Metabolic modulators following trauma sepsis: Sex hormones

[Sex differences in hepatobiliary and transplantation surgery]

Gender-specific differences in hepatobiliary and transplantation surgery are decisive for the diagnosis, treatment and long-term outcomes. Men exhibit a higher risk of late recurrences and cancer-specific death after liver cancer resection. The emphasis on screening recommendations and ensuring equal access to treatment options are vital to minimize disparities. In kidney and liver transplantations, women are less frequently listed and endure longer waiting times, while men dominate the waiting list. Gender-specific disparities in drug compatibility necessitate differentiated dosing. Further studies are needed to ensure equity in transplantation treatment. Individualized treatment considering these differences can enhance treatment outcomes and the quality of life of patients.

Sex differences and estrogen effects in cardiac mitochondria in human aortic stenosis and in the mouse heart

Introduction

Sex differences in the adaptation to pressure overload have been described in humans, as well as animal models, and have been related to sex-specific expression of mitochondrial genes. We therefore tested whether sex differences in cardiac mitochondrial respiration exist in humans with aortic stenosis (AS). We also examined whether these potential differences may be at least partially due to sex hormones by testing if mitochondrial respiration is affected by estrogen (17ß-estradiol (E2)).

Methods

Consecutive patients undergoing transapical aortic valve implantation (TAVI) (women, n = 7; men, n = 10) were included. Cardiac biopsies were obtained during TAVI and used directly for mitochondrial function measurements. Male and female C57BL/6J mice (n = 8/group) underwent sham surgery or gonadectomy (GDX) at the age of 2 months. After 14 days, mice were treated once with intraperitoneally injected vehicle (placebo), 17ß-estradiol (E2), estrogen receptor alpha (ERα) agonist [propyl pyrazole triol (PPT)], or ER beta (ERβ) agonist (BAY-1214257). Thereafter, mitochondrial measurements were performed directly in cardiac skinned fibers from isolated left ventricles and musculus solei.

Results

Mitochondrial State-3 respiration was higher in female than that in male human heart biopsies (15.0 ± 2.30 vs. 10.3 ± 2.05 nmol/mL/min/mg, p< 0.05). In the mouse model, mitochondrial State-3 respiration decreased significantly after GDX in female (27.6 ± 1.55 vs. 21.4 ± 1.71 nmol/mL/min/mg; p< 0.05) and male hearts (30.7 ± 1,48 vs. 23.7 ± 2,23 nmol/mL/min/mg; p< 0.05). In ovariectomized female mice, E2 and ERβ-agonist treatment restored the State-3 respiration to intact placebo level, whereas ERα-agonist treatment did not modulate State-3 respiration. The treatment with E2, ERα-, or ERβ-agonist did not modulate the State-3 respiration in GDX male mice.

Conclusion

We identified sex differences in mitochondrial respiration in the diseased human heart. This is in alignment with known sex differences in the gene expression and proteome level at the functional level. E2 and ERβ affect cardiac mitochondrial function in the mouse model, suggesting that they may also contribute to the sex differences in the human heart. Their roles should be further investigated.

The Determination of Mitochondrial Mass Is a Prerequisite for Accurate Assessment of Peripheral Blood Mononuclear Cells' Oxidative Metabolism

Mitochondria are responsible for ATP synthesis through oxidative phosphorylation in cells. However, there are limited data on the influence of mitochondrial mass (MM) in the adequate assessment of cellular stress assay (CSA) results in human peripheral blood mononuclear cells (PBMCs). Therefore, the aim of this study was to determine MM in PBMCS and assess its influence on the results of CSA measurements. Blood samples were collected and sent to the laboratory for MM and CSA measurements during different seasons of the year. The mitochondrial mass was determined based on the mtDNA:nDNA ratio in PBMCs using quantitative real-time PCR (qRT-PCR). CSA was measured using Seahorse technology. The MM was significantly lower during summer and autumn compared to winter and spring (p < 0.0001). On the contrary, we found that the maximal respiration per mitochondrion (MP) was significantly higher in summer and autumn compared to winter and spring (p < 0.0001). The estimated effect of MM on mitochondrial performance was -0.002 pmol/min/mitochondrion (p < 0.0001) and a correlation coefficient (r) of -0.612. Similarly, MM was negatively correlated with maximal respiration (r = -0.12) and spare capacity (in % r = -0.05, in pmol/min r = -0.11). In conclusion, this study reveals that MM changes significantly with seasons and is negatively correlated with CSA parameters and MP. Our findings indicate that the mitochondrial mass is a key parameter for determination of mitochondrial fitness. Therefore, we recommend the determination of MM during the measurement of CSA parameters for the correct interpretation and assessment of mitochondrial function.

The Regulation of Neutrophil Migration in Patients with Sepsis: The Complexity of the Molecular Mechanisms and Their Modulation in Sepsis and the Heterogeneity of Sepsis Patients

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Common causes include gram-negative and gram-positive bacteria as well as fungi. Neutrophils are among the first cells to arrive at an infection site where they function as important effector cells of the innate immune system and as regulators of the host immune response. The regulation of neutrophil migration is therefore important both for the infection-directed host response and for the development of organ dysfunctions in sepsis. Downregulation of CXCR4/CXCL12 stimulates neutrophil migration from the bone marrow. This is followed by transmigration/extravasation across the endothelial cell barrier at the infection site; this process is directed by adhesion molecules and various chemotactic gradients created by chemotactic cytokines, lipid mediators, bacterial peptides, and peptides from damaged cells. These mechanisms of neutrophil migration are modulated by sepsis, leading to reduced neutrophil migration and even reversed migration that contributes to distant organ failure. The sepsis-induced modulation seems to differ between neutrophil subsets. Furthermore, sepsis patients should be regarded as heterogeneous because neutrophil migration will possibly be further modulated by the infecting microorganisms, antimicrobial treatment, patient age/frailty/sex, other diseases (e.g., hematological malignancies and stem cell transplantation), and the metabolic status. The present review describes molecular mechanisms involved in the regulation of neutrophil migration; how these mechanisms are altered during sepsis; and how bacteria/fungi, antimicrobial treatment, and aging/frailty/comorbidity influence the regulation of neutrophil migration.

Sex as Biological Variable in Cardiac Mitochondrial Bioenergetic Responses to Acute Stress

Cardiac dysfunction/damage following trauma, shock, sepsis, and ischemia impacts clinical outcomes. Acute inflammation and oxidative stress triggered by these injuries impair mitochondria, which are critical to maintaining cardiac function. Despite sex dimorphisms in consequences of these injuries, it is unclear whether mitochondrial bioenergetic responses to inflammation/oxidative stress are sex-dependent. We hypothesized that sex disparity in mitochondrial bioenergetics following TNFα or H2O2 exposure is responsible for reported sex differences in cardiac damage/dysfunction. Methods and Results: Cardiomyocytes isolated from age-matched adult male and female mice were subjected to 1 h TNFα or H2O2 challenge, followed by detection of mitochondrial respiration capacity using the Seahorse XF96 Cell Mito Stress Test. Mitochondrial membrane potential (ΔΨm) was analyzed using JC-1 in TNFα-challenged cardiomyocytes. We found that cardiomyocytes isolated from female mice displayed a better mitochondrial bioenergetic response to TNFα or H2O2 than those isolated from male mice did. TNFα decreased ΔΨm in cardiomyocytes isolated from males but not from females. 17β-estradiol (E2) treatment improved mitochondrial metabolic function in cardiomyocytes from male mice subjected to TNFα or H2O2 treatment. Conclusions: Cardiomyocyte mitochondria from female mice were more resistant to acute stress than those from males. The female sex hormone E2 treatment protected cardiac mitochondria against acute inflammatory and oxidative stress.

A prospective, phase II, single-centre, cross-sectional, randomised study investigating Dehydroepiandrosterone supplementation and its Profile in Trauma: ADaPT

INTRODUCTION

The improvements in short-term outcome after severe trauma achieved through early resuscitation and acute care can be offset over the following weeks by an acute systemic inflammatory response with immuneparesis leading to infection, multiorgan dysfunction/multiorgan failure (MOF) and death. Serum levels of the androgen precursor dehydroepiandrosterone (DHEA) and its sulfate ester DHEAS, steroids with immune-enhancing activity, are low after traumatic injury at a time when patients are catabolic and immunosuppressed. Addressing this deficit and restoring the DHEA(S) ratio to cortisol may provide a range of physiological benefits, including immune modulatory effects.

