Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

Twelve-months safety of valvosoft non-invasive ultrasound therapy (NIUT) in patients with severe symptomatic aortic valve stenosis: a first-in-human study

Background

Despite overall favourable outcome of surgical and transcatheter aortic valve replacement (SAVR/TAVR) in patients with severe calcific aortic stenosis (CAS), not all patients are eligible for an invasive treatment1 because of too high predicted mortality and complications.

Cardiawave© has developed a novel non-invasive ultrasound therapy (NIUT) device called Valvosoft to treat calcific aortic stenosis (CAS). Based on preclinical results2,3, a prospective first-in-human study was conducted in two centres in 10 patients in 2019 and a second one in 4 patients in 2020. All patients had symptomatic severe CAS and were not eligible for aortic valve replacement according to local heart teams.

Methods

Fourteen patients with severe symptomatic CAS not eligible for valve replacement were enrolled. Transthoracic therapeutic ultrasound was delivered by the Valvosoft transducer coupled with an echocardiographic phased-array probe for real-time monitoring. Clinical and echocardiographic evaluation were performed at baseline, discharge, 1-, 3-, 6- and 12-months follow-up. Additionally, the 4 patients of the second study had a brain-MRI performed before and after treatment to rule out silent cerebrovascular events.

Results

Patients were advanced in age (82.4±5.3 years) with severe comorbidities (57% with heart failure and 50% with coronary heart disease) and severe CAS. No adverse events occurred during the procedure other than isolated ventricular extrasystoles. No device- or procedure-related SAEs were reported at 1-month follow-up as adjudicated by the Clinical Event Committee (CEC). No death, stroke or TIAs or deterioration of neurological status were observed at 1-month follow-up for all 14 patients.

During 12-months follow-up, 5 out of the 14 patients died (from 2 to 7 months after the procedure). All deaths were adjudicated as non-procedure related. The survival rate was higher (100%, 93%, 79%, 64% at 1-, 3-, 6- and 12-months) comparing to the natural evolution of the disease on an equivalent studied population4 (94%, 73%, 73%, 54% at 1, 3, 6 and 12-months). No abnormality was detected in any of the 4 patients who had a brain-MRI before and after treatment.

Conclusions

NIUT seemed feasible and safe and in a small first cohort of very frail patients with severe comorbidities suffering from severe symptomatic CAS. Brain-MRIs performed before and after treatment ruled out silent cerebrovascular events. The survival comparison of the studied population contrasted to the natural evolution of the disease suggests that NIUT is beneficial for these patients with no other medical option.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This study has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement 829492 and is supported by the French Government, managed by the National Research Agency (ANR) under the program “Investissements d'avenir” with the reference ANR-16-RHUS-0003 and ANR VALVOSOFT-17-CE19-0019-02.

Prehospital triage of acute aortic syndrome using a machine learning algorithm

Background

Acute aortic syndrome (AAS) comprises a complex and potentially fatal group of conditions requiring emergency specialist management. The aim of this study was to build a prediction algorithm to assist prehospital triage of AAS.

Methods

Details of consecutive patients enrolled in a regional specialist aortic network were collected prospectively. Two prediction algorithms for AAS based on logistic regression and an ensemble machine learning method called SuperLearner (SL) were developed. Undertriage was defined as the proportion of patients with AAS not transported to the specialist aortic centre, and overtriage as the proportion of patients with alternative diagnoses but transported to the specialist aortic centre.

Results

Data for 976 hospital admissions between February 2010 and June 2017 were included; 609 (62·4 per cent) had AAS. Overtriage and undertriage rates were 52·3 and 16·1 per cent respectively. The population was divided into a training cohort (743 patients) and a validation cohort (233). The area under the receiver operating characteristic (ROC) curve values for the logistic regression score and the SL were 0·68 (95 per cent c.i. 0·64 to 0·72) and 0·87 (0·84 to 0·89) respectively (P < 0·001) in the training cohort, and 0·67 (0·60 to 0·74) and 0·73 (0·66 to 0·79) in the validation cohort (P = 0·038). The logistic regression score was associated with undertriage and overtriage rates of 33·7 (bootstrapped 95 per cent c.i. 29·3 to 38·3) and 7·2 (4·8 to 9·8) per cent respectively, whereas the SL yielded undertriage and overtriage rates of 1·0 (0·3 to 2·0) and 30·2 (25·8 to 34·8) per cent respectively.

Conclusion

A machine learning prediction model performed well in discriminating AAS and could be clinically useful in prehospital triage of patients with suspected AAS.

Blood CD9+ B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation

Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24^hi CD38^hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24^hi CD38^hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9⁺ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24^hi CD38^hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

Percutaneous radiofrequency ablation of lung metastases from colorectal carcinoma under C-arm cone beam CT guidance

PURPOSE

The aim of this study was to assess the feasibility, safety and efficacy of percutaneous radiofrequency ablation of lung metastases from colorectal carcinoma using C-arm cone beam computed tomography (CBCT) guidance.

