RESUMEN
Sepsis is a leading cause of death worldwide, despite the use of multimodal therapies. Common antibiotic regimens are being affected by a rising number of multidrug-resistant pathogens, and new therapeutic approaches are therefore needed. Antibiotics have immunomodulatory properties which appear to be beneficial in the treatment of sepsis. We hypothesized that the last-resort antibiotics vancomycin (VAN) and daptomycin (DMC) modulate cell migration, phagocytosis, and protein cytokine levels in a murine model of lipopolysaccharide (LPS)-induced sepsis. Ten to twelve-week-old C57BL/6 mice (n = 4-6 animals per group) were stimulated with LPS for 20 h, followed by the administration of VAN or DMC. The outcome parameters were leukocyte accumulation and effector function. Quantification of the immune cells in the peritoneal lavage was performed using flow cytometry analysis. Phagocytosis was measured using pHrodo E. coli BioParticles. The response of the cytokines TNFα, IL-6, and IL-10 was measured in vitro using murine peritoneal macrophages stimulated with LPS and VAN or DMC. VAN decreased both the peritoneal macrophage and the dendritic cell populations following LPS stimulation. DMC reduced the dendritic cell population in the peritoneal cavity in LPS-infected mice. Both antibiotics increased the phagocytic activity in peritoneal macrophages, but this effect was diminished in response to LPS. Phagocytosis of dendritic cells was increased in LPS-infected animals treated with VAN. VAN and DMC differently modulated the levels of pro-and anti-inflammatory cytokines. In a murine model of LPS-induced sepsis, VAN and DMC exhibit immunomodulatory effects on cells involved in innate immunity. The question of whether these antibiotics exhibit synergistic effects in the treatment of septic patients, beyond their bactericidal properties, should be further evaluated in future studies.
Asunto(s)
Antibacterianos/farmacología , Daptomicina/farmacología , Inmunidad Innata/efectos de los fármacos , Sepsis/inmunología , Vancomicina/farmacología , Animales , Citocinas/metabolismo , Células Dendríticas/efectos de los fármacos , Recuento de Leucocitos , Lipopolisacáridos , Macrófagos Peritoneales/efectos de los fármacos , Masculino , Ratones , Ratones Endogámicos C57BL , Cavidad Peritoneal/citología , Fagocitosis/efectos de los fármacos , Sepsis/inducido químicamenteRESUMEN
Postconditioning attenuates inflammation and fibrosis in myocardial infarction (MI). The aim of this study was to investigate whether postconditioning with the cytosine-phosphate-guanine (CpG)-containing Toll-like receptor-9 (TLR9) ligand 1668-thioate (CpG) can modulate inflammation and remodeling in reperfused murine MI. Thirty minutes of left descending coronary artery (LAD) occlusion was conducted in 12-wk-old C57BL/6 mice. Mice were treated with CpG intraperitoneally 5 min before reperfusion. The control group received PBS; the sham group did not undergo ischemia. M-mode echocardiography (3, 7, and 28 days) and Millar left ventricular (LV) catheterization were performed (7 and 28 days) before the hearts were excised and harvested for immunohistochemical (6 h, 24 h, 3 days, 7 days, and 28 days), gene expression (6 h, 24 h, and 3 days; Taqman RT-qPCR), protein, and FACS analysis (24 h and 3 days). Mice treated with CpG showed significantly better LV function after 7 and 28 days of reperfusion. Protein and mRNA expressions of proinflammatory and anti-inflammatory cytokines were significantly induced after CpG treatment. Histology revealed fewer macrophages in CpG mice after 24 h, confirmed by FACS analysis with a decrease in both classically M1- and alternative M2a-monocytes. CpG treatment reduced apoptosis and cardiomyocyte loss and was associated with induction of adaptive mechanisms, e.g., of heme-oxigenase-1 and ß-/α-myosin heavy chain (MHC) ratio. Profibrotic markers collagen type Iα (Col-Ια) and Col-III induction was abrogated in CpG mice, accompanied by fewer myofibroblasts. This led to the formation of a smaller scar. Differential matrix metalloproteinase (MMP)/tissue inhibitor of metalloproteinase (TIMP) expression contributed to attenuated remodeling in CpG, resulting in preserved cardiac function in a Toll-like receptor 1- and TLR9-dependent manner. Our study suggests a cardioprotective mechanism of CpG postconditioning, involving Toll-like receptor-driven modulation of inflammation. This is followed by attenuated remodeling and preserved LV function.NEW & NOTEWORTHY Cytosine-phosphate-guanine (CpG) postconditioning seems to mediate inflammation via Toll-like receptor-1 and Toll-like receptor-9 signaling. Enhanced cytokine and chemokine expressions are partly attenuated by IL-10 and matrix metalloproteinase-8 (MMP8) induction, being associated with lower macrophage infiltration and M1-monocyte differentiation. Furthermore, switch from α- to ß-MHC and balanced MMP/TIMP expression led to lesser cardiomyocyte apoptosis, smaller scar size, and preserved cardiac function. Data of pharmacological postconditioning have been widely disappointing to date. Our study suggests a new pathway promoting myocardial postconditioning via Toll-like receptor activation.
