RESUMEN
Operative mortality is an important outcome for patients, surgeons, healthcare institutions, and policy makers. Although measures of perioperative mortality have conventionally been limited to in-hospital and 30-day mortality (or a composite endpoint combining both), there is a large body of evidence emerging to support the extension of the perioperative period after lung resection to a minimum of 90 days after surgery. Several large-volume studies from centers across the world have reported that 90-day mortality after lung resection is double 30-day mortality. Hence, true perioperative mortality after lung resection is likely to be significantly higher than what is currently reported. In the contemporary era, where new treatment modalities such as stereotactic ablative body radiotherapy are emerging as viable nonsurgical alternatives for the treatment of lung cancer, accurate estimation of perioperative risk and reliable reporting of perioperative mortality are of particular importance. It is likely that shifting the discussion from 30-day to 90-day mortality will lead to altered decision making, particularly for specific patient subgroups at an increased risk of 90-day mortality. We believe that 90-day mortality should be adopted as the standard measure of perioperative mortality after lung resection and that strategies to reduce the risk of mortality within 90 days of surgery should be investigated.
Asunto(s)
Neoplasias Pulmonares/cirugía , Neumonectomía/métodos , Complicaciones Posoperatorias/mortalidad , Humanos , Neoplasias Pulmonares/mortalidad , Periodo Perioperatorio , Tasa de Supervivencia , Factores de TiempoRESUMEN
BACKGROUND: A narrow-profile powered vascular stapler (PVS) was developed to provide superior access and precise staple placement in thoracic procedures. The objective of this study was to determine if the PVS would yield an equivalent rate of hemostatic interventions compared with standard of care (SOC) staplers in video-assisted thoracoscopic surgery lobectomy. MATERIALS AND METHODS: A randomized, controlled, multicenter study was conducted comparing PVS with SOC staplers in lobectomies performed for non-small cell lung cancer. The primary performance endpoint was the incidence of intraoperative hemostatic interventions, and the primary safety endpoint was the frequency of postoperative bleeding-related interventions. RESULTS: A total of 98 subjects participated in the SOC group and 103 in the PVS group. Rates of intraoperative hemostatic interventions were 5.3% and 8.3% for the SOC and PVS groups, respectively. These rates were not statistically different (P = 0.137), although the upper bound of the 95% confidence interval for the difference in intervention rates between PVC and SOC exceeded a predefined 3% criterion for equivalence. Simple compressions were performed more frequently in the PVS subjects, which accounted for the higher intervention rate in this group. Postoperative interventions for bleeding were required in one SOC subject (1.0%) and one subject from the PVS group (0.9%). Procedure-related adverse events occurred in 21 (21.9%) SOC subjects and 23 (21.9%) PVS subjects, with no adverse events related to use of the study devices. CONCLUSIONS: The PVS exhibited similar overall safety and effectiveness to SOC staplers in video-assisted thoracoscopic surgery lobectomy.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/cirugía , Neumonectomía/instrumentación , Hemorragia Posoperatoria/epidemiología , Grapado Quirúrgico/instrumentación , Cirugía Torácica Asistida por Video/instrumentación , Adulto , Anciano , Anciano de 80 o más Años , Pérdida de Sangre Quirúrgica/prevención & control , Femenino , Hemostasis Quirúrgica/estadística & datos numéricos , Humanos , Incidencia , Cuidados Intraoperatorios/métodos , Cuidados Intraoperatorios/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Tempo Operativo , Neumonectomía/efectos adversos , Hemorragia Posoperatoria/etiología , Estudios Prospectivos , Nivel de Atención , Grapado Quirúrgico/efectos adversos , Cirugía Torácica Asistida por Video/efectos adversosRESUMEN
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether induction (neoadjuvant) chemoradiotherapy (iCRT) compared with other therapeutic strategies improves survival in patients with Pancoast tumours. Altogether 248 papers were identified using the below-mentioned search. Ten of them represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. Four studies were retrospective comparative studies of induction chemoradiotherapy and surgery (trimodal therapy) versus other therapeutic strategies. Two studies were retrospective and four were prospective investigating trimodal therapy. These papers comprised a total of 550 patients. The overall survival was better with trimodal therapy compared with RT (radiotherapy) followed by surgery group in all three comparative studies. The 2-year survival varied in the trimodal therapy group from 70 to 93%, in comparison to RT group where variation was from 22 to 49%. Five-year survival for trimodal therapy varied between 36.4 and 84% in the results of two comparative studies, compared with 11 and 49% for RT and surgery, respectively. One paper looked at survival in patients who underwent surgery alone [30% at 2-year and 20% at 4-year overall survival (OS)]. The 5-year OS in the retrospective group varied between 38 and 59%. Similar results were reported for the prospective group with 5-year OS between 44 and 56%. Despite a large variation in pCR (complete pathological response) (15-93%) and R0 (77-100%) reported, both represented a positive prognostic factor for survival. Three papers looked at the impact of staging following induction chemoradiotherapy. The majority of patients had T3 disease. An advantage in survival was seen in patients with early disease compared with advanced stage. No randomized controlled trials were identified. All the 10 articles suggested there was a benefit in trimodal therapy with improvement in overall survival. We conclude that combining induction chemoradiotherapy with surgery for Pancoast tumour may offer a survival benefit compared with radiotherapy with surgery or surgery alone.
