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BACKGROUND: Despite significant advances in the conservative management of pyogenic spondylodiscitis, consecutive instability, deformity, and/or neurologic compromise demands a prompt surgical intervention. However, in rare cases involving additional multilevel epidural abscess formation, the appropriate surgical strategy remains controversial. In this retrospective cohort analyses, we evaluated the efficacy of a single-stage posterior approach with the addition of a one-time multilevel epidural lavage via the surgically exposed interlaminar fenestration of the infected segment. METHODS: From January 2009 through December 2010, 73 patients presenting pyogenic spondylodiscitis with instability of the lumbar spine were admitted. In all cases, the surgical strategy included a radical resection of the affected intervertebral disc and stabilization by intervertebral fusion using a titanium cage with autologous bone grafting in a level-dependent posterior approach with additional pedicle screw-and-rod instrumentation. In cases where multilevel abscess formation was evident, the standard surgical procedure was complemented by drainage and irrigation of the abscess from posterior by carefully advancing a soft infant feeding tube via the surgically exposed epidural space under fluoroscopic guidance. All patients received complementary oral antibiotic therapy for 12 weeks and were followed-up for a minimum of 12 months postoperatively. RESULTS: Ten patients (three male and seven female patients; mean age: 64.9 ± 10.9 years) presented with an additional lumbar epidural abscess extending beyond three levels proximal or distal to the infected disc. In all 10 patients the laboratory-chemical inflammatory parameters (leukocyte count, C-reactive protein) remained within the physiologic range after completing antibiotic therapy throughout the 1-year follow-up period. The plain radiographs and magnetic resonance imaging demonstrated solid fusion and the complete remission of the initial abscess formation after 3 to 6 months with no recurrence of infection, respectively. CONCLUSION: The onetime epidural lavage presented in this small patient cohort proved to be an effective surgical adjunct with minimal exposure-related morbidity. We believe that the possibility of early mobilization and the patient's increased rehabilitation potential reduce the risk of nosocomial complications that often coincide with this multimorbid high-risk group of patients.
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Discitis/terapia , Absceso Epidural/terapia , Fusión Vertebral/métodos , Irrigación Terapéutica/métodos , Anciano , Catéteres , Discitis/microbiología , Discitis/cirugía , Absceso Epidural/microbiología , Absceso Epidural/cirugía , Femenino , Humanos , Vértebras Lumbares/microbiología , Vértebras Lumbares/patología , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Fusión Vertebral/instrumentación , Irrigación Terapéutica/instrumentación , Resultado del TratamientoRESUMEN
OBJECTIVE: Non-union of osteoporotic vertebra fractures are a seldom entity. However, when back pain persists in the course of conservatively treated osteoporotic vertebra fractures, a non-union should be considered. We thus sought to validate our diagnostic algorithm in patients with known osteoporotic vertebra fractures presenting persistent back pain and advert to the diagnosis and treatment of vertebral non-unions. PATIENTS AND METHODS: Patients admitted with preexisting osteoporotic vertebra fractures and therapy-resistant back pain were retrospectively analysed. All admitted patients were subject to standard plain radiographs in erect position and conventional CT or MR imaging of the spine, respectively. In addition, patients with suspected non-union were subject to lateral fulcrum radiographs in supine position. RESULTS: From a total of 172 admitted patients, four patients presented with non-union of a fractured osteoporotic vertebra (2%). The subsequent surgical therapy included cement-augmented rod-and-screw stabilization, with or without additional correction of deformity, and kyphoplasty (N = 3) or kyphoplasty alone (N = 1). All surgical interventions were successful in pain reduction and allowed immediate and improved postoperative mobilisation. CONCLUSIONS: Non-union of osteoporotic vertebra fractures must be considered when symptoms outlast conservative treatment. In these cases, plain lateral fulcrum radiographs are a simple and effective adjunct to the conventional diagnostic methods. Surgical stabilization then proves to be the effective treatment of choice.