Asunto(s)
Apoptosis , Poscondicionamiento Isquémico/métodos , Infarto del Miocardio/terapia , Daño por Reperfusión Miocárdica/terapia , Función Ventricular Izquierda , Animales , Antiinflamatorios/administración & dosificación , Antiinflamatorios/farmacología , Antiinflamatorios/uso terapéutico , Células Cultivadas , Colágeno/genética , Colágeno/metabolismo , Citocinas/genética , Citocinas/metabolismo , Femenino , Hemo-Oxigenasa 1/genética , Hemo-Oxigenasa 1/metabolismo , Inyecciones Intraperitoneales , Macrófagos/efectos de los fármacos , Macrófagos/metabolismo , Masculino , Ratones , Ratones Endogámicos C57BL , Infarto del Miocardio/tratamiento farmacológico , Daño por Reperfusión Miocárdica/tratamiento farmacológico , Miocardio/metabolismo , Cadenas Pesadas de Miosina/genética , Cadenas Pesadas de Miosina/metabolismo , Oligodesoxirribonucleótidos/administración & dosificación , Oligodesoxirribonucleótidos/farmacología , Oligodesoxirribonucleótidos/uso terapéutico , Inhibidores Tisulares de Metaloproteinasas/genética , Inhibidores Tisulares de Metaloproteinasas/metabolismo , Receptor Toll-Like 9/agonistasRESUMEN
BACKGROUND AND GOAL OF THE STUDY: Pulmonary inflammation, increased vascular permeability, and pulmonary edema, occur in response to primary pulmonary infections like pneumonia but are also evident in endotoxemia or sepsis. Mechanical ventilation augments pre-existing lung injury and inflammation resulting from exposure to microbial products. The objective of this study was to test the hypothesis that low-tidal-volume prevent ventilation induced lung injury in sepsis. MATERIALS AND METHODS: 10-12-week-old male C57BL/6N-mice received an intraperitoneal (i.p.) injection with equipotent dosages of LPS, 1668-thioate, 1612-thioate, or PBS. 120 min after injection, mice were randomized to low- (LV, 7 ± 1 ml/kg) or high-tidal-volume (HV, 25 ± 1 ml/kg) ventilation. Hemodynamic and ventilatory parameters were recorded and inflammatory markers were analyzed form BAL that was generated after 90 minute ventilation. RESULTS AND DISCUSSION: Arterial blood pressures declined during mechanical ventilation in all groups. pO2 decreased in LPS injected and CO2 increased in sham, LPS, and 1612-thioate administered mice at 45 min and in 1668-thioate injected mice after 90 minute LV ventilation compared to respective HV groups. BAL protein concentrations increased in HV ventilated and 1668- or 1612-thioat pre-treated mice. BAL TNF-α protein concentrations increased in both LPS- and 1668-thioate-injected and IL-1ß protein concentrations only in LPS-injected and HV ventilated mice. Most notably, no increased protein concentrations were observed in any of the LV ventilated groups. CONCLUSION: We conclude that low-tidal-volume ventilation may be a potential strategy for the prevention of ventilator induced lung injury in a murine model of systemic TLR agonist induced lung injury.
Asunto(s)
Inflamación/terapia , Sepsis/terapia , Volumen de Ventilación Pulmonar , Lesión Pulmonar Inducida por Ventilación Mecánica/prevención & control , Animales , Presión Arterial , Líquido del Lavado Bronquioalveolar , Dióxido de Carbono/sangre , Hemodinámica , Inflamación/complicaciones , Inflamación/patología , Masculino , Ratones , Ratones Endogámicos C57BL , Oxígeno/sangre , Mecánica Respiratoria , Sepsis/complicaciones , Sepsis/patología , Lesión Pulmonar Inducida por Ventilación Mecánica/patologíaRESUMEN
BACKGROUND: The aim of our study was the identification of genetic variants associated with postoperative complications after cardiac surgery. METHODS: We conducted a prospective, double-blind, multicenter, randomized trial (RIPHeart). We performed a genome-wide association study (GWAS) in 1170 patients of both genders (871 males, 299 females) from the RIPHeart-Study cohort. Patients undergoing non-emergent cardiac surgery were included. Primary endpoint comprises a binary composite complication rate covering atrial fibrillation, delirium, non-fatal myocardial infarction, acute renal failure and/or any new stroke until hospital discharge with a maximum of fourteen days after surgery. RESULTS: A total of 547,644 genotyped markers were available for analysis. Following quality control and adjustment for clinical covariate, one SNP reached genome-wide significance (PHLPP2, rs78064607, p = 3.77 × 10- 8) and 139 (adjusted for all other outcomes) SNPs showed promising association with p < 1 × 10- 5 from the GWAS. CONCLUSIONS: We identified several potential loci, in particular PHLPP2, BBS9, RyR2, DUSP4 and HSPA8, associated with new-onset of atrial fibrillation, delirium, myocardial infarction, acute kidney injury and stroke after cardiac surgery. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov NCT01067703, prospectively registered on 11 Feb 2010.
