VIDAS Enzyme-Linked Fluorescent Immunoassay for Detection of Salmonella in Foods: Collaborative Study

The VIDAS SLM method for detection of Salmonella was compared with the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Twenty laboratories participated in the evaluation. Each laboratory tested one or more of 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. No significant differences (P< 0.05) were observed between the 2 methods. The 2 methods were in agreement for 99% of 1544 samples analyzed. Of the 20 samples out of agreement, 8 were VIDAS SLM positive and BAM/AOAC negative, and 12 were VIDAS SLM negative and BAM/AOAC positive. The VIDAS SLM method for detection of Salmonella in foods has been adopted first action by AOAC INTERNATIONAL.

Abstract P2-01-31: Validation of novel diagnostic kits using the semi-dry dot-blot method for detecting metastatic lymph nodes in breast cancer; distinguishing macrometastases and micrometastases

Background: The semi-dry dot-blot (SDB) method is a diagnostic procedure for detecting lymph node (LN) metastases. Metastases are confirmed by the presence of cytokeratin (CK) in lavage fluid of sectioned LNs that contain anti-pancytokeratin antibody, based on the theory that epithelial components such as CK are not found in normal LNs. We evaluated two novel SDB kits that use the newly developed anti-CK19 antibody for diagnosing LN metastases in breast cancer.

Methods: We obtained 159 LNs dissected from 93 breast cancer patients from July 2013 to December 2015 at Nagasaki University Hospital, including 38 dissected axillary LNs and 121 sentinel LNs, sliced at 2-mm intervals and washed with phosphate-buffered saline. The suspended cells in the lavage fluid of sliced LNs were centrifuged and lysed to extract protein. This extracted protein was used with a low-power and a high-power kit to diagnose LN metastasis. The washed LNs were blindly diagnosed by pathologists using hematoxylin and eosin (H&E) stain. Diagnoses based on the kit were compared with their H&E counterparts.

Results: Of the 159 LNs, 68 were assessed as positive and 91 as negative by permanent pathological examination with H&E. Sensitivity, specificity, and accuracy of the low-power kit for detecting LN metastases was 83.8%, 100%, and 93.1%, respectively. In 11 false-negative cases, there were nine micrometastases, producing a sensitivity of 96.4% for detecting macrometastases. Sensitivity, specificity, and accuracy of the high-power kit for detecting LN metastases was 92.6%, 92.3%, and 92.5%, respectively. Combining the low- and high-power kit results, sensitivity, specificity and accuracy for distinguishing macrometastases from micrometastases was 94.5%, 95.2%, and 95.0%, respectively. Diagnosis was achieved in approximately 20 min using the kits, at a cost of less than 25 USD.

Conclusions: The kits in our study were accurate, quick, and cost-effective in diagnosing LN metastases without the loss of LN tissue. The kits' ability to distinguish macrometastases from micrometastases was excellent, which is important, clinically.

Citation Format: Otsubo R, Hirakawa H, Oikawa M, Inamasu E, Baba M, Matsumoto M, Yano H, Kinoshita N, Abe K, Fukuoka J, Nagayasu T. Validation of novel diagnostic kits using the semi-dry dot-blot method for detecting metastatic lymph nodes in breast cancer; distinguishing macrometastases and micrometastases [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-31.

Abstract P4-21-14: A randomized phase II trial of trastuzumab + capecitabine versus lapatinib + capecitabine in patients with HER2-positive metastatic breast cancer previously treated with trastuzumab and taxanes: WJOG6110B/ELTOP

Background: In patients with HER2-positive metastatic breast cancer (MBC) who progressed on trastuzumab (H)-based therapy, both continuing H beyond progression and switching to lapatinib (L) in combination with chemotherapy are valid options. However, it is unclear which strategy is more effective and how we can select a proper strategy in each patient.

