Hemoadsorption by extracorporeal cytokine adsorption therapy (CytoSorb®) in the management of septic shock: A retrospective observational study

INTRODUCTION

Sepsis results in immunologic disturbances with the release of various inflammatory mediators such as cytokines. Cytokines can damage the cells, and the continuous release of inflammatory mediators leads to severely impaired immunity. Therefore, the reduction in cytokine levels by hemoadsorption represents a new concept for blood purification. CytoSorb^® as a hemoadsorption device is a detoxification system, which aims to decrease the cytokines levels. This study was conducted to understand any beneficial effects of CytoSorb^® therapy in septic patients.

METHODOLOGY

This was a retrospective and observational study, approved by the scientific and ethics committee of Max Super Specialty Hospital, Patparganj, Delhi, India and conducted in compliance with current International Council for Harmonization, Good Clinical Practice, Schedule Y, and Indian Council of Medical Research guidelines. Subjects of either gender (age > 18 year) were included in the study. The data were presented as mean ± standard deviation and categorical as frequency and percentage (%). A p value less than 0.05 (p < 0.05) was considered to be statistically significant.

RESULTS

A total number of 36 patients were included in the study. Majority of the patients were male with mean age (56.36 ± 14.83). After therapy, procalcitonin and total leucocyte count levels decreased within 24 h. Post therapy, sepsis-related organ failure assessment (SOFA) score of Day (D)1, D2, and D3 reduced to 10.4 ± 3.63, 8.7 ± 4.02, and 7.8 ± 3.67, respectively. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and predicted mortality were lower in the survivor group as compared to the non-survivor group.

CONCLUSION

Hemoadsorption using the extracorporeal adsorption device (CytoSorb^®) might be an effective rescue therapy in stabilizing septic shock patients.

Erosion and intrusion of silicone rubber scleral buckle. Presentation and management

OBJECTIVE

To describe the clinical presentation and management of erosion and intrusion of silicone rubber implants that are used in scleral buckling procedures for the treatment of retinal detachment.

METHODS

The authors identified four patients from their practices during the last 20 years (1978-1998) who had erosion or intrusion of silicone rubber scleral buckles that were used to manage retinal detachment. Approximately 4400 scleral buckling procedures were performed during this period. A retrospective review of the medical records of all patients was performed. Factors that influenced management decisions concerning the intruding buckle are emphasized.

RESULTS

All four patients had myopia. The interval between placement of the scleral buckle and development of intrusion ranged from 1 to 20 years. The buckles were intrascleral in three cases and episcleral in one. Recurrent detachment and vitreous hemorrhage were indications for surgical intervention in three cases. After the surgical removal of buckling elements, visual acuity stabilized in all patients and the retina remained attached in all cases.

CONCLUSIONS

Erosion and intrusion of scleral buckle are rare complications of scleral buckling procedures. The intruding buckle may be left intact unless there is significant threat to the integrity of ocular structures, recurrent detachment, or hemorrhage. Manipulation of the encircling band or buckle does not necessarily alter the visual acuity or the status of the retina.

Identification of tyrosine residues in vascular endothelial growth factor receptor-2/FLK-1 involved in activation of phosphatidylinositol 3-kinase and cell proliferation

Activation of vascular endothelial growth factor receptor-2 (VEGFR-2) plays a critical role in vasculogenesis and angiogenesis. However, the mechanism by which VEGFR-2 activation elicits these cellular events is not fully understood. We recently constructed a chimeric receptor containing the extracellular domain of human CSF-1R/c-fms, fused with the entire transmembrane and cytoplasmic domains of murine VEGFR-2 (Rahimi, N., Dayanir, V., and Lashkari, K. (2000) J. Biol. Chem. 275, 16986-16992). In this study we used VEGFR-2 chimera (herein named CKR) to elucidate the signal transduction relay of VEGFR-2 in porcine aortic endothelial (PAE) cells. Mutation of tyrosines 799 and 1173 individually on CKR resulted in partial loss of CKR's ability to stimulate cell growth. Double mutation of these sites caused total loss of CKR's ability to stimulate cell growth. Interestingly, mutation of these sites had no effect on the ability of CKR to stimulate cell migration. Further analysis revealed that tyrosines 799 and 1173 are docking sites for p85 of phosphatidylinositol 3-kinase (PI3K). Pretreatment of cells with wortmannin, an inhibitor of PI3K, and rapamycin, a potent inhibitor of S6 kinase, abrogated CKR-mediated cell growth. However, expression of a dominant negative form of ras (N(17)ras) and inhibition of the mitogen-activated protein kinase (MAPK) pathway by PD98059 did not attenuate CKR-stimulated cell growth. Altogether, these results demonstrate that activation of VEGFR-2 results in activation of PI3K and that activation of PI3K/S6kinase pathway, but not Ras/MAPK, is responsible for VEGFR-2-mediated cell growth.