Asunto(s)
Lesión Renal Aguda/genética , Fibrilación Atrial/genética , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Delirio/genética , Infarto del Miocardio/genética , Polimorfismo de Nucleótido Simple , Accidente Cerebrovascular/genética , Lesión Renal Aguda/diagnóstico , Anciano , Fibrilación Atrial/diagnóstico , Proteínas del Citoesqueleto/genética , Delirio/diagnóstico , Fosfatasas de Especificidad Dual/genética , Femenino , Predisposición Genética a la Enfermedad , Estudio de Asociación del Genoma Completo , Proteínas del Choque Térmico HSC70/genética , Humanos , Masculino , Persona de Mediana Edad , Fosfatasas de la Proteína Quinasa Activada por Mitógenos/genética , Estudios Multicéntricos como Asunto , Infarto del Miocardio/diagnóstico , Fosfoproteínas Fosfatasas/genética , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Canal Liberador de Calcio Receptor de Rianodina/genética , Accidente Cerebrovascular/diagnóstico , Resultado del TratamientoRESUMEN
We previously demonstrated that pre-conditioning with CpG oligonucleotide (ODN) 1668 induces quick up-regulation of gene expression 3 hours post-murine myocardial ischaemia/reperfusion (I/R) injury, terminating inflammatory processes that sustain I/R injury. Now, performing comprehensive microarray and biocomputational analyses, we sought to further enlighten the "black box" beyond these first 3 hours. C57BL/6 mice were pretreated with either CpG 1668 or with control ODN 1612, respectively. Sixteen hours later, myocardial ischaemia was induced for 1 hour in a closed-chest model, followed by reperfusion for 24 hours. RNA was extracted from hearts, and labelled cDNA was hybridized to gene microarrays. Data analysis was performed with BRB ArrayTools and Ingenuity Pathway Analysis. Functional groups mediating restoration of cellular integrity were among the top up-regulated categories. Genes known to influence cardiomyocyte survival were strongly induced 24 hours post-I/R. In contrast, proinflammatory pathways were down-regulated. Interleukin-10, an upstream regulator, suppressed specifically selected proinflammatory target genes at 24 hours compared to 3 hours post-I/R. The IL1 complex is supposed to be one regulator of a network increasing cardiovascular angiogenesis. The up-regulation of numerous protective pathways and the suppression of proinflammatory activity are supposed to be the genetic correlate of the cardioprotective effects of CpG 1668 pre-conditioning.
Asunto(s)
Regulación de la Expresión Génica/efectos de los fármacos , Daño por Reperfusión Miocárdica/genética , Oligodesoxirribonucleótidos/farmacología , Animales , Cardiotónicos/farmacología , Supervivencia Celular/efectos de los fármacos , Supervivencia Celular/genética , Interleucina-10/genética , Interleucina-10/metabolismo , Masculino , Ratones Endogámicos C57BL , Daño por Reperfusión Miocárdica/tratamiento farmacológico , Daño por Reperfusión Miocárdica/patología , Miocitos Cardíacos/efectos de los fármacos , Miocitos Cardíacos/fisiología , Análisis de Secuencia por Matrices de Oligonucleótidos , Transducción de Señal/efectos de los fármacos , Transducción de Señal/genética , Factores de Tiempo , Regulación hacia Arriba/efectos de los fármacosRESUMEN
BACKGROUND: Remote ischemic preconditioning (RIPC) has been suggested to protect against certain forms of organ injury after cardiac surgery. Previously, we reported the main results of RIPHeart (Remote Ischemic Preconditioning for Heart Surgery) Study, a multicenter trial randomizing 1403 cardiac surgery patients receiving either RIPC or sham-RIPC. METHODS AND RESULTS: In this follow-up paper, we present 1-year follow-up of the composite primary end point and its individual components (all-cause mortality, myocardial infarction, stroke and acute renal failure), in a sub-group of patients, intraoperative myocardial dysfunction assessed by transesophageal echocardiography and the incidence of postoperative neurocognitive dysfunction 5 to 7 days and 3 months after surgery. RIPC neither showed any beneficial effect on the 1-year composite primary end point (RIPC versus sham-RIPC 16.4% versus 16.9%) and its individual components (all-cause mortality [3.4% versus 2.5%], myocardial infarction [7.0% versus 9.4%], stroke [2.2% versus 3.1%], acute renal failure [7.0% versus 5.7%]) nor improved intraoperative myocardial dysfunction or incidence of postoperative neurocognitive dysfunction 5 to 7 days (67 [47.5%] versus 71 [53.8%] patients) and 3 months after surgery (17 [27.9%] versus 18 [27.7%] patients), respectively. CONCLUSIONS: Similar to our main study, RIPC had no effect on intraoperative myocardial dysfunction, neurocognitive function and long-term outcome in cardiac surgery patients undergoing propofol anesthesia. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01067703.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Cognición , Precondicionamiento Isquémico Miocárdico/métodos , Infarto del Miocardio/epidemiología , Daño por Reperfusión Miocárdica/epidemiología , Trastornos Neurocognitivos/epidemiología , Anestésicos Intravenosos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Método Doble Ciego , Ecocardiografía Transesofágica , Alemania/epidemiología , Humanos , Incidencia , Precondicionamiento Isquémico Miocárdico/efectos adversos , Precondicionamiento Isquémico Miocárdico/mortalidad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/prevención & control , Daño por Reperfusión Miocárdica/diagnóstico por imagen , Daño por Reperfusión Miocárdica/prevención & control , Trastornos Neurocognitivos/diagnóstico , Trastornos Neurocognitivos/prevención & control , Trastornos Neurocognitivos/psicología , Pruebas Neuropsicológicas , Propofol/efectos adversos , Estudios Prospectivos , Factores Protectores , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Experimental animal models are indispensable components of preclinical sepsis research. Reproducible results highly rely on defined and invariant baseline conditions. Our hypothesis was that the murine gut microbiota varies among