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Wisén E, Kvarnström A, Sand-Bown L, Rizell M, Pivodic A, Ricksten SE, Svennerholm K. Argipressin for prevention of blood loss during liver resection: a study protocol for a randomised, placebo-controlled, double-blinded trial (ARG-01). BMJ Open 2023; 13:e073270. [PMID: 37620260 PMCID: PMC10450082 DOI: 10.1136/bmjopen-2023-073270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Liver resection carries a high risk for extensive bleeding and need for blood transfusions, which is associated with significant negative impact on outcome. In malignant disease, the most common indication for surgery, it also includes increased risk for recurrence of cancer. Argipressin decreases liver and portal blood flow and may have the potential to reduce bleeding during liver surgery, although this has not been explored. METHOD AND ANALYSIS ARG-01 is a prospective, randomised, placebo-controlled, double-blinded study on 248 patients undergoing liver resection at Sahlgrenska University Hospital, Sweden. Patients will be randomised to one of two parallel groups, infusion of argipressin or normal saline administered peroperatively. The primary endpoint is peroperative blood loss. Secondary outcomes include need for blood transfusion, perioperative variables, length of hospital stay, the inflammatory response, organ damage markers and complications at 30 days. ETHICS AND DISSEMINATION The study is enrolling patients since March 2022. The trial is approved by the Swedish Ethical Review Authority (Dnr 2021-03557) and the Swedish Medical Product Agency (Dnr 5.1-2021-90115). Results will be announced at scientific meetings and in international peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT05293041 and EudraCT, 2021-001806-32.
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Affiliation(s)
- Ellinor Wisén
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Västra Götaland, Sweden
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Kvarnström
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Västra Götaland, Sweden
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lena Sand-Bown
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Rizell
- Transplantation Center, Sahlgrenska University Hospital, Gothenburg, Sweden
- Deparment of Surgery, University of Gothenburg Institute of Clinical Sciences, Goteborg, Västra Götaland, Sweden
| | - Aldina Pivodic
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- APNC Sweden, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Västra Götaland, Sweden
| | - Kristina Svennerholm
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Västra Götaland, Sweden
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
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Park KS, Svennerholm K, Crescitelli R, Lässer C, Gribonika I, Andersson M, Boström J, Alalam H, Harandi AM, Farewell A, Lötvall J. Detoxified synthetic bacterial membrane vesicles as a vaccine platform against bacteria and SARS-CoV-2. J Nanobiotechnology 2023; 21:156. [PMID: 37208676 DOI: 10.1186/s12951-023-01928-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/13/2023] [Indexed: 05/21/2023] Open
Abstract
The development of vaccines based on outer membrane vesicles (OMV) that naturally bud off from bacteria is an evolving field in infectious diseases. However, the inherent inflammatory nature of OMV limits their use as human vaccines. This study employed an engineered vesicle technology to develop synthetic bacterial vesicles (SyBV) that activate the immune system without the severe immunotoxicity of OMV. SyBV were generated from bacterial membranes through treatment with detergent and ionic stress. SyBV induced less inflammatory responses in macrophages and in mice compared to natural OMV. Immunization with SyBV or OMV induced comparable antigen-specific adaptive immunity. Specifically, immunization with Pseudomonas aeruginosa-derived SyBV protected mice against bacterial challenge, and this was accompanied by significant reduction in lung cell infiltration and inflammatory cytokines. Further, immunization with Escherichia coli-derived SyBV protected mice against E. coli sepsis, comparable to OMV-immunized group. The protective activity of SyBV was driven by the stimulation of B-cell and T-cell immunity. Also, SyBV were engineered to display the SARS-CoV-2 S1 protein on their surface, and these vesicles induced specific S1 protein antibody and T-cell responses. Collectively, these results demonstrate that SyBV may be a safe and efficient vaccine platform for the prevention of bacterial and viral infections.
