Novel pharmacologic approaches to the management of sepsis: targeting the host inflammatory response

Dexmedetomidine attenuates inflammation and organ injury partially by upregulating Nur77 in sepsis

PURPOSE

The aim of this study was to investigate the effect of dexmedetomidine (Dex) on inflammation and organ injury in sepsis, as well as the potential relationship between Dex and nuclear receptor 77 (Nur77).

METHODS

We investigated the effects of dexmedetomidine on lipopolysaccharide (LPS)-induced inflammation in RAW264.7 cells and organ injury in the cecal ligation and puncture (CLP) mouse model. Additionally, we examined the relationship between dexmedetomidine and Nur77. The expression levels of Nur77 in RAW264.7 cells were analyzed under various types of stimulation using quantitative reverse transcription polymerase chain reaction and western blot analysis. Inflammatory cytokine levels in the cells were evaluated using enzyme-linked immunoassay. Organ injuries were assessed by examining tissue histology and pathology of the lung, liver, and kidney.

RESULTS

Dexmedetomidine increased the expression of Nur77 and IL-10, and downregulated inflammatory cytokines (IL-1β and TNF-α) in LPS-treated RAW264.7 cells. The effect of dexmedetomidine on inhibiting inflammation in LPS-treated RAW264.7 cells was promoted by overexpressing Nur77, while it was reversed by downregulating Nur77. Additionally, dexmedetomidine promoted the expression of Nur77 in the lung and CLP-induced pathological changes in the lung, liver, and kidney. Activation of Nur77 with the agonist Cytosporone B (CsnB) significantly suppressed the production of IL-1β and TNF-α in LPS-treated RAW264.7 cells. In contrast, knockdown of Nur77 augmented IL-1β and TNF-α production in LPS-treated RAW264.7 cells.

CONCLUSION

Dexmedetomidine can attenuate inflammation and organ injury, at least partially, via upregulating Nur77 in sepsis.

Inflammasome-mediated GSDMD activation facilitates escape of Candida albicans from macrophages

Candida albicans is the most common cause of fungal sepsis. Inhibition of inflammasome activity confers resistance to polymicrobial and LPS-induced sepsis; however, inflammasome signaling appears to protect against C. albicans infection, so inflammasome inhibitors are not clinically useful for candidiasis. Here we show disruption of GSDMD, a known inflammasome target and key pyroptotic cell death mediator, paradoxically alleviates candidiasis, improving outcomes and survival of Candida-infected mice. Mechanistically, C. albicans hijacked the canonical inflammasome-GSDMD axis-mediated pyroptosis to promote their escape from macrophages, deploying hyphae and candidalysin, a pore-forming toxin expressed by hyphae. GSDMD inhibition alleviated candidiasis by preventing C. albicans escape from macrophages while maintaining inflammasome-dependent but GSDMD-independent IL-1β production for anti-fungal host defenses. This study demonstrates key functions for GSDMD in Candida's escape from host immunity in vitro and in vivo and suggests that GSDMD may be a potential therapeutic target in C. albicans-induced sepsis.

In vitro and molecular docking studies of an anti-inflammatory scaffold with human peroxiredoxin 5 and tyrosine kinase receptor

A new series of 4-(3-(2-amino-3,5-dibromophenyl)-1-(4-substitutedbenzoyl)-4,5-dihydro-1H-pyrazol-5-yl)benzonitrile (4a-h) compounds were synthesized and evaluated for in-vitro anti-inflammatory activities. The spectral (IR, NMR) and elemental analyses data of the product indicated the formation of new pyrazoles 4a-h. Compound 4e exhibited potent anti-inflammatory property with 85.45 % inhibitions. This value was compared with standard diclofenac sodium. This data is explained using molecular docking analysis of receptor- ligand binding. These results demonstrated that pyrazole derivatives are potential inhibitors of Human Peroxiredoxin 5 and Tyrosine kinase receptor in the treatment of inflammation related illness.

Quality Control Measures and Validation in Gene Association Studies: Lessons for Acute Illness

Acute illness is a complex constellation of responses involving dysregulated inflammatory and immune responses, which are ultimately associated with multiple organ dysfunction. Gene association studies have associated single-nucleotide polymorphisms (SNPs) with clinical and pharmacological outcomes in a variety of disease states, including acute illness. With approximately 4 to 5 million SNPs in the human genome and recent studies suggesting that a large portion of SNP studies are not reproducible, we suggest that the ultimate clinical utility of SNPs in acute illness depends on validation and quality control measures. To investigate this issue, in December 2018 and January 2019 we searched the literature for peer-reviewed studies reporting data on associations between SNPs and clinical outcomes and between SNPs and pharmaceuticals (i.e., pharmacogenomics) published between January 2011 to February 2019. We review key methodologies and results from a variety of clinical and pharmacological gene association studies, including trauma and sepsis studies, as illustrative examples on current SNP association studies. In this review article, we have found three key points which strengthen the potential accuracy of SNP association studies in acute illness and other diseases: providing evidence of following a protocol quality control method such as the one in Nature Protocols or the OncoArray QC Guidelines; enrolling enough patients to have large cohort groups; and validating the SNPs using an independent technique such as a second study using the same SNPs with new patient cohorts. Our survey suggests the need to standardize validation methods and SNP quality control measures in medicine in general, and specifically in the context of complex disease states such as acute illness.

Septic shock in pediatrics: the state-of-the-art

OBJECTIVE

Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock.

SOURCE OF DATA

A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years.

SYNTHESIS OF DATA

Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection.

CONCLUSIONS

The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.

Inhibition of GPR 55 improves dysregulated immune response in experimental sepsis

Sepsis is a medical condition caused by dysregulated systemic inflammatory response against infection, resulting in high mortality. Despite intensive research over the last few decades, the results from multiple clinical trials targeting specific inflammatory mediators have been disappointing. In the present study, we investigated the role of G protein-coupled receptor GPR55 modulation on immune response in an experimental sepsis model (endotoxemia). Immune response was evaluated by analyzing leukocyte-endothelial interactions and capillary perfusion in the intestinal microcirculation using intravital microscopy. In addition, the levels of plasma inflammatory cytokines were measured. The results demonstrated that GPR55 inhibition using antagonists, CID16020046 or O-1918, significantly reduced leukocyte adherence in intestinal submucosal venules and decreased proinflammatory cytokine TNF-α and IL-6 production. These data suggest that GPR55 inhibition may be a novel therapeutic target for attenuating hyperinflammation during sepsis.