different distributors of laboratory animals and that these variations influence the phenotype of abdominal sepsis derived from a bacterial inoculum model (intraperitoneal stool injection). MATERIALS AND METHODS: Male C57BL/6 mice (8-wk old) purchased from Charles River (CR), Janvier (J), and Harlan (H) were sacrificed, and the bacterial composition of feces was analyzed using CHROMagar orientation medium. Stool was injected intraperitoneally into CR mice, followed by clinical observation and gene expression analysis. Experiments were repeated 16 mo later under the same conditions. RESULTS: Stool analysis revealed profound intervendor differences in bacterial composition, mainly regarding Staphylococcus aureus and Bacillus licheniformis. Mice challenged with CR as well as H feces developed significantly higher severity of disease and died within the observation period, whereas stool from J mice did not induce any of these symptoms. Real-time polymerase chain reaction revealed corresponding results with significant upregulation of proinflammatory cytokines and vascular leakage-related mediators in CR and H injected animals. Sixteen months later, the bacterial fecal composition had significantly shifted. The differences in clinical phenotype of sepsis after intraperitoneal stool injection had vanished. CONCLUSIONS: We are the first to demonstrate vendor and time effects on the murine fecal microbiota influencing sepsis models of intraabdominal stool contamination. The intestinal microbiota must be defined and standardized when designing and interpreting past and future studies using murine abdominal sepsis models.
Asunto(s)
Heces/microbiología , Microbioma Gastrointestinal , Sepsis/microbiología , Abdomen , Animales , Inyecciones Intraperitoneales , Masculino , Ratones , Ratones Endogámicos C57BL , Fenotipo , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Anesthesia for pediatric cardiac surgery requires a high level of expert knowledge. There are currently no recommendations and standards for anesthetic management for congenital cardiac surgery in Germany. AIM: The aim of the present study was to assess the current status of structural and personnel anesthetic standards at pediatric cardiac surgery centers in Germany. METHODS: All cardiac surgical centers in Germany were reviewed for an active program for congenital heart surgery. Centers with an active program were invited to respond to an online survey. The questionnaire containing 55 items in 16 categories assessed current practice in pediatric cardiac anesthesia. RESULTS: An active program for pediatric cardiac surgery was identified at 27 centers. The response rate to the survey was 96.3%. A specialized group of anesthesiologists for pediatric cardiac anesthesia was reported from 26 centers (92.3%). The mean size of this group was 4.8 anesthesiologists per center. However, the annual case load of centers and relative annual case load per specialized anesthesiologist varied considerably between 12.5 and 250. Nonanesthesiologists performed sedation and general anesthesia for diagnostic and therapeutic interventions outside the operating theater in children with congenital heart diseases in 24 centers (77%). Although special equipment, for example, pediatric TEE, near-infrared spectroscopy, and devices for mechanical auto transfusion were available in most centers, their routine use was not always part of standard operating procedures. The proposal for mean adequate training in pediatric cardiac anesthesia as estimated by the participating centers was 10.8 months. CONCLUSION: The present study represents the current structural situation for anesthesia at German pediatric cardiac surgery centers.
Asunto(s)
Anestesia/estadística & datos numéricos , Pediatría/estadística & datos numéricos , Cirugía Torácica/estadística & datos numéricos , Anestesiólogos , Anestesiología/educación , Niño , Sedación Consciente , Alemania , Encuestas de Atención de la Salud , Cardiopatías Congénitas/cirugía , Humanos , Grupo de Atención al Paciente , Pediatría/educación , Indicadores de Calidad de la Atención de Salud , Encuestas y Cuestionarios , Cirugía Torácica/educación , Recursos HumanosRESUMEN
BACKGROUND: Remote ischemic preconditioning (RIPC), a phenomenon in which a transient ischemia applied to a nonvital tissue protects another organ or tissue from subsequent lethal ischemic injury, is reported to protect the myocardium to withstand a subsequent prolonged ischemic event in patients undergoing cardiac surgery with cardiopulmonary bypass. It remains unclear whether oxidative stress and endogenous antioxidant enzymes play a role in the mechanistic pathways of RIPC. The aim of the present study was to evaluate the effects of RIPC on oxidative stress and extracellular concentrations of melatonin, extracellular superoxide dismutase (eSOD) and extracellular glutathione peroxidase (eGPx) in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: Thirty-two patients were randomly assigned to receive either RIPC (N.=15) or sham-RIPC (N.=17). Blood samples were collected immediately before and after RIPC and at the end of surgery. Melatonin levels were determined by radioimmunoassay. Plasma concentrations of eSOD, eGPx and 8-hydroxydeoxyguanosine (8-OhdG) as a marker of DNA oxidative stress were measured via ELISA. RESULTS: We found that RIPC compared to Sham-RIPC independently predicted higher melatonin concentrations at the end of surgery. However, it had no effect on eSOD, eGPx, and DNA oxidative stress. eSOD levels significantly increased during CPB time, while systemic eGPx levels decreased. High baseline melatonin concentration independently predicted lower 8-OHdG levels at the end of surgery. CONCLUSIONS: Our results suggest that extracellular antioxidative enzymes such as eSOD and eGPx as well as oxidative stress levels in the perioperative period do not play a predominant role in the mechanistic pathways of RIPC. RIPC modulates systemic melatonin concentrations but does not affect eSOD, eGPx and oxidative stress levels.
