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Lin CL, Su MC, Kao CH, Lin CL, Yang TY. Estimating the incidence rate ratio of common cold among patients with non-apnea sleep disorders: a retrospective cohort study. PSYCHOL HEALTH MED 2023; 28:2897-2907. [PMID: 35282723 DOI: 10.1080/13548506.2022.2050269] [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: 09/02/2020] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
The purpose was to explore the potential effects of nonapnea sleep disorders (NSDs) and hypnotic use on the incidence of common cold. This study adapted population-based retrospective cohort study designed. We used the data from the Taiwan National Health Insurance Research Database between 1998 and 2011. In total, 59,476 patients with NSDs were included in the study cohort, and the reference cohort comprised 59,476 propensity score-matched patients. We conducted a Poisson regression analysis to assess the incidence of common cold. The overall incidence of common cold was significantly higher than that in the reference cohort. Compared with the patients of the reference cohort without hypnotic use, those of the NSDs cohort with benzodiazepines and zolpidem use had higher incidence of common cold. In conclusion, study cohort had a higher incidence of developing common cold, and particularly pronounced in NSDs with hypnotic use.
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Affiliation(s)
- Chia-Ling Lin
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Mei-Chen Su
- Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Chia-Hung Kao
- Department of Medicine, China Medical University, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Tse-Yen Yang
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
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2
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A nationwide cohort study of the association of benzodiazepines with SARS-CoV-2 infection and clinical outcomes. Sci Rep 2022; 12:15947. [PMID: 36153398 PMCID: PMC9509375 DOI: 10.1038/s41598-022-20335-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 09/12/2022] [Indexed: 11/22/2022] Open
Abstract
The evidence for the impact of benzodiazepine (BZD) use on infection or clinical outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is limited. We evaluated the association of BZD use with SARS-CoV-2 infection and the clinical outcomes of coronavirus disease 2019 (COVID-19) using a nationwide COVID-19 database from South Korea. This nationwide cohort study was performed using the COVID-19 database from the Health Insurance Review and Assessment Service of Korea, and SARS-CoV-2 positivity was investigated according to BZD use. SARS-CoV-2-positive adult patients were assessed in three groups, those who needed hospitalization, those with severe symptoms requiring intensive care, and those who died. A multivariate logistic regression model was used for all the analyses. After adjusting for potential confounding factors, there was no association between BZD use and SARS-CoV-2 positivity. SARS-CoV-2-positive patients with BZD use showed an increased risk of need for hospitalization from COVID-19 compared to those without BZD use (odds ratio [OR]: 1.33, 95% confidence interval [CI] 1.07–1.65). In addition, there was a higher risk for long-term users (OR: 2.64, 95% CI 1.08–6.47). Chronic BZD use contributed to a higher risk of the need for hospitalization among COVID-19 patients, whereas BZD use did not increase the risk of SARS-CoV-2 test positivity, severe outcomes, or mortality.
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Meng L, Huang J, He Q, Zhao Y, Zhao W, Tan J, Sun S, Yang J. Hypnotics and infections: disproportionality analysis of the U.S. Food & Drug Administration adverse event reporting system database. J Clin Sleep Med 2022; 18:2229-2235. [PMID: 35713182 PMCID: PMC9435343 DOI: 10.5664/jcsm.10094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/24/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES There is no consensus information on infections associated with nonbenzodiazepines. Knowledge about infections related to newly marketed hypnotics (orexin receptor antagonists and melatonin receptor agonists) is scarce. The study aimed to detect infection signals for nonbenzodiazepines, orexin receptor antagonists, and melatonin receptor agonists by analyzing data from the U.S. Food & Drug Administration adverse event reporting system. METHODS A disproportionality analysis was performed to quantitatively detect infection signals for hypnotics by calculating the reporting odds ratio and the 95% confidence interval. Data registered in the U.S. Food & Drug Administration adverse event reporting system from 2010-2020 were retrieved. RESULTS A total of 3,092 patients with infection were extracted for the 3 classes of hypnotic drugs. Nonbenzodiazepines were associated with a higher disproportionality of infections (reporting odds ratio: 1.10; 95% confidence interval, 1.06-1.14). The association of infections was not present for melatonin receptor agonists (reporting odds ratio: 0.86; 95% confidence interval, 0.74-1.00) and orexin receptor antagonists (reporting odds ratio: 0.19; 95% confidence interval, 0.15-0.25). Significant reporting associations were identified for nonbenzodiazepines concerning the categories of bone and joint infections, dental and oral soft tissue infections, upper respiratory tract infections, and urinary tract infections. CONCLUSIONS Nonbenzodiazepines had a positive signal for infections, while orexin receptor antagonists and melatonin receptor agonists had a negative signal. More research needs to be conducted to confirm this relationship. CITATION Meng L, Huang J, He Q, et al. Hypnotics and infections: disproportionality analysis of the U.S. Food & Drug Administration adverse event reporting system database. J Clin Sleep Med. 2022;18(9):2229-2235.
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Affiliation(s)
- Long Meng
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University; Key Laboratory of Biochemistry and Molecular Pharmacology, Department of Pharmacology, Chongqing Medical University, Chongqing, China
| | - Jing Huang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qin He
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yibei Zhao
- Key Laboratory of Biochemistry and Molecular Pharmacology, Department of Pharmacology, Chongqing Medical University, Chongqing, China
| | - Wenlong Zhao
- College of Medical Informatics, Chongqing Medical University; Medical Data Science Academy, Chongqing Medical University, Chongqing, China
| | - Juntao Tan
- Medical Records and Statistics Room, People’s Hospital of Chongqing Banan District, Chongqing, China
| | - Shusen Sun
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Western New England University, Springfield, MA
- Department of Pharmacy, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Junqing Yang
- Key Laboratory of Biochemistry and Molecular Pharmacology, Department of Pharmacology, Chongqing Medical University, Chongqing, China
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Ackerman RS, Luddy KA, Icard BE, Piñeiro Fernández J, Gatenby RA, Muncey AR. The Effects of Anesthetics and Perioperative Medications on Immune Function: A Narrative Review. Anesth Analg 2021; 133:676-689. [PMID: 34100781 DOI: 10.1213/ane.0000000000005607] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Preclinical and clinical studies have sought to better understand the effect of anesthetic agents, both volatile and intravenous, and perioperative adjuvant medications on immune function. The immune system has evolved to incorporate both innate and adaptive components, which are delicately interwoven and essential for host defense from pathogens and malignancy. This review summarizes the complex and nuanced relationship that exists between each anesthetic agent or perioperative adjuvant medication studied and innate and adaptive immune function with resultant clinical implications. The most commonly used anesthetic agents were chosen for review including volatile agents (sevoflurane, isoflurane, desflurane, and halothane), intravenous agents (propofol, ketamine, etomidate, and dexmedetomidine), and perioperative adjuvant medications (benzodiazepines, opioids, nonsteroidal anti-inflammatory drugs [NSAIDs], and local anesthetic agents). Patients who undergo surgery experience varying combinations of the aforementioned anesthetic agents and adjuncts, depending on the type of surgery and their comorbidities. Each has unique effects on immunity, which may be more or less ideal depending on the clinical situation. Further study is needed to better understand the clinical effects of these relationships so that patient-specific strategies can be developed to improve surgical outcomes.