Methods: We conducted an open label, multicenter, randomized phase II trial to comparatively evaluate efficacy and safety of H + capecitabine (X) (HX) or L + X (LX) in women with HER2-positive MBC who were previously treated with taxanes and progressed on H-containing regimens. Patients treated with more than two chemotherapy regimens for MBC were excluded. Those treated with pertuzumab and/or T-DM1 were allowed to enroll in this study. Patients with brain metastases were also included if they are asymptomatic. Patients received H (4mg/kg loading then 2mg/kg weekly or 8mg/kg loading then 6mg/kg every 3 weeks) and X (2500 mg/m2/day on days 1-14 every 3weeks) in HX arm and L (1250 mg/day) and X (2000 mg/m2/day on days 1-14 every 3weeks) in LX arm until progression or intolerable toxicity. The primary endpoint was progression-free survival (PFS) and secondary endpoints included overall survival (OS), objective response rate (ORR), proportion of subjects progressing with brain metastases as site of first progression, and safety.We also assessed biomarkers in tumor tissues and circulating cell-free DNA.

Results: Between May 2011 and December 2014, 86 patients (43 in HX arm and 43 in LX arm) were enrolled in this study. Median age was 58 years (range 34-81), ECOG performance status was 0 (63%), 1 (35%), or 2 (2%), 63% had hormone receptor-positive disease, 15% had brain metastases, 56% had relapsed after primary surgery, and 23% had received adjuvant or neo-adjuvant trastuzumab. Median follow-up time was 44.6 months. Median PFS was 6.1 months in HX arm and 7.1 months in LX arm (hazard ratio 0.81 90% CI 0.55-1.21; p=0.39), median OS was 31.0 months in HX arm and not reached in LX arm (hazard ratio 0.58 95% CI 0.26-1.31; p=0.18), ORR was 40% in HX arm and 41% in LX arm (p=1.00), disease control rate was 73% in HX arm and 92% in LX arm (p=0.038), and proportion of subjects progressing with brain metastases as site of first progression was 5% in HX arm and 5% in LX arm. Grade 3-4 toxicities included hand-foot syndrome (21% in HX arm and 21% in LX arm) and diarrhea (9% in HX arm and 16% in LX arm). In subgroup analyses, PFS benefit in LX arm compared to HX arm was significantly larger among patients who had received previous systemic treatment for metastatic disease for less than 1 year (interaction p=0.007). Subgroup analyses by biomarkers will be presented at the meeting.

Conclusions: In women with HER2-positive MBC previously treated with trastuzumab and taxanes, lapatinib + capecitabine tended to yield better PFS and OS than trastuzumab beyond progression + capecitabine, although they were not statistically significant.Background: In patients with HER2-positive metastatic breast cancer (MBC) who progressed on trastuzumab (H)-based therapy, both continuing H beyond progression and switching to lapatinib (L) in combination with chemotherapy are valid options. However, it is unclear which strategy is more effective and how we can select a proper strategy in each patient.

Methods: We conducted an open label, multicenter, randomized phase II trial to comparatively evaluate efficacy and safety of H + capecitabine (X) (HX) or L + X (LX) in women with HER2-positive MBC who were previously treated with taxanes and progressed on H-containing regimens. Patients treated with more than two chemotherapy regimens for MBC were excluded. Those treated with pertuzumab and/or T-DM1 were allowed to enroll in this study. Patients with brain metastases were also included if they are asymptomatic. Patients received H (4mg/kg loading then 2mg/kg weekly or 8mg/kg loading then 6mg/kg every 3 weeks) and X (2500 mg/m2/day on days 1-14 every 3weeks) in HX arm and L (1250 mg/day) and X (2000 mg/m2/day on days 1-14 every 3weeks) in LX arm until progression or intolerable toxicity. The primary endpoint was progression-free survival (PFS) and secondary endpoints included overall survival (OS), objective response rate (ORR), proportion of subjects progressing with brain metastases as site of first progression, and safety.We also assessed biomarkers in tumor tissues and circulating cell-free DNA.

