First detection of oxacillinase-mediated resistance to carbapenems in Klebsiella pneumoniae from Morocco

The frequency of carbapenem resistance due to class-D beta-lactamases (i.e. oxacillinases) among the world's Enterobacteriaceae is increasing. Recently, in Morocco, two isolates of carbapenem-resistant Klebsiella pneumoniae were recovered from the same patient, one harbouring plasmid-encoded bla-(OXA-48) and the other the bla-(OXA-1) gene. This represents the first evidence of bla(OXA-48)-mediated carbapenem-resistance in Enterobacteriaceae in Morocco.

Expression of the gene encoding the pro-apoptotic BNIP3 protein and stimulation of hypoxia-inducible factor-1α (HIF-1α) protein following focal cerebral ischemia in rats

Hypoxia is a common cause of cell death and is implicated in many disease processes including stroke and chronic degenerative disorders. In response to hypoxia, cells express a variety of genes which allow adaptation to altered metabolic demands, decreased oxygen demands, and the removal of irreversibly damaged cells. Hypoxia-inducible factor-1 (HIF-1) is a transcription factor that regulates the adaptive response to hypoxia in cells. In this study, we reported an early, time-related, gradual up-regulation of HIF-1alpha, and a moderate increase in vascular endothelial growth factor (VEGF)- and erythropoietin (Epo)-levels following transient focal ischemia. Moreover, we demonstrated, for the first time a specific localization of the pro-apoptotic regulator BNIP3 in striatal and cortical neurons after transient focal ischemia in rats. Prolonged intranuclear BNIP3 immunoreactivity was associated with delayed neuronal death. Experiments showed protein increases on Western blots of brain tissue with peaks at 48h after ischemia. Epo responds to ischemia in an early stage, whereas VEGF and BNIP3 accumulate in cells at later times after ischemia. This suggests the possibility that BH3-only proteins might be one of the major downstream effectors of HIF-1alpha in hypoxic cell death. These findings open the possibility that the hypoxia-regulated pro-apoptotic protein BNIP3 enters the nucleus and could interact with other proteins involved in DNA structure, transcription or mRNA splicing after focal brain ischemia.

Induction and redistribution of XAF1, a new antagonist of XIAP in the rat brain after transient focal ischemia

Apoptotic cell death occurs in neurons after cerebral ischemia. To investigate the molecular basis of this mechanism of cell death, we explored the expression and localization of Smac/DIABLO, a newly identified mitochondrial apoptogenic molecule, and XAF1, a recently identified antagonist of XIAP anti-caspase activity in the rat brain following focal ischemia. Transient focal cerebral ischemia was produced for 90 min in rats. We observed changes in the expression of Smac, XAF1, and XIAP during reperfusion. The expression level of Smac/DIABLO was negligible under normal conditions and was moderately increased by 6-24 h reperfusion on both immunohistochemical and Western blotting levels. In opposition to the orthodox method of Western blotting employing electrophoretic analysis and homogenization, the immunohistochemical investigations of XIAP provided spatial information. Immunohistochemical analysis showed that the subcellular localization of XIAP became more extensive within cells during reperfusion, as compared with the normal state. Under normal conditions, XIAP was localized predominantly in the cytoplasm and the perinuclear region. However, at 6, 12, 24, and 48 h post-reperfusion, XIAP exhibited a diffuse distribution, including nuclear and cytoplasmic compartments. Interestingly, the expression of XAF1 exhibited significant changes during reperfusion. XAF1 expression was increased and there was a cellular redistribution with a nuclear localization in the post-ischemic phase by 6-24 h. XAF1 expression apparently enhances neuronal susceptibility to degeneration either by suppressing the ability of XIAP to complex with caspases or by sequestering XIAP in nuclear inclusions. These finding indicate that Smac/DIABLO, XAF1, and XIAP are implicated in the pathophysiological mechanisms of reperfusion injury.

