Department of Neurosurgery, Fuyang Fifth People's Hospital, Anhui, China
| | - Ruhai Wang
- Department of Neurosurgery, Fuyang Fifth People's Hospital, Anhui, China
- *Correspondence: Ruhai Wang
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Cui Y, Wang XH, Zhao Y, Chen SY, Sheng BY, Wang LH, Chen HS. Change of Serum Biomarkers to Post-Thrombolytic Symptomatic Intracranial Hemorrhage in Stroke. Front Neurol 2022; 13:889746. [PMID: 35720096 PMCID: PMC9202348 DOI: 10.3389/fneur.2022.889746] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Symptomatic intracranial hemorrhage (sICH) is a terrible complication after intravenous alteplase in stroke, and numerous biomarkers have been investigated. However, the change of biomarkers to sICH has not been well determined. Aim To investigate the association between the change of biomarkers and sICH. Methods This is a prospective cohort study, and patients with sICH within 24 h after thrombolysis were enrolled, while patients without sICH were matched by propensity score matching with a ratio of 1:1. The blood samples were collected before and 24 h after intravenous thrombolysis (IVT), and preset 49 serum biomarkers were measured by microarray analysis. Protein function enrichment analyses were performed to detect the association between the change of biomarkers and sICH. Results Of consecutive 358 patients, 7 patients with sICH in 24 h were assigned to the sICH group, while 7 matched patients without any ICH were assigned to the non-sICH group. A total of 9 biomarkers were found to significantly change before vs. after thrombolysis between groups, including increased biomarkers, such as brain-derived neurotrophic factor, C-C motif chemokine ligand (CCL)-24, interleukin (IL)-6, IL-10, IL-18, and vascular endothelial growth factor, and decreased biomarkers, such as CCL-11, intercellular adhesion molecule-1, and IL-7. Conclusions This is the first study to identify changes in serum biomarkers in patients with sICH after IVT, and found that 6 neuroinflammatory and 3 neuroprotective biomarkers may be associated with brain injury following post-thrombolytic sICH. Clinical Trial Registration https://www.clinicaltrials.gov, identifier: NCT02854592.
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Affiliation(s)
- Yu Cui
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Xin-Hong Wang
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yong Zhao
- Department of Neurology, Haicheng Hospital of Traditional Chinese Medicine, Haicheng, China
| | - Shao-Yuan Chen
- Department of Neurology, Chinese People's Liberation Army 321 Hospital, Baicheng, China
| | - Bao-Ying Sheng
- Department of Neurology, Jiamusi University First Affiliated Hospital, Jiamusi, China
| | - Li-Hua Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
- *Correspondence: Hui-Sheng Chen
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Nasa P. Outcome of Hemorrhagic Stroke: Host Immune Response can Be a Prediction Tool! Indian J Crit Care Med 2022. [PMID: 35110832 DOI: 10.5005/jp-journals-10071-24095.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Nasa P. Outcome of Hemorrhagic Stroke: Host Immune Response can Be a Prediction Tool! Indian J Crit Care Med 2022;26(1):2-4.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
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Abstract
How to cite this article: Nasa P. Outcome of Hemorrhagic Stroke: Host Immune Response can Be a Prediction Tool! Indian J Crit Care Med 2022;26(1):2-4.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
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Kaur B, Kobayashi Y, Cugini C, Shimizu E. A Mini Review: The Potential Biomarkers for Non-invasive Diagnosis of Pulpal Inflammation. FRONTIERS IN DENTAL MEDICINE 2021; 2:718445. [PMID: 38947881 PMCID: PMC11212789 DOI: 10.3389/fdmed.2021.718445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
For assessing the adequacy of vital pulp therapy for an inflamed pulp, the use of non-invasive diagnostic tools is necessary to avoid further damage to the teeth. Detection of biomarkers that are indicative of the inflammatory status in pulp can be a promising tool for this purpose. These biomarkers need to be reliably correlated with pulpal inflammation and to be easily detected without pulp exposure. This mini-review article aims to review biomarkers that are present in gingival crevicular fluid (GCF) in inflamed pulp conditions. Several studies have reported the availability of various biomarkers including cytokines, proteases, elastase, neuropeptides, and growth factors. Non-invasive pulpal diagnostic methods will be useful as well to determine reversibility, irreversibility, or necrosis of inflamed pulp. These types of molecular diagnoses via analyzing the proteome have revolutionized the medical field, and are one of the most promising empirical methodologies that a clinician can utilize for the proactive identification of pulpal disease.
