RESUMO
Interiorization and multiplication of Trypanosoma cruzi within its host cells are usually assessed by counting parasites in fixed and stained cover slip preparations, a subjective and time-consuming method. Here we describe an immunoenzymatic assay (ELISA) for assessing the number of internalized parasites in infected LLC-MK2 seed on chamber slides (NUNC). ELISA was performed employing a rabbit polyclonal serum against trypomastigote components (MOP) and anti-rabbit IgG conjugated to peroxidase. The bottom of the chamber slide was then detached and processed for quantification of internalized parasites by the conventional method. Data analysis showed a linear relationship between optical densities and number of internalized parasites (r2 = 93.99, p < 0.001). The assay was also efficient to assess inhibition of parasite interiorization induced by the monosaccharide NAc-D-glucosamine.
Assuntos
Ensaio de Imunoadsorção Enzimática/métodos , Trypanosoma cruzi/crescimento & desenvolvimento , Animais , Contagem de Células , Células Cultivadas , CoelhosRESUMO
A study was carried out on the radiosensitivity of Biomphalaria glabrata embryos submitted to doses of 5, 10, 15, 20 and 25 Gy of 60Co during the cleavage, blastula, gastrula, young trochophore and trochophore stages. Mortality, malformation and hatching were the parameters used to evaluate the damage induced by ionizing radiation. Estimated LD50 values (15 days) showed that the cleavage stage (4.3 Gy) was approximately four times more radiosensitive than the trochophore stage (17.0 Gy). Susceptibility to malformation induction was higher in the blastula, gastrula and young trochophore stages. Several types of morphogenetic malformations were observed, such as head malformations, exogastrulas, shell malformations, and embryos with everted stomodeum, with nonspecific malformations being the most frequent. The types of malformation induced by radiation probably are not radiation-specific and do not depend on the dose applied. The dose of 15 Gy was sufficient to greatly reduce the number of hatching snails regardless of the embryonic stage irradiated. We conclude that the effect of 60Co gamma radiation on B. glabrata embryos presented a specific pattern.
Assuntos
Biomphalaria/efeitos da radiação , Radioisótopos de Cobalto , Embrião não Mamífero/efeitos da radiação , Desenvolvimento Embrionário , Raios gama , Radiação Ionizante , Animais , Brasil , Dose Letal MedianaRESUMO
Electrophysiological studies of crotoxin, a potent neurotoxic fraction from Crotalus durissus terrificus venom, have shown a pre- and post-synaptic action. In order to determine the specific site of this activity, we performed an immunohistochemical analysis on striated muscle from CBA/J mice, injected with crotoxin (5 LD50), iv, using a single-step immunoperoxidase assay with peroxidase-conjugated antibodies to whole venom. Control muscle and muscle obtained from treated animals 15 min after injection showed no staining. However, 30 min after injection, the neuromuscular motor end plate of mice who received crotoxin was clearly stained, including thin terminations, without any morphological alteration. Sixty min after administration, the motor end plate was no longer intact, but only roughly formed stained areas without clearly identifiable structures were present. These data show specific crotoxin binding to neural end plates in striated muscle, with a subsequent toxin-induced degeneration of this structure.
Assuntos
Crotoxina/metabolismo , Placa Motora/metabolismo , Músculos/metabolismo , Animais , Crotoxina/administração & dosagem , Crotoxina/isolamento & purificação , Membro Posterior , Imuno-Histoquímica , Camundongos , Camundongos Endogâmicos CBA , Fatores de TempoRESUMO
1. Rodent experimental models have been useful to study severe malaria but few serial and controlled studies have been conducted. In the present investigation, we describe the histopathology of lethal and non-lethal rodent malaria induced by Plasmodium berghei and P. chabaudi. P. berghei malaria shows a uniformly lethal course, while P. chabaudi malaria produces a non-lethal acute infection with recovery and periodical recrudescences. Sequential histopathological changes were also characterized in P. chabaudi malaria to determine the evolution of the lesions. 2. P. berghei-infected mice have a more severe organ involvement and lower blood regenerative changes than P. chabaudi-infected mice. Two patterns of organ involvement were observed by comparing the two infections. The first is related to nonspecific parasitized red blood cell clearance by liver and spleen. The second is related to specific changes due to a specific parasite strain interaction with the host, such as those found in the lungs. 3. Sequential changes in P. chabaudi-infected mice were characterized by perihepatocytic reticulin fiber deposition during the recovery from infection, which faded in subsequent stages. Other organs had a similar regressive evolution, except splenic lymphoid tissue which underwent histological restoration or even hypertrophy after depletion in the acute stage. No brain or heart lesions were observed in either model during the acute and subsequent stages. 4. P. chabaudi infection, whose histopathology is described here for the first time, should be useful as a non-lethal experimental model to study the evolution of histopathological alterations in malaria.