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Cementos para Huesos , Fracturas no Consolidadas/cirugía , Cifoplastia/métodos , Fracturas Osteoporóticas/cirugía , Fracturas de la Columna Vertebral/cirugía , Anciano , Anciano de 80 o más Años , Dolor de Espalda/etiología , Tornillos Óseos , Femenino , Fijación Interna de Fracturas , Fracturas no Consolidadas/complicaciones , Humanos , Vértebras Lumbares/lesiones , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Fracturas Osteoporóticas/complicaciones , Estudios Retrospectivos , Fracturas de la Columna Vertebral/complicaciones , Vértebras Torácicas/lesiones , Vértebras Torácicas/cirugía , Resultado del TratamientoRESUMEN
STUDY DESIGN: A case report. OBJECTIVE: To demonstrate delayed diagnosis of screw malpositioning with perforation of the thoracic aorta after posterior stabilization of a Th7-vertebral collapse due to multiple myeloma. Relevant diagnostic and therapeutic strategies are outlined in the context of a rather unfortunate series of interventional events. SUMMARY OF BACKGROUND DATA: Pedicle screw instrumentation has become a well-established standard in the surgical treatment of various disorders of the spinal column. Particularly at the upper-thoracic level, the close anatomic relationship of the spine to the aorta places it and other major structures at high risk. Although iatrogenic vascular injuries are rare, a few cases have been described. METHODS: A 64-year-old female patient remarked progressive back pain after 2 years of uneventful recovery from a multilevel posterior stabilization by pedicle screw and rod instrumentation because of an osteolytic collapse of the Th7 vertebra. The subsequent computed tomographic scan demonstrated kyphotic deformity of the thoracic spine with transspinal and periaortic screw malplacement. RESULTS: The revision strategy was an interdisciplinary single session two-phase operation. The primary phase included a left-sided thoracotomy, mobilization of the thoracic aorta, and posterior implant removal under vascular monitoring in right lateral position. The initially planned corporectomy of Th7 and subsequent vertebral body replacement by cage implantation via the anterior approach was dismissed because of critical tissue adhesions of the thoracic aorta to the anterior vertebral column. Finally, the thoracotomy was closed, the patient transferred into prone position and stabilized by a multilevel posterior reinstrumentation under fluoroscopy guidance. CONCLUSION: Although the clinical course in malpositioned pedicle screw instrumentation may stay unremarkable, this case illustrates that in a proven injury to the thoracic aorta revision is mandatory to prevent further vascular damage. The appropriate strategy demands exact and provident planning using a preferably interdisciplinary approach.
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Aorta Torácica/lesiones , Neoplasias Óseas/cirugía , Tornillos Óseos/efectos adversos , Mieloma Múltiple/cirugía , Procedimientos Ortopédicos/efectos adversos , Vértebras Torácicas/cirugía , Lesiones del Sistema Vascular/etiología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Neoplasias Óseas/complicaciones , Neoplasias Óseas/patología , Descompresión Quirúrgica , Diagnóstico Tardío , Remoción de Dispositivos , Femenino , Humanos , Imagen por Resonancia Magnética , Persona de Mediana Edad , Mieloma Múltiple/complicaciones , Mieloma Múltiple/patología , Procedimientos Ortopédicos/instrumentación , Valor Predictivo de las Pruebas , Reoperación , Estenosis Espinal/etiología , Estenosis Espinal/cirugía , Vértebras Torácicas/diagnóstico por imagen , Vértebras Torácicas/patología , Toracotomía , Factores de Tiempo , Tomografía Computarizada por Rayos X , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/cirugíaRESUMEN
Patients with ankylosing spondylitis are at significant risk for sustaining cervical spine injuries following trauma predisposed by kyphosis, stiffness and osteoporotic bone quality of the spine. The risk of sustaining neurological deficits in this patient population is higher than average. The present review article provides an outline on the specific injury patterns in the cervical spine, diagnostic algorithms and specific treatment modalities dictated by the underlying disease in patients with ankylosing spondylitis. An emphasis is placed on the risks and complication patterns in the treatment of these rare, but challenging injuries.
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Post-traumatic disc degeneration with consecutive loss of reduction and kyphosis remains a debatable issue within both the operative and nonoperative treatment regimen of thoracolumbar spine fractures. Intervertebral disc (IVD) cell apoptosis has been suggested to play a vital role in promoting the degeneration process. To evaluate and compare apoptosis-regulating signaling mechanisms, IVDs were obtained from patients with thoracolumbar spine fractures (n = 21), patients suffering from symptomatic IVD degeneration (n = 6), and from patients undergoing surgical resection of a primary vertebral tumor (n = 3 used as control samples). All tissues were prospectively analyzed in regards to caspase-3/7, -8, and -9 activity, apoptosis-receptor expression levels, and gene expression of the mitochondria-bound apoptosis-regulating proteins Bax and Bcl-2. Morphologic changes characteristic for apoptotic cell death were confirmed by H&E staining. Statistical significance was designated at p < 0.05 using the Student's t-test. Both traumatic and degenerative IVD demonstrated a significant increase of caspase-3/7 activity with evident apoptosis. Although caspase-3/7 activation was significantly greater in degenerated discs, both showed equally significant activation of the initiator caspases 8 and 9. Traumatic IVD alone demonstrated a significant increase of the Fas receptor (FasR), whereas the TNF receptor I (TNFR I) was equally up-regulated in both morbid IVD groups. Only traumatic IVD showed distinct changes in up-regulated TNF expression, in addition to significantly down-regulated antiapoptotic Bcl-2 protein. Our results suggest that post-traumatic disc changes may be promoted and amplified by both the intrinsic mitochondria-mediated and extrinsic receptor-mediated apoptosis signaling pathways, which could be, in part, one possible explanation for developing subsequent disc degeneration.
