RESUMEN
BACKGROUND: Robotic surgery may improve surgical performance during minimally invasive pancreatoduodenectomy as compared to 3D- and 2D-laparoscopy but comparative studies are lacking. This study assessed the impact of robotic surgery versus 3D- and 2D-laparoscopy on surgical performance and operative time using a standardized biotissue model for pancreatico- and hepatico-jejunostomy using pooled data from two randomized controlled crossover trials (RCTs). METHODS: Pooled analysis of data from two RCTs with 60 participants (36 surgeons, 24 residents) from 11 countries (December 2017-July 2019) was conducted. Each included participant completed two pancreatico- and two hepatico-jejunostomies in biotissue using 3D-robotic surgery, 3D-laparoscopy, or 2D-laparoscopy. Primary outcomes were the objective structured assessment of technical skills (OSATS: 12-60) rating, scored by observers blinded for 3D/2D and the operative time required to complete both anastomoses. Sensitivity analysis excluded participants with excess experience compared to others. RESULTS: A total of 220 anastomoses were completed (robotic 80, 3D-laparoscopy 70, 2D-laparoscopy 70). Participants in the robotic group had less surgical experience [median 1 (0-2) versus 6 years (4-12), p < 0.001], as compared to the laparoscopic group. Robotic surgery resulted in higher OSATS ratings (50, 43, 39 points, p = .021 and p < .001) and shorter operative time (56.5, 65.0, 81.5 min, p = .055 and p < .001), as compared to 3D- and 2D-laparoscopy, respectively, which remained in the sensitivity analysis. CONCLUSION: In a pooled analysis of two RCTs in a biotissue model, robotic surgery resulted in better surgical performance scores and shorter operative time for biotissue pancreatic and biliary anastomoses, as compared to 3D- and 2D-laparoscopy.
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Laparoscopía , Procedimientos Quirúrgicos Robotizados , Competencia Clínica , Humanos , Imagenología Tridimensional/métodos , Laparoscopía/métodos , Pancreaticoduodenectomía/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Procedimientos Quirúrgicos Robotizados/métodosRESUMEN
BACKGROUND: Body composition is associated with mortality; however its routine assessment is too time-consuming. PURPOSE: To demonstrate the value of artificial intelligence (AI) to extract body composition measures from routine studies, we aimed to develop a fully automated AI approach to measure fat and muscles masses, to validate its clinical discriminatory value, and to provide the code, training data and workflow solutions to facilitate its integration into local practice. METHODS: We developed a neural network that quantified the tissue components at the L3 vertebral body level using data from the Liver Tumor Challenge (LiTS) and a pancreatic cancer cohort. We classified sarcopenia using accepted skeletal muscle index cut-offs and visceral fat based its median value. We used Kaplan Meier curves and Cox regression analysis to assess the association between these measures and mortality. RESULTS: Applying the algorithm trained on LiTS data to the local cohort yielded good agreement [>0.8 intraclass correlation (ICC)]; when trained on both datasets, it had excellent agreement (>0.9 ICC). The pancreatic cancer cohort had 136 patients (mean age: 67 ± 11 years; 54% women); 15% had sarcopenia; mean visceral fat was 142 cm2. Concurrent with prior research, we found a significant association between sarcopenia and mortality [mean survival of 15 ± 12 vs. 22 ± 12 (p < 0.05), adjusted HR of 1.58 (95% CI: 1.03-3.33)] but no association between visceral fat and mortality. The detector analysis took 1 ± 0.5 s. CONCLUSIONS: AI body composition analysis can provide meaningful imaging biomarkers from routine exams demonstrating AI's ability to further enhance the clinical value of radiology reports.
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Neoplasias Pancreáticas , Sarcopenia , Anciano , Inteligencia Artificial , Composición Corporal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Músculo Esquelético/patología , Neoplasias Pancreáticas/diagnóstico por imagen , Neoplasias Pancreáticas/patología , Sarcopenia/patología , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: We tested the added value of 3D-vision on procedure time and surgical performance during robotic pancreatoduodenectomy anastomoses in biotissue. Robotic surgery has the advantage of articulating instruments and 3D-vision. Consensus is lacking on the added value of 3D-vision during laparoscopic surgery. Given the improved dexterity with robotic surgery, the added value of 3D-vision may be even less with robotic surgery. METHODS: In this experimental randomized controlled cross-over trial, 20 surgeons and surgical residents from 5 countries performed robotic pancreaticojejunostomy and hepaticojejunostomy anastomoses in a biotissue organ model using the da Vinci® system and were randomized to start with either 3D- or 2D-vision. Primary endpoint was the time required to complete both anastomoses. Secondary endpoint was the objective structured assessment of technical skill (OSATS; range 12-60) rating; scored by two observers blinded to 3D/2D. RESULTS: Robotic 3D-vision reduced the combined operative time from 78.1 to 57.3 min (24.6% reduction, p < 0.001; 20.8 min reduction, 95% confidence intervals 12.8-28.8 min). This reduction was consistent for both anastomoses and between surgeons and residents, p < 0.001. Robotic 3D-vision improved OSATS performance by 6.1 points (20.8% improvement, p = 0.003) compared to 2D (39.4 to 45.1 points, ± 5.5). CONCLUSION: 3D-vision has a considerable added value during robotic pancreatoduodenectomy anastomoses in biotissue in both time reduction and improved surgical performance as compared to 2D-vision.
