Toward a theory regarding the pathogenesis of the systemic inflammatory response syndrome: what we do and do not know about cytokine regulation

Effects of NF-κB Inhibitor on Sepsis Depend on the Severity and Phase of the Animal Sepsis Model

Hyperinflammation occurs in sepsis, especially in the early phase, and it could have both positive and negative effects on sepsis. Previously, we showed that a new concept of NF-κB inhibitor, exosome-based super-repressor IκBα (Exo-srIκB) delivery, has a beneficial effect on sepsis. Here, we further investigate the therapeutic effects of Exo-srIκB at different severities and phases of sepsis using an animal polymicrobial intra-abdominal infection model. We used a rat model of fecal slurry polymicrobial sepsis. First, we determined the survival effects of Exo-srIκB on sepsis according to the severity. We used two different severities of the animal sepsis model. The severe model had a mortality rate of over 50%. The mild/moderate model had a less than 30% mortality rate. Second, we administered the Exo-srIκB at various time points (1 h, 6 h, and 24 h after fecal slurry administration) to determine the therapeutic effect of Exo-srIκB at different phases of sepsis. Lastly, we determined the effects of the Exo-srIκB on cytokine production, arterial blood gas, electrolyte, and lactate. The survival gain was statistically significant in the severe sepsis model when Exo-srIκB was administered 6 h after sepsis. Interleukin 6 and interleukin-10 were significantly decreased in the kidney when administered with Exo-srIκB. The laboratory data showed that lactate, glucose, and potassium levels were significantly lowered in the NF-κB inhibitor group. In conclusion, Exo-srIκB exhibited a beneficial therapeutic effect when administered 6 h post fecal slurry administration in a severe sepsis model.

[Clinical and morphological features of lung injury long-term after SARS-CoV-2 recovery]

AIM

To study the clinical and histological profile of lung tissue in patients with persistent pulmonary disease, respiratory symptoms and CT findings after SARS-CoV-2 infection.

MATERIALS AND METHODS

The study included 15 patients (7 females and 8 males) with a mean age of 57.7 years. All patients underwent laboratory tests, chest computed tomography, echocardiography, and pulmonary function tests. Pulmonary tissue and bronchoalveolar lavage samples were obtained by fibrobronchoscopy, transbronchial forceps (2 patients), and lung cryobiopsy (11 patients); open biopsy was performed in 2 patients. Cellular composition, herpesvirus DNA, SARS-CoV-2, Mycobacterium tuberculosis complex, galactomannan optical density index, and bacterial and fungal microflora growth were determined in bronchoalveolar lavage. SARS-CoV-2 was also identified in samples from the nasal mucosa, throat and feces using a polymerase chain reaction.

RESULTS

The results showed no true pulmonary fibrosis in patients recovered from SARS-CoV-2 infection with persistent respiratory symptoms, functional impairment, and CT findings after SARS-CoV-2 infection. The observed changes comply with the current and/or resolving infection and inflammatory process.

CONCLUSION

Thus, no true pulmonary fibrosis was found in patients after SARS-CoV-2 infection with persistent respiratory symptoms, functional impairment, and CT findings. The observed changes comply with the current and/or resolving infection and inflammatory process.

Effects of positive end-expiratory pressure on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in acute brain injury: Friend or foe? A scoping review

Background

Patients with acute brain injury (ABI) are a peculiar population because ABI does not only affect the brain but also other organs such as the lungs, as theorized in brain-lung crosstalk models. ABI patients often require mechanical ventilation (MV) to avoid the complications of impaired respiratory function that can follow ABI; MV should be settled with meticulousness owing to its effects on the intracranial compartment, especially regarding positive end-expiratory pressure (PEEP). This scoping review aimed to (1) describe the physiological basis and mechanisms related to the effects of PEEP in ABI; (2) examine how clinical research is conducted on this topic; (3) identify methods for setting PEEP in ABI; and (4) investigate the impact of the application of PEEP in ABI on the outcome.

Methods

The five-stage paradigm devised by Peters et al. and expanded by Arksey and O'Malley, Levac et al., and the Joanna Briggs Institute was used for methodology. We also adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension criteria. Inclusion criteria: we compiled all scientific data from peer-reviewed journals and studies that discussed the application of PEEP and its impact on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in adult patients with ABI. Exclusion criteria: studies that only examined a pediatric patient group (those under the age of 18), experiments conducted solely on animals; studies without intracranial pressure and/or cerebral perfusion pressure determinations, and studies with incomplete information. Two authors searched and screened for inclusion in papers published up to July 2023 using the PubMed-indexed online database. Data were presented in narrative and tubular form.

Results

The initial search yielded 330 references on the application of PEEP in ABI, of which 36 met our inclusion criteria. PEEP has recognized beneficial effects on gas exchange, but it produces hemodynamic changes that should be predicted to avoid undesired consequences on cerebral blood flow and intracranial pressure. Moreover, the elastic properties of the lungs influence the transmission of the forces applied by MV over the brain so they should be taken into consideration. Currently, there are no specific tools that can predict the effect of PEEP on the brain, but there is an established need for a comprehensive monitoring approach for these patients, acknowledging the etiology of ABI and the measurable variables to personalize MV.

Conclusion

PEEP can be safely used in patients with ABI to improve gas exchange keeping in mind its potentially harmful effects, which can be predicted with adequate monitoring supported by bedside non-invasive neuromonitoring tools.

DRG2 in macrophages is crucial for initial inflammatory response and protection against Listeria monocytogenes infection

Innate immune response is critical for the control of Listeria monocytogenes infection. Here, we identified developmentally regulated GTP-binding protein 2 (DRG2) in macrophages as a major regulator of the innate immune response against L. monocytogenes infection. Both whole-body DRG2 knockout (KO) mice and macrophage-specific DRG2 KO mice had low levels of IL-6 during early infection and increased susceptibility to L. monocytogenes infection. Following an initial impaired inflammatory response of macrophages upon i.p. L. monocytogenes infection, DRG2-/- mice showed delayed recruitment of neutrophils and monocytes into the peritoneal cavity, which led to elevated bacterial burden, inflammatory cytokine production at a late infection time point, and liver micro-abscesses. DRG2 deficiency decreased the transcriptional activity of NF-κB and impaired the inflammatory response of both bone marrow-derived and peritoneal macrophages upon L. monocytogenes stimulation. Our findings reveal that DRG2 in macrophages is critical for the initial inflammatory response and protection against L. monocytogenes infection.

From Infection to Death: An Overview of the Pathogenesis of Visceral Leishmaniasis

Kala-azar, also known as visceral leishmaniasis (VL), is a disease caused by Leishmania infantum and L. donovani. Patients experience symptoms such as fever, weight loss, paleness, and enlarged liver and spleen. The disease also affects immunosuppressed individuals and has an overall mortality rate of up to 10%. This overview explores the literature on the pathogenesis of preclinical and clinical stages, including studies in vitro and in animal models, as well as complications and death. Asymptomatic infection can result in long-lasting immunity. VL develops in a minority of infected individuals when parasites overcome host defenses and multiply in tissues such as the spleen, liver, and bone marrow. Hepatosplenomegaly occurs due to hyperplasia, resulting from parasite proliferation. A systemic inflammation mediated by cytokines develops, triggering acute phase reactants from the liver. These cytokines can reach the brain, causing fever, cachexia and vomiting. Similar to sepsis, disseminated intravascular coagulation (DIC) occurs due to tissue factor overexpression. Anemia, hypergammaglobulinemia, and edema result from the acute phase response. A regulatory response and lymphocyte depletion increase the risk of bacterial superinfections, which, combined with DIC, are thought to cause death. Our understanding of VL's pathogenesis is limited, and further research is needed to elucidate the preclinical events and clinical manifestations in humans.