MATERIAL AND METHODS

This single-center prospective observational study was performed from August 2013 to August 2016, and included consecutive patients referred for radiofrequency ablation of lung metastases from colorectal cancer. Radiofrequency ablation procedures were performed under C-arm CBCT guidance. Feasibility was assessed by probe accuracy placement, time to accurate placement and number of C-arm CBCT acquisitions to reach the target lesion. Safety was assessed by the report of adverse event graded using the common terminology criteria for adverse events (CTCAE-V4.0). Efficacy was assessed by metastases response rate using RECIST 1.1 and ¹⁸FDG-PET-CT tumor uptake at 6months.

RESULTS

Fifty-four consecutive patients (32 men, 22 women) with a mean age of 63±8 (SD) years (range: 51-81years) with a total of 56 lung metastasis from colorectal metastases were treated in a single session. The mean tumor diameter was 25.6±4.5 (SD)mm (range: 17-31mm). Median time to insert the needle into the target lesion was 10min (range: 5-25min). Median number of needles repositioning and C-arm CBCT acquisition per patient was 1 (range: 0-3) and 4 (range: 3-6) respectively. The accuracy for radiofrequency ablation probe placement was 2±0.2 (SD)mm (range: 0-9mm). Pneumothorax requiring chest tube placement occurred in one patient (CTCAE-V4.0 grade 3). At 6months, all patients were alive with tumor response rate of -27% and had no significant activity on the ¹⁸FDG-PET CT follow-up.

CONCLUSION

Percutaneous radiofrequency ablation of lung metastases from colorectal cancer under C-arm CBCT guidance is feasible and safe, with immediate and short-term results similar to those obtained using conventional CT guidance.

Psychiatric consequences of intraoperative awareness: short review and case series

Intraoperative awareness is an unwanted outcome that consists of an explicit recall of events during a surgical procedure performed under general anesthesia. Despite its relatively infrequent occurrence, intraoperative awareness is of significant concern due to frequent adverse psychiatric sequelae. We present three patients who developed posttraumatic sequelae following an episode of awareness under anesthesia and discuss the importance of early detection and specific care.

Impact of preoperative maintenance or interruption of aspirin on thrombotic and bleeding events after elective non-cardiac surgery: the multicentre, randomized, blinded, placebo-controlled, STRATAGEM trial

BACKGROUND

Patients receiving anti-platelet agents for secondary cardiovascular prevention frequently require non-cardiac surgery. A substantial proportion of these patients have their anti-platelet drug discontinued before operation; however, there is uncertainty about the impact of this practice. The aim of this study was to compare the effect of maintenance or interruption of aspirin before surgery, in terms of major thrombotic and bleeding events.

METHODS

Patients treated with anti-platelet agents for secondary prevention and undergoing intermediate- or high-risk non-cardiac surgery were included in this multicentre, randomized, placebo-controlled, trial. We substituted non-aspirin anti-platelets with aspirin (75 mg daily) or placebo starting 10 days before surgery. The primary outcome was a composite score evaluating both major thrombotic and bleeding adverse events occurring within the first 30 postoperative days weighted by their severity (weights were established a priori using a Delphi consensus process). Analyses followed the intention-to-treat principle.

RESULTS

We randomized 291 patients (n=145, aspirin group, and n=146, placebo group). The most frequent surgical procedures were orthopaedic surgery (52.2%), abdominal surgery (20.6%), and urologic surgery (15.5%). No significant difference was observed neither in the primary outcome score [mean values (SD)=0.67 (2.05) in the aspirin group vs 0.65 (2.04) in the placebo group, P=0.94] nor at day 30 in the number of major complications between groups.

CONCLUSIONS

In these at-risk patients undergoing elective non-cardiac surgery, we did not find any difference in terms of occurrence of major thrombotic or bleeding events between preoperative maintenance or interruption of aspirin.

Diastolic heart failure in anaesthesia and critical care

Diastolic heart failure is an underestimated pathology with a high risk of acute decompensation during the perioperative period. This article reviews the epidemiology, risk factors, pathophysiology, and treatment of diastolic heart failure. Although frequently underestimated, diastolic heart failure is a common pathology. Diastolic heart failure involves heart failure with preserved left ventricular (LV) function, and LV diastolic dysfunction may account for acute heart failure occurring in critical care situations. Hypertensive crisis, sepsis, and myocardial ischaemia are frequently associated with acute diastolic heart failure. Symptomatic treatment focuses on the reduction in pulmonary congestion and the improvement in LV filling. Specific treatment is actually lacking, but encouraging data are emerging concerning the use of renin-angiotensin-aldosterone axis blockers, nitric oxide donors, or, very recently, new agents specifically targeting actin-myosin cross-bridges.