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Affiliation(s)
- Brahmleen Kaur
- Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ, United States
| | - Yoshifumi Kobayashi
- Department of Oral Biology, Rutgers School of Dental Medicine, Newark, NJ, United States
| | - Carla Cugini
- Department of Oral Biology, Rutgers School of Dental Medicine, Newark, NJ, United States
| | - Emi Shimizu
- Department of Oral Biology, Rutgers School of Dental Medicine, Newark, NJ, United States
- Department of Endodontics, Rutgers School of Dental Medicine, Newark, NJ, United States
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Abstract
PURPOSE OF REVIEW Nontraumatic intracerebral hemorrhage (ICH) is the second most common type of stroke. This article summarizes the basic pathophysiology, classification, and management of ICH and discusses the available evidence on therapy for hematoma, hematoma expansion, and perihematomal edema. RECENT FINDINGS Current available data on potential therapeutic options for ICH are promising, although none of the trials have shown improvement in mortality rate. The literature available on reversal of anticoagulation and antiplatelet agents after an ICH and resumption of these medications is also increasing. SUMMARY ICH continues to have high morbidity and mortality. Advances in therapeutic options to target secondary brain injury from the hematoma, hematoma expansion, and perihematomal edema are increasing. Data on reversal therapy for anticoagulant-associated or antiplatelet-associated ICH and resumption of these medications are evolving.
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Zhang Y, Long H, Wang S, Xiao W, Xiong M, Liu J, Chen L, Chen R, Wei X, Shu Y, Zeng Y, Zhang L. Genome-Wide DNA Methylation Pattern in Whole Blood Associated With Primary Intracerebral Hemorrhage. Front Immunol 2021; 12:702244. [PMID: 34484198 PMCID: PMC8414634 DOI: 10.3389/fimmu.2021.702244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/28/2021] [Indexed: 12/12/2022] Open
Abstract
Primary intracerebral hemorrhage (ICH) is a significant cause of morbidity and mortality throughout the world. ICH is a multifactorial disease that emerges from interactions among multiple genetic and environmental factors. DNA methylation plays an important role in the etiology of complex traits and diseases. We used the Illumina Infinium Human Methylation 850k BeadChip to detect changes in DNA methylation in peripheral blood samples from patients with ICH and healthy controls to explore DNA methylation patterns in ICH. Here, we compared genomic DNA methylation patterns in whole blood from ICH patients (n = 30) and controls (n = 34). The ICH and control groups showed significantly different DNA methylation patterns at 1530 sites (p-value < 5.92E-08), with 1377 hypermethylated sites and 153 hypomethylated sites in ICH patients compared to the methylation status in healthy controls. A total of 371 hypermethylated sites and 35 hypomethylated sites were in promoters, while 738 hypermethylated sites and 67 hypomethylated sites were in coding regions. Furthermore, the differentially methylated genes between ICH patients and controls were largely related to inflammatory pathways. Abnormalities in the DNA methylation pattern identified in the peripheral blood of ICH patients may play an important role in the development of ICH and warranted further investigation.
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Affiliation(s)
- Yupeng Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Hongyu Long
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Sai Wang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Wenbiao Xiao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Meishan Xiong
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Jianyi Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Lei Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Ruijuan Chen
- Department of Geriatrics, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xueli Wei
- Department of Geriatrics, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yi Shu
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yi Zeng
- Department of Geriatrics, Second Xiangya Hospital, Central South University, Changsha, China
| | - Le Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
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Xu Y, Ma HY, Qiao CY, Peng Y, Ding Q, Xiang RL, Wang LZ, Yan JF, Hou Y, Di F. Significance of changes in the concentration of inflammatory factors in blood or cerebrospinal fluid in evaluating the severity and prognosis of spontaneous cerebral hemorrhage: A systematic review and meta-analysis. Clin Neurol Neurosurg 2021; 205:106631. [PMID: 33887504 DOI: 10.1016/j.clineuro.2021.106631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/22/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Spontaneous intracerebral hemorrhage (SICH) often leads to severe disability, while inflammation plays an important role in SICH-induced secondary brain injury. The purpose of this study was to investigate the value of inflammatory factors as a means of evaluating the prognosis of SICH and to investigate the relationship between inflammatory factors and the severity and prognosis of SICH. METHODS The articles published before November 1 2020 were searched through PubMed, EMBASE, Cochrane library and web of science. Revman5.3 was used, using the inverse variance model to pool the SMD of TNF-a and interleukin concentration. RESULTS A total of 25 studies involving 3333 subjects were included in this paper. The concentration of TNF-α in the blood or cerebrospinal fluid of severe SICH patients was significantly higher than that of milder SICH patients or healthy population; SICH patients with high TNF-α concentration had a 1.06 times greater odds of poor outcomes than patients with low TNF-α concentration, odds ratio (OR) = 1.06[95% CI, 1.01-1.12]. The concentration of interleukin-6 (IL-6) in severe SICH patients was significantly higher than that in milder SICH patients; patients with high IL-6 concentration had a 2.61 times greater odds of poor outcomes than patients with low IL-6 concentration, OR = 2.61[95% CI, 1.79-3.80]. CONCLUSIONS The detection of concentrations of TNF-α and IL-6 in peripheral blood may be helpful for the objective and quantitative assessment of the severity and prognosis of patients with SICH, and have certain significance for the selection of appropriate treatment options.