Resolvin D1 Promotes SIRT1 Expression to Counteract the Activation of STAT3 and NF-κB in Mice with Septic-Associated Lung Injury

Resolvin D1 (RvD1) is a novel endogenous docosahexaenoic acid (DHA)-derived lipid mediators, which possesses a dual role of anti-inflammation and promotes inflammation resolution. The aim of the present study was to assess the effects of RvD1 on cecal ligation and puncture (CLP) model of sepsis and explore the underlying mechanism. Six-to-eight-week-old male C57BL/6 mice were randomly divided into following three groups: sham-operated group (SO), CLP model group (CLP), and CLP+RvD1 group (RvD1). The SO group underwent the sham operation. The RvD1 groups were administered RvD1 (10-ng/g body weight) by penile vein injection, but the CLP groups were administered the same volume of vehicle (PBS) after CLP. We assessed the survival benefit of RvD1 in CLP-induced septic mice for 7 days. After 24 h, mice were sacrificed, bronchoalveolar lavage fluids (BALF) was collected for proinflammatory cytokines assay, and albumin assay and the lung tissues were harvested for histologic analysis, myeloperoxidase (MPO) activity and the expression of Sirtuin 1 (SIRT1), signal transducers, and activators of transcription 3 (STAT3), nuclear factor-κB (NF-κB), and mitogen-activated protein kinases (MAPKs). RvD1 treatment increased the survival time in mice with sepsis induced by CLP, reducing the MPO activity and albumin level at 24 h. The levels of inflammatory cytokines, including tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6) in BALF were significantly decreased by RvD1. RvD1 promoted SIRT1 expression and suppressed the activation of NF-κB, STAT3, ERK, and p38 in lung tissues of septic mice. These results suggest that RvD1 may improve survival and attenuate the degree of lung inflammation reaction in mice with CLP by suppressing STAT3, NF-κB, ERK, and p38 expressions through a mechanism partly dependent on SIRT1.

A Validation Argument for a Simulation-Based Training Course Centered on Assessment, Recognition, and Early Management of Pediatric Sepsis

INTRODUCTION

Early recognition of sepsis remains one of the greatest challenges in medicine. Novice clinicians are often responsible for the recognition of sepsis and the initiation of urgent management. The aim of this study was to create a validity argument for the use of a simulation-based training course centered on assessment, recognition, and early management of sepsis in a laboratory-based setting.

METHODS

Five unique simulation scenarios were developed integrating critical sepsis cues identified through qualitative interviewing. Scenarios were piloted with groups of novice, intermediate, and expert pediatric physicians. The primary outcome was physician recognition of sepsis, measured with an adapted situation awareness global assessment tool. Secondary outcomes were physician compliance with pediatric advanced life support (PALS) guidelines and early sepsis management (ESM) recommendations, measured by two internally derived tools. Analysis compared recognition of sepsis by levels of expertise and measured association of sepsis recognition with the secondary outcomes.

RESULTS

Eighteen physicians were recruited, six per study group. Each physician completed three sepsis simulations. Sepsis was recognized in 19 (35%) of 54 simulations. The odds that experts recognized sepsis was 2.6 [95% confidence interval (CI) = 0.5-13.8] times greater than novices. Adjusted for severity, for every point increase in the PALS global performance score, the odds that sepsis was recognized increased by 11.3 (95% CI = 3.1-41.4). Similarly, the odds ratio for the PALS checklist score was 1.5 (95% CI = 0.8-2.6). Adjusted for severity and level of expertise, the odds of recognizing sepsis was associated with an increase in the ESM checklist score of 1.8 (95% CI = 0.9-3.6) and an increase in ESM global performance score of 4.1 (95% CI = 1.7-10.0).

CONCLUSIONS

Although incomplete, evidence from initial testing suggests that the simulations of pediatric sepsis were sufficiently valid to justify their use in training novice pediatric physicians in the assessment, recognition, and management of pediatric sepsis.

LpA-II:B:C:D:E: a new immunochemically-defined acute phase lipoprotein in humans

Background

Previous studies of lipoproteins in patients with sepsis have been performed on density fractions isolated by conventional ultracentrifugation that are heterogeneous and provide no information about the cargo of apoproteins present in the immunochemically distinct subclasses that populate the density classes. Since apoproteins are now known to have important roles in host defense, we have separated these subclasses according to their apoprotein content and characterized their changes during experimental endotoxemia in human volunteers.

Methods

We have studied apoB- and apoA containing lipoprotein subclasses in twelve healthy male volunteers before and for 8 h after a single dose of endotoxin (ET; 2 μg/kg) to stimulate inflammation.

Results

After endotoxin, TG, TC, apoB and the apoB-containing lipoprotein cholesterol-rich subclass LpB and two of the three triglyceride-rich subclasses (TGRLP: Lp:B:C, LpB:C:E+ LpB:E) all declined. In contrast, the third TGRLP, LpA-II:B:C:D:E (“complex particle”), after reaching a nadir at 4 h rose 49% above baseline, p = .006 at 8 h and became the dominant particle in the TGRLP pool. This increment exceeds the threshold of > 25% change required for designation as an acute phase protein. Simultaneous decreases in LpA-I:A-II and LpB:C:E + LpB:E suggest that these subclasses undergo post-translational modification and contribute to the formation of new LpA-II:B:C:D:E particles.

Conclusions

We have identified a new acute phase lipoprotein whose apoprotein constituents have metabolic and immunoregulatory properties applicable to host defense that make it well constituted to engage in the APR.

Pparγ Expression in T Cells as a Prognostic Marker of Sepsis

Translating murine data to the human situation, we proposed that the level of peroxisome proliferator-activated receptor γ (PPARγ) expression in T cells from septic patients correlates with clinical outcome. In this preliminary report, we analyzed PPARγ mRNA expression in CD3 T cells derived from blood of a very small number of septic patients (n = 18) on various days up to 2 weeks after the initial diagnosis. CD3 T cell count was determined by flow cytometry. T cells from n = 11 healthy donors were included as controls. Maximal PPARγ mRNA expression was observed on the day of sepsis diagnosis (day 0; 5,896 ± 1,523 copies PPARγ mRNA/25 ng mRNA, P < 0.05 vs. controls). In contrast, the number of CD3 T cells was significantly decreased in septic patients compared with healthy controls (296 ± 31 vs. 1,803 ± 134 T cells/μL blood, P < 0.001). Setting two arbitrary limits: patients with a PPARγ expression in T cells higher than 7,000 copies/25 ng mRNA, of whom five of six patients died during the ICU stay, and patients with a T cell count below 100 T cells/μL blood, of whom five of eight patients died, we identified a correlation between sepsis survival and low T cell number, paired with high T cell-specific PPARγ expression. Among all 18 sepsis patients, four fulfilled the criteria for both arbitrary settings and all four of these patients subsequently died. We suggest that both high PPARγ expression in T cells and low absolute T cell number in blood of septic patients may have the potential as a new prognostic marker for a poor sepsis outcome.