OBJECTIVE

Our primary objective is to establish a dose suitable for DHEA supplementation in patients after acute trauma to raise circulating DHEA levels to at least 15 nmol/L. Secondary objectives are to assess if DHEA supplementation has any effect on neutrophil function, metabolic and cytokine profiles and which route of administration (oral vs sublingual) is more effective in restoring circulating levels of DHEA, DHEAS and downstream androgens.

METHODS AND ANALYSIS

A prospective, phase II, single-centre, cross-sectional, randomised study investigating Dehydroepiandrosterone supplementation and its profile in trauma, with a planned recruitment between April 2019 and July 2021, that will investigate DHEA supplementation and its effect on serum DHEA, DHEAS and downstream androgens in trauma. A maximum of 270 patients will receive sublingual or oral DHEA at 50, 100 or 200 mg daily over 3 days. Females aged ≥50 years with neck of femur fracture and male and female major trauma patients, aged 16-50 years with an injury severity score ≥16, will be recruited.

ETHICS AND DISSEMINATION

This protocol was approved by the West Midlands - Coventry and Warwickshire Research Ethics Committee (Reference 18/WM/0102) on 8 June 2018. Results will be disseminated via peer-reviewed publications and presented at national and international conferences.

TRIAL REGISTRATION

This trial is registered with the European Medicines Agency (EudraCT: 2016-004250-15) and ISRCTN (12961998). It has also been adopted on the National Institute of Health Research portfolio (CPMS ID:38158).

TRIAL PROGRESSION

The study recruited its first patient on 2 April 2019 and held its first data monitoring committee on 8 November 2019. DHEA dosing has increased to 100 mg in both male cohorts and remains on 50 mg in across all female groups.

NMR-based serum and urine metabolomic profile reveals suppression of mitochondrial pathways in experimental sepsis-associated acute kidney injury

Sepsis-associated acute kidney injury (SA-AKI) is a significant problem in the critically ill that causes increased death. Emerging understanding of this disease implicates metabolic dysfunction in its pathophysiology. This study sought to identify specific metabolic pathways amenable to potential therapeutic intervention. Using a murine model of sepsis, blood and tissue samples were collected for assessment of systemic inflammation, kidney function, and renal injury. Nuclear magnetic resonance (NMR)-based metabolomics quantified dozens of metabolites in serum and urine that were subsequently submitted to pathway analysis. Kidney tissue gene expression analysis confirmed the implicated pathways. Septic mice had elevated circulating levels of inflammatory cytokines and increased levels of blood urea nitrogen and creatinine, indicating both systemic inflammation and poor kidney function. Renal tissue showed only mild histological evidence of injury in sepsis. NMR metabolomic analysis identified the involvement of mitochondrial pathways associated with branched-chain amino acid metabolism, fatty acid oxidation, and de novo NAD⁺ biosynthesis in SA-AKI. Renal cortical gene expression of enzymes associated with those pathways was predominantly suppressed. Renal cortical fatty acid oxidation rates were lower in septic mice with high inflammation, and this correlated with higher serum creatinine levels. Similar to humans, septic mice demonstrated renal dysfunction without significant tissue disruption, pointing to metabolic derangement as an important contributor to SA-AKI pathophysiology. Metabolism of branched-chain amino acid and fatty acids and NAD⁺ synthesis, which all center on mitochondrial function, appeared to be suppressed. Developing interventions to activate these pathways may provide new therapeutic opportunities for SA-AKI.NEW & NOTEWORTHY NMR-based metabolomics revealed disruptions in branched-chain amino acid metabolism, fatty acid oxidation, and NAD⁺ synthesis in sepsis-associated acute kidney injury. These pathways represent essential processes for energy provision in renal tubular epithelial cells and may represent targetable mechanisms for therapeutic intervention.

High Expression Level of PPARγ in CD24 Knockout Mice and Gender-Specific Metabolic Changes: A Model of Insulin-Sensitive Obesity

Background: The heat-stable HSA/CD24 gene encodes a protein that shows high expression levels in adipocyte precursor cells but low levels in terminally differentiated adipocytes. Its high expression in many types of human cancer suggests an association between cancer, diabetes, and obesity, which is currently unclear. In addition, peroxisome proliferator-activated receptor gamma (PPARγ) is a regulator of adipogenesis that plays a role in insulin sensitivity, lipid metabolism, and adipokine expression in adipocytes. Aim: To assess gender-dependent changes in CD24 KO and its association with PPARγ expression. Experimental approach: WT and CD24 KO mice were monitored from birth up to 12 months, and various physiological and molecular characteristics were analysed. Mean body weight and adipose mass were higher in KO mice than in WT mice. Male, but not female, KO mice showed increased insulin sensitivity, glucose uptake, adipocyte size, and PPARγ expression than WT mice. In addition, enteric bacterial populations, assessed through high-throughput sequencing of stool 16S rRNA genes, were significantly different between male KO and WT mice. Conclusions: CD24 may negatively regulate PPARγ expression in male mice. Furthermore, the association between the CD24 and insulin sensitivity suggests a possible mechanism for diabetes as a cancer risk factor. Finally, CD24 KO male mice may serve as a model of obesity and insulin hyper-sensitivity.

Sex differences in disease presentation, surgical and oncological outcome of liver resection for primary and metastatic liver tumors-A retrospective multicenter study

Background

Sex differences are becoming of rising interest in many fields of medicine. It remains unknown whether sex has a role in postoperative and long-term outcome after hepatic resection (HR). The aim of this study was to investigate sex differences in disease presentation, surgical and oncological outcome after curative HR.

Methods

Retrospective analysis of 1010 patients who underwent HR between 2005 and 2018 at two tertiary hospitals in Austria. Demographics and survival data were obtained from a prospectively maintained database. Univariate analysis was used to identify sex differences for the entire cohort and for sub-cohorts. Disease-free- and overall survival was assessed by the Kaplan-Meier estimate and results were compared by log-rank tests.

Results

436 females and 574 males were analyzed. Women were younger (p<0.001), had less liver cirrhosis (p<0.001), cardiac comorbidities (p<0.001), diabetes (28 (p<0.001) and obesity (p<0.001). Type of HR and surgical management did not vary by sex. Ninety-day morbidity (p = 0.179) and -mortality (p = 0.888) were comparable. In patients with malignant disease, no differences in disease-free- and overall survival was observed, neither for the entire cohort nor for the subgroups according to tumor entity or type of resection. Only in HCC patients, females showed an inferior OS (p = 0.029).

Conclusion

This study delivers new insights on the impact of sex differences in liver surgery. Despite the fact that male patients have a higher incidence of preoperative morbidities, we did not observe specific disparities in terms of immediate postoperative as well as long term oncological outcome between sexes.

Can distinctly different rapid estrogen actions share a common mechanistic step?

Contribution to Special Issue on Fast effects of steroids. This paper reviews early evidence for the existence of rapid, non-genomic effects of estrogens on neurons, and, further, proposes that these rapid effects are often synergistic with later, genomic effects. Finally, suggestions about potential molecular mechanisms underlying the rapid effects of estrogens are offered. A mechanistic step we propose to be common among rapid estrogenic actions includes membrane ER's binding to histamine, and NMDA receptors and subsequent dimerization, and clustering (respectively) in a manner that enhances histamine and NMDA actions.