Receptor chimeras indicate that the vascular endothelial growth factor receptor-1 (VEGFR-1) modulates mitogenic activity of VEGFR-2 in endothelial cells

Vascular endothelial growth factor (VEGF) provokes angiogenesis in vivo and stimulates growth and differentiation of endothelial cells in vitro. Although VEGF receptor-1 (VEGFR-1) and VEGFR-2 are known to be high affinity receptors for VEGF, it is not clear which of the VEGFRs are responsible for the transmission of the diverse biological responses of VEGF. For this purpose we have constructed a chimeric receptor for VEGFR-1 (CTR) and VEGFR-2 (CKR) in which the extracellular domain of each receptor was replaced with the extracellular domain of human colony-stimulating factor-1 receptor (CSF-1R), and these receptors were expressed in pig aortic endothelial (PAE) cells. We show that CKR individually expressed in PAE cells is readily tyrosine-phosphorylated in vivo, autophosphorylated in vitro, and stimulates cell proliferation in a CSF-1-dependent manner. In contrast, CTR individually expressed in PAE cells showed no significant in vivo, in vitro tyrosine phosphorylation and cell growth in response to CSF-1 stimulation. The kinase activity of CKR was essential for its biological activity, since mutation of lysine 866 to arginine abolished its in vivo, in vitro tyrosine phosphorylation and mitogenic signals. Remarkably, activation of CTR repressed CKR-mediated mitogen-activate protein kinase activation and cell proliferation. Similar effects were observed for VEGFR-2 co-expressed with VEGFR-1. Collectively, these findings demonstrate that VEGFR-2 activation plays a positive role in angiogenesis by promoting endothelial cell proliferation. In contrast, activation of VEGFR-1 plays a stationary role in angiogenesis by antagonizing VEGFR-2 responses.

Vascular endothelial growth factor and hepatocyte growth factor levels are differentially elevated in patients with advanced retinopathy of prematurity

Although the roles of vascular endothelial growth factor (VEGF) and hepatocyte growth factor (HGF) in angiogenesis are well described, the putative roles of these factors in retinopathy of prematurity (ROP) remain unknown. We evaluated VEGF and HGF protein levels in subretinal fluid of eyes with ROP, and expression of their corresponding receptors in retrolental membranes associated with stage 5 ROP. We examined subretinal fluid samples from eyes using rhegmatogenous retinal detachment as a control. VEGF and HGF were differentially elevated in eyes with ROP. In Stage 5 ROP (n = 22), the mean VEGF and HGF levels were 14.77 +/- 14.01 ng/ml and 16.56 +/- 9.62 ng/ml, respectively. Interestingly, in patients with active stage 4 ROP, mean VEGF levels were highly elevated (44.16 +/- 18.72 ng/ml), whereas mean HGF levels remained very low (4.77 +/- 2.50 ng/ml). Next, we investigated in vivo expression of VEGF receptor-2 and HGF receptor in retrolental membranes from 16 patients with stage 5 ROP. Both VEGF receptor-2 and HGF receptor proteins were detected mainly in posterior portions of the membrane as well as in vessel walls and along the retinal interface where angiogenesis was active. These findings together suggest that VEGF and HGF play important roles in the pathogenesis of ROP.

Development of an acoustic telemetry tag for monitoring electromyograms in free-swimming fish

We report the development of an acoustic telemetry tag used to monitor electromyograms (EMGs) remotely from free-swimming marine fish. The device described amplifies and filters the EMG and then converts the electrical waveform into a frequency-modulated acoustic signal that is transmitted through water. The signal is then received, demodulated and recorded by the receiving system. The EMG tag described has been tested on a range of species, including toadfish Opsanus τ, spiny dogfish Squalus acanthias, yellowfin tuna Thunnus albacares and eastern Pacific bonito Sarda chiliensis, in different tank environments. In certain tanks the fidelity with which the system replicates the EMG is sufficient to quantify accurately the onset, offset, duration, the integrated area under the absolute value of the signal and the number of signal zero crossings. This EMG tag will expand the scope of questions that can be addressed about the behavior and physiology of free-swimming fish.