Results: Between May 2011 and December 2014, 86 patients (43 in HX arm and 43 in LX arm) were enrolled in this study. Median age was 58 years (range 34-81), ECOG performance status was 0 (63%), 1 (35%), or 2 (2%), 63% had hormone receptor-positive disease, 15% had brain metastases, 56% had relapsed after primary surgery, and 23% had received adjuvant or neo-adjuvant trastuzumab. Median follow-up time was 44.6 months. Median PFS was 6.1 months in HX arm and 7.1 months in LX arm (hazard ratio 0.81 90% CI 0.55-1.21; p=0.39), median OS was 31.0 months in HX arm and not reached in LX arm (hazard ratio 0.58 95% CI 0.26-1.31; p=0.18), ORR was 40% in HX arm and 41% in LX arm (p=1.00), disease control rate was 73% in HX arm and 92% in LX arm (p=0.038), and proportion of subjects progressing with brain metastases as site of first progression was 5% in HX arm and 5% in LX arm. Grade 3-4 toxicities included hand-foot syndrome (21% in HX arm and 21% in LX arm) and diarrhea (9% in HX arm and 16% in LX arm). In subgroup analyses, PFS benefit in LX arm compared to HX arm was significantly larger among patients who had received previous systemic treatment for metastatic disease for less than 1 year (interaction p=0.007). Subgroup analyses by biomarkers will be presented at the meeting.

Conclusions: In women with HER2-positive MBC previously treated with trastuzumab and taxanes, lapatinib + capecitabine tended to yield better PFS and OS than trastuzumab beyond progression + capecitabine, although they were not statistically significant.

Citation Format: Takano T, Tsurutani J, Takahashi M, Yamanaka T, Sakai K, Ito Y, Fukuoka J, Kimura H, Kawabata H, Tamura K, Matsumoto K, Aogi K, Sato K, Nishio K, Nakagawa K, Saeki T. A randomized phase II trial of trastuzumab + capecitabine versus lapatinib + capecitabine in patients with HER2-positive metastatic breast cancer previously treated with trastuzumab and taxanes: WJOG6110B/ELTOP [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-14.

A multicenter phase II study of carboplatin and paclitaxel for advanced thymic carcinoma: WJOG4207L

BACKGROUND

Thymic carcinoma (TC) is an exceptionally rare tumor, which has a very poor prognosis differing from thymoma. Till date, there has been no report of any results of clinical trials focusing on TC. The role of non-anthracycline-based chemotherapy has not been elucidated since the previous studies included a relatively small number of TC patients. This single-arm study evaluated carboplatin and paclitaxel (CbP) in chemotherapy-naive patients with advanced TC.

PATIENTS AND METHODS

The study treatment consisted of carboplatin (area under the curve 6) and paclitaxel (200 mg/m(2)) every 3 weeks for a maximum of six cycles. The primary end point was objective response rate (ORR) by independent review. The secondary end points included overall survival (OS), progression-free survival (PFS), and safety. Based on the SWOG 2-stage design, the planned sample size of 40 patients was determined to reject the ORR of 20% under the expectation of 40% with a power of 0.85 and a type I error of 0.05.

RESULTS

Forty patients from 21 centers were enrolled for this study from May 2008 to November 2010. Of the 39 patients evaluable for analysis, 36 were pathologically diagnosed by independent review, and 97% patients were eventually TC. There was 1/13 complete/partial responses with an ORR of 36% (95% confidence interval 21%-53%; P = 0.031). The median PFS was 7.5 (6.2-12.3) months, while OS did not reach the median value. Major adverse event was grade 3-4 neutropenia in 34 patients (87%). There was no treatment-related death.

CONCLUSIONS

In this largest trial with TC, CbP showed promising efficacy in advanced TC when compared with anthracycline-based chemotherapy, which is the current standard treatment of thymic neoplasm. Our results established that CbP, one of the standard treatments for non-small-cell lung cancer, might be an option as a chemotherapy regimen for TC.

Surfactant protein C G100S mutation causes familial pulmonary fibrosis in Japanese kindred

Several mutations in the surfactant protein C (SP-C) gene (SFTPC) have been reported as causing familial pulmonary fibrosis (FPF). However, the genetic background and clinical features of FPF are still not fully understood. We identified one Japanese kindred, in which at least six individuals over three generations were diagnosed with pulmonary fibrosis. We examined the patients radiologically and histopathologically and sequenced their SFTPC and ABCA3 genes. We also established a cell line stably expressing the mutant gene. All the patients had similar radiological and histopathological characteristics. Their histopathological pattern was that of usual interstitial pneumonia, showing numerous fibroblastic foci even in areas without abnormal radiological findings on chest high-resolution computed tomography. No child had respiratory symptoms in the kindred. Sequencing of SFTPC showed a novel heterozygous mutation, c.298G>A (G100S), in the BRICHOS domain of proSP-C, which co-segregated with the disease. However, in the ABCA3 gene, no mutation was found. In vitro expression of the mutant gene revealed that several endoplasmic reticulum stress-related proteins were strongly expressed. The mutation increases endoplasmic reticulum stress and induces apoptotic cell death compared with wild-type SP-C in alveolar type II cells, supporting the significance of this mutation in the pathogenesis of pulmonary fibrosis.