Asunto(s)
Antineoplásicos/uso terapéutico , Quimioterapia de Inducción/métodos , Síndrome de Pancoast/tratamiento farmacológico , Anciano , Humanos , Masculino , Síndrome de Pancoast/mortalidad , Pronóstico , Tasa de Supervivencia/tendencias , Reino Unido/epidemiologíaRESUMEN
AIM: We aimed to determine whether metastatic index is a factor determining long-term survival in patients undergoing curative resection for non-small-cell lung cancer. METHODS: There were 2695 consecutive pulmonary resections performed between October 2001 and September 2011 in our institution; 1795 were potentially curative resections for non-small-cell lung cancer with bronchial margin length data available. Benchmarking against the International Association for the Study of Lung Cancer data set was performed. Cox multivariate analysis was undertaken. Metastatic index was defined as N stage× bronchial resection margin length. RESULTS: Benchmarking failed to reveal any significant differences between our data and the International Association for the Study of Lung Cancer data set. Univariate analysis identified metastatic index as a significant factor determining long-term survival (p = 0.04). Cox regression demonstrated that metastatic index (hazard ratio 1.29, p = 0.0002), age (hazard ratio 1.02, p < 0.0001), body mass index (hazard ratio 0.98, p = 0.006), female sex (hazard ratio 0.65, p < 0.0001), T1 stage (hazard ratio 0.67, p < 0.0001), T2 stage (hazard ratio 2.13, p < 0.0001), T3 stage (hazard ratio 1.59, p = 0.03), forced expiratory volume in 1 s (hazard ratio 0.70, p < 0.0001), pneumonectomy (hazard ratio 1.43, p = 0.001), histology subtype adenosquamous (hazard ratio 3.77, p = 0.01) and squamous (hazard ratio 0.83, p = 0.03) were all significant determinants of long-term survival. CONCLUSION: Metastatic index is a significant factor determining long-term survival in patents with adenocarcinoma undergoing potentially curative surgery with a lobectomy.
Asunto(s)
Adenocarcinoma/secundario , Adenocarcinoma/cirugía , Carcinoma de Pulmón de Células no Pequeñas/secundario , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Técnicas de Apoyo para la Decisión , Neoplasias Pulmonares/patología , Neoplasias Pulmonares/cirugía , Neumonectomía , Adenocarcinoma/mortalidad , Adenocarcinoma del Pulmón , Benchmarking , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Bases de Datos Factuales , Femenino , Humanos , Estimación de Kaplan-Meier , Neoplasias Pulmonares/mortalidad , Metástasis Linfática , Masculino , Análisis Multivariante , Estadificación de Neoplasias , Neumonectomía/efectos adversos , Neumonectomía/mortalidad , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Using a large, prospectively collected and independently validated thoracic database, we created a risk-prediction tool for in-hospital mortality with the aim of improving on the accuracy of Thoracoscore. METHODS: A prospectively collected and independently validated database containing lung resections was utilized, N = 2574. Logistic regression analysis with bootstrapping, and by the use of a random training and test set was utilized. Comparisons against the Thoracoscore, ESOS.01 and the Society of Thoracic Surgeons (STS) models were performed. RESULTS: A logistic model identified age [odds ratio (OR) 1.1, 95% confidence interval (CI) 1.0-1.2, P = 0.0002], sex (OR 0.34, 95% CI 0.14-0.83, P = 0.02), predicted postoperative FEV1 (OR 0.96, 95% CI 0.94-0.99, P = 0.002), emphysema (OR 3.2, 95% CI 1.0-9.9, P = 0.04), excess alcohol consumption (OR 1.0, 95% CI 1.0-1.0, P = 0.04), pre-existing renal disease (OR 4.3, 95% CI 1.1-17.1, P = 0.04), predicted in-hospital mortality with an receiver operating curve (ROC) of 0.81 and a Hosmer-Lemeshow test of 0.9. Bootstrap analysis confirmed the above risk factors (ROC 0.82 and Hosmer-Lemeshow 0.2). Comparisons between Thoracoscore, ESOS.01 and the STS risk models demonstrated that none was very accurate, as all had low ROC values of 0.69, 0.70 and 0.61, respectively. The STS risk model does not apply to our population (ROC 0.61, Hosmer-Lemeshow, P = 0.004), and the ESOS.01 has poor predictive power (Hosmer-Lemeshow, P < 0.0001). CONCLUSIONS: Logistic regression based on age, sex, predicted postoperative FEV1, alcohol consumption and pre-existing renal disease predicts in-hospital mortality with improved accuracy compared with the use of Thoracoscore, ESOS.01 and the STS risk model.
Asunto(s)
Mortalidad Hospitalaria , Modelos Estadísticos , Neumonectomía/mortalidad , Anciano , Análisis por Conglomerados , Femenino , Humanos , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/cirugía , Masculino , Estudios Prospectivos , Curva ROC , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
The tumour-node metastasis (TNM) classification system is anatomically based. We investigated whether the addition of simple physiological variables, age and body mass index (BMI), would affect survival curves, i.e. a composite anatomical and physiological staging system. We retrospectively analysed a prospectively validated thoracic surgery database (n = 1981). Cox multivariate analysis was performed to determine possible significant factors. Kaplan-Meier survival curves were constructed with combined anatomical and physiological factors. Cox multivariate analysis revealed age (P < 0.001) and BMI (P = 0.01) as significant factors affecting survival. Receiver operating curve analysis determined cut-off levels for age of 67 and BMI of 27.6. A composite anatomical and physiological survival curve based on TNM for BMI > 27.6 and age < 67 was produced. Age and BMI criteria resulted in significantly different survival curves, for stage I (P < 0.0001) and stage II (P = 0.0032), but not for stage III (P = 0.06). Neural network analysis confirmed the importance of BMI and age above cancer stage with regard to long-term survival. Combining age < 67, BMI > 27.6 and TNM anatomical classification results in very different estimated survival curves from the usual TNM system. Patients from stages I, II and III may have survival equivalent to a stage higher or lower depending on their age and BMI.