The role of human milk feeds on inotrope use in newborn infants with sepsis

Background

Regarding neonatal hypotension, there is no certainty as to whether inotrope properties are beneficial or whether they may be harmful. However, given that the antioxidant content of human milk plays a compensatory role in neonatal sepsis and that human milk feeding has direct effects in modulating the cardiovascular function of sick neonates, this research hypothesized that human milk feeds might predict lower requirements of vasopressors in the management of neonatal septic shock.

Method

Between January 2002 and December 2017, all late preterm and full-term infants attending a neonatal intensive care unit, with clinical and laboratory findings of bacterial or viral sepsis, were identified in a retrospective study. During their first month of life, data on feeding type and early clinical characteristics were collected. A multivariable logistic regression model was constructed to determine the impact of human milk on the use of vasoactive drugs in septic newborns.

Results

322 newborn infants were eligible to participate in this analysis. Exclusively formula-fed infants were more likely to be delivered via C-section, to have a lower birth weight and a lower 1-minute Apgar score than their counterparts. Human milk-fed newborns had 77% (adjusted OR = 0.231; 95% CI: 0.07-0.75) lower odds of receiving vasopressors than exclusively formula-fed newborns.

Conclusion

We report that any human milk feeding is associated with a decrease in the need for vasoactive medications in sepsis-affected newborns. This observation encourages us to undertake further research to determine whether human milk feeds mitigate the use of vasopressors in neonates with sepsis.

Cerebral amyloid angiopathy-related cardiac injury: Focus on cardiac cell death

Cerebral amyloid angiopathy (CAA) is a kind of disease in which amyloid β (Aβ) and other amyloid protein deposits in the cerebral cortex and the small blood vessels of the brain, causing cerebrovascular and brain parenchymal damage. CAA patients are often accompanied by cardiac injury, involving Aβ, tau and transthyroxine amyloid (ATTR). Aβ is the main injury factor of CAA, which can accelerate the formation of coronary artery atherosclerosis, aortic valve osteogenesis calcification and cardiomyocytes basophilic degeneration. In the early stage of CAA (pre-stroke), the accompanying locus coeruleus (LC) amyloidosis, vasculitis and circulating Aβ will induce first hit to the heart. When the CAA progresses to an advanced stage and causes a cerebral hemorrhage, the hemorrhage leads to autonomic nervous function disturbance, catecholamine surges, and systemic inflammation reaction, which can deal the second hit to the heart. Based on the brain-heart axis, CAA and its associated cardiac injury can create a vicious cycle that accelerates the progression of each other.

Clinical Criteria for Persistent Inflammation, Immunosuppression, and Catabolism Syndrome: An Exploratory Analysis of Optimal Cut-Off Values for Biomarkers

Background: While clinical criteria have been proposed for persistent inflammation, immunosuppression, and catabolism syndrome (PICS) using C-reactive protein (CRP), albumin, and lymphocyte count, there is no substantial basis for their optimal cut-off values. We herein aimed to develop and externally validate clinical criteria for PICS by investigating the optimal cut-off values for these biomarkers using machine-learning approaches and confirmed it with external validation. Methods: To develop criteria, we included ICU patients treated at a tertiary care hospital in Japan between 2018 and 2021 (derivation cohort). We introduced CRP, albumin and lymphocyte counts at around day 14 into six machine-learning models to predict PICS, defined as the compound outcome of the Barthel index (BI) < 70 at hospital discharge and in-hospital death. We incorporated the results of these models to assess the optimal cut-off values for biomarkers. We then developed and externally validated criteria for PICS using a nationwide claims database in Japan (validation cohort). Results: In the derivation cohort, 291 out of 441 patients had BI < 70 or in-hospital death. Based on machine-learning models, the optimal cut-off values for biomarkers to predict them were a CRP of 2.0 mg/dL, albumin of 3.0 g/dL, and a lymphocyte count of 800/μL, with an AUROC of 0.67. In the external validation cohort, 4492 out of 15,302 patients had BI < 70 or in-hospital death. The AUROC of the criteria was 0.71, with sensitivity of 0.71 and specificity of 0.68 to predict PICS. Conclusions: We herein provide a fundamental basis for PICS clinical criteria with CRP >2.0 mg/dL, albumin <3.0 g/dL, and a lymphocyte count <800/μL on day 14. The criteria developed will identify patients with PICS whose long-term mortality and activity of daily living may be poor.

Serial Change of Endotoxin Tolerance in a Polymicrobial Sepsis Model

Immune suppression is known to occur during sepsis. Endotoxin tolerance is considered a mechanism of immune suppression in sepsis. However, the timing and serial changes in endotoxin tolerance have not been fully investigated. In this study, we investigated serial changes in endotoxin tolerance in a polymicrobial sepsis model. Herein, we used a rat model of fecal slurry polymicrobial sepsis. After induction of sepsis, endotoxin tolerance of peripheral blood mononuclear cells (PBMCs) and splenocytes was measured at various time points (6 h, 12 h, 24 h, 48 h, 72 h, 5 days, and 7 days), through the measurement of TNF-α production after stimulation with lipopolysaccharide (LPS) in an ex vivo model. At each time point, we checked for plasma tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-10 levels. Moreover, we analyzed reactive oxygen species (ROS) as measured by 2′,7′-dichlorodihydrofluorescein, plasma lactate, serum alanine aminotransferase (ALT), and creatinine levels. Nuclear factor (NF)-κB, IL-1 receptor-associated kinase (IRAK)-M, and cleaved caspase 3 levels were measured in the spleen. Endotoxin tolerance, measured by TNF-α production stimulated through LPS in PBMCs and splenocytes, was induced early in the sepsis model, starting from 6 h after sepsis. It reached a nadir at 24 to 48 h after sepsis, and then started to recover. Endotoxin tolerance was more prominent in the severe sepsis model. Plasma cytokines peaked at time points ranging from 6 to 12 h after sepsis. ROS levels peaked at 12 h and then decreased. Lactate, ALT, and serum creatinine levels increased up to 24 to 48 h, and then decreased. Phosphorylated p65 and IRAK-M levels of spleen increased up to 12 to 24 h and then decreased. Apoptosis was prominent 48 h after sepsis, and then recovered. In the rat model of polymicrobial sepsis, endotoxin tolerance occurred earlier and started to recover from 24 to 48 h after sepsis.

Posterior Reversible Encephalopathy Syndrome in the Setting of Asparaginase-associated Pancreatitis in 2 Pediatric Patients With Acute Leukemia

Asparaginase, a critical component of current pediatric acute leukemia treatment protocols, is associated with a number of serious side effects, one of which is pancreatitis. Pancreatitis can result in significant morbidity and mortality from necrosis, pseudocyst formation, hemorrhage, systemic inflammation, intestinal perforation, and sepsis. Another rare complication of pancreatitis is posterior reversible encephalopathy syndrome, likely mediated by systemic inflammation secondary to pancreatic autodigestion and proinflammatory cytokine-mediated vascular endothelial damage. Here, we review this association in the literature and report 2 pediatric patients with leukemia who developed posterior reversible encephalopathy syndrome in the setting of asparaginase-associated pancreatitis.