Estrogen/ERα signaling axis participates in osteoblast maturation via upregulating chromosomal and mitochondrial complex gene expressions

Estrogen deficiency usually leads to bone loss and osteoporosis in postmenopausal women. Osteoblasts play crucial roles in bone formation. However, osteoblast functions are influenced by mitochondrial bioenergetic conditions. In this study, we investigated the roles of the estrogen and estrogen receptor alpha (ERα) axis in mitochondrial energy metabolism and subsequent osteoblast mineralization. Exposure of rat calvarial osteoblasts to estradiol caused substantial improvements in alkaline phosphatase activities and cell calcification. In parallel, treatment of human osteoblast-like U2OS cells, derived from a female osteosarcoma patient, with estradiol specifically augmented ERα levels. Sequentially, estradiol stimulated translocation of ERα to nuclei in human osteoblasts and induced expressions of genomic respiratory chain complex NDUFA10, UQCRC1, cytochrome c oxidase (COX)8A, COX6A2, COX8C, COX6C, COX6B2, COX412, and ATP12A genes. Concurrently, estradiol stimulated translocation of ERα to mitochondria from the cytoplasm. A bioinformatic search found the existence of four estrogen response elements in the 5’-promoter region of the mitochondrial cox i gene. Interestingly, estradiol induced COX I mRNA and protein expressions in human osteoblasts or rat calvarial osteoblasts. Knocking-down ERα translation concurrently downregulated estradiol-induced COX I mRNA expression. Consequently, exposure to estradiol led to successive increases in the mitochondrial membrane potential, the mitochondrial enzyme activity, and cellular adenosine triphosphate levels. Taken together, this study showed the roles of the estradiol/ERα signaling axis in improving osteoblast maturation through upregulating the mitochondrial bioenergetic system due to induction of definite chromosomal and mitochondrial complex gene expressions. Our results provide novel insights elucidating the roles of the estrogen/ERα alliance in regulating bone formation.

Ethyl pyruvate reduces acute lung damage following trauma and hemorrhagic shock via inhibition of NF-κB and HMGB1

OBJECTIVE

After blunt thoracic trauma (TxT) and hemorrhagic shock with resuscitation (H/R) intense local inflammatory response and cell loss frequently impair the pulmonary function. Ethyl pyruvate (EP) has been reported to improve the pathophysiologic derangements in models of acute inflammation. Here, we studied the effects of EP on inflammation and lung damage after TxT+H/R.

METHODS

Twenty four female Lewis rats (180-240g) were randomly divided into 3 groups: two groups underwent TxT followed by hemorrhagic shock (35±3mmHg) for 60min and resuscitation with either Ringers-Lactat (RL) alone or RL supplemented with EP (EP, 50mg/kg). Sham operated animals underwent surgical procedures. Two hours later bronchoalveolar lavage fluid (BAL), lung tissue and blood were collected for analyses.

RESULTS

EP significantly improved pO₂ levels compared to RL after TxT+H/R. TxT+H/R induced elevated levels of lactate dehydrogenase, total protein concentration in BAL and lung damage as evidenced by lung histology; these effects were significantly reduced by EP. Local inflammatory markers, lung TNF-alpha protein levels and infiltration with polymorphonuclear leukocytes (PMNL) significantly decreased in EP vs. RL group after TxT+H/R. Indicators of apoptosis as reduced BCL-2 and increased FAS gene expression after TxT+H/R were significantly increased or decreased, respectively, by EP after TxT+H/R. EP reduced TxT+H/R-induced p65 phosphorylation, which was concomitant with reduced HMGB1 levels in lung sections.

CONCLUSIONS

Taken together, TxT+H/R induced strong inflammatory response and apoptotic changes as well as lung injury which were markedly diminished by EP. Our results suggest that this might be mediated via NF-κB and/or HMGB1 dependent mechanism.

The grapes and wrath: using resveratrol to treat the pathophysiology of hemorrhagic shock

Resveratrol, a naturally occurring polyphenol found in grapes, has been shown to reduce oxidative stress and inflammation in a variety of conditions. Recently, resveratrol has been investigated as a potential adjunct to resuscitation therapy for hemorrhagic shock-a condition characterized by tissue hypoxia, mitochondrial dysfunction, and inflammation. Although standard resuscitation restores tissue perfusion, it can exacerbate oxidative stress and organ damage. In rodent models of severe hemorrhagic shock, resveratrol mitigates reperfusion injury, preserves organ function, and improves survival. While many of these benefits can be attributed to its ability to activate sirtuin 1, resveratrol interacts with many targets that are relevant to ischemia-reperfusion. Here, we explore the probable mechanisms, potential benefits, and possible problems associated with administering resveratrol as an adjunct during resuscitation of hemorrhagic shock.

Inflammation and Outcome in Traumatic Brain Injury: Does Gender Effect on Survival and Prognosis?

INTRODUCTION

Traumatic Brain Injury (TBI) accounts for the majority of trauma deaths and there has been increased interest in the understanding the role of prognostic factors. C-Reactive Protein (CRP) level increases rapidly in response to trauma.

AIM

Aim of the present study was to indicate the role of CRP as a predictor of outcome in TBI patients based on their gender category.

MATERIALS AND METHODS

A prospective cohort study in a surgical Intensive Care Unit (ICU) in one of the Zanjan University of Medical Science hospital was designed. Fifty nine head trauma patients were divided into two groups based on their gender. Serum CRP was measured 48 hours after trauma. All data including the length of ICU stay, the duration of mechanical ventilation, the Glasgow Coma Scale (GCS) at discharge, and mortality were collected. The relationship between the clinical features and serum CRP level was also studied.

RESULTS

In the male group, CRP level was not significantly correlated with the length of ICU stay, the duration of mechanical ventilation and GCS at discharge. In the female group, CRP level was positively correlated with the length of ICU stay and the duration of mechanical ventilation; however, CRP level was not significantly correlated with GCS at discharge. These results remain constant in female sub group with severe head injury contrast to female with mild injury.

CONCLUSION

The GCS level can predict the outcome of females with severe head injury better than females with mild head injury and males.

Role of p38 MAPK pathway in 17β-estradiol-mediated attenuation of hemorrhagic shock-induced hepatic injury

Although 17β-estradiol (E2) treatment following hemorrhagic shock or ischemic reperfusion prevents organs from dysfunction and injury, the precise mechanism remains unknown. We hypothesize that the E2-mediated attenuation of liver injury following hemorrhagic shock and fluid resuscitation occurs via the p38 mitogen-activated protein kinase (MAPK)-dependent heme oxygenase (HO)-1 pathway. After a 5-cm midline laparotomy, male rats underwent hemorrhagic shock (mean blood pressure ∼40 mmHg for 90 min) followed by fluid resuscitation. At the onset of resuscitation, rats were treated with vehicle, E2 (1 mg/kg) alone, or E2 plus p38 MAPK inhibitor SB-203580 (2 mg/kg), HO-1 inhibitor chromium mesoporphyrin-IX chloride (2.5 mg/kg) or estrogen receptor antagonist ICI 182,780 (3 mg/kg). At 2 h after hemorrhagic shock and fluid resuscitation, the liver injury markers were significantly increased compared with sham-operated control. Hemorrhagic shock resulted in a significant decrease in p38 MAPK phosphorylation compared with the shams. Administration of E2 following hemorrhagic shock normalized liver p38 MAPK phosphorylation, further increased HO-1 expression, and reduced cleaved caspase-3 levels. Coadministration of SB-203580 abolished the E2-mediated attenuation of the shock-induced liver injury markers. In addition, administration of chromium mesoporphyrin-IX chloride or ICI 182,780 abolished E2-mediated increases in liver HO-1 expression or p38 MAPK activation following hemorrhagic shock. Our results collectively suggest that the salutary effects of E2 on hepatic injury following hemorrhagic shock and resuscitation are in part mediated through an estrogen-receptor-related p38 MAPK-dependent HO-1 upregulation.

Traumatic injury among females: does gender matter?

BACKGROUND

Trauma remains one of the leading causes of morbidity and mortality worldwide. Generally, the incidence of traumatic injuries is disproportionately high in males. However, trauma in females is underreported.

AIM

To study the epidemiology and outcome of different mechanisms and types of traumatic injuries in women.

METHODS

We conducted a traditional narrative review using PubMed, MEDLINE and EMBASE, searching for English-language publications for gender-specific trauma between January 1993 and January 2013 using key words "trauma", "gender", "female" and "women".

RESULTS

Among 1150 retrieved articles, 71 articles were relevant over 20 years. Although it is an important public health problem, traumatic injuries among females remain under-reported.

CONCLUSION

There is a need for further research and evaluation of the exact burden of traumatic injuries among females together with the implementation of effective community based preventive programs.

Factors associated with in-hospital outcomes in 594 consecutive patients suffering from severe blunt chest trauma

BACKGROUND AND AIMS

Blunt thoracic injury is a common cause for hospital admission after trauma. The effect of the number of rib fractures on the outcome is controversial. In this study, our hypothesis was that an increasing number of rib fractures correlates with mortality and hospital resource utilization. In addition to mortality, our focus was on the length of stay at hospital and in the intensive care unit, ventilator days, and the days in continuous positive airway pressure.

