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Zingerone Inhibits the Neutrophil Extracellular Trap Formation and Protects against Sepsis via Nrf2-Mediated ROS Inhibition. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3990607. [PMID: 35126812 PMCID: PMC8816574 DOI: 10.1155/2022/3990607] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/26/2021] [Accepted: 12/30/2021] [Indexed: 11/20/2022]
Abstract
Neutrophils release chromatin and antimicrobial proteins to trap and kill microbes, which is termed as neutrophil extracellular trap (NET) formation. NETs play a pivotal role in host defense against infection. However, emerging evidence indicated that NETs also contribute to an exaggerated inflammatory response and organic injuries in sepsis. Zingerone, a natural compound extracted from Zingiber officinale, exerts antioxidant, anti-inflammatory, and antioncogenic properties. In this study, we found that treatment with zingerone reduced organ injury and improved the outcome in a cecal ligation puncture- (CLP-) induced polymicrobial sepsis model. Administration of zingerone also alleviates reactive oxygen species (ROS) accumulation and systematic inflammation in septic mice and inhibits neutrophil extracellular traps (NETs) formation in vivo and in vitro. Furthermore, inhibition of nuclear factor erythroid 2-related factor 2 (Nrf2) with its specific antagonist significantly counteracted the suppressive effects of zingerone on ROS and NETs and retarded the protective role of zingerone against sepsis-associated organ injury. In addition, exposure to zingerone does not affect phagocytic activity of neutrophils in vitro and bacterial dissemination in vivo. Above all, our results indicate that zingerone treatment obviously attenuates NET formation and inflammatory response via Nrf2-mediated ROS inhibition, thus providing a novel therapeutic strategy against sepsis-induced injury.
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Li C, Davis X, Lahni P, Stuck J, Williamson L, Kaplan J. Obesity protects against sepsis-induced and norepinephrine-induced white adipose tissue browning. Am J Physiol Endocrinol Metab 2021; 321:E433-E442. [PMID: 34370596 PMCID: PMC8461795 DOI: 10.1152/ajpendo.00380.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/22/2022]
Abstract
Sepsis is a dysregulated systemic response to infection and can lead to organ damage and death. Obesity is a significant problem worldwide and affects outcomes from sepsis. Our laboratory demonstrated that white adipose tissue (WAT) undergoes browning during sepsis, a process whereby WAT adopts a brown adipose tissue phenotype. However, this browning process was not observed in obese mice during sepsis. White adipose tissue browning is detrimental in patients with burn injury and cancer. We hypothesize that norepinephrine (NE) induces WAT browning in nonobese mice but not in obese mice similarly to sepsis-induced WAT browning. Six-week-old C57BL/6 male mice were randomized to a high-fat diet or normal diet. After 6-7 wk of feeding, polymicrobial sepsis was induced by cecal ligation and puncture (CLP). Norepinephrine was administered intraperitoneally via osmotic minipumps for 18 h or 72 h (no CLP) at which time tissue and plasma were harvested. Controls were mice that underwent CLP (no NE) with 18-h harvest. A separate group of mice underwent pretreatment with NE or vehicle infusion for 72 h, CLP was performed, and at 18 h had tissue and plasma harvested. Sepsis resulted in significant weight loss in both nonobese and obese mice. NE treatment alone caused weight loss in obese mice. Septic nonobese mice had higher uncoupling protein-1 (UCP1) expression compared with control and obese septic mice. NE treatment increased UCP1 expression in nonobese, but not obese mice. NE-treated obese septic mice had lower lung myeloperoxidase (MPO) activity, alanine aminotransferase (ALT), aspartate aminotransferase (AST), TNFα, and IL-6 levels compared with NE-treated nonobese septic mice. Obesity protects mice from septic-induced and NE-induced WAT browning.NEW & NOTEWORTHY White adipose tissue browning is detrimental in patients with burn injury and cancer. WAT browning occurs in nonobese mice and can be induced by β receptor norepinephrine infusion, but obese mice are resistant to sepsis-induced and norepinephrine-induced WAT browning. We propose that the lack of WAT browning and unchanged inflammatory cytokine response may contribute to the protection of obese mice from sepsis.
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Affiliation(s)
- Cheryl Li
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Xenia Davis
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joanna Stuck
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lauren Williamson
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer Kaplan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Abstract
Regulatory guidelines mandate housing for laboratory mice at temperatures below their thermoneutral zone, creating chronic cold stress. However, increases in housing temperature could alter immune responses. We hypothesized housing mice at temperatures within their thermoneutral zone would improve sepsis survival and alter immune responses. Male C57BL/6 mice were housed at 22°C or 30°C after cecal ligation and puncture (CLP) for 10 days. Survival of mice housed at 30°C (78%) after CLP was significantly increased compared with mice housed at 22°C (40%). Experimental groups were repeated with mice euthanized at 0, 12, 24, and 48 h post-surgery to examine select immune parameters. Raising housing temperature minimally altered systemic, peritoneal, or splenic cell counts. However, IL-6 levels in plasma and peritoneal lavage fluid were significantly lower at 12 h post-surgery in mice housed at 30°C compared with 22°C. Bacterial colony counts from peritoneal lavage fluid were significantly lower in mice housed at 30°C and in vivo studies suggested this was the result of increased phagocytosis by neutrophils. As previously demonstrated, adoptive transfer of fibrocytes significantly increased sepsis survival compared with saline at 22°C. However, there was no additive effect when adoptive transfer was performed at 30°C. Overall, the results demonstrated that thermoneutral housing improves survival after CLP by increasing local phagocytic activity and technical revisions may be necessary to standardize the severity of the model across different housing temperatures. These findings stress the pronounced impact housing temperature has on the CLP model and the importance of reporting housing temperature.
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Nam K, Jo WY, Kwon SM, Kang P, Cho YJ, Jeon Y, Kim TK. Association Between Postoperative Body Temperature and All-Cause Mortality After Off-Pump Coronary Artery Bypass Graft Surgery: A Retrospective Observational Study. Anesth Analg 2019; 130:1381-1388. [PMID: 31567327 DOI: 10.1213/ane.0000000000004416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Inadvertent perioperative hypothermia is common in patients undergoing off-pump coronary artery bypass grafting (OPCAB). We investigated the association between early postoperative body temperature and all-cause mortality in patients undergoing OPCAB. METHODS We reviewed the electronic medical records of 1714 patients who underwent OPCAB (median duration of follow-up, 47 months). Patients were divided into 4 groups based on body temperature at the time of intensive care unit admission after surgery (moderate-to-severe hypothermia, <35.5°C; mild hypothermia, 35.5°C-36.5°C; normothermia, 36.5°C-37.5°C; and hyperthermia, ≥37.5°C). Cox proportional hazards models were used to assess the association between body temperature and all-cause mortality. The association between early postoperative changes in body temperature and all-cause mortality was also assessed by dividing the patients into 4 categories according to the body temperature measured at postoperative intensive care unit admission and the average body temperature during the first 3 postoperative days. RESULTS Compared to the normothermia group, the adjusted hazard ratios of all-cause mortality were 2.030 (95% confidence interval, 1.407-2.930) in the moderate-to-severe hypothermia group and 1.445 (95% confidence interval, 1.113-1.874) in the mild hypothermia group. Patients who were hypothermic at postoperative intensive care unit admission but attained normothermia thereafter were at a lower risk of all-cause mortality compared to patients who did not regain normothermia (adjusted hazard ratio, 0.631; 95% confidence interval, 0.453-0.878), while they were still at a higher risk of all-cause mortality than those who were consistently normothermic (adjusted hazard ratio, 1.435; 95% confidence interval, 1.090-1.890). CONCLUSIONS Even mild early postoperative hypothermia was associated with all-cause mortality after OPCAB. Patients who regained normothermia postoperatively were at lower risk of all-cause mortality compared to those who did not.
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Affiliation(s)
- Karam Nam
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Woo Young Jo
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seok Min Kwon
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Pyoyoon Kang
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Youn Joung Cho
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yunseok Jeon
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tae Kyong Kim
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
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Prompt Administration of Antibiotics and Fluids in the Treatment of Sepsis: A Murine Trial. Crit Care Med 2019; 46:e426-e434. [PMID: 29369056 DOI: 10.1097/ccm.0000000000003004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Sepsis, the acute organ dysfunction caused by a dysregulated host response to infection, poses a serious public health burden. Current management includes early detection, initiation of antibiotics and fluids, and source control as necessary. Although observational data suggest that delays of even a few hours in the initiation of antibiotics or IV fluids is associated with survival, these findings are controversial. There are no randomized data in humans, and prior animal studies studied time from experimental manipulation, not from the onset of clinical features of sepsis. Using a recently developed murine cecal ligation and puncture model that precisely monitors physiologic deterioration, we hypothesize that incremental hourly delays in the first dose of antibiotics, in the first bolus of fluid resuscitation, or a combination of the two at a clinically relevant point of physiologic deterioration during polymicrobial sepsis will shorten survival. DESIGN Randomized laboratory animal experimental trial. SETTING University basic science laboratory. SUBJECTS Male C57BL/6J, female C57BL/6J, aged (40-50 wk old) male C57BL/6J, and BALB/C mice. INTERVENTIONS Mice (n = 200) underwent biotelemetry-enhanced cecal ligation and puncture and were randomized after meeting validated criteria for acute physiologic deterioration. Treatment groups consisted of a single dose of imipenem/cilastatin, a single bolus of 30 mL/kg fluid resuscitation, or a combination of the two. Mice were allocated to receive treatment at the time of meeting deterioration criteria, after a 2-hour delay or after a 4-hour delay. MEASUREMENTS AND MAIN RESULTS Hourly delays in the initiation of antibiotic therapy led to progressively shortened survival in our model (p < 0.001). The addition of fluid resuscitation was unable to rescue animals, which received treatment 4 hours after meeting enrollment criteria. Systemic inflammation was increased, and host physiology was increasingly deranged with hourly delays to antibiotics. CONCLUSIONS We conclude that antibiotic therapy is highly time sensitive, and efforts should be made to deliver this critical therapy as early as possible in sepsis, perhaps extending into the first point of medical contact outside the hospital.