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Affiliation(s)
- Yan Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100160, China
| | - Hai-Yang Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100160, China
| | - Chun-You Qiao
- Department of Endocrinology, Zhangjiakou First Hospital, Zhangjiakou, Hebei 075041, China
| | - Yi Peng
- Department of Endocrinology, Zhangjiakou First Hospital, Zhangjiakou, Hebei 075041, China
| | - Qi Ding
- Department of Neurosurgery, Zhangjiakou First Hospital, Zhangjiakou, Hebei 075041, China
| | - Ruo-Lan Xiang
- Department of Physiology and Pathophysiology, Peking University School of Basic Medical Sciences, Beijing 100191, China
| | - Li-Zhong Wang
- Department of Neurosurgery, Zhangjiakou First Hospital, Zhangjiakou, Hebei 075041, China
| | - Jun-Fei Yan
- Department of Neurosurgery, Zhangjiakou First Hospital, Zhangjiakou, Hebei 075041, China
| | - Yuan Hou
- Department of Neurosurgery, Zhangjiakou First Hospital, Zhangjiakou, Hebei 075041, China
| | - Fei Di
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100160, China; Department of Neurosurgery, Zhangjiakou First Hospital, Zhangjiakou, Hebei 075041, China.
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Morais Filho ABD, Rego TLDH, Mendonça LDL, Almeida SSD, Nóbrega MLD, Palmieri TDO, Giustina GZD, Melo JP, Pinheiro FI, Guzen FP. The physiopathology of spontaneous hemorrhagic stroke: a systematic review. Rev Neurosci 2021; 32:631-658. [PMID: 33594841 DOI: 10.1515/revneuro-2020-0131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/22/2021] [Indexed: 12/29/2022]
Abstract
Hemorrhagic stroke (HS) is a major cause of death and disability worldwide, despite being less common, it presents more aggressively and leads to more severe sequelae than ischemic stroke. There are two types of HS: Intracerebral Hemorrhage (ICH) and Subarachnoid Hemorrhage (SAH), differing not only in the site of bleeding, but also in the mechanisms responsible for acute and subacute symptoms. This is a systematic review of databases in search of works of the last five years relating to the comprehension of both kinds of HS. Sixty two articles composed the direct findings of the recent literature and were further characterized to construct the pathophysiology in the order of events. The road to the understanding of the spontaneous HS pathophysiology is far from complete. Our findings show specific and individual results relating to the natural history of the disease of ICH and SAH, presenting common and different risk factors, distinct and similar clinical manifestations at onset or later days to weeks, and possible complications for both.