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock

OBJECTIVES

The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock."

DESIGN

Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups.

MEASUREMENTS AND MAIN RESULTS

The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations.

CONCLUSIONS

The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.

Systemic blockade of P2X7 receptor protects against sepsis-induced intestinal barrier disruption

Sepsis, during which the intestinal epithelial barrier is frequently disrupted, remains a challenging and life-threatening problem in clinical practice. The P2X7 receptor (P2X7R) is a non-selective adenosine triphosphate-gated cation channel present in macrophages that is involved in inflammatory responses. However, little is known about the role of P2X7R in macrophages during sepsis-induced intestinal barrier disruption. In this study, mice were treated with the P2X7R antagonist A740003 or the agonist BzATP by intra-peritoneal injection after the induction of gut-origin sepsis. The survival rates, inflammatory responses, intestinal barrier integrity, macrophage marker expression, and ERK and NF-κB activities were evaluated. Intestinal macrophages were also isolated and studied after exposure to Brilliant Blue G or BzATP. We found that a systemic P2X7R blockade downregulated sepsis-induced inflammatory responses and attenuated intestinal barrier dysfunction based on the evidence that mice in the A740003-treated group exhibited alleviated pro-inflammatory cytokine synthesis, intestinal hyperpermeability, epithelial apoptosis rates and tight junction damage compared with the septic mice. These changes were partly mediated by the inhibition of M1 macrophages activation via ERK/NF-κB pathways. Our data presented herein show that a P2X7R blockade could be a potential therapeutic target for the treatment of sepsis-induced intestinal barrier dysfunction.

Sepsis in Pediatric Cardiac Intensive Care

OBJECTIVES

In this review, we will discuss risk factors for developing sepsis; the role of biomarkers in establishing an early diagnosis, in monitoring therapeutic efficacy, in stratification, and for the identification of sepsis endotypes; and the pathophysiology and management of severe sepsis and septic shock, with an emphasis on the impact of sepsis on cardiovascular function.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSIONS

There is a lot of excitement in the field of sepsis research today. Scientific advances in the diagnosis and clinical staging of sepsis, as well as a personalized approach to the treatment of sepsis, offer tremendous promise for the future. However, at the same time, it is also evident that sepsis mortality has not improved enough, even with progress in our understanding of the molecular pathophysiology of sepsis.

Effectiveness of Multiple Blood-Cleansing Interventions in Sepsis, Characterized in Rats

Sepsis is a serious, life-threatening condition that presents a growing problem in medicine, but there is still no satisfying solution for treating it. Several blood cleansing approaches recently gained attention as promising interventions that target the main site of problem development–the blood. The focus of this study is an evaluation of the theoretical effectiveness of hemoadsorption therapy and pathogen reduction therapy. This is evaluated using the mathematical model of Murine sepsis, and the results of over 2,200 configurations of single and multiple intervention therapies simulated on 5,000 virtual subjects suggest the advantage of pathogen reduction over hemoadsorption therapy. However, a combination of two approaches is found to take advantage of their complementary effects and outperform either therapy alone. The conducted computational experiments provide unprecedented evidence that the combination of two therapies synergistically enhances the positive effects beyond the simple superposition of the benefits of two approaches. Such a characteristic could have a profound influence on the way sepsis treatment is conducted.

Inhibiting IκBβ-NFκB signaling attenuates the expression of select pro-inflammatory genes

Multiple mediators of septic shock are regulated by the transcription factor nuclear factor κB (NFκB). However, complete NFκB inhibition can exacerbate disease, necessitating evaluation of targeted strategies to attenuate the pro-inflammatory response. Here, we demonstrate that in murine macrophages, low-dose NFκB inhibitors specifically attenuates lipopolysaccharide (LPS)-induced IκBβ degradation and the expression of a select subset of target genes (encoding IL1β, IL6, IL12β). Gain- and loss-of-function experiments demonstrate the necessary and sufficient role of inhibitor of NFκB family member IκBβ (also known as NFKBIB) in the expression of these genes. Furthermore, both fibroblasts and macrophages isolated from IκBβ overexpressing mice demonstrate attenuated LPS-induced IκBβ-NFκB signaling and IL1β, IL6 and IL12β expression. Further confirming the role of IκBβ and its NFκB subunit binding partner cRel in LPS-induced gene expression, pre-treatment of wild-type mouse embryonic fibroblasts with a cell-permeable peptide containing the cRel nuclear localization sequence attenuated IL6 expression. We prove that LPS-induced IκBβ-NFκB signaling can be selectively modulated to attenuate the expression of select pro-inflammatory target genes, thus providing therapeutic insights for patients exposed to systemic inflammatory stress.

Immune activation efficacy of indolicidin is enhanced upon conjugation with carbon nanotubes and gold nanoparticles

Antibiotic resistance is concern of today's world. Search for alternative molecules, for treatment and immune stimulation, remains at the forefront. One such group of biomolecules with promise, along the line of immune stimulation or therapy, is host defense peptide (HDP). These molecules, however, are required at a higher dose to be effective which leads to high cost. To alleviate such problems, an aid can be used to achieve similar efficacy but at a smaller effective dose of the immune stimulant. We hypothesised that by conjugating HDPs with carbon nanotubes and/or gold nanoparticles, it would be possible to stimulate a protective immune response in host system at a lower dosage of HDP. In this report, we characterized, using biophysical methodologies, conjugation of Indolicidin, as a representative of HDP. We further established efficacy of peptide-nanomaterial conjugates in activating innate immunity and protecting against pathogen infection in vitro at a significantly small dose.

Synthesis and biological evaluation of novel indole-2-one and 7-aza-2-oxindole derivatives as anti-inflammatory agents

Sepsis, a typically acute inflammatory disease, is the biggest cause of death in ICU (intensive care unit). Novel anti-inflammatory alternatives are still in urgent need. In this study, we designed and synthesized 30 indole-2-one and 7-aza-2-oxindole derivatives based on the skeleton of tenidap, and their anti-inflammatory activity was determined by evaluating the inhibitory potency against lipopolysaccharide (LPS)-stimulated tumor necrosis factor (TNF)-α and interleukin (IL)-6 release in RAW264.7 macrophages. Quantitative SAR (structure-activity relationship) analysis revealed that a high molecular polarizability and low lipid/water partition coefficient (ALogP) in indole-2-one are beneficial for anti-inflammatory activity. Moreover, compounds 7i and 8e inhibited the expression of TNF-α, IL-6, COX-2, PGES, and iNOS in LPS-stimulated macrophages, and 7i exhibited a significant protection from LPS-induced septic death in mouse models. These data present a series of new indole-2-one compounds with potential therapeutic effects in acute inflammatory diseases.

