Enteral Nutrition in Critically Ill Patient With Septic Shock Requiring Vasopressor: Case Report

Nutritional support in critically ill patients is an essential aspect of treatment. In particular, the benefits of enteral nutrition (EN) are well recognized, and various guidelines recommend early EN within 48 hours in critically ill patients. However, there is still controversy regarding EN in critically ill patients with septic shock requiring vasopressors. Therefore, this case report aims to provide basic data for the safe and effective nutritional support in septic shock patients who require vasopressors. A 62-year-old male patient was admitted to the intensive care unit with a deep neck infection and mediastinitis that progressed to a septic condition. Mechanical ventilation was initiated after intubation due to progression of respiratory acidosis and deterioration of mental status, and severe hypotension required the initiation of norepinephrine. Due to hemodynamic instability, the patient was kept nil per os. Subsequently, trophic feeding was initiated at the time of norepinephrine dose tapering and was gradually increased to achieve 75% of the energy requirement through EN by the 7th day of enteral feeding initiation. Although there were signs of feeding intolerance during the increasing phase of EN, adjusting the rate of EN resolved the issue. This case report demonstrates the gradual progression and adherence to EN in septic shock patient requiring vasopressors, and the progression observed was relatively consistent with existing studies and guidelines. In the future, further case reports and continuous research will be deemed necessary for safe and effective nutritional support in critically ill patients with septic shock requiring vasopressors.

Abstract TP76: Increased Regulatory T Cells After Treatment of Poly (adp-ribose) Polymerase-1 Inhibitor in Patients With Acute Ischemic Stroke

Background: Regulatory T cells (Tregs) have been suggested to have modulatory function of immune response and improve outcome after ischemic stroke. Thus, various strategies to increase Treg in animal model of ischemic stroke have been studied with successful results. The aim of this study is to demonstrate Treg (CD4 + CD25 + FoxP3 + ) proportion in peripheral blood of ischemic stroke patient and the potential effect of poly (ADP-ribose) polymerase-1 (PARP-1) inhibitor on Treg proportion.

Methods: Peripheral blood samples were collected from 12 ischemic stroke patients (within 72 hours of stroke onset) and 5 control subjects. Demographics and clinical information were obtained from patients and control subjects. Fluorescence-activate cell sorting (FACS) analyses and quantitative reverse transcription polymerase chain reaction (qRT-PCR) were performed with peripheral blood mononuclear cells (PBMCs) before and after PARP-1 inhibitor (3-AB, JPI-289 1 μm, JPI-289 10 μm) treatment for 24 hours.

Results: Treg proportion was significantly higher in healthy control (3.5 ± 1.8 %) than ischemic stroke patients (1.6 ± 0.6 %) ( p < 0.001). In ischemic stroke patients, regulatory T cell proportion was positively correlated with age (r = 0.595, p = 0.041), but did not show association with infarct volume (r = 0.367, p = 0.241). After PARP-1 inhibitor treatment, the proportion of Treg was increased in high dose (10 μm) JPI-289 group (2.1 ± 0.7 %). However, 3-AB and low dose (1 μm) JPI-289 did not show significant changes of Treg proportion. RT-PCR showed increased expression of Treg associated transcription factors such as FoxP3 and CTLA-4 mRNA after PARP-1 inhibitor treatment. PARP-1 inhibitor treatment also decreased pro-inflammatory cytokines such as IFN-γ, TNF-α, and IL-17 and increased anti-inflammatory cytokines such as IL-4, IL-10, and TGF-β1.

Conclusion: Treg proportion was decreased in patient with acute ischemic stroke. However, it was up-regulated after treatment of PARP-1 inhibitors, especially with high dose JPI-289. In addition, PARP-1 inhibitor showed possible anti-inflammatory effect by regulating cytokines. PARP-1 inhibitor may ameliorate outcome of ischemic stroke by immune modulation.

Association of meal frequency with metabolic syndrome in Korean adults: from the Korea National Health and Nutrition Examination Survey (KNHANES)

BACKGROUND

Although previous studies have established a close relationship between caloric intake and metabolic syndrome, there is limited research exploring the impact of meal frequency adjusted by caloric intake on metabolic syndrome (MetS).