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Affiliation(s)
- Robert S Ackerman
- From the Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Benjamin E Icard
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | | | - Robert A Gatenby
- the Department of Cancer Biology and Evolution.,Department of Radiology
| | - Aaron R Muncey
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida
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Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research. Drugs R D 2018; 17:493-507. [PMID: 28865038 PMCID: PMC5694420 DOI: 10.1007/s40268-017-0207-7] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Various adverse events resulting from, or associated with, benzodiazepine and/or Z-drug use have been extensively reported on and discussed in great detail within the biomedical literature. It is widely accepted that motor vehicle accidents and falls leading to fractures in older adults are major adverse events that have been shown to occur more frequently in users of sedative-hypnotic medication, especially of the benzodiazepine and related Z-drug variety. However, the last few years have seen increasing reports in the literature raising the issue of benzodiazepine and Z-drug exposure in the development of other serious medical issues including dementia, infections, respiratory disease exacerbation, pancreatitis, and cancer. This article provides an overview and interpretation on the current state of evidence regarding each of these associations and proposes what gaps in the evidence for drug-exposure–harm associations need to be addressed in the future for the purpose of evaluating causality of harm as it relates to these drugs.
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The Relationship Between Sedatives, Sedative Strategy, and Healthcare-Associated Infection: A Systematic Review. Infect Control Hosp Epidemiol 2016; 37:1234-42. [PMID: 27322888 DOI: 10.1017/ice.2016.129] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Healthcare-associated infections (HAIs) cause significant morbidity in critically ill patients. An underappreciated but potentially modifiable risk factor for infection is sedation strategy. Recent trials suggest that choice of sedative agent, depth of sedation, and sedative management can influence HAI risk in mechanically ventilated patients. OBJECTIVE To better characterize the relationships between sedation strategies and infection. METHODS Systematic literature review. RESULTS We found 500 articles and accepted 70 for review. The 3 most common sedatives for mechanically ventilated patients (benzodiazepines, propofol, and dexmedetomidine) have different pharmacologic and immunomodulatory effects that may impact infection risk. Clinical data are limited but retrospective observational series have found associations between sedative use and pneumonia whereas prospective studies of sedative interruptions have reported possible decreases in bloodstream infections, pneumonia, and ventilator-associated events. CONCLUSION Infection rates appear to be highest with benzodiazepines, intermediate with propofol, and lowest with dexmedetomidine. More data are needed but studies thus far suggest that a better understanding of sedation practices and infection risk may help hospital epidemiologists and critical care practitioners find new ways to mitigate infection risk in critically ill patients. Infect Control Hosp Epidemiol 2016;1-9.
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Nakafero G, Sanders RD, Nguyen-Van-Tam JS, Myles PR. The association between benzodiazepines and influenza-like illness-related pneumonia and mortality: a survival analysis using UK Primary Care data. Pharmacoepidemiol Drug Saf 2016; 25:1263-1273. [PMID: 27215827 DOI: 10.1002/pds.4028] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/16/2016] [Accepted: 04/19/2016] [Indexed: 01/30/2023]
Abstract
PURPOSE Bacterial superinfections, including pneumonia, are frequent complications of influenza-like illness (ILI). Clinical and laboratory evidence suggests that benzodiazepines and Z-drugs may influence susceptibility to infections and mortality. We investigated whether benzodiazepines and zopiclone modify the occurrence of ILI-related pneumonia and mortality. METHODS We obtained data on 804 051 ILI patients from a comprehensive primary care database, the Clinical Practice Research Datalink. The follow-up period started from the diagnosis of ILI for 30 days. Pneumonia and deaths occurring within the 30-day follow-up period were considered as potentially 'ILI related'. Exposure to benzodiazepines and zopiclone was determined in the period preceding a diagnosis of ILI with current use defined as a prescription for benzodiazepines in the month prior to ILI diagnosis. Cox regression was used for the analyses. Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) are presented. RESULTS Influenza-like illness-related pneumonia and mortality were noted in 1117 and 707 ILI patients, respectively. Current exposure to benzodiazepines was associated with increased occurrence of both ILI-related pneumonia and mortality (ILI-related pneumonia adjusted HR 4.24, 95%CI [2.27, 7.95]; ILI-related mortality adjusted HR 20.69, 95%CI [15.54, 27.54]). A similar increase in ILI-related mortality but not pneumonia was observed with current zopiclone use (ILI-related mortality adjusted HR 10.86, 95%CI [6.93, 17.02]; ILI-related pneumonia adjusted HR 1.97, 95%CI [0.63, 6.12]). CONCLUSION Benzodiazepines may increase the likelihood of pneumonia and mortality related to ILI. A cautionary approach to prescribing benzodiazepine is suggested in people known to be at increased risk of pneumonia or mortality. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Georgina Nakafero
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.
| | - Robert D Sanders
- Department of Anaesthesiology, University of Wisconsin, Madison, WI, USA
| | | | - Puja R Myles
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
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Nakafero G, Sanders RD, Nguyen-Van-Tam JS, Myles PR. Association between benzodiazepine use and exacerbations and mortality in patients with asthma: a matched case-control and survival analysis using the United Kingdom Clinical Practice Research Datalink. Pharmacoepidemiol Drug Saf 2015; 24:793-802. [PMID: 26013409 DOI: 10.1002/pds.3799] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 03/23/2015] [Accepted: 04/21/2015] [Indexed: 11/09/2022]
Abstract
PURPOSE To investigate the association between the gamma-aminobutyric acid (GABA)ergic drugs, benzodiazepines or zopiclone and the occurrence of asthma exacerbations and subsequent mortality in a cohort of asthma patients. METHODS The number of patients that were included were 105,747 for those without asthma exacerbation and 25,895 for those with exacerbated asthma. A nested case-control study probed the association between benzodiazepines or zopiclone and occurrence of asthma exacerbation (primary outcome) using conditional logistic regression. Cox regression was used to determine the association between the drugs and all-cause mortality in patients with recorded asthma exacerbation. Adjusted matched odds ratios (adj mOR) and adjusted hazard ratios (adj HR) with 95% confidence intervals (CI) are presented. RESULTS Current benzodiazepine use was associated with increased occurrence of asthma exacerbation (adj mOR 1.49; 95%CI [1.15, 1.93]; P = 0.001) as was current zopiclone use (adj mOR 1.59; 95%CI [1.37, 1.85]; P < 0.001). In patients with an asthma exacerbation, current benzodiazepine use was associated with increased all-cause mortality during a median follow-up of 2 years (adj HR 2.78; 95%CI [1.26, 6.12]; P = 0.011), and the association between zopiclone use and all-cause mortality showed borderline statistical significance (adj HR 1.58; 95%CI [0.98, 2.54]; P = 0.058). CONCLUSION Benzodiazepines and zopiclone may increase the likelihood of asthma exacerbation, and benzodiazepines may also increase the likelihood of mortality following exacerbation. These data suggest that caution should be exercised when prescribing benzodiazepines to patients with asthma.