Assuntos
Malária/patologia , Plasmodium chabaudi , Animais , Encéfalo/patologia , Modelos Animais de Doenças , Rim/patologia , Fígado/patologia , Pulmão/patologia , Masculino , Camundongos , Camundongos Endogâmicos BALB C , Miocárdio/patologia , Plasmodium berghei/patogenicidade , Plasmodium chabaudi/patogenicidade , Baço/patologiaRESUMO
Clinical and experimental evidence suggests that iron-deficient hosts are less susceptible to severe malaria and that iron supplementation aggravates infection. In the present study, 60 weanling Wistar rats were fed standard diets with different iron concentrations: 21 mg/kg (group 1), 45 mg/kg (group 2) and 113 mg/kg (group 3). Ferrous sulfate (FeSO4 x 7H2O) was added to the normal-iron and iron-supplemented diets (groups 2 and 3, respectively). Data are reported as mean +/- SEM. After 16 days of regimen, eight rats from each group were killed to measure serum iron concentration (SI) and transferrin saturation capacity (TSC). At this moment, rats from group 1 were underweight and their dietary intake was significantly lower than that of animals from the other groups. Severe iron deficiency (SI = 49.2 +/- 4.5 micrograms/100 ml and TSC = 8.3 +/- 0.7%) was observed in rats from group 1, while the animals from the other groups were iron-sufficient (group 2: SI = 186.5 +/- 28.5 micrograms/100 ml and TSC = 27.3 +/- 3.4%; group 3: SI = 137.3 +/- 18.2 micrograms/100 ml and TSC = 21.3 +/- 2.3%). Nine animals from each group were then infected with the malaria parasite Plasmodium berghei, whereas three animals from each group were used as noninfected controls. Parasitemias (% of infected red blood cells) peaked 7 days post-infection in animals from groups 2 and 3 (mean values of 2.4% and 1.7%, respectively), but in animals from group 1 parasitemias increased until the 9th day post-infection (mean at peak, 2.3%) and parasite clearance was significantly slower than in the other groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Deficiências de Ferro , Malária/parasitologia , Plasmodium berghei/crescimento & desenvolvimento , Animais , Peso Corporal , Ferro/administração & dosagem , Ferro/sangue , Malária/sangue , Masculino , Ratos , Ratos Wistar , Fatores de TempoRESUMO
We conducted a retrospective analysis of Toxoplasma encephalitis patients from Instituto de Infectologia Emílio Ribas, the main AIDS hospital of São Paulo, Brazil, during two different stages of the HIV epidemics, in 1988 (38 patients) and 1991 (33 patients). There were AIDS-related demographic differences, but the clinical presentation and diagnostic efficiency were similar, usually based on tomography and clinical response to therapy, with a clear distinction from other CNS infections, based on clinical and laboratory findings. Specific serologic studies were performed less often in 1991, with a high frequency of therapy change. The direct acute death rate from Toxoplasma encephalitis was high during both periods, i.e. 8/38 in 1988 and 10/33 in 1991. The direct acute death rate for the patients from the two periods as a whole was 25.4% (18/71), related to the time of HIV infection, absence of fever and presence of meningeal irritation at presentation, blood leukocytes higher than 10,000/mm3 and blood lymphocytes lower than 350/mm3. Toxoplasma encephalitis is a preventable disease when adequate prophylactic therapy is used and is relatively easy to treat in diagnosed HIV patients. Unfortunately, this severe and deadly disorder is the HIV diagnostic disease in several patients, and our data support the need for careful management of these patients, especially in those countries with a high toxoplasmosis prevalence where AIDS is concurrent with economic and public health problems.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Encefalite/epidemiologia , Toxoplasmose Cerebral/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/mortalidade , Adulto , Brasil/epidemiologia , Encefalite/diagnóstico , Encefalite/mortalidade , Feminino , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Toxoplasmose Cerebral/diagnóstico , Toxoplasmose Cerebral/mortalidadeRESUMO
Toxoplasmosis is a highly prevalent zoonotic human infection caused by the Apicomplexa protozoon Toxoplasma gondii. The acute disease is usually mild or asymptomatic, except for foetal infection transmitted by acutely infected pregnant women, which courses as a devastating disease. In order to determine possible regional variations in risk factors, we studied the frequency of seronegativity in areas of the São Paulo Metropolitan Region, comparing titers and age groups. The prevalence of seronegativity was determined retrospectively in 1286 pregnant women receiving prenatal care at public health services in four selected areas of the São Paulo Metropolitan Region of similar socioeconomic background. The São Paulo City area had the higher frequency of seronegativity (41.1%), followed by the Northwest (31.5%) and Southwest (29.9%) areas, with similar intermediate levels, and by the Northeast (22.5%) area with the lowest frequency (p < 0.001). A rough estimate disclosed about 280 infected infants/year in the São Paulo Metropolitan Region. Serological titers analyzed by age group suggested a decline in antibody levels with age, as shown by a lower frequency of higher titers in older groups. Our study emphasizes the importance of determining the regional prevalence of toxoplasmosis for proper planning of public health prenatal care.