The ischaemic penumbra

The concept of an ischaemic penumbra, surrounding a focal cerebral lesion, is now widely accepted, although no universal definition of the 'penumbra' exists. In the present review, we consider the penumbra as that volume of brain tissue at the periphery of a focal, irreversibly damaged area that is threatened by recruitment into necrosis. Implicit to such a definition are several secondary concepts. First, the penumbra is both spatial, in that it surrounds the densely ischaemic core, but it is also temporal, in that its evolution toward infarction is a relatively progressive phenomenon. The pertinent literature is summarized. Second, penumbral tissue is potentially salvageable; the most recent animal studies are reviewed. Third, because electrically silent and pathologically damaged tissues have identical functional characteristics, it is evident that most clinical rating scales, be they neurological, behavioural, or psychological, are poorly adapted to address the problem of the penumbra. Finally, the penumbral tissue is remarkably and intensively 'active': multiple processes of cell death and repair occur and involve molecular mechanisms, electrophysiology and the vasculature.

Potential mechanisms of interleukin-1 involvement in cerebral ischaemia

Interleukin-1 (IL-1) has pleiotropic actions in the central nervous system. During the last decade, a growing corpus of evidence has indicated an important role of this cytokine in the development of brain damage following cerebral ischaemia. The expression of IL-1 in the brain is dramatically increased during the early and chronic stage of infarction. The most direct evidence that IL-1 contributes significantly to ischaemic injury is that (1) central administration of IL-1beta exacerbates brain damage, and (2) injection or over-expression of interleukin-1 receptor antagonist, and blockade of interleukin-1beta converting enzyme activity reduce, dramatically, infarction and improve behavioural deficit. The mechanisms underlying IL-1 actions in stroke are not definitively elucidated, and it seems likely that its effects are mediated through stimulation and inhibition of wide range of pathophysiological processes.

Evaluation of the ratio of cerebral blood flow to cerebral blood volume as an index of local cerebral perfusion pressure

Local cerebral perfusion pressure (CPP), a crucial parameter that should allow a better assessment of the haemodynamic compromise in cerebrovascular diseases, is not currently measurable by non-invasive means. Experimental and clinical studies have suggested that the regional ratio of cerebral blood flow to cerebral blood volume (CBF:CBV), as measured by PET, represents an index of local CPP in focal ischaemia. The present study was designed to evaluate further the reliability of the CBF:CBV ratio during manipulations of CPP by deliberately varying mean arterial pressure (MAP) in the anaesthetized baboon. Cortical CBF, CBV, cerebral metabolic rate for oxygen (CMRO2) and oxygen extraction fraction were measured by PET using the (15)O steady-state technique in 10 anaesthetized baboons. Five baboons (Group A) underwent four PET examinations at different levels of MAP: base line (101 +/- 6 mmHg) followed by moderate hypotension (58 +/- 3 mmHg) and, in a separate experiment, minor hypotension (72 +/- 3 mmHg) followed by profound hypotension (34 +/- 5 mmHg). Trimetaphan was used to lower MAP to minor and moderate levels while profound hypotension was achieved by the combined effects of trimetaphan and lower-body negative pressure. Five other baboons (Group B) were subjected to hypertension (121 +/- 2 mmHg) induced by metaraminol and were compared with their base line state (81 +/- 10 mmHg). While CBF displayed significant changes with varying MAP, i.e. decrease and increase with hypotension and hypertension, respectively (-11% from base line to moderate hypotension compared with -20%, from minor to profound hypotension and +31% from base line to hypertension), CBV was more variable and did not significantly change, except with profound hypotension when the increase was significant (+13%). The CBF:CBV ratio decreased significantly at all stages of hypotension (-21 and -31%) and was significantly increased during hypertension (+30%). Importantly, the CBF:CBV ratio demonstrated a significant correlation with MAP (rho = 0.78, Spearman's rank correlation coefficient, P < 0.01). No major changes in CMRO2 were noted during either hypotension or hypertension. Our results demonstrate that, under physiological conditions, cortical CBF:CBV is significantly correlated with CPP, itself a function of MAP. In the investigated range of MAP, the relationships between CBF:CBV and MAP appear to be linear. These findings further argue for the reliability of CBF:CBV as an index of CPP in situations where increases or decreases of MAP without superimposed changes in cerebrovascular tone are encountered, and they confirm the potential usefulness of this regional ratio for clinical investigations and management in cerebrovascular diseases.

