1
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Shumba P, Sura T, Moll K, Chakrakodi B, Tölken LA, Hoßmann J, Hoff KJ, Hyldegaard O, Nekludov M, Svensson M, Arnell P, Skrede S, Norrby-Teglund A, Siemens N. Neutrophil-derived reactive agents induce a transient SpeB negative phenotype in Streptococcus pyogenes. J Biomed Sci 2023; 30:52. [PMID: 37430325 DOI: 10.1186/s12929-023-00947-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Streptococcus pyogenes (group A streptococci; GAS) is the main causative pathogen of monomicrobial necrotizing soft tissue infections (NSTIs). To resist immuno-clearance, GAS adapt their genetic information and/or phenotype to the surrounding environment. Hyper-virulent streptococcal pyrogenic exotoxin B (SpeB) negative variants caused by covRS mutations are enriched during infection. A key driving force for this process is the bacterial Sda1 DNase. METHODS Bacterial infiltration, immune cell influx, tissue necrosis and inflammation in patient´s biopsies were determined using immunohistochemistry. SpeB secretion and activity by GAS post infections or challenges with reactive agents were determined via Western blot or casein agar and proteolytic activity assays, respectively. Proteome of GAS single colonies and neutrophil secretome were profiled, using mass spectrometry. RESULTS Here, we identify another strategy resulting in SpeB-negative variants, namely reversible abrogation of SpeB secretion triggered by neutrophil effector molecules. Analysis of NSTI patient tissue biopsies revealed that tissue inflammation, neutrophil influx, and degranulation positively correlate with increasing frequency of SpeB-negative GAS clones. Using single colony proteomics, we show that GAS isolated directly from tissue express but do not secrete SpeB. Once the tissue pressure is lifted, GAS regain SpeB secreting function. Neutrophils were identified as the main immune cells responsible for the observed phenotype. Subsequent analyses identified hydrogen peroxide and hypochlorous acid as reactive agents driving this phenotypic GAS adaptation to the tissue environment. SpeB-negative GAS show improved survival within neutrophils and induce increased degranulation. CONCLUSIONS Our findings provide new information about GAS fitness and heterogeneity in the soft tissue milieu and provide new potential targets for therapeutic intervention in NSTIs.
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Affiliation(s)
- Patience Shumba
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Thomas Sura
- Department of Microbial Proteomics, Institute of Microbiology, University of Greifswald, Greifswald, Germany
| | - Kirsten Moll
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Bhavya Chakrakodi
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Lea A Tölken
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Jörn Hoßmann
- Helmholtz Center for Infection Research, Brunswick, Germany
| | - Katharina J Hoff
- Institute of Mathematics and Computer Science, University of Greifswald, Greifswald, Germany
| | - Ole Hyldegaard
- Department of Anaesthesia, Head and Orthopedic Center, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Mattias Svensson
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Per Arnell
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Nikolai Siemens
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany.
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2
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Movert E, Bolarin JS, Valfridsson C, Velarde J, Skrede S, Nekludov M, Hyldegaard O, Arnell P, Svensson M, Norrby-Teglund A, Cho KH, Elhaik E, Wessels MR, Råberg L, Carlsson F. Interplay between human STING genotype and bacterial NADase activity regulates inter-individual disease variability. Nat Commun 2023; 14:4008. [PMID: 37414832 PMCID: PMC10326033 DOI: 10.1038/s41467-023-39771-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 06/28/2023] [Indexed: 07/08/2023] Open
Abstract
Variability in disease severity caused by a microbial pathogen is impacted by each infection representing a unique combination of host and pathogen genomes. Here, we show that the outcome of invasive Streptococcus pyogenes infection is regulated by an interplay between human STING genotype and bacterial NADase activity. S. pyogenes-derived c-di-AMP diffuses via streptolysin O pores into macrophages where it activates STING and the ensuing type I IFN response. However, the enzymatic activity of the NADase variants expressed by invasive strains suppresses STING-mediated type I IFN production. Analysis of patients with necrotizing S. pyogenes soft tissue infection indicates that a STING genotype associated with reduced c-di-AMP-binding capacity combined with high bacterial NADase activity promotes a 'perfect storm' manifested in poor outcome, whereas proficient and uninhibited STING-mediated type I IFN production correlates with protection against host-detrimental inflammation. These results reveal an immune-regulating function for bacterial NADase and provide insight regarding the host-pathogen genotype interplay underlying invasive infection and interindividual disease variability.