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Affiliation(s)
- Georgina Nakafero
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Robert D Sanders
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | | | - Puja R Myles
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
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Sanders RD, Grover V, Goulding J, Godlee A, Gurney S, Snelgrove R, Ma D, Singh S, Maze M, Hussell T. Immune cell expression of GABAA receptors and the effects of diazepam on influenza infection. J Neuroimmunol 2015; 282:97-103. [PMID: 25903735 DOI: 10.1016/j.jneuroim.2015.04.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 03/30/2015] [Accepted: 04/01/2015] [Indexed: 11/19/2022]
Abstract
Benzodiazepines increase vulnerability to infection through α1 subunit dependent Υ-amino-butyric-type-A (GABAA) signalling. Immune cell expression of GABAA receptors and the effect of diazepam on influenza infection was investigated. In patients with pneumonia, α1 GABAA subunits were expressed on alveolar macrophages and blood monocytes. In mice, influenza induced dynamic changes in immune cell GABAA subunit expression: α1 subunits decreased on alveolar macrophage, but increased on monocytes, CD4+ and CD8+ T cells. Following influenza viral infection, diazepam delayed weight loss on day 3 but later increased weight loss. Viral load was unaffected but increased bacterial superinfection was noted on day 10.
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Affiliation(s)
- Robert D Sanders
- Department of Anaesthesia, University of Wisconsin, Madison, United States.
| | - Vimal Grover
- Department of Critical Care Medicine, Royal Marsden Hospital, London, United Kingdom.
| | - John Goulding
- Department of Pathology, Immunology & Lab Medicine, University of Florida, United States.
| | | | - Stefan Gurney
- Department of Anaesthesia, Royal Brompton Hospital, United Kingdom.
| | - Robert Snelgrove
- Department of Leukocyte Biology, Imperial College London, United Kingdom.
| | - Daqing Ma
- Department of Anaesthetics, Intensive Care & Pain Medicine, Imperial College London, United Kingdom.
| | - Suveer Singh
- Department of Anaesthetics, Intensive Care & Pain Medicine, Chelsea & Westminster Hospital, United Kingdom.
| | - Mervyn Maze
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, United States.
| | - Tracy Hussell
- Manchester Collaborative Centre for Inflammation Research, Manchester, United Kingdom.
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Clavier T, Tonon MC, Foutel A, Besnier E, Lefevre-Scelles A, Morin F, Gandolfo P, Tuech JJ, Quillard M, Veber B, Dureuil B, Castel H, Compère V. Increased plasma levels of endozepines, endogenous ligands of benzodiazepine receptors, during systemic inflammation: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:633. [PMID: 25407756 PMCID: PMC4326502 DOI: 10.1186/s13054-014-0633-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/31/2014] [Indexed: 12/30/2022]
Abstract
Introduction Recent work has shown that benzodiazepines interact with the immune system and exhibit anti-inflammatory effects. By using in vitro models, researchers in several studies have shown that the peptidergic endogenous ligands of benzodiazepine receptors, named endozepines, are involved in the immune response. All endozepines identified so far derive from diazepam-binding inhibitor (DBI), which generates several biologically active fragments. The aim of the present study was to measure plasma levels of DBI-like immunoreactivity (DBI-LI) in a rat model of sepsis and in patients with systemic inflammation from septic or non-septic origin. Methods Cecal ligation and puncture (CLP) or sham surgery was performed in rats. Blood samples were taken from animals, patients hospitalized for digestive surgery with inflammatory diseases, and healthy volunteers. Measurements of plasma DBI-related peptides were carried out by radioimmunoassay in animal and human samples. Results In the rats, CLP provoked an increase of plasma DBI-LI (+37%) 6 hours postsurgery. In humans, DBI-LI levels were significantly higher in the systemic inflammation group than in the healthy volunteer group (48.6 (32.7 to 77.7) pg/ml versus 11.1 (5.9 to 35.3) pg/ml, P < 0.001). We found a positive correlation between endozepine levels and Acute Physiology and Chronic Health Evaluation II score (rs = 0.33 (0.026 to 0.58), P < 0.05) and tumor necrosis factor α levels (rs = 0.43 (0.14 to 0.65), P < 0.01). The area under the receiver operating characteristic curve for endozepines was 0.842 (95% CI (0.717 to 0.966), P < 0.0001) for discriminating patients with inflammation from healthy volunteers. Conclusions Endozepines might be involved in the inflammatory response in patients with systemic inflammation.
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Affiliation(s)
- Thomas Clavier
- Institut National de la Santé et de la Recherche Médicale (Inserm), U982, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Normandy University, Institute for Research and Innovation in Biomedicine (IRIB), Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Rouen University, Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Department of Anesthesiology and Critical Care, Rouen University Hospital, Rue de Germont, 76000, Rouen, France.
| | - Marie-Christine Tonon
- Institut National de la Santé et de la Recherche Médicale (Inserm), U982, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Normandy University, Institute for Research and Innovation in Biomedicine (IRIB), Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Rouen University, Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Place Emile Blondel, 76130, Mont-Saint-Aignan, France.
| | - Anne Foutel
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rue de Germont, 76000, Rouen, France.
| | - Emmanuel Besnier
- Institut National de la Santé et de la Recherche Médicale (Inserm), U982, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Normandy University, Institute for Research and Innovation in Biomedicine (IRIB), Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Rouen University, Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Department of Anesthesiology and Critical Care, Rouen University Hospital, Rue de Germont, 76000, Rouen, France.
| | - Antoine Lefevre-Scelles
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rue de Germont, 76000, Rouen, France.
| | - Fabrice Morin
- Institut National de la Santé et de la Recherche Médicale (Inserm), U982, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Normandy University, Institute for Research and Innovation in Biomedicine (IRIB), Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Rouen University, Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Place Emile Blondel, 76130, Mont-Saint-Aignan, France.
| | - Pierrick Gandolfo
- Institut National de la Santé et de la Recherche Médicale (Inserm), U982, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Normandy University, Institute for Research and Innovation in Biomedicine (IRIB), Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Rouen University, Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Place Emile Blondel, 76130, Mont-Saint-Aignan, France.