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6
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Aydın H, Şimşek T, Demiraran Y. Effects of Inadvertent Perioperative Hypothermia on Metabolic and Inflammatory Mediators. Turk J Anaesthesiol Reanim 2019; 47:448-455. [PMID: 31828241 DOI: 10.5152/tjar.2019.94715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 01/23/2019] [Indexed: 11/22/2022] Open
Abstract
Objective The aim of the present study was to investigate the effects of perioperative undesirable hypothermia on inflammatory (interleukin (IL)-8, IL-10, IL-18, IL-23 and pentraxin (PTX)-3) and metabolic responses (cortisol and insulin) and recovery time. Methods A total of 60 patients between the ages of 18 and 65 years who were in the lumbar stabilisation operation were included in the study. In this prospective, randomised controlled study, two groups were constituted as with warmed (Group N) and not warmed (Group C) patients before and during the operation. Diuresis, blood loss, body temperature and side effects were recorded with IL-8, IL-10, IL-18, IL-23, PTX-3, cortisol and insulin levels. Results Perioperative diuresis was significantly higher in Group C. Aldrete score was significantly higher in Group N with less shivering and vomiting in the postoperative period. IL-10, PTX-3 and cortisol levels were found to be significantly higher in Group C in the first postoperative hour. PTX-3 and cortisol were found to be significantly higher in Group C after 24 h of the operation. Insulin was significantly higher in Group N. In 72 h, IL-8 in Group N and cortisol level in Group C were significantly higher. Conclusion Positive effects of heating the patients in the perioperative period on haemorrhage, diuresis, complications and recovery time were observed in our study. In addition, maintenance of normothermia appeared to modulate the biomarkers that indicate the inflammatory and metabolic responses.
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Affiliation(s)
- Halide Aydın
- Clinic of Anaesthesiology and Reanimation, Van Training and Research Hospital, Van, Turkey
| | - Tuncer Şimşek
- Department of Anaesthesiology and Reanimation, Çanakkale Onsekiz Mart University School of Medicine, Çanakkale, Turkey
| | - Yavuz Demiraran
- Deparment of Anaesthesiology and Reanimation, Medipol University School of Medicine, İstanbul, Turkey
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Rungsung S, Singh TU, Rabha DJ, Kumar T, Cholenahalli Lingaraju M, Parida S, Paul A, Sahoo M, Kumar D. Luteolin attenuates acute lung injury in experimental mouse model of sepsis. Cytokine 2018; 110:333-343. [DOI: 10.1016/j.cyto.2018.03.042] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 03/24/2018] [Accepted: 03/30/2018] [Indexed: 12/30/2022]
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Abstract
OBJECTIVE Our knowledge of the molecular mechanisms of sepsis has attained exponential growth. Yet, the pillars of its care remain antibiotics, fluid resuscitation, and physiologic support of failing organ systems. The inability to bring biologic breakthroughs to the bedside is not for lack of effort. Over 60 clinical trials of novel therapies, each heavily supported by the momentum of biologic data suggesting clinical utility, have been conducted and have failed to identify benefit. This mass of "negative" clinical data abut an equally towering mound of knowledge of sepsis biology, which collectively have led investigators to ask, "what happened?" DATA SOURCES Review of published scientific literature via MEDLINE searches using key terms related to the article topics. STUDY SELECTION Original articles, review articles, and systematic reviews were considered. DATA EXTRACTION Articles were selected for inclusion based upon author consensus. DATA SYNTHESIS Here, we present a synthetic review of some of the challenges in translating experimental animal models of sepsis to the bedside. We commence with the concept that the heterogeneity in the kinetics of the sepsis response serves as an important, often underappreciated but surmountable, source of translational impedance. Upon this groundwork, we discuss distinctions between animal experimentation and clinical trial design in the elements for hypothesis testing: cohort selection, power and sample size, randomization and blinding, and timing of intervention. From this concept, we develop a contextual framework for advancing the paradigm of animal-based investigations to facilitate science that transitions from molecule to medicine. CONCLUSIONS A persistent divide exists between the laboratory and clinical research arenas, which may be addressable via systematic targeting of identified translational gaps.
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Affiliation(s)
- Anthony J. Lewis
- Department of Surgery, University of Pittsburgh, Pittsburgh, USA
| | - Janet S. Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew R. Rosengart
- Department of Surgery, University of Pittsburgh, Pittsburgh, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
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9
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Mai SHC, Sharma N, Kwong AC, Dwivedi DJ, Khan M, Grin PM, Fox-Robichaud AE, Liaw PC. Body temperature and mouse scoring systems as surrogate markers of death in cecal ligation and puncture sepsis. Intensive Care Med Exp 2018; 6:20. [PMID: 30054760 PMCID: PMC6063809 DOI: 10.1186/s40635-018-0184-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/09/2018] [Indexed: 12/29/2022] Open
Abstract
Background Despite increasing ethical standards for conducting animal research, death is still often used as an endpoint in mouse sepsis studies. Recently, the Murine Sepsis Score (MSS), Mouse Clinical Assessment Score for Sepsis (M-CASS), and Mouse Grimace Scale (MGS) were developed as surrogate endpoint scoring systems for assessing pain and disease severity in mice. The objective of our study was to compare the effectiveness of these scoring systems and monitoring of body temperature for predicting disease progression and death in the cecal ligation and puncture (CLP) sepsis model, in order to better inform selection of surrogate endpoints for death in experimental sepsis. Methods C57Bl/6J mice were subjected to control sham surgery, or moderate or severe CLP sepsis. All mice were monitored every 4 h for surrogate markers of death using modified versions of the MSS, M-CASS, and MGS scoring systems until 24 h post-operatively, or until endpoint (inability to ambulate) and consequent euthanasia. Results Thirty percent of mice subjected to moderate severity CLP reached endpoint by 24 h post-CLP, whereas 100% undergoing severe CLP reached endpoint within 20 h. Modified MSS, M-CASS, and MGS scores all increased, while body temperature decreased, in a time-dependent and sepsis severity-dependent manner, although modified M-CASS scores showed substantial variability. Receiver operating characteristic curves demonstrate that the last recorded body temperature (AUC = 0.88; 95% CI 0.77–0.99), change in body temperature (AUC = 0.89; 95% CI 0.78–0.99), modified M-CASS (AUC = 0.93; 95% CI 0.85–1.00), and modified MSS (AUC = 0.95; 95% CI 0.88–1.01) scores are all robust for predicting death in CLP sepsis, whereas modified MGS (AUC = 0.78; 95% CI 0.63–0.92) is less robust. Conclusions The modified MSS and body temperature are effective markers for assessing disease severity and predicting death in the CLP model, and should thus be considered as valid surrogate markers to replace death as an endpoint in mouse CLP sepsis studies.
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Affiliation(s)
- Safiah H C Mai
- Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton St. E., DBRI Room C5-107, Hamilton, ON, L8L 2X2, Canada
| | - Neha Sharma
- Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton St. E., DBRI Room C5-107, Hamilton, ON, L8L 2X2, Canada
| | - Andrew C Kwong
- Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton St. E., DBRI Room C5-107, Hamilton, ON, L8L 2X2, Canada
| | - Dhruva J Dwivedi
- Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton St. E., DBRI Room C5-107, Hamilton, ON, L8L 2X2, Canada.,Department of Medicine, McMaster University, 1280 Main St. W, Hamilton, ON, L8S 4K1, Canada
| | - Momina Khan
- Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton St. E., DBRI Room C5-107, Hamilton, ON, L8L 2X2, Canada
| | - Peter M Grin
- Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton St. E., DBRI Room C5-107, Hamilton, ON, L8L 2X2, Canada.,Department of Medicine, McMaster University, 1280 Main St. W, Hamilton, ON, L8S 4K1, Canada
| | - Alison E Fox-Robichaud
- Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton St. E., DBRI Room C5-107, Hamilton, ON, L8L 2X2, Canada.,Department of Medicine, McMaster University, 1280 Main St. W, Hamilton, ON, L8S 4K1, Canada
| | - Patricia C Liaw
- Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton St. E., DBRI Room C5-107, Hamilton, ON, L8L 2X2, Canada. .,Department of Medicine, McMaster University, 1280 Main St. W, Hamilton, ON, L8S 4K1, Canada.