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Affiliation(s)
- Elin Movert
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden
| | | | | | - Jorge Velarde
- Division of Infectious Diseases, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Hyldegaard
- Department of Anaesthesia, Head and Orthopedic Center, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Per Arnell
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Svensson
- Centre for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Centre for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Kyu Hong Cho
- Department of Biology, Indiana State University, Terre Haute, USA
| | - Eran Elhaik
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden
| | - Michael R Wessels
- Division of Infectious Diseases, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Lars Råberg
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden
| | - Fredric Carlsson
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden.
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3
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Palma Medina LM, Rath E, Jahagirdar S, Bruun T, Madsen MB, Strålin K, Unge C, Hansen MB, Arnell P, Nekludov M, Hyldegaard O, Lourda M, dos Santos VAM, Saccenti E, Skrede S, Svensson M, Norrby-Teglund A. Discriminatory plasma biomarkers predict specific clinical phenotypes of necrotizing soft-tissue infections. J Clin Invest 2021; 131:149523. [PMID: 34263738 PMCID: PMC8279592 DOI: 10.1172/jci149523] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/25/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUNDNecrotizing soft-tissue infections (NSTIs) are rapidly progressing infections frequently complicated by septic shock and associated with high mortality. Early diagnosis is critical for patient outcome, but challenging due to vague initial symptoms. Here, we identified predictive biomarkers for NSTI clinical phenotypes and outcomes using a prospective multicenter NSTI patient cohort.METHODSLuminex multiplex assays were used to assess 36 soluble factors in plasma from NSTI patients with positive microbiological cultures (n = 251 and n = 60 in the discovery and validation cohorts, respectively). Control groups for comparative analyses included surgical controls (n = 20), non-NSTI controls (i.e., suspected NSTI with no necrosis detected upon exploratory surgery, n = 20), and sepsis patients (n = 24).RESULTSThrombomodulin was identified as a unique biomarker for detection of NSTI (AUC, 0.95). A distinct profile discriminating mono- (type II) versus polymicrobial (type I) NSTI types was identified based on differential expression of IL-2, IL-10, IL-22, CXCL10, Fas-ligand, and MMP9 (AUC >0.7). While each NSTI type displayed a distinct array of biomarkers predicting septic shock, granulocyte CSF (G-CSF), S100A8, and IL-6 were shared by both types (AUC >0.78). Finally, differential connectivity analysis revealed distinctive networks associated with specific clinical phenotypes.CONCLUSIONSThis study identifies predictive biomarkers for NSTI clinical phenotypes of potential value for diagnostic, prognostic, and therapeutic approaches in NSTIs.TRIAL REGISTRATIONClinicalTrials.gov NCT01790698.FUNDINGCenter for Innovative Medicine (CIMED); Region Stockholm; Swedish Research Council; European Union; Vinnova; Innovation Fund Denmark; Research Council of Norway; Netherlands Organisation for Health Research and Development; DLR Federal Ministry of Education and Research; and Swedish Children's Cancer Foundation.