MATERIAL AND METHODS

The present investigation is a retrospective study from a single trauma center. The study includes patients with severe thoracic injury (thoracic Abbreviated Injury Scale (AIS) > 2) admitted to hospital after blunt trauma. Patients with isolated thoracic spine injuries and patients who were dead on arrival were excluded. Vital signs, laboratory results on admission, given care, intensive care unit and hospital length of stay, injuries, and in-hospital mortality were collected for the study.

RESULTS

A total of 594 patients from a 5-year period (2003-2007) were included in the study. The mean age of the patients was 45 years, and 76.9% of the patients were males. The average Injury Severity Score was 22, and the patients had on average 5.5 injuries. Overall mortality was 6.4%. In the multivariate analysis, the mortality was associated with base excess and tromboplastin time in admission. The number of rib fractures did not correlate with the outcome measures, but the presence of bilateral rib fractures correlated with the outcome measures other than mortality.

CONCLUSIONS

The number of rib fractures does not correlate with mortality or the length of stay in the intensive care unit in blunt trauma patients with severe thoracic injury. Mortality in these patients correlated with the degree of hypoperfusion (base excess) and coagulation abnormalities (tromboplastin time) on admission.

Medical errors in hospitalized pediatric trauma patients with chronic health conditions

Objective:

This study compares medical errors in pediatric trauma patients with and without chronic conditions.

Methods:

The 2009 Kids’ Inpatient Database, which included 123,303 trauma discharges, was analyzed. Medical errors were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The medical error rates per 100 discharges and per 1000 hospital days were calculated and compared between inpatients with and without chronic conditions.

Results:

Pediatric trauma patients with chronic conditions experienced a higher medical error rate compared with patients without chronic conditions: 4.04 (95% confidence interval: 3.75–4.33) versus 1.07 (95% confidence interval: 0.98–1.16) per 100 discharges. The rate of medical error differed by type of chronic condition. After controlling for confounding factors, the presence of a chronic condition increased the adjusted odds ratio of medical error by 37% if one chronic condition existed (adjusted odds ratio: 1.37, 95% confidence interval: 1.21–1.5), and 69% if more than one chronic condition existed (adjusted odds ratio: 1.69, 95% confidence interval: 1.48–1.53). In the adjusted model, length of stay had the strongest association with medical error, but the adjusted odds ratio for chronic conditions and medical error remained significantly elevated even when accounting for the length of stay, suggesting that medical complexity has a role in medical error. Higher adjusted odds ratios were seen in other subgroups.

Conclusion:

Chronic conditions are associated with significantly higher rate of medical errors in pediatric trauma patients. Future research should evaluate interventions or guidelines for reducing the risk of medical errors in pediatric trauma patients with chronic conditions.

Gender-specific differences in severely injured patients between 2002 and 2011: data analysis with matched-pair analysis

INTRODUCTION

Previous studies reported divergent results concerning the effect of gender on patient outcome after severe injury. Results suggest that women have better outcomes because they have lower rates of sepsis and multi-organ failure. The objective of this analysis was to study gender differences in a Level 1 trauma center in Germany.

METHODS

Patients who were admitted to hospital between 2002 and 2011 with an Injury Severity Score (ISS) ≥16 were included. Data were collected from the Trauma Registry of the German Society for Trauma Surgery and from hospital records. The effects of gender on a variety of parameters were investigated. To eliminate the influence of differences in ISS, an analysis of groups with similar ISS was performed. Also, a matched-pair analysis of 422 patients was performed.

RESULTS

A total of 962 patients met the inclusion criteria. The mortality rate was lower in male patients (25.4% versus 36.59%). Female patients had more severe head injuries, received less fluid volume and had a lower rate of sepsis. Men were more frequently involved in motorcycle accidents and sustained more penetrating trauma. Women were more frequently involved in pedestrian accidents and sustained more falls from under 3 m. The effects of gender were reduced when the data were analyzed by matching ISS. The mortality rate was significantly different in the ISS 26 to 35 group but in mostly all groups, the mortality rate was higher in women. In the matched-pair analysis, the rate of sepsis and the length of the ICU stay were significantly lower in women and the mortality rate showed no significant difference (28.1% for male patients versus 33.01% for female patients). Women died after an average of 5.22 days, and men died after an average of 9.02 days.

CONCLUSIONS

Gender-based differences in patient outcome after severe trauma were observed in this study. Women are more likely to die in the first days after trauma. Upon extended hospital stay, women had a better survival rate because they had a lower rate of sepsis. No significant differences in mortality rate could be found, but there was a trend towards a higher rate in female patients.

[Mitochondrial and microcirculatory distress syndrome in the critical patient. Therapeutic implications]

Mitochondrial and microcirculatory distress syndrome (MMDS) can occur during systemic inflammatory response syndrome (SIRS), and is characterized by cytopathic tissue hypoxia uncorrected by oxygen transport optimization, and associated with an acquired defect in the use of oxygen and energy production in mitochondria, leading to multiple organ dysfunction (MOD). We examine the pathogenesis of MMDS, new diagnostic methods, and recent therapeutic approaches adapted to each of the three phases in the evolution of the syndrome. In the initial phase, the aim is prevention and early reversal of mitochondrial dysfunction. Once the latter is established, the aim is to restore flow of the electron chain, mitochondrial respiration, and to avoid cellular energy collapse. Finally, in the third (resolution) stage, treatment should focus on stimulating mitochondrial biogenesis and the repair or replacement of damaged mitochondria.

17β-estradiol confers protection after traumatic brain injury in the rat and involves activation of G protein-coupled estrogen receptor 1

Abstract Traumatic brain injury (TBI) is a significant public health problem in the United States. Despite preclinical success of various drugs, to date all clinical trials investigating potential therapeutics have failed. Recently, sex steroid hormones have sparked interest as possible neuroprotective agents after traumatic injury. One of these is 17β-estradiol (E2), the most abundant and potent endogenous vertebrate estrogen. The goal of our study was to investigate the acute potential protective effects of E2 or the specific G protein-coupled estrogen receptor 1 (GPER) agonist G-1 when administered in an intravenous bolus dose 1 hour post-injury in the lateral fluid percussion (LFP) rodent model of TBI. The results of this study show that, when assessed at 24 hours post-injury, E2 or G-1 confers protection in adult male rats subjected to LFP brain injury. Specifically, we found that an acute bolus dose of E2 or G-1 administered intravenously 1 hour post-TBI significantly increases neuronal survival in the ipsilateral CA 2/3 region of the hippocampus and decreases neuronal degeneration and apoptotic cell death in both the ipsilateral cortex and CA 2/3 region of the hippocampus. We also report a significant reduction in astrogliosis in the ipsilateral cortex, hilus, and CA 2/3 region of the hippocampus. Finally, these effects were observed to be chiefly dose-dependent for E2, with the 5 mg/kg dose generating a more robust level of protection. Our findings further elucidate estrogenic compounds as a clinically relevant pharmacotherapeutic strategy for treatment of secondary injury following TBI, and intriguingly, reveal a novel potential therapeutic target in GPER.

Hepatic gene expression patterns following trauma-hemorrhage: effect of posttreatment with estrogen

The aim of this study was to examine the role of estrogen on hepatic gene expression profiles at an early time point following trauma-hemorrhage in rats. Groups of injured and sham controls receiving estrogen or vehicle were killed 2 h after injury and resuscitation, and liver tissue was harvested. Complementary RNA was synthesized from each RNA sample and hybridized to microarrays. A large number of genes were differentially expressed at the 2-h time point in injured animals with or without estrogen treatment. The upregulation or downregulation of a cohort of 14 of these genes was validated by reverse transcription-polymerase chain reaction. This large-scale microarray analysis shows that at the 2-h time point, there is marked alteration in hepatic gene expression following trauma-hemorrhage. However, estrogen treatment attenuated these changes in injured animals. Pathway analysis demonstrated predominant changes in the expression of genes involved in metabolism, immunity, and apoptosis. Upregulation of low-density lipoprotein receptor, protein phosphatase 1, regulatory subunit 3C, ring-finger protein 11, pyroglutamyl-peptidase I, bactericidal/permeability-increasing protein, integrin, αD, BCL2-like 11, leukemia inhibitory factor receptor, ATPase, Cu transporting, α polypeptide, and Mk1 protein was found in estrogen-treated trauma-hemorrhaged animals. Thus, estrogen produces hepatoprotection following trauma-hemorrhage likely via antiapoptosis and improving/restoring metabolism and immunity pathways.