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Affiliation(s)
- Kyong-Su Park
- Krefting Research Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Kristina Svennerholm
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rossella Crescitelli
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Lässer
- Krefting Research Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Inta Gribonika
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Mickael Andersson
- Department of Chemistry and Molecular Biology, Centre for Antibiotic Resistance, University of Gothenburg, Gothenburg, Sweden
| | - Jonas Boström
- Department of Chemistry and Molecular Biology, Centre for Antibiotic Resistance, University of Gothenburg, Gothenburg, Sweden
| | - Hanna Alalam
- Department of Chemistry and Molecular Biology, Centre for Antibiotic Resistance, University of Gothenburg, Gothenburg, Sweden
| | - Ali M Harandi
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- BC Children's Hospital Research Institute, Vaccine Evaluation Center, University of British Columbia, Columbia, Canada
| | - Anne Farewell
- Department of Chemistry and Molecular Biology, Centre for Antibiotic Resistance, University of Gothenburg, Gothenburg, Sweden
| | - Jan Lötvall
- Krefting Research Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Wisén E, Almazrooa A, Sand Bown L, Rizell M, Ricksten S, Kvarnström A, Svennerholm K. Myocardial, renal and intestinal injury in liver resection surgery-A prospective observational pilot study. Acta Anaesthesiol Scand 2021; 65:886-894. [PMID: 33811772 DOI: 10.1111/aas.13823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Post-operative organ complications in liver resection surgery are not uncommon. This prospective observational pilot study was performed to evaluate the incidence, degree and timing of myocardial, renal and intestinal injury in patients undergoing liver resection surgery using the low central venous pressure (LCVP) technique and the Pringle manoeuvre. METHODS Blood samples were obtained before, during and after elective liver resection until post-operative day (POD) 5. High-sensitive troponin T (hs-TnT), serum creatinine, urea, intestinal fatty acid binding protein (I-FABP), D-lactate, arterial lactate, portal lactate, amylase, as well as urine N-acetyl-ß-D-glucosaminidase (NAG) were analysed. Systemic haemodynamics were measured intraoperatively. RESULTS Eighteen patients fulfilled the protocol. The Pringle manoeuvre was used in all but 1 patient. hs-TnT increased significantly over time (P < .001) and 5 patients (28%) developed myocardial injury. Five patients had a pre-operative elevation of hs-TnT, four of those developed myocardial injury. Serum creatinine increased significantly over time (P = .015). Acute kidney injury (AKI) occurred in 5 patients (28%), while NAG, as a marker of tubular injury, was not affected. I-FABP increased over time (P < .001) with a maximal 75% increase at 3 hours after resection. D-lactate was below detection level at all measuring points. CONCLUSIONS In patients undergoing liver resection surgery, using LCVP technique and Pringle manoeuvre, myocardial injury was seen in approximately 30% of the patients post-operatively and almost 30% developed transient AKI in the early post-operative period with no tubular injury. Furthermore, a transient increase of the enterocyte damage marker I-FABP was demonstrated with no signs of gut barrier dysfunction.
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Affiliation(s)
- Ellinor Wisén
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Abdulrahman Almazrooa
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Lena Sand Bown
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Magnus Rizell
- Department of Transplantation and Liver Surgery Sahlgrenska academyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Sven‐Erik Ricksten
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Andreas Kvarnström
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Kristina Svennerholm
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
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Park K, Svennerholm K, Crescitelli R, Lässer C, Gribonika I, Lötvall J. Synthetic bacterial vesicles combined with tumour extracellular vesicles as cancer immunotherapy. J Extracell Vesicles 2021; 10:e12120. [PMID: 34262675 PMCID: PMC8254025 DOI: 10.1002/jev2.12120] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 06/09/2021] [Accepted: 06/21/2021] [Indexed: 12/15/2022] Open
Abstract
Bacterial outer membrane vesicles (OMV) have gained attention as a promising new cancer vaccine platform for efficiently provoking immune responses. However, OMV induce severe toxicity by activating the innate immune system. In this study, we applied a simple isolation approach to produce artificial OMV that we have named Synthetic Bacterial Vesicles (SyBV) that do not induce a severe toxic response. We also explored the potential of SyBV as an immunotherapy combined with tumour extracellular vesicles to induce anti-tumour immunity. Bacterial SyBV were produced with high yield by a protocol including lysozyme and high pH treatment, resulting in pure vesicles with very few cytosolic components and no RNA or DNA. These SyBV did not cause systemic pro-inflammatory cytokine responses in mice compared to naturally released OMV. However, SyBV and OMV were similarly effective in activation of mouse bone marrow-derived dendritic cells. Co-immunization with SyBV and melanoma extracellular vesicles elicited tumour regression in melanoma-bearing mice through Th-1 type T cell immunity and balanced antibody production. Also, the immunotherapeutic effect of SyBV was synergistically enhanced by anti-PD-1 inhibitor. Moreover, SyBV displayed significantly greater adjuvant activity than other classical adjuvants. Taken together, these results demonstrate a safe and efficient strategy for eliciting specific anti-tumour responses using immunotherapeutic bacterial SyBV.