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Laparoscopía , Pancreaticoduodenectomía , Procedimientos Quirúrgicos Robotizados , Robótica , Adulto , Estudios Cruzados , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: Patients undergoing pancreatic resection frequently require rehabilitation facilities after hospital discharge. We evaluated the predictive role of validated markers of frailty on rehabilitation facility placement to identify patients who may require this service. METHODS: Single-center retrospective cohort study of patients who underwent pancreatic resection from 2010 to 2015. 90-day morbidity and mortality were calculated. Postoperative validated markers of frailty (Activities of Daily Living scale, Braden scale [assesses pressure ulcer risk, lower scores = higher risk] and Morse fall scale) were evaluated via multivariate regression to identify predictors of discharge to rehabilitation facility. RESULTS: 470 patients with complete data were included. Mean age was 62 and 49.2% were male. Postoperative median length of stay (LOS) was 8 (IQR 7-10). 92 (19.66%) patients were discharged to rehabilitation facilities and 138 (29.49%) patients were readmitted within 90 days. On multivariate analysis, age, sex, LOS > 8 days, inpatient Comprehensive Complication Index (CCI) and initial Braden scale were predictive of rehabilitation placement. CONCLUSION: A marker of frailty routinely collected daily by nursing staff, the Braden scale, is available to help surgeons predict the need for postoperative rehabilitation placement after pancreatic resection. Engaging discharge planning services for at-risk patients may help prevent delayed hospital discharge and should be further evaluated.
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Técnicas de Apoyo para la Decisión , Fragilidad/diagnóstico , Evaluación Geriátrica/métodos , Pancreatectomía/rehabilitación , Alta del Paciente , Úlcera por Presión/etiología , Centros de Rehabilitación , Accidentes por Caídas , Actividades Cotidianas , Anciano , Boston , Femenino , Fragilidad/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Pancreatectomía/efectos adversos , Valor Predictivo de las Pruebas , Úlcera por Presión/diagnóstico , Úlcera por Presión/rehabilitación , Estudios Retrospectivos , Medición de Riesgo , Factores de RiesgoRESUMEN
IMPORTANCE: Quality assessment is an important instrument to ensure optimal surgical outcomes, particularly during the adoption of new surgical technology. The use of the robotic platform for complex pancreatic resections, such as the pancreaticoduodenectomy, requires close monitoring of outcomes during its implementation phase to ensure patient safety is maintained and the learning curve identified. OBJECTIVE: To report the results of a quality analysis and learning curve during the implementation of robotic pancreaticoduodenectomy (RPD). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of a prospectively maintained database of 200 consecutive patients who underwent RPD in a large academic center from October 3, 2008, through March 1, 2014, was evaluated for important metrics of quality. Patients were analyzed in groups of 20 to minimize demographic differences and optimize the ability to detect statistically meaningful changes in performance. EXPOSURES: Robotic pancreaticoduodenectomy. MAIN OUTCOMES AND MEASURES: Optimization of perioperative outcome parameters. RESULTS: No statistical differences in mortality rates or major morbidity were noted during the study. Statistical improvements in estimated blood loss and conversions to open surgery occurred after 20 cases (600 mL vs 250 mL [P = .002] and 35.0% vs 3.3% [P < .001], respectively), incidence of pancreatic fistula after 40 cases (27.5% vs 14.4%; P = .04), and operative time after 80 cases (581 minutes vs 417 minutes [P < .001]). Complication rates, lengths of stay, and readmission rates showed continuous improvement that did not reach statistical significance. Outcomes for the last 120 cases (representing optimized metrics beyond the learning curve) included a mean operative time of 417 minutes, median estimated blood loss of 250 mL, a conversion rate of 3.3%, 90-day mortality of 3.3%, a clinically significant (grade B/C) pancreatic fistula rate of 6.9%, and a median length of stay of 9 days. CONCLUSIONS AND RELEVANCE: Continuous assessment of quality metrics allows for safe implementation of RPD. We identified several inflexion points corresponding to optimization of performance metrics for RPD that can be used as benchmarks for surgeons who are adopting this technology.
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Educación Médica Continua , Curva de Aprendizaje , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/normas , Garantía de la Calidad de Atención de Salud/métodos , Robótica/normas , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pancreaticoduodenectomía/educación , Estudios Retrospectivos , Robótica/educaciónRESUMEN
Many of the beneficial and adverse effects of niacin are mediated via a G protein receptor, G protein-coupled receptor 109A/hydroxycarboxylic acid 2 receptor (GPR109A/HCA2), which is highly expressed in adipose tissue and macrophages. Here we demonstrate that immune activation increases GPR109A/HCA2 expression. Lipopolysaccharide (LPS), TNF, and interleukin (IL) 1 increase GPR109A/HCA2 expression 3- to 5-fold in adipose tissue. LPS also increased GPR109A/HCA2 mRNA levels 5.6-fold in spleen, a tissue rich in macrophages. In peritoneal macrophages and RAW cells, LPS increased GPR109A/HCA2 mRNA levels 20- to 80-fold. Zymosan, lipoteichoic acid, and polyinosine-polycytidylic acid, other Toll-like receptor activators, and TNF and IL-1 also increased GPR109A/HCA2 in macrophages. Inhibition of the myeloid differentiation factor 88 or TIR-domain-containing adaptor protein inducing IFNß pathways both resulted in partial inhibition of LPS stimulation of GPR109A/HCA2, suggesting that LPS signals an increase in GPR109A/HCA2 expression by both pathways. Additionally, inhibition of NF-κB reduced the ability of LPS to increase GPR109A/HCA2 expression by â¼50% suggesting that both NF-κB and non-NF-κB pathways mediate the LPS effect. Finally, preventing the LPS-induced increase in GPR109A/HCA2 resulted in an increase in TG accumulation and the expression of enzymes that catalyze TG synthesis. These studies demonstrate that inflammation stimulates GPR109A/HCA2 and there are multiple intracellular signaling pathways that mediate this effect. The increase in GPR109A/HCA2 that accompanies macrophage activation inhibits the TG accumulation stimulated by macrophage activation.
