Epirubicin for the Treatment of Sepsis and Septic Shock (EPOS-1): study protocol for a randomised, placebo-controlled phase IIa dose-escalation trial.

INTRODUCTION: Sepsis remains the major cause of death among hospitalised patients in intensive care. While targeting sepsis-causing pathogens with source control or antimicrobials has had a dramatic impact on morbidity and mortality of sepsis patients, this strategy remains insufficient for about one-third of the affected individuals who succumb. Pharmacological targeting of mechanisms that reduce sepsis-defining organ dysfunction may be beneficial. When given at low doses, the anthracycline epirubicin promotes tissue damage control and lessens the severity of sepsis independently of the host-pathogen load by conferring disease tolerance to infection. Since epirubicin at higher doses can be myelotoxic, a first dose-response trial is necessary to assess the potential harm of this drug in this new indication. METHODS AND ANALYSIS: Epirubicin for the Treatment of Sepsis and Septic Shock-1 is a randomised, double-blind, placebo-controlled phase 2 dose-escalation phase IIa clinical trial to assess the safety of epirubicin as an adjunctive in patients with sepsis. The primary endpoint is the 14-day myelotoxicity. Secondary and explorative outcomes include 30-day and 90-day mortality, organ dysfunction, pharmacokinetic/pharmacodynamic (PK/PD) and cytokine release. Patients will be randomised in three consecutive phases. For each study phase, patients are randomised to one of the two study arms (epirubicin or placebo) in a 4:1 ratio. Approximately 45 patients will be recruited. Patients in the epirubicin group will receive a single dose of epirubicin (3.75, 7.5 or 15 mg/m2 depending on the study phase. After each study phase, a data and safety monitoring board will recommend continuation or premature stopping of the trial. The primary analyses for each dose level will report the proportion of myelotoxicity together with a 95% CI. A potential dose-toxicity association will be analysed using a logistic regression model with dose as a covariate. All further analyses will be descriptive. ETHICS AND DISSEMINATION: The protocol is approved by the German Federal Institute for Drugs and Medical Devices. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05033808.

The IL-33-induced p38-/JNK1/2-TNFα axis is antagonized by activation of ß-adrenergic-receptors in dendritic cells.

IL-33, an IL-1 cytokine superfamily member, induces the activation of the canonical NF-κB signaling, and of Mitogen Activated Protein Kinases (MAPKs). In dendritic cells (DCs) IL-33 induces the production of IL-6, IL-13 and TNFα. Thereby, the production of IL-6 depends on RelA whereas the production of IL-13 depends on the p38-MK2/3 signaling module. Here, we show that in addition to p65 and the p38-MK2/3 signaling module, JNK1/2 are essential for the IL-33-induced TNFα production. The central roles of JNK1/2 and p38 in DCs are underpinned by the fact that these two MAPK pathways are controlled by activated ß-adrenergic receptors resulting in a selective regulation of the IL-33-induced TNFα response in DCs.

Colonization Dynamics of Subcortical Insects on Forest Sites With Relatively Stressed and Unstressed Loblolly Pine Trees.

Loblolly pine (Pinus taeda L.) is the most important commercial tree species in the southeastern United States. Since the 1950s, there have been reports of loblolly pines showing reduced growth and increased mortality, particularly in central Alabama and western Georgia, United States; the phenomenon is termed as southern pine decline (SPD). Recently, the role of rhizophagous (root-feeding) insects in loblolly pine health within the context of SPD has come under greater scrutiny. We investigated the impacts of subcortical insects, particularly rhizophagous weevils (Coleoptera: Curculionidae), on loblolly pine health in northeastern Georgia. We created plots-representing a gradient of increased relative tree stress-from ungirdled trees, ungirdled trees baited with ethanol and turpentine (ungirdled-baited), and girdled trees. In total, 10,795 subcortical insects from four families (Buprestidae, Cerambycidae, Curculionidae, and Siricidae) and >82 species were trapped in two years. Almost half of the insects trapped (46% of individuals and 11% of species) were nonnative to North America. Insect captures in plots with girdled trees were 61 and 187% greater than those with ungirdled-baited and ungirdled trees, respectively. Tree treatment impacted captures of native, but not nonnative insects. Relative feeding area by the rhizophagous weevils Hylobius pales (Herbst) and Pachylobius picivorus (Germar) on pine twigs placed in pitfall traps was 1, 17, and 82% in plots with ungirdled, ungirdled-baited, and girdled trees, respectively. Hence, there was a strong association of native subcortical insects, especially rhizophagous weevils, with relatively highly stressed trees, confirming that they are secondary instead of primary pine colonizers.