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Affiliation(s)
- Kyong‐Su Park
- Krefting Research CentreInstitute of MedicineUniversity of GothenburgGothenburgSweden
| | - Kristina Svennerholm
- Department of Anesthesiology and Intensive Care MedicineInstitute of Clinical ScienceSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Rossella Crescitelli
- Krefting Research CentreInstitute of MedicineUniversity of GothenburgGothenburgSweden
| | - Cecilia Lässer
- Krefting Research CentreInstitute of MedicineUniversity of GothenburgGothenburgSweden
| | - Inta Gribonika
- Department of Microbiology and ImmunologyInstitute of BiomedicineUniversity of GothenburgGothenburgSweden
| | - Jan Lötvall
- Krefting Research CentreInstitute of MedicineUniversity of GothenburgGothenburgSweden
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Osbeck Sandblom H, Dotevall H, Svennerholm K, Tuomi L, Finizia C. Characterization of dysphagia and laryngeal findings in COVID-19 patients treated in the ICU-An observational clinical study. PLoS One 2021; 16:e0252347. [PMID: 34086717 PMCID: PMC8177545 DOI: 10.1371/journal.pone.0252347] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/12/2021] [Indexed: 12/19/2022] Open
Abstract
Background Dysphagia appears to be common in patients with severe COVID-19. Information about the characteristics of dysphagia and laryngeal findings in COVID-19 patients treated in the intensive care unit (ICU) is still limited. Objectives The aim of this study was to evaluate oropharyngeal swallowing function and laryngeal appearance and function in patients with severe COVID-19. Method A series of 25 ICU patients with COVID-19 and signs of dysphagia were examined with fiberendoscopic evaluation of swallowing (FEES) during the latter stage of ICU care or after discharge from the ICU. Swallowing function and laryngeal findings were assessed with standard rating scales from video recordings. Results Pooling of secretions was found in 92% of patients. Eleven patients (44%) showed signs of silent aspiration to the trachea on at least one occasion. All patients showed residue after swallowing to some degree both in the vallecula and hypopharynx. Seventy-six percent of patients had impaired vocal cord movement. Erythema of the vocal folds was found in 60% of patients and edema in the arytenoid region in 60%. Conclusion Impairment of oropharyngeal swallowing function and abnormal laryngeal findings were common in this series of patients with severe COVID-19 treated in the ICU. To avoid complications related to dysphagia in this patient group, it seems to be of great importance to evaluate the swallowing function as a standard procedure, preferably at an early stage, before initiation of oral intake. Fiberendoscopic evaluation of swallowing is preferred due to the high incidence of pooling of secretion in the hypopharynx, silent aspiration, and residuals. Further studies of the impact on swallowing function in short- and long-term in patients with COVID-19 are warranted.
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Affiliation(s)
- Hanna Osbeck Sandblom
- Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Dotevall
- Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristina Svennerholm
- Department of Anaesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lisa Tuomi
- Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
| | - Caterina Finizia
- Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Einarsson F, Sandström C, Svennerholm K, Oras J, Rylander C. Outcomes of catheter-directed interventions in high-risk pulmonary embolism-a retrospective analysis. Acta Anaesthesiol Scand 2021; 65:499-506. [PMID: 33245785 PMCID: PMC7986106 DOI: 10.1111/aas.13753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND First-line treatment of high-risk pulmonary embolism with persistent hypotension and/or signs of shock is intravenous thrombolysis. However, if thrombolysis is contraindicated due to risk of serious bleeding, or if it yields insufficient effect, surgical thrombectomy or catheter-directed intervention (CDI) plus anticoagulation is recommended. The aim of this study was to assess the outcomes of the CDI modality introduced in a tertiary referral centre in 2013. METHODS Retrospective comparison between patients treated with CDI plus anticoagulation (n = 22) and patients treated with anticoagulation only (n = 23) as used before the CDI technique was available. The main outcomes of interest were 90-day survival and reduction of right to left ventricle diameter (RV/LV) ratio, using the Fischer's exact test and a mixed model, respectively, for statistical analysis. RESULTS Ninety-day survival was 59% after CDI and 61% after anticoagulation only; P = .903. The rate of RV/LV ratio reduction was 0.4 units higher per 24 hours in the CDI group (median 2.1 pre-treatment), than in the anticoagulation only group (median 1.3 pre-treatment); P = .007. CONCLUSION In patients with high-risk pulmonary embolism, 90-day survival was similar after treatment with CDI plus anticoagulation compared to anticoagulation only. The mean reduction in RV/LV ratio was larger in the CDI group. Our results support the use of CDI in selected patients, respecting the limitations and potential side effects of each technical device used.