Assuntos
Anticorpos Antiprotozoários/análise , Toxoplasma/imunologia , Toxoplasmose/epidemiologia , Adolescente , Adulto , Fatores Etários , Animais , Brasil/epidemiologia , Feminino , Imunofluorescência , Humanos , Imunoglobulina G/análise , Gravidez , Prevalência , Condições Sociais , População UrbanaRESUMO
Human schistosomiasis, caused by Schistosoma mansoni, is highly prevalent in Brazil and usually diagnosed by time consuming stool analysis. Serological tests are of limited use in this disease, mainly for epidemiological studies, showing no discrimination between previous contact with the parasite and active infections. In the present study, we standardized and compared a Dot-ELISA for IgM and IgG antibodies against S. mansoni antigens from eggs and worms with a routine IgG and IgM immunofluorescence assay using similar antigens, in the study of sera from 27 patients who had quantified egg stool excretion. The positivity obtained for IgG Dot-ELISA was 96.3% and 88.9% for IgM Dot-ELISA with worm antigen and 92.6% and 90.9% with egg antigen. The IFI presented similar positivities using worm antigen, 92.6% (IgG) and 96.3% (IgM), and lower results with egg antigen, 77.8%(IgG and IgM). The patients studied were divided into two groups according to their egg excretion, with greater positivity of serological tests in higher egg excreters. When comparing the quantitative egg excretion and the serological titers of the patients, we detected a correlation only with IgM Dot-ELISA, with r = 0.552 (p = 0.0127). These data show that Dot-ELISA can be used for the detection of specific antibodies against S. mansoni in sera from suspected patients or in epidemiological studies and, with further purification of egg antigen and larger samples, IgM Dot-ELISA could be a possible tool for rough estimates of parasite burden in epidemiological studies.
Assuntos
Anticorpos Anti-Helmínticos/sangue , Ensaio de Imunoadsorção Enzimática/métodos , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Schistosoma mansoni/imunologia , Esquistossomose mansoni/diagnóstico , Adolescente , Adulto , Animais , Brasil , Fezes/parasitologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Contagem de Ovos de Parasitas , Esquistossomose mansoni/imunologia , Sensibilidade e EspecificidadeRESUMO
A Dot-ELISA using a measles virus (MV) antigen obtained by sodium deoxycholate treatment was standardized and evaluated for IgM and IgG antibody detection in measles patients and measles-vaccinated subjects. A total of 192 serum samples were studied, comprising 47 from patients with acute and convalescent measles, 55 from 9-month old children prior to measles vaccination and 41 from children of the same age after vaccination, and 49 from patients with unrelated diseases. The diagnostic performances of the IgG Dot-ELISA and IgG immunofluorescence test (IFT) were found to be close, varying from 0.97 to 1.00 in sensitivity and the specificities were maximum (1.00). Nevertheless, the sensitivity of the IgM Dot-ELISA (0.85) was higher than that (0.63) of the IgM IFT, although both assays had comparably high (1.00) specificities. The IgM Dot-ELISA in particular proved to be more sensitive in relation to other assays studied by revealing antibodies in 80.0% (12/15) of vaccinated children on the 15th day after immunization. In contrast, the IgM IFT, failed to detect antibodies in the same group of vaccinated children. The stability of the MV antigen was longer than that of the IFT antigen, and the reproducibility of the Dot-Elisa was satisfactory.