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10
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Turhan AH, Atıcı A, Sürmeli S. Effects of hypothermia on lung inflammation in a rat model of meconium aspiration syndrome. Acta Cir Bras 2018; 33:483-490. [PMID: 30020309 DOI: 10.1590/s0102-865020180060000002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/12/2018] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate the effects of hypothermia treatment on meconium-induced inflammation. METHODS Fifteen rats were instilled with human meconium (MEC, 1.5 mL/kg, 65 mg/mL) intratracheally and ventilated for 3 hours. Eight rats that were ventilated and not instilled with meconium served as a sham group. In MEC-hypothermia group, the body temperature was lowered to 33±0.5°C. Analysis of the blood gases, interleukin (IL)-1β, IL-6, IL-8, and tumor necrosis factor (TNF)-α in bronchoalveolar lavage (BAL) fluid samples, and histological analyses of the lungs were performed. RESULTS The BAL fluid TNF-α, IL-1β, IL-6 and IL-8 concentrations were significantly higher in the MEC-hypothermia group than in the MEC-normothermia (p < 0.001, p < 0.001, p = 0.001, p < 0.001, respectively) and sham-controlled groups (p < 0.001, p < 0.001, p < 0.001, p < 0.001, respectively). CONCLUSION Meconium-induced inflammatory cytokine production is affected by the body temperature control.
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Affiliation(s)
- Ali Haydar Turhan
- Associate Professor, Department of Pediatrics, Division of Neonatology, School of Medicine, University of Başkent, Istanbul, Turkey. Scientific, intellectual, conception and design of the study; acquisition of data, analysis and interpretation of data; technical procedures; statistics analysis; manuscript preparation and writing
| | - Aytuğ Atıcı
- Professor, Department of Pediatrics, Division of Neonatology, School of Medicine, University of Mersin, Turkey. Scientific and intellectual content of the study, manuscript preparation
| | - Serra Sürmeli
- MD, Department of Pediatrics, Division of Neonatology, School of Medicine, University of Mersin, Turkey. Acquisition, analysis and interpretation of data; technical procedures
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Rabha DJ, Singh TU, Rungsung S, Kumar T, Parida S, Lingaraju MC, Paul A, Sahoo M, Kumar D. Kaempferol attenuates acute lung injury in caecal ligation and puncture model of sepsis in mice. Exp Lung Res 2018; 44:63-78. [DOI: 10.1080/01902148.2017.1420271] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Dipankar Jyoti Rabha
- Division of Pharmacology and Toxicology, ICAR-Indian Veterinary Research Institute, Bareilly, Uttar Pradesh, India
| | - Thakur Uttam Singh
- Division of Pharmacology and Toxicology, ICAR-Indian Veterinary Research Institute, Bareilly, Uttar Pradesh, India
| | - Soya Rungsung
- Division of Pharmacology and Toxicology, ICAR-Indian Veterinary Research Institute, Bareilly, Uttar Pradesh, India
| | - Tarun Kumar
- Division of Pharmacology and Toxicology, ICAR-Indian Veterinary Research Institute, Bareilly, Uttar Pradesh, India
| | - Subhashree Parida
- Division of Pharmacology and Toxicology, ICAR-Indian Veterinary Research Institute, Bareilly, Uttar Pradesh, India
| | - Madhu Cholenahalli Lingaraju
- Division of Pharmacology and Toxicology, ICAR-Indian Veterinary Research Institute, Bareilly, Uttar Pradesh, India
| | | | - Monalisa Sahoo
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India
| | - Dinesh Kumar
- Division of Pharmacology and Toxicology, ICAR-Indian Veterinary Research Institute, Bareilly, Uttar Pradesh, India
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Joachim R, Suber F, Kobzik L. Characterising Pre-pubertal Resistance to Death from Endotoxemia. Sci Rep 2017; 7:16541. [PMID: 29185479 PMCID: PMC5707402 DOI: 10.1038/s41598-017-16743-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/15/2017] [Indexed: 02/06/2023] Open
Abstract
Sepsis is a common and deadly syndrome in which a dysregulated host response to infection causes organ failure and death. The current lack of treatment options suggests that a new approach to studying sepsis is needed. Pre-pubertal children show a relative resistance to death from severe infections and sepsis. To explore this phenomenon experimentally, we used an endotoxemia model of sepsis in mice. Following intra-peritoneal injection of endotoxin, pre-pubertal mice showed greater survival than post-pubertal mice (76.3% vs. 28.6%), despite exhibiting a similar degree of inflammation after two hours. Age-associated differences in the inflammatory response only became evident at twenty hours, when post-pubertal mice showed prolonged elevation of serum cytokines and differential recruitment of peritoneal immune cells. Mechanistically, prevention of puberty by hormonal blockade or acceleration of puberty by oestrogen treatment led to increased or decreased survival from endotoxemia, respectively. Additionally, the adoptive transfer of pre-pubertal peritoneal cells improved the survival of post-pubertal recipient mice, while post-pubertal peritoneal cells or vehicle did not. These data establish a model for studying childhood resistance to mortality from endotoxemia, demonstrate that oestrogen is responsible for an increased susceptibility to mortality after puberty, and identify peritoneal cells as mediators of pre-pubertal resistance.
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Affiliation(s)
- Rose Joachim
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Freeman Suber
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Lester Kobzik
- Harvard T. H. Chan School of Public Health, Boston, MA, USA.
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13
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Steele AM, Starr ME, Saito H. Late Therapeutic Intervention with Antibiotics and Fluid Resuscitation Allows for a Prolonged Disease Course with High Survival in a Severe Murine Model of Sepsis. Shock 2017; 47:726-734. [PMID: 27879561 PMCID: PMC5432399 DOI: 10.1097/shk.0000000000000799] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Current animal models of sepsis often incorporate antibiotics to be consistent with clinical standards for treatment of patients in the intensive care unit. However, such experimental intervention is commonly initiated very early after infectious insult, which likely blunts the progression of systemic inflammation and downstream pathology. The objective of this study was to establish an animal model of sepsis with delayed therapeutic intervention, allowing a longer disease course and downstream pathology, but still resulting in a high survival rate. Severe lethal abdominal infection was initiated in young adult (17-18-week-old) C57BL/6 mice by cecal slurry (CS) injection. When initiated early (1- or 6-h post-CS injection), antibiotic treatment (imipenem, 1.5 mg/mouse i.p., twice/day for 5 days) rescued the majority of mice; however, few of these mice showed evidence of bacteremia, cytokinemia, or organ injury. When antibiotic treatment was delayed until late time-points (12- or 24-h post-CS injection) the majority of animals did not survive beyond 48 h. When fluid resuscitation (physiological saline, s.c.) was performed in combination with antibiotic treatment (twice daily) beginning at these late time-points, the majority of mice survived (75%) and showed bacteremia, cytokinemia, organ dysfunction, and prolonged body weight loss (<90% for 4 weeks). We recommend that this new repeated combination treatment with antibiotics and fluids resuscitation be initiated at a late time point after bacteremia becomes evident because this model more closely mimics the downstream pathological characteristics of severe clinical sepsis yet maintains a high survival rate. This model would be advantageous for studies on severe sepsis and postintensive care illness.
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Affiliation(s)
- Allison M. Steele
- Department of Physiology, University of Kentucky, Lexington, KY 40536
| | - Marlene E. Starr
- Department of Surgery, University of Kentucky, Lexington, KY 40536
| | - Hiroshi Saito
- Department of Physiology, University of Kentucky, Lexington, KY 40536
- Department of Surgery, University of Kentucky, Lexington, KY 40536
- Markey Cancer Center, University of Kentucky, Lexington, KY 40536
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Use of Biotelemetry to Define Physiology-Based Deterioration Thresholds in a Murine Cecal Ligation and Puncture Model of Sepsis. Crit Care Med 2017; 44:e420-31. [PMID: 26862708 DOI: 10.1097/ccm.0000000000001615] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Murine models of critical illness are commonly used to test new therapeutic interventions. However, these interventions are often administered at fixed time intervals after the insult, perhaps ignoring the inherent variability in magnitude and temporality of the host response. We propose to use wireless biotelemetry monitoring to define and validate criteria for acute deterioration and generate a physiology-based murine cecal ligation and puncture model that is more similar to the conduct of human trials of sepsis. DESIGN Laboratory and animal research. SETTING University basic science laboratory. SUBJECTS Male C57BL/6 mice. INTERVENTIONS Mice underwent cecal ligation and puncture, and an HD-X11 wireless telemetry monitor (Data Sciences International) was implanted that enabled continuous, real-time measurement of heart rate, core temperature, and mobility. We performed a population-based analysis to determine threshold criteria that met face validity for acute physiologic deterioration. We assessed construct validity by temporally matching mice that met these acute physiologic deterioration thresholds with mice that had not yet met deterioration threshold. We analyzed matched blood samples for blood gas, inflammatory cytokine concentration, cystatin C, and alanine aminotransferase. MEASUREMENTS AND MAIN RESULTS We observed that a 10% reduction in both heart rate and temperature sustained for greater than or equal to 10 minutes defined acute physiologic deterioration. There was significant variability in the time to reach acute deterioration threshold across mice, ranging from 339 to 529 minutes after cecal ligation and puncture. We found adequate construct validity, as mice that met criteria for acute deterioration had significantly worse shock, systemic inflammation (elevated tumor necrosis factor-α, p = 0.003; interleukin-6, p = 0.01; interleukin-10, p = 0.005), and acute kidney injury when compared with mice that had not yet met acute deterioration criteria. CONCLUSIONS We defined a murine threshold for acute physiologic deterioration after cecal ligation and puncture that has adequate face and construct validity. This model may enable a more physiology-based model for evaluation of novel therapeutics in critical illness.