Quantification of left ventricular modification in weightlessness conditions from the spatio-temporal analysis of 2D echocardiographic images

Two-dimensional echocardiography (2DE) performed during flights with a parabolic trajectory to simulate weightlessness provides a unique means to study left ventricular (LV) modifications to prevent post-flight orthostatic intolerance in astronauts. However, conventional analysis of 2DE is based on manual tracings and depends on experience. Accordingly, the aim was objectively to quantify, from 2DE images, the LV modifications related to different gravity levels, by applying a semi-automated level-set border detection technique. The algorithm validation was performed by the comparison of manual tracing results, obtained by two independent observers with 20 images, with the semi-automated measurements. To quantify LV modifications, three consecutive cardiac cycles were analysed for each gravity phase (1 Gz, 1.8 Gz, 0 Gz). The level-set procedure was applied frame-by-frame to detect the LV endocardial contours and obtain LV area against time curves, from which end-diastolic (EDA) and end-systolic (ESA) areas were computed and averaged to compensate for respiratory variations. Linear regression (y = 0.91x + 1.47, r = 0.99, SEE:0.80cm2) and Bland-Altman analysis (bias = -0.58 cm2, 95% limits of agreement= +/- 2.14cm2) showed excellent correlation between the semi-automatic and manually traced values. Inter-observer variability was 5.4%, and the inter-technique variability was 4.1%. Modifications in LV dimensions during the parabola were found: compared with 1 Gz values, EDA and ESA were significantly reduced at 1.8 Gz by 8.8 +/- 5.5% and 12.1 +/- 10.1%, respectively, whereas, during 0 Gz, EDA and ESA increased by 13.3 +/- 7.3% and 11.6 +/- 5.1%, respectively, owing to abrupt changes in venous return. The proposed method resulted in fast and reliable estimations of LV dimensions, whose changes caused by different gravity conditions were objectively quantified.

Changes in Doppler mitral inflow patterns during parabolic flight

Aim of the study was to evaluate by transthoracic Doppler the alterations in mitral inflow velocity pattern caused by acute changes in loading conditions occurring during parabolic flights. Each parabola included normogravity (1 Gz, 1 min), mild hypergravity (1.8 Gz, 20 sec), microgravity (0 Gz, 24 sec) and mild hypergravity (1.8 Gz, 20 sec) phases. Pulsed-Doppler images were digitally acquired in 11 unmedicated subjects (46 +/- 5 years), in standing upright position and supine resting. Doppler profiles were semi-automatically traced and inflow parameters extracted and averaged onto three consecutive beats. Only in standing position, significant alterations during microgravity (p<0.05) were noted in several parameters.

[In vitro effects of antiallergic eyedrops on complement activation induced by particulate matter]

BACKGROUND

Recent decades have been marked by an increasing number of patients suffering from ocular allergic-like symptoms without being associated with an increase in IgE levels. These symptoms include heaviness of the lid, foreign body sensation, burning, stinging and photophobia. Both epidemiological studies and controlled human exposure clinical studies have shown cause-effect relationships between allergic-like symptoms and environmental factors such as outdoor air pollutants or poor indoor air quality. An ocular surface subclinical inflammation is thought to be responsible for pseudoallergic, pollution-related conjunctivitis. The complement system is considered as one of the major effector mechanisms involved in initiation of the subclinical inflammation that leads to IgE-independent eye irritation.

PURPOSE

To study the capability of nine antiallergic eyedrops commonly used in the treatment of allergic conjunctivitis to inhibit complement activation induced in vitro by pollutants.

METHODS

Normal human serum obtained from healthy individuals was used as a source of complement. Activation of complement was assessed using the complement hemolytic 50% (CH50) assay, in the absence or the presence of antiallergic eyedrops and in the absence or the presence of various stimuli, including sand, common house dust, eye mascara, and Dactylis glomerata pollen extract. Zymosan was used as a standardized complement activator. The following eyedrops were studied: Naabak (4.9% N-acetyl aspartic acid-glutamic acid, NAAGA, sodium salt), Almide (lodoxamide 0.1%), Levophta (0.05% levocabastine), Emadine (0.05% emedastine), Tilavist (2% nedocromil), Allergodil (0.05% azelastine), Patanol (olopatadine), and Zaditen (0.025% ketotifen). Effects of preservative-free lodoxamide and ketotifen were also assessed and compared to those of the preserved formulations. A solution of 0.01% benzalkonium chloride (BAC), the most widely used preservative in topical eyedrops, was also tested.

RESULTS

Zymosan-induced activation of complement (30+/-6%) was significantly lowered by preincubation of serum with unpreserved NAAGA (16.6+/-4%, p=0.0026) or benzalkonium-preserved nedocromil (20+/-2%, p=0.022). Preserved levocabastine, emedastine, olopatadine and ketotifen did not interfere with zymosan-induced complement activation, whereas preserved azelastine, lodoxamide and benzalkonium chloride significantly aggravated complement activation induced by zymosan. Similar results were obtained when complement activation was triggered by sand, common house dust, mascara, or by an allergenic extract of Dactylis glomerata pollen. In the absence of complement activator, none of the antiallergic eyedrops induced a significant change in CH50 titer, indicating that the deleterious pro-inflammatory effect of preserved azelastine and lodoxamide may occur only once complement activation has been initiated, i.e., on an inflamed ocular surface.

CONCLUSION

Among the antiallergic eyedrops tested in this study, only Naabak and Tilavist were found to significantly inhibit complement activation triggered by particulate matters or pollen allergenic extract. Such an anticomplement activity confers these two molecules a potential in the therapeutic management of pollution-related pseudoallergic conjunctivitis.