Role of biphasic changes in splenic dendritic cell activity in a mouse model of multiple organ dysfunction syndrome

To analyze the changes in splenic dendritic cell (DC) activity and serum cytokine levels during the progression of multiple organ dysfunction syndrome (MODS). A C57BL/6 mouse model of MODS was established by intraperitoneal injection of zymosan. Immunohistochemistry and flow cytometry were used to detect expression of I-A(b) (MHC-II molecules of mice) as well as co-stimulatory and co-inhibitory molecules in spleen and DC surface. The levels of various cytokines in serum and spleen tissue were analyzed 6 h, 12 h, 24 h, 48 h, 5 d and 12 d after injury. Death occurred at 24-48 h and 10-12 d after injury. The expression of I-A(b) and CD86 in spleen tissue and on DCs increased 6-12 h after injury, followed by gradual reduction and at 12 d. The inhibitory molecule, PD-L1, was expressed on normal DCs, but expression of PD-1 was undetectable. PD-L1 and PD-1 expression increased and remained high at 5 d and 12 d after injury. In addition, TNF and IL-1 levels increased 6-12 h after injury; HMGB1 and IL-10 levels increased 24 h and 5 d after injury, respectively. In contrast, IL-2 and IL-12 decreased with disease progression. At 12 d after injury, proinflammatory and anti-inflammatory cytokine levels remained high, while IL-2 and IL-12 were significantly reduced. IL-10 and IL-12 changes in spleen were consistent with those in serum. MODS progression was characterized by changes in splenic DC activity as well as altered serum pro-inflammatory and anti-inflammatory cytokine levels, suggesting early immune activation and predominant immune tolerance at the late stage.

Serum cytokines associated with severity and complications of kala-azar

OBJECTIVES

Recent clinical data suggest that severe kala-azar (or visceral leishmaniasis) is an exaggerated innate immune response mediated by inflammatory cytokines, leading to a systemic inflammatory syndrome similar to what is observed in malaria, sepsis and other diseases. We tested this hypothesis by measuring serum cytokines in individuals with kala-azar.

METHODS

We compared patients with severe kala-azar (i.e. hemorrhagic manifestations, n = 38) with patients without evidence of hemorrhage (n = 96). We conducted a detailed clinical and laboratory evaluation, measuring serum IL-1beta, IL-6, IL-8, IL-10, IL-12, interferon-gamma, and TNF-alpha, and markers of disseminated intravascular coagulation (DIC).

RESULTS

Infants had higher levels of inflammatory cytokines, while HIV-infected patients had lower concentrations of IL-10 and interferon-gamma. Higher levels of IL-6, interferon-gamma, and IL-8 were found among deceased patients. IL-8 and interferon-gamma were independently associated with bleeding. Several cytokines were associated with different signs of severe clinical and laboratory manifestations, including DIC. IL-6 was highly positively and independently associated with IL-1beta, IL-8, IL-10, and negatively associated with TNF-alpha. IL-1beta and TNF-alpha were also highly independently associated with disease severity.

CONCLUSION

In its severe form, kala-azar, a neglected tropical disease, initiates a systemic inflammatory response that leads to DIC and other manifestations. Children may have higher risk of death due to the more intense cytokine release. The data supports the notion that IL-6 is the central cytokine that is associated with lethal disease, but interferon-gamma, IL1beta, IL-8, and TNF-alpha are also involved with disease severity. Inhibition of IL-6 is a potential target of adjuvant therapy for severe or pediatric forms of this disease.

Inhibition of IKKβ in enterocytes exacerbates sepsis-induced intestinal injury and worsens mortality

OBJECTIVES

Nuclear factor-κB is a critical regulator of cell-survival genes and the host inflammatory response. The purpose of this study was to investigate the role of enterocyte-specific NF-kB in sepsis through selective ablation of IkB kinase.

DESIGN

Prospective, randomized controlled study.

SETTING

Animal laboratories in university medical centers.

SUBJECTS AND INTERVENTIONS

Mice lacking functional NF-kB in their intestinal epithelium (Vil-Cre/Ikkβ) and wild-type mice were subjected to sham laparotomy or cecal ligation and puncture. Animals were killed at 24 hours or followed 7 days for survival.

MEASUREMENTS AND MAIN RESULTS

Septic wild-type mice had decreased villus length compared with sham mice, whereas villus atrophy was further exacerbated in septic Vil-Cre/Ikkβ mice. Sepsis induced an increase in intestinal epithelial apoptosis compared with sham mice, which was further exacerbated in Vil-Cre/Ikkβ mice. Sepsis induced intestinal hyperpermeability in wild-type mice compared with sham mice, which was further exacerbated in septic Vil-Cre/Ikkβ mice. This was associated with increased intestinal expression of claudin-2 in septic wild-type mice, which was further increased in septic Vil-Cre/Ikkβ mice. Both, pro-inflammatory and anti-inflammatory cytokines were increased in serum following cecal ligation and puncture, and interleukin 10 and monocyte chemoattractant protein-1 levels were higher in septic Vil-Cre/Ikkβ mice than in septic wild-type mice. All septic mice were bacteremic, but no differences in bacterial load were identified between wild-type and Vil-Cre/Ikkβ mice. To determine the functional significance of these results, animals were followed for survival. Septic wild-type mice had lower mortality than septic Vil-Cre/Ikkβ mice (47% vs 80%, p<0.05). Antitumor necrosis factor administration decreased intestinal apoptosis, permeability, and mortality in wild-type septic mice, and a similar improvement in intestinal integrity and survival were seen when antitumor necrosis factor was given to Vil-Cre/Ikkβ mice.

CONCLUSIONS

Enterocyte-specific NF-kB has a beneficial role in sepsis by partially preventing sepsis-induced increases in apoptosis and permeability, which are associated with worsening mortality.

Effects of dexmedetomidine on early and late cytokines during polymicrobial sepsis in mice

OBJECTIVE

We investigated whether dexmedetomidine provided protective effects on cecal ligation and puncture (CLP)-induced septic mice, through suppressing the expression of pro-inflammatory cytokines [tumor necrosis factor-α (TNF-α) and interlukin-6 (IL-6)] and high mobility group box 1 (HMGB1).