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Affiliation(s)
- Anthony J. Lewis
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew R. Rosengart
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Beltramini AM, Salata RA, Ray AJ. Thermoregulation and Risk of Surgical Site Infection. Infect Control Hosp Epidemiol 2015; 32:603-10. [DOI: 10.1086/660017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Surgical site infections (SSIs) occur in approximately 2%–5% of patients undergoing surgery in the acute care setting in the United States. These infections result in increased length of stay, higher risk of death, and increased cost of care compared with that in uninfected surgical patients. Given the inclusion of maintenance of perioperative normothermia for all major surgeries as a means of lowering the risk of infection in the Surgical Care Improvement Project 2009, we prepared a summary of the literature to determine the strength and quantity of the evidence underlying the performance measure. Although the data are generally supportive of perioperative normothermia as a means of reducing the risk of SSIs, a more rigorous approach using standard SSI definitions as well as standardized temperature measurements (and timing thereof) will further delineate the role played by temperature regulation in SSI development.
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Abstract
The renin-angiotensin (Ang) system is involved in maintaining cardiovascular function by regulating blood pressure and electrolyte homeostasis. More recently, alternative pathways within the renin-angiotensin system have been described, such as the ACE-2/Ang-(1-7)/Mas axis, with opposite effects to the ones of the ACE/Ang-II/AT1 axis. Correspondingly, our previous work reported that Ang-(1-7) via its receptor Mas inhibits the mRNA expression of the proinflammatory cytokines interleukin 6 (IL-6) and tumor necrosis factor-α increased by lipopolysaccharide (LPS) in mouse peritoneal macrophages. These data led us to investigate the functional role of the Ang-(1-7)/Mas axis in an in vivo LPS model. In this work, we present evidence that Ang-(1-7) via Mas significantly reduced the LPS-increased production of circulating cytokines, such as IL-6, IL-12, and CXCL-1. This inhibitory effect was mediated by Mas because it was not detectable in Mas-deficient (Mas) mice. Accordingly, IL-6, CXCL-1, and CXCL-2 levels were higher after LPS treatment in the absence of Mas. Mas mice were less resistant to LPS-induced endotoxemia, their survival rate being 50% compared with 95% in wild-type mice. Telemetric analyses showed that Mas mice presented more pronounced LPS-induced hypothermia with a 3°C lower body temperature compared with wild-type mice. Altogether, our findings suggest that Ang-(1-7) and Mas inhibit LPS-induced cytokine production and hypothermia and thereby protect mice from the fatal consequences of endotoxemia.
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Billeter AT, Hellmann J, Roberts H, Druen D, Gardner SA, Sarojini H, Galandiuk S, Chien S, Bhatnagar A, Spite M, Polk HC. MicroRNA-155 potentiates the inflammatory response in hypothermia by suppressing IL-10 production. FASEB J 2014; 28:5322-36. [PMID: 25231976 DOI: 10.1096/fj.14-258335] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Therapeutic hypothermia is commonly used to improve neurological outcomes in patients after cardiac arrest. However, therapeutic hypothermia increases sepsis risk and unintentional hypothermia in surgical patients increases infectious complications. Nonetheless, the molecular mechanisms by which hypothermia dysregulates innate immunity are incompletely understood. We found that exposure of human monocytes to cold (32°C) potentiated LPS-induced production of TNF and IL-6, while blunting IL-10 production. This dysregulation was associated with increased expression of microRNA-155 (miR-155), which potentiates Toll-like receptor (TLR) signaling by negatively regulating Ship1 and Socs1. Indeed, Ship1 and Socs1 were suppressed at 32°C and miR-155 antagomirs increased Ship1 and Socs1 and reversed the alterations in cytokine production in cold-exposed monocytes. In contrast, miR-155 mimics phenocopied the effects of cold exposure, reducing Ship1 and Socs1 and altering TNF and IL-10 production. In a murine model of LPS-induced peritonitis, cold exposure potentiated hypothermia and decreased survival (10 vs. 50%; P < 0.05), effects that were associated with increased miR-155, suppression of Ship1 and Socs1, and alterations in TNF and IL-10. Importantly, miR-155-deficiency reduced hypothermia and improved survival (78 vs. 32%, P < 0.05), which was associated with increased Ship1, Socs1, and IL-10. These results establish a causal role of miR-155 in the dysregulation of the inflammatory response to hypothermia.
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Affiliation(s)
- Adrian T Billeter
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Jason Hellmann
- Diabetes and Obesity Center, Institute of Molecular Cardiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Henry Roberts
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Devin Druen
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Sarah A Gardner
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Harshini Sarojini
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Susan Galandiuk
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Sufan Chien
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Aruni Bhatnagar
- Diabetes and Obesity Center, Institute of Molecular Cardiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Matthew Spite
- Diabetes and Obesity Center, Institute of Molecular Cardiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Hiram C Polk
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
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Abstract
BACKGROUND Acute lung injury (ALI) is characterized by inflammation, leukocyte activation, neutrophil recruitment, endothelial dysfunction, and epithelial injury, which are all affected by fever. Fever is common in the intensive care unit, but the relationship between fever and outcomes in ALI has not yet been studied. We evaluated the association of temperature dysregulation with time to ventilator liberation, ventilator-free days, and in-hospital mortality. METHODS Analysis of a prospective cohort study, which recruited consecutive patients with ALI from 13 intensive care units at four hospitals in Baltimore, Maryland. The relationship of fever and hypothermia with ventilator liberation was assessed with a Cox proportional hazards model. We evaluated the association of temperature during the first 3 days after ALI with ventilator-free days, using multivariable linear regression models, and the association with mortality was evaluated by robust Poisson regression. MEASUREMENTS AND MAIN RESULTS Of 450 patients, only 12% were normothermic during the first 3 days after ALI onset. During the first week post-ALI, each additional day of fever resulted in a 33% reduction in the likelihood of successful ventilator liberation (95% confidence interval [CI] for adjusted hazard ratio, 0.57 to 0.78; P < 0.001). Hypothermia was independently associated with decreased ventilator-free days (hypothermia during each of the first 3 d: reduction of 5.58 d, 95% CI: -9.04 to -2.13; P = 0.002) and increased mortality (hypothermia during each of the first 3 d: relative risk, 1.68; 95% CI, 1.06 to 2.66; P = 0.03). CONCLUSIONS Fever and hypothermia are associated with worse clinical outcomes in ALI, with fever being independently associated with delayed ventilator liberation.
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Iskander KN, Osuchowski MF, Stearns-Kurosawa DJ, Kurosawa S, Stepien D, Valentine C, Remick DG. Sepsis: multiple abnormalities, heterogeneous responses, and evolving understanding. Physiol Rev 2013; 93:1247-88. [PMID: 23899564 DOI: 10.1152/physrev.00037.2012] [Citation(s) in RCA: 284] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Sepsis represents the host's systemic inflammatory response to a severe infection. It causes substantial human morbidity resulting in hundreds of thousands of deaths each year. Despite decades of intense research, the basic mechanisms still remain elusive. In either experimental animal models of sepsis or human patients, there are substantial physiological changes, many of which may result in subsequent organ injury. Variations in age, gender, and medical comorbidities including diabetes and renal failure create additional complexity that influence the outcomes in septic patients. Specific system-based alterations, such as the coagulopathy observed in sepsis, offer both potential insight and possible therapeutic targets. Intracellular stress induces changes in the endoplasmic reticulum yielding misfolded proteins that contribute to the underlying pathophysiological changes. With these multiple changes it is difficult to precisely classify an individual's response in sepsis as proinflammatory or immunosuppressed. This heterogeneity also may explain why most therapeutic interventions have not improved survival. Given the complexity of sepsis, biomarkers and mathematical models offer potential guidance once they have been carefully validated. This review discusses each of these important factors to provide a framework for understanding the complex and current challenges of managing the septic patient. Clinical trial failures and the therapeutic interventions that have proven successful are also discussed.
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Affiliation(s)
- Kendra N Iskander
- Department of Pathology, Boston University School of Medicine, Boston, Massachusetts, USA
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21
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Rim KP, Kim K, Jo YH, Lee JH, Rhee JE, Kang KW, Suh GJ, Kwon WY, Lee MJ, Lee HS. Effect of therapeutic hypothermia according to severity of sepsis in a septic rat model. Cytokine 2012; 60:755-61. [PMID: 22980485 DOI: 10.1016/j.cyto.2012.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 07/26/2012] [Accepted: 08/13/2012] [Indexed: 11/19/2022]
Abstract
AIM OF STUDY The effects of therapeutic hypothermia (HT) during experimental sepsis may be influenced by disease severity. We experimentally investigated the effect of therapeutic HT on varying disease severity in a septic rat model. MATERIALS AND METHODS An adult male Sprague-Dawley rat model of intra-abdominal sepsis was used. To modify the disease severity, we used two different models; a moderate severe sepsis model (MSSM) and a severe septic shock model (SSSM). All rats were randomized to a hypothermia group (HT, 30-32°C) or a normothermia group (NT, 36-38°C) 1h after sepsis induction in each model. HT was maintained for 4h and rewarming was conducted for 2h. Survival time was recorded for up to 12h in the SSSM group and 24h in the MSSM group. Acute lung and liver injury, cytokine, and malondialdehyde (MDA) levels were investigated 7h after sepsis induction. Hemodynamic profiles were also evaluated. RESULTS In the SSSM, there were survival benefits and reduced acute lung and liver injury with therapeutic HT. Therapeutic HT was also associated with significantly reduced levels of plasma interleukin-6 and tissue malondialdehyde (MDA) levels in the liver and lung compared with the NT group in the SSSM. There was a tendency for the mean arterial pressure to be higher in the HT group compared to the NT group in the SSSM. In MSSM, however, there was no such beneficial effect. CONCLUSION In this rat model of severe septic shock, therapeutic HT showed beneficial effects. In contrast, therapeutic HT did not show protective effect in the moderate sepsis model.