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Affiliation(s)
- Freyr Einarsson
- Department of Anaesthesiology and Intensive Care MedicineInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Charlotte Sandström
- Department of RadiologyInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Kristina Svennerholm
- Department of Anaesthesiology and Intensive Care MedicineInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Jonatan Oras
- Department of Anaesthesiology and Intensive Care MedicineInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care MedicineInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
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Fryk K, Rylander C, Svennerholm K. Repeated and adaptive multidisciplinary assessment of a patient with acute pulmonary embolism and recurrent cardiac arrests. BMJ Case Rep 2020; 13:13/9/e234647. [PMID: 32878851 DOI: 10.1136/bcr-2020-234647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
High-risk pulmonary embolism (PE) is a life-threatening condition that must be recognised and treated rapidly. The importance of correct risk stratification to guide therapeutic decisions has prompted the introduction of multidisciplinary PE response teams (PERTs). The recommended first-line treatment for high-risk PE is intravenous thrombolysis. Alternatives to consider if thrombolysis has insufficient effect or may cause significant haemorrhagic complications include catheter-directed intervention (CDI) and surgical thrombectomy. For patients in deep shock or cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be instituted for cardiopulmonary rescue and support during CDI, thrombectomy or pharmacological treatment. We present a complex case of high-risk PE that illustrates the importance of an early PERT conference and repeated decision-making when the initial therapy fails. After a trial of thrombolysis with insufficient effect, VA-ECMO was used to reverse circulatory and respiratory collapse in a patient with PE and recurrent episodes of cardiac arrest.
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Affiliation(s)
- Karin Fryk
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Christian Rylander
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Kristina Svennerholm
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden
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Park KS, Svennerholm K, Crescitelli R, Lässer C, Gribonika I, Lötvall J. Abstract LB-095: Synergistic cancer immunotherapy using tumor tissue derived exosomes and artificially produced bacterial outer membrane vesicles. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-lb-095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Checkpoint inhibitors work only in cancers that host inflammatory cells, and “cold” tumors normally do not respond. Therefore, making “cold” tumors “hot” is required to increase the response rate to immunooncology therapies in general. Bacteria and bacterial products have been utilized for cancer immunotherapy for more than 100 years, but currently no such treatment is available because of the severe side effects that are observed. In this study, we produced artificial outer membrane vesicles (aOMVs) from Escherichia coli outer membrane, and injected them together with cancer tissue-derived exosomes to booster an immune response to the malignancy. Firstly, outer membranes were obtained from E. coli by chemical means, followed by ionic stress and applied mild energy to generate aOMVs. The yield and purity of aOMVs were analyzed by nanoparticle tracking analysis and transmission electron microscopy. The protein and RNA contents were examined by label-free quantitative mass spectrometry and bioanalyzer. Inflammation was evaluated in macrophage cell line (RAW 264.7) and mice in vivo, and bone marrow-derived dendritic cells were used to assess the immunomodulatory functions of the aOMVs. For the study of antitumor activity, mice were subcutaneously inoculated with B16F10 cells and then subcutaneously immunized with aOMVs and melanoma exosomes five times at 3-day intervals. Also, anti-mouse PD-1 antibody was intraperitoneally injected into mice 1 day prior to immunization to investigate the effects of combination therapy. To elucidate the immunogenic mechanism, blood and spleen were obtained for antibody titer and splenocyte function study. As a result, bacterial aOMVs presented nanosized spherical shape with closed membranes and exhibited high yield and purity with very few cytosolic components. These aOMVs do not cause pro-inflammatory cytokine responses in RAW 264.7 cells and mice in vivo, despite high exposure levels. The aOMVs could be taken up by dendritic cells to stimulate cytokine and maturation marker expression. Co-immunization with aOMVs and melanoma tissue-derived exosomes elicited tumor regression in melanoma-bearing mice through Th-1 type T cell immunity and anti-tumor exosome IgG antibody production. Also, the immunotherapeutic effect of aOMVs was synergistically enhanced by anti-PD-1 inhibitor. Collectively, bacterial aOMVs can be produced in a large quantities with high purity, but are “detoxified" compared to naturally released OMVs. The non-toxic aOMVs are powerful adjuvants for eliciting specific anti-tumor response, suggesting that aOMVs may be novel bacterial vesicle-mimetics clinically applicable as cancer treatment.