OBJECTIVE

To evaluate the association of meal frequency and MetS after adjusting for confounding factors including caloric intake in Korean men and women.

METHODS

We analyzed the national representative data of a total 12,389 adults (5171 men, 7218 women) from the Korean National Health and Nutrition Examination Survey (KNHANES) 2010-2012. Subjects were categorized as eating 3 meals/day (MF3) or 2 or fewer meals/day (MF ≤ 2). Daily caloric intake was calculated using CAN-Pro 4.0 (The Korean Nutrition Society, Seoul, Korea).

RESULTS

The prevalence of components of MetS differed significantly according to meal frequency in both men and women. In an unadjusted analysis, the prevalence of MetS in women was significantly higher in the MF3 group than the MF ≤ 2 group (27.5% vs. 17.8%, P < 0.001), whereas the prevalence of MetS in men did not differ between the MF3 and MF ≤ 2 groups (24.6% vs. 22.7%, P = 0.281). However, after adjusting for age, caloric intake, smoking status, alcohol consumption, physical activity, income, and education level, men in the MF ≤ 2 group had an increased risk of metabolic syndrome compared to men in the MF3 group (OR = 1.37, 95%, CI = 1.12-1.67). On the other hand, meal frequency did not affect the risk of metabolic syndrome in women after adjusting for confounding factors including caloric intake (OR = 1.09, 95%, CI = 0.90-1.31).

CONCLUSIONS

This study suggests that lower meal frequency adjusted for caloric intake, physical activity, age, smoking, alcohol, income, and education may be associated with increased risk of MetS in Korean men.

Mesenchymal Stem Cells Modulate the Functional Properties of Microglia via TGF-β Secretion

: The regulation of microglial cell phenotype is a potential therapeutic intervention in neurodegenerative disease. Previously, we reported that transforming growth factor-β (TGF-β) levels in mesenchymal stromal cells (MSCs) could be used as potential biological markers to predict the effectiveness of autologous MSC therapy in patients with amyotrophic lateral sclerosis. However, the underlying mechanism of TGF-β in MSCs was not fully elucidated in determining the functional properties of microglia. In this study, we aimed to clarify the role of TGF-β that is involved in MSC effectiveness, especially focusing on microglia functional properties that play a pivotal role in neuroinflammation. We found that MSC-conditioned media (MSC-CM) inhibited proinflammatory cytokine expression, restored alternative activated microglia phenotype markers (fractalkine receptor, mannose receptor, CD200 receptor), and enhanced phagocytosis in lipopolysaccharide (LPS)-stimulated microglia. In addition, TGF-β in MSC-CM played a major role in these effects by inhibiting the nuclear factor-κB pathway and restoring the TGF-β pathway in LPS-stimulated microglia. Recombinant TGF-β also induced similar effects to MSC-CM in LPS-stimulated microglia. Therefore, we propose that MSCs can modulate the functional properties of microglia via TGF-β secretion, switching them from a classically activated phenotype to an inflammation-resolving phenotype. The latter role may be associated with the inhibition of neuroinflammatory processes in neurodegenerative disorders.

SIGNIFICANCE

The results of this study showed that microglia functional properties may be modulated depending on the composition and quantity of mesenchymal stromal cell (MSC)-secreting factors. Transforming growth factor (TGF)-β is proposed as a modulator of microglia functional properties among MSC-secreting factors, and this study aligns with a previous clinical study by these same authors. TGF-β releasing capacity could be an important factor enhancing the therapeutic efficacy of MSCs in clinical trials.