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Affiliation(s)
- Kwang Pil Rim
- Department of Emergency Medicine, Seoul Medical Center, 316 Sinnae-dong, Jungnang-gu, Seoul 131-130, Republic of Korea
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Tokuda K, Kida K, Marutani E, Crimi E, Bougaki M, Khatri A, Kimura H, Ichinose F. Inhaled hydrogen sulfide prevents endotoxin-induced systemic inflammation and improves survival by altering sulfide metabolism in mice. Antioxid Redox Signal 2012; 17:11-21. [PMID: 22221071 PMCID: PMC3342565 DOI: 10.1089/ars.2011.4363] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
AIMS The role of hydrogen sulfide (H(2)S) in endotoxin (lipopolysaccharide [LPS])-induced inflammation is incompletely understood. We examined the impact of H(2)S breathing on LPS-induced changes in sulfide metabolism, systemic inflammation, and survival in mice. RESULTS Mice that breathed air alone exhibited decreased plasma sulfide levels and poor survival rate at 72 h after LPS challenge. Endotoxemia markedly increased alanine aminotransferase (ALT) activity and nitrite/nitrate (NOx) levels in plasma and lung myeloperoxidase (MPO) activity in mice that breathed air. In contrast, breathing air supplemented with 80 ppm of H(2)S for 6 h after LPS challenge markedly improved survival rate compared to mice that breathed air alone (p<0.05). H(2)S breathing attenuated LPS-induced increase of plasma ALT activity and NOx levels and lung MPO activity. Inhaled H(2)S suppressed LPS-induced upregulation of inflammatory cytokines, while it markedly induced anti-inflammatory interleukin (IL)-10 in the liver. Beneficial effects of H(2)S inhalation after LPS challenge were associated with restored sulfide levels and markedly increased thiosulfate levels in plasma. Increased thiosulfate levels after LPS challenge were associated with upregulation of rhodanese, but not cystathionine-γ-lyase (CSE), in the liver. Administration of sodium thiosulfate dose-dependently improved survival after LPS challenge in mice. INNOVATION By measuring changes in plasma levels of sulfide and sulfide metabolites using an advanced analytical method, this study revealed a critical role of thiosulfate in the protective effects of H(2)S breathing during endotoxemia. CONCLUSION These observations suggest that H(2)S breathing prevents inflammation and improves survival after LPS challenge by altering sulfide metabolism in mice.
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Affiliation(s)
- Kentaro Tokuda
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine at the Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts 02129, USA
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Miao P, Kong Y, Ma Y, Zeng H, Yu Z. Hypothermia predicts the prognosis in colon ascendens stent peritonitis mice. J Surg Res 2012; 181:129-35. [PMID: 22739046 DOI: 10.1016/j.jss.2012.05.078] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 05/17/2012] [Accepted: 05/30/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND The mortality rate of severe sepsis remains unacceptably high. It is difficult to make advances in the treatment of this problematic and increasingly frequent medical condition. In severe sepsis, hypothermia can be recognized as an important feature. The present study investigated the role of hypothermia in the prognosis of the colon ascendens stent peritonitis (CASP) model. METHODS We employed the CASP model for wild-type C57BL/6 mice. We compared physiologic indices in survivor and non-survivor groups after CASP to test whether low temperature might be a helpful predictor in sepsis. To certify this hypothesis, we examined the survival rate, peritoneal leukocytes, and organ damage. We also measured the bacterial burden and inflammatory cytokine levels at different times. RESULTS The temperature varied dramatically in the survivors' group compared with the non-survivors' group at 18 h. We divided the CASP models into a mild group and a severe group, based on temperatures above or below 32°C at 18 h. Mice in the severe group had a lower survival rate (0% versus 87.5%), more peritoneal leukocytes, more bacterial culture results, higher expressions of cytokines, and more classical features in pathology compared with the mild group. CONCLUSIONS Hypothermia (below 32°C at 18 h) might be a predictor of prognosis in CASP-induced sepsis.
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Affiliation(s)
- Peng Miao
- Department of General Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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24
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Shah NG, Hasday JD. Does temperature make a difference? It depends on how hot (or cold), for how long, and in what clinical context. Crit Care Med 2012; 40:326-7. [PMID: 22179364 DOI: 10.1097/ccm.0b013e3182372bbb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Katlic MR, Facktor MA, Berry SA, McKinley KE, Bothe A, Steele GD. ProvenCare lung cancer: a multi-institutional improvement collaborative. CA Cancer J Clin 2011; 61:382-96. [PMID: 21748730 DOI: 10.3322/caac.20119] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Geisinger's ProvenCare™ Program (for elective coronary artery bypass surgery, total hip replacement, and others) has shown that the principles of reliability science, facilitated by a robust electronic health record and institutional commitment, allow the re-engineering of complicated clinical processes. This eliminates unwarranted variation and promotes the completion of evidence-based elements of care. It has not been established that ProvenCare can be generalized to other institutions. Now, under the auspices of the American College of Surgeons Commission on Cancer, ProvenCare has been adapted to a multi-institutional collaborative for the care of the patient with resectable lung cancer.
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Affiliation(s)
- Mark R Katlic
- Department of Thoracic Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA, USA.
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Inflammatory Effects of Hypothermia and Inhaled H2S During Resuscitated, Hyperdynamic Murine Septic Shock. Shock 2011; 35:396-402. [DOI: 10.1097/shk.0b013e3181ffff0e] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tiruvoipati R, Ong K, Gangopadhyay H, Arora S, Carney I, Botha J. Hypothermia predicts mortality in critically ill elderly patients with sepsis. BMC Geriatr 2010; 10:70. [PMID: 20875107 PMCID: PMC2955035 DOI: 10.1186/1471-2318-10-70] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 09/27/2010] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Advanced age is one of the factors that increase mortality in intensive care. Sepsis and multi-organ failure are likely to further increase mortality in elderly patients.We compared the characteristics and outcomes of septic elderly patients (> 65 years) with younger patients (≤ 65 years) and identified factors during the first 24 hours of presentation that could predict mortality in elderly patients. METHODS This study was conducted in a Level III intensive care unit with a case mix of medical and surgical patients excluding cardiac and neurosurgical patients.We performed a retrospective review of all septic patients admitted to our ICU between July 2004 and May 2007. In addition to demographics and co-morbidities, physiological and laboratory variables were analysed to identify early predictors of mortality in elderly patients with sepsis. RESULTS Of 175 patients admitted with sepsis, 108 were older than 65 years. Elderly patients differed from younger patients with regard to sex, temperature (37.2°C VS 37.8°C p < 0.01), heart rate, systolic blood pressure, pH, HCO3, potassium, urea, creatinine, APACHE III and SAPS II. The ICU and hospital mortality was significantly higher in elderly patients (10.6% Vs 23.14% (p = 0.04) and 19.4 Vs 35.1 (p = 0.02) respectively). Elderly patients who died in hospital had a significant difference in pH, HCO3, mean blood pressure, potassium, albumin, organs failed, lactate, APACHE III and SAPS II compared to the elderly patients who survived while the mean age and co-morbidities were comparable. Logistic regression analysis identified temperature (OR [per degree centigrade decrease] 0.51; 95% CI 0.306- 0.854; p = 0.010) and SAPS II (OR [per point increase]: 1.12; 95% CI 1.016-1.235; p = 0.02) during the first 24 hours of admission to independently predict increased hospital mortality in elderly patients. CONCLUSIONS The mortality in elderly patients with sepsis is higher than the younger patients. Temperature (hypothermia) and SAPS II scores during the first 24 hours of presentation independently predict hospital mortality.
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Affiliation(s)
| | - Kevin Ong
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
| | - Himangsu Gangopadhyay
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
| | - Subhash Arora
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
| | - Ian Carney
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
| | - John Botha
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
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Mencía S, Berroya A, López-Herce J, Botrán M, Urbano J, Carrillo A. [Effects of induced hypothermia in critically ill children]. Med Intensiva 2010; 34:363-9. [PMID: 20207445 DOI: 10.1016/j.medin.2010.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 01/14/2010] [Accepted: 01/17/2010] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study the efficacy of induced hypothermia (IH) in children, its effect on hemodynamic, hematological, and biochemical parameters and its side effects. DESIGN Retrospective, observational study. SETTING Pediatric intensive care unit. PATIENTS Pediatric patients requiring induced hypothermia. INTERVENTIONS None. DATA COLLECTED The following variables were recorded prior to the initiation of IH and after 4, 24, 48, 72, and 120 hours: heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), diuresis, dose of inotropic, sedative, and muscle relaxant drugs, fluid balance, hematocrit, white cell count, white cell differential percentages, platelet count, blood levels of glucose, sodium, and potassium, C reactive protein, lactate, coagulation times, pressure ulcers, shivering, infections and death. RESULTS Thirty-one patients with a mean age of 20 months (SD: 39.8) were included in the study. The mean duration of IH was 3.97 days (range: 1 to 11 days). Among the IH effects, there was a significant fall in heart rate, with no changes in SBP, DBP, or diuresis. The blood tests revealed a progressive and significant fall in platelet count and an increase in C reactive protein levels. The fall in hematocrit and glucose and lactate levels was not significant. Positive cultures were detected in 25.8% of the patients during IH, most commonly from the bronchial aspirate (65%). CONCLUSIONS Induced hypothermia can be useful in some critically ill children. Tolerance is generally good and there are usually few side effects, which can be controlled through appropriate monitoring.