Endothelin-B receptors in cerebral resistance arterioles and their functional significance after focal cerebral ischemia in cats

In the cerebral circulation, endothelin-A receptor activation mediates marked prolonged vasoconstriction whereas endothelin-B (ETB) receptor activation effects dilation. In contrast to some peripheral vascular beds, ET(B) receptor-induced vasoconstriction has not yet been demonstrated in brain vessels. In this study in chloralose-anesthetized cats, with perivascular microapplications of ET(B) selective agonist (BQ-3020) and antagonist (BQ-788), we investigated whether ET(B) receptor-mediated constriction could be uncovered in cortical arterioles in vivo. In addition, we examined whether normal dilator response to ET(B) receptor activation is preserved in postischemic cerebral arterioles. The first microapplication of the selective ET(B) receptor agonist BQ-3020 (1 micromol/L) onto a pial cortical arteriole elicited marked dilation (caliber increased by 26.3 +/- 15.1% from preinjection baseline). A second application of BQ-3020 (10-minute interval) onto the same vessel failed to evoke any significant vasomotor response. Subsequent (third and fourth) adventitial microapplication of the ET(B) receptor agonist on the same arteriolar site effected a significant constriction of cerebral arterioles (-15.3 +/- 12.7% and -9.7 +/- 6.3% from preinjection baseline, respectively, at 20 and 30 minutes after the first application). The pial arterioles did not display tachyphylaxis to repeated applications of potassium (10 mmol/L). The perivascular application of the ET(B) receptor antagonist BQ-788 (0.001 to 1 micromol/L) had no effect on arteriolar caliber per se but blocked both BQ-3020-induced dilation (inhibitory concentration approximately 5 nmol/L) and vasoconstriction elicited by repeated activation of ET(B) receptors. After middle cerebral artery occlusion, most of the arterioles examined displayed a sustained dilation. The microapplication of BQ-3020 into the perivascular space surrounding postischemic dilated arterioles elicited a constriction of a similar magnitude to that induced by application of CSF (-17 +/- 7% and -17 +/- 7% from preinjection baseline, respectively). The adventitial microapplication of the ET(B) receptor antagonist (BQ-788, 0.1 micromol/L) on postocclusion dilated pial arterioles effected no change in the arteriolar caliber when compared with preinjection baseline. This BQ-788-induced response was significantly different from that induced by perivascular microinjection of CSF (P < 0.001, analysis of variance). These investigations indicate that (1) repeated activation of ET(B) receptors displays tachyphylaxis of the vasodilator response but also uncovers significant constriction of cerebral arterioles in vivo; (2) the ability of BQ-3020 to elicit dilation is lost within 30 minutes of induced focal ischemia; and (3) ET(B)-mediated contractile tone contributes in a small but significant manner in limiting postischemia dilation of cortical pial arterioles.

Progressive impairment of brain oxidative metabolism reversed by reperfusion following middle cerebral artery occlusion in anaesthetized baboons

A better understanding of the temporospatial evolution of ischaemic brain tissue towards necrosis would be of crucial value to establish and validate therapeutic strategies for stroke in man. By means of sequential positron emission tomographic (PET) studies performed through the acute to the chronic stages of infarction, we addressed the question of the effect of 6 h temporary occlusion of the middle cerebral artery (MCAO) on the evolution of the volume of severely hypometabolic tissue in anaesthetized baboons and compared it to that reported previously in permanently occluded baboons. Thirteen anaesthetized baboons underwent serial PET (15O steady-state technique) examinations before and 1, 4, 7, 24-48 h and 15-62 days following transorbital MCAO. Reperfusion, at 6 h post-occlusion, was assessed by Doppler sonography and cerebral blood flow (CBF) values after clip removal. In each baboon, the infarct volume was calculated by standard histological procedures 20-91 days after MCAO. The severely hypometabolic tissue volume, as defined by a threshold of oxidative metabolism, showed a progressive increase for up to 24-48 h in a not dissimilar manner to that found in baboons with permanent occlusion. However, these hypometabolic volumes regressed in the chronic stage (p < 0.05). Permanent and temporary occluded baboons, when taken together, showed a highly significant relationship between histological and chronic hypometabolic volumes (r = 0.84; p < 0.001). Moreover, the final hypometabolic volume where cerebral metabolic rate of oxygen (CMRO2) was below 40% of contralateral metabolism corresponded well to that of histological infarction volume. We conclude that, in anaesthetized baboons, restoration of blood flow will reverse (even if not immediately) the progressive derangement of metabolism after MCAO and markedly limit the final volume of consolidated infarction.)