Assuntos
Ensaio de Imunoadsorção Enzimática/métodos , Sarampo/diagnóstico , Ensaio de Imunoadsorção Enzimática/normas , Feminino , Imunofluorescência , Humanos , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Lactente , Masculino , Sarampo/sangue , Sarampo/tratamento farmacológico , Vacina contra Sarampo/uso terapêutico , Vírus do Sarampo/imunologia , Sensibilidade e EspecificidadeRESUMO
Cryptosporidium sp., a coccidian parasite usually found in the faeces of cattle, has been recently implicated as an agent of human intestinal disease, mainly in immunocompromised patients. In the study realized, by an indirect immunofluorescence technique, specific immunoglobulins (IgG and IgM) have been demonstrated in human serum against Cryptosporidium oocysts. Purified oocysts were used as antigens in the indirect immunofluorescence assay. After analyzing this test in sera from selected groups of patients, the frequency of both specific IgG and IgM of immunocompetent children who were excreting oocysts in their faeces was 62% and in children with negative excretion of oocytes was 20% and 40%, respectively. In adults infected with the human immunodeficiency virus (HIV) and who were excreting Cryptosporidium in their stools, the frequency was 57% for IgG but only 2% for IgM. Twenty three percent of immunocompromised adults with not determined excretion of oocysts in their stools had anti-Cryptosporidium IgG in their sera. Children infected with human immunodeficiency virus had no IgM and only 14% had IgG detectable in their sera. The indirect immunofluorescence assay, when used with other parasitological techniques appears to be useful for retrospective population studies and for diagnosis of acute infection. The humoral immune response of HIV positive patients to this protozoan agent needs clarification.
Assuntos
Criptosporidiose/diagnóstico , Técnica Indireta de Fluorescência para Anticorpo , Adulto , Animais , Anticorpos Antiprotozoários/análise , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Cryptosporidium/imunologia , Infecções por HIV/parasitologia , Humanos , Lactente , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
UNLABELLED: The aim of the study was to evaluate in vitro the antileishmanial activity of triterpenes and sterols isolated from Musa paradisiaca (banana) fruit peel used traditionally to treat leishmaniasis. The compounds were isolated from the ethanolic extract of the peel of the banana fruit by column chromatography. The chemical structure of compounds was determined by (1)H and (13)C - nuclear magnetic resonance spectroscopy. The cytotoxicity was measured in RAW 264.7 cells and LLC-MK2. Leishmanicidal activity against L. infantum chagasi promastigotes was performed by the MTT colorimetric method and activity against amastigotes was assayed in mammalian cells using in situ ELISA method. Five compounds were identified, consisting of three triterpenes: cycloeucalenone, 31-norcyclolaudenone and 24-methylene-cicloartanol and a mixture of two sterols: beta-sitosterol and stigmasterol. With the exception of cycloeucalenone, all compounds showed statistically similar activity against promastigote to pentamidine. While, acting against amastigotes, excluding 31-norcyclolaudenone, other compounds showed activity similar to amphotericin B. All compounds showed low cytotoxicity in mammalian cells. CONCLUSION: This study partially confirms the use of Musa paradisiaca in folk medicine against leishmaniasis. Further in vivo studies are necessary to evaluate the efficacy.
Assuntos
Antiprotozoários/farmacologia , Leishmania infantum/efeitos dos fármacos , Musa/química , Extratos Vegetais/farmacologia , Esteróis/farmacologia , Triterpenos/farmacologia , Animais , Linhagem Celular , Frutas/química , Macaca mulatta , Camundongos , Estrutura Molecular , Extratos Vegetais/química , Esteróis/químicaRESUMO
Hamsters (Mesocricetus auratus) were inoculated with L. (L.) chagasi and killed on days 7, 15, 30, 45 and 60 after infection. The lymphoid organs developed initial proliferation of the B lymphocyte zone with recovery by the 60th day group when pyroninophilic cells were prominent. The T lymphocyte area showed a progressive selective decrease of lymphocytes and cellular density with cellular pleomorphism including macrophages, plasma cells and reticular cells. The mean volume of the white pulp increased with the lymphoid follicle hyperplasia but returned to its initial level by day 60. The main red pulp change was marked hyperplasia of the phagocytic mononuclear cells containing parasites from the 30th day of infection onward. These changes are compatible with the humoral and cellular immunoresponse found in patients with visceral leishmaniasis (VL).