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Affiliation(s)
- S Mencía
- Sección de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España.
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Abstract
Early excision of the burn eschar has been one of the most significant advances in modern burn care. Historical advances in understanding of the pathophysiology of burn injury and the systemic inflammatory response fueled by the burn wound, and refinements in the techniques of tangential and fascial excision, have led to earlier excision and grafting of the burn wound with improvements in morbidity and mortality. Efforts to control blood loss, and good operative planning and attention to special areas, can lead to the safe excision and grafting of large burns.
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Affiliation(s)
- Michael J Mosier
- Department of Surgery, Harborview Medical Center, University of Washington Regional Burn Center, Seattle, 98104, USA
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Morita Y, Oda S, Sadahiro T, Nakamura M, Oshima T, Otani S, Hirasawa H. The effects of body temperature control on cytokine production in a rat model of ventilator-induced lung injury. Cytokine 2009; 47:48-55. [DOI: 10.1016/j.cyto.2009.04.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 03/18/2009] [Accepted: 04/09/2009] [Indexed: 11/24/2022]
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Nichol AD, Cooper DJ. Can we improve neurological outcomes in severe traumatic brain injury? Something old (early prophylactic hypothermia) and something new (erythropoietin). Injury 2009; 40:471-8. [PMID: 19371869 DOI: 10.1016/j.injury.2009.01.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 12/18/2008] [Accepted: 01/02/2009] [Indexed: 02/02/2023]
Abstract
Traumatic brain injury is a leading cause of mortality and long-term morbidity, particularly affecting young people. With our best therapies, one half of the patients with severe traumatic brain injury are never capable of living independently. Two interventions, which have real potential to improve neurological outcomes in patients with traumatic brain injury, are (i) very early induction of prophylactic hypothermia and (ii) exogenous erythropoietin therapy. There is substantial experimental evidence, a plausible biological rationale, and supportive clinical evidence from clinical trials to suggest a possible beneficial effect of prophylactic hypothermia and also for exogenous erythropoietin therapy in severe traumatic brain injury. Despite the recent guidelines and publications recommending these interventions, critical care clinicians should be conservative towards implementing these therapies outside clinical trials due to substantial efficacy and safety concerns. Nevertheless the high morbidity and mortality associated with severe traumatic brain injury (TBI) demands that we investigate the safety and efficacy of these promising potential therapies as a matter of urgency.
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Affiliation(s)
- Alistair D Nichol
- Australian and New Zealand Intensive Care-Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital Campus, Commercial Road, Melbourne, Australia.
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Tavares-Murta BM, Cordeiro AO, Murta EFC, Cunha FDQ, Bisinotto FMB. Effect of myocardial protection and perfusion temperature on production of cytokines and nitric oxide during cardiopulmonary bypass. Acta Cir Bras 2008; 22:243-50. [PMID: 17625660 DOI: 10.1590/s0102-86502007000400003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Accepted: 06/15/2007] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To investigate the effects of different conditions used during cardiopulmonary bypass (CPB) surgery on accompanying production of cytokine and nitric oxide (NO). METHODS Patients undergoing CPB for the first time were prospectively enrolled and divided into two groups according to CPB parameters performed: i) normothermia (36.5-37 degrees C) with blood cardioplegia (NB group, n=10) and ii) hypothermia (29-31 degrees C) with crystalloid cardioplegia (HC group, n=10). Plasma samples obtained following intubation (baseline), during (5 and 30 min) and after (4 and 24 h) CPB were assayed for cytokines (ELISA) and NO metabolites (Griess reaction). RESULTS Peak concentrations of interleukin (IL)-6 and IL-8 were reached at 4 h post CPB in both groups, but in the HC group those levels increased earlier and persisted for longer (24 h) compared to baseline (P < 0.05). IL-10 levels also increased at 4 h compared to baseline, but only significantly so in the HC group. NO metabolites were reduced in HC group at all time points compared to baseline (P < 0.05), while no significant differences were detected in the NB group. CONCLUSION The association between increased systemic levels of cytokines and reduced NO production in the HC group suggests that different myocardial protection and/or perfusion temperature used during CPB may contribute to the extent of inflammatory response.
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Abstract
Targeted IL-10 therapy improves survival in preclinical models of critical illness, and intestine-specific IL-10 decreases inflammation in models of chronic Inflammatory disease. We therefore sought to determine whether intestine-specific overexpression of IL-10 would improve survival in sepsis. Transgenic mice that overexpress IL-10 in their gut epithelium (Fabpi-IL-10 mice) and wild-type (WT) littermates (n = 127) were subjected to cecal ligation and puncture with a 27-gauge needle. The 7-day survival rate was 45% in transgenic animals and 30% in WT animals (P < or = 0.05). Systemic levels of IL-10 were undetectable in both groups of animals under basal conditions and were elevated to a similar degree in septic animals regardless of whether they expressed the transgene. Local parameter of injury, including gut epithelial apoptosis, intestinal permeability, peritoneal lavage cytokines, and stimulated cytokines from intraepithelial lymphocytes, were similar between transgenic and WT mice. However, in stimulated splenocytes, proinflammatory cytokines monocyte chemoattractant protein 1 (189 +/- 43 vs. 40 +/- 8 pg/mL) and IL-6 (116 +/- 28 vs. 34 +/- 9 pg/mL) were lower in Fabpi-IL-10 mice than WT littermates despite the intestine-specific nature of the transgene (P < 0.05). Cytokine levels were similar in blood and bronchoalveolar lavage fluid between the 2 groups, as were circulating LPS levels. Transgenic mice also had lower white blood cell counts associated with lower absolute neutrophil counts (0.5 +/- 0.1 vs. 1.0 +/- 0.2 10(3)/mm3; P < 0.05). These results indicate that gut-specific overexpression of IL-10 improves survival in a murine model of sepsis, and interactions between the intestinal epithelium and the systemic immune system may play a role in conferring this survival advantage.
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KENNEDY SEANE, ERLICH JONATHANH. Murine renal ischaemia-reperfusion injury (Methods in Renal Research Paper). Nephrology (Carlton) 2008; 13:390-6. [DOI: 10.1111/j.1440-1797.2008.00979.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Ahmed A, Aboshady I, Munir SM, Gondi S, Brewer A, Gertz SD, Lai D, Shaik NA, Shankar K, Deswal A, Casscells SW. Decreasing Body Temperature Predicts Early Rehospitalization in Congestive Heart Failure. J Card Fail 2008; 14:489-96. [DOI: 10.1016/j.cardfail.2008.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Revised: 02/07/2008] [Accepted: 02/12/2008] [Indexed: 10/22/2022]
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Backster A, Teo A, Swift M, Polk HC, Harken AH. Transforming the surgical "time-out" into a comprehensive "preparatory pause". J Card Surg 2007; 22:410-6. [PMID: 17803578 DOI: 10.1111/j.1540-8191.2007.00435.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We propose expansion of the standard "time-out" into a comprehensive "preparatory pause" encompassing five well-documented perioperative risk avoidance strategies: beta-adrenergic blockade, DVT prophylaxis, preoperative antibiotics, normothermia, and euglycemia. Although all members of the surgical team acknowledge the clear benefit of these five prophylactic strategies, published national compliance even in the target patient population is a disappointingly consistent 50%. We have developed and field-tested a "preparatory pause" form that we appended to our "surgical time-out." By politely challenging our surgical team as to the inclusion of these five risk avoidance strategies in 167 consecutive patients, we increased our compliance to more than 90% for each preventive measure. We have not attempted to quantify the physical and psychological benefit of complication avoidance due to the enhanced activation of these five prophylactic strategies. Using published surgical complication prevalence data, with and without these accepted risk avoidance measures, we estimate the number of complications per 100 patients avoided. Utilizing the Medicare payment schedule for each complication, we approximate the purely financial benefit of the "preparatory pause" to be $88,640 per 100 patients, or almost $900 per patient. The now standard surgical "time-out" is designed to avoid the gratifyingly uncommon problem of "wrong patient,""wrong procedure," and "wrong site." Many surgeons negotiate an entire career without stumbling over these disastrous problems. We propose expansion of the "time-out" to include five well-documented perioperative risk avoidance strategies that many of us overlook all too often.
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Affiliation(s)
- Anika Backster
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California, USA
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Osuchowski MF, Welch K, Yang H, Siddiqui J, Remick DG. Chronic sepsis mortality characterized by an individualized inflammatory response. THE JOURNAL OF IMMUNOLOGY 2007; 179:623-30. [PMID: 17579084 PMCID: PMC4429887 DOI: 10.4049/jimmunol.179.1.623] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Late mortality in septic patients often exceeds the lethality occurring in acute sepsis, yet the immunoinflammatory alterations preceding chronic sepsis mortality are not well defined. We studied plasma cytokine concentrations preceding late septic deaths (days 6-28) in a murine model of sepsis induced by polymicrobial peritonitis. The late prelethal inflammatory response varied from a virtually nonexistent response in three of 14 to a mixed response in eight of 14 mice to the concurrent presence of nearly all measured cytokines, both proinflammatory and anti-inflammatory in three of 14 mice. In responding mice a consistent prelethal surge of plasma MIP-2 (1.6 vs 0.12 ng/ml in survivors; mean values), MCP-1 (2.0 vs 1.3 ng/ml), soluble TNF receptor type I (2.5 vs 0.66 ng/ml), and the IL-1 receptor antagonist (74.5 vs 3.3 ng/ml) was present, although there were infrequent increases in IL-6 (1.9 vs 0.03 ng/ml) and IL-10 (0.12 vs 0.04 ng/ml). For high mobility group box 1, late mortality was signaled by its decrease in plasma levels (591 vs 864 ng/ml). These results demonstrate that impeding mortality in the chronic phase of sepsis may be accurately predicted by plasma biomarkers, providing a mechanistic basis for individualized therapy. The pattern of late prelethal responses suggest that the systemic inflammatory response syndrome to compensatory anti-inflammatory response syndrome transition paradigm fails to follow a simple linear pattern.