Association Between Usual Vitamin K Intake and Anticoagulation in Patients Under Warfarin Therapy

This study aimed to explore the correlation between usual vitamin K intake and response to anticoagulant therapy among patients under warfarin therapy. We conducted a retrospective survey of patients (n = 50) on continuous warfarin therapy. Clinical information and laboratory parameters were sourced from medical records. Anticoagulant effect was evaluated by using the percent time in therapeutic range (TTR) and the coefficient of variation (CV) of International normalized ratio (INR). Dietary vitamin K intake was assessed using a semi-quantitative food frequency questionnaire that has been developed for the purpose of assessing dietary intake of vitamin K. A total of 50 patients aged between 21 and 87 years were included in the study. The mean vitamin K intake was 262.8 ± 165.2 µg/day. Study subjects were divided into tertiles according to their usual vitamin K intake. The proportion of men was significantly higher in second and third tertile than first tertile (p = 0.028). The mean percent TTR was 38.4 ± 28.4% and CV of INR was 31.8 ± 11.8%. Long-term warfarin therapy group (≥ 3 years) had a higher percentage of TTR as compared to the control group (< 3 years) (p = 0.046). No statistically significant correlation was found between usual vitamin K intake and percent TTR (p > 0.05). In conclusion, no significant association was observed between usual vitamin K intake and anticoagulant effects. Further studies are required to consider inter-individual variability of vitamin K intake. Development of assessment tools to measure inter-individual variability of vitamin K intake might be helpful.

Biological markers of mesenchymal stromal cells as predictors of response to autologous stem cell transplantation in patients with amyotrophic lateral sclerosis: an investigator-initiated trial and in vivo study

Bone marrow mesenchymal stromal cells (MSCs) can modify disease progression in amyotrophic lateral sclerosis (ALS) model. However, there are currently no accurate biological markers for predicting the efficacy of autologous MSC transplants in ALS patients. This open-label, single-arm, investigator-initiated clinical study was designed to identify markers of MSCs that could be used as potential predictors of response to autologous MSC therapy in patients with ALS. We enrolled 37 patients with ALS who received autologous MSCs via intrathecal injection in two monthly doses. After a 6-month follow-up period, the patients were categorized as responders and non-responders based on their scores on the revised ALS Functional Rating Scale (ALSFRS-R). Biological markers including β-fibroblast growth factor-2, stromal cell-derived factor-1α, vascular endothelial growth factor (VEGF), insulin-like growth factor-1, brain-derived neurotrophic factor, angiogenin (ANG), interleukin (IL)-4, IL-10, and transforming growth factor-β (TGF-β) were measured in the MSC cultures and their levels were compared between the responders and nonresponders. To confirm the markers' predictive ability, MSCs isolated from one patient in each group were transplanted into the cisterna magna of mutant SOD1(G93A) transgenic mice to measure their lifespans, locomotor activity, and motor neuron numbers. The levels of VEGF, ANG, and TGF-β were significantly higher in responders than in nonresponders. In the mouse model, the recipients of responder MSCs had a significantly slower onset of symptoms and a significantly longer lifespan than the recipients of nonresponders or controls. Our data suggest that VEGF, ANG, and TGF-β levels in MSCs could be used as potential biological markers to predict the effectiveness of autologous MSC therapy and to identify those patients who could optimally benefit from MSC treatment.

Erythropoietin modulates the immune-inflammatory response of a SOD1(G93A) transgenic mouse model of amyotrophic lateral sclerosis (ALS)

Temporal patterns of inflammatory cytokine levels reflect the immune-inflammatory role in pathogenic mechanisms of SOD1 animal model of Amyotrophic Lateral Sclerosis (ALS) and these cytokines have important roles in both toxic and protective functions depending on the stage of disease progression in ALS patients. Erythropoietin (EPO) has various neuroprotective effects, including the reduction of inflammation, the enhancement of survival signals, and the prevention of neuronal cell death. This study was undertaken to evaluate the temporal pattern of inflammatory cytokine levels induced by EPO treatment in the SOD1(G93A) mice model of ALS. We treated mice with 5 IU of EPO per gram of animal weight once every other week after the mice were 60 days old, and pro/anti-inflammatory cytokines were analyzed at 30, 60, 90, and 120 days of age. In untreated controls, pro-inflammatory cytokines (IFN-γ, TNF-α, IL-1β, CCL2 (MCP-1), CCL5 (RANTES), CXCL10 (IP-10), and IL-17A) were gradually increased with aging. In contrast, increment of anti-inflammatory cytokines (IL-4, IL-10, and TGF-β) showed the highest level at 90 days of age and their levels were remarkably faded until 120 days of age. EPO treatment, however, showed significantly decreased level of pro-inflammatory cytokines. And, up-regulated levels of anti-inflammatory cytokines with EPO were highly maintained until 120 days. In addition, the treatment of EPO delayed symptom onset, prolonged time of rotarod failure, and showed more preserved number of motoneurons. These findings suggest that EPO may be a potential therapeutic candidate having ability to modulate immune-inflammation in ALS.