Effects of Glucocorticoid Therapy on Sepsis Depend Both on the Dose of Steroids and on the Severity and Phase of the Animal Sepsis Model

Steroids are currently being used in sepsis, particularly in septic shock. However, clinical trials to date have shown contradictory results. This could be attributed to the different patient endotypes and steroid doses, which have also contributed to the inconclusive results. We investigated the effects of glucocorticoid therapy on sepsis in a polymicrobial sepsis model in a variety of settings, such as steroid dose, severity, and sepsis phase. We used a rat model of fecal slurry polymicrobial sepsis. First, we investigated the optimum dose of steroids in a sepsis model. We administered different doses of dexamethasone after sepsis induction (0.1DEX; 0.1 mg/kg, 0.2DEX; 0.2 mg/kg, 5DEX; 5 mg/kg). Second, we used two different severities of the fecal slurry polymicrobial sepsis rat model to examine the effects of the steroids. A moderate or severe model was defined as a survival rate of approximately 70% and 30%, respectively. Third, we administered steroids in an early (1 h after sepsis induction) or late phase (25 h after sepsis). In all the experiments, we investigated the survival rates. In the determined optimal model and settings, we measured serum lactate, alanine transferase (ALT), creatinine, tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-10, and arterial blood gas. We evaluated the bacterial burden in the blood and spleen. Endotoxin tolerance of peripheral blood mononuclear cells (PBMCs) and splenocytes was also investigated to determine the level of immune suppression 24 h after sepsis by measuring TNF-α production after stimulation with lipopolysaccharide (LPS) in an ex vivo model. Early treatment of 0.2 mg/kg dexamethasone in a severe sepsis model showed the best beneficial effects. In moderate- or late-phase sepsis, there was no survival gain with steroid treatment. DEX0.2 group showed less acute kidney injury manifested by serum creatinine and blood urea nitrogen. DEX decreased the levels of cytokines, including IL-6, IL-10, and TNF-α. Colony-forming units were significantly decreased in the blood when administered with dexamethasone. Endotoxin tolerance was not significantly different between the DEX0.2 and control groups. In conclusion, early treatment of 0.2 mg/kg dexamethasone improved the outcomes of rats in a severe sepsis model.

Identification of potential biomarkers and immune infiltration in pediatric sepsis via multiple-microarray analysis

Immune adjustment has become a sepsis occurring in the development of an important mechanism that cannot be ignored. This article from the perspective of immune infiltration of pediatric sepsis screening markers, and promote the understanding of disease mechanisms. Bioinformatics integrated six data sets of pediatric sepsis by using the surrogate variable analysis package and then analyzed differentially expressed genes (DEGs), immune infiltration and weighted gene co-expression network analysis of characteristics (WGCNA) of immune infiltration between pediatric sepsis and the control. Common genes of WGCNA and DEGs were used to functional annotation, pathway enrichment analysis and protein-protein interaction network. Support vector machine (SVM), least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression were used to confirm the key genes for the diagnosis of pediatric sepsis. Receiver operating characteristic (ROC) curve, C index, principal component analysis (PCA) and GiViTi calibration band were used to evaluate the diagnostic performance of key genes. Decision curve analysis (DCA) was used to evaluate the clinical application value of key genes. Lastly, the correlation between key genes and immune cells was analyze. NK cells Resting and NK cell activated in pediatric sepsis during immune infiltration were significantly lower than those in the control group, while M1 Macrophages were higher than those in the control group. ROC, C-index, PCA, GiViTi calibration band and DCA indicated that MCEMP1, CD177, MMP8 and OLFM4 had high diagnostic performance for pediatric sepsis. There is a negative correlation between 4 key genes and NK cells resting, NK cells activated. Except for MCEMP1, the other 3 genes were positively correlated with M1 Macrophages. This study revealed differences in immune responses in pediatric sepsis and identified four key genes as potential biomarkers. Pediatric sepsis in pathology maybe understood better by learning about how it develops.

Immune Intervention in Sepsis

Sepsis is a host immune disorder induced by infection. It can lead to multiple organ dysfunction syndrome (MODS), which has high morbidity and mortality. There has been great progress in the clinical diagnosis and treatment of sepsis, such as improvements in pathogen detection technology, innovations regarding anti-infection drugs, and the development of organ function support. Abnormal immune responses triggered by pathogens, ranging from excessive inflammation to immunosuppression, are recognized to be an important cause of the high mortality rate. However, no drugs have been approved specifically for treating sepsis. Here, we review the recent research progress on immune responses in sepsis to provide a theoretical basis for the treatment of sepsis. Constructing and optimizing a dynamic immune system treatment regimen based on anti-infection treatment, fluid replacement, organ function support, and timely use of immunomodulatory interventions may improve the prognosis of sepsis patients.

Understanding the Immunologic Characteristics of Neurologic Manifestations of SARS-CoV-2 and Potential Immunological Mechanisms

Similar to its predecessors, coronavirus disease 2019 (COVID-19) exhibits neurotrophic properties, which lead to progression of neurologic sequelae. Besides direct viral invasion to the central nervous system (CNS), indirect CNS involvement through viral-mediated immune response is plausible. Aberrant immune pathways such as extreme release of cytokines (cytokine storm), autoimmunity mediated by cross-reactivity between CNS components and viral particles, and microglial activation propagate CNS damage in these patients. Here, we review the currently available evidence to discuss the plausible immunologic pathways that may contribute to the development of COVID-19 neurological complications, namely Alzheimer’s disease, Parkinson’s disease, stroke, multiple sclerosis, Guillain-Barre syndrome, seizure, and brainstem involvement.

Leptin and fractalkine: novel subcutaneous cytokines in burn injury

Burn injury is a pathology underpinned by progressive and aberrant inflammation. It is a major clinical challenge to survival and quality of life. Although the complex local and disseminating pathological processes of a burn injury ultimately stem from local tissue damage, to date relatively few studies have attempted to characterise the local inflammatory mediator profile. Here, cytokine content and associated transcriptional changes were measured in rat skin for three hours immediately following induction of a scald-type (60°C, 2 min) burn injury model. Leptin (P=0.0002) and fractalkine (P=0.0478) concentrations were significantly elevated post-burn above pre-burn and control site values, coinciding with the development of burn site oedema and differential expression of leptin mRNA (P=0.0004). Further, gene sequencing enrichment analysis indicated cytokine-cytokine receptor interaction (P=1.45×10-6). Subsequent behavioural studies demonstrated that, following subcutaneous injection into the dorsum of the paw, both leptin and fractalkine induced mechanical allodynia, heat hyperalgesia and the recruitment of macrophages. This is the first report of leptin elevation specifically at the burn site, and the first report of fractalkine elevation in any tissue post-burn which, together with the functional findings, calls for exploration of the influence of these cytokines on pain, inflammation and burn wound progression. In addition, targeting these signalling molecules represents a therapeutic potential as early formative mediators of these pathological processes.

The prognostic value of serum procalcitonin measurements in critically injured patients: a systematic review

Background

Major trauma is associated with high incidence of septic complications and multiple organ dysfunction (MOD), which markedly influence the outcome of injured patients. Early identification of patients at risk of developing posttraumatic complications is crucial to provide early treatment and improve outcomes. We sought to evaluate the prognostic value of serum procalcitonin (PCT) levels after trauma as related to severity of injury, sepsis, organ dysfunction, and mortality.