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Affiliation(s)
- Laura M. Palma Medina
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Eivind Rath
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - Sanjeevan Jahagirdar
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
| | - Trond Bruun
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Martin B. Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kristoffer Strålin
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases and
| | - Christian Unge
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Bo Hansen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Per Arnell
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Hyldegaard
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Magda Lourda
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Vitor A.P. Martins dos Santos
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
- LifeGlimmer GmbH, Berlin, Germany
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
| | - Steinar Skrede
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Mattias Svensson
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
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4
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Bruun T, Rath E, Madsen MB, Oppegaard O, Nekludov M, Arnell P, Karlsson Y, Babbar A, Bergey F, Itzek A, Hyldegaard O, Norrby-Teglund A, Skrede S. Risk Factors and Predictors of Mortality in Streptococcal Necrotizing Soft-tissue Infections: A Multicenter Prospective Study. Clin Infect Dis 2021; 72:293-300. [PMID: 31923305 PMCID: PMC7840107 DOI: 10.1093/cid/ciaa027] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [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: 09/11/2019] [Accepted: 01/09/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Necrotizing soft-tissue infections (NSTI) are life-threatening conditions often caused by β-hemolytic streptococci, group A Streptococcus (GAS) in particular. Optimal treatment is contentious. The INFECT cohort includes the largest set of prospectively enrolled streptococcal NSTI cases to date. METHODS From the INFECT cohort of 409 adults admitted with NSTI to 5 clinical centers in Scandinavia, patients culture-positive for GAS or Streptococcus dysgalactiae (SD) were selected. Risk factors were identified by comparison with a cohort of nonnecrotizing streptococcal cellulitis. The impact of baseline factors and treatment on 90-day mortality was explored using Lasso regression. Whole-genome sequencing of bacterial isolates was used for emm typing and virulence gene profiling. RESULTS The 126 GAS NSTI cases and 27 cases caused by SD constituted 31% and 7% of the whole NSTI cohort, respectively. When comparing to nonnecrotizing streptococcal cellulitis, streptococcal NSTI was associated to blunt trauma, absence of preexisting skin lesions, and a lower body mass index. Septic shock was significantly more frequent in GAS (65%) compared to SD (41%) and polymicrobial, nonstreptococcal NSTI (46%). Age, male sex, septic shock, and no administration of intravenous immunoglobulin (IVIG) were among factors associated with 90-day mortality. Predominant emm types were emm1, emm3, and emm28 in GAS and stG62647 in SD. CONCLUSIONS Streptococcal NSTI was associated with several risk factors, including blunt trauma. Septic shock was more frequent in NSTI caused by GAS than in cases due to SD. Factors associated with mortality in GAS NSTI included age, septic shock, and no administration of IVIG.
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Affiliation(s)
- Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Bruun Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Michael Nekludov
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Per Arnell
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ylva Karlsson
- Department of Anesthesiology and Intensive Care, Blekinge County Council Hospital, Karlskrona, Sweden
| | - Anshu Babbar
- Helmholtz-Zentrum für Infektionsforschung GmbH, Braunschweig, Germany
| | | | - Andreas Itzek
- Helmholtz-Zentrum für Infektionsforschung GmbH, Braunschweig, Germany
| | - Ole Hyldegaard
- Hyperbaric Medicine Center, Department of Anesthesiology and Surgery, Head and Orthopedic Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Norway
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5
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DeJournett J, Nekludov M, DeJournett L, Wallin M. Performance of a closed-loop glucose control system, comprising a continuous glucose monitoring system and an AI-based controller in swine during severe hypo- and hyperglycemic provocations. J Clin Monit Comput 2020; 35:317-325. [PMID: 32006145 PMCID: PMC7943496 DOI: 10.1007/s10877-020-00474-2] [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] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 01/24/2020] [Indexed: 01/04/2023]
Abstract
Intensive care unit (ICU) patients develop stress induced insulin resistance causing hyperglycemia, large glucose variability and hypoglycemia. These glucose metrics have all been associated with increased rates of morbidity and mortality. The only way to achieve safe glucose control at a lower glucose range (e.g., 4.4–6.6 mmol/L) will be through use of an autonomous closed loop glucose control system (artificial pancreas). Our goal with the present study was to assess the safety and performance of an artificial pancreas system, composed of the EIRUS (Maquet Critical Care AB) continuous glucose monitor (CGM) and novel artificial intelligence-based glucose control software, in a swine model using unannounced hypo- and hyperglycemia challenges. Fourteen piglets (6 control, 8 treated) underwent sequential unannounced hypoglycemic and hyperglycemic challenges with 3 IU of NovoRapid and a glucose infusion at 17 mg/kg/min over the course of 5 h. In the Control animals an experienced ICU physician used every 30-min blood glucose values to maintain control to a range of 4.4–9 mmol/L. In the Treated group the artificial pancreas system attempted to maintain blood glucose control to a range of 4.4–6.6 mmol/L. Five of six Control animals and none of eight Treated animals experienced severe hypoglycemia (< 2.22 mmol/L). The area under the curve 3.5 mmol/L was 28.9 (21.1–54.2) for Control and 4.8 (3.1–5.2) for the Treated animals. The total percent time within tight glucose control range, 4.4–6.6 mmol/L, was 32.8% (32.4–47.1) for Controls and 55.4% (52.9–59.4) for Treated (p < 0.034). Data are median and quartiles. The artificial pancreas system abolished severe hypoglycemia and outperformed the experienced ICU physician in avoiding clinically significant hypoglycemic excursions.