Asunto(s)
Neoplasias Pulmonares/patología , Estadificación de Neoplasias/métodos , Factores de Edad , Anciano , Biopsia , Índice de Masa Corporal , Inglaterra , Femenino , Humanos , Estimación de Kaplan-Meier , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/fisiopatología , Neoplasias Pulmonares/terapia , Ganglios Linfáticos/patología , Metástasis Linfática , Masculino , Persona de Mediana Edad , Análisis Multivariante , Redes Neurales de la Computación , Tomografía de Emisión de Positrones , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: We proposed that a right-sided right ventricle-pulmonary artery conduit during the stage I Norwood procedure would facilitate pulmonary artery reconstruction during the stage II procedure. METHODS: Between 2002 and 2006, 153 patients underwent Norwood stage I reconstruction with a right ventricle-pulmonary artery conduit (125 in the right-sided group and 28 in the left-sided group). The previous 150 consecutive classic Norwood procedures (1997-2002) were used as a control group. Outcomes from stages I and II were analyzed, including ventricular function and pulmonary artery morphology. RESULTS: The 30-day survival was 88% (110/125) in the right-sided group, 75% (21/28) in the left-sided group, and 70% (105/150) in the control group (P < .001, right-sided vs control groups). The conduit length was 35 +/- 9 mm in the right-sided group and 26 +/- 8 mm in the left-sided group (P = .001). Survival at 6 months demonstrated a significant survival benefit in the right-sided right ventricle-pulmonary artery conduit group over the control group (P = .009, log-rank test). There was no difference in ventricular function between the groups and no regional dyskinesia associated with the right ventricle-pulmonary artery conduit. Despite larger branch pulmonary artery size in the right ventricle-pulmonary artery conduit groups (compared with the control group), central pulmonary artery stenoses were common (62% in the right conduit and 80% in the left conduit). Bypass and ischemic times at stage II were 49 +/- 10 and 23 +/- 13 minutes in the right-sided group compared with 61.5 +/- 9.5 and 31 +/- 14 minutes in the left-sided group (P < .001 and P = .03, respectively). The 30-day mortality after the stage II procedure was 1.3% (1/76) in the right-sided group, 0% (0/18) in the left-sided group, and 3.3% (3/90) in the control group. CONCLUSION: The right-sided conduit is a safe technique and has improved 30-day and overall post-stage II survival compared with that seen with the classic Norwood procedure. The right ventricle-pulmonary artery conduit is associated with central pulmonary artery stenosis but good development of the branch pulmonary arteries and preservation of ventricular function. The right-sided conduit significantly reduces cardiopulmonary bypass times at stage II.
Asunto(s)
Procedimientos Quirúrgicos Cardiovasculares , Defectos del Tabique Interventricular/cirugía , Ventrículos Cardíacos/cirugía , Procedimientos de Cirugía Plástica/métodos , Arteria Pulmonar/cirugía , Procedimientos Quirúrgicos Cardiovasculares/mortalidad , Niño , Preescolar , Femenino , Defectos del Tabique Interventricular/complicaciones , Humanos , Masculino , Arteria Pulmonar/diagnóstico por imagen , Radiografía , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del Tratamiento , Disfunción Ventricular/etiología , Disfunción Ventricular/fisiopatología , Disfunción Ventricular/cirugíaRESUMEN
BACKGROUND: Activation of the alveolar macrophage is centrally important to the development of lung ischemia reperfusion injury. Alveolar macrophages and type 2 pneumocytes secrete a variety of proinflammatory mediators in response to oxidative stress. The manner in which they interact and how the macrophage may influence pneumocyte responses in lung ischemia reperfusion injury is unknown. Utilizing an in vitro model of hypoxia and reoxygenation, we sought to determine if the proinflammatory response of type 2 pneumocytes to oxidative stress would be amplified by alveolar macrophage secretory products. METHODS: Cultured pneumocytes were exposed to control media or media from cultured macrophages exposed to hypoxia and reoxygenation. Pneumocytes were subsequently subjected to hypoxia and reoxygenation and assessed for both nuclear translocation of nuclear factor kappa B and inflammatory cytokine and chemokine secretion. To examine for any reciprocal interactions, we reversed the experiment, exposing macrophages to conditioned pneumocyte media. RESULTS: In the presence of media from stimulated macrophages, production of proinflammatory mediators by type 2 pneumocytes was dramatically enhanced. In contrast, exposure of the macrophage to conditioned pneumocyte media had an inhibitory effect on macrophage responses subsequently exposed to hypoxia and reoxygenation. CONCLUSIONS: The alveolar macrophage drives the development of lung reperfusion injury in part through amplification of the inflammatory response of type 2 pneumocytes subjected to hypoxia and reoxygenation.