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rue de Germont, 76000, Rouen, France.
| | - Muriel Quillard
- Department of Medical Biochemistry, Institute of Clinical Biology, Rouen University Hospital, 76000, Rouen, France.
| | - Benoit Veber
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rue de Germont, 76000, Rouen, France.
| | - Bertrand Dureuil
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rue de Germont, 76000, Rouen, France.
| | - Hélène Castel
- Institut National de la Santé et de la Recherche Médicale (Inserm), U982, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Normandy University, Institute for Research and Innovation in Biomedicine (IRIB), Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Rouen University, Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Place Emile Blondel, 76130, Mont-Saint-Aignan, France.
| | - Vincent Compère
- Institut National de la Santé et de la Recherche Médicale (Inserm), U982, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Normandy University, Institute for Research and Innovation in Biomedicine (IRIB), Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Rouen University, Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Place Emile Blondel, 76130, Mont-Saint-Aignan, France. .,Department of Anesthesiology and Critical Care, Rouen University Hospital, Rue de Germont, 76000, Rouen, France.
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Smith MA, Hibino M, Falcione BA, Eichinger KM, Patel R, Empey KM. Immunosuppressive aspects of analgesics and sedatives used in mechanically ventilated patients: an underappreciated risk factor for the development of ventilator-associated pneumonia in critically ill patients. Ann Pharmacother 2013; 48:77-85. [PMID: 24259637 DOI: 10.1177/1060028013510698] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To evaluate the evidence describing the immunosuppressive and pharmacokinetic properties of commonly used analgesic and sedation agents in critically ill patients. DATA SOURCES MEDLINE (January 1980-September 2013) was searched. STUDY SELECTION AND DATA EXTRACTION All in vitro and in vivo studies that evaluated the immune-modulating properties of analgesic and sedation agents commonly used in the critically ill were included. Full-text and abstract-only articles (noted) were included in this review. Inclusion criteria were met by 46 studies and were evaluated. DATA SYNTHESIS Analgesic and sedation agents have been shown to be immunosuppressive in a variety of models. In vitro models use a variety of immune cells to demonstrate the immunosuppressive properties of opioids, benzodiazepines, and to a lesser extent, propofol. In each case, animal studies provide more robust data supporting the concept that opioids, benzodiazepines, and propofol exhibit immunosuppressive activities ranging from innate to adaptive immune alterations. Human studies, though more limited, provide further support that these agents inhibit the immune response. In contrast, data have shown that dexmedetomidine may attenuate the immune system. Clinical trial data evaluating the immunosuppressive properties of these agents is limited. CONCLUSIONS Analgesic and sedation agents have clearly been shown to alter cellular function and other mediators of the immune system; yet the clinical impact remains to be fully elucidated. The mechanism by which sedation interruption reduces ventilator-associated pneumonia may in fact be a reduction in immunosuppressive effects. Studies linking the immune-modulating effects of analgesic and sedation agents in critically ill patients are needed.
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Frank B, Fulton RL, Lees KR, Sanders RD. Impact of benzodiazepines on functional outcome and occurrence of pneumonia in stroke: evidence from VISTA. Int J Stroke 2013; 9:890-4. [PMID: 24148353 DOI: 10.1111/ijs.12148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 04/29/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Benzodiazepines have been proposed both as a neuroprotectant and risk factor for pneumonia in acute stroke. AIMS We assessed the impact of benzodiazepine exposure on the modified Rankin scale score distribution at 90 days as well as pneumonia rates among patients registered in a trials archive. METHOD We used an age, baseline National Institutes of Health Stroke Score, and thrombolysis-rate adjusted Cochran-Mantel-Haenszel test to test significance (P) followed by proportional odds logistic regression analysis to estimate the odds ratios for improved modified Rankin scale score, and binary logistic regression to estimate the odds ratio for developing pneumonia. RESULTS Data were available for 5938 patients, of whom 1800 received benzodiazepines. No association of benzodiazepine use and overall stroke outcome could be found (odds ratio 0·90, 95% confidence interval 0·82-1·00, P=0·121). Pneumonia occurred in 12·8% of patients treated with benzodiazepines and in 13·6% of the controls (odds ratio 0·99, 95% confidence interval 0·83-1·18, P=0·904). CONCLUSION In this nonrandomized comparison, treatment with benzodiazepines as a concomitant medication had no independent impact on stroke outcome.
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Affiliation(s)
- Benedikt Frank
- Department of Medicine and Therapeutics, Faculty of Medicine, University of Glasgow, Glasgow, UK; Department of Neurology, University of Duisburg-Essen, Essen, Germany
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Benzodiazepine augmented γ-amino-butyric acid signaling increases mortality from pneumonia in mice. Crit Care Med 2013; 41:1627-36. [PMID: 23478657 DOI: 10.1097/ccm.0b013e31827c0c8d] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Benzodiazepines are used for treating anxiety, epilepsy, muscle spasm, alcohol withdrawal, palliation, insomnia, and sedation as they allosterically modulate γ-amino-butyric acid type A (GABAA) receptors. Despite widespread use, the importance and mechanism of their immune side-effects are poorly understood. Herein we sought to elucidate the impact and mechanism of benzodiazepine-induced susceptibility to infection at anxiolytic doses in mice. DESIGN Animal randomized controlled trial. SETTING Laboratory. SUBJECTS Adult female C57BL/6 and BALB/c mice. INTERVENTIONS The effect of a subsedative, anxiolytic dose of diazepam (2 mg kg intraperitoneal) was investigated in a murine Streptococcus pneumoniae pneumonia model. MEASUREMENT AND MAIN RESULTS Mortality, bacterial and cytokine load, cell recruitment, and intracellular pH were measured. Diazepam treatment did not affect immune homeostasis in the lung. However, diazepam increased mortality and bacterial load from S. pneumoniae pneumonia. The increases in mortality and bacterial load were reversed by a GABAA antagonist, bicuculline, indicating dependence on GABAA receptor signaling. While cell recruitment was unaltered by diazepam, the cytokine response to infection was affected, suggesting that local responses to the pathogen were perturbed. Macrophage and monocytes expressed benzodiazepine sensitive (α1-γ2) GABAA receptors. Interestingly macrophage GABAA receptor expression was regulated by bacterial toll-like receptor agonists and cytokines indicating an endogenous role in the immune response. Functionally diazepam appeared to counteract the endogenous down-regulation of GABAA signaling during infection. Consistent with augmented GABAA signaling, diazepam provoked intracellular acidosis in macrophage, leading to impaired cytokine production, bacterial phagocytosis and killing. In contrast, selective benzodiazepines that do not target the α1 GABAA subunit did not affect macrophage function ex vivo or increase susceptibility to pneumonia in vivo. CONCLUSIONS Our data highlight the regulation of macrophage function by GABAA receptor signaling and the potential harm of benzodiazepine exposure during pneumonia. Therapeutically, selective drugs may improve the safety profile of benzodiazepines.