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Affiliation(s)
- Jeremy DeJournett
- Ideal Medical Technologies, 18 N Kensington Rd, Asheville, NC 28804 USA
| | - Michael Nekludov
- Karolinska University Hospital, Karolinska Universitetssjukhuset, Eugeniavägen 3, 171 76 Solna, Sweden
| | - Leon DeJournett
- Ideal Medical Technologies, 18 N Kensington Rd, Asheville, NC 28804 USA
| | - Mats Wallin
- Maquet Critical Care AB, Röntgenvägen 2, 17154 Solna, Sweden
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Bergsten H, Madsen MB, Bergey F, Hyldegaard O, Skrede S, Arnell P, Oppegaard O, Itzek A, Perner A, Svensson M, Norrby-Teglund A, Nekludov M, Kjellberg A, Bruun T, Nedrebø T, Skutlaberg DH, Babbar A, Rosén A, Martins dos Santos VAP, Nekludov M, Kjellberg A, Bruun T, Nedrebø T, Skutlaberg DH, Babbar A, Rosén A, Martins dos Santos VAP. Correlation Between Immunoglobulin Dose Administered and Plasma Neutralization of Streptococcal Superantigens in Patients With Necrotizing Soft Tissue Infections. Clin Infect Dis 2020; 71:1772-1775. [DOI: 10.1093/cid/ciaa022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/08/2020] [Indexed: 12/18/2022] Open
Abstract
Abstract
Analyses of plasma collected pre- and postadministration of intravenous immunoglobulin (IVIG) from patients with group A Streptococcus necrotizing soft tissue infections demonstrated a negative correlation between IVIG dose and toxin-triggered T-cell proliferation (r = −.67, P < .0001). One 25-g IVIG dose was sufficient to yield plasma-neutralizing activity against streptococcal superantigens.
Clinical Trials Registration. NCT 01790698 and NCT02111161.
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Affiliation(s)
- Helena Bergsten
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Huddinge, Stockholm, Sweden
| | - Martin Bruun Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Ole Hyldegaard
- Department of Anesthesia and Surgery, Hyperbaric Unit, Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Per Arnell
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Andreas Itzek
- Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mattias Svensson
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Huddinge, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Huddinge, Stockholm, Sweden
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7
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Madsen MB, Skrede S, Perner A, Arnell P, Nekludov M, Bruun T, Karlsson Y, Hansen MB, Polzik P, Hedetoft M, Rosén A, Saccenti E, Bergey F, Martins dos Santos VAP, Norrby-Teglund A, Hyldegaard O. Patient’s characteristics and outcomes in necrotising soft-tissue infections: results from a Scandinavian, multicentre, prospective cohort study. Intensive Care Med 2019; 45:1241-1251. [DOI: 10.1007/s00134-019-05730-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/02/2019] [Indexed: 12/19/2022]
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Bartek Jr. J, Skyrman S, Nekludov M, Mathiesen T, Lind F, Schechtmann G. Hyperbaric Oxygen Therapy as Adjuvant Treatment for Hardware-Related Infections in Neuromodulation. Stereotact Funct Neurosurg 2018; 96:100-107. [DOI: 10.1159/000486684] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022]
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9
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Babbar A, Bruun T, Hyldegaard O, Nekludov M, Arnell P, Pieper DH, Itzek A. Pivotal Role of Preexisting Pathogen-Specific Antibodies in the Development of Necrotizing Soft-Tissue Infections. J Infect Dis 2018; 218:44-52. [DOI: 10.1093/infdis/jiy110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anshu Babbar
- Microbial Interactions and Processes, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ole Hyldegaard
- Hyperbaric Unit, Department of Anesthesia, Center for Head and Orthopedics, Rigshospitalet, Copenhagen
| | - Michael Nekludov
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Stockholm
| | - Per Arnell
- Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden
| | - Dietmar H Pieper
- Microbial Interactions and Processes, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Andreas Itzek
- Microbial Interactions and Processes, Helmholtz Center for Infection Research, Braunschweig, Germany
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10
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Madsen MB, Skrede S, Bruun T, Arnell P, Rosén A, Nekludov M, Karlsson Y, Bergey F, Saccenti E, Martins dos Santos VAP, Perner A, Norrby-Teglund A, Hyldegaard O. Necrotizing soft tissue infections - a multicentre, prospective observational study (INFECT): protocol and statistical analysis plan. Acta Anaesthesiol Scand 2018; 62:272-279. [PMID: 29082520 DOI: 10.1111/aas.13024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/08/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The INFECT project aims to advance our understanding of the pathophysiological mechanisms in necrotizing soft tissue infections (NSTIs). The INFECT observational study is part of the INFECT project with the aim of studying the clinical profile of patients with NSTIs and correlating these to patient-important outcomes. With this protocol and statistical analysis plan we describe the methods used to obtain data and the details of the planned analyses. METHODS The INFECT study is a multicentre, prospective observational cohort study. Patients with NSTIs are enrolled in