Methods

We searched PubMed, MEDLINE, EMBASE, the Cochrane Database, and references of included articles. Two investigators independently identified eligible studies and extracted data. We included original studies that assessed the prognostic value of serum PCT levels in predicting severity of injury, sepsis, organ dysfunction, and mortality among critically injured adult patients.

Results

Among 2015 citations, 19 studies (17 prospective; 2 retrospective) met inclusion criteria. Methodological quality of included studies was moderate. All studies showed a strong correlation between initial PCT levels and Injury Severity Score (ISS). Twelve out of 16 studies demonstrated significant elevation of initial PCT levels in patients who later developed sepsis after trauma. PCT level appeared a strong predictor of MOD in seven out of nine studies. While two studies did not show association between PCT levels and mortality, four studies demonstrated significant elevation of PCT levels in non-survivors versus survivors. One study reported that the PCT level of ≥ 5 ng/mL was associated with significantly increased mortality (OR 3.65; 95% CI 1.03–12.9; p = 0.04).

Conclusion

PCT appears promising as a surrogate biomarker for trauma. Initial peak PCT level may be used as an early predictor of sepsis, MOD, and mortality in trauma population.

SIRS Triggered by Acute Right Ventricular Function, Mimicked Septic Shock

Background

The systemic inflammatory response syndrome (SIRS) is a complex immune response which can be precipitated by non-infectious aetiologies such as trauma, burns or pancreatitis. Addressing the underlying cause is crucial because it can be associated with increased mortality. Although the current literature associates chronic heart failure with SIRS, acute right ventricular dysfunction has not previously been reported to trigger SIRS. This case report describes the presentation of acute right ventricular dysfunction that triggered SIRS and mimicked septic shock.

Case presentation

A 70-year-old male presented to the Intensive Care Unit (ICU) with elevated inflammatory markers and refractory hypotension after a robotic-assisted laparoscopic radical choledochectomy with pancreaticoduodenectomy. Septic shock was misdiagnosed, and he was later found to have a pulmonary embolus. Thrombectomy and antimicrobials had no significant efect on lowering the elevated inflammatory markers or improving the persistent hypotension. Through Point of Care Ultrasound (POCUS), right ventricular dysfunction was diagnosed. Treatment with intravenous milrinone improved blood pressure, normalised inflammatory markers and led to a prompt discharge from the ICU.

Conclusion

Acute right ventricular dysfunction can trigger SIRS, which may mimic septic shock and delay appropriate treatment.

Screening and identification of non-inflammatory specific protein markers in Wilms' tumor tissues

Wilms' tumor is one of the most common malignancies in children, and early diagnosis is critical for its subsequent treatment and prognosis. Our previous study employed proteomics to investigate protein markers in the serum of Wilms' tumor children. The present study aimed to identify specific protein markers in Wilms' tumor. Proteomic comparison of Wilms' tumor with normal kidney tissues and the sera of systemic inflammatory response syndrome (SIRS) controls was performed. Surface-enhanced laser desorption ionization time-of-flight (SELDI-TOF-MS) identified a protein with m/z 8350 as specific to Wilms' tumor. The target protein was purified using sodium dodecylsulfate polyacrylamide gel electrophoresis (SDS-PAGE) and identified as profilin-1 by matrix-assisted laser desorption/ionization time-of-flight/time-of-flight (MALDI-TOF/TOF). Its expression was validated using real-time polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA). Our data identify profilin-1 as a potential protein marker for Wilms' tumor and demonstrate the feasibility of the above procedures for screening and identification of tumor-specific protein markers.

Functional immune monitoring in severely injured patients-A pilot study

After severe trauma, the resulting excessive inflammatory response is countered by compensatory anti-inflammatory mechanisms. The systemic inflammatory response to trauma enhanced by inappropriately timed surgical second hits may be detrimental for the patient. On the other hand, overwhelming anti-inflammatory mechanisms may put patients at increased risk from secondary local and systemic infections. The ensuing sepsis and organ dysfunction due to immune dysregulation remain the leading causes of death after injury. To date, there are no clinically applicable techniques to monitor the pro-/anti-inflammatory immune status of the patients and the remaining ability to react to microbial stimuli. Therefore, in the present study, we used a highly standardized and easy-to-use system to draw peripheral whole blood from polytraumatized patients (ISS ≥ 32, n = 7) and to challenge it with bacterial lipopolysaccharide. Secreted cytokines were compared with those in samples from healthy volunteers. We observed a significant decrease in the release of monocyte-derived mediators. Surprisingly, we detected stable or even increased concentrations of cytokines related to T cell maturation and function. For clinical practicability, we reduced the incubation time before supernatants were collected. Even after an abbreviated stimulation period, a stable release of almost all analysed parameters in patient blood could be detected. In conclusion, the data are indicative of a clinically well-applicable approach to monitor the immune status in severely injured patients in a short time. This may be used to optimize the timing of necessary surgical interventions to avoid a boost of proinflammation and reduce risk of secondary infections.

Ceria Nanoparticles Fabricated with 6-Aminohexanoic Acid that Overcome Systemic Inflammatory Response Syndrome

Systemic inflammatory response syndrome (SIRS) is self-destructive and uncontrollable inflammatory response of the whole body triggered by infection, trauma, or a variety of severe injuries. Although reactive oxygen species play a pivotal role in the development of SIRS, the trials with conventional antioxidants have failed to improve patient outcome. Ceria nanoparticles (CeNPs) have potent, autocatalytic reactive oxygen species scavenging activities, which may have sufficient therapeutic effects for SIRS. Herein, 3 nm CeNPs are fabricated totally in aqueous phase by using 6-aminohexanoic acid (6-AHA) and their Ce³⁺ to Ce⁴⁺ ratio is increased to enhance antioxidative properties. The obtained 6-AHA-CeNPs demonstrate strong antioxidative and anti-inflammatory effects in various biofluids and inflammatory cells. In SIRS animal models, 6-AHA-CeNPs are demonstrated to reduce multiple organ injuries and inflammation. Moreover, 6-AHA-CeNPs decrease mortality and improve clinical scores of SIRS models. These findings suggest that 6-AHA-CeNPs have potential as a therapeutic nanomedicine for SIRS.