Increased admission serum estradiol level is correlated with high mortality in patients with severe acute pancreatitis

BACKGROUND

Sexual dimorphism in critical diseases has been documented. Severe acute pancreatitis is a disease with high mortality. We hypothesized that admission sex hormone levels may be used as an early predictor of outcome in these patients.

METHODS

A prospective cohort of patients with severe acute pancreatitis admitted to the intensive care unit for at least 48 h were enrolled (n = 62). Serum levels of estradiol, progesterone, and testosterone were determined on admission. The association of sex hormone levels and various disease severity scoring systems with patient outcome was analyzed.

RESULTS

There was no difference in overall mortality between the sexes. However, estradiol was significantly elevated in nonsurvivors (39 vs. 206 pg/mL, p < 0.001). The estradiol level was the best single-variable predictor of mortality (area under the curve 0.97), followed by the sequential organ failure assessment score, the multiple organ dysfunction score, and the acute physiology and chronic health care evaluation II (APACHE II) score. A serum estradiol level of 102 pg/mL was both sensitive and specific to predict mortality. There were no differences between survivors and non-survivors in terms of age, body mass index, or progesterone and testosterone levels.

CONCLUSIONS

Admission serum estradiol level is a good marker of disease severity and predictor of death in patients with severe acute pancreatitis.

Sex-specific differences in Type 2 Diabetes Mellitus and dyslipidemia therapy: PPAR agonists

The influence of sex on the development of obesity, Type 2 Diabetes Mellitus (T2DM), and dyslipidemia is well documented, although the molecular mechanism underlying those differences reminds elusive. Ligands of peroxisome proliferator-activated receptors (PPARs) are used as oral antidiabetics (PPARgamma agonists: thiazolidinediones, TZDs), or for the treatment of dyslipidemia and cardiovascular diseases, due to their lipid-lowering properties (PPARalpha agonists: fibrates), as PPARs control transcription of a set of genes involved in the regulation of lipid and carbohydrate metabolism. Given a high prevalence of those metabolic disorders, and thus a broad use of PPAR agonists, the present review will discuss distinct aspects of sex-specific differences in antiobesity treatment using those groups of PPAR ligands.

Role of Akt/HO-1 pathway in estrogen-mediated attenuation of trauma-hemorrhage-induced lung injury

BACKGROUND

Despite advances in intensive care medicines, hemorrhagic shock leading to multiple organ failure remains the major causes of death in the injured host. Although studies have shown that 17β-estradiol (E2) prevents trauma-hemorrhage-induced lung damage, it remains unknown whether protein kinase B (Akt)/heme oxygenase (HO)-1 plays any role in E2-mediated lung protection after trauma-hemorrhage.

MATERIALS AND METHODS

After a 5-cm midline laparotomy, male rats underwent hemorrhagic shock (mean blood pressure ∼40 mm Hg for 90 min) followed by fluid resuscitation. At the onset of resuscitation, rats were treated with vehicle, E2 (1 kg/mg), E2 plus phosphoinositide 3-kinase inhibitor LY294002 (5 mg/kg), or LY294002. At 2 h after trauma-hemorrhage or sham operation, lung tissue myeloperoxidase activity, wet-to-dry-weight ratio, inflammatory mediators, and apoptosis were measured. Lung Akt, HO-1, and cleaved caspase-3 protein levels were also determined.

RESULTS

E2 attenuated the trauma-hemorrhage-induced increase in lung myeloperoxidase activity, edema formation, inflammatory mediator levels, and apoptosis, which was blocked by co-administration of LY294002. Administration of E2 normalized lung Akt phosphorylation and further increased HO-1 expression and decreased cleaved caspase-3 levels after trauma-hemorrhage. Co-administration of LY294002 prevented the E2-mediated attenuation of shock-induced lung injury.

CONCLUSIONS

Our results collectively suggest that Akt-dependent HO-1 upregulation may play a critical role in E2-meditated lung protection after trauma-hemorrhage.

Gender influences outcomes in trauma patients with elevated systolic blood pressure

BACKGROUND

This analysis explored the association between gender and systolic blood pressure (SBP) in trauma patients and then established how gender influenced outcomes in those with elevated SBP.

METHODS

Demographics and outcomes were compared using the Los Angeles County Trauma System Database and multivariable modeling determined predictors for SBP, pneumonia, and mortality.

RESULTS

Age and male sex were significant predictors for increased SBP, whereas the Injury Severity Score (ISS) ≥16 was a significant predictor for decreased SBP. In both male and female TBI patients, SBP ≥160 mmHg was associated with increased pneumonia (Adjusted odds ratio [AOR] = 1.74, P = .002 and AOR = 2.37, P = .046, respectively), whereas SBP ≥160 mmHg was a predictor for mortality only among male TBI patients (AOR = 1.48, P = .03). In non-TBI patients, SBP ≥160 mmHg was not a predictor for pneumonia or mortality in either sex.

CONCLUSIONS

In this retrospective review of trauma registry data, men presented with higher SBP. In patients with TBI, regardless of gender, increased SBP was associated with increased pneumonia, and in men with TBI increased SBP was associated with increased mortality. The cause and relevance of these epidemiological findings require further investigation.

The metabolic syndrome in critically ill patients

Metabolic support in intensive care is a rapidly evolving field with new information being gathered almost on a daily basis. In endocrine practice, over the last 20 years, researchers have focussed on a new entity, termed the "metabolic syndrome". This describes the constellation of abnormalities which include central adiposity, insulin resistance and inflammation. All of these predispose the individual to a greater risk of cardiovascular events. Of interest is the observation that some of the metabolic abnormalities in sepsis and multiple organ dysfunction syndrome of critical illness share several common features with that of the metabolic syndrome. In this chapter we describe the features of the metabolic syndrome as is understood in endocrine parlance, the metabolic abnormalities of critical illness and explore the common threads underlying the pathophysiology and the treatment of the two syndromes. The role of adiponectin in the metabolic abnormalities in both the metabolic syndrome and in sepsis are reviewed. The potential role of the pleiotropic effects of statins in the therapy of sepsis is also discussed.

Risk factors for liver failure and mortality after hepatectomy associated with portal vein resection

OBJECTIVE

To report the postoperative outcome of hepatectomy associated with portal vein resection (PVR) and to identify risk factors of clinical value for predicting postoperative liver failure and mortality.

SUMMARY BACKGROUND DATA

Resection of the portal vein during hepatectomy allows an increase in the number of patients who may benefit from a potentially curative operation that is, however, technically difficult and may increase postoperative morbidity and mortality. Few data are available about risk factors for liver failure and mortality after such extensive operations.

METHODS

Between July 1996 and July 2008, a total of 1348 patients were operated on for liver disease in our institution. Among them, 55 patients underwent liver resection associated with PVR. Medical records of these patients were prospectively collected and retrospectively analyzed.

RESULTS

Overall mortality for this selected group of patients was 7.2%. Irreversible liver failure was the main cause of death. Overall morbidity was 58.1%. A total of 94% of the patients (n = 52) underwent a major (≥ 3 segments) or an extended > 4 segments) right or left hepatectomy. Univariate analysis showed that male gender (P = 0.004), extended liver resection (P = 0.028), and, particularly, extended right hepatectomy (P = 0.015) were significantly associated with an increased risk of postoperative liver failure. Male gender was the single independent risk factor for liver failure. Moreover, the presence of liver steatosis (P = 0.014), an extended right hepatectomy procedure (P = 0.047), and postoperative liver failure (P = 0.046) were significantly associated with an increased rate of postoperative mortality.

CONCLUSION

The present study confirmed that major or extended hepatic resection with PVR can be performed with acceptable overall morbidity and mortality rates. Preoperative selection of the patients should take in consideration the gender and the extent of hepatic resection to avoid irreversible postoperative liver failure. Extended right hepatectomy with PVR should be carefully considered in patients with liver steatosis due to the high risk of postoperative mortality.

Evidence of hormonal basis for improved survival among females with trauma-associated shock: an analysis of the National Trauma Data Bank

BACKGROUND

Basic science research suggests that sex hormones affect survival after traumatic shock. This study sought to determine the independent effect of gender on mortality among trauma patients in different hormone-related age groups.