Asunto(s)
Citocinas/metabolismo , Activación de Macrófagos/fisiología , Macrófagos Alveolares/metabolismo , Estrés Oxidativo/fisiología , Oxígeno/farmacología , Animales , Hipoxia de la Célula/fisiología , Células Cultivadas , Quimiocinas/metabolismo , Medios de Cultivo Condicionados , Modelos Animales de Enfermedad , Ensayo de Inmunoadsorción Enzimática , Mediadores de Inflamación/metabolismo , Interleucina-1beta/metabolismo , Masculino , Probabilidad , Ratas , Ratas Long-Evans , Valores de Referencia , Daño por Reperfusión/fisiopatología , Sensibilidad y Especificidad , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
BACKGROUND: We present a series of simulation studies that explore the relative performance of several phylogenetic network approaches (statistical parsimony, split decomposition, union of maximum parsimony trees, neighbor-net, simulated history recombination upper bound, median-joining, reduced median joining and minimum spanning network) compared to standard tree approaches, (neighbor-joining and maximum parsimony) in the presence and absence of recombination. PRINCIPAL FINDINGS: In the absence of recombination, all methods recovered the correct topology and branch lengths nearly all of the time when the substitution rate was low, except for minimum spanning networks, which did considerably worse. At a higher substitution rate, maximum parsimony and union of maximum parsimony trees were the most accurate. With recombination, the ability to infer the correct topology was halved for all methods and no method could accurately estimate branch lengths. CONCLUSIONS: Our results highlight the need for more accurate phylogenetic network methods and the importance of detecting and accounting for recombination in phylogenetic studies. Furthermore, we provide useful information for choosing a network algorithm and a framework in which to evaluate improvements to existing methods and novel algorithms developed in the future.
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Técnicas Genéticas , Algoritmos , Animales , Biología Computacional , Gráficos por Computador , Simulación por Computador , Evolución Molecular , Reacciones Falso Positivas , Humanos , Modelos Genéticos , Modelos Estadísticos , Filogenia , Recombinación Genética , Reproducibilidad de los Resultados , Alineación de SecuenciaRESUMEN
BACKGROUND: Inhibition of the nuclear enzyme poly ribose synthetase (PARS) protects against in vivo lung ischemia reperfusion injury (LIRI). The effectiveness of intratracheal treatment suggests that PARS inhibition may primarily modulate alveolar macrophage (AM) activation. These studies attempted to characterize the effects of PARS on AM activation in response to oxidative stress. METHODS: Primary cultures of AM were rendered hypoxic for 2 h and reoxygenated for up to 4 h. Cells were preincubated with INO-1001, a specific PARS inhibitor 1 h prior to hypoxia. Gel shift assays characterized nuclear factor kappa B (NFkappaB), and enzyme linked immunosorbent assay quantitated chemokine/cytokine protein secretion. RESULTS: Hypoxia and reoxygenation resulted in an increase in the early nuclear translocation of NFkappaB, and an increase in the secretion of the cytokine tumor necrosis factor-alpha (TNF-alpha), chemokines macrophage inflammatory protein (MIP-1alpha), monocyte chemoattractant protein one (MCP-1) and cytokine induced neutrophil chemoattractant (CINC). Pretreatment of AM with INO-1001 decreased both the early translocation of NFkappaB and the production of TNF-alpha (p<0.05) and MIP-1alpha p=0.02, but did not affect CINC or MCP-1 production. CONCLUSIONS: These findings indicate that PARS inhibition in the AM blunts their response to oxidative stress and may help explain the protective effects of intratracheal PARS inhibition in LIRI.
Asunto(s)
Inhibidores Enzimáticos/farmacología , Hipoxia/enzimología , Macrófagos Alveolares/enzimología , Oxígeno/metabolismo , Inhibidores de Poli(ADP-Ribosa) Polimerasas , Animales , Supervivencia Celular/efectos de los fármacos , Células Cultivadas , Quimiocinas/metabolismo , Indoles/farmacología , Masculino , FN-kappa B/metabolismo , Estrés Oxidativo/efectos de los fármacos , Poli(ADP-Ribosa) Polimerasas/metabolismo , Ratas , Ratas Long-Evans , Organismos Libres de Patógenos EspecíficosRESUMEN
BACKGROUND: Heart transplantation is an accepted treatment modality for end-stage heart failure. However, acute cellular rejection (ACR) continues to be a morbid complication. Recently a novel mechanism of inflammatory allograft injury has been characterized which involves overactivation of the nuclear enzyme poly (ADP-ribose) polymerase (PARP). In the present studies, we compared the efficacy of INO-1001, a novel, potent PARP inhibitor, in limiting ACR with and without adjuvant low-dose cyclosporine (CSA). METHODS: Heterotopic heart transplantation was performed utilizing Brown-Norway strains as donors and Lewis rats as recipients. Groups received daily intraperitoneal injections of: vehicle, low-dose CSA, low-dose INO-1001, high-dose INO-1001, and low-dose CSA combined with high-dose INO-1001. Additional animals were sacrificed on postoperative Day 5 for histologic assessments of allograft inflammation, including immunohistochemistry for nitrotyrosine and poly (ADP-ribose) (the product of PARP) staining. RESULTS: PARP inhibition significantly prolonged allograft survival relative to vehicle controls. The combination of low-dose CSA and INO-1001 resulted in a marked increase in allograft survival and significant reductions in allograft rejection scores. This was associated with decreased nitrotyrosine and PAR staining in transplanted cardiac allografts. CONCLUSIONS: Pharmacologic inhibition of INO-1001 prolongs allograft survival in a dose-dependent fashion in a rodent model of heart transplantation. PARP inhibitors may permit reductions in the dose of CSA needed for adequate immunosuppression after heart transplantation.