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Modelos Animales de Enfermedad , Grasa Intraabdominal/metabolismo , Activación de Macrófagos , Macrófagos Peritoneales/metabolismo , Receptores Acoplados a Proteínas G/metabolismo , Receptores Nicotínicos/metabolismo , Transducción de Señal , Regulación hacia Arriba , Células 3T3-L1 , Animales , Línea Celular Transformada , Células Cultivadas , Femenino , Infecciones por Bacterias Gramnegativas/inmunología , Infecciones por Bacterias Gramnegativas/metabolismo , Infecciones por Bacterias Gramnegativas/patología , Infecciones por Bacterias Grampositivas/inmunología , Infecciones por Bacterias Grampositivas/metabolismo , Infecciones por Bacterias Grampositivas/patología , Grasa Intraabdominal/inmunología , Grasa Intraabdominal/patología , Metabolismo de los Lípidos , Macrófagos Peritoneales/inmunología , Macrófagos Peritoneales/patología , Ratones , Ratones Endogámicos C57BL , Micosis/inmunología , Micosis/metabolismo , Micosis/patología , Interferencia de ARN , Receptores Acoplados a Proteínas G/antagonistas & inhibidores , Receptores Acoplados a Proteínas G/genética , Receptores Nicotínicos/genética , Virosis/inmunología , Virosis/metabolismo , Virosis/patologíaRESUMEN
BACKGROUND: Treatment of pancreatic adenocarcinoma in the elderly is often complicated by comorbidities that preclude surgery, chemotherapy and/or conventional external beam radiation therapy (EBRT). Stereotactic body radiotherapy (SBRT) has thus garnered interest in this setting. METHODS: A retrospective review of 26 patients of age ≥ 80 with pancreatic adenocarcinoma treated with definitive SBRT+/-chemotherapy from 2007-2011 was performed. Twenty-seven percent of patients were stage I, 38% were stage II, 27% were stage III and 8% were stage IV. Patients most commonly received 24 Gy/1 fraction or 30-36 Gy/3 fractions. Kaplan-Meier was used to estimate overall survival (OS), local control (LC), cause specific survival (CSS) and freedom-from-metastatic disease (FFMD). RESULTS: The median age was 86 (range 80-91), and median follow-up was 11.6 months (3.5-24.6). The median planning target volume was 21.48 cm3 (6.1-85.09). Median OS was 7.6 months with 6/12 month OS rates of 65.4%/34.6%, respectively. Median LC was 11.5 months, 6-month and 12-month actuarial LC rates were 60.1% and 41.2%, respectively. There were no independent predictors for LC, but there was a trend for improved LC with prescription dose greater than 20 Gy (p = 0.063). Median CSS was 6.3 months, and 6-month and 12-month actuarial CSS were 53.8% and 23.1%, respectively. Median FFMD was 8.4 months, and 6-month and 12-month actuarial rates were 62.0% and 41.4%, respectively. Nine patients (47%) had local failures, 11 (58%) had distant metastasis, and 7 (37%) had both. There were no acute or late grade 3+ toxicities. CONCLUSIONS: Definitive SBRT is feasible, safe and effective in elderly patients who have unresectable disease, have comorbidities precluding surgery or decline surgery.
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Adenocarcinoma/cirugía , Neoplasias Pancreáticas/cirugía , Radiocirugia/métodos , Adenocarcinoma/mortalidad , Anciano de 80 o más Años , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Neoplasias Pancreáticas/mortalidad , Estudios RetrospectivosRESUMEN
LPS treatment of macrophages induces TG accumulation, which is accentuated by TG-rich lipoproteins or FFA. We defined pathways altered during macrophage activation that contribute to TG accumulation. Glucose uptake increased with activation, accompanied by increased GLUT1. Oxidation of glucose markedly decreased, whereas incorporation of glucose-derived carbon into FA and sterols increased. Macrophage activation also increased uptake of FFA, associated with an increase in CD36. Oxidation of FA was markedly reduced, whereas the incorporation of FA into TGs increased, associated with increased GPAT3 and DGAT2. Additionally, macrophage activation decreased TG lipolysis; however, expression of ATGL or HSL was not altered. Macrophage activation altered gene expression similarly when incubated with exogenous FA or AcLDL. Whereas activation with ligands of TLR2 (zymosan), TLR3 (poly I:C), or TLR4 (LPS) induced alterations in macrophage gene expression, leading to TG accumulation, treatment of macrophages with cytokines had minimal effects. Thus, activation of TLRs leads to accumulation of TG in macrophages by multiple pathways that may have beneficial effects in host defense but could contribute to the accelerated atherosclerosis in chronic infections and inflammatory diseases.