METHODS

Review of severely injured trauma patients with shock included in the National Trauma Databank. Patients were stratified into three groups on the basis of likely hormonal status: prehormonal (age, 0-12 years), hormonal (age,13-64 years), and posthormonal (age, ≥ 65 years). Multiple logistic regression was used to analyze the independent effect of gender on mortality in each group, adjusting for anatomic and physiologic injury severity.

RESULTS

A total of 48,394 patients met our inclusion criteria (Injury Severity Score ≥ 16 and systolic blood pressure <90 mm Hg). Crude mortality was higher (p < 0.05) for males in all categories: prehormonal = 29% for males (n = 3,553) versus 24% for females (n = 1,831); hormonal = 34% for males (n = 26,778) versus 30% for females (n = 8,677) and posthormonal = 36% for males (n = 4,280) versus 31% for females (n = 3,275). After adjusting for covariates, women in the hormonally active group had a 14% decreased odds of death (0.86 [95% CI, 0.76-0.93]) compared with men. Females did not exhibit this survival advantage in the prehormonal (odds of death = 0.92 [0.74-1.14]) or posthormonal (odds of death = 0.90 [0.76-1.05]) groups.

CONCLUSIONS

Females aged between 13 and 64 years exhibit significantly lower mortality than males after trauma-associated shock. This outcome difference is lost at the extremes of age (preadolescent children and individuals aged ≥ 65 years) where the effects of sex hormones are absent or diminished. These findings suggest that hormonal differences play a role in the gender-based outcome disparities after traumatic shock.

Sex-related differences in gene expression following Coxiella burnetii infection in mice: potential role of circadian rhythm

Background

Q fever, a zoonosis due to Coxiella burnetii infection, exhibits sexual dimorphism; men are affected more frequently and severely than women for a given exposure. Here we explore whether the severity of C. burnetii infection in mice is related to differences in male and female gene expression profiles.

Methodology/Principal Findings

Mice were infected with C. burnetii for 24 hours, and gene expression was measured in liver cells using microarrays. Multiclass analysis identified 2,777 probes for which expression was specifically modulated by C. burnetti infection. Only 14% of the modulated genes were sex-independent, and the remaining 86% were differentially expressed in males and females. Castration of males and females showed that sex hormones were responsible for more than 60% of the observed gene modulation, and this reduction was most pronounced in males. Using functional annotation of modulated genes, we identified four clusters enriched in males that were related to cell-cell adhesion, signal transduction, defensins and cytokine/Jak-Stat pathways. Up-regulation of the IL-10 and Stat-3 genes may account for the high susceptibility of men with Q fever to C. burnetii infection and autoantibody production. Two clusters were identified in females, including the circadian rhythm pathway, which consists of positive (Clock, Arntl) and negative (Per) limbs of a feedback loop. We found that Clock and Arntl were down-modulated whereas Per was up-regulated; these changes may be associated with efficient bacterial elimination in females but not in males, in which an exacerbated host response would be prominent.

Conclusion

This large-scale study revealed for the first time that circadian rhythm plays a major role in the anti-infectious response of mice, and it provides a new basis for elucidating the role of sexual dimorphism in human infections.

Gender Differences in Glucose Variability after Severe Trauma

Gender differences in the physiological response to trauma can affect outcome. Both hyperglycemia and blood glucose (BG) variability predict a poor outcome after trauma. This study examined the hypothesis that both BG levels and the degree of BG variability after trauma are gender-specific and correlate with mortality and morbidity. A retrospective observational cohort study of 1915 trauma patients requiring critical care was performed. Admission BG as well as all BG values obtained during the first week while in the intensive care unit were analyzed. In each patient, the mean BG and the degree of BG variability were calculated. A total of 1560 males and 355 females were studied with an overall mortality rate of 12 per cent. Seventy-six per cent of deaths had a BG greater than 125 mg/dL on admission and as BG variability worsened, the mortality rate also increased. There was a significant difference in male BG variability when comparing survivors with nonsurvivors. Female BG variability did not predict mortality. Failed glucose homeostasis is an important marker of endocrine dysfunction after severe injury. Increased BG variability in males is associated with a higher mortality rate. In females, mortality cannot be predicted based on BG levels or BG variability. These data have significant implications for gender-related differences in postinjury management.

Yield of smear microscopy and radiological findings of male and female patients with tuberculosis in abuja, Nigeria

Objective. To describe the yield of smear-microscopy and radiological findings by male and female patients with symptoms of tuberculosis in Abuja, Nigeria. Methods. Patients ≥15 years old with cough for >3 weeks submitted 3 sputum samples for smear microscopy. One specimen was cultured using MGIT-960. All patients had lung X-rays and screened for HIV. Results. were more likely to be smear-positive than females (262/774 [34%] and 137/547 [25%], P < .01), but similar proportions of males and females were culture-positive (437/691 [63%] and 294/495 [59%], P = .09). 317/626 (50.6%) males and 249/419 (59.4%) females were HIV-positive (P < .005). Among culture-positives patients, HIV-infected males were less likely to have positive smears than HIV-negative males (49.2% versus 66%, P = .001). Among females, smear positivity did not vary with HIV (46.4% for HIV-positive and 52.9% for HIV-negative, P = .38). Of 274 culture-confirmed TB cases, 226 (82.5%) had cavities, and 271 (99%) had ≥1 lung areas affected. HIV-positive males were more likely to have lung cavities than HIV-positive females (85% versus 69%, P < .04) and to have ≥3 lung areas affected (P = .03). Conclusion. Differences in the yield of smear-microscopy, culture and X-rays on presentation are due to several factors including HIV coinfection and gender.

Anti-Emetic Dexamethasone and Postoperative Infection Risk: A Retrospective Cohort Study

Nausea and vomiting are common complications of anaesthesia. Dexamethasone is an effective prophylaxis but is immunosuppressive and may increase postoperative infection risk. This retrospective cohort study examined the association between the administration of a single intraoperative anti-emetic dose of dexamethasone (4 to 8 mg) and postoperative infection in 439 patients undergoing single procedure, non-emergency surgery in a university trauma centre. Exclusion criteria included comorbidities, immunosuppressive medications or procedures that confer an increased infection risk. In the 10-week study period and three-month follow-up period, there were 98 documented infections (22.3% of the cohort), of which 43 were detected only on post-discharge follow-up. Anti-emetic dexamethasone was given to 108 patients (24.6%). Stepwise, multivariate logistic regression modelling identified significant associations between female gender, symptomatic reflux, respiratory disease and the risk of infection. The adjusted odds ratio for dexamethasone was 0.88 (0.5 to 1.5, P=0.656). We did not demonstrate an association between anti-emetic doses of dexamethasone and postoperative infection.

Thyroid surgery in octogenarians is associated with higher complication rates

BACKGROUND

The incidence of thyroid nodules increases with age and little information is available regarding the risks of thyroid surgery in elderly patients. The aim of this study was to determine whether thyroid surgery in patients > or =80 is associated with higher complication rates.

METHODS

Out of 3,568 patients undergoing thyroid surgery between July 2001 and October 2007 at a single institution, the records of 90 consecutive patients > or =80 years were reviewed retrospectively and compared with a cohort of 242 randomly selected patients aged 18-79, who underwent thyroid surgery during the same time period. Clinical variables included age, gender, pre-operative diagnosis, substernal component, previous surgery, final pathology, length of stay, comorbidities, American Society of Anesthesiologists (ASA) score, body mass index, postoperative complications, and mortality.

RESULTS

Preoperative indications for surgery included benign disease in 51% vs 39%, suspected malignancy in 19% vs 26%, and suspected follicular neoplasms in 30% vs 35% in the octogenarian patient group (> or =80 years old) vs the younger patient cohort (P = NS). Octogenarians had 20% significant malignancy on final pathology vs 27% in the younger cohort (P = NS). The overall complication rate in the octogenarian group was 24% vs 9% in the younger cohort (P < .001). Male gender and ASA > or =3 were found to be independent risk factors for perioperative complications after thyroid surgery, while age alone was not.

CONCLUSION

Age > or =80 is associated with higher morbidity after thyroid surgery, although not independently. Earlier operative intervention may be advised in those at high risk for disease progression, whereas follow-up strategies without operation may be advised for others.