β-PIX is critical for transplanted mesenchymal stromal cell migration

Bone marrow-derived mesenchymal stromal cells (MSCs) have been used successfully as a source of stem cells for treating neurodegenerative diseases. However, for reasons that are not clear, autologous MSC transplants have not yielded successful results in human trials. To test one possible reason, we compared the migratory ability of MSCs from amyotrophic lateral sclerosis (ALS) patients with those of healthy controls. We found that MSCs derived from ALS patients (ALS-MSCs) had a reduced ability to migrate, which may explain why autologous transplantation is not successful. We also found that expression of one of the intracellular factors implicated in migration, β-PIX, was significantly reduced in ALS-MSCs compared with healthy stem cells. Restoration of β-PIX expression by genetic manipulation restored the migratory ability of ALS-MSCs, and inhibition of β-PIX expression with shRNA reduced the migration of healthy MSCs. We suggest that transplantation of allogeneic or genetically modified autologous stem cells might be a more promising strategy for ALS patients than transplantation of autologous stem cells.

The functional deficiency of bone marrow mesenchymal stromal cells in ALS patients is proportional to disease progression rate

Amyotrophic lateral sclerosis (ALS) is caused by motor neuron death. The relationship between the prognosis of ALS patients and the function of their bone marrow mesenchymal stromal cells (BM-MSCs) is unclear. We designed this study to assess the correlation between the progression rate of the ALS Functional Rating Scale-revised version (ΔFS), which is reported to predict prognosis, and the pluripotency and trophic factor secreting capacity of ALS patients' BM-MSCs. We evaluated ΔFS in 23 ALS patients and isolated BM-MSCs from those patients and five healthy people. Levels of Nanog, Oct-4, and Nestin mRNA were examined to evaluate pluripotency, and levels of BDNF, ECGF1, bFGF-2, HGF, IGF-1, PGF, TGF-1β, SDF-1α, GDNF, VEGF, and ANG mRNA were examined to assess trophic factor secreting capacity. In addition, we measured the protein levels of Nanog, Oct-4, Nestin, SDF-1α, ANG, bFGF-2, VEGF, IGF-1, GDNF, and BDNF. mRNA levels of Nanog, Oct-4, ECGF1, bFGF-2, HGF, IGF-1, PGF, TGF-1β, SDF-1α, GDNF, VEGF, and ANG were negatively correlations with ΔFS. However, those of Nestin and BDNF were not significantly correlated with ΔFS. Similarly, Nanog, Oct-4, SDF-1α, ANG, bFGF-2, VEGF, IGF-1, and GDNF protein levels had a significant negative correlation with ΔFS. Results indicate that the pluripotency and trophic factor secreting capacity of the BM-MSCs of ALS patients are reduced in proportion to a poorer prognosis. We therefore suggest that healthy allogeneic BM-MSCs might be a better option for cell therapy in ALS patients.

Erythropoietin increases the motility of human bone marrow-multipotent stromal cells (hBM-MSCs) and enhances the production of neurotrophic factors from hBM-MSCs