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Activación de Macrófagos , Macrófagos/metabolismo , Triglicéridos/metabolismo , Animales , Línea Celular , Ácidos Grasos/metabolismo , Expresión Génica/efectos de los fármacos , Glucosa/metabolismo , Lipólisis , Lipopolisacáridos/farmacología , Activación de Macrófagos/efectos de los fármacos , Ratones , Factor 88 de Diferenciación Mieloide/fisiología , Receptores Toll-Like/fisiologíaRESUMEN
Angiopoietin like protein 4 (ANGPTL4) inhibits lipoprotein lipase (LPL) activity. Previous studies have shown that Toll-like Receptor (TLR) activation increases serum levels of ANGPTL4 and expression of ANGPTL4 in liver, heart, muscle, and adipose tissue in mice. ANGPTL4 is expressed in macrophages and is induced by inflammatory saturated fatty acids. The absence of ANGPTL4 leads to the increased uptake of pro-inflammatory saturated fatty acids by macrophages in the mesentery lymph nodes due to the failure of ANGPTL4 to inhibit LPL activity, resulting in peritonitis, intestinal fibrosis, weight loss, and death. Here we determined the effect of TLR activation on the expression of macrophage ANGPTL4. LPS treatment resulted in a 70% decrease in ANGPTL4 expression in mouse spleen, a tissue enriched in macrophages. In mouse peritoneal macrophages, LPS treatment also markedly decreased ANGPTL4 expression. In RAW cells, a macrophage cell line, LPS, zymosan, poly I:C, and imiquimod all inhibited ANGPTL4 expression. In contrast, neither TNF, IL-1, nor IL-6 altered ANGPTL4 expression. Finally, in cholesterol loaded macrophages, LPS treatment still decreased ANGPTL4 expression. Thus, while in most tissues ANGPTL4 expression is stimulated by inflammatory stimuli, in macrophages TLR activators inhibit ANGPTL4 expression, which could lead to a variety of down-stream effects important in host defense and wound repair.
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Angiopoyetinas/biosíntesis , Activación de Macrófagos/inmunología , Macrófagos Peritoneales/inmunología , Receptores Toll-Like/metabolismo , Aminoquinolinas/farmacología , Proteína 4 Similar a la Angiopoyetina , Angiopoyetinas/genética , Animales , Femenino , Imiquimod , Lipopolisacáridos/inmunología , Lipopolisacáridos/farmacología , Activación de Macrófagos/efectos de los fármacos , Macrófagos Peritoneales/efectos de los fármacos , Macrófagos Peritoneales/metabolismo , Ratones , Ratones Endogámicos C57BL , Poli I-C/farmacología , Receptores Toll-Like/agonistas , Zimosan/inmunología , Zimosan/farmacologíaRESUMEN
The acute phase response (APR) produces marked alterations in lipid and carbohydrate metabolism including decreasing plasma ketone levels. Fibroblast growth factor 21 (FGF21) is a recently discovered hormone that regulates lipid and glucose metabolism and stimulates ketogenesis. Here we demonstrate that lipopolysaccharide (LPS), zymosan, and turpentine, which induce the APR, increase serum FGF21 levels 2-fold. Although LPS, zymosan, and turpentine decrease the hepatic expression of FGF21, they increase FGF21 expression in adipose tissue and muscle, suggesting that extrahepatic tissues account for the increase in serum FGF21. After LPS administration, the characteristic decrease in plasma ketone levels is accentuated in FGF21-/- mice, but this is not due to differences in expression of carnitine palmitoyltransferase 1α or hydroxymethyglutaryl-CoA synthase 2 in liver, because LPS induces similar decreases in the expression of these genes in FGF21-/- and control mice. However, in FGF21-/- mice, the ability of LPS to increase plasma free fatty acid levels is blunted. This failure to increase plasma free fatty acid could contribute to the accentuated decrease in plasma ketone levels because the transport of fatty acids from adipose tissue to liver provides the substrate for ketogenesis. Treatment with exogenous FGF21 reduced the number of animals that die and the rapidity of death after LPS administration in leptin-deficient ob/ob mice and to a lesser extent in control mice. FGF21 also protected from the toxic effects of cecal ligation and puncture-induced sepsis. Thus, FGF21 is a positive APR protein that protects animals from the toxic effects of LPS and sepsis.