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Affiliation(s)
- Marcin F. Osuchowski
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Kathy Welch
- Center for Statistical Consultation and Research, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Huan Yang
- Laboratory of Biomedical Science, Institute for Medical Research at North Shore-Long Island Jewish System, Manhasset, NY 11030
| | - Javed Siddiqui
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Daniel G. Remick
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109
- Address correspondence and reprint requests to: Dr. Daniel G. Remick at the current address: Department of Pathology and Laboratory Medicine, Boston University School of Medicine, 670 Albany Street, Room 441, Boston, MA 02118.
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Wong PF, Kumar S, Leaper DJ. Systemic Warming as an Adjunct to Resuscitation in Peritonitis: A Pilot, Randomized Controlled Trial. Surg Infect (Larchmt) 2007; 8:387-95. [PMID: 17635062 DOI: 10.1089/sur.2006.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Bacterial peritonitis is accompanied by a high risk of sepsis and endotoxin production resulting in physiological derangements and a high mortality rate. Localized and systemic warming improves tissue perfusion, oxygen tension, and outcomes after surgery. The purpose of this study was to examine the effectiveness of systemic warming as an adjunct to standard antibiotic and fluid resuscitation in patients with peritonitis. METHODS In this pilot randomized controlled trial, patients presenting with an acute abdomen were randomized into control and warmed groups using sequential envelopes. Local Ethics Committee approval was obtained. Systemic warming was delivered using the Inditherm warming mattress set at 40 degrees C. Standard oxygen, fluid resuscitation, and antibiotics were delivered simultaneously. Acute Physiology and Chronic Health Evaluation (APACHE) II scores were recorded on admission and 24 h later or just prior to surgery, whichever was earlier. RESULTS Thirty-three patients were recruited. The APACHE II scores on admission were comparable (median 9.0 [range 2-23] and 9.0 [0-20], respectively, for the control and warmed groups (p = 0.70; Mann-Whitney U test)). No patient showed any adverse effects of warming. There were statistically significant improvements in APACHE II scores (p = 0.028; Wilcoxon signed ranks test) and the magnitude of its change (p = 0.048; Mann-Whitney U test) in the warmed group compared with the control group. CONCLUSIONS Systemic warming may reduce physiological derangements and improve the prognosis in patients with intra-abdominal crisis. The technique may be used safely as an adjunct to standard resuscitation in peritonitis.
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Affiliation(s)
- Peng Foo Wong
- Department of Surgery, James Cook University Hospital, Middlesbrough, Cleveland, United Kingdom.
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Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC. Expanded Surgical Time Out: A Key to Real-Time Data Collection and Quality Improvement. J Am Coll Surg 2007; 204:527-32. [PMID: 17382210 DOI: 10.1016/j.jamcollsurg.2007.01.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 01/03/2007] [Indexed: 11/25/2022]
Abstract
UNLABELLED Some of the concepts contained here have been discussed and incorporated in another publication, but the data are entirely unique to this manuscript. (See: Transforming the Surgical "Time-Out" Into a Comprehensive "Preparatory Pause." Backster A, Teo A, Swift M, MD, Polk HC Jr, MD, FACS, Harken AH, MD, FACS. J Cardiac Surg, in press.) BACKGROUND The increasing push for quality improvement coincides with the slowly growing use of surgical time out (STO) to lessen the likelihood of wrong-site operation. We believe that the use of STO as a reflective pause or a preoperative briefing has broader value. The purpose of this article is to describe one institution's experience with this technique and to validate its potential use by others. STUDY DESIGN An enhanced use of STO was conducted in a 400-bed teaching hospital in calendar year 2006. Before and after conducts and constructs were rated. RESULTS The institution found the technique to be of value, and substantially clarified and improved its performances with respect to prophylactic antibiotic choice and timing; appropriate maintenance of intraoperative temperature and glycemia; and institution of secondary issues, such as maintenance of beta-blockade and appropriate venous thromboembolism prophylaxis. Surgeon leadership and real-time data collection became essential and helpful components. CONCLUSIONS Prompt feedback to surgeons is vital; identification of future targets for performance improvement is feasible, although useless measures are eliminated. Because surgeons grapple with pay-for-performance, STO is a useful safety, data, and quality improvement tool.
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Affiliation(s)
- Terry Altpeter
- University of Louisville Hospital, Department of Surgery, University of Louisville School of Medicine and Quality, Louisville, KY 40292, USA
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Lindenblatt N, Menger MD, Klar E, Vollmar B. Systemic hypothermia increases PAI-1 expression and accelerates microvascular thrombus formation in endotoxemic mice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:R148. [PMID: 17062126 PMCID: PMC1751084 DOI: 10.1186/cc5074] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Revised: 08/15/2006] [Accepted: 10/24/2006] [Indexed: 11/19/2022]
Abstract
Introduction Hypothermia during sepsis significantly impairs patient outcome in clinical practice. Severe sepsis is closely linked to activation of the coagulation system, resulting in microthrombosis and subsequent organ failure. Herein, we studied whether systemic hypothermia accelerates microvascular thrombus formation during lipopolysacharide (LPS)-induced endotoxemia in vivo, and characterized the low temperature-induced endothelial and platelet dysfunctions. Methods Ferric-chloride induced microvascular thrombus formation was analyzed in cremaster muscles of hypothermic endotoxemic mice. Flow cytometry, ELISA and immunohistochemistry were used to evaluate the effect of hypothermia on endothelial and platelet function. Results Control animals at 37°C revealed complete occlusion of arterioles and venules after 759 ± 115 s and 744 ± 112 s, respectively. Endotoxemia significantly (p < 0.05) accelerated arteriolar and venular occlusion in 37°C animals (255 ± 35 s and 238 ± 58 s, respectively). This was associated with an increase of circulating endothelial activation markers, agonist-induced platelet reactivity, and endothelial P-selectin and plasminogen activator inhibitor (PAI)-1 expression. Systemic hypothermia of 34°C revealed a slight but not significant reduction of arteriolar (224 ± 35 s) and venular (183 ± 35 s) occlusion times. Cooling of the endotoxemic animals to 31°C core body temperature, however, resulted in a further acceleration of microvascular thrombus formation, in particular in arterioles (127 ± 29 s, p < 0.05 versus 37°C endotoxemic animals). Of interest, hypothermia did not affect endothelial receptor expression and platelet reactivity, but increased endothelial PAI-1 expression and, in particular, soluble PAI-1 antigen (sPAI-Ag) plasma levels. Conclusion LPS-induced endotoxemia accelerates microvascular thrombus formation in vivo, most probably by generalized endothelial activation and increased platelet reactivity. Systemic hypothermia further enhances microthrombosis in endotoxemia. This effect is associated with increased endothelial PAI-1 expression and sPAI-Ag in the systemic circulation rather than further endothelial activation or modulation of platelet reactivity.
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Affiliation(s)
- Nicole Lindenblatt
- Department of Experimental Surgery, University of Rostock, Schillingallee, Rostock 18055, Germany
- Department of General Surgery, University of Rostock, Schillingallee, Rostock, 18055, Germany
| | - Michael D Menger
- Institute for Clinical and Experimental Surgery, University of Saarland, Kirrberger Straße, Homburg-Saar, 66424, Germany
| | - Ernst Klar
- Department of General Surgery, University of Rostock, Schillingallee, Rostock, 18055, Germany
| | - Brigitte Vollmar
- Department of Experimental Surgery, University of Rostock, Schillingallee, Rostock 18055, Germany
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Abstract
A recent hypothesis postulates that sepsis moves through different phases, with periods of enhanced inflammation alternating with periods of immune suppression. In this study we determined the levels of inflammation present during early and late septic deaths to examine whether death was due to hyperinflammation or immunosuppression. The murine model of sepsis induced by cecal ligation and puncture (CLP) was used. Complete blood counts, plasma interleukin-6 (IL-6) levels, and body weights were determined. Mice that died within the first 4 days had increased plasma levels of IL-6, indicating that there was activation of the immune system. Cecal resection on day 4 after CLP resulted in decreased abscess size, lower circulating neutrophil counts, decreased anemia, and improved survival compared to the results for mice that received only antibiotic and fluid therapy. All of the mice that died in the chronic phase of infection (after day 4) had positive peritoneal cultures containing significantly more bacteria than the cultures for surviving mice. After day 4, none of the surviving mice exhibited increases in the plasma levels of IL-6. Dying mice exhibited mixed IL-6 responses; for 41% of the mice there was never an increase in the IL-6 levels in the chronic phase, while for other mice the levels of IL-6 transiently increased prior to death. Peritoneal macrophages were obtained in the late phase of sepsis from moribund and healthy mice and were stimulated ex vivo. The cells from the moribund mice produced significantly less IL-6 than the cells obtained from healthy mice produced. These results indicate that in mice that die in the early phase there is uniformly increased inflammation. However, during the chronic phase of sepsis, some mice die with evidence of immunosuppression (increased bacterial growth and low IL-6 levels), while other mice die with immunostimulation (high IL-6 levels and bacterial growth). Determining the inflammatory status of individual patients may help guide appropriate, targeted therapy.