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Cao F, Guo Y, Zhang Q, Fan Y, Liu Q, Song J, Zhong H, Yao S. Integration of Transcriptome Resequencing and Quantitative Proteomics Analyses of Collagenase VII-Induced Intracerebral Hemorrhage in Mice. Front Genet 2021; 11:551065. [PMID: 33424913 PMCID: PMC7793737 DOI: 10.3389/fgene.2020.551065] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022] Open
Abstract
Objective Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and morbidity rates. Our aim was to comprehensively analyze transcriptome and proteome in an experimental ICH model. Methods All mice were divided into ICH model (n = 3) and sham groups (n = 3). ICH was induced by collagenase VII. The ipsilateral hemisphere was used for whole transcriptome and proteomics resequencing. After preprocessing, differentially expressed lncRNAs (DElncRNAs), mRNAs (DEmRNAs), miRNAs (DEmiRNAs), and DEproteins between ICH and sham groups were identified. Functional enrichment analysis was performed using the clusterProfiler package, followed by protein–protein interaction (PPI) analysis. After that, the Pearson correlation coefficient between DEmRNAs and DElncRNAs or between DEmRNAs and DEproteins was calculated. DElncRNAs with similar functions were analyzed by the GOSemSim package. After prediction of DEmiRNA–DEmRNA and DElncRNA–DEmiRNA relationships, a competing endogenous RNA (ceRNA) network was constructed. Several DEmRNAs and DElncRNAs were validated in ipsilateral hemisphere tissues of the ICH model and control groups using RT-qPCR and western blot. Results Between the ICH and sham groups, 31 DElncRNAs, 367 DEmRNAs, 35 DEmiRNAs, and 96 DEproteins were identified. DEmRNAs were mainly enriched in inflammation, such as cytokine–cytokine receptor interaction, IL-17, and TNF signaling pathways. A PPI network of DEmRNAs was constructed and hub genes were identified, such as IL6 (degree = 59), TNF (degree = 44), and CXCR2 (degree = 39). 24 DElncRNAs with similar functions were identified, including 15 up- and 9 down-regulated lncRNAs. After integration of DEmiRNA–DEmRNA and DElncRNA–DEmiRNA relationships, we constructed a ceRNA network, composed of 71 DEmRNAs, 17 DEmiRNAs, and 12 DElncRNAs. RT-qPCR and western blot results confirmed that C3, Fga, and Slc4a1 proteins were more lowly expressed and Penk was more highly expressed in ICH than control groups, which could become potential markers for ICH. Conclusion Our findings identified ICH-related DE-RNAs and proteins and potential molecular mechanisms of ICH by transcriptome resequencing and quantitative proteomic analyses.
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Affiliation(s)
- Fang Cao
- Department of Cerebrovascular Disease, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yu Guo
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Qiang Zhang
- Department of Cerebrovascular Disease, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yinchun Fan
- Department of Cerebrovascular Disease, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Qian Liu
- Department of Cerebrovascular Disease, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jiancheng Song
- Department of Cerebrovascular Disease, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Hua Zhong
- College of Life Sciences, Wuhan University, Wuhan, China
| | - Shengtao Yao
- Department of Cerebrovascular Disease, Affiliated Hospital of Zunyi Medical University, Zunyi, China
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18
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Bernstein JE, Browne JD, Savla P, Wiginton J, Patchana T, Miulli DE, Wacker MR, Duong J. Inflammatory Markers in Severity of Intracerebral Hemorrhage II: A Follow Up Study. Cureus 2021; 13:e12605. [PMID: 33585095 PMCID: PMC7872478 DOI: 10.7759/cureus.12605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Spontaneous intracerebral hemorrhage (ICH) results in significant morbidity and mortality. The pathogenesis of brain injury after ICH is thought to be due to mechanical damage followed by ischemic, cytotoxic, and inflammatory changes in the underlying and surrounding tissue. Various inflammatory and non-inflammatory biomarkers have been studied as predictors and potential therapeutic targets for intracerebral hemorrhage. Our prior study showed an association with low vascular endothelial growth factor (VEGF) levels and increased mortality. This current study looks to expand on our prior results and will look at the relationship between tumor necrosis factor alpha (TNFα), C-reactive protein (CRP), VEGF, Homocysteine (Hcy), and CRP to albumin ratio (CAR) in predicting outcomes and severity in spontaneous intracerebral hemorrhage. Methods We conducted a retrospective chart review of patients with spontaneous intracerebral hemorrhage with TNFα, CRP, VEGF, Hcy levels drawn on admission. Albumin and CRP levels on admission were used to calculate CAR. Ninety-nine patients were included in the study. Primary outcomes included death, early neurologic decline (END), and hemorrhage size. Secondary outcomes included late neurologic decline (LND), Glasgow Coma Scale (GCS) on admission, GCS on discharge, ICH score, change in hemorrhage size, need for surgical intervention, and length of ICU stay. Results A total of 99 patients were included in this study, with 42% requiring surgical intervention and an overall mortality of 16%. Basal ganglia hemorrhage was seen in 41% of patients. Hcy and CAR were significantly correlated with ICH size in basal ganglia patients (r-=0.36, p=0.03; r=0.43, p=0.03, respectively). CAR was significantly correlated with ICH score (r=0.33, p=0.007874). Admission VEGF levels less than 45 pg/ml had 8.4-fold increase in mortality (odds ratio [OR] 8.4545, p=0.0488). Patients with TNFα levels greater than 1.40 pg/ml had a 4.1-fold increase in mortality (OR 4.1, p=0.04) Conclusion Our study demonstrated that low levels (<45 pg/ml) of VEGF were associated with an 8.4-fold increase in mortality, supporting the neuroprotective effect of this protein. Elevated Hcy and CAR levels were associated with an increase in hemorrhage size in patients with basal ganglia hemorrhages. TNFα levels greater than 1.40 pg/ml were associated with a 4.1-fold increase in mortality, and this together with CAR being correlated with increased hemorrhage size and ICH score further demonstrate the inflammatory consequences after intracerebral hemorrhage. Future studies directed at lowering CRP, TNFα, and Hcy and/or increasing VEGF in intracerebral hemorrhage patients are needed and may be beneficial.