Asunto(s)
Antioxidantes/metabolismo , Procedimientos Quirúrgicos Cardíacos , Precondicionamiento Isquémico/métodos , Melatonina/sangre , Extremidad Superior/irrigación sanguínea , 8-Hidroxi-2'-Desoxicoguanosina , Anciano , Biomarcadores/sangre , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Puente Cardiopulmonar , Daño del ADN , Desoxiguanosina/análogos & derivados , Desoxiguanosina/sangre , Femenino , Alemania , Glutatión Peroxidasa/sangre , Humanos , Precondicionamiento Isquémico/efectos adversos , Masculino , Persona de Mediana Edad , Estrés Oxidativo , Proyectos Piloto , Flujo Sanguíneo Regional , Superóxido Dismutasa/sangre , Factores de Tiempo , Torniquetes , Resultado del TratamientoRESUMEN
Increased pulmonary vascular resistance is a critical complication in sepsis. Toll-like receptor (TLR) as well as angiopoietin (ANG) signalling both contribute to the emergence of pulmonary arterial hypertension. We hypothesized that TLR stimulation by bacterial ligands directly affects expression and secretion of ligands and receptors of the angiopoietin/TIE axis. Microvascular endothelial (HPMEC) and smooth muscle cells (SMC) of pulmonary origin were incubated with thrombin and with ligands for TLR2, -4, -5, and -9. Expression and secretion of ANG1, -2, TIE2 and IL-8 were determined using quantitative real-time PCR and ELISA. TLR stimulation had no impact either on the expression of ANG2 and TIE2 in HPMEC or on that of ANG1 in SMC. However, overall levels of both released ANG1 and -2 were halved upon stimulation with the TLR9 ligand CpG, and ANG2 release was significantly enhanced by TLR4 activation when initially provoked by sequentially performed stimulation. Furthermore, enhanced ANG2 activity increased endothelial permeability, as demonstrated in an in vitro transwell assay. We conclude that sole TLR stimulation by bacterial ligands plays no significant role for altered expression and secretion of ANG1, -2 and TIE2 in human pulmonary vascular cells. The interplay between various stimuli is required to induce imbalances between ANG1 and -2.
Asunto(s)
Angiopoyetina 1/biosíntesis , Angiopoyetina 2/biosíntesis , Arteria Pulmonar/metabolismo , Receptor TIE-2/biosíntesis , Receptores Toll-Like/biosíntesis , Angiopoyetinas/biosíntesis , Células Cultivadas , Flagelina/toxicidad , Células Endoteliales de la Vena Umbilical Humana/efectos de los fármacos , Células Endoteliales de la Vena Umbilical Humana/metabolismo , Humanos , Mediadores de Inflamación/metabolismo , Microvasos/efectos de los fármacos , Microvasos/metabolismo , Neumonía/inducido químicamente , Neumonía/metabolismo , Arteria Pulmonar/efectos de los fármacos , Transducción de Señal/efectos de los fármacos , Transducción de Señal/fisiologíaRESUMEN
OBJECTIVE: To determine whether the implementation of patient blood management (PBM) is effective to decrease the use of red blood cell without impairment of patient's safety. BACKGROUND: The World Health Organization encouraged all member states to implement PBM programs employing multiple combined strategies to increase and preserve autologous erythrocyte volume to minimize red blood cell transfusions. Data regarding safety issues are not sufficiently available. METHODS: In this prospective, multicenter study, surgical inpatients from four German University Hospitals were analyzed before (pre-PBM) and after the implementation of PBM. PBM program included multiple measures (ie, preoperative optimization of hemoglobin levels, blood-sparing techniques, and standardization of transfusion practice). Primary aim was to show noninferiority of the PBM cohort with a margin of 0.5%. Secondary endpoints included red blood cell utilization. RESULTS: A total of 129,719 patients discharged between July 2012 and June 2015 with different inclusion periods for pre-PBM (54,513 patients) and PBM (75,206 patients) were analyzed. The primary endpoint was 6.53% in the pre-PBM versus 6.34% in the PBM cohort. The noninferiority aim was achieved (P < 0.001). Incidence of acute renal failure decreased in the PBM cohort (2.39% vs 1.67%; P < 0.001, regression model). The mean number of red blood cell transfused per patient was reduced from 1.21â±â0.05 to 1.00â±â0.05 (relative change by 17%, P < 0.001). CONCLUSIONS: The data presented show that implementation of PBM with a more conscious handling of transfusion practice can be achieved even in large hospitals without impairment of patient's safety. Further studies should elucidate which PBM measures are most clinically and cost effective. TRIAL REGISTRATION: PBM-Study ClinicalTrials.gov, NCT01820949.