Asunto(s)
Supervivencia de Injerto , Trasplante de Corazón , Inhibidores de Poli(ADP-Ribosa) Polimerasas , Animales , Ciclosporina/uso terapéutico , Modelos Animales de Enfermedad , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Inhibidores Enzimáticos/uso terapéutico , Indoles/uso terapéutico , Poli(ADP-Ribosa) Polimerasas/metabolismo , Ratas , Ratas Endogámicas Lew , Tirosina/análogos & derivados , Tirosina/metabolismoRESUMEN
BACKGROUND: The activation of poly (adenosine diphosphate) ribose synthetase (PARS) is known to be important in the cellular response to oxidative stress. Previous studies have reported that PARS inhibition confers protection in models of endotoxic shock and ischemia-reperfusion. The purpose of this study was to determine the role of PARS inhibition in lung ischemia-reperfusion injury (LIRI). METHODS: Left lungs of Long-Evans rats were rendered ischemic for 90 minutes and reperfused for up to 4 hours. Treated animals received 3 mg/kg of INO-1001 (a PARS inhibitor) intravenously 30 minutes before ischemia. Injury was quantitated in terms of tissue myeloperoxidase (MPO) content, vascular permeability ((125)I radiolabeled bovine serum albumin extravasation) and bronchoalveolar lavage (BAL) leukocyte content. BAL fluid was assessed for cytokine and chemokine content by enzyme-linked immunoassay. Further samples were processed for nuclear protein analysis by electromobility shift assay (EMSA) and cellular death by terminal deoxyribonucleotidyl transferase-mediated d-UTP biotin nick-end labeling (TUNEL) assay and caspase-3 staining. RESULTS: Lung vascular permeability was reduced in treated animals by 73% compared with positive controls (p < 0.009). The protective effects of PARS inhibition correlated with a 46% reduction in tissue MPO content (p < 0.008) and marked reductions in BAL leukocyte accumulation. This positively correlated with the diminished expression of pro-inflammatory mediators and nuclear transcription factors, as well as decreased levels of cellular death. CONCLUSIONS: The deleterious effects of LIRI are in part mediated by the formation of free radicals and superoxides, which lead to DNA single-strand breaks. This leads to activation of PARS, which causes rapid cellular energy depletion and cell death. PARS inhibition is protective against this and represents a potentially useful therapeutic tool in the prevention of LIRI.
Asunto(s)
Indoles/uso terapéutico , Inhibidores de Poli(ADP-Ribosa) Polimerasas , Poli(ADP-Ribosa) Polimerasas/fisiología , Daño por Reperfusión/enzimología , Daño por Reperfusión/prevención & control , Animales , Masculino , Ratas , Ratas Long-EvansRESUMEN
BACKGROUND: Obliterative bronchiolitis (OB) is the main cause of late mortality among long-term survivors of lung transplantation. Although p38 kinase is functional in multiple acute inflammatory injury models, its role in chronic lung rejection is undefined. p38 regulates the expression of the cytokines tumor necrosis (TNF)-alpha and interleukin (IL)-1beta, 2 mediators involved in the development of OB in a tracheal transplant model. These studies assessed whether specific inhibition of p38 with FR167653 (FR) protects against the development of OB in rat tracheal allografts. METHODS: Rat airways were heterotopically transplanted from Brown-Norway donors into Lewis recipients, and animals were sacrificed on day 14 (6 per group). Treated animals received 10 mg/kg daily of FR intraperitoneally beginning either immediately or at day 7 after transplant. Allografts were assessed by computerized morphometry, and tracheas were processed for TNF-alpha mRNA and protein expression by quantitative reverse transcriptase-polymerase chain reaction and immunohistochemistry, respectively. Electrophoretic mobility shift assays evaluated nuclear factor kappa beta (NFkappaB) transactivation. RESULTS: Control allografts averaged 61% occlusion and 98% loss of epithelium at 14 days, whereas FR administration reduced luminal occlusion to 28% (p < 0.001) and epithelial loss to 71% (p < 0.001). Delayed treatment beginning on day 7 slowed progression of disease, as tracheal occlusion averaged 44% and epithelial loss averaged 80%, both of which were significant (p < 0.05) improvements relative to 14-day controls. NFkappa transactivation (p < 0.004) and TNF-alpha mRNA and protein expression were reduced dramatically by FR at 14 days. CONCLUSIONS: A specific p38 inhibitor, FR 167653, ameliorates obliterative airway disease in rat tracheal allografts via attenuated NFkappaB transactivation, which ultimately results in diminished TNF-alpha mRNA and protein expression.