METHODS

The model of sepsis was set up by CLP in 136 male BALB/c mice (40 mice for survival studies and 96 for cytokine studies) which were divided into four groups, including a C, CLP, DEX + CLP and CLP + DEX group. The serum levels of TNF-α, IL-6 and HMGB1 were detected at 6, 12, 24 and 48 h after operations, and lung HMGB1 mRNA were analyzed at 24 and 48 h. The mortality rates were calculated 7 days after the operations.

RESULTS

The mortality rates 7 days after operations were significantly lower in the CLP + DEX (50 %) and DEX + CLP (30 %) groups than in the CLP group (90 %). Serum concentrations of IL-6 and TNF-α decreased significantly in dexmedetomidine administration groups compared with the CLP group. The levels of HMGB1 and lung HMGB1 mRNA were lower in the dexmedetomidine administration groups than in the CLP group. There was a significant correlation between lung HMGB1 mRNA and serum HMGB1(r = 0.858).

CONCLUSIONS

Dexmedetomidine could reduce the mortality rate and inhibit pro-inflammatory cytokine responses during polymicrobial sepsis in mice.

Synthesis and Anti-inflammatory Evaluation of Novel Benzimidazole and Imidazopyridine Derivatives

Sepsis, an acute inflammatory disease, remains the most common cause of death in intensive care units. A series of benzimidazole and imidazopyridine derivatives were synthesized and screened for anti-inflammatory activities, and the imidazopyridine series showed excellent inhibition of the expression of inflammatory cytokines in LPS-stimulated macrophages. Compounds X10, X12, X13, X14, and X15 inhibited TNF-α and IL-6 release in a dose-dependent manner, and X12 showed no cytotoxicity in hepatic cells. Furthermore, X12 exhibited a significant protection against LPS-induced septic death in mouse models. Together, these data present a series of new imidazopyridines with potential therapeutic effects in acute inflammatory diseases.

Pediatric sepsis: preparing for the future against a global scourge

Sepsis is a leading cause of morbidity and mortality among children worldwide. As consensus statements emerge regarding early recognition and goal-directed management of sepsis, scrutiny should be given to the unique characteristics of sepsis in children. Pediatric patients are not small adults! Sepsis epidemiology, pathophysiology, and management strategy can vary significantly from those for adults. Herein, we describe the epidemiology of pediatric sepsis, in both resource-rich and resource-poor worlds, and discuss how the pathophysiology of pediatric sepsis differs from that for adults. We discuss the timeline of management of pediatric sepsis, studying how discoveries over the past 50 years have changed the way sepsis is treated. Finally, we discuss the future of pediatric sepsis. We focus on approaches that carry the most substantive impact on the global burden of disease.

Antisense inhibition of secretory and cytosolic phospholipase A2 reduces the mortality in rats with sepsis*

OBJECTIVE

Phospholipase A(2) has been implicated to play a pivotal role in the pathogenesis of sepsis syndrome. The two major forms of phospholipase A(2) isoenzymes, secretory phospholipase A(2) and cytosolic phospholipase A(2), are overexpressed during sepsis. The objective of this study was to test the hypothesis that inhibition of the overexpressed secretory phospholipase A(2) and cytosolic phospholipase A(2) during sepsis benefits the disease's eventual outcome.

DESIGN

Short-chain antisense oligonucleotide molecules were designed with the aid of computer software programs, and their in vitro efficacies were assessed in cell culture systems based on inhibition of target protein expression. The in vivo efficacies were determined in intact sepsis rats using 35-day survival rate as a primary efficacy end point.

SETTING

Animal research laboratory at a university.

SUBJECTS

Male Sprague-Dawley rats (180-200 g).

INTERVENTIONS

Sepsis was induced by cecal ligation and puncture. Antibiotics were administered subcutaneously once daily at 12 mg/kg, for 20 days. Oligonucleotides (antisense or mismatch) were administered intravenously once daily at 2 mg/kg to 0.8 mg/kg in a decreasing order, for 20 days.

MEASUREMENTS AND MAIN RESULTS

In cell culture systems, 21 of the 105 antisense constructs were found to be efficacious in inhibiting secretory phospholipase A(2) IIa and cytosolic phospholipase A(2) IVa protein expression. In sepsis rats, antisense oligonucleotides were capable of reducing their target protein expression by 18%-61% in major organs such as liver, heart, and kidney. In animal experiments, sepsis without any treatment (Group 1) had a median survival time of 2 days and a zero (0) percent survival rate at day 14. Sepsis with antibiotic treatment (Group 2) had a median survival time of 6 days and a 35-day survival rate of 28%. Sepsis with cotreatment of antibiotics and antisense oligonucleotides (one against secretory phospholipase A2 IIa and the other against cytosolic phospholipase A(2) IVa) (Group 4) increased the median survival time from 6 to 35 days and the 35-day survival rate from 28% to 58.8% as compared with antibiotics alone (Group 4 vs. Group 2; p <.05). Sepsis with cotreatment of antibiotics and mismatch oligonucleotides (Group 3) did not affect the median survival time and the 35-day survival rate as compared to antibiotics alone (Group 3 vs. Group 2; p >.05).

CONCLUSIONS

The results demonstrate that antisense strategy against secretory phospholipase A(2) IIa and cytosolic phospholipase A(2) IVa can inhibit their target protein expression in major organs and greatly improve the clinical outcome, i.e., an absolute reduction in 35-day mortality of 30.8%, in rats with sepsis. Our studies, thus, provide an improved method for the treatment of sepsis by targeting multiple forms of phospholipase A(2) isoenzymes with DNA antisense oligomers.

Prophylactic zinc supplementation reduces bacterial load and improves survival in a murine model of sepsis

OBJECTIVE

We previously demonstrated that altered zinc homeostasis is an important feature of pediatric sepsis, thus raising the possibility of zinc supplementation as a therapeutic strategy in sepsis. Herein, we tested the hypothesis that prophylactic zinc supplementation would be beneficial in a murine model of peritoneal sepsis.

DESIGN

Murine model of sepsis (intraperitoneal fecal-slurry injection).

SETTING

Basic science research laboratory.

SUBJECTS

C57BL/6 male mice.

INTERVENTIONS

Intraperitoneal fecal-slurry injection, with or without zinc supplementation (10 mg/kg of intraperitoneal zinc gluconate for 3 days prior to intraperitoneal fecal-slurry injection).