five Scandinavian hospitals, which are all referral centres for NSTIs. The primary outcomes are the descriptive variables of the patients. Secondary outcomes include identification of factors associated with 90-day mortality and amputation; associations between affected body part, maximum skin defect and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score and 90-day mortality; 90-day mortality in patients with and without acute kidney injury (AKI) and LRINEC score of six and above or below six; and association between affected body part at arrival and microbiological findings. Exploratory outcomes include univariate analyses of baseline characteristics associations with 90-day mortality. The statistical analyses will be conducted in accordance with the predefined statistical analysis plan. CONCLUSION Necrotizing soft tissue infections result in severe morbidity and mortality. The INFECT study will be the largest prospective study in patients with NSTIs to date and will provide important data for clinicians, researchers and policy makers on the characteristics and outcomes of these patients.
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Affiliation(s)
- M. B. Madsen
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - S. Skrede
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - T. Bruun
- Department of Medicine; Haukeland University Hospital; Bergen Norway
| | - P. Arnell
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - A. Rosén
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - M. Nekludov
- Department of Anaesthesia; Surgical Services and Intensive Care; Karolinska Institutet; Karolinska University Hospital; Stockholm Sweden
| | - Y. Karlsson
- Department of Anaesthesiology and Intensive Care; Blekinge County Hospital; Karlskrona Sweden
| | | | - E. Saccenti
- Laboratory of Systems and Synthetic Biology; Wageningen University & Research; Wageningen the Netherlands
| | - V. A. P. Martins dos Santos
- LifeGlimmer GmBH; Berlin Germany
- Laboratory of Systems and Synthetic Biology; Wageningen University & Research; Wageningen the Netherlands
| | - A. Perner
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - A. Norrby-Teglund
- Centre for Infectious Medicine; Karolinska Institutet; Karolinska University Hospital; Huddinge Sweden
| | - O. Hyldegaard
- Department of Anaesthesia; Centre of Head and Orthopaedics; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
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Lindblad C, Thelin EP, Nekludov M, Frostell A, Nelson DW, Svensson M, Bellander BM. Assessment of Platelet Function in Traumatic Brain Injury-A Retrospective Observational Study in the Neuro-Critical Care Setting. Front Neurol 2018; 9:15. [PMID: 29434566 PMCID: PMC5790800 DOI: 10.3389/fneur.2018.00015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 06/05/2017] [Accepted: 01/09/2018] [Indexed: 11/13/2022] Open
Abstract
Background Despite seemingly functional coagulation, hemorrhagic lesion progression is a common and devastating condition following traumatic brain injury (TBI), stressing the need for new diagnostic techniques. Multiple electrode aggregometry (MEA) measures platelet function and could aid in coagulopathy assessment following TBI. The aims of this study were to evaluate MEA temporal dynamics, influence of concomitant therapy, and its capabilities to predict lesion progression and clinical outcome in a TBI cohort. Material and methods Adult TBI patients in a neurointensive care unit that underwent MEA sampling were retrospectively included. MEA was sampled if the patient was treated with antiplatelet therapy, bled heavily during surgery, or had abnormal baseline coagulation values. We assessed platelet activation pathways involving the arachidonic acid receptor (ASPI), P2Y12 receptor, and thrombin receptor (TRAP). ASPI was the primary focus of analysis. If several samples were obtained, they were included. Retrospective data were extracted from hospital charts. Outcome variables were radiologic hemorrhagic progression and Glasgow Outcome Scale assessed prospectively at 12 months posttrauma. MEA levels were compared between patients on antiplatelet therapy. Linear mixed effect models and uni-/multivariable regression models were used to study longitudinal dynamics, hemorrhagic progression and outcome, respectively. Results In total, 178 patients were included (48% unfavorable outcome). ASPI levels increased from initially low values in a time-dependent fashion (p < 0.001). Patients on cyclooxygenase inhibitors demonstrated low ASPI levels (p < 0.001), while platelet transfusion increased them (p < 0.001). The first ASPI (p = 0.039) and TRAP (p = 0.009) were significant predictors of outcome, but not lesion progression, in univariate analyses. In multivariable analysis, MEA values were not independently correlated with outcome. Conclusion A general longitudinal trend of MEA is identified in this TBI cohort, even in patients without known antiplatelet therapies. Values appear also affected by platelet inhibitory treatment and by platelet transfusions. While significant in univariate models to predict outcome, MEA values did not independently correlate to outcome or lesion progression in multivariable analyses. Further prospective studies to monitor coagulation in TBI patients are warranted, in particular the interpretation of pathological MEA values in patients without antiplatelet therapies.