Cell therapy has been extensively studied as an approach to repair damage in nervous system diseases. Multipotent stromal cells [MSCs] are well known to have neuroprotective effects and neural differentiation potential. The ability to induce migration of MSCs near nervous system damage via direct transplantation or via intravenous injections and increase the secretion of neurotrophic factors from MSCs might improve our ability to repair damage to the nervous system through cell therapy. In the present study, we investigated whether recombinant human erythropoietin [rhEPO], known to have a hematopoietic effect, could increase the motility of human bone marrow [hBM]-MSCs and enhance production of neurotrophic factors from hBM-MSCs. Based on the results of our MTT assay, trypan blue staining, and bromodeoxyuridine ELISA, rhEPO treatment increases the viability of MSCs but not their proliferation. With a migration assay kit, we demonstrated that the motility of hBM-MSCs was enhanced in rhEPO-treated cells. Immunoblotting assays revealed increased expression of phospho-Akt, phospho-GSK-3beta, phospho-extracellular signal-regulated kinase (ERK), beta PAK-interacting exchange factor (PIX), CXCR4, phospho tyrosine kinase B (TrkB), and vascular endothelial growth factor receptor-2 [VEGFR-2] in rhEPO-treated cells. Reverse transcription-polymerase chain reaction and gelatin zymography demonstrated that rhEPO treatment induces MMP-2 mRNA level and activity. In the studies using ELISAs, we found that rhEPO could increase levels of stromal cell-derived factor-1alpha, VEGF, and brain-derived neurotrophic factors. These findings suggest that rhEPO can increase the viability and motility of hBM-MSCs by affecting various intracellular signals including Akt, ERK, beta-PIX, CXCR4, TrkB, VEGFR-2, and MMP-2 and can enhance the production of neurotrophic factors from hBM-MSCs.

Amyloid-beta-induced neurotoxicity is reduced by inhibition of glycogen synthase kinase-3

Deposition of amyloid-beta protein (Abeta) is one of the most important pathologic features in Alzheimer's disease. It is well known that Abeta induces neuronal cell death through several pathogenic mechanisms. Although the role of glycogen synthase kinase (GSK)-3beta in the neurotoxicity of Abeta has been highlighted, there has been no report evaluating the effect of direct GSK-3beta inhibition on Abeta-induced neurotoxicity. Thus, in this study, the relationship between GSK-3beta activity and Abeta-induced neurotoxicity was explored. To investigate the role of GSK-3beta in Abeta-induced neurotoxicity, neurons were treated with amyloid beta-protein (1-42) (Abeta42) oligomers with or without the addition of a GSK-3beta inhibitor for 72 h. An MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) assay, trypan blue staining, and DAPI staining all showed that Abeta42 treatment alone resulted in decreased neuronal cell viability in a concentration-dependent manner. Abeta42 treatment significantly increased the activity of GSK-3beta and cell death signals such as phosphorylated Tau (pThr231), cytosolic cytochrome c, and activated caspase-3. Abeta42 treatment also resulted in decreased survival signals, including that of heat shock transcription factor-1. Treatment with a GSK-3beta inhibitor prevented Abeta-induced cell death. These results suggest that the neurotoxic effect of Abeta42 is mediated by GSK-3beta activation and that inhibition of GSK-3beta can reduce Abeta42-induced neurotoxicity.

Glycogen synthase kinase-3β activity plays very important roles in determining the fate of oxidative stress-inflicted neuronal cells

Glycogen synthase kinase-3, especially the beta form (GSK-3beta), plays key roles in oxidative stress-induced neuronal cell death, an important pathogenic mechanism of various neurodegenerative diseases. Although the neuroprotective effects of GSK-3beta inhibitors have been described, the optimal level of GSK-3beta inhibition for neuronal cell survival has not yet been determined. We investigated the effect of varying GSK-3beta activity on the viability of oxidative stress-injured neuronally differentiated PC12 (nPC12) cells and intracellular signals related with the GSK-3beta and caspase-3 pathways. Compared to the nPC12 control cells treated with only 100 microM H(2)O(2), treatment of 50-200 nM GSK-3beta inhibitor II or 25-500 nM GSK-3beta inhibitor VIII reduced the increased enzyme activity by about 50% and protected the cells against H(2)O(2)-induced oxidative stress. The optimal concentration of GSK-3beta inhibitor II enhanced heat shock transcription factor-1 levels, decreased levels of phosphorylated tau (Ser202) and cytosolic cytochrome c, activated caspase-3, and cleaved poly (ADP-ribose) polymerase. In contrast, higher concentrations of GSK-3beta inhibitor II (more than 500 nM) induced neuronal cell death and showed opposite effects relative to the above described intracellular signals. These results suggest that optimized inhibitor levels for modulating GSK-3beta activity may prevent apoptosis induced by oxidative stress associated with neurodegenerative diseases.