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Apoptosis/fisiología , Disco Intervertebral/metabolismo , Vértebras Lumbares/lesiones , Enfermedades de la Columna Vertebral/metabolismo , Fracturas de la Columna Vertebral/metabolismo , Vértebras Torácicas/lesiones , Adulto , Anciano , Caspasas/metabolismo , Regulación hacia Abajo , Femenino , Humanos , Disco Intervertebral/enzimología , Disco Intervertebral/fisiopatología , Masculino , Persona de Mediana Edad , Mitocondrias/metabolismo , Estudios Prospectivos , Proteínas Proto-Oncogénicas c-bcl-2/metabolismo , Transducción de Señal/fisiología , Receptor fas/metabolismoRESUMEN
INTRODUCTION: The innate immune response to trauma hemorrhage involves inflammatory mediators, thus promoting cellular dysfunction as well as cell death in diverse tissues. These effects ultimately bear the risk of post-traumatic complications such as organ dysfunction, multiple organ failure, or adult respiratory distress syndrome. In this study, a murine model of resuscitated hemorrhagic shock (HS) was used to determine the apoptosis in spleen as a marker of cellular injury and reduced immune functions. METHODS: Male C57BL-6 mice were subjected to sham operation or resuscitated HS. At t = 0 hours, t = 24 hours, and t = 72 hours, mice were euthanized and the spleens were removed and evaluated for apoptotic changes via DNA fragmentation, caspase activities, and activation of both extrinsic and intrinsic apoptotic pathways. Spleens from untreated mice were used as control samples. RESULTS: HS was associated with distinct lymphocytopenia as early as t = 0 hours after hemorrhage without regaining baseline levels within the consecutive 72 hours when compared with sham and control groups. A rapid activation of splenic apoptosis in HS mice was observed at t = 0 hours and t = 72 hours after hemorrhage and predominantly confirmed by increased DNA fragmentation, elevated caspase-3/7, caspase-8, and caspase-9 activities, and enhanced expression of intrinsic mitochondrial proteins. Accordingly, mitochondrial pro-apoptotic Bax and anti-apoptotic Bcl-2 proteins were inversely expressed within the 72-hour observation period, thereby supporting significant pro-apoptotic changes. Solely at t = 24 hours, expression of the anti-apoptotic Mcl-1 protein shows a significant increase when compared with sham-operated and control animals. Furthermore, expression of extrinsic death receptors were only slightly increased. CONCLUSION: Our data suggest that HS induces apoptotic changes in spleen through a biphasic caspase-dependent mechanism and imply a detrimental imbalance of pro- and anti-apoptotic mitochondrial proteins Bax, Bcl-2, and Mcl-1, thereby promoting post-traumatic immunosuppression.
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Apoptosis/fisiología , Fragmentación del ADN , Genes bcl-2/fisiología , Proteínas de Neoplasias/fisiología , Proteínas Proto-Oncogénicas c-bcl-2/fisiología , Choque Hemorrágico/fisiopatología , Bazo/fisiología , Proteína X Asociada a bcl-2/fisiología , Animales , Caspasas/metabolismo , Recuento de Células , Linfopenia/etiología , Masculino , Ratones , Ratones Endogámicos C57BL , Proteína 1 de la Secuencia de Leucemia de Células Mieloides , Resucitación , Choque Hemorrágico/complicaciones , Choque Hemorrágico/inmunología , Bazo/enzimología , Bazo/metabolismoRESUMEN
The immunological sequelae following multiple trauma constitute an ongoing challenge in critical care management. The overall immune response to multiple trauma is a multilevel complex interdependently involving neurohormonal, cellular and haemodynamic factors. Immunoparalysis is characterised by a reduced capacity to present antigens via downregulated HLA-DR and an unbalanced monocyte-T cell interaction. Trauma-induced death of functionally conducive immune cells in the early recovery phase is significant in the emergence of posttraumatic multiple organ dysfunction or failure. Novel findings may contribute to more appropriate immunomonitoring and improved treatment. We must consider the preservation and support of immune function as the ultimate therapeutic goal, which may override the current strategy of simply antagonising excessive pro- or anti-inflammatory immune responses of the severely injured person. This review focuses on the injury-induced conduct of key immune effector cells and associated effects promoting immunoparalysis after multiple trauma.