Asunto(s)
Antiinflamatorios no Esteroideos/farmacología , Bronquiolitis Obliterante/tratamiento farmacológico , Pirazoles/farmacología , Piridinas/farmacología , Animales , Bronquiolitis Obliterante/genética , Bronquiolitis Obliterante/metabolismo , Ensayo de Cambio de Movilidad Electroforética , Inmunohistoquímica , Interleucina-1/análisis , Trasplante de Pulmón , Masculino , Modelos Animales , FN-kappa B/metabolismo , Complicaciones Posoperatorias/terapia , ARN Mensajero/genética , ARN Mensajero/metabolismo , Ratas , Ratas Endogámicas Lew , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Factores de Tiempo , Transcripción Genética/efectos de los fármacos , Trasplante Homólogo , Factor de Necrosis Tumoral alfa/análisis , Factor de Necrosis Tumoral alfa/genética , Proteínas Quinasas p38 Activadas por Mitógenos/antagonistas & inhibidoresRESUMEN
BACKGROUND: Obliterative bronchiolitis (OB) is the major long-term complication affecting lung transplant recipients, and is characterized pathologically by chronic inflammatory and fibroproliferative airway disease. Based on studies revealing anti-inflammatory and anti-apoptotic properties of poly (ADP)-ribose synthetase (PARS) inhibitors, we hypothesized that their administration would be protective in a heterotopic model of experimental OB. METHODS: We transplanted rat tracheas from Brown-Norway donors into Lewis recipients, and treated 2 groups with a novel PARS inhibitor, INO-1001. One group received 14 days of treatment, whereas a second received delayed treatment beginning on Day 7 post-transplant. Tracheas were analyzed by light microscopy and computerized morphometry. Effects on cytokine transcription, nuclear transcription factor activation and cellular death were assessed by in situ hybridization for tumor necrosis factor-alpha (TNF-alpha), electromobility shift assays for nuclear factor-kappaB (NF-kappaB) and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assays, respectively. RESULTS: PARS inhibition significantly decreased luminal obstruction (p < 0.001) and enhanced preservation of epithelial lining (p < 0.001) at 14 days post-transplant. Day 7 controls confirmed the development of an obstructive lesion in the lumen, averaging 28% occlusion. Delayed treatment (beginning on Day 7) arrested (p < 0.001) progression of the established lesion. Allograft airways treated with INO-1001 demonstrated attenuated NF-kappaB nuclear translocation, reduced transcription of TNF-alpha mRNA, and decreased cellular death on TUNEL and caspase 3 staining. CONCLUSIONS: PARS inhibition is anti-inflammatory, protects against experimental OB, and is associated with enhanced preservation of respiratory epithelium and decreased cellular death. Delayed treatment with INO-1001 arrests progression of the lesion developed by Day 7. These studies suggest that activation of PARS plays a critical role in the development of airway obliterative disease.
Asunto(s)
Bronquiolitis Obliterante/tratamiento farmacológico , Indoles/farmacología , Inhibidores de Poli(ADP-Ribosa) Polimerasas , Tráquea/metabolismo , Animales , Bronquiolitis Obliterante/metabolismo , Caspasa 3 , Caspasas/metabolismo , Ensayo de Cambio de Movilidad Electroforética , Hibridación in Situ , Etiquetado Corte-Fin in Situ , Masculino , Modelos Animales , FN-kappa B/análisis , FN-kappa B/metabolismo , Poli(ADP-Ribosa) Polimerasas/metabolismo , Complicaciones Posoperatorias/tratamiento farmacológico , ARN Mensajero/genética , ARN Mensajero/metabolismo , Ratas , Ratas Endogámicas Lew , Tráquea/patología , Tráquea/trasplante , Trasplante Homólogo , Factor de Necrosis Tumoral alfa/genéticaRESUMEN
BACKGROUND: We previously demonstrated that intravenous poly (ADP) ribose synthetase (PARS) inhibition protects against experimental lung ischemia reperfusion injury (LIRI) in an in situ, hilar occlusion model. This study determined its efficacy when administered intratracheally (IT). METHODS: Left lungs of rats were rendered ischemic for 90 minutes, and reperfused for up to 4 hours. Treated animals received INO-1001, a PARS inhibitor, intratracheally 30 minutes before ischemia, while controls were given IT vehicle at equivalent volumes. All groups contained at least 4 animals. Lung injury was quantitated utilizing vascular permeability to radiolabeled albumin, tissue myeloperoxidase (MPO) content, alveolar leukocyte cell counts, and arterial pO(2) at 4 hours of reperfusion. Electrophoretic mobility shift assays (EMSA) assessed the nuclear translocation of NFkappaB and AP-1 in injured left lungs, while ELISAs quantitated secreted cytokine induced neutrophil chemoattractant (CINC) and MCP-1 protein in bronchoalveolar lavage fluid. RESULTS: Intratracheal PARS inhibition was 73% (p < 0.0001) and 87% (p < 0.0001) protective against increases in vascular permeability and alveolar leukocyte accumulation, respectively, and improved arterial pO(2) (p < 0.0004) at 4 hours of reperfusion. Myeloperoxidase (MPO) activity in treated lungs was reduced by 70% (p < 0.02). The nuclear translocation of NFkappaB and AP-1 was attenuated at 15 minutes of reperfusion, and the secretion of CINC and MCP-1 (p < 0.05) protein into the alveolus was diminished at 4 hours of reperfusion. CONCLUSIONS: Intratracheal INO-1001 protects against experimental LIRI. The reduction in secreted chemokine protein at 4 hours of reperfusion appears to be mediated at the pretranscriptional level through attenuated NFkappaB and AP-1 activation. This route may optimize future donor organ management and improve lung recipient outcomes.