Cellular mechanisms of injury after major trauma

This is the Fourth article in the Journal's series on major trauma. Chaudry and Bland, leading experts in the field, consider the cellular implications of injury.

Mechanism of salutary effects of estrogen on cardiac function following trauma-hemorrhage: Akt-dependent HO-1 up-regulation

OBJECTIVES

Because administration of 17beta-estradiol following trauma-hemorrhage improves cardiovascular responses, we investigated whether the salutary effects of 17beta-estradiol on cardiac function are mediated via Akt-dependent heme oxygenase-1 up-regulation under those conditions.

DESIGN

Experimental animal study.

SETTING

University laboratory.

SUBJECTS

Male Sprague-Dawley rats.

INTERVENTIONS

Rats underwent trauma-hemorrhage (mean blood pressure approximately 40 mm Hg for 90 mins) followed by fluid resuscitation. Before resuscitation, rats received either vehicle, 17beta-estradiol (1 mg/kg), or 17beta-estradiol plus the phosphoinositide 3-kinase inhibitor wortmannin (1 mg/kg). At 2 hrs after trauma-hemorrhage or sham operation, the rats were killed.

MEASUREMENTS AND MAIN RESULTS

Cardiac function, heart tissue myeloperoxidase activity, cardiac and circulatory cytokine levels, cardiac intercellular adhesion molecule-1, and chemokine levels were measured. Cardiac Akt and heme oxygenase-1 were also determined. We found that 17beta-estradiol prevented the trauma-hemorrhage-induced impairment in cardiac function and increase in cardiac myeloperoxidase activity. Cardiac and systemic interleukin-6 and tumor necrosis factor-alpha levels as well as cardiac intercellular adhesion molecule-1, cytokine-induced neutrophil chemoattractant-1, and macrophage inflammatory protein-2 contents were increased following trauma-hemorrhage, which were normalized by 17beta-estradiol. Administration of 17beta-estradiol following trauma-hemorrhage restored cardiac Akt phosphorylation and further increased heme oxygenase-1 expression. Coadministration of wortmannin following trauma-hemorrhage abolished the previous effects by 17beta-estradiol.

CONCLUSIONS

These results suggest that the 17beta-estradiol-meditated improvement in cardiac function following trauma-hemorrhage occurs via Akt-dependent heme oxygenase-1 up-regulation.

Proteome and system ontology of hemorrhagic shock: exploring early constitutive changes in postshock mesenteric lymph

BACKGROUND

Postshock mesenteric lymph (PSML) is the mechanistic link between splanchnic ischemia reperfusion (IR) and remote organ injury. We hypothesize that an unbiased inspection of the proteome of PSML will reveal previously unrecognized aberrations in systems biology provoked by hemorrhage-induced mesenteric IR injury in vivo.

METHODS

Shock was induced in male Sprague-Dawley rats by controlled hemorrhage, and the mesenteric duct was cannulated for lymph collection. Preshock and postshock lymph were collected for differential in-gel electrophoresis (DIGE)-based proteomics. Proteins that increased or decreased in relative concentration > or =1.5-fold were selected for trypsin digestion and analysis by mass spectrometry (MS).

RESULTS

Evidence of tissue injury was detected by an increase in cell/tissue proteins in PSML. Components of coagulation were depleted, whereas products of hemolysis were increased. Haptoglobin was decreased, which supports an early postshock hemolytic process. Interestingly, several protective protease inhibitors were decreased in PSML. The unexpected findings were an increase in alpha-enolase (a key glycolitic enzyme and cell-surface plasminogen binding receptor, +2.4-fold change) and increased major urinary protein (MUP, a sex-specific lipid-binding protein, +17.1-fold change) in PSML.

CONCLUSION

A proteomic evaluation of PSML revealed evidence of several shock-associated processes: protein release from tissue injury, depletion of coagulation factors and evidence of hemolysis, depletion of protective protease inhibitors, and an increase in abundance of lipid carriers. These results suggest that constitutive changes in the proteome of PSML may provide novel insights into the complex pathophysiology of postshock systems biology.

Hyperglycemia and Clinical Outcome in Aneurysmal Subarachnoid Hemorrhage

Background and Purpose— Hyperglycemia may worsen outcome after aneurysmal subarachnoid hemorrhage. We performed a systematic review to investigate the relation between admission hyperglycemia and outcome after aneurysmal subarachnoid hemorrhage.

Methods— We included cohort studies or clinical trials of patients with aneurysmal subarachnoid hemorrhage admitted within 72 hours that documented admission glucose levels or the rate of hyperglycemia. Outcome had to be assessed prospectively after 3 or more months. The overall mean glucose level was calculated by weighting for the number of patients included in each study. To calculate the effect size, we pooled the ORs and 95% 95% CIs of poor clinical outcome in patients with or without hyperglycemia.

Results— We searched MEDLINE, EMBASE, Science Citation Index, and the bibliographies of relevant studies. We included 17 studies totaling 4095 patients. The mean admission glucose level was 9.3 mmol/L (range, 7.4 to 10.9 mmol/L; 14 studies, 3373 patients) and the median proportion of patients with hyperglycemia was 69% (range, 29 to 100; 16 studies, 3995 patients; cutoff levels of hyperglycemia, 5.7 to 12.0 mmol/L). The pooled OR (8 studies, 2164 patients) for poor outcome associated with hyperglycemia was 3.1 (95% CI, 2.3 to 4.3). Cutoff points for defining hyperglycemia varied across studies (6.4 to 11.1 mmol/L), but this had no clear effect on the observed OR for poor outcome.

Conclusions— After aneurysmal subarachnoid hemorrhage, admission glucose levels are often high and hyperglycemia is associated with an increased risk of poor clinical outcome. A randomized clinical trial is warranted to study the potential benefit of glycemic control after aneurysmal subarachnoid hemorrhage.

Age and gender specific prevalence of HTLV-1

BACKGROUND

The seroprevalence of Human T-cell Leukemia Virus Type 1 (HTLV-1) is female predominant despite the higher incidence of Adult T-cell Leukemia (ATL) in males. If the mother-to-child transmission of HTLV-1 is more common for male infants than in female infants, longer exposure to the virus for males may explain the paradoxically higher incidence of ATL.

OBJECTIVES

To test the hypothesis that the seroprevalence of HTLV-1 is male predominant during adolescence.

STUDY DESIGN

The presence of HTLV-1 antibody in 272,043 blood samples donated to a regional blood bank in an HTLV-1 high-endemic region was assessed.

RESULTS

The entire population of female donors had a significantly higher seroprevalence compared to males (2.05% and 1.80%, respectively, p<0.0001). However, compared with male donors, the carrier rate for female donors was lower for the youngest subgroup (16-19 years, p=0.0011); was similar for the next two age subgroups (20-29 years and 30-39 years); and was significantly higher for the last two age subgroups (40-49 years and over 50-64 years, both p<0.0001). In general, older age subgroups led to higher seroprevalence in both genders.

CONCLUSIONS

HTLV-1 infection is more common for males until after age 20, when male to female sexual transmission becomes likely. This suggests that mother-to-child transmission is more common for males.

Neuroimmune regulation in immunocompetence, acute illness, and healing

Adaptive immunocompetence is maintained by growth hormone (GH), prolactin (PRL), and vasopressin (VP). Innate or natural immunocompetence depends on cytokines, hormones (especially of the hypothalamus-pituitary-adrenal axis), and catecholamines. The acute phase response (APR, or acute febrile illness) is an emergency defense reaction whereby the adaptive, T cell-dependent, immune reactions are suppressed and the innate immune function is dramatically amplified. Infection and various forms of injury induce APR. Cytokines [interleukin (IL)-1beta, tumor necrosis factor-alpha, and IL-6] stimulate corticotropin-releasing hormone (CRH) and VP secretion and cause a "sympathetic outflow." Colony-stimulating factors activate leukocytes. CRH is a powerful activator of the pituitary adrenocortical axis and elevates glucocorticoid (GC) levels. Cytokines, GCs, and catecholamines play fundamental roles in the amplification of natural immune defense mechanisms. VP supports the APR at this stage. However, VP remains active and is elevated for a longer period than is CRH. VP, but not CRH, is elevated during chronic inflammatory diseases. VP controls adaptive immune function and stimulates adrenocorticotropic hormone (ACTH) and PRL secretion. PRL maintains the function of the thymus and of the T cell-dependent adaptive immune system. The ACTH-adrenal axis stimulates natural immunity and of suppressor/regulatory T cells, which suppress the adaptive immune system. VP also has a direct effect on lymphoid cells, the significance of which remains to be elucidated. It is suggested that VP regulates the process of recovery from acute illness.