Frequent homozygous deletion of the LKB1/STK11 gene in non-small cell lung cancer

LKB1/STK11 is a tumor suppressor and a negative regulator of mammalian target of rapamycin signaling. It is inactivated in 30% of lung cancer cell lines but only 5-15% of primary lung adenocarcinomas. There is evidence that homozygous deletion (HD) of chromosome 19p at the LKB locus contributes to the inactivation of the gene in primary human lung cancers. Here, we used several complementary genetic approaches to assess the LKB1 locus in primary non-small cell lung cancers (NSCLCs). We first analyzed 124 NSCLC cases for allelic imbalance using eight microsatellite markers on chromosome 19p, which revealed an overall rate of 65% (80 of 124) loss of heterozygosity (LOH). We next used chromogenic in situ hybridization (CISH) to directly examine the chromosomal status of the LKB1 locus. In all, 65 of 124 LOH tested samples were available for CISH and 58 of those (89%) showed either loss of one copy of chromosome 19p (LOH, 40 of 65 cases, 62%) or both copies (HD 18 of 65 cases, 28%). The occurrence of HD was significantly more frequent in Caucasian (35%) than in African-American patients (6%) (P=0.04). A total of 62 of 124 samples with LOH at one or both markers immediately flanking the LKB1 gene were further analyzed by directly sequencing the complete coding region, which identified 7 of 62 (11%) tumors with somatic mutations in the gene. Jointly, our data identified total inactivation of the LKB1 gene by either HD or LOH with somatic mutation in 39% of tested samples, whereas loss of chromosome 19p region by HD or LOH at the LKB1 region occured in 90% of NSCLC.

Multicentre prospective phase II trial of gefitinib for advanced non-small cell lung cancer with epidermal growth factor receptor mutations: results of the West Japan Thoracic Oncology Group trial (WJTOG0403)

The purpose of this study was to evaluate the efficacy of gefitinib and the feasibility of screening for epidermal growth factor receptor (EGFR) mutations among select patients with advanced non-small cell lung cancer (NSCLC). Stage IIIB/IV NSCLC, chemotherapy-naive patients or patients with recurrences after up to two prior chemotherapy regimens were eligible. Direct sequencing using DNA from tumour specimens was performed by a central laboratory to detect EGFR mutations. Patients harbouring EGFR mutations received gefitinib. The primary study objective was response; the secondary objectives were toxicity, overall survival (OS), progression-free survival (PFS), 1-year survival (1Y-S) and the disease control rate (DCR). Between March 2005 and January 2006, 118 patients were recruited from 15 institutions and were screened for EGFR mutations, which were detected in 32 patients – 28 of whom were enrolled in the present study. The overall response rate was 75%, the DCR was 96% and the median PFS was 11.5 months. The median OS has not yet been reached, and the 1Y-S was 79%. Thus, gefitinib chemotherapy in patients with advanced NSCLC harbouring EGFR mutations was highly effective. This trial documents the feasibility of performing a multicentre phase II study using a central typing laboratory, demonstrating the benefit to patients of selecting gefitinib treatment based on their EGFR mutation status.

Pathologic approach to pulmonary hemorrhage

The pathologist's approach to pulmonary hemorrhage is outlined. Most cases fall into those examples of pulmonary hemorrhage caused by localized sites of bleeding, and those examples that fall within the spectrum of diffuse alveolar hemorrhage. The histologic evaluation of pulmonary hemorrhage is outlined including assessment of fresh hemorrhage in alveolar spaces (including exclusion of traumatic hemorrhage related to the procedure) and the presence of hemosiderin and its various causes. The most common causes of diffuse alveolar hemorrhage and clues to their clinically pathologic diagnosis are discussed.