Time-variant spectral analysis of heart rate variability during parabolic flight with and without LBNP

Modifications of autonomic activity during parabolic flight were studied by a time-variant model able to estimate low (LF, 0.04-0.14 Hz) and high (HF, 0.14-0.35 Hz) frequency spectral components on a beat-to-beat basis. Ten subjects were studied with and without lower body negative pressure (LBNP). ECG and Gz load were digitized (500 Hz) and RR interval variability series extracted. Beat-to-beat mean RR, variance, LF and HF power were obtained. One-way ANOVA (p<0.01) was used to compare values obtained during starting 1Gz (I), first 1.8Gz (II), 0Gz (III), second 1.8Gz (IV), ending 1Gz (V). Without LBNP, total and LF power increased during 0Gz to 1.69 +/- 1.41 and 2.87 +/- 4.66 respectively (mean +/- SD, normalized by phase I value). With LBNP, their change during 0Gz (1.38 +/- 1.37 and 1.54 +/- l.04 respectively) reached significance only with phase II and phase V. Phase I HF power was higher than in the other phases, both without and with LBNP.

Changes in left ventricular size during parabolic flights by two-dimensional echocardiography and level set method

This study aims to evaluate changes on cardiac chambers size, induced by gravitational stresses. During parabolic flight, seven subjects underwent 2-D transthoracic echocardiography at three different gravity phases (1 Gz, 1.8 Gz, and 0 Gz). LV endocardial borders were detected applying a semi-automatic segmentation procedure based on level set methods. LV cavity area was computed frame-by-frame for a whole cardiac cycle during each gravity phase. Expected modifications in LV area with different gravity were found: at 1.8 Gz, end-diastolic (ED) and end-systolic (ES) areas were significantly (p<0.05) reduced of 10.7 +/- 5.4% and 21.6 +/- 11.1% respectively, compared to 1 Gz values, while they were increased of 11.2 +/- 5.4% and 11.1 +/- 6% during 0 Gz. Fractional area change was augmented of 20.9 +/- 29.1% at 1.8 Gz, while it remained unchanged at 0 Gz, compared with 1 Gz values. Furthermore, LV filling due to atrial contraction was increased at 0 Gz of 39 +/- 35.6%.

Gram-positive and gram-negative bacteria do not trigger monocytic cytokine production through similar intracellular pathways

Toll-like receptors (TLRs) are involved in human monocyte activation by lipopolysaccharide (LPS) and Staphylococcus aureus Cowan (SAC), suggesting that gram-positive and gram-negative bacteria may trigger similar intracellular events. Treatment with specific kinase inhibitors prior to cell stimulation dramatically decreased LPS-induced cytokine production. Blocking of the p38 pathway prior to LPS stimulation decreased interleukin-1alpha (IL-1alpha), IL-1ra, and tumor necrosis factor alpha (TNF-alpha) production, whereas blocking of the ERK1/2 pathways inhibited IL-1alpha, IL-1beta, and IL-1ra but not TNF-alpha production. When cells were stimulated by SAC, inhibition of the p38 pathway did not affect cytokine production, whereas only IL-1alpha production was decreased in the presence of ERK kinase inhibitor. We also demonstrated that although LPS and SAC have been shown to bind to CD14 before transmitting signals to TLR4 and TLR2, respectively, internalization of CD14 occurred only in monocytes triggered by LPS. Pretreatment of the cells with SB203580, U0126, or a mixture of both inhibitors did not affect internalization of CD14. Altogether, these results suggest that TLR2 signaling does not involve p38 mitogen-activated protein kinase signaling pathways, indicating that divergent pathways are triggered by gram-positive and gram-negative bacteria, thereby inducing cytokine production.

Lipopolysaccharide complexed with soluble CD14 binds to normal human monocytes

Using flow cytometry we have compared the binding of Neisseria meningitidis lipopolysaccharide labeled with fluorescein isothiocyanate (FITC-LPS) to normal human monocytes in whole blood with the binding to chinese hamster ovary (CHO) cells transfected with human CD14 gene (hCD14-CHO cells). Binding of FITC-LPS to cells was dose dependent, saturable and enhanced in the presence of increasing concentrations of serum. Blockade of membrane CD14 with saturating concentrations of anti-CD14 monoclonal antibody (mAb) My4 inhibited 50% of the binding of FITC-LPS to monocytes and 100% to hCD14-CHO cells. Similarly, removal of membrane CD14 by phosphatidylinositol phospholipase C (PI-PLC) treatment of the cells partially decreased the binding of FITC-LPS to monocytes but totally inhibited the binding to hCD14-CHO-transfected cells. These results suggest that binding of FITC-LPS to monocytes is not only mediated by membrane CD14. Using two-color flow cytometry, we observed that FITC-LPS binds to My4-saturated monocytes in association with soluble (s)CD14 present in serum as revealed by staining with rhodamine-labeled My4 mAb. The binding of FITC-LPS/sCD14 complexes to monocytes treated with saturating amounts of unlabeled My4 prior to addition of the complexes was completely inhibited by anti-CD14 mAb 10G33. When cells were first saturated with a mixture of My4 and 10G33 mAb, washed and further incubated with FITC-LPS/sCD14, inhibition of the binding of LPS was similar to that observed with cells saturated with My4 alone, showing that the binding of FITC-LPS is not mediated by the 10G33 epitope present on mCD14. These results suggest that either the 10G33 epitope on sCD14 is involved in the binding of LPS/sCD14 complexes to the cells, or that 10G33 mAb inhibits the binding of FITC-LPS to sCD14. Taken together, these data indicate that sCD14 which is present in normal serum, in addition to membrane CD14, enables LPS to bind monocytes through an as yet unidentified molecule and that sCD14 does not simply serve as a shuttle for transfer of LPS to membrane CD14.