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Anemia/prevención & control , Transfusión de Eritrocitos , Complicaciones Posoperatorias/prevención & control , Anemia/diagnóstico , Anemia/etiología , Protocolos Clínicos , Estudios Controlados Antes y Después , Femenino , Alemania , Hemoglobinas/metabolismo , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Seguridad del Paciente , Selección de Paciente , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Estudios ProspectivosRESUMEN
OBJECTIVES: Prehospital hypothermia is defined as a core temperature <36.0 °C and has been shown to be an independent risk factor for early death in patients with trauma. In a retrospective study, a possible correlation between the body temperature at the time of admission to the emergency room and subsequent in-hospital transfusion requirements and the in-hospital mortality rate was explored. SETTING: This is a retrospective single-centre study at a primary care hospital in Germany. PARTICIPANTS: 15,895 patients were included in this study. Patients were classified by admission temperature and transfusion rate. Excluded were ambulant patients and patients with missing data. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome values were length of stay (LOS) in days, in-hospital mortality, the transferred amount of packed red blood cells (PRBCs), and admission to an intensive care unit. Secondary influencing variables were the patient's age and the Glasgow Coma Scale. RESULTS: In 22.85% of the patients, hypothermia was documented. Hypothermic patients died earlier in the course of their hospital stay than non-hypothermic patients (p<0.001). The administration of 1-3 PRBC increased the LOS significantly (p<0.001) and transfused patients had an increased risk of death (p<0.001). Prehospital hypothermia could be an independent risk factor for mortality (adjusted OR 8.521; p=0.001) and increases the relative risk for transfusion by factor 2.0 (OR 2.007; p=0.002). CONCLUSIONS: Low body temperature at hospital admission is associated with a higher risk of transfusion and death. Hence, a greater awareness of prehospital temperature management should be established.
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Transfusión Sanguínea/estadística & datos numéricos , Mortalidad Hospitalaria , Hipotermia/fisiopatología , Unidades de Cuidados Intensivos/organización & administración , Tiempo de Internación/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Alemania , Escala de Coma de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Plasmacytoid dendritic cells (pDCs) are a major source of type I interferon (IFN) and are important for host defense by sensing microbial DNA via TLR9. pDCs also play a critical role in the pathogenesis of IFN-driven autoimmune diseases. Yet, this autoimmune reaction is caused by the recognition of self-DNA and has been linked to TLR9-independent pathways. Increasing evidence suggests that the cytosolic DNA receptor cyclic GMP-AMP (cGAMP) synthase (cGAS) is a critical component in the detection of pathogens and contributes to autoimmune diseases. It has been shown that binding of DNA to cGAS results in the synthesis of cGAMP and the subsequent activation of the stimulator of interferon genes (STING) adaptor to induce IFNs. Our results show that the cGAS-STING pathway is expressed and activated in human pDCs by cytosolic DNA leading to a robust type I IFN response. Direct activation of STING by cyclic dinucleotides including cGAMP also activated pDCs and knockdown of STING abolished this IFN response. These results suggest that pDCs sense cytosolic DNA and cyclic dinucleotides via the cGAS-STING pathway and that targeting this pathway could be of therapeutic interest.
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ADN/inmunología , Células Dendríticas/inmunología , Células Dendríticas/metabolismo , Interferón Tipo I/metabolismo , Proteínas de la Membrana/metabolismo , Nucleotidiltransferasas/metabolismo , Transducción de Señal , Células Cultivadas , Citosol/inmunología , Citosol/metabolismo , Expresión Génica , Humanos , Inmunidad Innata , Factor 3 Regulador del Interferón/genética , Factor 3 Regulador del Interferón/metabolismo , Interferón Tipo I/genética , Proteínas de la Membrana/genética , Nucleotidiltransferasas/genética , Receptor Toll-Like 9/metabolismoRESUMEN
BACKGROUND: Toll-like receptors (TLRs) are involved in a variety of cardiovascular disorders, including septic cardiomyopathy, ischemia/reperfusion, heart failure, and cardiac hypertrophy. Previous research revealed that TLR4 promotes cardiac hypertrophy in vivo. Therefore, we investigated whether TLR2 is also involved in the development of cardiac hypertrophy. METHODS: Tlr2 deficient and wild type mice were subjected to transverse aortic constriction (TAC) or sham operation procedure. Left ventricular, heart and lung weights as well as hemodynamic parameters were determined after 3, 14 or 28 days. Real-time RT PCR was used to evaluate left ventricular gene expression. Protein content was determined via ELISA. RESULTS: TAC increased systolic left ventricular pressure, contraction and relaxations velocities as well as the heart weight in both genotypes. Tlr2 deficiency significantly enhanced cardiac hypertrophy after 14 and 28 days of TAC. Left ventricular end-diastolic pressure and heart rate increased in Tlr2(-/-) TAC mice only. Fourteen days of TAC led to a significant elevation of ANP, BNP, TGFß and TLR4 mRNA levels in Tlr2(-/-) left ventricular tissue. CONCLUSION: These data suggest that Tlr2 deficiency may promote the development of cardiac hypertrophy and ventricular remodeling after transverse aortic constriction.