Reduced Plasma Amino Acid Levels During Allogeneic Hematopoietic Stem Cell Transplantation Are Associated with Systemic Inflammation and Treatment-Related Complications

Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) are challenged by cytotoxic effects of the conditioning regimen, resulting in tissue damage, systemic inflammation, and increased metabolic demands for amino acids to regenerate damaged tissues, reconstitute hematopoietic cells, and establish antioxidant defenses. To date, few studies have addressed the role of plasma amino acid (PAA) levels during transplantation, and it remains unknown if amino acid deficiency can aggravate treatment-related morbidity. We determined plasma levels of the 23 human amino acids in 80 HSCT recipients (age 1.1 to 55.4 years) before conditioning and on days +7 and +21 post-transplant along with C-reactive protein (CRP) and IL-6 levels on day +7. Significant changes were observed in plasma concentrations of several human amino acids during HSCT. On day +7, numerous amino acids were inversely correlated with both CRP and IL-6, including glutamic acid, serine, alanine, glutamine, arginine, cysteine, glycine, histidine, lysine, tryptophan, threonine, taurine, proline, and methionine (r = -.22 to -.66; all P < .05). Patients who developed sinusoidal obstruction syndrome (SOS) had significantly lower mean total PAA levels compared with patients without SOS (2013 ng/L [95% confidence interval (CI), 1709 to 2318 ng/L] versus 2706 ng/L [95% CI, 2261 to 3150 ng/L]; P = .006), along with lower individual levels of glutamic acid, serine, arginine, glycine, lysine, valine, tryptophan, threonine, and proline on day +7 (all P < .05). Patients with severe acute graft-versus-host disease had a lower mean total PAA level (1922 ng/L [95% CI, 1738 to 2106 ng/L] versus 2649 ng/L [95% CI, 2244 to 3055 ng/L]; P = .014) and lower levels of serine, glutamine, cysteine, glycine, lysine, and threonine on day +7 (all P < .05). These results indicate a relationship between low concentrations of certain amino acids and the risk of treatment-related complications.

A Comparative Review of Equine SIRS, Sepsis, and Neutrophils

The most recent definition of sepsis in human medicine can be summarized as organ dysfunction caused by a dysregulated host response to infection. In equine medicine, although no consensus definition is available, sepsis is commonly described as a dysregulated host systemic inflammatory response to infection. Defense against host infection is the primary role of innate immune cells known as neutrophils. Neutrophils also contribute to host injury during sepsis, making them important potential targets for sepsis prevention, diagnosis, and treatment. This review will present both historical and updated perspectives on the systemic inflammatory response (SIRS) and sepsis; it will also discuss the impact of sepsis on neutrophils, and the impact of neutrophils during sepsis. Future identification of clinically relevant sepsis diagnosis and therapy depends on a more thorough understanding of disease pathogenesis across species. To gain this understanding, there is a critical need for research that utilizes a clearly defined, and consistently applied, classification system for patients diagnosed with, and at risk of developing, sepsis.

Augmented renal clearance

Adding to the complexity of caring for critically ill patients is the fact that many of them have a creatinine clearance that exceeds 130 mL/min/1.73 m². This phenomenon, termed augmented renal clearance (ARC), has only recently been widely recognized and its pathogenesis remains incompletely understood. However, ARC has been shown to result in increased dose requirements for drugs that are primarily eliminated by renal excretion, including many antimicrobial agents and enoxaparin. Recognition of ARC is hampered by the fact that the standard creatinine-based equations used to estimate renal function are not accurate in this clinical setting and the diagnosis is best established using both serum and urine creatinine measurements to calculate clearance. So a high index of clinical suspicion and awareness is usually required before this step is taken to confirm the diagnosis of ARC.

Regulation and Role of Chitotriosidase during Lung Infection with Klebsiella pneumoniae

Chitinases and chitinase-like proteins are an evolutionary conserved group of proteins. In the absence of chitin synthesis in mammals, the conserved presence of chitinases suggests their roles in physiology and immunity, but experimental evidence to prove these roles is scarce. Chitotriosidase (chit1) is one of the two true chitinases present in mammals and the most prevalent chitinase in humans. In this study, we investigated the regulation and the role of chit1 in a mouse model of Klebsiella pneumoniae lung infection. We show that chitinase activity in bronchoalveolar lavage fluid is significantly reduced during K. pneumoniae lung infection. This reduced activity is inversely correlated with the number of neutrophils. Further, instilling neutrophil lysates in lungs decreased chitinase activity. We observed degradation of chit1 by neutrophil proteases. In a mouse model, chit1 deficiency provided a significant advantage to the host during K. pneumoniae lung infection by limiting bacterial dissemination. This phenotype was independent of inflammatory changes in chit1-/- mice as they exerted a similar inflammatory response. The decreased dissemination resulted in improved survival in chit1-/- mice infected with K. pneumoniae in the presence or absence of antibiotic therapy. The beneficial effects of chit1 deficiency were associated with altered Akt activation in the lungs. Chit1-/- mice induced a more robust Akt activation postinfection. The role of the Akt pathway in K. pneumoniae lung infection was confirmed by using an Akt inhibitor, which impaired health and survival. These data suggest a detrimental role of chit1 in K. pneumoniae lung infections.

Anti-inflammatory effects and anti-oxidant capacity of Myrathius arboreus (Cecropiaceae) in experimental models

BACKGROUND

Inflammation is involved in various diseases; search for safe treatments is warranted. Anti-inflammatory effects of ethanol extract of Myrathius arboreus (EEMa) were studied in carrageenan-induced model, formaldehyde sub-acute-induced model, and in 48 h lipopolysaccharide-induced air pouch model of inflammation. EEMa membrane-stabilizing activities and anti-oxidant capacity were determined in vitro.

METHODS

In the carrageenan model EEMa (125, 250, or 500 mg/kg), indomethacin (5 mg/kg), or vehicle 3 mL/kg was administered orally in rats (n=5). After 1 h, 0.1 mL of 1% carrageenan was injected into the right hind paw of rats. Change in edema sizes was measured for 3 h with plethysmometer. One-tenth milliliter (0.1 mL) of 2.5% formaldehyde was injected into the rat paw on the first day and the third day to induce sub-acute inflammation; changes in the edema sizes were determined, and percentages of inhibitions were calculated. Anti-inflammatory effects of EEMa were further examined in lipopolysaccharide (LPS)-induced air-pouch based on leukocytes count, volume of exudates, levels of malondialdehyde, glutathione, superoxide dismutase, nitric oxides, and tumor necrosis factor released into the inflammatory fluids. EEMa-free radicals scavenging activities were studied in DPPH and reducing power tests. Membrane-stabilizing activities of EEMa were evaluated in the red blood cell lysis induced by thermal and hypotonic solution.

RESULTS

EEMa (250, 500 mg/kg) produced significant (p<0.001; p<0.05) inhibition of inflammation when compared with vehicle. Also, EEMa (250, 500, or 1000 μg/mL) significantly stabilized membrane and produced free radical scavenging activities.

CONCLUSIONS

M. arboreus possesses anti-inflammatory and the anti-oxidant properties that might benefit translational medicine.

Acute Liver Failure: Mechanisms of Disease and Multisystemic Involvement

Acute liver failure is accompanied by a pathologic syndrome common to numerous different etiologies of liver injury. This acute liver failure syndrome leads to potentially widespread devastating end-organ consequences. Systemic dysregulation and dysfunction is likely propagated via inflammation as well as underlying hepatic failure itself. Decoding the mechanisms of the disease process and multisystemic involvement of acute liver failure offers potential for targeted treatment opportunities and improved clinical outcomes in this sick population.

Prevalence of the systemic inflammatory response syndrome in patients who underwent orthognathic surgery

PURPOSE

The systemic inflammatory response syndrome (SIRS) is the body's response to an insult, such as infection, trauma, burn, and surgical stress linked to several factors deemed potential for multiple organ failure if left untreated. Thus, the aim of this paper was a prospective study to examine the incidence of SIRS in postoperative patients who underwent orthognathic surgery from June/2013 to July/2016.

METHODS

The sample consisted of 80 patients who underwent bimaxillary orthognathic surgery, with data on vital signs and white blood cell count collected preoperatively, and the same data collected in the immediate postoperative period, in addition to CO₂ pressure in arterial blood by blood gas analysis. The data were tabulated and cases of SIRS (2 or more signs out of four pre-set signs) were identified within 24 h after surgery.