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Affiliation(s)
- Jacob E Bernstein
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Jonathan D Browne
- School of Medicine, California University of Science and Medicine, Colton, USA
| | - Paras Savla
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Tye Patchana
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | | | - Jason Duong
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
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Luo Y, Reis C, Chen S. NLRP3 Inflammasome in the Pathophysiology of Hemorrhagic Stroke: A Review. Curr Neuropharmacol 2020; 17:582-589. [PMID: 30592254 PMCID: PMC6712291 DOI: 10.2174/1570159x17666181227170053] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 11/26/2018] [Accepted: 12/19/2018] [Indexed: 12/14/2022] Open
Abstract
Hemorrhagic stroke is a devastating disease with high morbidity and mortality. There is still a lack of effective ther-apeutic approach. The recent studies have shown that the innate immune system plays a significant role in hemorrhagic stroke. Microglia, as major components in innate immune system, are activated and then can release cytokines and chemo-kines in response to hemorrhagic stroke, and ultimately led to neuroinflammation and brain injury. The NOD-like receptor family, pyrin domain containing 3 (NLRP3) inflammasome is predominantly released by microglia and is believed as the main contributor of neuroinflammation. Several studies have focused on the role of NLRP3 inflammasome in hemorrhagic stroke-induced brain injury, however, the specific mechanism of NLRP3 activation and regulation remains unclear. This re-view summarized the mechanism of NLRP3 activation and its role in hemorrhagic stroke and discussed the translational sig-nificance.
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Affiliation(s)
- Yujie Luo
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Department of Neurosurgery, Taizhou Hospital, Wenzhou Medical University, Linhai, Zhejiang, China
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Saand AR, Yu F, Chen J, Chou SHY. Systemic inflammation in hemorrhagic strokes - A novel neurological sign and therapeutic target? J Cereb Blood Flow Metab 2019; 39:959-988. [PMID: 30961425 PMCID: PMC6547186 DOI: 10.1177/0271678x19841443] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Growing evidences suggest that stroke is a systemic disease affecting many organ systems beyond the brain. Stroke-related systemic inflammatory response and immune dysregulations may play an important role in brain injury, recovery, and stroke outcome. The two main phenomena in stroke-related peripheral immune dysregulations are systemic inflammation and post-stroke immunosuppression. There is emerging evidence suggesting that the spleen contracts following ischemic stroke, activates peripheral immune response and this may further potentiate brain injury. Whether similar brain-immune crosstalk occurs in hemorrhagic strokes such as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is not established. In this review, we systematically examined animal and human evidence to date on peripheral immune responses associated with hemorrhagic strokes. Specifically, we reviewed the impact of clinical systemic inflammatory response syndrome (SIRS), inflammation- and immune-associated biomarkers, the brain-spleen interaction, and cellular mediators of peripheral immune responses to ICH and SAH including regulatory T cells (Tregs). While there is growing data suggesting that peripheral immune dysregulation following hemorrhagic strokes may be important in brain injury pathogenesis and outcome, details of this brain-immune system cross-talk remain insufficiently understood. This is an important unmet scientific need that may lead to novel therapeutic strategies in this highly morbid condition.