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Affiliation(s)
- Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Michael Nekludov
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Arvid Frostell
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Hannerz J, Nekludov M, Blombäck M, Antovic J. Thrombin activatable fibrinolysis inhibitor antigen could not be detected in cerebrospinal fluid. Thromb Haemost 2017. [DOI: 10.1055/s-0037-1616162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
PRIMARY OBJECTIVE to investigate the presence of circulating microparticles (MPs) of brain tissue origin in the systemic and cerebrovenous blood of patients with severe traumatic brain injury (TBI). RESEARCH DESIGN Prospective observational study in 15 consecutive patients with severe isolated TBI. METHODS AND PROCEDURES We repeatedly measured concentrations of MPs expressing glial fibrillary acidic protein (GFAP), neuron-specific enolase (NSE) and aquaporin-4 (AQP4), in arterial and cerebrovenous blood at admittance to hospital and up to 72 hours after the injury. MAIN OUTCOMES AND RESULTS Concentrations of MPs expressing GFAP and AQP4 were significantly higher in the TBI group compared with healthy controls: GFAP 2.0 [1.1-7.9] vs. 1.3 [1-2.1] × 106/mL, p < 0.001; AQP4 0.1 [0.07-0.22] vs. 0.08 [0.06-0.11] × 106/mL, p < 0.001 (median, range). No transcranial gradients were found. Levels of NSE-expressing MPs were also higher in the TBI group compared with healthy controls: 0.4 [0.25-2.1] vs. 0.26 [0.13-0.98] × 106/mL, p < 0.05; however, regarding NSE-positive non-platelet MPs, there were no differences between patients and controls. CONCLUSIONS Patients with TBI have higher numbers of brain-derived MPs. Further studies are needed, however, to identify specific and sensitive MP markers of brain injury.
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Affiliation(s)
- M Nekludov
- a Karolinska Institutet, Department of Physiology and Pharmacology, section for Anesthesiology and Intensive Care , Karolinska University Hospital Solna , Stockholm , Sweden
| | - B-M Bellander
- b Karolinska Institutet, Department of Clinical Neuroscience, section for Neurosurgery , Karolinska University Hospital Solna , Stockholm , Sweden
| | - D Gryth
- a Karolinska Institutet, Department of Physiology and Pharmacology, section for Anesthesiology and Intensive Care , Karolinska University Hospital Solna , Stockholm , Sweden
| | - H Wallen
- c Karolinska Institutet , Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyds Hospital , Stockholm , Sweden
| | - F Mobarrez
- c Karolinska Institutet , Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyds Hospital , Stockholm , Sweden.,d Karolinska Institutet , Department of Medicine, Rheumatology Unit , Stockholm , Sweden
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14
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Elander J, Nekludov M, Larsson A, Nordlander B, Eksborg S, Hydman J. Reply to the letter concerning article: ‘Cervical necrotizing fasciitis: descriptive, retrospective analysis of 59 cases treated at a single center’. Eur Arch Otorhinolaryngol 2017; 274:2971. [DOI: 10.1007/s00405-017-4487-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 01/23/2017] [Indexed: 10/20/2022]
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15
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Radecka E, Stjernqvist P, Nyren S, Nekludov M. [Iatrogenic cerebral arterial gas embolism after lung biopsy]. Lakartidningen 2017; 114:D93A. [PMID: 28350416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Eva Radecka
- Thoraxradiologiska kliniken - PhD, Specialist i radiologi, ÖL, Karolinska Universitetssjukhuset Solna Stockholm, Sweden Thoraxradiologiska kliniken, Karolinska Universitetsjukhuset Solna - Stockholm, Sweden
| | - Paula Stjernqvist
- ANOPIVA kliniken - ST-läkare, Karolinska Universitetssjukhuset Solna Stockholm, Sweden ANOPIVA kliniken, Karolinska Universitetssjukhuset Solna - Stockholm, Sweden