Citation Format: Kyong-su Park, Kristina Svennerholm, Rossella Crescitelli, Cecilia Lässer, Inta Gribonika, Jan Lötvall. Synergistic cancer immunotherapy using tumor tissue derived exosomes and artificially produced bacterial outer membrane vesicles [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-095.
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Affiliation(s)
- Kyong-su Park
- 1Krefting research centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Kristina Svennerholm
- 2Department of anesthesiology and Intensive Care Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Rossella Crescitelli
- 1Krefting research centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Lässer
- 1Krefting research centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Inta Gribonika
- 3Department of Microbiology and Immunology, University of Gothenburg, Gothenburg, Sweden
| | - Jan Lötvall
- 1Krefting research centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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Park KS, Svennerholm K, Shelke GV, Bandeira E, Lässer C, Jang SC, Chandode R, Gribonika I, Lötvall J. Mesenchymal stromal cell-derived nanovesicles ameliorate bacterial outer membrane vesicle-induced sepsis via IL-10. Stem Cell Res Ther 2019; 10:231. [PMID: 31370884 PMCID: PMC6676541 DOI: 10.1186/s13287-019-1352-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/11/2019] [Accepted: 07/22/2019] [Indexed: 12/16/2022] Open
Abstract
Background Sepsis remains a source of high mortality in hospitalized patients despite proper antibiotic approaches. Encouragingly, mesenchymal stromal cells (MSCs) and their produced extracellular vesicles (EVs) have been shown to elicit anti-inflammatory effects in multiple inflammatory conditions including sepsis. However, EVs are generally released from mammalian cells in relatively low amounts, and high-yield isolation of EVs is still challenging due to a complicated procedure. To get over these limitations, vesicles very similar to EVs can be produced by serial extrusions of cells, after which they are called nanovesicles (NVs). We hypothesized that MSC-derived NVs can attenuate the cytokine storm induced by bacterial outer membrane vesicles (OMVs) in mice, and we aimed to elucidate the mechanism involved. Methods NVs were produced from MSCs by the breakdown of cells through serial extrusions and were subsequently floated in a density gradient. Morphology and the number of NVs were analyzed by transmission electron microscopy and nanoparticle tracking analysis. Mice were intraperitoneally injected with Escherichia coli-derived OMVs to establish sepsis, and then injected with 2 × 109 NVs. Innate inflammation was assessed in peritoneal fluid and blood through investigation of infiltration of cells and cytokine production. The biodistribution of NVs labeled with Cy7 dye was analyzed using near-infrared imaging. Results Electron microscopy showed that NVs have a nanometer-size spherical shape and harbor classical EV marker proteins. In mice, NVs inhibited eye exudates and hypothermia, signs of a systemic cytokine storm, induced by intraperitoneal injection of OMVs. Moreover, NVs significantly suppressed cytokine release into the systemic circulation, as well as neutrophil and monocyte infiltration in the peritoneum. The protective effect of NVs was significantly reduced by prior treatment with anti-interleukin (IL)-10 monoclonal antibody. In biodistribution study, NVs spread to the whole mouse body and localized in the lung, liver, and kidney at 6 h. Conclusions Taken together, these data indicate that MSC-derived NVs have beneficial effects in a mouse model of sepsis by upregulating the IL-10 production, suggesting that artificial NVs may be novel EV-mimetics clinically applicable to septic patients. Electronic supplementary material The online version of this article (10.1186/s13287-019-1352-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kyong-Su Park
- Krefting Research Centre, Institute of Medicine, University of Gothenburg, 40530, Gothenburg, Sweden.