Asunto(s)
Pulmón/irrigación sanguínea , Inhibidores de Poli(ADP-Ribosa) Polimerasas , Fármacos Sensibilizantes a Radiaciones/administración & dosificación , Daño por Reperfusión/prevención & control , Animales , Líquido del Lavado Bronquioalveolar/citología , Permeabilidad Capilar , Quimiocinas CXC/análisis , Ensayo de Cambio de Movilidad Electroforética , Inhibidores Enzimáticos/administración & dosificación , Péptidos y Proteínas de Señalización Intercelular/análisis , Intubación Intratraqueal , Pulmón/metabolismo , FN-kappa B/análisis , Oxígeno/sangre , Peroxidasa/análisis , Ratas , Ratas Long-Evans , Daño por Reperfusión/metabolismo , Factor de Transcripción AP-1/análisisRESUMEN
BACKGROUND: Alpha chemokines function predominantly to recruit and activate neutrophils, which are important effectors of acute lung injury. This study evaluated whether blockade of 2 potent alpha chemokines, macrophage inflammatory protein-2 (MIP-2) and cytokine-induced neutrophil chemoattractant (CINC), is protective against lung ischemia-reperfusion injury in a warm in situ hilar clamp model. METHODS: Left lungs of Long-Evans rats underwent normothermic ischemia for 90 minutes and reperfusion for up to 4 hours. Treated animals received antibodies to MIP-2 or CINC immediately prior to reperfusion. Lung injury was quantitated by vascular permeability to (125)I-radiolabeled bovine serum albumin, lung tissue neutrophil sequestration (myeloperoxidase [MPO] content), and alveolar leukocyte content in bronchoalveolar lavage (BAL) fluid. CINC and MIP-2 mRNA expression were assessed by northern blot, while ribonuclease protection assays were performed to evaluate mRNA expression for a number of early response cytokines. MIP-2 and CINC protein expression in injured lungs was determined by immunoblotting. RESULTS: Treatment with antibodies to CINC or MIP-2 was associated with significant protection against increases in vascular permeability, MPO content and alveolar leukocyte sequestration in injured lungs. Expression of CINC and MIP-2 mRNA peaked after 2 hours of reperfusion in injured lungs, and protein levels were evident on immunoblotting after 3 hours of reperfusion. Neither CINC nor MIP-2 blockade appeared to modulate cytokine mRNA expression. CONCLUSIONS: CINC and MIP-2 are important mediators involved in direct lung ischemia-reperfusion injury. They appear to function by modulating neutrophil recruitment, but not inflammatory cytokine release.
Asunto(s)
Quimiocinas CXC/fisiología , Pulmón/irrigación sanguínea , Daño por Reperfusión/fisiopatología , Animales , Northern Blotting , Western Blotting , Lavado Broncoalveolar , Permeabilidad Capilar/fisiología , Quimiocina CXCL2 , Quimiocinas CXC/análisis , Modelos Animales de Enfermedad , Péptidos y Proteínas de Señalización Intercelular/análisis , Péptidos y Proteínas de Señalización Intercelular/fisiología , Peroxidasa/análisis , Ratas , Ratas Long-EvansRESUMEN
OBJECTIVE: Tumor necrosis factor-alpha is a proinflammatory mediator required for the development of experimental lung ischemia-reperfusion injury. The alveolar macrophage is a rich source of tumor necrosis factor-alpha in multiple models of acute lung injury. The present study was undertaken to determine whether the alveolar macrophage is an important source of tumor necrosis factor-alpha in lung ischemia-reperfusion injury and whether suppression of its function protects against injury. METHODS: Left lungs of Long-Evans rats underwent normothermic ischemia for 90 minutes and reperfusion for up to 4 hours. Treated animals received gadolinium chloride, a rare earth metal that inhibits macrophage function. Injury was quantitated via lung tissue neutrophil accumulation (myeloperoxidase content), lung vascular permeability, and bronchoalveolar lavage fluid leukocyte, cytokine, and chemokine content. Separate samples were generated for immunohistochemistry. RESULTS: Tumor necrosis factor-alpha secretion occurred at 15 minutes of reperfusion and was localized to the alveolar macrophage by immunohistochemistry. In gadolinium-treated animals, lung vascular permeability was reduced by 66% at 15 minutes (P <.03) of reperfusion and by 34% at 4 hours (P <.02) of reperfusion. Suppression of macrophage function resulted in a 35% reduction in lung myeloperoxidase content (P <.03) and similar reductions in bronchoalveolar lavage leukocyte accumulation. Tumor necrosis factor-alpha and microphage inflammatory protein-1alpha protein levels were markedly reduced in the bronchoalveolar lavage of gadolinium-treated animals by enzyme-linked immunosorbent assay. CONCLUSIONS: The alveolar macrophage secretes tumor necrosis factor-alpha protein by 15 minutes of reperfusion, which orchestrates the early events that eventually result in lung ischemia-reperfusion injury at 4 hours. Gadolinium pretreatment markedly reduces tumor necrosis factor-alpha elaboration, resulting in significant protection against lung ischemia-reperfusion injury.