RESULTS

From the sample of 80 patients, 26 (32.5% of total) patients had SIRS with higher incidence in females who are 40 years old.

CONCLUSION

The incidence of patients who develop SIRS after orthognathic surgery is relatively high and we should pay attention to the possible complications that these cases can evolve.

Variants in LTA, TNF, IL1B and IL10 genes associated with the clinical course of sepsis

The aim of this study was to explore the association between some SNPs of the TNF, LTA, IL1B and IL10 genes with cytokine concentrations and clinical course in Colombian septic patients. We conducted a cross-sectional study to genotype 415 septic patients and 205 patients without sepsis for the SNPs -308(G/A) rs1800629 of TNF; +252 (G/A) rs909253 of LTA; -511(A/G) rs16944 and +3953(C/T) rs1143634 of IL1B; and -1082(A/G) rs1800896, -819(C/T) rs1800871 and -592(C/A) rs1800872 of IL10. The association of theses SNPs with the following parameters was evaluated: (1) the presence of sepsis; (2) severity and clinical outcomes; (3) APACHE II and SOFA scores; and (4) procalcitonin, C-reactive protein, tumor necrosis factor, lymphotoxin alpha, interleukin 1 beta and interleukin 10 plasma concentrations. We found an association between the SNP LTA +252 with the development of sepsis [OR 1.29 (1.00-1.68)]; the SNP IL10 -1082 with sepsis severity [OR 0.53 (0.29-0.97)]; the TNF -308 with mortality [OR 0.33 (0.12-0.95)]; and the IL10 -592 and IL10 -1082 with admission to the intensive care unit (ICU) [OR 3.36 (1.57-7.18)] and [OR 0.18 (0.04-0.86)], respectively. None of the SNPs were associated with cytokine levels, procalcitonin and C-reactive protein serum concentrations, nor with APACHE II and SOFA scores. Our results suggest that these genetic variants play an important role in the development of sepsis and its clinical course.

Effects of sevoflurane and propofol on the development of pneumonia after esophagectomy: a retrospective cohort study

Background

Postoperative pneumonia (PP) is one of the common complications following esophagectomy and associated with poor short- and long-term outcomes. Sevoflurane and propofol, which have inflammatory-modulating effects, are common used general anesthetics. This study aimed to compare the effects of anesthesia with sevoflurane and propofol on the development of PP after esophageal surgery for cancer.

Methods

The electronic medical records of patients who underwent elective esophagectomy between July 2013 and July 2016 were reviewed. We conducted univariate and multivariate logistics analysis and propensity score matching analysis to compare the effect of sevoflurane and propofol on the incidence of PP and to identify the risk factors for PP after esophagectomy.

Results

Overall, the incidence of postoperative pneumonia was 9.5%. There was no significant difference in the rates of PP between sevoflurane group and propofol group either before or after propensity score matching (9.6% vs 8.0%, P = 0.606; 7.7% vs 6.4%, P = 0.754, respectively). Univariate and multivariate analysis revealed that alcohol use (OR 1.513; 95% CI 1.062–2.156), surgical procedure (Sweet: referent; Ivor-Lewis: OR 1.993; 95% CI 1.190–3.337; Three-incision: OR 1.878; 95% CI 1.296–2.722) and surgeon experience (high-volume: referent; low-volume: OR 1.525; 95% CI 1.090–2.135) were significant risk factors of postoperative pneumonia.

Conclusions

Sevoflurane did not differ from propofol in terms of affecting the risk of PP development after esophagectomy.

Interleukin-6 and interleukin-10 plasma levels and mRNA expression in polytrauma patients

PURPOSE

Host response to polytrauma occasionally has unpredictable outcomes. Immune response is a major factor influencing patient's outcome. This study evaluated the interaction of two main cytokines in immune response after major trauma, specifically interleukin-6 (IL-6) and interleukin-10 (IL-10). Plasma level of these cytokines is determined by mRNA expression of these cytokines genes which may decide the outcome of polytrauma patients.

METHODS

This prospective multicenter trial held at four trauma centers enrolled 54 polytrauma patients [Injury Severity Score (ISS) ≥ 16]. Plasma levels and mRNA expression of IL-6 and IL-10 were measured for 5 days after trauma. Clinical evaluation was conducted to observe whether patients endured multiple organ dysfunction syndrome (MODS) and death. MODS evaluation was performed using sequential organ failure assessment (SOFA). Trauma load which in this study is represented with ISS, plasma level, expression of cytokine genes and patient's outcome were examined with correlation test and statistical analysis.

RESULTS

The elevated IL-6/IL-10 ratio indicated increased activity of systemic inflammation response, especially pro-inflammation response which bears higher probability of progressing to MODS and death. The decline of IL-6/IL-10 ratio with heavy trauma load (ISS > 30) showed that compensatory anti-inflammation response syndrome (CARS) state was more dominant than systemic inflammatory response syndrome (SIRS), indicating that malfunction and failure of immune system eventually lead to MODS and deaths. The statistical significance in plasma level of cytokines was found in the outcome group which was defined as bearing a low trauma load but mortality.

CONCLUSION

The pattern of cytokine levels in inflammation response has great impact on the outcome of polytrauma patients. Further study at the genetic level is needed to investigate inflammation process which may influence patient's outcome.

A new multiple trauma model of the mouse

Background

Blunt trauma is the most frequent mechanism of injury in multiple trauma, commonly resulting from road traffic collisions or falls. Two of the most frequent injuries in patients with multiple trauma are chest trauma and extremity fracture. Several trauma mouse models combine chest trauma and head injury, but no trauma mouse model to date includes the combination of long bone fractures and chest trauma. Outcome is essentially determined by the combination of these injuries. In this study, we attempted to establish a reproducible novel multiple trauma model in mice that combines blunt trauma, major injuries and simple practicability.

Methods

Ninety-six male C57BL/6 N mice (n = 8/group) were subjected to trauma for isolated femur fracture and a combination of femur fracture and chest injury. Serum samples of mice were obtained by heart puncture at defined time points of 0 h (hour), 6 h, 12 h, 24 h, 3 d (days), and 7 d.

Results

A tendency toward reduced weight and temperature was observed at 24 h after chest trauma and femur fracture. Blood analyses revealed a decrease in hemoglobin during the first 24 h after trauma. Some animals were killed by heart puncture immediately after chest contusion; these animals showed the most severe lung contusion and hemorrhage. The extent of structural lung injury varied in different mice but was evident in all animals. Representative H&E-stained (Haematoxylin and Eosin-stained) paraffin lung sections of mice with multiple trauma revealed hemorrhage and an inflammatory immune response. Plasma samples of mice with chest trauma and femur fracture showed an up-regulation of IL-1β (Interleukin-1β), IL-6, IL-10, IL-12p70 and TNF-α (Tumor necrosis factor- α) compared with the control group. Mice with femur fracture and chest trauma showed a significant up-regulation of IL-6 compared to group with isolated femur fracture.

Conclusions

The multiple trauma mouse model comprising chest trauma and femur fracture enables many analogies to clinical cases of multiple trauma in humans and demonstrates associated characteristic clinical and pathophysiological changes. This model is easy to perform, is economical and can be used for further research examining specific immunological questions.