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Citocinas/inmunología , Enfermedades del Sistema Inmune/inmunología , Tolerancia Inmunológica/inmunología , Inmunidad Celular/inmunología , Traumatismo Múltiple/inmunología , Síndrome de Respuesta Inflamatoria Sistémica/inmunología , Linfocitos T/inmunología , HumanosRESUMEN
BACKGROUND: Today's management of patients with multiple injuries remains controversial with regard to damage control and the appropriate timing of operative treatment ("second hit"). Among the multitude of physiologic parameters critical to the immune defense and clinical course of recovery, recent research has proven the regulation of distinct pro- and anti-inflammatory mediators to be closely associated with posttraumatic outcome and complications, including systemic inflammatory response syndrome (SIRS) and sepsis. This study sought to investigate the significance of multiple injuries and consecutive operative treatment ("second hit") with regard to the early inflammatory profile and its importance within the host's immune function. METHODS: Peripheral whole blood was obtained from 32 patients with multiple injuries (injury severity score [ISS] >20) and 14 healthy control subjects on the day of injury (day 0) and 24 hours thereafter (day 1). Trauma patients were divided into two groups (trauma versus trauma + immediate operation ["second hit"]). Whole blood was centrifuged at 400 g at room temperature for subsequent plasma collection and analyses of Interleukin-6 (IL-6), IL-10 and soluble triggering receptor expressed on myeloid cells (sTREM)-1 plasma concentrations by enzyme-linked immunosorbent assay, respectively. RESULTS: IL-6 plasma levels from second hit trauma patients (n = 18, ISS 35.5 +/- 12.2) significantly exceeded values determined in both trauma patients without a second hit (n = 14, ISS 30.5 +/- 5.3) and healthy control subjects (n = 14) by posttrauma day 1 (p < 0.05). IL-10 plasma concentrations on day 1 were equally and significantly elevated in both trauma patient populations, when compared with control samples (p < 0.05). In contrast, sTREM-1 was exclusively increased in trauma patients with a second hit, suggesting a strong proinflammatory response in patients with multiple injuries challenged with immediate surgical care (p < 0.05). CONCLUSION: Immediate surgical treatment of patients with multiple injuries augments the proinflammatory immune response in the early phase of recovery as determined by increased IL-6 and sTREM-1 plasma levels. If not required solely for damage control, the early second hit from additional surgical stress might promote posttraumatic complications by surcharging the innate immune response to injury.
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Inmunidad Innata/inmunología , Inflamación/inmunología , Traumatismo Múltiple/inmunología , Procedimientos Quirúrgicos Operativos/efectos adversos , Adolescente , Adulto , Anciano , Biomarcadores/sangre , Femenino , Humanos , Inflamación/etiología , Interleucina-10/sangre , Interleucina-6/sangre , Masculino , Glicoproteínas de Membrana/sangre , Persona de Mediana Edad , Traumatismo Múltiple/sangre , Receptores Inmunológicos/sangre , Receptor Activador Expresado en Células Mieloides 1RESUMEN
BACKGROUND: Ischemic preconditioning has been shown to protect the liver from ischemia/reperfusion injury. We hypothesized that IL-6 directly modulates the protective effects of ischemic preconditioning. METHODS: Three weeks after undergoing splenic transposition, wild-type C57BL/6 and IL-6 null mice underwent 75 minutes of total hepatic ischemia with or without prior ischemic preconditioning (10 minutes of ischemia followed by 15 minutes of reperfusion). After reperfusion, serum ALT, serum IL-6, hepatic IL-6 mRNA, hepatic pSTAT3, and liver histology were evaluated. RESULTS: In wild-type mice, survival at 24 hours was greater in the preconditioned group compared with the non-preconditioned group (75% vs 40%, P<.05). In IL-6 null mice, however, ischemic preconditioning did not improve survival when compared with the non-preconditioned group. Preconditioning significantly reduced hepatocellular injury in wild-type mice (P<.05) when compared with IL-6 null animals. This protection was associated with significant increases in serum IL-6, hepatic IL-6 mRNA, and hepatic pSTAT3 levels (P<.05). The protective effects of ischemic preconditioning that correlated with significant increases in systemic IL-6, hepatic IL-6 mRNA abundance, and pSTAT3 levels, were not observed in IL-6 null mice. CONCLUSIONS: The protective effects of ischemic preconditioning during total hepatic ischemia/reperfusion injury are dependent on IL-6 signaling and are associated with increased phosphorylation of hepatic STAT3.