Hepatocyte growth factor receptor in human RPE cells: implications in proliferative vitreoretinopathy

PURPOSE

To determine whether hepatocyte growth factor (HGF) receptor (HGFR) is expressed in retinal pigment epithelial (RPE) cells and to test whether RPE cells are responsive to HGF. To evaluate expression of HGFR in human donor eyes and in several epiretinal membranes associated with proliferative vitreoretinopathy and idiopathic epiretinal membranes.

METHODS

HGF-dependent migration and proliferation in primary and simian virus (SV) 40-transformed human RPE cells was studied using a Boyden chamber and [3H]thymidine uptake, respectively. The expression and tyrosine phosphorylation of HGFR protein was evaluated in RPE cells by immunoprecipitation and western blot analysis. Expression of HGFR in human donor eyes and in several epiretinal membranes associated with proliferative vitreoretinopathy (PVR) and idiopathic epiretinal membranes was analyzed by immunohistochemistry.

RESULTS

HGFR was expressed in RPE cells and was tyrosine-phosphorylated in response to HGF. Whereas HGF was a potent motogen for RPE cells, it induced only a modest, dose-dependent uptake of [3H]thymidine. Evaluation of human donor eyes showed that the RPE monolayer was the major cell type that was strongly positive for HGFR. HGFR was uniformly and readily detected in the cellular component of epiretinal membranes associated with PVR, whereas little or no HGFR was found in idiopathic epiretinal membranes.

CONCLUSIONS

HGFR is expressed in cultured RPE cells, in the RPE monolayer in human donor eyes, and in epiretinal membranes obtained from patients with PVR. Furthermore, HGF is a potent chemoattractant for cultured human RPE cells. These observations suggest a role for HGF and HGFR in normal function of RPE cells and in RPE-related disease such as PVR.

Sound production of gray whales, Eschrichtius robustus, along their migration route: a new approach to signal analysis

Sound production of gray whales was investigated to determine their acoustic repertoire along the migration route, and to compare sound production in deep and shallow water. Recording was conducted off Monterey Bay and Carmel Bay, California, during the annual migrations of 1988 through 1991. Sounds were analyzed through digital signal processing. Six acoustic variables were measured. Three variables were used for final classification, chosen for their clarity in the presence of high levels of ambient noise (poor signal-to-noise ratio). These variables were 3-dB bandwidth, center frequency, and harmonic/sideband interval. Q ratio was used as an indicator of how broadband or narrow band a signal was relative to other gray whale signals. Four categories of signals were determined: M1, M3, M4, and M5. All signal types were concentrated below 1500 Hz. M3 signals had the lowest center frequency, averaging below 100 Hz. M1 were pulses and bonging signals, M3 were low-frequency moans, M4 were grunts, and M5 were subsurface exhalations. The rate of sound production was lower when whales traveled over deep water than over shallow water. Rate of sound production was less along the migration route compared to the lagoons. M3 signals were the most common, comprising 46.6% of the repertoire along the migration route, with M1 signals comprising 37.4%.

Proton magnetic resonance spectroscopy of vitreal changes in experimental streptococcal endophthalmitis

We used magnetic resonance spectroscopy to examine endophthalmitis in rabbits inoculated with a virulent strain of Streptococcus pneumoniae. On different days after infection, the animals were sacrificed and the vitreous isolated and examined with water-suppressed proton magnetic resonance spectroscopy. A broad resonance corresponding to the methyl envelope of lipoprotein lipids appeared 2 days after infection and persisted until the eyes developed phthisis (around 10 days postinfection). This resonance was absent in the control eye and the bacterial culture; it could be used as the marker of breakdown of blood-vitreous barrier and onset of endophthalmitis-induced changes.

Characterization of functional changes in macular holes and cysts

Precise characterization of functional loss in small retinal lesions is difficult with conventional techniques. Using the scanning laser ophthalmoscope, the authors evaluated functional changes and fixation behavior in 26 eyes with macular holes and 15 eyes with macular cysts. A dense scotoma was present over all macular holes; 24 had no detectable functional alteration at the margins of the hole, and fixation was above the horizontal meridian in all eyes. Nine eyes with cysts had no detectable functional loss over the cyst. Only two eyes had small areas of dense scotoma within the cyst area, and four had areas of relative scotoma. Fixation was central in all eyes. Characterization of functional changes is helpful in differentiating holes from cysts. Photocoagulation at the margin of the holes may result in further functional damage.