MEASUREMENTS AND MAIN RESULTS

Survival over 3 days following intraperitoneal fecal-slurry injection, markers of inflammation, bacterial load studies, and immunophenotyping studies. Zinc-supplemented mice demonstrated a significant survival advantage compared to control (nonsupplemented) mice. Zinc-supplemented mice also demonstrated moderate reductions of inflammation and immune activation. The survival advantage primarily correlated with reduced in vivo bacterial load in zinc-supplemented mice, compared to controls. In addition, peritoneal macrophages harvested from zinc-supplemented mice demonstrated a significantly enhanced phagocytosis capacity for Escherichia coli and Staphylococcus aureus, compared to peritoneal macrophages harvested from control mice.

CONCLUSION

Prophylactic zinc supplementation reduces bacterial load and is beneficial in a murine model of peritoneal sepsis.

A novel small molecule, HK-156, inhibits lipopolysaccharide-induced activation of NF-κB signaling and improves survival in mouse models of sepsis

AIM

To characterize a small molecule compound HK-156 as a novel inhibitor of the nuclear factor κB (NF-κB) signaling pathway.

METHODS

THP-1 monocytes and HEK293/hTLR4A-MD2-CD14 cells were tested. HK-156 and compound 809, an HK-156 analogue, were synthesized. A luciferase assay was used to evaluate the transcriptional activity of NF-κB. The levels of cytokines were measured with cytokine arrays, ELISA and quantitative PCR. An electrophoretic mobility shift assay (EMSA), immunofluorescence, Western blot and mass spectrometry were used to investigate the molecular mechanisms underlying the actions of the agent. BALB/c mice challenged with lipopolysaccharide (LPS, 15 mg/kg, ip) were used as a mouse experimental endotoxemia model.

RESULTS

In HEK293hTLR4/NF-κB-luc cells treated with LPS (1000 ng/mL), HK-156 inhibited the transcriptional activity of NF-κB in a concentration-dependent manner (IC₅₀=6.54 ± 0.37 μmol/L). Pretreatment of THP-1 monocytes with HK-156 (5, 10 and 20 μmol/L) significantly inhibited LPS-induced release and production of TNF-α and IL-1β, attenuated LPS-induced translocation of NF-κB into the nucleus and its binding to DNA, and suppressed LPS-induced phosphorylation and degradation of IκBα, and phosphorylation of IKKβ and TGFβ-activated kinase (TAK1). Meanwhile, HK-156 (5, 10 and 20 μmol/L) slightly suppressed LPS-induced activation of p38. The effect of HK-156 on LPS-induced activation of NF-κB signaling was dependent on thiol groups of cysteines in upstream proteins. In mouse models of sepsis, pre-injection of HK-156 (50 mg/kg, iv) significantly inhibited TNFα production and reduced the mortality caused by the lethal dose of LPS.

CONCLUSION

HK-156 inhibits LPS-induced activation of NF-κB signaling by suppressing the phosphorylation of TAK1 in vitro, and exerts beneficial effects in a mouse sepsis model. HK-156 may therefore be a useful therapeutic agent for treating sepsis.

The new vitamin E derivative, ETS-GS, protects against cecal ligation and puncture-induced systemic inflammation in rats

Sepsis-related systemic inflammation frequently occurs in the critical care setting. Systemic inflammation is implicated in the progression of organ injury, which is associated with a high mortality rate. Recently, vitamin E and glutamic acid have been reported to attenuate inflammation. We therefore investigated whether the vitamin E derivative, ETS-GS, could inhibit the secretion of cytokines and high-mobility group box 1 (HMGB1), and thereby reduce organ damage in a rat model of cecal ligation and puncture (CLP)-induced sepsis. Male Wistar rats weighing 250-300 g were used. Rats received water or ETS-GS (10 mg/kg) by oral administration for 3 weeks, and then sepsis was induced by CLP under sevoflurane anesthesia. Serum levels of interleukin-6, tumor necrosis factor-α, and HMGB1 were determined at 3, 6, and 12 h after CLP; lung histology was assessed at 12 h. Histology results showed markedly reduced interstitial edema and leukocytic infiltration in lung tissue harvested at 12 h in ETS-GS-treated mice compared with untreated controls. ETS-GS treatment also attenuated the CLP-induced increase in serum levels of cytokines and HMGB1. To investigate the mechanisms by which ETS-GS exerts its anti-inflammatory effects, the phosphorylation of Akt, IκBα, and mitogen-activated protein kinase (MAPK) was assessed in mouse macrophage RAW264.7 cells stimulated with LPS, with and without ETS-GS. In these in vitro studies, ETS-GS-induced phosphoinositide 3-kinase (PI3K)-Akt phosphorylation and inhibited IκBα and MAPK phosphorylation. ETS-GS blocked the CLP-induced septic shock response and protected against acute lung injury. This mechanism appeared to be mediated by the induction of PI3K-Akt and the inhibition of IκBα and MAPK phosphorylation. Given these results, ETS-GS shows promise as a potential therapeutic agent for sepsis.

Changes in group II phospholipase A2 gene expression in rat heart during sepsis

BACKGROUND

This study was undertaken to investigate alterations of group II phospholipase A2 (PLA2) gene expression and its underlying mechanism in rat heart during different phases of sepsis.

MATERIALS AND METHODS

Sepsis was induced by cecal ligation and puncture (CLP). Experiments were divided into three groups, control, early sepsis, and late sepsis. Early and late sepsis refers to those animals sacrificed at 9 and 18 h, respectively, after CLP. PLA2 enzyme activity, group II PLA2 protein level, messenger RNA (mRNA) abundance, transcription rate, and half-life were measured.

RESULTS

PLA2 activity was decreased by 29% during early sepsis but it was increased by 49% during late sepsis. Group II PLA2 protein level was decreased by 27% during early sepsis but it was increased by 35.3% during late sepsis. Group II PLA2 mRNA was decreased by 21% during early sepsis but it was increased by 141% during late sepsis. The transcription rate of group II PLA2 mRNA was reduced by 25% during early sepsis but it was elevated by 67% during late sepsis. The half-life of group II PLA2 mRNA remained unaltered during early and late phases of sepsis.

CONCLUSIONS

These results demonstrate that PLA2 activity, group II PLA2 protein level, the mRNA abundance, and transcription rate were concurrently underexpressed during early sepsis, while they were overexpressed during late sepsis, with no change in the degradation of gene transcript. These data indicate that the biphasic changes in group II PLA2 gene expression are regulated transcriptionally during sepsis.