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Interleucina-6/fisiología , Isquemia/prevención & control , Precondicionamiento Isquémico , Hígado/irrigación sanguínea , Daño por Reperfusión/prevención & control , Factor de Transcripción STAT3/fisiología , Alanina Transaminasa/sangre , Animales , Femenino , Interleucina-6/sangre , Interleucina-6/metabolismo , Isquemia/patología , Hígado/metabolismo , Hígado/patología , Ratones , Ratones Endogámicos C57BL , Ratones Noqueados , ARN Mensajero/metabolismo , Daño por Reperfusión/patologíaRESUMEN
BACKGROUND: Vertebral fractures resulting from high energy trauma often comprise the risk of posttraumatic degenerative changes in the affected intervertebral discs (IVD). Particularly in conservatively treated patients, or in cases after implant removal of an exclusively posterior stabilization, consecutive disc degeneration and the associated functional losing of the spinal segment clearly represent detrimental treatment results. In this regard, apoptosis of IVD cells has been suggested to be involved in the critical changes of the extracellular matrix. METHODS: To investigate whether fractures of the vertebrae induce apoptosis in the affected IVD, disc tissue from patients (n = 17) undergoing open reduction and internal fixation of thoracolumbar spine fractures were analysed in regards to caspase activity, apoptosis-receptor expression levels and gene expression of apoptosis-regulating proteins such as Bax and Bcl-2. Healthy IVD tissue (n = 3) obtained from patients undergoing surgical resection of adjacent vertebrae were used as control samples. RESULTS: In contrast to healthy control IVD tissues, samples from traumatic thoracolumbar IVD showed positive TUNEL staining and a significant increase of caspase-3/7 activity. Interestingly, analyses of the initiator caspase-8 and -9 revealed significantly increased activation levels compared to control values, suggesting the coexistent activation of both the extrinsic (receptor-mediated) and intrinsic (mitochondria-mediated) apoptosis pathway. Accordingly, expression levels of the Fas receptor (FasR) mRNA were significantly increased. Although the TNF receptor I (TNFR I) was only slightly upregulated, corresponding TNFalpha from trauma IVD presented significantly increased mRNA expression values. Furthermore, traumatic IVD cells demonstrated significantly reduced expression of the mitochondria-bound anti-apoptotic Bcl-2, thereby maintaining baseline transcriptional levels of the pro-apoptotic Bax protein when compared to control IVD cells. CONCLUSION: Our data suggest that thoracolumbar fractures induce early caspase-dependent apoptosis in IVD cells of the affected intervertebral disc, in part, by downregulation of the anti-apoptotic protein Bcl-2 (intrinsic apoptosis pathway), as well as signalling via the death receptor complex (TNFR I and FasR).
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OBJECTIVE: Severe inflammation and sepsis remain a serious clinical challenge worldwide. Despite modern supportive medicine and an improved understanding of the underlying pathophysiology, mortality rates remain high in patients suffering from this severe inflammatory process. The often excess production of pro- and anti-inflammatory cytokines frequently found in the circulation of septic patients has stimulated the search for reliable inflammatory mediators that can be used for the diagnosis and prediction of clinical outcome. Interleukin (IL)-18, formerly termed interferon-gamma inducing factor, is a pro-inflammatory and Th1 cytokine suggested to play a significant role in the pathogenesis of this disease. This review focuses on our current understanding of the pro-inflammatory cytokine, IL-18, and its potentially unique role in sepsis. METHODS: Bibliographic search of the most recent literature (1995-2005) relating to IL-18 and its role in inflammatory diseases, with emphasis on its pathophysiological importance in sepsis. In addition, a summary of the author's own experimental data from this particular field of research set in the context of current knowledge regarding IL-18. RESULTS AND CONCLUSIONS: Several studies have shown elevated plasma IL-18 concentrations to be associated with poor clinical outcome in severe inflammatory and septic conditions. Moreover, a significant increase in IL-18 concentrations has been shown to discriminate between Gram-positive and Gram-negative related sepsis, and, thus, may potentially augment existing diagnostic tools. Biological neutralization of IL-18 via caspase-1 intervention or through the administration of IL-18-binding protein has been promulgated as a promising therapeutic approach, but additional studies are required to evaluate its full potential in acute inflammatory diseases.