| | - Sven Nyren
- Thoraxradiologiska kliniken - docent, ÖL, Karolinska Universitetssjukhuset Solna Stockholm, Sweden Thoraxradiologiska kliniken, Karolinska Universitetssjukhuset Solna - Stockholm, Sweden
| | - Michael Nekludov
- ANOPIVA kliniken - PhD, Specialist i anestesiologi, specialist i hyperbarmedicin, BÖL, Karolinska Universitetssjukhuset Solna Stockholm, Sweden - ANOPIVA kliniken Stockholm, Sweden
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16
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Thelin EP, Bellander BM, Nekludov M. Biochemical response to hyperbaric oxygen treatment of a transhemispheric penetrating cerebral gunshot injury. Front Neurol 2015; 6:62. [PMID: 25852640 PMCID: PMC4369642 DOI: 10.3389/fneur.2015.00062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 10/31/2014] [Accepted: 03/10/2015] [Indexed: 11/23/2022] Open
Abstract
Hyperbaric oxygen (HBO) therapy has been suggested a treatment option in order to reduce the development of secondary insults succeeding traumatic brain injury. This case report studied the course of a 23-year-old gentleman with a close range transhemispheric gunshot wound. The biochemical parameters, using a multi-modal monitoring in the neuro-intensive care unit, improved following HBO treatment.
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Affiliation(s)
- Eric Peter Thelin
- Section for Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet , Stockholm , Sweden
| | - Bo-Michael Bellander
- Section for Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet , Stockholm , Sweden
| | - Michael Nekludov
- Department of Pharmacology and Physiology, Karolinska Institutet , Stockholm , Sweden
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17
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Nekludov M, Mobarrez F, Gryth D, Bellander BM, Wallen H. Formation of microparticles in the injured brain of patients with severe isolated traumatic brain injury. J Neurotrauma 2014; 31:1927-33. [PMID: 24956150 DOI: 10.1089/neu.2013.3168] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [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: 12/26/2022] Open
Abstract
The potential pathophysiological role of circulating microparticles (MPs) has been recognized in various conditions, such as cardiovascular and thrombotic diseases. Traumatic brain injury (TBI) has a complex pathophysiology that involves coagulopathy and inflammation. We investigated endothelial-, platelet-, and leukocyte-derived microparticles (EMPs, PMPs, and LMPs, respectively) in 16 patients with severe isolated TBI. Arterial and cerebrovenous samples were taken repeatedly, during 1-72 h after injury. Subpopulations of MPs, exposing tissue factor (TF) and P-selection, were also studied. MP counts in cerebrovenous samples, irrespective of cellular origin, were higher in TBI cases, compared to healthy controls (peak levels of EMPs were approximately 7 times higher, PMPs 1.4 times higher, and LMPs 2 times higher, respectively; p<0.001 for all). MP counts declined sharply from high levels shortly after the trauma toward slightly elevated levels 72 h later. EMPs and PMPs exposing TF, as well as PMPs exposing P-selection, showed a transcranial gradient with higher concentration in cerebrovenous, compared to arterial, samples. In contrast, LMPs exposing TF were higher in arterial samples, suggesting accumulation of LMPs in the brain. We conclude that the pattern of circulating MPs is altered after TBI. PMPs exposing P-selection and EMPs exposing TF seem to be generated in the injured brain, whereas LMPs exposing TF are accumulated. The pathophysiological significance of these changes in MP pattern in TBI should be further investigated. Including MPs exposing brain-specific antigens in the assessment of brain injury would give further information of origin and likely give additional information of the size of the injury, given that the MP phenotypes investigated in the present study are not brain-specific markers.