Effects of ghrelin on pulmonary NOD2 mRNA expression and NF-κB activation when protects against acute lung injury in rats challenged with cecal ligation and puncture

BACKGROUND

Many studies have shown that ghrelin can down-regulate inflammatory cytokine expression via the inhibition of NF-κB activity and therefore, its administration to septic patients is considered beneficial. However, our knowledge of ghrelin's effects on the upstream activators of the NF-κB pathway, such as NOD2, is still limited. This study aimed to investigate the possible involvement of the NOD2 signaling pathway in the anti-inflammatory effects of ghrelin.

METHODS

Twenty-four male SD rats received cecal ligation and puncture (CLP) or sham operation, followed by infusion of saline or ghrelin. The lungs were harvested 6h after CLP or sham operation and analyzed for lung histopathology, neutrophil infiltration, inflammatory cytokines (TNF-α, and IL-6), NOD2 mRNA expression, and activation of NF-κB. Furthermore, survival was recorded for ten days in additional groups of rats.

RESULTS

Compared with sham group, neutrophil infiltration, TNF-α and IL-6 levels, NOD2 mRNA expression, as well as NF-κB activation in lungs from rats undergoing CLP were significantly increased. After the administration of ghrelin, all inflammatory parameters analyzed were lower than those without ghrelin following CLP. In addition, ghrelin improved survival after CLP.

CONCLUSION

Our results indicate that in a CLP model of sepsis, the beneficial effects that ghrelin has on inflammatory outcomes are mediated at least in part through inhibition of NOD2 expression upstream of NF-κB.

The ability of an ethanol extract of Cinnamomum cassia to inhibit Src and spleen tyrosine kinase activity contributes to its anti-inflammatory action

ETHNOPHARMACOLOGICAL RELEVANCE

Cinnamomum cassia Blume (Aceraceae) has been traditionally used to treat various inflammatory diseases such as gastritis. However, the anti-inflammatory mechanism of Cinnamomum cassia has not been fully elucidated. This study examined the anti-inflammatory mechanism of 95% ethanol extract (Cc-EE) of Cinnamomum cassia.

MATERIALS AND METHODS

The effect of Cc-EE on the production of inflammatory mediators in RAW264.7 cells and peritoneal macrophages was investigated. Molecular mechanisms underlying the effects, especially inhibitory effects, was elucidated by analyzing the activation of transcription factors and their upstream signaling, and by evaluating the kinase activity of target enzymes.

RESULTS

Cc-EE of Cinnamomum cassia diminished the production of nitric oxide (NO), tumor necrosis factor (TNF)-α, and prostaglandin (PG)E(2), in lipopolysaccharide (LPS)-activated RAW264.7 cells and peritoneal macrophages in a dose-dependent manner. Cc-EE also blocked mRNA expression of inducible NO synthase (iNOS), cyclooxygenase (COX)-2, and TNF-α by suppressing the activation of nuclear factor (NF)-κB, and simultaneously inhibited its upstream inflammatory signaling cascades, including spleen tyrosine kinase (Syk) and Src. Consistent with these findings, the extract directly blocked the kinase activities of Src and Syk.

CONCLUSION

Cc-EE exerts strong anti-inflammatory activity by suppressing Src/Syk-mediated NF-κB activation, which contributes to its major ethno-pharmacological role as an anti-gastritis remedy. Future work will be focused on determining whether the extract can be further developed as an anti-inflammatory drug.

Prevention of sepsis in children: a new paradigm for public policy

Sepsis is one of the leading causes of death worldwide. While the management of critically ill patients with sepsis is certainly better now compared to 20 years ago, sepsis-associated mortality remains unacceptably high. Annual deaths from sepsis in both children and adults far surpass the number of deaths from acute myocardial infarction (AMI), stroke, or cancer. Given the substantial toll that sepsis takes worldwide, prevention of sepsis remains a global priority. Multiple effective prevention strategies exist. Antibiotic prophylaxis, immunizations, and healthcare quality improvement initiatives are important means through which we may reduce the morbidity and mortality from sepsis around the world. Inclusion of these strategies in a coordinated and thoughtful campaign to reduce the global burden of sepsis is necessary for the improvement of pediatric health worldwide.

Pediatric Sepsis - Part I: "Children are not small adults!"

The recognition, diagnosis, and management of sepsis remain among the greatest challenges in pediatric critical care medicine. Sepsis remains among the leading causes of death in both developed and underdeveloped countries and has an incidence that is predicted to increase each year. Unfortunately, promising therapies derived from preclinical models have universally failed to significantly reduce the substantial mortality and morbidity associated with sepsis. There are several key developmental differences in the host response to infection and therapy that clearly delineate pediatric sepsis as a separate, albeit related, entity from adult sepsis. Thus, there remains a critical need for well-designed epidemiologic and mechanistic studies of pediatric sepsis in order to gain a better understanding of these unique developmental differences so that we may provide the appropriate treatment. Herein, we will review the important differences in the pediatric host response to sepsis, highlighting key differences at the whole-organism level, organ system level, and cellular and molecular level.

Sepsis in the pediatric cardiac intensive care unit

The survival rate for children with congenital heart disease (CHD) has increased significantly coincident with improved techniques in cardiothoracic surgery, cardiopulmonary bypass and myocardial protection, and perioperative care. Cardiopulmonary bypass, likely in combination with ischemia-reperfusion injury, hypothermia, and surgical trauma, elicits a complex, systemic inflammatory response that is characterized by activation of the complement cascade, release of endotoxin, activation of leukocytes and the vascular endothelium, and release of proinflammatory cytokines. This complex inflammatory state causes a transient immunosuppressed state, which may increase the risk of hospital-acquired infection in these children. Postoperative sepsis occurs in nearly 3% of children undergoing cardiac surgery and has been associated with longer length of stay and mortality risks in the pediatric cardiac intensive care unit. Herein, we review the epidemiology, pathobiology, and management of sepsis in the pediatric cardiac intensive care unit.

Benznidazole treatment attenuates liver NF-κB activity and MAPK in a cecal ligation and puncture model of sepsis

Recent studies have shown that Benznidazole (BZL), known for its antiparasitic action on Trypanosoma cruzi, modulates pro-inflammatory cytokines and nitric oxide (NO) release in activated macrophages by blocking NF-κB through inhibition of IKK in vitro. As so far, little is known about the mechanism by which BZL provokes the inhibition of inflammatory response in sepsis in vivo, we aimed to delineate the possible role of BZL as a modulator in liver inflammation in mice with sepsis induced by cecal ligation and puncture (CLP). Specifically, we analyzed leukocytes, liver production of TNF-α and NO and the intracellular pathways modulated by these mediators, including NF-κB and MAPKs, in the liver of mice 24 h post-CLP. Our results show that BZL reduces leukocytes in peripheral blood accompanied by an increase in peritoneal macrophages 24h after CLP. In the liver of these septic mice, BZL decreased expression of mRNA and protein for TNF-α and NOS-2 by inhibition of NF-κB and MAPK (p-38 and ERK). The body of evidence suggests that the immunomodulatory effects of BZL could act selectively, as it is able to decrease the systemic inflammatory reaction and the hepatic response but it can increase the number of cells in the site of infection.