Dissociation between beta-2 microglobulin and IL-1 production in hemodialyzed patients

BACKGROUND

beta-2 microglobulin is predominant in amyloid deposits in patients undergoing long term hemodialysis. Amyloid accumulation has been ascribed to dialysis membranes, endotoxin contamination of the dialysate, uremia and chronic systemic inflammation associated with enhanced monocytic cytokine production in hemodialyzed patients. Interleukin-1 has been proposed to play a critical role in the induction of beta-2 microglobulin synthesis and release.

METHODS

We examined if monocytes contribute to beta-2 microglobulin production upon stimulation with inflammatory mediators that are generated during hemodialysis and investigated the production of beta-2 microglobulin by cells from patients, with and without clinical signs of amyloidosis, at the time when patients' monocytes contained maximal intracellular accumulation of IL-1.

RESULTS

We demonstrated that only monocytes are able to release increased levels of beta-2 microglobulin upon stimulation by IL-1, TNF alpha, C5a and LPS. Increased levels of beta-2 microglobulin were associated with increased levels of beta-2 microglobulin mRNA. Before dialysis session, 20-60% of circulating CD14+ monocytes from patients contained IL-1. At the time when maximal IL-1 production was detected, we showed by RT-PCR increased transcription of IL-1 gene in patients' monocytes. We observed that monocytes from patients with amyloidosis contained higher amounts of IL-1 as compared to monocytes from patients without clinical signs of amyloidosis, but could not secrete increased amounts of beta-2 microglobulin upon LPS-stimulation.

CONCLUSIONS

Our data indicated that chronic inflammation, as demonstrated by increased intracellular IL-1 expression, is not associated with increased production of beta-2 microglobulin by monocytes from patients on hemodialysis.

High tumor necrosis factor serum level is associated with increased survival in patients with abdominal septic shock: a prospective study in 59 patients

BACKGROUND

In several studies including patients with septic shock of various origins, high serum cytokine levels have been reported to correlate with poor outcome. The aim of this prospective study was to assess the prognostic value of cytokine serum levels in a group of patients with perioperative septic shock of digestive origin.

METHODS

From January 1992 to December 1994, 59 patients were evaluated (mean age, 68 +/- 15 years). From the first day of septic shock to day 7, blood was drawn every day to measure the conventional biologic parameters (white blood cell count, platelet count, hematocrit, blood urea nitrogen level, serum electrolytes level, pH, blood gases, serum lactate level, coagulation parameters, liver function tests) and tumor necrosis factor (TNF), interleukin-1, and interleukin-6.

RESULTS

No difference was observed between the 26 survivors and the 33 nonsurvivors with regard to age, gender, and cause of sepsis. On admission, mean platelet count was significantly higher in the survivors than in the nonsurvivors (260 +/- 142 versus 177 +/- 122 10(9)/L; p = 0.01). Mean blood urea nitrogen level was significantly lower in the survivors than in the nonsurvivors (9.6 +/- 9 versus 12 +/- 7 mmol/L; p = 0.04). No difference was observed between survivors and nonsurvivors for the other conventional biologic parameters and for serum interleukin-1 and interleukin-6 levels. Mean serum TNF level tended to be higher in survivors than in nonsurvivors (565 +/- 1325 versus 94 +/- 69 pg/ml; not significant). In the group survivor 9 (35%) of 26 patients had a serum TNF level greater than 200 pg/ml versus 2 (6%) of 33 patients in the nonsurvivor group (p < 0.02). Survival was noted in 6 (100%) of 6 patients who had both a serum TNF level greater than 200 pg/ml and a platelet count greater than 100.10(9)/L versus 1 (11%) of 9 in patients with neither of these criteria (p < 0.01).

CONCLUSIONS

In our patients with abdominal septic shock, high serum TNF levels were associated with increased survival. The high serum level of TNF may reflect the efficacy of peritoneal inflammatory response against abdominal sepsis. Although this possibility must be further explored, a score combining the serum TNF level and platelet count could be helpful for the prognostic assessment of patients with abdominal septic shock.