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Reacción de Fase Aguda/metabolismo , Factores de Crecimiento de Fibroblastos/metabolismo , Leptina/deficiencia , Sepsis/metabolismo , Células 3T3-L1 , Reacción de Fase Aguda/sangre , Reacción de Fase Aguda/etiología , Animales , Electroforesis en Gel de Poliacrilamida , Ensayo de Inmunoadsorción Enzimática , Ácidos Grasos no Esterificados/sangre , Femenino , Factores de Crecimiento de Fibroblastos/sangre , Factores de Crecimiento de Fibroblastos/genética , Estimación de Kaplan-Meier , Cetonas/sangre , Leptina/genética , Lipopolisacáridos/toxicidad , Hígado/efectos de los fármacos , Hígado/metabolismo , Ratones , Ratones Endogámicos C57BL , Ratones Noqueados , PPAR alfa/deficiencia , PPAR alfa/genética , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Sepsis/sangre , Sepsis/fisiopatologíaRESUMEN
Inhibition of adipocyte triglyceride biosynthesis is required for fatty acid mobilization during inflammation. Triglyceride biosynthesis requires glycerol 3-phosphate and phosphoenolpyruvate carboxykinase (PEPCK) plays a key role. We demonstrate that LPS, zymosan, and TNF-α decrease PEPCK in liver and fat. Turpentine decreases PEPCK in liver, but not in fat. The LPS-induced decrease in PEPCK does not occur in TLR4 deficient animals, indicating that this receptor is required. The LPS-induced decrease in hepatic PEPCK does not occur in TNF receptor/IL-1 receptor knockout mice, but occurs in fat, indicating that TNF-α/IL-1 is essential for the decrease in liver but not fat. In 3T3-L1 adipocytes TNF-α, IL-1, IL-6, and IFNγ inhibit PEPCK indicating that there are multiple pathways by which PEPCK is decreased in adipocytes. The binding of PPARγ and RXRα to the PPARγ response element in the PEPCK promoter is markedly decreased in adipose tissue nuclear extracts from LPS treated animals. Lipopolysaccharide and zymosan reduce PPARγ and RXRα expression in fat, suggesting that a decrease in PPARγ and RXRα accounts for the decrease in PEPCK. Thus, there are multiple cytokine pathways by which inflammation inhibits PEPCK expression in adipose tissue which could contribute to the increased mobilization of fatty acids during inflammation.
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Tejido Adiposo/enzimología , Inflamación/enzimología , Hígado/enzimología , Fosfoenolpiruvato Carboxilasa/biosíntesis , Células 3T3-L1 , Animales , Citocinas/biosíntesis , ADN Complementario/biosíntesis , ADN Complementario/aislamiento & purificación , Ensayo de Cambio de Movilidad Electroforética , Ácidos Grasos no Esterificados/metabolismo , Femenino , Gluconeogénesis/efectos de los fármacos , Inflamación/inducido químicamente , Lipólisis/efectos de los fármacos , Lipopolisacáridos/farmacología , Ratones , Ratones Endogámicos C57BL , Ratones Noqueados , PPAR gamma/metabolismo , ARN/biosíntesis , ARN/aislamiento & purificación , Reacción en Cadena en Tiempo Real de la Polimerasa , Receptor alfa X Retinoide/metabolismo , Receptor Toll-Like 4/efectos de los fármacos , Receptor Toll-Like 4/genética , Receptor Toll-Like 4/metabolismo , Trementina/farmacología , Zimosan/farmacologíaRESUMEN
OBJECTIVE AND DESIGN: The aim of this study was to examine the expression of G protein-coupled receptor 81 (GPR81) in mouse adipose tissue in response to inflammatory stimuli. GPR81 is activated by lactate resulting in the inhibition of lipolysis. MATERIALS AND TREATMENT: Mice were injected with saline, lipopolysaccharide (LPS), zymosan, or turpentine, N = 5 per group. 3T3-L1 adipocytes were treated with tumor necrosis factor alpha, interleukin (IL)-l beta, IL-6, or interferon gamma. METHODS: GPR81 expression levels were measured by real-time PCR and statistical significance was determined by Student's t test. RESULTS: LPS resulted in a marked decrease in GPR81 mRNA level in mouse adipose tissue in C57BL/6 and OuJ mice, an effect that was not observed in HeJ mice, which have a mutation in TLR4. Zymosan and turpentine also decreased adipose tissue GPR81 expression. Cytokine treatment of 3T3-L1 adipocytes had no effect on GPR81 expression. GPR81 expression was decreased in ob/ob mice, an animal model of type 2 diabetes that is characterized by inflammation. CONCLUSION: Inflammation decreases the expression of GPR81 in adipose tissue.
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Tejido Adiposo/metabolismo , Regulación de la Expresión Génica , Inflamación/metabolismo , Receptores Acoplados a Proteínas G/biosíntesis , Células 3T3-L1/citología , Adipocitos/metabolismo , Animales , Citocinas/metabolismo , Femenino , Interferón gamma/biosíntesis , Interleucina-1beta/biosíntesis , Interleucina-6/biosíntesis , Lipólisis , Masculino , Ratones , Ratones Endogámicos C57BL , Receptor Toll-Like 4/metabolismoRESUMEN
Carbohydrate response element binding protein (ChREBP) is a recently discovered transcription factor whose levels and activity are increased by glucose leading to the activation of target genes, which include acetyl-CoA carboxylase, fatty acid synthase, and liver-type pyruvate kinase. Here, we demonstrate that lipopolysaccharide (LPS) treatment causes a marked decrease in ChREBP mRNA and protein levels in the liver of mice fed a normal chow diet or in mice fasted for 24 h and then re-fed a high carbohydrate diet. This decrease occurs rapidly and is a sensitive response (half-maximal dose 0.1 µg/mouse). The decrease in ChREBP is accompanied by a decrease in the expression of ChREBP target genes. Zymosan and turpentine treatment also decrease hepatic ChREBP levels and the expression of its target genes. Additionally, tumor necrosis factor alpha (TNF-α) and interleukin-1 beta (IL-1ß) decrease liver ChREBP expression both in vivo and in Hep3B cells in culture. Finally, LPS decreased ChREBP expression in muscle and adipose tissue. These studies demonstrate that ChREBP is down-regulated during the acute phase response resulting in alterations in the expression of ChREBP regulated target genes. Thus, ChREBP joins a growing list of transcription factors that are regulated during the acute phase response.