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Affiliation(s)
- Michael Nekludov
- 1 Karolinska Institute, Department of Physiology and Pharmacology, Section for Anesthesiology, Karolinska University Hospital , Stockholm, Sweden
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Wallén H, Agren A, Nekludov M. ["Triple therapy" with warfarin, clopidogrel and acetylsalicylic acid. High risk treatment with unclear benefit]. Lakartidningen 2007; 104:3640-3642. [PMID: 18193674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Affiliation(s)
- Michael Nekludov
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Margareta Blombäck
- Department of MolMed and Surgery, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Håkan N. Wallen
- Department of Clinical Science, Karolinska Institutet, and Division of Cardiology, Danderyd Hospital, Stockholm, Sweden
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20
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Nekludov M, Antovic J, Bredbacka S, Blombäck M. Coagulation Abnormalities Associated with Severe Isolated Traumatic Brain Injury: Cerebral Arterio-Venous Differences in Coagulation and Inflammatory Markers. J Neurotrauma 2007; 24:174-80. [PMID: 17263681 DOI: 10.1089/neu.2006.0173] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although coagulopathy is known to be the major contributor to a poor outcome of traumatic brain injury (TBI), the mechanisms that trigger coagulation abnormalities have not been studied in detail. We undertook a prospective observational study at a neurosurgical ICU (NICU) in a university hospital. We examined 11 patients with severe isolated TBI, at admittance to the hospital and during the next 3 days. We collected cerebrovenous blood samples from a jugular bulb catheter, arterial blood, and cerebrospinal fluid (CSF) samples. We measured concentrations of thrombin-antithrombin complex (TAT), fibrin D-dimer (DD), prothrombin fragment 1 + 2 (F1 + 2), interleukin-6 (IL-6), and complement complex (C5b-9). All patients had some degree of consumption coagulopathy at the study start and a tendency to thrombocytopenia during the next few days. Levels of DD (3.6 +/- 2.7 mg/L), TAT (86 +/- 72 microg/L) and F1 + 2 (5.9 +/- 6.8 nmol/L) were significantly increased shortly after the trauma compared to reference values, with considerable transcranial gradients for TAT (49 microg/L) and F1 + 2 (3.2 nmol/L). Compared to controls, IL-6 levels were increased more than a hundredfold in both blood (283 +/- 192 ng/L) and CSF (424 +/- 355 ng/L) samples, with a transcranial gradient at the study start (107 ng/L). C5b-9 levels were moderately increased in blood samples, 270 +/- 114 microg/L, versus controls, 184 +/- 39 (p < 0.05). We conclude that activation of the coagulation system takes place during the passage of blood through the damaged brain, and is already evident hours after the trauma. IL-6 and activation of the complement system (C5b-9) co-vary with hemostatic parameters in TBI patients.
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Affiliation(s)
- Michael Nekludov
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital and Institutet, 17176 Stockholm, Sweden.
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Abstract
BACKGROUND Treatment of patients in the prone position is a well-established method to improve oxygenation in general intensive care unit (ICU) practice. This method is rarely used in a neurosurgical ICU, considering the risk of intracranial hypertension. The aim of this study was to analyse the effect of prone position on intracranial pressure (ICP), cerebral perfusion pressure (CPP) and systemic oxygenation in patients with reduced intracranial compliance. We hypothesize that the beneficial effects of prone position can outweigh the hazardous effects on the intracranial pressure. METHODS Eight patients with traumatic brain injury or subarachnoid hemorrhage (SAH) were studied in the supine and prone posture. Hemodynamics, arterial oxygenation, respiratory mechanics, ICP and CPP were continuously measured. RESULTS A significant improvement in PaO(2) was observed in the prone position, from 12.6 +/- 1.4 kPa to 15.7 +/- 3.2 kPa (P= 0.02). Both intracranial pressure and mean arterial pressure increased in the prone position, from 12 +/- 6 to 15 +/- 4 mmHg (P= 0.03) and from 78 +/- 8 to 88 +/- 8 mmHg (P= 0.005), respectively. Arterial pressure increased to a greater extent than ICP, resulting in improved CPP, from 66 +/- 7 to 73 +/- 8 mmHg (P= 0.03) in the prone position. CONCLUSIONS The prone position can be used to improve the oxygenation as well as CPP in patients with traumatic brain injury or SAH. However, this method results in raised ICP, and should be used cautiously in patients with reduced intracranial compliance.
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Affiliation(s)
- M Nekludov
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital and Institutet, Stockholm, Sweden.
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