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Infecciones Bacterianas/inmunología , Interleucina-18/fisiología , Sepsis/inmunología , Sepsis/microbiología , Infecciones Bacterianas/complicaciones , Pronóstico , Sepsis/diagnósticoRESUMEN
Caspase-9 is believed to play an essential role in sepsis-induced lymphocyte apoptosis. The aim of this study was therefore to evaluate its contribution within the caspase-dependent apoptosis pathway in a murine model of polymicrobial sepsis. Local injections of Z-LEHD-fmk, a specific caspase-9 inhibitor, into thymi of septic mice led to the complete inhibition of caspase-9, decreased apoptosis of resident tissue cells, and, in addition, reduced further downstream caspase-3 activity. In contrast to its systemic administration, only local injections improved the overall survival of septic mice. However, local injections of a pancaspase inhibitor (Z-VAD-fmk) did not improve survival, although caspase-3 activity was reduced to a similar degree as by the administration of Z-LEHD-fmk. These results indicate that local apoptosis of lymphatic tissue in polymicrobial sepsis is processed dependent of caspase-9 and suggests alternative caspase-dependent beneficial effects, which may determine a positive outcome.
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Inhibidores de Caspasas , Inhibidores de Cisteína Proteinasa/farmacología , Sepsis/tratamiento farmacológico , Sepsis/mortalidad , Timo/enzimología , Clorometilcetonas de Aminoácidos , Animales , Apoptosis/efectos de los fármacos , Caspasa 9/metabolismo , Inhibidores de Cisteína Proteinasa/administración & dosificación , Citocinas/sangre , Relación Dosis-Respuesta a Droga , Femenino , Linfocitos/efectos de los fármacos , Linfocitos/patología , Ratones , Ratones Endogámicos C57BL , Oligopéptidos , Sepsis/metabolismo , Sepsis/microbiología , Tasa de Supervivencia , Timo/efectos de los fármacosRESUMEN
Flagellin, the principal component of bacterial flagella, is a ligand for Toll-like receptor 5 (TLR5) or TLR11 and contributes to systemic inflammation during sepsis through activation of dendritic cells (DCs) and other cells of the innate immune system. Here, we report that flagellin and the TLR4 ligand, lipopolysaccharide (LPS), induced phenotypic and functional maturation of murine bone marrow-derived DCs and enhanced DC accumulation in the draining popliteal lymph node following their footpad injection. It is interesting that flagellin injection enhanced myeloid (CD8alpha(-1)) and plasmacytoid (plasmacytoid DC antigen(+) B220(+)) DC subsets, whereas LPS only increased myeloid DCs in the draining lymph node. In addition, the footpad injection of flagellin or LPS induced significant CD4(+) T cell activation in the draining popliteal lymph node, as judged by increased CD69 or CD25 expression. We illustrate, for the first time, that flagellin also increases natural killer (NK) cell number and activation status in the draining lymph node after footpad injection. Using coculture with enriched carboxy-fluorescein diacetate succinimidyl ester-labeled NK cells, flagellin-treated DCs induce significant NK cell proliferation and activation. In fact, direct treatment of NK cells with flagellin induces a greater increase in cell proliferation than treatment with LPS. In contrast, flagellin treatment of NK cells was not a strong inducer of interferon-gamma (IFN-gamma) production, indicating that NK cell proliferation and IFN-gamma production may be regulated differentially. These data suggest that flagellin is a capable maturation agent for murine myeloid-derived DCs, and flagellin-activated DCs and flagellin itself are potent inducers of NK cell proliferation.