Neuronal microdysgenesis and acquired lesions of the hippocampal formation connected with seizure activities in Ihara epileptic rat

The present study was designed to examine the morphological features of the hippocampal formation in the Ihara epileptic rat (IER), and to characterize genetically programmed lesions and acquired lesions connected with seizure activities. Neuropathological investigation of the hippocampal formation was performed in four separate groups, 2-month-old IERs with neither abnormal behaviors nor any seizure activity, and 12-month-old IERs of both sexes with abnormal behaviors, circling seizures or generalized tonic-clonic convulsions. In every IER examined, there were invariable and fundamental neuropathological findings consisting of abnormal neuronal clusters in the CA1 of the hippocampal formation. Moreover, disarrangement of neuronal cells, such as dispersion and gaps in lamination of pyramidal neurons, were observed. These changes were thought to represent genetically programmed lesions, neuronal microdysgenesis, because they were common findings in 2-month-old and 12-month-old IERs of both sexes. An enlargement of the dentate gyrus was also found in rats that experienced generalized tonic-clonic convulsions or circling seizures. This enlargement of the dentate gyrus, on the other hand, was categorized as a secondary and acquired lesion connected with seizure activities. It is suggested that the neuronal microdysgenesis in the hippocampal formation of IER has an intimate relationship with epileptogenesis and/or an enhancement of seizure susceptibility.

Expression of brain specific chondroitin sulfate proteoglycans, neurocan and phosphacan, in the developing and adult hippocampus of Ihara's epileptic rats

Ihara's epileptic rats (IER) is an animal model of temporal lobe epilepsy with mycrodysgenesis, that exhibit abnormal migration of hippocampal neurons and recurrent spontaneous seizures. As an attempt to elucidate the roles of extracellular matrix molecules in the epileptogenecity and mossy fiber sprouting, immunohistochemical localization of brain specific chondroitin sulfate proteoglycans (CSPGs), neurocan and phosphacan, was examined in the hippocampus of postnatal IER and Sprague-Dawley (SD) rats using monoclonal antibodies 1G2 against neurocan and 6B4 against phosphacan. There was no difference in the expression of these two CSPGs between IER and SD rats in the 1st postnatal week. However, the expression of neurocan was poor in the hippocampus of IER in the 2nd and 3rd weeks whereas intense labeling of neurocan was present throughout the hippocampus of SD rats. Labeling of neurocan was almost absent in the hippocampus, while phosphacan was diffusely expressed in the stratum oriens and radiatum of Ammon's horn, and in the hilus and inner one-third molecular layer of the dentate gyrus at the 2nd month after birth. There was no difference in the expression of neurocan and phosphacan between IER and SD rats at the 2nd month after birth. By contrast, phosphacan was reduced in the inner molecular layer of the dentate gyrus in 8-month-old IER, while neurocan was reexpressed in the outer molecular layer and hilus in 3- and 8-month-old IER. It was suggested that the insufficient expression of neurocan may affect the development of neuronal organization in the hippocampus, and that the remodeling of extracellular matrix in the dentate gyrus may contribute to the mossy fiber sprouting into the inner molecular layer.

Mossy fiber sprouting in the dentate gyrus in a newly developed epileptic mutant, Ihara epileptic rat

We examined the correlation between seizure activity and development of mossy fiber sprouting in the hippocampal formation using Timm staining in a newly developed Ihara epileptic rat (IER). The sprouting of mossy fibers were clearly shown in the inner molecular portion of the dentate gyrus and in the stratum oriens of CA3 pyramidal cell layer with repeated seizures. A positive correlation between the frequency of generalized tonic and clonic convulsions and the Timm staining score in molecular layer of dentate gyrus was revealed. Sprouting of mossy fiber in IER seems to be linked with seizure activities resulting from epileptic bursts, not to the genetic mutation.