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Effects of 18-kDa translocator protein knockdown on gene expression of glutamate receptors, transporters, and metabolism, and on cell viability affected by glutamate. Pharmacogenet Genomics 2012; 22:606-19. [PMID: 22732722 DOI: 10.1097/fpc.0b013e3283544531] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Previously, several important roles for glutamate have been described for the biology of primary brain tumors. For example, glutamate has been suggested to promote glioma cell proliferation by the activation of the 2-amino-3-(5-methyl-3-oxo-1,2-oxazol-4-yl)propanoic acid (AMPA) subtype of glutamate receptors. In the present study, we determined the potential regulatory roles of the 18-kDa translocator protein (TSPO) in the glutamatergic system in relation to cell death of brain tumor cells through knockdown of the TSPO by genetic manipulation. MATERIALS AND METHODS With microarray analysis and validation of gene expression of particular genes using real-time PCR, we found effects because of small inhibitory RNA knockdown of the TSPO in human U118MG glioblastoma cells on gene expression of glutamate receptors, glutamate transporters, and enzymes for glutamate metabolism. We also applied antisense RNA to silence TSPO in rat C6 glioblastoma cells and assayed the effects on DNA fragmentation, indicative of apoptosis, because of glutamate exposure. RESULTS In particular, the effects of TSPO silencing in human U118MG cells related to glutamate metabolism indicate a net effect of a reduction in glutamate levels, which may potentially protect the cells in question from cell death. The TSPO knockdown in C6 cells showed that TSPO is required for the induction of apoptosis because of glutamate exposure. CONCLUSION These findings show that interactions between the TSPO and the glutamatergic system may play a role in tumor development of glioblastoma cells. This may also have implications for our understanding of the involvement of the TSPO in secondary brain damage and neurodegenerative diseases.
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Ely EW, Dittus RS, Girard TD. Point: should benzodiazepines be avoided in mechanically ventilated patients? Yes. Chest 2012; 142:281-284. [PMID: 22871750 DOI: 10.1378/chest.12-1189] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Nashville, TN; Center for Health Services Research, Nashville, TN; Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.
| | - Robert S Dittus
- Center for Health Services Research, Nashville, TN; Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Timothy D Girard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Nashville, TN; Center for Health Services Research, Nashville, TN
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Babcock GF, Hernandez L, Yadav E, Schwemberger S, Dugan A. The burn wound inflammatory response is influenced by midazolam. Inflammation 2012; 35:259-70. [PMID: 21400122 DOI: 10.1007/s10753-011-9313-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Burn patients requiring hospitalization are often treated for anxiety with benzodiazepines (BDZs). Benzodiazepines are reported to influence immune system function. Immune system alterations are a major cause of burn-induced mortality. We wanted to determine whether the BDZ, midazolam given daily at an anxiolytic dose, had any influence on the burn injury-induced inflammatory response in the blood and wound. Mice received a 15% total body surface area flame burn and received either midazolam 1 mg/kg i.p. or saline 0.1 ml daily. Blood and skin wounds were harvested 24 h after injection on post-burn day 2, 3, 7, or 8. Mice treated with midazolam had significantly lower serum IL-1β (p=0.002), TNF-α (p=0.002), IL-6 (p=0.016), IL-10 (p=0.009), and TGF-β (p=0.004) than saline-treated mice, with little impact on serum chemokine levels. In the wound, TNF-α and IL-10 were the only cytokines significantly influenced by the drug, being lower (p=0.018) and higher (p=0.006), respectively. The chemokines in the wound influenced significantly by midazolam were MIP-1α, MIP-1β, and MIP-2 while MCP-1 and KC were not. There were more inflammatory cells at the burn wound margin in midazolam-treated mice on post-burn day 3. Although serum nitrate/nitrite was significantly increased by midazolam (p=0.03), both eNOS and iNOS mRNA expression in the wound were similar to the saline group. We found that midazolam given daily after burn injury significantly influenced the inflammatory response. The clinical implications of these findings on wound healing and shock following burn injury, especially larger burns, deserve further investigation.
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Affiliation(s)
- George F Babcock
- Department of Research, Shriners Hospital Cincinnati, University of Cincinnati, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
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Abstract
As the armamentarium for sedation in the critically ill expands, opportunities will develop to modulate the immune responses of patients by way of the direct immune and neural-immune interactions of the sedatives. Control of autonomic activity through the use of appropriate sedation may be critical in this matter. Likewise analgesic-based sedation, with increased opioid dosage, may not prove beneficial in the setting of infection; whether avoidance of morphine in preference for a fentanyl derivative will help is unclear. However, as the immune effects seem dependent on the m receptor, it is improbable that a significant difference would be uncovered. Similarly, the present evidence suggests benzodiazepines are deleterious in infection; further studies are required urgently to evaluate this evidence. As an alternative to benzodiazepine-based sedation, dexmedetomidine has shown a remarkable 70% mortality benefit in a small secondary analysis of septic patients from the MENDS trial. Further powered clinical studies should now be undertaken to investigate the potential benefit of the α2-adrenoceptor agonist in this setting, with comparisons with propofol.
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Affiliation(s)
- Robert D Sanders
- Magill Department of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, SW10 9NH, London, UK.
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Mice treated with a benzodiazepine had an improved survival rate following Pseudomonas aeruginosa infection. J Burn Care Res 2010; 31:1-12. [PMID: 20061831 DOI: 10.1097/bcr.0b013e3181cb8e82] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Psychological stress has a high incidence after burn injury, therefore, anxiolytic drugs are often prescribed. Unfortunately, to date, no burn study has investigated the effects of anxiolytic drugs on the ability to fight infection. This study was undertaken to determine if psychological stress, anxiety-modulating drugs, or both, alter survival following an infection. On day 0, 7-week-old male C57Bl/6 mice either received a 15% full-thickness flame burn or were sham treated (anesthesia and shaved), whereas controls received no treatment. Mice received midazolam (1 mg/kg intraperitoneally) or saline daily and were stressed by exposure to rat in a guinea pig cage or placed in an empty cage for 1 hour a day, beginning on postburn day 1. For the survival experiments, mice either received bacteria after 2 or 8 consecutive days of predator exposure and drug treatment, which continued daily for 7 days after inoculation. In a separate set of experiments, after eight daily injections of midazolam, mice were given lipopolysaccharide, bacteria, or saline and were killed 12 hours later. Mice that received midazolam had improved survival rates when compared with their saline-treated counterparts, and the protective effect was more significant the more days they received the drug. For most of the cytokines, the bacteria-induced increase was significantly attenuated by midazolam as was the amount of bacteria in the liver. The protective effect seems to be independent of the drug's anxiolytic activity as there were no significant differences in survival between the predator-stressed and the nonstressed mice. The mechanisms responsible for the protective effect remain to be elucidated.