| | - Kristina Svennerholm
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, 40530, Gothenburg, Sweden
| | - Ganesh V Shelke
- Krefting Research Centre, Institute of Medicine, University of Gothenburg, 40530, Gothenburg, Sweden
| | - Elga Bandeira
- Krefting Research Centre, Institute of Medicine, University of Gothenburg, 40530, Gothenburg, Sweden
| | - Cecilia Lässer
- Krefting Research Centre, Institute of Medicine, University of Gothenburg, 40530, Gothenburg, Sweden
| | - Su Chul Jang
- Codiak BioSciences Inc, 500 Technology Square, 9th floor, Cambridge, MA, 02139, USA
| | - Rakesh Chandode
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, 40530, Gothenburg, Sweden
| | - Inta Gribonika
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, 40530, Gothenburg, Sweden
| | - Jan Lötvall
- Krefting Research Centre, Institute of Medicine, University of Gothenburg, 40530, Gothenburg, Sweden
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Wisén E, Svennerholm K, Bown LS, Houltz E, Rizell M, Lundin S, Ricksten SE. Vasopressin and nitroglycerin decrease portal and hepatic venous pressure and hepato-splanchnic blood flow. Acta Anaesthesiol Scand 2018; 62:953-961. [PMID: 29578250 DOI: 10.1111/aas.13117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/05/2018] [Accepted: 02/23/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Various methods are used to reduce venous blood pressure in the hepato-splanchnic circulation, and hence minimise blood loss during liver surgery. Previous studies show that combination of vasopressin and nitroglycerin reduces portal pressure and flow in patients with portal hypertension, and in this study we investigated this combination in patients with normal portal pressure. METHOD In all, 13 patients were studied. Measurements were made twice to confirm baseline (C1 and BL), during vasopressin infusion 4.8 U/h (V), and during vasopressin infusion combined with nitroglycerin infusion (V + N). Portal venous pressure (PVP), hepatic venous pressure (HVP), central haemodynamics and arterial and venous blood gases were obtained at each measuring point, and portal (splanchnic) and hepato-splanchnic blood flow changes were calculated. RESULTS Vasopressin alone did not affect PVP, whereas HVP increased slightly. In combination with nitroglycerin, PVP decreased from 10.1 ± 1.6 to 8.9 ± 1.3 mmHg (P < 0.0001), and HVP decreased from 7.9 ± 1.9 to 6.2 ± 1.3 mmHg (P = 0.001). Vasopressin reduced portal blood flow by 47 ± 19% and hepatic venous flow by 11 ± 18%, respectively. Addition of nitroglycerin further reduced portal- and hepatic flow by 55 ± 13% and 30 ± 13%, respectively. Vasopressin alone had minor effects on central haemodynamics, whereas addition of nitroglycerin reduced cardiac index (3.2 ± 0.7 to 2.7 ± 0.5; P < 0.0001). The arterial-portal vein lactate gradient was unaffected. CONCLUSION The combination of vasopressin and nitroglycerin decreases portal pressure and hepato-splanchnic blood flow, and could be a potential treatment to reduce bleeding in liver resection surgery.
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Affiliation(s)
- E. Wisén
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - K. Svennerholm
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - L. S. Bown
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - E. Houltz
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - M. Rizell
- Department of Transplantation and Liver Surgery; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - S. Lundin
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - S.-E. Ricksten
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
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Wisén E, Svennerholm K, Sand Bown L, Houltz E, Rizell M, Lundin S, Ricksten SE. Vasopressin and nitroglycerin decrease portal and hepatic venous pressure and hepato-splanchnic blood flow. Acta Anaesthesiol Scand 2018; 62:1161-1161. [PMID: 29671867 DOI: 10.1111/aas.13125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- E Wisén
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - K Svennerholm
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - L Sand Bown
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Houltz
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M Rizell
- Department of Transplantation and Liver Surgery, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - S Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - S-E Ricksten
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Svennerholm K, Rodsand P, Hellman U, Waldenström A, Lundholm M, Ahrén D, Biber B, Ronquist G, Haney M. DNA Content in Extracellular Vesicles Isolated from Porcine Coronary Venous Blood Directly after Myocardial Ischemic Preconditioning. PLoS One 2016; 11:e0159105. [PMID: 27434143 PMCID: PMC4951030 DOI: 10.1371/journal.pone.0159105] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/27/2016] [Indexed: 12/20/2022] Open
Abstract
Background Extracellular vesicles (EV) are nano-sized membranous structures released from most cells. They have the capacity to carry bioactive molecules and gene expression signals between cells, thus mediating intercellular communication. It is believed that EV confer protection after ischemic preconditioning (IPC). We hypothesize that myocardial ischemic preconditioning will lead to rapid alteration of EV DNA content in EV collected from coronary venous effluent. Materials and Methods In a porcine myocardial ischemic preconditioning model, EV were isolated from coronary venous blood before and after IPC by differential centrifugation steps culminating in preparative ultracentrifugation combined with density gradient ultracentrifugation. The EV preparation was validated, the DNA was extracted and further characterized by DNA sequencing followed by bioinformatics analysis. Results Porcine genomic DNA fragments representing each chromosome, including mitochondrial DNA sequences, were detected in EV isolated before and after IPC. There was no difference detected in the number of sequenced gene fragments (reads) or in the genomic coverage of the sequenced DNA fragments in EV isolated before and after IPC. Gene ontology analysis showed an enrichment of genes coding for ion channels, enzymes and proteins for basal metabolism and vesicle biogenesis and specific cardiac proteins. Conclusions This study demonstrates that porcine EV isolated from coronary venous blood plasma contain fragments of DNA from the entire genome, including the mitochondria. In this model we did not find specific qualitative or quantitative changes of the DNA content in EV collected immediately after an in vivo myocardial IPC provocation. This does not rule out the possibility that EV DNA content changes in response to myocardial IPC which could occur in a later time frame.