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Affiliation(s)
- Aisha R Saand
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Fang Yu
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jun Chen
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sherry H-Y Chou
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,3 Department of Neurosurgery, School of Medicine, University of Pittsburgh, PA, USA
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Apaza T L, Tena Pérez V, Serban AM, Alonso Navarro MJ, Rumbero A. Alkamides from Tropaeolum tuberosum inhibit inflammatory response induced by TNF-α and NF-κB. JOURNAL OF ETHNOPHARMACOLOGY 2019; 235:199-205. [PMID: 30753883 DOI: 10.1016/j.jep.2019.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 02/03/2019] [Accepted: 02/08/2019] [Indexed: 06/09/2023]
Abstract
ETHNO-PHARMACOLOGICAL RELEVANCE Tropaeolum tuberosum, commonly known as "Mashua", is one of the plants most frequently used by Andean (Peruvian-Bolivian) people as food and medicine. It is used as a remedy against a wide range of diseases, especially those related with inflammation. OBJECTIVES This study aims to identify compounds active against inflammatory related conditions. MATERIALS AND METHODS A bioassay-guided isolation of anti-inflammatory compounds from black and purple tubers of T. tuberosum was performed measuring TNF-α and NF-κB production in THP-1 monocytic cells. RESULTS The bioassay-guided isolation led to one active compound from purple T. tuberosum, N-oleoyldopamine (1), and another active compound from black T. tuberosum, N-(2-Hydroxyethyl)-7Z,10Z,13Z,16Z-docosatetraenamide (2). Both compounds displayed anti-TNF-α activity with IC50 values of 3.12 ± 0.19 μM and 1.56 ± 0.15 μM, respectively. Also, both compounds suppressed NF-κB with IC50 of 3.54 ± 0.02 μM and 1.77 ± 0.07 μM, respectively. CONCLUSIONS We identified bioactive compounds from purple and black Tropaeolum tuberosum responsible for their anti-inflammatory activity: N-oleoyldopamine (1) and N-(2-Hydroxyethyl)-7Z,10Z,13Z,16Z-docosatetraenamide (2). This is the first report which isolates these compounds from T. tuberosum and describes their anti-inflammatory activities.
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Affiliation(s)
- Luis Apaza T
- Department of Chemistry, Faculty of Sciences, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Department of Pharmacology, Faculty of Pharmacy, Universidad Complutense de Madrid, Ciudad Universitaria s/n, 28040 Madrid, Spain.
| | - Victor Tena Pérez
- Department of Chemistry, Faculty of Sciences, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain
| | - Andreea Madalina Serban
- Marie Schlodowska Curie University Hospital for Children, Constantin Brancoveanu Boulevard, 077120 Bucharest, Romania
| | - Matías J Alonso Navarro
- Department of Chemistry, Faculty of Sciences, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain
| | - Angel Rumbero
- Department of Chemistry, Faculty of Sciences, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain
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Zhu H, Wang Z, Yu J, Yang X, He F, Liu Z, Che F, Chen X, Ren H, Hong M, Wang J. Role and mechanisms of cytokines in the secondary brain injury after intracerebral hemorrhage. Prog Neurobiol 2019; 178:101610. [PMID: 30923023 DOI: 10.1016/j.pneurobio.2019.03.003] [Citation(s) in RCA: 184] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 03/07/2019] [Accepted: 03/16/2019] [Indexed: 12/18/2022]
Abstract
Intracerebral hemorrhage (ICH) is a common and severe cerebrovascular disease that has high mortality. Few survivors achieve self-care. Currently, patients receive only symptomatic treatment for ICH and benefit poorly from this regimen. Inflammatory cytokines are important participants in secondary injury after ICH. Increases in proinflammatory cytokines may aggravate the tissue injury, whereas increases in anti-inflammatory cytokines might be protective in the ICH brain. Inflammatory cytokines have been studied as therapeutic targets in a variety of acute and chronic brain diseases; however, studies on ICH are limited. This review summarizes the roles and functions of various pro- and anti-inflammatory cytokines in secondary brain injury after ICH and discusses pathogenic mechanisms and emerging therapeutic strategies and directions for treatment of ICH.
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Affiliation(s)
- Huimin Zhu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China
| | - Zhiqiang Wang
- Central laboratory, Linyi People's Hospital, Linyi, Shandong 276003, China
| | - Jixu Yu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China; Central laboratory, Linyi People's Hospital, Linyi, Shandong 276003, China; Genetics and Aging Research Unit, Department of Neurology, Massachusetts General Hospital, Boston, MA 02129, USA
| | - Xiuli Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Feng He
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China
| | - Zhenchuan Liu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China.
| | - Fengyuan Che
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China; Central laboratory, Linyi People's Hospital, Linyi, Shandong 276003, China.