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Comunicación Celular/efectos de los fármacos , Células Dendríticas/metabolismo , Flagelina/farmacología , Células Asesinas Naturales/efectos de los fármacos , Activación de Linfocitos/efectos de los fármacos , Subgrupos Linfocitarios/efectos de los fármacos , Células 3T3 , Animales , Linfocitos T CD4-Positivos/efectos de los fármacos , Linfocitos T CD4-Positivos/metabolismo , Comunicación Celular/fisiología , Recuento de Células , Diferenciación Celular/efectos de los fármacos , Diferenciación Celular/fisiología , Proliferación Celular/efectos de los fármacos , Células Dendríticas/efectos de los fármacos , Femenino , Flagelina/genética , Flagelina/aislamiento & purificación , Técnicas In Vitro , Interferón gamma/biosíntesis , Interferón gamma/efectos de los fármacos , Células Asesinas Naturales/fisiología , Lipopolisacáridos/farmacología , Ganglios Linfáticos/efectos de los fármacos , Ganglios Linfáticos/metabolismo , Activación de Linfocitos/fisiología , Subgrupos Linfocitarios/fisiología , Ratones , Ratones Endogámicos C3H , Ratones Endogámicos C57BL , FenotipoRESUMEN
Despite recent advances in the prospective identification of the patient with sepsis who may benefit from anti-inflammatory or antithrombotic therapies, successful treatment regimens have been fairly modest. We have explored whether determination of several proinflammatory cytokine or mediator concentrations can complement physiologic scoring systems to identify patients with severe sepsis who will survive or expire within 28 days. The design of the study included an exploratory analysis performed in conjunction with a prospective, randomized, double-blind, placebo-controlled, multicenter, clinical trial and involved 33 academic institutions in the United States. One hundred twenty-four patients with severe sepsis with or without septic shock were included in this analysis. Blood samples were obtained at baseline and on days 1 through 4, and were evaluated for proinflammatory and anti-inflammatory cytokine concentrations, as well as for procalcitonin and total protein C levels. Baseline concentrations and changes in the concentrations of these mediators were evaluated in relationship to the Acute Physiology and Chronic Health Evaluation (APACHE) II and multiple organ dysfunction (MOD) scores, and 28-day all-cause mortality. Using univariate logistic regression analyses, APACHE II and MOD scores, age (but not gender), and baseline plasma interleukin (IL)-6 and soluble tumor necrosis factor receptor (sTNFR) 1 (log transformed) concentrations were all predictive of increased 28-day all-cause mortality (P < 0.01). Baseline total protein C, IL-8, IL-10, TNF-alpha, and procalcitonin concentrations, and the change in plasma cytokine concentrations from baseline over the initial 4 days were not useful in predicting outcome. Selected baseline proinflammatory cytokine concentrations and APACHE II score were correlated (P < 0.01). IL-6 concentration is a strong candidate for predicting clinical outcome in patients with severe sepsis alone, or when combined with the APACHE II or MOD scores. The potential usefulness of the combination of cytokine measurements and prognostic scores to identify patients who may benefit from treatment with anti-inflammatory or antithrombotic therapies should be further evaluated.
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Citocinas/sangre , Sepsis/sangre , Sepsis/mortalidad , Anciano , Calcitonina/sangre , Calcitonina/metabolismo , Péptido Relacionado con Gen de Calcitonina , Citocinas/metabolismo , Método Doble Ciego , Femenino , Humanos , Inflamación , Interleucina-10/metabolismo , Interleucina-6/sangre , Interleucina-6/metabolismo , Interleucina-8/metabolismo , Masculino , Persona de Mediana Edad , Placebos , Pronóstico , Proteína C/metabolismo , Precursores de Proteínas/sangre , Precursores de Proteínas/metabolismo , Receptores del Factor de Necrosis Tumoral/metabolismo , Análisis de Regresión , Síndrome de Dificultad Respiratoria/diagnóstico , Riesgo , Sepsis/diagnóstico , Factores de Tiempo , Resultado del Tratamiento , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
OBJECTIVE: Whether anticytokine therapies have a place in the treatment of severe sepsis and septic shock remains a question. Although a number of preclinical studies have shown efficacy in primate models of bacteremic shock when administered prophylactically, these same therapies have a significantly diminished effectiveness when administered therapeutically. This study investigated whether delayed administration of a novel anti-human interferon-gamma monoclonal antibody could improve outcome and reduce organ injury in a lethal model of Escherichia coli bacteremia, when administered after the onset of shock. DESIGN: Randomized, prospective, double-blinded intervention study. SUBJECTS: Cynomolgus monkeys. INTERVENTIONS: Treatment with a humanized monoclonal antibody directed against human interferon-gamma (INNO 202), administered after the onset of shock, induced by the infusion of live E. coli. MEASUREMENTS AND MAIN RESULTS: Five of the six vehicle-treated monkeys died or were killed within 24-72 hrs after E. coli administration, and all died within 5 days. In contrast, six of the eight animals treated with the anti-interferon-gamma survived for 7 days, and three of the eight animals survived 14 days (p = .013 vs. vehicle). Delayed treatment with the anti-interferon-gamma monoclonal antibody did not restore hemodynamics or reduce the amount of crystalloid-containing fluid required to resuscitate the animals but did attenuate renal failure (p < .05) and the magnitude of the inflammatory cytokine response (p < .05). CONCLUSIONS: In a primate model of E. coli bacteremic shock, delayed neutralization of interferon-gamma after the onset of shock improved survival and attenuated the pathologic changes associated with the development of organ dysfunction. These findings suggest that interferon-gamma blockade represents a potentially effective mode of late intervention in lethal septic shock.