Triggering of complement receptors CR1 (CD35) and CR3 (CD11b/CD18) induces nuclear translocation of NF-kappa B (p50/p65) in human monocytes and enhances viral replication in HIV-infected monocytic cells

Monocyte/macrophages may harbor HIV in a nonproductive fashion for prolonged periods of time. Viral gene expression may be reactivated by stimulation of the cells with LPS or cytokines such as TNF-alpha in vitro. The effect of LPS and TNF-alpha is mediated by their ability to induce nuclear translocation of the DNA-binding heterodimer NF-kappa B (p50/p65), which binds to a specific sequence in the HIV-long terminal repeat. The present study demonstrates that triggering of complement receptors CR1 (CD35) and CR3 (CD11b/CD18) enhances viral replication in HIV-infected human monocytic cells. Monocytic cell lines and normal peripheral blood monocytes were infected with HIV-1 in vitro and cultured in the presence or absence of F(ab')2 fragments of monoclonal anti-CR1 or anti-CR3 Abs or with C3 fragments. Stimulation of CR1 or CR3 induces a two- to fourfold increase in the amount of cell-associated and released p24 Ag in cell cultures that was equivalent to that observed in control cultures triggered with LPS. We further observed that stimulation of CR1 or CR3 induces the nuclear translocation of NF-kappa B p50/p65 in infected cells. Translocation of NF-kappa B p50/p65 was also observed following stimulation of CR1 or CR3 of uninfected peripheral blood monocytes from HIV-seronegative donors. The amount of protein translocated was similar to that observed when cells were stimulated with rhTNF-alpha. TNF-alpha did not mediate the translocation of NF-kappa B p50/p65 induced by triggering of complement receptors. Taken together, these observations suggest that HIV gene expression may be activated in infected monocytes through interaction of the cells with complement-opsonized particles and that enhanced viral replication is associated with C3 receptor-mediated nuclear translocation of the NF-kappa B complex.

Triggering of complement receptors CR1 (CD35) and CR3 (CD11b/CD18) induces nuclear translocation of NF-kappa B (p50/p65) in human monocytes and enhances viral replication in HIV-infected monocytic cells

Monocyte/macrophages may harbor HIV in a nonproductive fashion for prolonged periods of time. Viral gene expression may be reactivated by stimulation of the cells with LPS or cytokines such as TNF-alpha in vitro. The effect of LPS and TNF-alpha is mediated by their ability to induce nuclear translocation of the DNA-binding heterodimer NF-kappa B (p50/p65), which binds to a specific sequence in the HIV-long terminal repeat. The present study demonstrates that triggering of complement receptors CR1 (CD35) and CR3 (CD11b/CD18) enhances viral replication in HIV-infected human monocytic cells. Monocytic cell lines and normal peripheral blood monocytes were infected with HIV-1 in vitro and cultured in the presence or absence of F(ab')2 fragments of monoclonal anti-CR1 or anti-CR3 Abs or with C3 fragments. Stimulation of CR1 or CR3 induces a two- to fourfold increase in the amount of cell-associated and released p24 Ag in cell cultures that was equivalent to that observed in control cultures triggered with LPS. We further observed that stimulation of CR1 or CR3 induces the nuclear translocation of NF-kappa B p50/p65 in infected cells. Translocation of NF-kappa B p50/p65 was also observed following stimulation of CR1 or CR3 of uninfected peripheral blood monocytes from HIV-seronegative donors. The amount of protein translocated was similar to that observed when cells were stimulated with rhTNF-alpha. TNF-alpha did not mediate the translocation of NF-kappa B p50/p65 induced by triggering of complement receptors. Taken together, these observations suggest that HIV gene expression may be activated in infected monocytes through interaction of the cells with complement-opsonized particles and that enhanced viral replication is associated with C3 receptor-mediated nuclear translocation of the NF-kappa B complex.

Involvement of Wnt-1 in the formation of the mes/metencephalic boundary

Wnt-1, a putative signaling molecule, is required before the 7 somite stage (E8.5) for the development of midbrain structures in the mouse. We show here that Wnt-1 is also needed for the formation of a boundary between the mesencephalic and metencephalic domains of the neural tube. In embryos homozygous for the Wnt-1sw allele, mesencephalic and metencephalic markers fail to segregate and the establishment of a straight limit of Otx-2 and Wnt-1 expression at the mid-hindbrain junction is impaired. In addition, as observed previously in heterotopic mes/metencephalic transplantation experiments in avian embryos, Wnt-1 expression is induced at the border of ectopic mes- and metencephalic islands observed in Wnt-1sw/sw mutants, suggesting that, in situ, interactions between mes- and metencephalic cells reinforce Wnt-1 expression at the boundary.

Frequency of bacteremia associated with transesophageal echocardiography in intensive care unit patients: a prospective study of 139 patients

OBJECTIVE

To determine the occurrence rate of bacteremia associated with transesophageal echocardiography in intensive care unit (ICU) patients.

DESIGN

A prospective study of 139 patients undergoing transesophageal echocardiography.

SETTING

The medical ICU of a tertiary referral teaching hospital.

PATIENTS

One hundred thirty-nine ICU patients (mean age 58 yrs) who underwent transesophageal echocardiography.