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Pandharipande PP, Sanders RD, Girard TD, McGrane S, Thompson JL, Shintani AK, Herr DL, Maze M, Ely EW. Effect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: an a priori-designed analysis of the MENDS randomized controlled trial. Crit Care 2010; 14:R38. [PMID: 20233428 PMCID: PMC2887145 DOI: 10.1186/cc8916] [Citation(s) in RCA: 263] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 02/16/2010] [Accepted: 03/16/2010] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Benzodiazepines and alpha2 adrenoceptor agonists exert opposing effects on innate immunity and mortality in animal models of infection. We hypothesized that sedation with dexmedetomidine (an alpha2 adrenoceptor agonist), as compared with lorazepam (a benzodiazepine), would provide greater improvements in clinical outcomes among septic patients than among non-septic patients. METHODS In this a priori-determined subgroup analysis of septic vs non-septic patients from the MENDS double-blind randomized controlled trial, adult medical/surgical mechanically ventilated patients were randomized to receive dexmedetomidine-based or lorazepam-based sedation for up to 5 days. Delirium and other clinical outcomes were analyzed comparing sedation groups, adjusting for clinically relevant covariates as well as assessing interactions between sedation group and sepsis. RESULTS Of the 103 patients randomized, 63 (31 dexmedetomidine; 32 lorazepam) were admitted with sepsis and 40 (21 dexmedetomidine; 19 lorazepam) without sepsis. Baseline characteristics were similar between treatment groups for both septic and non-septic patients. Compared with septic patients who received lorazepam, the dexmedetomidine septic patients had 3.2 more delirium/coma-free days (DCFD) on average (95% CI for difference, 1.1 to 4.9), 1.5 (-0.1, 2.8) more delirium-free days (DFD) and 6 (0.3, 11.1) more ventilator-free days (VFD). The beneficial effects of dexmedetomidine were more pronounced in septic patients than in non-septic patients for both DCFDs and VFDs (P-value for interaction = 0.09 and 0.02 respectively). Additionally, sedation with dexmedetomidine, compared with lorazepam, reduced the daily risk of delirium [OR, CI 0.3 (0.1, 0.7)] in both septic and non-septic patients (P-value for interaction = 0.94). Risk of dying at 28 days was reduced by 70% [hazard ratio 0.3 (0.1, 0.9)] in dexmedetomidine patients with sepsis as compared to the lorazepam patients; this reduction in death was not seen in non-septic patients (P-value for interaction = 0.11). CONCLUSIONS In this subgroup analysis, septic patients receiving dexmedetomidine had more days free of brain dysfunction and mechanical ventilation and were less likely to die than those that received a lorazepam-based sedation regimen. These results were more pronounced in septic patients than in non-septic patients. Prospective clinical studies and further preclinical mechanistic studies are needed to confirm these results. TRIAL REGISTRATION NCT00095251.
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Affiliation(s)
- Pratik P Pandharipande
- Anesthesiology Service, VA TN Valley Health Care System, 1310 24th Avenue South, Nashville, TN 37212-2637, USA
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine; 324 MAB, Nashville, TN 37212-1120, USA
| | - Robert D Sanders
- Department of Leucocyte Biology & Magill Department of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - Timothy D Girard
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine; T-1218 MCN, Nashville, TN 37232-2650, USA
- Center for Health Services Research, Vanderbilt University School of Medicine; 6th Floor MCE, Suite 6100, Nashville, TN 37232-8300, USA
- Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center; 1310 24th Avenue South, Nashville, TN 37212-2637, USA
| | - Stuart McGrane
- Anesthesiology Service, VA TN Valley Health Care System, 1310 24th Avenue South, Nashville, TN 37212-2637, USA
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine; 324 MAB, Nashville, TN 37212-1120, USA
| | - Jennifer L Thompson
- Department of Biostatistics, Vanderbilt University School of Medicine; S-2323 MCN, Nashville, TN 37232-2158, USA
| | - Ayumi K Shintani
- Department of Biostatistics, Vanderbilt University School of Medicine; S-2323 MCN, Nashville, TN 37232-2158, USA
| | - Daniel L Herr
- Department of Surgery and Surgical Critical Care, Washington Hospital Center; 110 Irving St NW, Room 4B42, Washington, DC 20010, USA
| | - Mervyn Maze
- Department of Anesthesiology and Perioperative Care, University of California San Francisco; 521 Parnassus Avenue, C455, San Francisco, CA 94143-0648, USA
| | - E Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine; T-1218 MCN, Nashville, TN 37232-2650, USA
- Center for Health Services Research, Vanderbilt University School of Medicine; 6th Floor MCE, Suite 6100, Nashville, TN 37232-8300, USA
- Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center; 1310 24th Avenue South, Nashville, TN 37212-2637, USA
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Qiao H, Sanders RD, Ma D, Wu X, Maze M. Sedation improves early outcome in severely septic Sprague Dawley rats. Crit Care 2009; 13:R136. [PMID: 19691839 PMCID: PMC2750194 DOI: 10.1186/cc8012] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 07/14/2009] [Accepted: 08/19/2009] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Sepsis, a systemic inflammatory response to infective etiologies, has a high mortality rate that is linked both to excess cytokine activity and apoptosis of critical immune cells. Dexmedetomidine has recently been shown to improve outcome in a septic cohort of patients when compared to patients randomized to a benzodiazepine-based sedative regimen. We sought to compare the effects of dexmedetomidine and midazolam, at equi-sedative doses, on inflammation and apoptosis in an animal model of severe sepsis. METHODS After central venous access, Sprague Dawley rats underwent cecal ligation and intestinal puncture (CLIP) with an 18 G needle without antibiotic cover and received either saline, or an infusion of comparable volume of saline containing midazolam (0.6 mg.kg-1.h-1) or dexmedetomidine (5 ug.kg-1.h-1) for 8 hours. Following baseline measurements and CLIP, blood was sampled for cytokine measurement (tumour necrosis factor (TNF)-alpha and interleukin (IL)-6; n = 4-6 per group) at 2, 4 and 5 hours, and animal mortality rate (MR) was monitored (n = 10 per group) every 2 hours until 2 hours had elapsed. In addition, spleens were harvested and apoptosis was assessed by immunoblotting (n = 4 per group). RESULTS The 24 hour MR in CLIP animals (90%) was significantly reduced by sedative doses of either dexmedetomidine (MR = 20%) or midazolam (MR = 30%). While both sedatives reduced systemic levels of the inflammatory cytokine TNF-alpha (P < 0.05); only dexmedetomidine reduced the IL-6 response to CLIP, though this narrowly missed achieving significance (P = 0.05). Dexmedetomidine reduced splenic caspase-3 expression (P < 0.05), a marker of apoptosis, when compared to either midazolam or saline. CONCLUSIONS Sedation with midazolam and dexmedetomidine both improve outcome in polymicrobial severely septic rats. Possible benefits conveyed by one sedative regimen over another may become evident over a more prolonged time-course as both IL-6 and apoptosis were reduced by dexmedetomidine but not midazolam. Further studies are required to evaluate this hypothesis.