Cellular dysfunction in sepsis

Cellular dysfunction is a commonplace sequelum of sepsis and other systemic inflammatory conditions. Impaired energy production (related to mitochondrial inhibition, damage, and reduced protein turnover) appears to be a core mechanism underlying the development of organ dysfunction. The reduction in energy availability appears to trigger a metabolic shutdown that impairs normal functioning of the cell. This may well represent an adaptive mechanism analogous to hibernation that prevents a massive degree of cell death and thus enables eventual recovery in survivors.

The role of MIP-1 alpha in the development of systemic inflammatory response and organ injury following trauma hemorrhage

Although MIP-1alpha is an important chemokine in the recruitment of inflammatory cells, it remains unknown whether MIP-1alpha plays any role in the development of systemic inflammatory response following trauma-hemorrhage (T-H). C57BL/6J wild type (WT) and MIP-1alpha-deficient (KO) mice were used either as control, subjected to sham operation (cannulation or laparotomy only or cannulation plus laparotomy) or T-H (midline laparotomy, mean blood pressure 35 +/- 5 mmHg for 90 min, followed by resuscitation) and sacrificed 2 h thereafter. A marked increase in serum alpha-glutathione transferase, TNF-alpha, IL-6, IL-10, MCP-1, and MIP-1alpha and Kupffer cell cytokine production was observed in WT T-H mice compared with shams or control. In addition lung and liver tissue edema and neutrophil infiltration (myeloperoxidase (MPO) content) was also increased following T-H in WT animals. These inflammatory markers were markedly attenuated in the MIP-1alpha KO mice following T-H. Furthermore, compared with 2 h, MPO activities at 24 and 48 h after T-H declined steadily in both WT and KO mice. However, normalization of MPO activities to sham levels within 24 h was seen in KO mice but not in WT mice. Thus, MIP-1alpha plays an important role in mediating the acute inflammatory response following T-H. In the absence of MIP-1alpha, acute inflammatory responses were attenuated; rapidly recovered and less remote organ injury was noted following T-H. Thus, interventions that reduce MIP-1alpha levels following T-H should be useful in decreasing the deleterious inflammatory consequence of trauma.

Selective estrogen receptor-alpha and estrogen receptor-beta agonists rapidly decrease pulmonary artery vasoconstriction by a nitric oxide-dependent mechanism

Both endogenous and exogenous estrogen decrease pulmonary artery (PA) vasoconstriction. Whether these effects are mediated via estrogen receptor (ER)-alpha or ER-beta, and whether the contribution of ERs is stimulus-dependent, remains unknown. We hypothesized that administration of the selective ER-alpha agonist propylpyrazole triol (PPT) and/or the selective ER-beta agonist diarylpropiolnitrile (DPN) rapidly decreases PA vasoconstriction induced by pharmacologic and hypoxic stimuli via a nitric oxide (NO)-dependent mechanism. PA rings (n = 3-10/group) from adult male Sprague-Dawley rats were suspended in physiologic organ baths. Force displacement was measured. Vasoconstrictor responses to phenylephrine (10(-8)M - 10(-5)M) and hypoxia (Po(2) 35-45 mmHg) were determined. Endothelium-dependent and -independent vasorelaxation were measured by generating dose-response curves to acetylcholine (10(-8)M - 10(-4)M) and sodium nitroprusside (10(-9)M - 10(-5)M). PPT or DPN (10(-9)M - 5 x 10(-5)M) were added to the organ bath in the presence and absence of the NO-synthase inhibitor N(omega)-nitro-l-arginine methyl ester (l-NAME) (10(-4)M). Selective ER-alpha activation (PPT, 5 x 10(-5)M) rapidly (<20 min) decreased phenylephrine-induced vasoconstriction. This effect, as well as PPT's effects on endothelium-dependent vasorelaxation, were neutralized by l-NAME. In contrast, selective ER-beta activation (DPN, 5 x 10(-5)M) rapidly decreased phase II of hypoxic pulmonary vasoconstriction (HPV). l-NAME eliminated this phenomenon. Lower PPT or DPN concentrations were less effective. We conclude that both ER-alpha and ER-beta decrease PA vasoconstriction. The immediate onset of effect suggests a nongenomic mechanism. The contribution of specific ERs appears to be stimulus specific, with ER-alpha primarily modulating phenylephrine-induced vasoconstriction, and ER-beta inhibiting HPV. NO inhibition eliminates these effects, suggesting a central role for NO in mediating the pulmonary vascular effects of both ER-alpha and ER-beta.

The effects of estrogen on pulmonary artery vasoreactivity and hypoxic pulmonary vasoconstriction: potential new clinical implications for an old hormone

BACKGROUND AND OBJECTIVES

Recent research recognizes gender as a major factor determining the outcomes in trauma, ischemia/reperfusion, shock, and sepsis. In particular, estrogen has been demonstrated to exert protective effects in these settings. The effects of estrogens on the pulmonary vasculature are potent and complex yet not fully understood. A better mechanistic understanding may allow for future therapeutic interventions in pulmonary hypertensive crises after cardiac surgery and during acute lung injury as well as in patients with pulmonary arterial hypertension.

DATA SOURCES AND STUDY SELECTION

We searched PubMed for articles in the English language by using the search words pulmonary hypertension, hypoxic pulmonary vasoconstriction, estrogen, estradiol, inflammation, acute injury, ischemia reperfusion, sepsis, trauma, and burns. These were used in various combinations. We read the abstracts of the relevant titles to confirm their relevance, and the full articles were then extracted. References from extracted articles were checked for any additional relevant articles.

DATA EXTRACTION AND SYNTHESIS

Estrogen plays a critical role in the improved outcomes in the settings of trauma, shock, sepsis, myocardial ischemia/reperfusion, and acute lung injury. Several new mechanisms of action have been identified. In the pulmonary vasculature, estrogen causes vasodilation and attenuates the vasoconstrictor response to various stimuli, including hypoxia. This is mediated by increased levels of prostacyclin and nitric oxide as well as decreased levels of endothelin-1. In addition, effects on intracellular signaling pathways and several kinases as well as anti-inflammatory mechanisms may contribute as well. Recent studies suggest the importance of acute, nongenomic effects.

CONCLUSION

Estrogen exerts a variety of nongenomic actions, which may allow for future therapeutic interventions in pulmonary vascular disease.

Deleterious effects of endogenous and exogenous testosterone on mesenchymal stem cell VEGF production

Modulating the paracrine effects of bone marrow mesenchymal stem cells (BMSCs) may be important for the treatment of ischemic myocardial tissue. In this regard, endogenous estrogen may enhance BMSC vascular endothelial growth factor (VEGF) production. However, little information exists regarding the effect of testosterone on stem cell function. We hypothesized that 1) endogenous or exogenous estrogen will enhance stem cell production of VEGF and 2) endogenous or exogenous testosterone will inhibit BMSC VEGF production. BMSCs were collected from adult male, female, castrated male, and ovariectomized female rats. One hundred thousand cells were incubated with testosterone (1, 10, or 100 nM) or estrogen (0.15, 1.5, or 15 nM) for 48 h. Cell supernatants were collected, and VEGF was measured by ELISA. BMSCs harvested from castrated males, normal females, and ovariectomized females produced more VEGF compared with normal males. Castration was associated with the highest level (1,018 ± 98.26 pg/ml) of VEGF production by BMSCs, which was significantly more than that produced by BMSCs harvested from normal male and normal female animals. Exogenous testosterone significantly reduced VEGF production in BMSCs harvested from ovariectomized females in a dose-dependent manner. Exogenous estrogen did not alter BMSC VEGF production. These findings suggest that testosterone may work on BMSCs to decrease protective growth factor production and that effective removal of testosterone's deleterious effects via castration may prove to be beneficial in terms of protective factor production. By manipulating the mechanisms that BMSCs use to produce growth factors, we may be able to engineer stem cells to produce maximum growth factors during therapeutic use.