High performance seizure-monitoring system using a vibration sensor and videotape recording: behavioral analysis of genetically epileptic rats

A new seizure-monitoring apparatus containing a piezoceramic vibration sensor combined with videotape recording was developed. Behavioral analysis of Ihara's genetically epileptic rat (IGER), which is a recently developed novel mutant with spontaneously limbic-like seizures, was performed using this new device. Twenty 8-month-old male IGERs were monitored continuously for 72 h. Abnormal behaviors were detected by use of a vibration recorder, and epileptic seizures were confirmed by videotape recordings taken synchronously with vibration recording. Representative forms of seizures were generalized convulsions and circling seizures. Generalized convulsions were found in 13 rats, and circling seizures in 7 of 20 animals. Two rats had generalized and circling seizures, and two rats did not have seizures. Although there was no apparent circadian rhythm to the generalized seizures, circling seizures occurred mostly between 1800 and 0800 h. A correlation between the sleep-wake cycle and the occurrence of circling seizures seems likely. Without exception, all the seizure actions were recorded by the vibration recorder and the videotape recorder. To eliminate the risk of a false-negative result, investigators scrutinized the information obtained from the vibration sensor and the videotape recorder. The newly developed seizure-monitoring system was found to facilitate detailed analysis of epileptic seizures in rats.

[Different responses of morning dipping and nocturnal dipping to inhaled and/or oral steroids in chronic asthmatics]

Clinical experiences have suggested distinct differences in responses to anti-asthmatic drugs between patients suffering early morning asthmatic attacks and those experiencing nocturnal ones. However, there has been no report on any difference in the improvement of asthmatic flow dipping after inhaled and/or oral steroid treatment. In this retrospective study, the peak expiratory flow rates (PEF), which had been monitored four times a day, were reviewed in 40 chronic asthmatics. The group consisted of 19 patients with very low PEF (geometrical mean PEF/week [mPEF] < 60% of the personal best PEF), 15 patients with moderately low PEF (mPEF 60% to 70% of personal best PEF), 2 patients with mildly low PEF (mPEF 70% to 80% of personal best PEF) and 4 patients with occasionally low PEF (mPEF > 80% of personal best PEF). Of 40 chronic asthmatics, 22 patients had morning dipping alone and 10 patients had both morning dipping and nocturnal dipping. After inhaled and/or oral steroid treatment at sufficient level, mPEF was improved in all patients. All the dipping disappeared except for morning dipping in five cases. We concluded that there was a difference in responses to inhaled and/or oral steroids during early morning dipping and during nocturnal dipping in chronic asthmatics. There should be further investigation to discriminate between pathophysiological events that may be related to morning dipping and to nocturnal dipping.

The UAS of the yeast GAPDH promoter consists of multiple general functional elements including RAP1 and GRF2 binding sites

The upstream activating sequence (UAS) of TDH3, one of three genes encoding glyceraldehyde phosphate dehydrogenase in Saccharomyces cerevisiae, was characterized by using a series of external and internal deletion mutants of the TDH3 upstream region. The levels of activation by these deletions of transcription mediated through either the segment of TDH3 promoter or the segment of ADH1 (alcohol dehydrogenase 1 gene) promoter were quantitatively examined and the region between -583 and -447 was found to be required for full transcriptional activation with either promoter segment. It has been demonstrated that the protein binding site involved in the formation of two DNA-protein complexes is identical with the consensus RAP1 binding sequence by methylation interference assay. Surprisingly, the UAS fragment composed of the 22-mer sequence containing exclusively a RAP1 binding sequence showed full activation, suggesting that the RAP1-dependent transcriptional activation is a primary positive control in the TDH3 gene expression. In addition, a pair of inverted repeat sequences homologous to the binding sequence for GRF2, another yeast trans-acting factor, and directly repeated sequences containing a CATCC motif were also found upstream and downstream, respectively, of the RAP1 binding site. Deletion analysis suggested that these elements could also function as regulatory elements for transcription.

[Reduction in leukocyte elastase levels in patients with sepsis by administration of urinastatin]

Leukocyte elastase (LE) plays a role in the development of shock. Therefore, we examined the effects of urinastatin, a protease inhibitor, on LE in 7 patients with sepsis. LE levels before the administration of urinastatin were high in all patients, especially those in shock. Administration of urinastatin markedly decreased LE levels, with the decrease being more remarkable in patients showing high LE levels before treatment. These results suggest that urinastatin not only reduces LE levels but also suppresses factors that are involved in the development of septic shock.