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Affiliation(s)
- Hong Qiao
- Department of Anesthesiology, First Hospital, Peking University, No. 8 Xishiku St., Beijing 100034, PR China
| | - Robert D Sanders
- Department of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea & Westminster Hospital, 369 Fulham Rd, London, SW10 9NH, UK
| | - Daqing Ma
- Department of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea & Westminster Hospital, 369 Fulham Rd, London, SW10 9NH, UK
| | - Xinmin Wu
- Department of Anesthesiology, First Hospital, Peking University, No. 8 Xishiku St., Beijing 100034, PR China
| | - Mervyn Maze
- Department of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea & Westminster Hospital, 369 Fulham Rd, London, SW10 9NH, UK
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Abstract
The management of critically ill patients necessitates the use of sedatives and analgesics to provide patient comfort and cooperation. These drugs exert profound effects on all organ systems, not only the central nervous system, and this article describes the immunologic effects of the commonly used critical care sedatives: propofol, the benzodiazepines, opioids, and alpha(2)-adrenoceptor agonists. Benzodiazepines, opioids, and possibly even propofol worsen outcome in animal models of infection, whereas preliminary evidence suggests that the alpha(2)-adrenoceptor agonist, dexmedetomidine, may improve outcomes in the setting of infection. Given the burden of sepsis and secondary infections in critical care, choice of sedation may need to be carefully considered to preserve immune responses in critically ill patients.
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Affiliation(s)
- Robert D Sanders
- Magill Department of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, SW10 9NH, London, UK.
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Tsao CM, Wu CC, Liaw WJ, Ho ST. Effects of Midazolam on Organ Dysfunction in Rats with Endotoxemia Induced by Lipopolysaccharide. ACTA ACUST UNITED AC 2009; 47:10-6. [DOI: 10.1016/s1875-4597(09)60014-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Veenman L, Gavish M. The peripheral-type benzodiazepine receptor and the cardiovascular system. Implications for drug development. Pharmacol Ther 2006; 110:503-24. [PMID: 16337685 DOI: 10.1016/j.pharmthera.2005.09.007] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2005] [Accepted: 09/27/2005] [Indexed: 11/16/2022]
Abstract
Peripheral-type benzodiazepine receptors (PBRs) are abundant in the cardiovascular system. In the cardiovascular lumen, PBRs are present in platelets, erythrocytes, lymphocytes, and mononuclear cells. In the walls of the cardiovascular system, PBR can be found in the endothelium, the striated cardiac muscle, the vascular smooth muscles, and the mast cells. The subcellular location of PBR is primarily in mitochondria. The PBR complex includes the isoquinoline binding protein (IBP), voltage-dependent anion channel (VDAC), and adenine nucleotide transporter (ANT). Putative endogenous ligands for PBR include protoporphyrin IX, diazepam binding inhibitor (DBI), triakontatetraneuropeptide (TTN), and phospholipase A2 (PLA2). Classical synthetic ligands for PBR are the isoquinoline 1-(2-chlorophenyl)-N-methyl-N-(1-methyl-propyl)-3-isoquinolinecarboxamide (PK 11195) and the benzodiazepine 7-chloro-5-(4-chlorophenyl)-1,3-dihydro-1-methyl-2H-1,4-benzodiazepin-2-one (Ro5 4864). Novel PBR ligands include N,N-di-n-hexyl 2-(4-fluorophenyl)indole-3-acetamide (FGIN-1-27) and 7-chloro-N,N,5-trimethyl-4-oxo-3-phenyl-3,5-dihydro-4H-pyridazino[4,5-b]indole-1-acetamide (SSR180575), both possessing steroidogenic properties, but while FGIN-1-27 is pro-apoptotic, SSR180575 is anti-apoptotic. Putative PBR functions include regulation of steroidogenesis, apoptosis, cell proliferation, the mitochondrial membrane potential, the mitochondrial respiratory chain, voltage-dependent calcium channels, responses to stress, and microglial activation. PBRs in blood vessel walls appear to take part in responses to trauma such as ischemia. The irreversible PBR antagonist, SSR180575, was found to reduce damage correlated with ischemia. Stress, anxiety disorders, and neurological disorders, as well as their treatment, can affect PBR levels in blood cells. PBRs in blood cells appear to play roles in several aspects of the immune response, such as phagocytosis and the secretion of interleukin-2, interleukin-3, and immunoglobulin A (IgA). Thus, alterations in PBR density in blood cells may have immunological consequences in the affected person. In conclusion, PBR in the cardiovascular system may represent a new target for drug development.
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Affiliation(s)
- Leo Veenman
- Rappaport Family Institute for Research in the Medical Sciences, Technion-Israel Institute of Technology, Department of Pharmacology, Ephron Street, P.O. Box 9649, Bat-Galim, Haifa 31096, Israel
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Tavío MM, Vila J, Perilli M, Casañas LT, Maciá L, Amicosante G, Jiménez de Anta MT. Enhanced active efflux, repression of porin synthesis and development of Mar phenotype by diazepam in two enterobacteria strains. J Med Microbiol 2004; 53:1119-1122. [PMID: 15496390 DOI: 10.1099/jmm.0.45613-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The aim of this work was to determine whether diazepam could induce the multiple antibiotic resistance (Mar) phenotype in Klebsiella pneumoniae and Escherichia coli strains. The Mar phenotype is characterized by decreased susceptibility to multiple antibiotics due to the loss of porins and/or increased expression of active efflux systems. The effect of subinhibitory concentrations of diazepam on the susceptibility of different antimicrobial agents, outer-membrane protein expression and norfloxacin intracellular accumulation was studied. The results revealed that diazepam concentrations equal or twice adult dosage induced the same Mar phenotype as two well known E. coli marRAB inducers, sodium salicylate and sodium benzoate. Susceptibility to norfloxacin in a K. pneumoniae clinical isolate and E. coli strain Ag100 decreased due to enhanced active efflux and loss of porin expression. A decreased susceptibility to chloramphenicol, tetracycline, nalidixic acid and β-lactam antibiotics was also observed. In conclusion, like sodium salicylate or sodium benzoate, diazepam may induce the Mar phenotype.