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Regulación de la Expresión Génica , Hígado/metabolismo , Proteínas Nucleares/metabolismo , Factores de Transcripción/metabolismo , Acetil-CoA Carboxilasa/metabolismo , Animales , Factores de Transcripción Básicos con Cremalleras de Leucinas y Motivos Hélice-Asa-Hélice , Línea Celular , Carbohidratos de la Dieta/administración & dosificación , Endotoxinas/inmunología , Endotoxinas/metabolismo , Regulación de la Expresión Génica/efectos de los fármacos , Regulación de la Expresión Génica/inmunología , Interleucina-1beta/inmunología , Interleucina-1beta/metabolismo , Lipopolisacáridos/farmacología , Hígado/efectos de los fármacos , Ratones , Ratones Endogámicos C57BL , Proteínas Nucleares/genética , Proteínas Nucleares/inmunología , Factores de Transcripción/genética , Factores de Transcripción/inmunología , Factor de Necrosis Tumoral alfa/inmunología , Factor de Necrosis Tumoral alfa/metabolismo , Trementina/metabolismo , Zimosan/inmunología , Zimosan/metabolismoRESUMEN
BACKGROUND: Stereotactic body radiotherapy (SBRT) has been approved for the treatment of locally advanced pancreatic cancer. Placement of gold fiducials is required for real-time tracking and delivery of a high-dose therapeutic beam of radiation to the tumor. Traditionally, fiducials have been placed either intraoperatively or percutaneously. Recently, EUS-guided fiducial placement has been reported, but the safety and feasibility of this approach is not well defined. OBJECTIVE: The aim of this study was to determine the safety, feasibility, and limitations of EUS-guided placement of 0.8 x 5.0 mm fiducials via a 19-gauge needle for locally advanced and recurrent pancreatic cancer. DESIGN: Prospective study of patients with either locally advanced or recurrent pancreatic cancer referred for EUS-guided fiducial placement for SBRT at our institution over a 3-year period. SETTING: Tertiary referral center conducting >1800 EUS procedures annually. MAIN OUTCOME MEASUREMENTS: Primary outcome measurements included success, complications, and technical limitations of EUS-guided fiducial placement in pancreatic cancer. In addition, the percentage of patients successfully completing SBRT after EUS-guided fiducial placement was determined. RESULTS: A total of 51 patients (mean age 73 years; 57% male) with locally advanced (n = 36) and recurrent (n = 15) pancreatic cancer were referred for EUS-guided fiducial placement. Fiducials were successfully placed in 46 patients (90%), with technical failures occurring in 4 patients (8%) with recurrent cancer after pancreaticoduodenectomy. In 3 patients (7%), the fiducials spontaneously migrated from the original site of injection, thereby requiring a second EUS procedure for placement of additional fiducials. Of the 46 patients with fiducials placed under EUS guidance, 42 patients (91%) successfully completed SBRT. Two patients experienced disease progression before SBRT, 1 patient was lost to follow-up, and 1 patient experienced a complication at ERCP that precluded further therapy. Only 1 complication (2%), of mild pancreatitis, occurred in a patient undergoing simultaneous placement of fiducials and celiac plexus neurolysis for intractable abdominal pain. LIMITATIONS: Single-center experience and lack of a formal follow-up protocol to assess for complications. CONCLUSION: EUS-guided fiducial placement for SBRT in locally advanced and recurrent pancreatic cancer is safe and feasible. Successful placement was achieved in 90% of patients, with a low complication rate (2%). Furthermore, 91% of patients successfully completed SBRT after EUS-guided fiducial delivery. Although fiducials can spontaneously migrate from the initial injection site, the rate of migration is relatively low (7%), and no migration-related complications occurred over the course of this study. Limitations to EUS-guided fiducial placement may include surgically altered anatomy (pancreaticoduodenectomy) in patients with recurrent pancreatic cancer.
Asunto(s)
Endosonografía/métodos , Agujas , Recurrencia Local de Neoplasia/cirugía , Neoplasias Pancreáticas/cirugía , Radiocirugia/instrumentación , Anciano , Progresión de la Enfermedad , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Recurrencia Local de Neoplasia/diagnóstico por imagen , Neoplasias Pancreáticas/diagnóstico por imagen , Estudios Prospectivos , Reproducibilidad de los Resultados , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
The acute phase response is characterized by elevations in serum triglyceride levels due to both an increase in hepatic VLDL production and a delay in the clearance of triglyceride rich lipoproteins secondary to a decrease in lipoprotein lipase (LPL) activity. Recently there has been a marked increase in our understanding of factors that regulate LPL activity. GPIHBP1 facilitates the interaction of LPL and lipoproteins thereby allowing lipolysis to occur. Angiopoietin like proteins (ANGPTL) 3 and 4 inhibit LPL activity. In the present study, treatment of mice with LPS, an activator of TLR4 and a model of Gram-negative infections, did not alter the expression of GPIHBP1 in heart or adipose tissue. However, LPS decreased the expression of ANGPTL3 in liver and increased the expression of ANGPTL4 in heart, muscle, and adipose tissue. Serum ANGPTL4 protein levels were markedly increased at 8 and 16h following LPS treatment. Administration of zymosan, an activator of TLR2 and a model of fungal infections, also increased serum ANGPTL4 protein and mRNA levels in liver, heart, muscle, and adipose tissue. Finally, treatment of 3T3-L1 adipocytes with LPS or cytokines (TNF alpha, IL-1 beta, and interferon gamma) stimulated ANGPTL4 expression. These studies demonstrate that ANGPTL4 is a positive acute phase protein and the increase in ANGPTL4 could contribute to the hypertriglyceridemia that characteristically occurs during the acute phase response by inhibiting LPL activity.