| | - Xuemei Chen
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou 450000, Henan, China
| | - Honglei Ren
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Michael Hong
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jian Wang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Bernstein JE, Savla P, Dong F, Zampella B, Wiginton JG, Miulli DE, Wacker MR, Menoni R. Inflammatory Markers and Severity of Intracerebral Hemorrhage. Cureus 2018; 10:e3529. [PMID: 30613458 PMCID: PMC6314395 DOI: 10.7759/cureus.3529] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and purpose The pathogenesis of brain injury after intracerebral hemorrhage is thought to be due to mechanical damage followed by ischemic, cytotoxic, and inflammatory changes in the underlying and surrounding tissue.In recent years, there has been a greater research interest into the various inflammatory biomarkers and growth factors that are secreted during intracerebral hemorrhage. The biomarkers investigated in this study are tumor necrosis factor alpha (TNF alpha), C-reactive protein (CRP), homocysteine (Hcy), and vascular endothelial growth factor (VEGF). The aim of this study was to further investigate the effects of these biomarkers in predicting the acute severity outcome of intracerebral hemorrhage (ICH). Methods We conducted a retrospective chart review of patients with spontaneous ICH with TNF alpha, CRP, VEGF, and Hcy levels drawn on admission. Forty-two patients with spontaneous ICH with at least one of the above labs were included in the study. Primary outcomes included death, Glasgow Coma Scale (GCS) on admission, early neurologic decline (END), and hemorrhage size. Secondary outcomes included GCS on discharge, ICH score, functional outcome risk stratification scale of intracerebral hemorrhage (FUNC score), change in hemorrhage size, need for surgical intervention, and length of intensive care unit (ICU) stay. Results Forty-two patients with spontaneous intracerebral hemorrhage (ICH) were analyzed, 12 patients (28.5%) required surgical intervention, and four patients (9.5%) died. Only low VEGF serum values were found to predict mortality. TNF alpha, CRP, Hcy, and VEGF levels in our patients with ICH were not found to predict early neurologic decline and were not correlated with GCS on admission, initial hemorrhage size, change in hemorrhage size, need for surgical intervention, ICH score, FUNC score, midline shift, and length of ICU stay. CRP and Hcy were elevated in 58% and 31% of patients tested, respectively. GCS on admission and ICH score were significantly associated with mortality. Conclusion After careful statistical review of the data obtained from this patient population, only low VEGF values were found to be a significant predictor of mortality. However, elevated CRP and Hcy levels were associated with a non-significant trend in hemorrhage size and mortality suggesting that CRP and Hcy-lowering therapies may decrease hemorrhagic stroke risk and severity.
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Affiliation(s)
- Jacob E Bernstein
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Paras Savla
- Osteopathy, College of Osteopathic Medicine - Touro University, Vallejo, USA
| | - Fanglong Dong
- Clinical Research, Western University of Health Sciences, Pomona, USA
| | - Bailey Zampella
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James G Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Margaret R Wacker
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Rosalinda Menoni
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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Modeling prognostic factors for poor neurological outcome in conservatively treated patients with intracerebral hemorrhage: A focus on TNF-α. Clin Neurol Neurosurg 2018; 172:51-58. [DOI: 10.1016/j.clineuro.2018.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/15/2018] [Accepted: 06/26/2018] [Indexed: 12/21/2022]
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25
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Inflammatory Profiles of the Interleukin Family and Network in Cerebral Hemorrhage. Cell Mol Neurobiol 2018; 38:1321-1333. [PMID: 30027390 DOI: 10.1007/s10571-018-0601-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 07/06/2018] [Indexed: 12/19/2022]
Abstract
Cerebral hemorrhage is a series of devastating cerebrovascular diseases with high mortality, morbidity and recurrence rate. Localized and systemic immuno-reactions are involved. Aggregation of immunocytes, which were both recruited from the peripheral circulation and resident in the central nervous system, is induced and activated by hematoma-related blood components. Subsequently, various cytokines, chemokines, free radicals and toxic chemicals are secreted to participant host defense responses. Among these, neuro-inflammation plays critical roles in both the pathologic processes of secondary injuries and recovery of neural damages. Numerous treatment strategies have been proposed, aiming at controlling the balance between anti- and proinflammation. Here, we summarized our current understanding and potential clinical applications for cytokines of the interleukin family in the pathogenesis of hemorrhagic stroke. In addition, we conducted protein-protein network, gene ontology and KEGG analysis on the interleukins using online bioinformatic tools to further elaborate the comprehensive mechanisms of interleukins in cerebral hemorrhage.