INTERVENTIONS

Blood samples were systematically drawn for aerobic and anaerobic culture at the following times: before (blood culture 1), at the end of (blood culture 2), and 30 mins after (blood culture 3) transesophageal echocardiography examinations.

MEASUREMENTS AND MAIN RESULTS

The mean duration of transesophageal echocardiography was 35 mins (range 7 to 120). One hundred thirty-four patients received mechanical ventilation; 125 patients had a nasogastric tube. Fifty-one patients had one or more underlying conditions that usually justify antimicrobial prophylaxis of bacterial endocarditis before high-risk procedures. Fifty-six patients did not receive any antibiotic treatment at the time of transesophageal echocardiography. In 114 patients, the three blood cultures were negative. In six patients, transesophageal echocardiography was performed during a preexisting bacteremia. A contamination (only one positive blood culture of the three sampling times) with coagulase-negative staphylococci occurred in four patients at blood culture 1, five patients at blood culture 2, and six patients at blood culture 3. Contamination with Corynebacterium species occurred in two patients at blood culture 2. In one patient receiving cefotaxime and netilmicin, blood culture 1 was sterile and blood cultures 2 and 3 yielded coagulase-negative staphylococci. In one patient receiving no antibiotic treatment, blood culture 1 was sterile and blood cultures 2 and 3 yielded Enterococcus faecalis. None of these two patients received a specific antibiotic treatment or developed any secondary septic focus.

CONCLUSIONS

The overall frequency of bacteremia induced by transesophageal echocardiography in ICU patients was 1.4% (two of 139 patients) (95% confidence interval 0.2% to 5.1%). The frequency did not differ whether patients received antibiotics before transesophageal echocardiography (one [1.2%] of 83 patients) or not (one [1.8%] of 56 patients) (p = .96). Therefore, routine antimicrobial prophylaxis does not appear justified before transesophageal echocardiography in ICU patients.

Variation in arterial to end-tidal CO2 tension differences during anesthesia in the "kidney rest" lateral decubitus position

The course of arterial to end-tidal carbon dioxide tension difference [P(a-ET)CO2] was evaluated during general anesthesia in 25 patients scheduled for renal surgery performed in the "kidney position." The difference between arterial PCO2 (PaCO2) corrected to body temperature, and end-tidal PCO2 (PETCO2) measured by mass spectrometry was assessed after induction of anesthesia, after placement in the lateral decubitus position with back arched over a kidney bridge ("kidney position"), and every 20 min until the patients were replaced in the supine position at the end of the surgical procedure. Heart rate, arterial blood pressure, and esophageal temperature were simultaneously recorded. After induction of anesthesia, when the patients were lying supine (T1), P(a-ET)CO2 was 4.8 +/- 3.9 mm Hg (mean +/- SD). Placing the patients in the kidney position (T2) induced a significant increase in P(a-ET)CO2 (to 7.9 +/- 3.5 mm Hg; P less than 0.01). These alterations occurred without any significant change in mean arterial blood pressure or heart rate. A progressive increase in mean P(a-ET)CO2 occurred with maintenance of anesthesia; P(a-ET)CO2 reached 8.8 +/- 4.1 mm Hg (P less than 0.05 vs T2) and 8.9 +/- 4.4 mm Hg (P less than 0.05 vs T2) at 65 and 85 min, respectively, after lateral decubitus positioning. Large variations between and within patients were observed. Although stable mean arterial pressure was maintained, these changes were associated with a significant decrease in body temperature. These results demonstrate that P(a-ET)CO2 increases when patients are placed in the kidney position and may vary with the prolongation of anesthesia in this situation.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of the olivocerebellar projection in the rat: I. Transient biochemical compartmentation of the inferior olive

In the present study the early phases of the development of the inferior olive were examined by using immunocytochemical techniques. We observed that, from embryonic day 16 onward, antibodies against the calcium binding proteins parvalbumin and calbindin and the calcitonin gene related peptide stain partially overlapping territories of the inferior olive. This staining delimits a biochemical zonation of the inferior olive which is combinatory and transient. We have previously observed a biochemical parcellation of the cerebellar Purkinje cells which, like that of the inferior olive, is first observed at E16, involves the combined expression of marker proteins and is also transient. In order to know whether the biochemical compartmentations of the cerebellum and inferior olive arise independently, the time course of the development of the olivocerebellar projection was studied by anterograde and retrograde in vitro axonal tracing by using the fluorescent carbocyanine dye DiI. The olivocerebellar axons were found to reach the limit of the cerebellar plate at E16 and to enter it at E17. Even at this age the great majority of the climbing fibers are tightly fasciculated, which minimizes their interactions with the PC clusters. These observations indicate that the topographical heterogeneity of Purkinje cells and inferior olive neurons arise independently. The transient biochemical individualization of subgroups of neurons during development could contribute to recognition mechanisms.