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Affiliation(s)
- Hongyan Xiao
- Department of Pathology, University of Michigan, 2210 Medical Science I Building, 1301 Catherine Road, Ann Arbor, MI 48109-0602, USA
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Osuchowski MF, Welch K, Siddiqui J, Remick DG. Circulating cytokine/inhibitor profiles reshape the understanding of the SIRS/CARS continuum in sepsis and predict mortality. THE JOURNAL OF IMMUNOLOGY 2006; 177:1967-74. [PMID: 16849510 DOI: 10.4049/jimmunol.177.3.1967] [Citation(s) in RCA: 377] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Mortality in sepsis remains unacceptably high and attempts to modulate the inflammatory response failed to improve survival. Previous reports postulated that the sepsis-triggered immunological cascade is multimodal: initial systemic inflammatory response syndrome (SIRS; excessive pro-, but no/low anti-inflammatory plasma mediators), intermediate homeostasis with a mixed anti-inflammatory response syndrome (MARS; both pro- and anti-inflammatory mediators) and final compensatory anti-inflammatory response syndrome (CARS; excessive anti-, but no/low proinflammatory mediators). To verify this, we examined the evolution of the inflammatory response during the early phase of murine sepsis by repetitive blood sampling of septic animals. Increased plasma concentrations of proinflammatory (IL-6, TNF, IL-1beta, KC, MIP-2, MCP-1, and eotaxin) and anti-inflammatory (TNF soluble receptors, IL-10, IL-1 receptor antagonist) cytokines were observed in early deaths (days 1-5). These elevations occurred simultaneously for both the pro- and anti-inflammatory mediators. Plasma levels of IL-6 (26 ng/ml), TNF-alpha (12 ng/ml), KC (33 ng/ml), MIP-2 (14 ng/ml), IL-1 receptor antagonist (65 ng/ml), TNF soluble receptor I (3 ng/ml), and TNF soluble receptor II (14 ng/ml) accurately predicted mortality within 24 h. In contrast, these parameters were not elevated in either the late-deaths (day 6-28) or survivors. Surprisingly, either pro- or anti-inflammatory cytokines were also reliable in predicting mortality up to 48 h before outcome. These data demonstrate that the initial inflammatory response directly correlates to early but not late sepsis mortality. This multifaceted response questions the use of a simple proinflammatory cytokine measurement for classifying the inflammatory status during sepsis.
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Affiliation(s)
- Marcin F Osuchowski
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Shafi S, Elliott AC, Gentilello L. Is Hypothermia Simply a Marker of Shock and Injury Severity or an Independent Risk Factor for Mortality in Trauma Patients? Analysis of a Large National Trauma Registry. ACTA ACUST UNITED AC 2005; 59:1081-5. [PMID: 16385283 DOI: 10.1097/01.ta.0000188647.03665.fd] [Citation(s) in RCA: 126] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Successful application of induced hypothermia (HT) after stroke and cardiac arrest has led to a resurgence of interest in its potential protective effects in trauma patients. Although clinical studies demonstrate an adverse effect, they consist of small studies from single institutions. We tested the hypothesis that HT is associated with improved survival in trauma patients by analyzing a large, national trauma database. METHODS The study included all patients in the National Trauma Data Bank (1994-2002) aged 18 to 55 years old with temperature at presentation to the emergency department and base deficit (BD) recorded. Hypothermic (temperature, <35 degrees C; n = 3267) patients and patients with normothermia (temperature, > or =35 degrees C; n = 35,283) patients were compared. Two analyses were conducted to control for the association between HT and injury severity. First, hypothermic and normothermic (NT) patients were stratified by injury severity score (ISS) and shock (blood pressure < or = 90 mm Hg). Next, logistic regression was used to control for effects of age, sex, mechanism, ISS, head, chest, and abdominal injuries, BP, Glasgow Coma Scale score, and BD, with survival as the dependent and HT as the predictor variable. RESULTS Although HT was more common in more seriously injured patients, stratified analysis revealed that hypothermic patients have significantly higher mortality than patients with the same severity of injury who remain NT. Even after controlling for injury severity and the other potential confounders listed above, HT remained a strong, independent predictor of mortality (odds ratio, 1.19; 95% confidence interval, 1.05-1.35). CONCLUSION There is no apparent protective effect of HT in trauma patients. HT itself, not just its association with shock, injury severity, and other cofactors lead to a significant increase in mortality in injured patients. Continued, aggressive efforts to prevent and treat HT are warranted.
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Affiliation(s)
- Shahid Shafi
- Department of Surgery, Division of Burn, Trauma and Surgical Critical Care, University of Texas Southwestern Medical School, Dallas, Texas 75390-9158, USA.
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Chatterjee S, Premachandran S, Sharma D, Bagewadikar RS, Poduval TB. THERAPEUTIC TREATMENT WITH L-ARGININE RESCUES MICE FROM HEAT STROKE-INDUCED DEATH: PHYSIOLOGICAL AND MOLECULAR MECHANISMS. Shock 2005; 24:341-7. [PMID: 16205319 DOI: 10.1097/01.shk.0000180983.55623.2b] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Heat stroke-induced death is a major killer worldwide. Mice were subjected to acute heat stress by exposing them to whole-body hyperthermia (WBH) treatment and were used as a model to study heat stroke. Administration of L-arginine (L-arg, 120 mg/kg, i.p) 2 h after the cessation of WBH rescued the mice from heat-induced death and reduced the hypothermia. Heat shock protein 70 levels in the liver were increased significantly in heat-stressed mice administered L-arg compared with the heat-stressed group. WBH induced apoptosis, as indicated by DNA fragmentation, and increased levels of p53 and caspase-3 activity, which were significantly reduced by the administration of L-arg. The levels of inducible nitric oxide synthase in the liver, nitrite, and inflammatory cytokines like interleukin 1beta and tumor necrosis factor-alpha in the serum increased in WBH-treated mice. The levels of the above markers of heat stress significantly decreased in L-arg-treated mice. Kinin-B1 receptor (kinin-B1R) in cardiac tissue that is upregulated in heat stressed mice was significantly lower in L-arg-administered mice. These data suggest the potential use of L-arg, a nonessential amino acid that is used as an enteral diet supplement, to treat heat stroke-related injury when administered at the appropriate dose and time.
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Affiliation(s)
- Saurabh Chatterjee
- Immunology and Hyperthermia Section, Radiation Biology and Health Sciences Division, Bhabha Atomic Research Centre, Trombay, Mumbai-400 085, India
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Haas NP, Schaser KD. Soft tissue trauma: linking systemic hypothermia to sustained microvascular dysfunction. Crit Care Med 2005; 33:1879-81. [PMID: 16096479 DOI: 10.1097/01.ccm.0000174481.02429.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vyas D, Javadi P, DiPasco PJ, Buchman TG, Hotchkiss RS, Coopersmith CM. Early antibiotic administration but not antibody therapy directed against IL-6 improves survival in septic mice predicted to die on basis of high IL-6 levels. Am J Physiol Regul Integr Comp Physiol 2005; 289:R1048-53. [PMID: 15947070 PMCID: PMC1237117 DOI: 10.1152/ajpregu.00312.2005] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Elevated interleukin (IL)-6 levels correlate with increased mortality following sepsis. IL-6 levels >14,000 pg/ml drawn 6 h after cecal ligation and puncture (CLP) are associated with 100% mortality in ND4 mice, even if antibiotic therapy is initiated 12 h after septic insult. Our first aim was to see whether earlier institution of antibiotic therapy could improve overall survival in septic mice and rescue the subset of animals predicted to die on the basis of high IL-6 levels. Mice (n = 184) were subjected to CLP, had IL-6 levels drawn 6 h later, and then were randomized to receive imipenem, a broad spectrum antimicrobial agent, beginning 6 or 12 h postoperatively. Overall 1-wk survival improved from 25.5 to 35.9% with earlier administration of antibiotics (P < 0.05). In mice with IL-6 levels >14,000 pg/ml, 25% survived if imipenem was started at 6 h, whereas none survived if antibiotics were started later (P < 0.05). On the basis of these results, we examined whether targeted antibody therapy could improve survival in mice with elevated IL-6 levels. A different cohort of mice (n = 54) had blood drawn 6 h after CLP, and then they were randomized to receive either monoclonal anti-IL-6 IgG or irrelevant rat IgG. Anti-IL-6 antibody failed to improve either overall survival or outcome in mice with IL-6 levels >14,000 pg/ml. These results demonstrate that earlier systemic therapy can improve outcome in a subset of mice predicted to die in sepsis, but we are unable to demonstrate any benefit in similar animals using targeted therapy directed at IL-6.
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Affiliation(s)
| | | | | | - Timothy G Buchman
- Departments of Surgery
- Anesthesiology, and
- Medicine Washington University School of Medicine, 660 S. Euclid Ave. St. Louis, MO
| | - Richard S Hotchkiss
- Departments of Surgery
- Anesthesiology, and
- Medicine Washington University School of Medicine, 660 S. Euclid Ave. St. Louis, MO
| | - Craig M Coopersmith
- Departments of Surgery
- Anesthesiology, and
- Address correspondence to: Craig M. Coopersmith, MD, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, St. Louis, Missouri 63110, Phone: (314) 362-9342, Fax: (314) 362-1602, E-mail:
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