Asunto(s)
Reacción de Fase Aguda/metabolismo , Angiopoyetinas/biosíntesis , Hipertrigliceridemia/metabolismo , Células 3T3-L1 , Tejido Adiposo/metabolismo , Proteína 4 Similar a la Angiopoyetina , Animales , Femenino , Lipopolisacáridos , Lipoproteína Lipasa/antagonistas & inhibidores , Lipoproteína Lipasa/metabolismo , Hígado/metabolismo , Ratones , Ratones Endogámicos C57BL , Músculo Esquelético/metabolismo , Miocardio/metabolismoRESUMEN
Respiratory failure is a major cause of mortality during septic shock and is due in part to decreased ventilatory muscle contraction. Ventilatory muscles have high energy demands; fatty acid (FA) oxidation is an important source of ATP. FA oxidation is regulated by nuclear hormone receptors; studies have shown that the expression of these receptors is decreased in liver, heart, and kidney during sepsis. Here, we demonstrate that lipopolysaccharide (LPS) decreases FA oxidation and the expression of lipoprotein lipase (LPL), FA transport protein 1 (FATP-1), CD36, carnitine palmitoyltransferase beta, medium chain acyl-CoA dehydrogenase (MCAD), and acyl-CoA synthetase, key proteins required for FA uptake and oxidation, in the diaphragm. LPS also decreased mRNA levels of PPARalpha and beta/delta, RXRalpha, beta, and gamma, thyroid hormone receptor alpha and beta, and estrogen related receptor alpha (ERRalpha) and their coactivators PGC-1alpha, PGC-1beta, SRC1, SRC2, Lipin 1, and CBP. Zymosan resulted in similar changes in the diaphragm. Finally, in PPARalpha deficient mice, baseline CPT-1beta and FATP-1 levels were markedly decreased and were not further reduced by LPS suggesting that a decrease in the PPARalpha signaling pathway plays an important role in inducing some of these changes. The decrease in FA oxidation in the diaphragm may be detrimental, leading to decreased diaphragm contraction and an increased risk of respiratory failure during sepsis.
Asunto(s)
Diafragma/metabolismo , Lipopolisacáridos/farmacología , Receptores Citoplasmáticos y Nucleares/metabolismo , Animales , Western Blotting , Diafragma/efectos de los fármacos , Ácidos Grasos/metabolismo , Femenino , Ratones , Ratones Endogámicos C57BL , Oxidación-Reducción/efectos de los fármacos , Reacción en Cadena de la Polimerasa , Triglicéridos/metabolismoRESUMEN
Infection and inflammation affect adipose triglyceride metabolism, resulting in increased plasma free fatty acid (FFA) and VLDL levels during the acute-phase response. Lipin-1, a multifunctional protein, plays a critical role in adipose differentiation, mitochondrial oxidation, and triglyceride synthesis. Here, we examined whether LPS [a Toll-like receptor (TLR)-4 activator], zymosan (a TLR-2 activator), and proinflammatory cytokines regulate lipin-1 in adipose tissue. LPS administration caused a marked decrease in the levels of lipin-1 mRNA and protein in adipose tissue. The decrease in lipin-1 mRNA levels occurred rapidly and lasted for at least 24 h. In contrast, lipin-2 and -3 mRNA levels did not change, suggesting specific repression of lipin-1. Zymosan similarly decreased lipin-1 mRNA without affecting lipin-2 or lipin-3 mRNA levels. To determine the pathways by which LPS repressed lipin-1, we examined the effect of proinflammatory cytokines on cultured adipocytes. In 3T3-L1 adipocytes, TNF-alpha, IL-1beta, and IFN-gamma, but not LPS or IL-6, caused a decrease in lipin-1 mRNA levels. Furthermore, TNF-alpha and IL-1beta administration also decreased mRNA levels of lipin-1 in adipose tissue in mice. Importantly, the LPS-induced decrease in lipin-1 mRNA levels was significantly but not totally blunted in TNF-alpha/IL-1 receptor-null mice compared with controls, suggesting key roles for TNF-alpha/IL-1beta and other cytokines in mediating LPS-induced repression of lipin-1. Together, our results demonstrate that expression of lipin-1, one of the essential triglyceride synthetic enzymes, was suppressed by LPS, zymosan, and proinflammatory cytokines in mouse adipose tissue and in cultured 3T3-L1 adipocytes, which could contribute to a decrease in the utilization of FFA to synthesize triglycerides in adipose tissue, thus promoting the release of FFA into the circulation.