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Estenosis de la Válvula Aórtica/fisiopatología , Hipertrofia Ventricular Izquierda/fisiopatología , Receptor Toll-Like 2/fisiología , Animales , Estenosis de la Válvula Aórtica/genética , Matriz Extracelular/metabolismo , Regulación de la Expresión Génica , Hipertrofia Ventricular Izquierda/genética , Masculino , Ratones , Presión , ARN Mensajero/genética , Receptor Toll-Like 2/genéticaRESUMEN
BACKGROUND: Unresolved inflammation resulting in capillary leakage with endothelial barrier dysfunction is a major contributor to postoperative morbidity and mortality after coronary artery bypass graft (CABG). Angiopoietins (ANGs) are vascular growth factors, also mediating inflammation and disruption of the endothelium, thus inducing capillary leakage. We hypothesized that changes in the relative serum levels of ANG1 and ANG2 influence endothelial barrier function and perioperative morbidity after CABG. METHODS: After approval and informed consent, serum samples (n = 28) were collected pre CABG surgery, 1, 6, and 24 h after aortic de-clamping. ANG1, ANG2, soluble ANG receptor TIE2 (sTIE2), and IL-6 serum concentrations were analyzed by ELISA. Human pulmonary microvascular endothelial cells (HPMECs) were incubated with patient serum and FITC-dextran permeability was assessed. Furthermore, ANG2 secretion of HPMECs was analyzed after incubation with IL-6-containing patient serum. RESULTS: CABG induced an early and sustained increase of ANG2/ANG1 ratio (5-fold after 24 h compared to pre-surgery). These changes correlated with elevated serum lactate levels, fluid balance, as well as the duration of mechanical ventilation. Permeability of HPMECs significantly increased after incubation with post-surgery serum showing a marked shift of ANG2/ANG1 balance (18-fold) compared to serum with a less pronounced increase (6-fold). Furthermore, CABG resulted in increased IL-6 serum content. Pre-incubation with serum containing high levels of IL-6 amplified the ANG2 secretion by HPMECs; however, this was not influenced by blocking IL-6. CONCLUSIONS: CABG affects the balance between ANG1 and ANG2 towards a dominance of the barrier-disruptive ANG2. Our data suggest that this ANG2/ANG1 imbalance contributes to an increased postoperative endothelial permeability, likewise being reflected by the clinical course. The results strongly suggest a biological effect of altered angiopoietin balance during cardiac surgery on endothelial permeability.
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Angiopoyetina 1/metabolismo , Angiopoyetina 2/metabolismo , Puente de Arteria Coronaria/mortalidad , Células Endoteliales/metabolismo , Permeabilidad , Anciano , Anciano de 80 o más Años , Angiopoyetina 1/sangre , Angiopoyetina 2/sangre , Femenino , Humanos , Ácido Láctico/sangre , Masculino , Persona de Mediana Edad , Receptor TIE-2/metabolismo , Estadística como AsuntoRESUMEN
Transverse aortic constriction provokes a pro-inflammatory reaction and results in cardiac hypertrophy. Endogenous ligands contribute to cardiac hypertrophy via toll-like receptor (TLR)-4 binding. A lack of TLR4 signaling diminishes hypertrophy and inflammation. Wild type mice undergoing aortic constriction respond to a lipopolysaccharide second-hit stimulus with hyperinflammation. The objective of this study was to assess whether other second-hit challenges utilizing TLR ligands provoke a comparable inflammatory reaction, and to find out whether this response is absent in TLR4 deficient mice. Assuming that cardiac stress alters the expression of pattern recognition receptors we analyzed the effects of transverse aortic constriction and second-hit virulence factor treatment on TLR expression, as well as cytokine regulation. Wild type and Tlr4-/- mice were subjected to three days of TAC and subsequently confronted with gram-positive TLR2 ligand lipoteichoic acid (LTA, 15 mg/g bodyweight) or synthetic CpG-oligodesoxynucleotide 1668 thioate (20 nmol/kg bodyweight, 30 min after D-galactosamin desensitization) signaling via TLR9. Hemodynamic measurements and organ preservation were performed 6 h after stimulation. Indeed, the study revealed a robust enhancement of LTA induced pattern recognition receptor and cytokine mRNA expression and a LTA-dependent reduction of hemodynamic pressure in TAC wild type mice. Second-Hit treatment with CpG-ODNs led to similar results. However, second-hit effects were abolished in Tlr4-/- mice. In total, these data indicate for the first time that cardiac stress increases the inflammatory response towards both, gram-negative and gram-positive, TLR ligands as well as bacterial DNA. The decrease of the inflammatory response upon TLR2 and -9 ligand challenge in TAC Tlr4-/- mice demonstrates that a lack of TLR4 signaling does not only prevent left ventricular hypertrophy but also protects the mice from a cardiac stress induced hyperinflammatory reaction.