Chronic critical illness: prevalence, profile, and pathophysiology

The syndrome of chronic critical illness has well-documented emotional, social, and financial burdens for individuals, caregivers, and the health care system. The purpose of this article is to provide experienced acute and critical care clinicians with essential information about the prevalence and profile of the chronically critically ill patient needed for comprehensive care. In addition, pathophysiology contributing to chronic critical illness is addressed, though the exact mechanism underlying the conversion of acute critical illness to chronic critical illness is unknown. Clinicians can use this information to identify at-risk intensive care unit patients and to institute proactive care to minimize burden and distress experienced by patients and their caregivers.

Toward a clinically feasible gene expression-based subclassification strategy for septic shock: proof of concept

OBJECTIVE

To develop a clinically feasible stratification strategy for pediatric septic shock, using gene expression mosaics and a 100-gene signature representing the first 24 hrs of admission to the pediatric intensive care unit.

DESIGN

Prospective, observational study involving microarray-based bioinformatics.

SETTING

Multiple pediatric intensive care units in the United States.

PATIENTS

Ninety-eight children with septic shock.

INTERVENTIONS

None other than standard care.

MEASUREMENTS AND MAIN RESULTS

Patients were classified into three previously published, genome-wide, expression-based subclasses (subclasses A, B, and C) having clinically relevant phenotypic differences. The class-defining 100-gene signature was depicted for each individual patient, using mosaics generated by the Gene Expression Dynamics Inspector (GEDI). Composite mosaics were generated representing the average expression patterns for each of the three subclasses. Nine individual clinicians served as blinded evaluators. Each evaluator was shown the 98 individual patient mosaics and asked to classify each patient into one of the three subclasses, using the composite mosaics as the reference point. The respective sensitivities, specificities, positive predictive values, and negative predictive values of the subclassification strategy were ≥ 4% across the three subclasses. The classification strategy also generated positive likelihood ratios of ≥ 6.8 and negative likelihood ratios of ≤ .2 across the three subclasses. The κ coefficient across all possible interevaluator comparisons was 0.81.

CONCLUSIONS

We have provided initial evidence (proof of concept) for a clinically feasible and robust stratification strategy for pediatric septic shock based on a 100-gene signature and gene expression mosaics.

Leukocyte subset-derived genomewide expression profiles in pediatric septic shock

OBJECTIVE

To directly assess whether genomewide expression profiles derived from leukocyte subsets are comparable to that of whole blood as measured by enrichment for genes corresponding to metabolic and signaling pathways.

DESIGN

Prospective observational study involving microarray-based bioinformatics based on RNA individually derived from whole blood, neutrophils, monocytes, and lymphocytes, respectively.

SETTING

Three pediatric intensive care units in the United States.

PATIENTS

Children < or =10 yrs of age: five normal control subjects and 13 meeting criteria for septic shock on day 1 of presentation to the pediatric intensive care unit.

INTERVENTIONS

None other than standard care.

MEASUREMENTS AND MAIN RESULTS

Baseline analyses using whole blood-derived RNA demonstrated increased expression of genes corresponding to signaling pathways involving innate immunity, redox balance, and protein ubiquitination and decreased expression of genes corresponding to the adaptive immune system. Subsequent analyses using leukocyte-specific RNA were congruent with the gene expression profiles demonstrated using whole blood-derived RNA as measured by enrichment for genes corresponding to metabolic and signaling pathways. Gene network analysis, derived from a composite gene list involving the individual gene expression profiles of neutrophils, monocytes, and lymphocytes, respectively, revealed a gene network corresponding to antigen presentation, cell-mediated immunity, and humoral-mediated immunity. Finally, a subanalysis focused on network gene nodes localized to the nuclear compartment revealed functional annotations related to transcriptional repression and epigenetic regulation.

CONCLUSIONS

These data demonstrate that genome-level repression of adaptive immunity gene programs early in the course of pediatric septic shock remained evident when analyses were conducted using leukocyte subset-specific RNA.

In vitro and in vivo anti-inflammatory effects of ethanol extract from Acer tegmentosum

AIM OF STUDY

Acer tegmentosum has been traditionally used for folk medicine to treat hepatic disorders such as hepatitis, hepatic cancer, and hepatic cirrhosis. In this study, we demonstrate the ethno-pharmacological activity of Acer tegmentosum in in vitro and in vivo inflammatory conditions.

RESULTS

The 70% ethanol extract (At-EE) of Acer tegmentosum dose-dependently diminished the production of nitric oxide (NO), tumour necrosis factor (TNF)-alpha, and prostaglandin (PG)E(2), in lipopolysaccharide (LPS)-activated RAW264.7 cells and peritoneal macrophages, by a transcriptional mechanism. At-EE also suppressed the activation of nuclear factor (NF)-kappaB, activator protein (AP)-1, and cAMP-responsive element binding (CREB), and simultaneously blocked their upstream inflammatory signalling cascades, including Akt, p38, and JNK. Furthermore, At-EE protected against LPS-induced cell death induced by reactive oxygen species (ROS) and reactive nitrogen species (RNS) and neutralized reactive species generation. In agreement with the in vitro results, orally administered At-EE strongly ameliorated ear oedema formation induced by arachidonic acid.

CONCLUSION

At-EE displays strong anti-inflammatory activities in vitro and in vivo, contributing to its major ethno-pharmacological role such as anti-hepatitis remedy and may be applicable to novel anti-inflammatory therapeutics.

Death to sepsis: targeting apoptosis pathways in sepsis

Sepsis is a significant public health problem and is one of the leading causes of death in critically ill patients admitted to the intensive care unit. The cost, both in terms of lives lost and annual healthcare expenditures, from sepsis is staggering. Unfortunately, despite an increasing understanding of the unique molecular pathobiology of sepsis, mortality has remained more or less stable over the past decade. Moreover, promising therapies in preclinical models of sepsis have universally failed to live up to initial expectations in subsequent clinical trials. Multiple studies have demonstrated that apoptosis plays a major role in the pathobiology of sepsis and acute lung injury, making the apoptosis pathway an attractive target for therapy. Herein, the role of apoptosis in sepsis is briefly discussed, highlighting studies with one potential therapeutic agent targeting the apoptosis pathway.