Early reperfusion in the anesthetized baboon reduces brain damage following middle cerebral artery occlusion: a quantitative analysis of infarction volume

BACKGROUND AND PURPOSE

Because in humans the clinical benefits of reperfusion remain controversial, it is important to determine whether reperfusion per se reduces infarct volume. In the nonhuman primate, mostly semiquantitative assessments of infarction have been performed. When ischemic volumes have been calculated, it has been for the acute or subacute stages of experimental stroke and may thus not adequately reflect the total volume of consolidated infarction.

METHODS

Anesthetized baboons were subjected to 6 hours of either reversible or permanent middle cerebral artery occlusion (MCAO). Approximately 4 weeks later, the brains were processed for neuropathological examination to allow assessment of the final infarct volume determined by the difference of healthy tissue between occluded and nonoccluded hemispheres.

RESULTS

Reversible MCAO resulted in a small essentially subcortical infarction (mean+/-SD, 0.58+/-0.31 cm3) in 6 of 10 baboons: the infarct (pannecrosis) was restricted to the head of the caudate nucleus, internal capsule, and putamen; 4 of 10 baboons showed no evidence of macroscopic infarction. Permanent MCAO produced a larger subcortical infarct in all 7 baboons studied (2.37+/-1.32 cm3; P=.0006 by Wilcoxon-Mann-Whitney test); the lesion was more extensive and encompassed the external capsule and, in 2 baboons, the adjacent insular cortex.

CONCLUSIONS

We conclude that under optimal experimental conditions, an ischemic episode of 6 hours in duration is well tolerated in the anesthetized adolescent baboon, with 4 animals showing no signs of macroscopic brain damage. Thus, early reestablishment of cerebral blood flow after a focal ischemic insult is not detrimental but indeed is beneficial in terms of the final infarct volume (both at the subcortical and cortical levels) produced by occlusion of a major cerebral artery. The data further suggest a feasible time window in which to initiate and continue therapeutic interventions.

Effects of indomethacin on cerebral blood flow and oxygen metabolism: a positron emission tomographic investigation in the anaesthetized baboon

The aim of this study was to clarify the controversy about the effects of indomethacin on the coupling of cerebral blood flow (CBF) to cerebral oxygen metabolism (CMRO2). CBF, blood volume (CBV), oxygen extraction fraction (OEF) and CMRO2 were measured by positron emission tomography (PET) in five anaesthetized baboons before and during an i.v. administration of indomethacin (bolus 20 mg/kg followed by perfusion 10 mg/kg.h). Administration of indomethacin resulted in a marked and homogenous decrease of CBF in every region analysed (-28% to -40%) and a moderate reduction in CBV (-8% to -16%). In contrast, CMRO2 displayed a small increase in thalamus and pons (+10% and +13%, respectively). OEF increased greatly in all structures studied (+59% to +96%). These findings show that the potent cerebrovascular effects of indomethacin are not related to a decrease in CMRO2 as measured through the use of PET.

Relationships between high oxygen extraction fraction in the acute stage and final infarction in reversible middle cerebral artery occlusion: an investigation in anesthetized baboons with positron emission tomography