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Aorta/metabolismo , Hipertrofia Ventricular Izquierda/genética , Inflamación/genética , Receptor Toll-Like 4/genética , Animales , Aorta/patología , Humanos , Hipertrofia Ventricular Izquierda/fisiopatología , Inflamación/inducido químicamente , Inflamación/patología , Ligandos , Lipopolisacáridos/administración & dosificación , Lipopolisacáridos/toxicidad , Ratones , Ratones Transgénicos , Transducción de Señal , Ácidos Teicoicos/administración & dosificación , Receptor Toll-Like 2/biosíntesis , Receptor Toll-Like 2/genética , Receptor Toll-Like 4/metabolismoRESUMEN
BACKGROUND: Remote ischemic preconditioning (RIPC) is reported to reduce biomarkers of ischemic and reperfusion injury in patients undergoing cardiac surgery, but uncertainty about clinical outcomes remains. METHODS: We conducted a prospective, double-blind, multicenter, randomized, controlled trial involving adults who were scheduled for elective cardiac surgery requiring cardiopulmonary bypass under total anesthesia with intravenous propofol. The trial compared upper-limb RIPC with a sham intervention. The primary end point was a composite of death, myocardial infarction, stroke, or acute renal failure up to the time of hospital discharge. Secondary end points included the occurrence of any individual component of the primary end point by day 90. RESULTS: A total of 1403 patients underwent randomization. The full analysis set comprised 1385 patients (692 in the RIPC group and 693 in the sham-RIPC group). There was no significant between-group difference in the rate of the composite primary end point (99 patients [14.3%] in the RIPC group and 101 [14.6%] in the sham-RIPC group, P=0.89) or of any of the individual components: death (9 patients [1.3%] and 4 [0.6%], respectively; P=0.21), myocardial infarction (47 [6.8%] and 63 [9.1%], P=0.12), stroke (14 [2.0%] and 15 [2.2%], P=0.79), and acute renal failure (42 [6.1%] and 35 [5.1%], P=0.45). The results were similar in the per-protocol analysis. No treatment effect was found in any subgroup analysis. No significant differences between the RIPC group and the sham-RIPC group were seen in the level of troponin release, the duration of mechanical ventilation, the length of stay in the intensive care unit or the hospital, new onset of atrial fibrillation, and the incidence of postoperative delirium. No RIPC-related adverse events were observed. CONCLUSIONS: Upper-limb RIPC performed while patients were under propofol-induced anesthesia did not show a relevant benefit among patients undergoing elective cardiac surgery. (Funded by the German Research Foundation; RIPHeart ClinicalTrials.gov number, NCT01067703.).
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Procedimientos Quirúrgicos Cardíacos , Precondicionamiento Isquémico/métodos , Complicaciones Posoperatorias/prevención & control , Anciano , Anestesia Intravenosa , Puente Cardiopulmonar , Método Doble Ciego , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Isquemia , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Propofol , Estudios Prospectivos , Insuficiencia del Tratamiento , Troponina/sangre , Extremidad Superior/irrigación sanguíneaRESUMEN
AIMS: The incidence of secondary systemic fungal infections has sharply increased in bacterial septic patients. Antimycotics exhibit immunomodulatory properties, yet these effects are incompletely understood in secondary systemic fungal infections following bacterial sepsis. We investigated a model of systemic inflammation to determine whether antimycotics (liposomal amphotericin B (L-AMB), itraconazol (ITC), and anidulafungin (ANI)) modulate the gene and protein expression as well as the phagocytic activity of lipopolysaccharide (LPS)-stimulated human monocytes. MAIN METHODS: THP-1 monocytes were incubated with L-AMB, ITC or ANI and LPS. Gene expression levels of cytokines (TNF-
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Antifúngicos/farmacología , Citocinas/biosíntesis , Monocitos/efectos de los fármacos , Monocitos/metabolismo , Fagocitosis/efectos de los fármacos , Sepsis/patología , Anfotericina B/farmacología , Anidulafungina , Células Cultivadas , Equinocandinas/farmacología , Expresión Génica/efectos de los fármacos , Humanos , Inmunosupresores/farmacología , Inflamación/inducido químicamente , Inflamación/patología , Itraconazol/farmacologíaRESUMEN
BACKGROUND: Postoperative delirium (POD) occurs frequently after cardiac surgery and is associated with increased morbidity and mortality. We analysed whether perioperative bilateral BIS monitoring may detect abnormalities before the onset of POD in cardiac surgery patients. METHODS: In a prospective observational study, 81 patients undergoing cardiac surgery were included. Bilateral Bispectral Index (BIS)-monitoring was applied during the pre-, intra- and postoperative period, and BIS, EEG Asymmetry (ASYM), and Burst Suppression Ratio (BSR) were recorded. POD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit, and patients were divided into a delirium and non-delirium group. RESULTS: POD was detected in 26 patients (32%). A trend towards a lower ASYM was observed in the delirium group as compared to the non-delirium group on the preoperative day (ASYM = 48.2 ± 3.6% versus 50.0 ± 4.7%, mean ± sd, p = 0.087) as well as before induction of anaesthesia, with oral midazolam anxiolysis (median ASYM = 49.5%, IQR [47.4;51.5] versus 50.6%, IQR [49.1;54.2], p = 0.081). Delirious patients remained significantly (p = 0.018) longer in a burst suppression state intraoperatively (107 minutes, IQR [47;170] versus 44 minutes, IQR [11;120]) than non-delirious patients. Receiver operating analysis revealed burst suppression duration (area under the curve = 0.73, p = 0.001) and BSR (AUC = 0.68, p = 0.009) as predictors of POD. CONCLUSIONS: Intraoperative assessment of BSR may identify patients at risk of POD and should be investigated in further studies. So far it remains unknown whether there is a causal relationship or rather an association between intraoperative burst suppression and the development of POD. TRIAL REGISTRATION: clinicaltrials.gov NCT01048775.