Persistent Inflammation, Immunosuppression and Catabolism Syndrome

Following advances in critical care, in-hospital multiple organ failure-related mortality is declining. Consequently, incidence of chronic critical illness is increasing. These patients linger in the intensive care unit, have high resource utilization, and poor long-term outcomes. Within this population, the authors propose that a substantial subset of patients have a new phenotype: persistent inflammation, immunosuppression, and catabolism syndrome. There is evidence that myelodysplasia with expansion of myeloid-derived suppressor cells, innate and adaptive immune suppression, and protein catabolism with malnutrition are major contributors. Optimal care of these patients will require novel multimodality interventions.

Characterizing the relationship between systemic inflammatory response syndrome and early cardiac dysfunction in traumatic brain injury

Systolic dysfunction was recently described following traumatic brain injury (TBI), and systemic inflammation may be a contributing mechanism. Our aims were to 1) examine the association between the early systemic inflammatory response syndrome (SIRS) and systolic cardiac dysfunction following TBI, and 2) describe the longitudinal change in SIRS criteria, cardiac function, and hemodynamic parameters during the first week of hospitalization. We used a secondary analysis of a prospective cohort study examining cardiac function (with transthoracic echocardiography on the first day and serially over the first week of hospitalization) in 32 moderate-severe isolated TBI patients, and quantified the admission and daily SIRS response to injury. We determined the association of admission SIRS and systolic dysfunction following TBI. Admission SIRS was present in 7 (21%) patients and was associated with systolic dysfunction on multivariable analysis (relative risk 4.01; 95% 1.16-13.79, p = .028). Both SIRS criteria and systolic cardiac function improved over the first week of hospitalization. In conclusion, early SIRS is common among patients with moderate-severe TBI, and the presence of SIRS criteria on admission is associated with systolic cardiac dysfunction following TBI.

Effect of disrupted mitochondria as a source of damage-associated molecular patterns on the production of tumor necrosis factor α by splenocytes from dogs

OBJECTIVE To evaluate the effects of damage-associated molecular patterns (DAMPs) derived from disrupted mitochondria on canine splenocytes and other immune cells. SAMPLES Liver, spleen, and bone marrow samples obtained from 8 cadavers of healthy research Beagles that had been euthanized for other purposes. PROCEDURES Mitochondria were obtained from canine hepatocytes, and mitochondrial DAMPs (containing approx 75% mitochondrial proteins) were prepared. Mitochondrial DAMPs and the nuclear cytokine high-mobility group box protein 1 were applied to splenocytes, bone marrow-differentiated dendritic cells, and a canine myelomonocytic cell (DH82) line for 6 or 24 hours. Cell culture supernatants from splenocytes, dendritic cells, and DH82 cells were assayed for tumor necrosis factor α with an ELISA. Expression of tumor necrosis factor α mRNA in splenocytes was evaluated with a quantitative real-time PCR assay. RESULTS In all cell populations evaluated, production of tumor necrosis factor α was consistently increased by mitochondrial DAMPs at 6 hours (as measured by an ELISA). In contrast, high-mobility group box protein 1 did not have any independent proinflammatory effects in this experimental system. CONCLUSIONS AND CLINICAL RELEVANCE The study revealed an in vitro inflammatory effect of mitochondrial DAMPs (containing approx 75% mitochondrial proteins) in canine cells and validated the use of an in vitro splenocyte model to assess DAMP-induced inflammation in dogs. This experimental system may aid in understanding the contribution of DAMPs to sepsis and the systemic inflammatory response syndrome in humans. Further studies in dogs are needed to validate the biological importance of these findings and to evaluate the in vivo role of mitochondrial DAMPs in triggering and perpetuating systemic inflammatory states.

What is Acute Respiratory Distress Syndrome?

Acute respiratory distress syndrome (ARDS) is a form of acute lung injury which usually occurs within 24 hours of a major illness or injury. Unfortunately a clear definition of ARDS does not presently exist, and the variability in the diagnostic criteria may impact on the results of clinical trials for ARDS and our understanding of the epidemiology and pathogenesis of this syndrome. In this article the history of ARDS is reviewed and a few of the definitions that have evolved over wtime are explored in depth. In addition, several controversies with these existing defiitions are discussed.

Risk factors for nosocomial nontraumatic coma: sepsis and respiratory failure

Background

Coma’s are a major cause of clinical deterioration or death. Identification of risks that predispose to coma are important in managing patients; however, the risk factors for nosocomial nontraumatic coma (NNC) are not well known. Our aim was to investigate the risk factors in patients with NNC.

Methods

A retrospective case–control design was used to compare patients with NNC and a control group of patients without coma in a population-based cohort of 263 participants from the neurological intensive care unit in Shuyang County People’s Hospital of Northern China. Coma was diagnosed by a Glasgow Coma Scale score ≤8. Adjusted odds ratios for patients with NNC were derived from multivariate logistic regression analyses.

Results

A total of 96 subjects had NNC. The prevalence of NNC was 36.5% among the subjects. Among these, 82% had acute cerebrovascular etiology. Most of the NNC usually occurred at day 3 after admission to the neurological intensive care unit. Patients with NNC had higher hospital mortality rates (67.7% vs 3%, P<0.0001) and were more likely to have a central herniation (47.9% vs 0%, P<0.001) or uncal herniation (11.5% vs 0%, P<0.001) than those without NNC. Multiple logistic regression showed that systemic inflammatory response syndrome-positive sepsis (odds ratio =4, 95% confidence interval =1.875−8.567, P<0.001) and acute respiratory failure (odds ratio =3.275, 95% confidence interval =1.014−10.573, P<0.05) were the factors independently associated with a higher risk of NNC.

Conclusion

Systemic inflammatory response syndrome-positive sepsis and acute respiratory failure are independently associated with an increased risk of NNC. This information may be important for patients with NNC.

Continuous cardiac output and hemodynamic monitoring: high temporal correlation between plasma TNF-α and hemodynamic changes during a sepsis-like state in cancer immunotherapy

Through continuous cardiac output monitoring, we investigated the temporal relationship between hemodynamic changes and plasma cytokines in a cancer patient who developed collateral sepsis to immunotherapy. A 52-year-old male with metastatic renal cell carcinoma received interleukin-2 (IL-2) infusion completing 72 h of administration. The patient developed 3 sepsis-like states including systemic inflammatory response syndrome (SIRS), shock, and multiple organ dysfunction syndrome (MODS). Hemodynamic parameters including systemic vascular resistance index (SVRI), left ventricular stroke work index (LVSWI) and cardiac index (CI) were measured over 60 h. Peripheral blood was drawn when SVRI dropped 20% in the patient and plasma cytokines including TNF-α , IL-6 and IL-1β were measured using ELISA. After 60 h of immunotherapy, the patient showed a 63.4% decrease in SVRI, 54.5% decrease in LVSWI and 65.4% increase in CI. The evaluation of systemic cytokines revealed different kinetic patterns: (i) a sustained increase in TNFα levels through all 3 sepsis-like states; (ii) IL-6 increased preferentially during SIRS and shock, while up/down-responses were found during MODS; (iii) IL-1β was undetectable during the entire study period. A high temporal relationship between hemodynamic changes and plasma TNF-α, but not IL-6, was found. Although there are factors other than cytokines that can alter vascular resistance, this finding could represent an approach to evaluate the course of hemodynamia and probably the systemic cytokine expression after IL-2 administration in renal cancer.