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Affiliation(s)
- Kristina Svennerholm
- Anesthesiology and Intensive Care Medicine, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pouria Rodsand
- Anesthesiology and Intensive Care Medicine, Institute of Surgical and Perioperative Science, Umeå University, Umeå, Sweden
| | - Urban Hellman
- Cardiology, Institute of Heart Centre and Department of Public Health and Clinical Medicine, Medicine, Umeå University, Umeå, Sweden
| | - Anders Waldenström
- Cardiology, Institute of Heart Centre and Department of Public Health and Clinical Medicine, Medicine, Umeå University, Umeå, Sweden
| | - Marie Lundholm
- Pathology, Institute of Medical Biosciences, Umeå University, Umeå, Sweden
| | - Dag Ahrén
- National Bioinformatics Infrastructure Sweden (NBIS), Institute of Biology, Lund University, Lund, Sweden
| | - Björn Biber
- Anesthesiology and Intensive Care Medicine, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gunnar Ronquist
- Clinical Chemistry, Institutet of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Michael Haney
- Anesthesiology and Intensive Care Medicine, Institute of Surgical and Perioperative Science, Umeå University, Umeå, Sweden
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Svennerholm K, Rodsand P, Hellman U, Lundholm M, Waldenström A, Biber B, Ronquist G, Haney M. Myocardial ischemic preconditioning in a porcine model leads to rapid changes in cardiac extracellular vesicle messenger RNA content. Int J Cardiol Heart Vasc 2015; 8:62-67. [PMID: 28785681 PMCID: PMC5497283 DOI: 10.1016/j.ijcha.2015.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 04/28/2015] [Accepted: 05/05/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Kristina Svennerholm
- Anesthesiology and Intensive Care Medicine, Department of Clinical Science, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
| | - Pouria Rodsand
- Anesthesiology and Intensive Care Medicine, Department of Surgical and Perioperative Science, Umeå University, 90185 Umeå, Sweden
| | - Urban Hellman
- Cardiology, Heart Centre and Department of Public Health and Clinical Medicine, Umeå University, 90185 Umeå, Sweden
| | - Marie Lundholm
- Pathology, Department of Medical Biosciences, Umeå University, 90185 Umeå, Sweden
| | - Anders Waldenström
- Cardiology, Heart Centre and Department of Public Health and Clinical Medicine, Umeå University, 90185 Umeå, Sweden
| | - Björn Biber
- Anesthesiology and Intensive Care Medicine, Department of Clinical Science, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
| | - Gunnar Ronquist
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, 75185 Uppsala, Sweden
| | - Michael Haney
- Anesthesiology and Intensive Care Medicine, Department of Surgical and Perioperative Science, Umeå University, 90185 Umeå, Sweden
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Svennerholm K, Haney M, Biber B, Ulfhammer E, Saluveer O, Larsson P, Omerovic E, Jern S, Bergh N. Correction: Histone deacetylase inhibition enhances tissue plasminogen activator release capacity in atherosclerotic man. PLoS One 2015; 10:e0128283. [PMID: 25955488 PMCID: PMC4425699 DOI: 10.1371/journal.pone.0128283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Svennerholm K, Haney M, Biber B, Ulfhammer E, Saluveer O, Larsson P, Omerovic E, Jern S, Bergh N. Histone deacetylase inhibition enhances tissue plasminogen activator release capacity in atherosclerotic man. PLoS One 2015; 10:e0121196. [PMID: 25807501 PMCID: PMC4373842 DOI: 10.1371/journal.pone.0121196] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/26/2015] [Indexed: 11/18/2022] Open
Abstract
UNLABELLED The expression of the tissue plasminogen activator (t-PA) gene appears to be under epigenetic control and can be affected by histone deacetylation inhibition. The study aimed to test if histone deacetalyase inhibitor treatment lead to increased t-PA release or reduced exhaustion in t-PA release in response to stimulation, as well as change in plasminogen activator inhibitor-1 (PAI-1) in subjects with coronary disease. In this clinical study, 16 post-myocardial infarction subjects, the perfused forearm model was used with isoprenaline provocation during 20 minutes, to stimulate local t-PA release. Each subject was measured twice on the same day (repeated stimuli