Asunto(s)
Enfermedades Pulmonares/metabolismo , Macrófagos Alveolares/metabolismo , Daño por Reperfusión/metabolismo , Factor de Necrosis Tumoral alfa/metabolismo , Animales , Antiinflamatorios/farmacología , Apoptosis , Líquido del Lavado Bronquioalveolar/química , Líquido del Lavado Bronquioalveolar/citología , Permeabilidad Capilar , Caspasa 3 , Caspasas/análisis , Quimiocina CCL4 , Ensayo de Inmunoadsorción Enzimática , Gadolinio/farmacología , Inmunohistoquímica , Recuento de Leucocitos , Pulmón/irrigación sanguínea , Pulmón/metabolismo , Pulmón/patología , Proteínas Inflamatorias de Macrófagos/análisis , Neutrófilos , Peroxidasa/análisis , Ratas , Ratas Long-Evans , Factor de Necrosis Tumoral alfa/análisisRESUMEN
BACKGROUND: Although chemokines are functionally important in models of ischemia-reperfusion injury, little is known about their role in lung ischemia-reperfusion injury (LIRI). This study examined the role of the beta-chemokines, macrophage inflammatory protein (MIP)-1alpha, monocyte chemoattractant protein (MCP)-1, and regulated upon activation normal T cells expressed and secreted (RANTES) in LIRI. METHODS: Left lungs of Long-Evans rats underwent normothermic ischemia for 90 minutes and reperfusion for up to 4 hours. Treated animals received anti-MIP-1alpha, anti-MCP-1, or anti-RANTES antibodies before reperfusion. Changes in lung vascular permeability were measured with iodine 125-labeled bovine serum albumin. Neutrophil accumulation in the lung parenchyma was determined by myeloperoxidase activity, and bronchoalveolar lavage was performed to measure leukocyte cell counts. Western blots, Northern blots, and ribonuclease protection assays assessed beta-chemokine messenger RNA and protein levels. RESULTS: Animals receiving anti-MIP-1alpha demonstrated reduced vascular permeability compared with controls (p < 0.001). Attenuation of permeability was less dramatic in animals treated with anti-MCP-1 and anti-RANTES antibody, which demonstrated permeability decreases of 15% and 16%, respectively (p < 0.02). Lung neutrophil accumulation was reduced in animals receiving anti-MIP-1alpha antibody (p < 0.005) but was unchanged in animals receiving either anti-MCP-1 or anti-RANTES. Bronchoalveolar lavage leukocyte content was also reduced by treatment with anti-MIP-1alpha (p < 0.003) and was unchanged in anti-MCP-1-treated and anti-RANTES-treated animals. MIP-1alpha treatment decreased tumor necrosis factor-alpha messenger RNA in injured left lungs. CONCLUSIONS: MIP-1alpha is functionally significant in the development of LIRI. It likely exerts its effects in part by mediating the expression of proinflammatory and antiinflammatory cytokines and influencing tissue neutrophil recruitment. MCP-1 and RANTES seem to play relatively minor roles in the development of direct LIRI.
Asunto(s)
Quimiocinas CC/fisiología , Enfermedades Pulmonares/etiología , Daño por Reperfusión/etiología , Animales , Anticuerpos , Northern Blotting , Western Blotting , Líquido del Lavado Bronquioalveolar/citología , Permeabilidad Capilar/fisiología , Quimiocina CCL2/inmunología , Quimiocina CCL2/fisiología , Quimiocina CCL3 , Quimiocina CCL4 , Quimiocina CCL5/fisiología , Recuento de Leucocitos , Proteínas Inflamatorias de Macrófagos/inmunología , Proteínas Inflamatorias de Macrófagos/fisiología , Infiltración Neutrófila/fisiología , Peroxidasa/análisis , ARN/análisis , Ratas , Ratas Long-EvansRESUMEN
OBJECTIVES: We previously demonstrated that calcineurin inhibitors given intravenously ameliorate experimental lung ischemia-reperfusion injury. This study evaluates whether these effects can be achieved when these agents are delivered endotracheally. METHODS: Left lungs of Long Evans rats were rendered ischemic for 90 minutes and reperfused for up to 4 hours. Treated animals received tacrolimus endotracheally at doses of 0.2, 0.1, or 0.025 mg/kg 60 minutes before ischemia. Injury was quantitated in terms of vascular permeability. Additional animals treated at a dose of 0.1 mg/kg were assessed for lung tissue myeloperoxidase content and bronchoalveolar lavage leukocyte content. Bronchoalveolar lavage fluid was assessed for cytokine and chemokine content by enzyme-linked immunosorbent assay. Tissue samples were processed for nuclear factor-kappaB activation, and blood levels of tacrolimus were measured in treated animals. RESULTS: Left lung vascular permeability was reduced in treated animals in a dose-dependent fashion compared with controls. The protective effects correlated with a 47% (0.50% +/- 0.06% vs 0.27% +/- 0.08%, respectively) reduction in tissue myeloperoxidase content (P <.004) and marked reductions in bronchoalveolar lavage leukocyte accumulation. This protection was also associated with decreased nuclear factor-kappaB activation and diminished expression of proinflammatory mediators. Blood tacrolimus levels in treated animals at 4 hours of reperfusion were undetectable. CONCLUSIONS: Tacrolimus administered endotracheally is protective against lung ischemia-reperfusion injury in our model. This protection is associated with a decrease in nuclear factor-kappaB activation. This route of tacrolimus administration broadens its potential clinical use and decreases concerns about systemic and renal toxicity. It may be a useful therapy in lung donors to protect against lung ischemia-reperfusion injury.