Interferon-γ counteracts reduced endotoxin responsiveness of whole blood following trauma and cardiopulmonary bypass

Accidental as well as surgical trauma has been reported to cause reduced endotoxin responsiveness of blood in terms of cytokine production. In this study, the effect of interferon-γ (IFN-γ) on tumour necrosis factor-α (TNF-α)-producing capacity of whole blood after severe trauma and cardiac surgery was investigated. Blood samples of severely injured patients were collected at the first day after trauma and of cardiac surgery patients before, 4 h and 2 days after cardiopulmonary bypass (CPB). The blood samples were incubated with INF-γ (0—100 U/ml) for 20 h and subsequently lipopolysaccharide (LPS)-induced TNF-α production was determined. Compared to healthy donors, LPS-induced TNF-α production was significantly reduced in blood cultures of trauma patients on day 1 after trauma and 4 h after CPB. Pre-incubation with IFN-γ in vitro increased endotoxin-induced TNF-α production in volunteers' and all patients' blood specimens in a dose-dependent manner. IFN-γ prompted an elevation of cytokine synthesis in CPB patients' blood which equalled that of volunteers, whereas it caused a lower rise in TNF-α production in blood of multiply injured patients, reaching levels of untreated donors only after incubation with 100 U/ml IFN-γ. These experiments show that hyporesponsiveness of whole blood induced by trauma or cardiac surgery with CPB is not irreversible, but can be counteracted by the immunostimulant IFN-γ. IFN-γ, therefore, could be applied clinically in trauma patients or after cardiac surgery to prevent or to resolve infection complications.

Reduction of the intestinal endotoxin pool by three different SDD regimens in human volunteers

Aerobic Gram-negative bacilli (AGNB) carried in the gut by healthy individuals generate 1 mg of 'physiological' endotoxin per g of faeces. Successful eradication of AGNB from the gut would be expected to lead to a lowering of the intestinal endotoxin pool. This prompted us to evaluate the reduction of intestinal endotoxin in 6 healthy volunteers who each received 3 different oral antibiotic regimens. Regimen 1 was polymyxin E (600 mg/day), regimen 2 polymyxin E (400 mg/day) combined with tobramycin (320 mg/day) and regimen 3 pefloxacin (800 mg/day). Each regimen was separated by an antibiotic free period of 3 months. A faecal sample (minimally 2 g) was obtained from each volunteer, before treatment began and afterwards 3 times a week on alternating days (Monday, Wednesday, Friday) for 3 weeks. Each volunteer produced 30 samples, 10 each per oral antibiotic. The samples were serially diluted in nutrient broth for the colony count of AGNB, whilst endotoxin was measured using the classical Limulus amoebocyte lysate micro-assay. The base-line value of faecal AGNB was 10 3-4 colony forming units/g of faeces. All samples obtained on day 3 following antibiotic intake were negative for AGNB, and remained negative during antibiotic intake. The AGNB free carrier state was associated with a reduction in gut endotoxin. The reduction was approximately 10 ng (1 log) for polymyxin E and pefloxacin, whilst the combination of polymyxin/tobramycin significantly reduced the intestinal endotoxin concentrations from 1 mg to 100 ng in the gut; a reduction of 104. Although AGNB were killed by the three regimens, the 'free' endotoxin left in the gut was effectively neutralised by the combination polymyxin/tobramycin only. From a clinical point of view, gut-derived endotoxaemia may play a role in the systemic inflammatory response syndrome and hence the outcome, in critically ill intensive care patients. This study supports other work which indicates that mortality is significantly reduced in only those intensive care patients who received oral polymyxin/tobramycin.

Paradoxical Neutrophil Elastase Release in Endovascular Abdominal Aortic Aneurysm Repair

Endovascular repair of abdominal aortic aneurysm potentially avoids problems associated with prolonged aortic cross-clamping that occurs with open repair, but it appears to have its own biologic consequences, which may relate to neutrophil elastase release. Blood samples of consecutive patients undergoing open or endovascular abdominal aneurysm repair were analyzed for neutrophil elastase/α1-antitrypsin complex and free elastase. Free elastase rose from baseline and fell quickly in open repair patients, returning to baseline by 144 hours. In the endovascular repair group, it continued to increase for up to 144 hours. Bound elastase increased to 24 hours, returning to baseline in endovascular repair patients by 72 hours, but remaining elevated in open repair patients at 144 hours. Open repair patients showed raised elastase/α1-antitrypsin complex and initial raised free elastase levels. High free elastase levels in endovascular repair patients may reflect less bound elastase and may paradoxically lead to a prolonged inflammatory postoperative response.

Moracin C, A Phenolic Compound Isolated from Artocarpus heterophyllus, Suppresses Lipopolysaccharide-Activated Inflammatory Responses in Murine Raw264.7 Macrophages

Artocarpus heterophyllus, a popular tropical fruit commonly known as the jackfruit tree, is normally planted in subtropical or tropical areas. Since a variety of phytochemicals isolated from A. heterophyllus have been found to possess potently anti-inflammatory, antiviral and antimalarial activities, researchers have devoted much interest to its potential pharmaceutical value. However, the exact mechanism underlying its anti-inflammatory activity is not well characterized. In this study, seven natural products isolated from A. heterophyllus, including 25-Hydroxycycloart-23-en-3-one (HY), Artocarpin (AR), Dadahol A (DA), Morachalcone A (MA), Artoheterophyllin B (AB), Cycloheterophyllin (CY) and Moracin C (MC) were collected. Lipopolysaccharide (LPS)-stimulated inflammatory response in RAW264.7 macrophages were used in this study. Among these compounds, MC significantly inhibited LPS-activated reactive oxygen species (ROS) and nitric oxide (NO) release without marked cytotoxicity. Furthermore, MC effectively reduced LPS stimulated up-regulation of mRNA and protein expression of inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2), and serval pro-inflammatory cytokines (interleukin-1β (IL-1β), interleukin-6 (IL-6) and tumor necrosis factor α (TNF-α)). Mechanistic studies revealed that the anti-inflammatory effect of MC was associated with the activation of the mitogen activated protein kinases (MAPKs) (including p38, ERK and JNK) and nuclear factor-κB (NF-κB) pathways, especially reducing the nuclear translocation of NF-κB p65 subunit as revealed by nuclear separation experiment and confocal microscopy.

Role of inflammation and infection in the pathogenesis of human acute liver failure: Clinical implications for monitoring and therapy

Acute liver failure is a rare and devastating clinical condition. At present, emergency liver transplantation is the only life-saving therapy in advanced cases, yet the feasibility of transplantation is affected by the presence of systemic inflammation, infection and resultant multi-organ failure. The importance of immune dysregulation and acquisition of infection in the pathogenesis of acute liver failure and its associated complications is now recognised. In this review we discuss current thinking regarding the role of infection and inflammation in the pathogenesis of and outcome in human acute liver failure, the implications for the management of such patients and suggest directions for future research.

[Strategies for antifungal treatment failure in intensive care units]

Recent epidemiologic studies reveal both an increasing incidence and an escalation in resistance of invasive fungal infections in intensive care units. Primary therapy fails in 70 % of cases, depending on the underlying pathogens and diseases. The purpose of this review is to raise awareness for the topic of antifungal therapy failure, describe the clinical conditions in which it occurs, and suggest a possible algorithm for handling the situation of suspected primary therapy failure.