Asunto(s)
Adipocitos/efectos de los fármacos , Tejido Adiposo/efectos de los fármacos , Citocinas/farmacología , Lipopolisacáridos/farmacología , Proteínas Nucleares/genética , Células 3T3-L1 , Adipocitos/metabolismo , Tejido Adiposo/metabolismo , Animales , Femenino , Regulación de la Expresión Génica/efectos de los fármacos , Mediadores de Inflamación/farmacología , Ratones , Ratones Endogámicos C57BL , Músculo Esquelético/efectos de los fármacos , Músculo Esquelético/metabolismo , Proteínas Nucleares/metabolismo , PPAR alfa/genética , PPAR alfa/metabolismo , Fosfatidato Fosfatasa , ARN Mensajero/metabolismo , Zimosan/farmacologíaRESUMEN
Inflammation induces marked changes in lipid and lipoprotein metabolism. Proprotein convertase subtilisin kexin 9 (PCSK9) plays an important role in regulating LDL receptor degradation. Here, we demonstrate that LPS decreases hepatic LDL receptor protein but at the same time hepatic LDL receptor mRNA levels are not decreased. We therefore explored the effect of LPS on PCSK9 expression. LPS results in a marked increase in hepatic PCSK9 mRNA levels (4h 2.5-fold increase; 38h 12.5-fold increase). The increase in PCSK9 is a sensitive response with 1microg LPS inducing a (1/2) maximal response. LPS also increased PCSK9 expression in the kidney. Finally, zymosan and turpentine, other treatments that induce inflammation, also stimulated hepatic expression of PCSK9. Thus, inflammation stimulates PCSK9 expression leading to increased LDL receptor degradation and decreasing LDL receptors thereby increasing serum LDL, which could have beneficial effects on host defense.
Asunto(s)
Inflamación/enzimología , Receptores de LDL/metabolismo , Serina Endopeptidasas/biosíntesis , Animales , Femenino , Humanos , Inflamación/inducido químicamente , Inflamación/inmunología , Irritantes/toxicidad , Riñón/metabolismo , Lipopolisacáridos/inmunología , Lipopolisacáridos/toxicidad , Hígado/metabolismo , Ratones , Ratones Endogámicos C57BL , Proproteína Convertasa 9 , Proproteína Convertasas , ARN Mensajero/biosíntesis , ARN Mensajero/genética , Receptores de LDL/sangre , Serina Endopeptidasas/genética , Trementina/toxicidad , Zimosan/toxicidadRESUMEN
Inflammation produces marked changes in lipid metabolism, including increased serum fatty acids (FAs) and triglycerides (TGs), increased hepatic TG production and VLDL secretion, increased adipose tissue lipolysis, and decreased FA oxidation in liver and heart. Lipopolysaccharide (LPS) also increases TG and cholesteryl ester levels in kidneys. Here we confirm these findings and define potential mechanisms. LPS decreases renal FA oxidation by 40% and the expression of key proteins required for oxidation of FAs, including FA transport protein-2, fatty acyl-CoA synthase, carnitine palmitoyltransferase-1, medium-chain acyl-CoA dehydrogenase, and acyl-CoA oxidase. Similar decreases were observed in peroxisome proliferator-activated receptor alpha (PPARalpha)-deficient mice. LPS also caused a reduction in renal mRNA levels of PPARalpha (75% decrease), thyroid hormone receptor alpha (TRalpha) (92% decrease), and TRbeta (84% decrease), whereas PPARbeta/delta and gamma were not altered. Expression of PGC1 alpha and beta, coactivators required for PPARs and TR, was also decreased in kidneys of LPS-treated mice, as were mitochondrial genes regulated by PGC1 (Atp5g1, COX5a, Idh3a, and Ndufs8). Decreased renal FA oxidation could be a by-product of the systemic coordinated host response to increase FAs and TGs available for host defense and/or tissue repair. However, the kidney requires energy to support its transport functions, and the inability to generate energy via FA oxidation might contribute to the renal failure seen in severe sepsis.
Asunto(s)
Ácidos Grasos/metabolismo , Riñón/efectos de los fármacos , Riñón/metabolismo , Lipopolisacáridos/farmacología , Receptores Citoplasmáticos y Nucleares/metabolismo , Animales , Ácidos Grasos/genética , Femenino , Regulación de la Expresión Génica/efectos de los fármacos , Masculino , Ratones , Oxidación-Reducción/efectos de los fármacos , Receptores Activados del Proliferador del Peroxisoma/deficiencia , Receptores Activados del Proliferador del Peroxisoma/genética , ARN Mensajero/genética , ARN Mensajero/metabolismo , Receptores de Hormona Tiroidea/genética , Triglicéridos/sangreRESUMEN
Inflammation can produce abnormalities that could increase the risk for atherosclerosis including alterations in lipid and lipoprotein metabolism. Apolipoprotein M is a recently described HDL-associated apoprotein expressed mainly in the liver and kidney with protective effects against atherosclerosis. In this study, we describe the regulation of apolipoprotein M during the acute phase response. Stimuli that produce systemic inflammation, LPS, zymosan, or turpentine, decrease apolipoprotein M mRNA levels in the liver and kidney. Treatment of Hep3B hepatoma cells with TNF or IL-1 also decreased apolipoprotein M mRNA levels. The decrease in apolipoprotein M mRNA leads to a decrease in apolipoprotein M secretion into the media in Hep3B cells and a decrease in mouse serum following LPS administration. Moreover, in humans with acute bacterial infections or chronic HIV infection, serum apolipoprotein M levels are decreased. Apolipoprotein M is a negative acute response protein that decreases during infection and inflammation. These results are consistent with the finding that infections and inflammatory disorders accompanied by systemic inflammation are associated with an increased risk of atherosclerosis.