Asunto(s)
Bacteriemia/tratamiento farmacológico , Bacteriemia/inmunología , Infecciones por Escherichia coli/tratamiento farmacológico , Infecciones por Escherichia coli/inmunología , Interferón gamma/antagonistas & inhibidores , Choque Séptico/tratamiento farmacológico , Choque Séptico/inmunología , Animales , Anticuerpos Monoclonales/uso terapéutico , Bacteriemia/sangre , Bacteriemia/patología , Biomarcadores/sangre , Citocinas/sangre , Modelos Animales de Enfermedad , Infecciones por Escherichia coli/sangre , Infecciones por Escherichia coli/patología , Inflamación/sangre , Interferón gamma/sangre , Macaca fascicularis , Valores de Referencia , Choque Séptico/sangre , Choque Séptico/patología , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Cuidados Críticos , Antígenos de Histocompatibilidad Clase II/genética , ARN Mensajero/genética , Choque Séptico/genética , Choque Séptico/inmunología , Síndrome de Respuesta Inflamatoria Sistémica/genética , Síndrome de Respuesta Inflamatoria Sistémica/inmunología , Transcripción Genética/genética , Antígenos HLA-DR/genética , Humanos , Tolerancia Inmunológica/genética , Tolerancia Inmunológica/inmunología , Monocitos/inmunologíaRESUMEN
Murine total hepatic ischemia (THI) followed by reperfusion without shunting of the portal vein induces significant lethality in rodents due to intestinal congestion. Two methods have been promulgated to study THI and reperfusion in mice without intestinal congestion: subcutaneous splenic transposition which creates a portosystemic shunt via epigastric vessels, and a caudal shunt with 30% hepatectomy, which creates a portosystemic shunt via the small remnant of remaining caudal lobe. We compared outcome, inflammatory response and hepatic injury due to THI and reperfusion in these two models. Female C57BL/6 mice underwent ST, caudal shunt or no surgery prior to having 30 min of total hepatic ischemia followed by 60 min of reperfusion. Survival, surgical complications, serum AST/ALT and IL-6 were determined. Apoptotic and necrotic hepatocytes were identified by morphological criteria. Complication rates for the ST and caudal shunt procedures were 6.7 and 20%, respectively. Subsequent mortality rates following THI and 60 min reperfusion were 5.9 and 50% in mice with ST and caudal shunt, respectively. Both groups had elevated serum AST/ALT concentrations. However, in mice undergoing caudal shunt, AST/ALT levels were also significantly increased even without THI. The number of apoptotic hepatocytes after THI and reperfusion in mice following caudal shunt was significantly higher compared with those of ST (P<0.001). Both ST and caudal shunt can be used in models of THI and reperfusion to prevent significant lethality due to intestinal congestion. However, ST is a simple, safe and suitable model, whereas caudal shunt requires manipulation of the liver, and is associated with significant hepatic injury and morbidity.
Asunto(s)
Modelos Animales de Enfermedad , Hepatopatías/cirugía , Derivación Portosistémica Quirúrgica , Daño por Reperfusión/cirugía , Bazo/trasplante , Animales , Femenino , Hepatectomía , Intestinos/irrigación sanguínea , Intestinos/patología , Hepatopatías/mortalidad , Hepatopatías/fisiopatología , Ratones , Ratones Endogámicos C57BL , Daño por Reperfusión/mortalidad , Daño por Reperfusión/fisiopatología , Bazo/fisiopatología , Tasa de Supervivencia , Factores de TiempoRESUMEN
Adenovirus-based gene therapy offers a unique opportunity to target gene expression to the liver by systemic delivery. However, systemic administration of a first generation adenoviral construct elicits an inflammatory response leading to TNF-alpha-dependent liver injury. The aim of this study was to evaluate whether the systemic administration of recombinant adenovirus exacerbates a subsequent TNF-alpha-dependent liver injury induced by D-galactosamine and lipopolysaccharide. Surprisingly, low-dose adenovirus administration (10(5) particles) protects, while high-dose adenovirus (10(10) particles) is associated with an exaggerated hepatic inflammatory response from a subsequent D-galactosamine and lipopolysaccharide challenge. This exacerbation is TNF-alpha dependent, since treatment with a TNF inhibitor fully protects against the liver injury. Moreover, intravenous administration of an adenoviral construct expressing the anti-inflammatory protein interleukin-10 reduces TNF-alpha appearance and attenuates the increased hepatocyte injury. Taken together, this report demonstrates potential additive effects of TNF-alpha responses induced by adenovirus and other inflammatory signals, and suggests that the response can be mitigated by relative adenovirus particle dose or by inhibitors, such as TNF-binding protein or interleukin 10.