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Xu C, Ge H, Wang T, Qin J, Liu D, Liu Y. Increased Expression of T Cell Immunoglobulin and Mucin Domain 3 on CD14 + Monocytes Is Associated with Systemic Inflammatory Reaction and Brain Injury in Patients with Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2018; 27:1226-1236. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 11/20/2017] [Accepted: 11/28/2017] [Indexed: 12/12/2022] Open
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Peripheral glutamate and TNF-α levels in patients with intracerebral hemorrhage: Their prognostic values and interactions toward the formation of the edemal volume. Neurol Neurochir Pol 2018; 52:207-214. [DOI: 10.1016/j.pjnns.2017.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/06/2017] [Accepted: 10/08/2017] [Indexed: 11/23/2022]
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28
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Page MJ, Bester J, Pretorius E. The inflammatory effects of TNF-α and complement component 3 on coagulation. Sci Rep 2018; 8:1812. [PMID: 29379088 PMCID: PMC5789054 DOI: 10.1038/s41598-018-20220-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/16/2018] [Indexed: 12/24/2022] Open
Abstract
Tissue necrosis factor-α (TNF-α) and complement component 3 (C3) are two well-known pro-inflammatory molecules. When TNF-α is upregulated, it contributes to changes in coagulation and causes C3 induction. They both interact with receptors on platelets and erythrocytes (RBCs). Here, we look at the individual effects of C3 and TNF-α, by adding low levels of the molecules to whole blood and platelet poor plasma. We used thromboelastography, wide-field microscopy and scanning electron microscopy to study blood clot formation, as well as structural changes to RBCs and platelets. Clot formation was significantly different from the naïve sample for both the molecules. Furthermore, TNF-α exposure to whole blood resulted in platelet clumping and activation and we noted spontaneous plasma protein dense matted deposits. C3 exposure did not cause platelet aggregation, and only slight pseudopodia formation was noted. Therefore, although C3 presence has an important function to cause TNF-α release, it does not necessarily by itself cause platelet activation or RBC damage at these low concentrations. We conclude by suggesting that our laboratory results can be translated into clinical practice by incorporating C3 and TNF-α measurements into broad spectrum analysis assays, like multiplex technology, as a step closer to a patient-orientated, precision medicine approach.
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Affiliation(s)
- Martin J Page
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, Private Bag X1, MATIELAND, 7602, South Africa
| | - Janette Bester
- Department of Physiology, University of Pretoria, Pretoria, 0007, South Africa
| | - Etheresia Pretorius
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, Private Bag X1, MATIELAND, 7602, South Africa.
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Rendevski V, Aleksovski B, Stojanov D, Mihajlovska-Rendevska A, Aleksovski V, Baneva-Dolnenec N, Nikodijevic D, Gudeva-Nikovska D. Validation of the ELISA Method for Quantitative Detection of TNF-α in Patients with Intracerebral Hemorrhage. Open Access Maced J Med Sci 2017; 5:703-707. [PMID: 29104676 PMCID: PMC5661705 DOI: 10.3889/oamjms.2017.170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/01/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023] Open
Abstract
AIM: We aimed to investigate the sensitivity, reproducibility and validity of the commercial ELISA kits for quantitative detection of TNF-α and their potential application for screening purposes in patients with ICH. METHODS: Analysis of six independent standard series, evaluation of the deviation of the TNF-α concentration in patients with ICH, standard addition and visual analysis of whole UV-Vis spectra were carefully performed. RESULTS: Low standard deviations of the absorbance were detected for every standard, as well as in the samples of healthy controls and patients with ICH. The standard addition series have also confirmed high sensitivity and reproducibility of the assay, with a congruent shift of the standard curves with the concentration of TNF-α for the added plasma. The visual analyses of the gained spectra have revealed the absence of any matrix effects from the addition of the human plasma in the reconstituted standards. CONCLUSION: The commercial ELISA kits can be used in the clinical practice for screening purposes of the plasma TNF-α levels in patients with ICH.
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Affiliation(s)
- Vladimir Rendevski
- University Clinic for Neurosurgery, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Boris Aleksovski
- Faculty of Natural Sciences and Mathematics, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Dragan Stojanov
- Center of Radiology, Clinical Center Niš, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Ana Mihajlovska-Rendevska
- University Clinic for Radiology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Vasko Aleksovski
- University Clinic for Neurology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Natalija Baneva-Dolnenec
- University Clinic for Neurology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Dijana Nikodijevic
- University Clinic for Neurology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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Yu Z, Zheng J, Ma L, Guo R, Li M, Wang X, Lin S, Li H, You C. The predictive accuracy of the black hole sign and the spot sign for hematoma expansion in patients with spontaneous intracerebral hemorrhage. Neurol Sci 2017; 38:1591-1597. [DOI: 10.1007/s10072-017-3006-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/24/2017] [Indexed: 01/01/2023]
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