Studies in humans suggest that regions that show maximal increases in brain oxygen extraction fraction (OEF) in the hours following an ischemic episode are those most vulnerable for infarction and are often, although not always, associated with the final site of infarction. To clarify this issue, we followed the hemodynamic and metabolic characteristics of regions with an initially maximally increased OEF and compared them with the ultimately infarcted region in an experimental stroke model. Positron emission tomography (PET) was used to obtain functional images of the brain prior to and following reversible unilateral middle cerebral artery occlusion (MCAO) in 11 anesthetized baboons. To model early reperfusion, the clips were removed 6 h after occlusion. Successive measurements of regional CBF (rCBF), regional CMRO2 (rCMRO2), regional cerebral blood volume, and regional OEF (rOEF) were performed during the acute (up to 2 days) and chronic (> 15 days) stage. Late magnetic resonance imaging (MRI) scans (co-registered with PET) were obtained to identify infarction. Reversible MCAO produced an MRI-measurable infarction in 6 of 11 baboons; the others had no evidence of ischemic damage. Histological analysis confirmed the results of the MRI investigation but failed to show any evidence of cortical ischemic damage. The lesion was restricted to the head of the caudate nucleus, internal capsule, and putamen. The infarct volume obtained was 0.58 +/- 0.31 cm3. The infarcts were situated in the deep MCA territory, while the area of initially maximally increased OEF was within the cortical mantle. The mean absolute rCBF value in the infarct region of interest (ROI) was not significantly lower than in the highest-OEF ROI until 1-2 days post-MCAO. Cerebral metabolism in the deep MCA territory was always significantly lower than that of the cortical mantle; decreases in CMRO2 in the former region were evident as early as 1 h post-MCAO. In the cortical mantle, the rOEF was initially significantly higher than in the infarct-to-be zone. Subsequently, the OEF declined in both regions. The differences in the time course of changes in CMRO2 and OEF between these two regions, with the eventually infarcted area showing earlier metabolic degradation and in turn decline in OEF, presumably underlie their different final outcomes. In conclusion, following MCAO, the region that shows an early maximal increase in the OEF is both topographically and physiologically distinct from the region with final consolidated infarction if reperfusion is allowed at 6 h. This high OEF, although indicative of a threatened condition, is not an indicator of inescapable consolidated infarction and is thus a situation in which therapy could be envisaged. Whether or not it is at risk of infarction and thus constitutes one target for therapy remains to be seen.

Sequential studies of severely hypometabolic tissue volumes after permanent middle cerebral artery occlusion. A positron emission tomographic investigation in anesthetized baboons

BACKGROUND AND PURPOSE

In the positron emission tomography literature, markedly hypometabolic brain tissue (oxygen metabolism < 1.3 to 1.7 mL.100 g-1.min-1) has often been equated with irreversible damage in the human brain. By serial positron emission tomography measurements, we investigated the temporal evolution of the volume of severely hypometabolic brain tissue after permanent middle cerebral artery occlusion in anesthetized baboons with, as a perspective, the development of rational therapeutic strategies.

METHODS

Seven anesthetized and ventilated baboons underwent sequential positron emission tomography examinations with the 15O steady-state technique before and 1, 4, 7, and 24 hours and 14 to 29 days after occlusion. In each baboon the infarct volume was calculated by quantitative histological procedures after 19 to 41 days of occlusion.

RESULTS

The sequential measurement of regional oxygen metabolism demonstrated an extension (for > or = 24 hours) of the volume of severely hypometabolic tissue as defined by both absolute and relative metabolic thresholds, and this profile of evolutivity is observed no matter the threshold used. Mean (+/- SEM) infarction volume of 2.4 +/- 0.6 cm3 was comparable to a tissue volume with oxygen consumption < 40% of contralateral metabolism. The volume of hypometabolic tissue was essentially stable at the 1-, 4-, and 7-hour postocclusion studies, increased markedly at the 24-hour study point, and increased even further in the chronic-stage study (on average, 17 days after occlusion). The tissue that eventually displayed a severely hypometabolic state at the final measurement showed a significant decrease of oxygen metabolism and cerebral blood flow at each time analyzed. In that tissue, the oxygen extraction fraction increased significantly at 1 hour (although not thereafter).

CONCLUSIONS

The extension of severely hypometabolic volume after middle cerebral artery occlusion reinforces the concept of a dynamic penumbra and suggests the existence of a relatively large window of therapeutic opportunity in which it may be possible to develop neuroprotective strategies. Our study suggests that maximum infarct volume is determined at some time between 24 hours and 17 days after permanent middle cerebral artery occlusion in anesthetized baboons.