sequences) as well as on two different occasions, without treatment and after four weeks of treatment with valproic acid (500 mg, twice daily). Net forearm release for t-PA in response to isoprenaline at minutes 1.5, 3, 6, 9, 12, 15 and 18 was measured, allowing assessment of cumulative t-PA release. There was a reduction in the exhaustion of cumulative t-PA release during repeated and prolonged stimulation with valproic acid treatment compared to non-treatment. Plasma PAI-1 antigen was decreased following treatment compared to non-treatment (18.4 ± 10.0 vs. 11.0 ± 7.1 nanograms/ml respectively, mean with 95% confidence interval). These findings demonstrate that histone deacetylation inhibition increases the capacity for endogenous t-PA release in subjects with vascular disease. Furthermore, the fibrinolytic balance is favored with suppressed PAI-1 levels. More studies are needed to establish the clinical relevance of these findings. TRIAL REGISTRATION EU Clinical Trials Register 2012-004950-27.
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Affiliation(s)
- Kristina Svennerholm
- Anesthesiology and Intensive Care Medicine, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael Haney
- Anesthesiology and Intensive Care Medicine, Institute for Surgical and Perioperative Science, Umeå University, Umeå, Sweden
- * E-mail:
| | - Björn Biber
- Anesthesiology and Intensive Care Medicine, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Ulfhammer
- The Wallenberg Laboratory for Cardiovascular Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ott Saluveer
- The Wallenberg Laboratory for Cardiovascular Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pia Larsson
- The Wallenberg Laboratory for Cardiovascular Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elmir Omerovic
- The Wallenberg Laboratory for Cardiovascular Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sverker Jern
- The Wallenberg Laboratory for Cardiovascular Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niklas Bergh
- The Wallenberg Laboratory for Cardiovascular Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Svennerholm K, Lapidus L, Malm CJ, Redfors B, Stigendal L, Jönsson KZ, Rylander C. [Acute pulmonary embolism with hemodynamic compromise. Management and treatment]. Lakartidningen 2014; 111:669-672. [PMID: 24864511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Svennerholm K, Lapidus L, Stigendal L, Malm CJ, Zachrisson K, Redfors B, Rylander C. Incidence and Treatment Options for Massive Pulmonary Embolism in Sweden. J Intensive Care Soc 2014. [DOI: 10.1177/17511437140151s310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Swedish Healthcare is organised by relatively independent counties which are responsible for the appropriateness of delivered care. As a consequence, few formal guidelines are issued by national authorities or professional societies, which is the case for the treatment of pulmonary embolism (PE). The yearly incidence of PE in Swedish adults was 86/100,000 in 2011, corresponding to approximately 6000 cases with an overall mortality of 6.5%. Acute massive PE with circulatory shock carries mortality up to 50% but its true incidence in Sweden is not known. First-line treatment is intravenous thrombolysis but non-pharmacological alternatives for cases where thrombolysis has no effect or is contraindicated have recently undergone technical development. This includes catheter fragmentation, surgical embolectomy and extracorporeal circulatory support, which may be used as a bridge to further treatment in very unstable patients. This article summarises the treatment options for acute massive PE and their rationale as seen from a Swedish perspective.
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Affiliation(s)
- Kristina Svennerholm
- Anaesthesia and Intensive Care
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Leif Lapidus
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lennart Stigendal
- Haematology and Coagulation
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Bengt Redfors
- Thoracic Anaesthesia and Intensive Care
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian Rylander
- Anaesthesia and Intensive Care
- Sahlgrenska University Hospital, Gothenburg, Sweden
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