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Affiliation(s)
- María M Tavío
- Microbiology, Department of Clinical Sciences, School of Medicine, University of Las Palmas de G. C., Dr. Pasteur, 35080 Las Palmas, Spain 2Department of Microbiology, Hospital Clinic, IDIBAPS, School of Medicine, University of Barcelona, Villarroel, 170, 08036 Barcelona, Spain 3Department of Science and Biomedical Technology, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Jordi Vila
- Microbiology, Department of Clinical Sciences, School of Medicine, University of Las Palmas de G. C., Dr. Pasteur, 35080 Las Palmas, Spain 2Department of Microbiology, Hospital Clinic, IDIBAPS, School of Medicine, University of Barcelona, Villarroel, 170, 08036 Barcelona, Spain 3Department of Science and Biomedical Technology, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Mariagrazia Perilli
- Microbiology, Department of Clinical Sciences, School of Medicine, University of Las Palmas de G. C., Dr. Pasteur, 35080 Las Palmas, Spain 2Department of Microbiology, Hospital Clinic, IDIBAPS, School of Medicine, University of Barcelona, Villarroel, 170, 08036 Barcelona, Spain 3Department of Science and Biomedical Technology, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Lucía T Casañas
- Microbiology, Department of Clinical Sciences, School of Medicine, University of Las Palmas de G. C., Dr. Pasteur, 35080 Las Palmas, Spain 2Department of Microbiology, Hospital Clinic, IDIBAPS, School of Medicine, University of Barcelona, Villarroel, 170, 08036 Barcelona, Spain 3Department of Science and Biomedical Technology, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Laura Maciá
- Microbiology, Department of Clinical Sciences, School of Medicine, University of Las Palmas de G. C., Dr. Pasteur, 35080 Las Palmas, Spain 2Department of Microbiology, Hospital Clinic, IDIBAPS, School of Medicine, University of Barcelona, Villarroel, 170, 08036 Barcelona, Spain 3Department of Science and Biomedical Technology, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Gianfranco Amicosante
- Microbiology, Department of Clinical Sciences, School of Medicine, University of Las Palmas de G. C., Dr. Pasteur, 35080 Las Palmas, Spain 2Department of Microbiology, Hospital Clinic, IDIBAPS, School of Medicine, University of Barcelona, Villarroel, 170, 08036 Barcelona, Spain 3Department of Science and Biomedical Technology, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - María T Jiménez de Anta
- Microbiology, Department of Clinical Sciences, School of Medicine, University of Las Palmas de G. C., Dr. Pasteur, 35080 Las Palmas, Spain 2Department of Microbiology, Hospital Clinic, IDIBAPS, School of Medicine, University of Barcelona, Villarroel, 170, 08036 Barcelona, Spain 3Department of Science and Biomedical Technology, School of Medicine, University of L'Aquila, L'Aquila, Italy
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Kummer C, Netto ES, Marshall JC. The Immunomodulatory Effects of Anesthetic and Analgesic Agents. Intensive Care Med 2002. [DOI: 10.1007/978-1-4757-5551-0_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mühling J, Sablotzki A, Fuchs M, Krüll M, Dehne MG, Weiss S, Gonter J, Quandt D, Hempelmann G. Effects of diazepam on neutrophil (PMN) free amino acid profiles and immune functions in vitro. Metabolical and immunological consequences of L-alanyl-L-glutamine supplementation. J Nutr Biochem 2001; 12:46-54. [PMID: 11179861 DOI: 10.1016/s0955-2863(00)00144-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The objective of this study was to determine the effects of diazepam, L-alanyl-L-glutamine (ala-gln) or diazepam combined with ala-gln on polymorphonuclear leukocyte (PMN) free amino acid profiles. In a parallel study the effects on PMN immune functions were also documented for the first time. The incubation of whole blood with diazepam led to significant changes in PMN free glutamine, aspartate, glutamate, ornithine, arginine, citrulline, taurine and methionine as well as branched chain and neutral amino acid concentrations. Ala-gln caused significant increases in PMN glutamine and alanine and asparagine, aspartate, glutamate, ornithine, arginine, serine and glycine profiles. Regarding PMN immune functions, diazepam significantly decreased superoxide anion (O(2)(-)) and hydrogen peroxide production (H(2)O(2)) and myeloperoxidase activity (MPO) while ala-gln significantly increased PMN immune functions. Ala-gln supplemented to diazepam largely reversed the changes in PMN amino acid profiles and PMN immune functions brought about by diazepam. Overall, diazepam or ala-gln lead to significant changes in PMN free amino acids. Important PMN immune functions also seem to be affected. In regards to the results, there is significant relevance to the pharmacological regimens which enhance the supply of diazepam or ala-gln in whole blood suggesting that considerable changes in PMN "labile free amino acid pool" occur. These regimens often follow beneficial nutritional therapy or maleficent pharmacological stress and may be one of the determinants in cell nutrition which influence PMN function. It is partially through its effect on PMN labile free amino acid pool that ala-gln supplemented to diazepam may maintain PMN immune functions in vitro.
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Affiliation(s)
- J Mühling
- Department of Anaesthesiology and Intensive Care Medicine, Justus-Liebig-University, Giessen, Germany
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Freire-Garabal M, Varela M, Riveiro P, Balboa J, Liñares D, Mañá P, Mayán JM, Rey-Méndez M, Núñez MJ. Effects of nefazodone on the immune system of mice. Eur Neuropsychopharmacol 2000; 10:255-64. [PMID: 10871707 DOI: 10.1016/s0924-977x(00)00080-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Mice exposed to a chronic auditory stressor and treated with nefazodone (10 mg/kg/day s.c.), showed a reduction in stress-induced suppression of thymus and spleen cellularity, and in peripheral T-Iymphocyte population. The in vitro blastogenic response of spleen lymphoid cells to mitogen concanavalin A, the in vitro and in vivo activity of phagocytosis, both measured using the zymosan and carbon clearance tests, respectively, were also assessed and nefazodone was found to partially reverse the inhibitory effect of stress on those parameters. Nefazodone did not significantly affect those parameters in unstressed mice. In conclusion, this report provides evidence on the immunoprotective effects of this novel antidepressant drug against the adverse effects of stress in mice.
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Affiliation(s)
- M Freire-Garabal
- Department of Pharmacology, University of Santiago de Compostela, Campus Sur, s/n, 15705, Santiago de Compostela, Spain.
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