Development of the olivocerebellar projection in the rat: II. Matching of the developmental compartmentations of the cerebellum and inferior olive through the projection map

A transient biochemical parcellation has been observed by immunocytochemical methods, during the perinatal development of both the inferior olive and the cerebellum. In the present study, we sought a relationship between this developmental compartmentation and the organization of the olivocerebellar projection. In the inferior olive, a transient parvalbumin immunoreactivity restricted to the dorsal cap of the medial accessory olive is observed around birth. The climbing fiber projection of the dorsal cap was identified in the cerebellum of newborn rats based on its parvalbumin immunoreactivity. The pattern of this projection, restricted to lobules IX and X of the vermis, and to the flocculus, is indistinguishable from that of the adult medial accessory olive, which was previously described from axonal tracing experiments. The parvalbumin immunoreactive climbing fibers were followed between birth and postnatal day 7. In the caudal vermis, Purkinje cell subpopulations can be identified between embryonic day 20 and postnatal day three, on the basis of their differential immunostaining with an antibody directed against a specific peptide, PEP 19. In lobule X, the parvalbumin immunoreactive climbing fibers form two sagittal bands on each side of the midline, one medial and one lateral. The medial parvalbumin immunoreactive climbing fiber band is coextensive with a PEP 19 negative Purkinje cell cluster, indicating a clear relationship between the biochemical parcellations of the cerebellum and inferior olive.

Proximal trajectory of the brachium conjunctivum in rat fetuses and its early association with the parabrachial nucleus. A study combining in vitro HRP anterograde axonal tracing and immunocytochemistry

The proximal course of the developing brachium conjunctivum (BC) in the rat described from embryonic day 16 (E16) to one day postnatal (P1). Axons of the cerebellar deep nuclear neurons entering this bundle were identified by anterograde axonal tracing after in vitro horseradish peroxidase (HRP) injections in the cerebellar plate. At all ages, the main ascending limb of the BC can be followed from its emergence, dorsal to the cerebellar plate where it assumes an almost vertical course, up to its decussation. Close to the ventricle at E16, the decussating fibers are progressively displaced ventrally probably because of the fusion, on the midline, of bilaterally produced raphe neurons. In E16 and E17 embryos, labeled BC fibers extend beyond the decussation in the caudal part of the red nucleus. Decussating BC axons, in some E16 early embryos, end with large and complicated growth cones, as described previously in 'decision regions' for chick embryo motoneurons. Growth cones were never observed in this region in older embryos. In addition to the main ascending limb of the BC, we also traced its ipsilateral descending limb and the cerebello-olivary projections. In parallel, the development of a nucleus immunoreactive for the vitamin D-dependent calcium-binding protein (CaBP) is reported. By E16, its neurons migrate rostrally and settle in the region where the BC is demonstrated by tracing experiments. At E17 and thereafter this isthmic nucleus is composed of a shell of CaBP-immunoreactive neurons ensheathing an immunonegative cylinder. Between E17 and birth, in spite of the profound modifications of the isthmic region, this CaBP-immunoreactive nucleus remains in close proximity to the BC. This nucleus is identified as the marginal nucleus of the BC or parabrachial nucleus, by double-labeling experiments combining the visualization of the retrogradely labeled axons and neurons of the deep cerebellar nuclei inside the CaBP immunofluorescently labeled parabrachial nucleus. Subsequently the deep cerebellar neurons translocate caudoventrally moving away from the parabrachial nucleus inside which their axons become visible. This pattern of migration could indicate that a few neurons of the deep nuclei remain ectopic, wedged between the restiform body and the BC while receiving an appropriate Purkinje cell (PC) projection.

Cerebellar mutations affecting the postnatal survival of Purkinje cells in the mouse disclose a longitudinal pattern of differentially sensitive cells

The pattern of surviving Purkinje cells (PCs) was investigated in three cerebellar mutant mice with severe postnatal PC death. Two of these mutations, nervous (nr) and Purkinje cell degeneration (pcd) mutations are already well characterized. The third mutation is a new one, which appeared spontaneously in DW/J-Pas mice and was called tambaleante (tbl). PCs were identified by immunocytochemistry using an antibody against vitamin D-dependent calcium-binding protein which labels all the PCs in adult control mice. In each of the three mutations, surviving PCs are arranged according to a different and reproducible pattern which is symmetric relative to the midline. In NR and young PCD mutants, PCs are closely packed in broad sagittal bands. In TBL, they are more loosely arranged in a rather patchy pattern. In PCD and in TBL mutants the death of resistant PCs is only shortly delayed but in NR there is little change in the number of surviving PCs after 3 months. The differential sensitivity of subsets of PCs to the effect of nr, pcd, and tbl mutations is topographically determined. These results provide a new evidence of the PC heterogeneity which has been previously demonstrated by histochemical and immunohistochemical techniques. Moreover, in the anterior vermis of control mice, three thin sagittal bands of PCs are labeled by the Q113 monoclonal antibody. Similarly, in the anterior lobe of the NR cerebellum, the thin longitudinal strips of missing PCs coincide with the absence of Q113 immunoreactivity: in this region the nr mutation affects specifically the survival of Q113 positive cells. However, other clusters of Q113 immunoreactive PCs do survive in NR mice suggesting that susceptibility to the nr mutation and Q113 positivity are two independent markers of the underlying PC compartmentalization.