Assuntos
Leishmaniose Visceral/patologia , Sistema Linfático/patologia , Animais , Cricetinae , Leishmania donovani/isolamento & purificação , Leishmaniose Visceral/parasitologia , Linfonodos/patologia , Mesocricetus , Baço/parasitologia , Baço/patologia , Timo/patologia , Fatores de TempoRESUMO
A measles-specific enzyme-linked immunosorbent assay (ELISA)-IgG avidity test for serologic evaluation of the efficacy of measles vaccines with only one blood sample was evaluated after vaccination with three measles vaccine strains. Avidity indices were determined by the urea elution technique in samples presenting antibody titers > or = 100 mIU/ml. All 127 sera collected 2-8 weeks after primary vaccination with Biken-CAM70 measles vaccine had low avidity indices (LAI, when < or = 29%) with a time-dependent increase in avidity. In samples collected 6-10 weeks after vaccination with Edmonston-Zagreb, LAI were also observed in all 31 sera tested (mean = 15%) and in 233/242 (96.3%) filter paper samples from primary vaccination with Schwarz vaccine (mean = 14%). There was no difference in the mean avidity among the three groups of primary vaccinees, although the Schwarz group had higher antibody titers. In contrast, only 1/36 (2.8%) serum samples from children who were seropositive at the time of measles vaccination had LAI (mean = 56%), despite the fact that they were collected early (2-5 weeks after vaccination). Of 90 serum samples from children vaccinated in the past with two doses and of 42 cord blood serum samples, none had LAI. It is concluded that this test is a good tool for evaluating serologically the efficacy of a single dose schedule of measles vaccine. With only one postvaccination sample, the test can discriminate nonresponders (antibody titers below 100 mIU/ml), primary responders (antibody titers > or = 100 mIu/ml with LAI), and those previously immunized (antibody titers > or = 100 mIU/ml with high avidity indices). The seroconversion rate can be calculated after excluding the latter.
Assuntos
Anticorpos Antivirais/imunologia , Afinidade de Anticorpos , Ensaio de Imunoadsorção Enzimática , Imunoglobulina G/imunologia , Vacina contra Sarampo/imunologia , Adulto , Animais , Anticorpos Antivirais/sangue , Chlorocebus aethiops , Relação Dose-Resposta a Droga , Avaliação de Medicamentos , Feminino , Sangue Fetal , Humanos , Imunização , Imunoglobulina G/sangue , Lactente , Fatores de Tempo , Células VeroRESUMO
The ultrastructure of three cases of fatal human falciparum malaria was studied in order to identify the cytoadherence of the endothelial cells in relation to parasitized red blood cells and septal interstitial changes which could be related to respiratory distress. Two cases showed marked endothelial oedema narrowing the capillary lumen with areas of adherence preferentially related to knobs, accompanied by septal interstitial oedema. One case showed no endothelial cells oedema, no knobs in parasitized red blood cells with no cytoadherence, no septal interstitial oedema and no respiratory distress. Cytoadherence seems to be the mechanism responsible for the septal pulmonary changes in severe falciparum malaria.
Assuntos
Malária/complicações , Síndrome do Desconforto Respiratório/etiologia , Animais , Capilares/ultraestrutura , Adesão Celular , Endotélio Vascular/ultraestrutura , Eritrócitos/parasitologia , Eritrócitos/ultraestrutura , Humanos , Malária/patologia , Microscopia Eletrônica , Plasmodium falciparum , Edema Pulmonar/etiologia , Edema Pulmonar/patologiaRESUMO
The hypotheses that iron-deficient hosts are less susceptible to severe malaria and that iron supplementation aggravates infection have been supported by some clinical and experimental evidence. In the present study, the course of Plasmodium berghei infection was monitored in an experimental model of dietary iron deficiency and iron supplementation. Weanling Wistar rats were fed purified diets with different iron concentrations: 20 mg/kg (Group D, n = 24), 50 mg/kg (Group N, n = 24) and 100 mg/kg (Group S, n = 12). After 15 d, rats from Group D were anemic (mean hemoglobin 81 g/l). The next day, 12 rats from Group D (thereafter Group DS) and 12 rats from Group N (thereafter Group NS) were transferred to the same iron-supplemented diet as in Group S, whereas the remaining animals (Groups D, N and S) were maintained on the original diets for further 14 d. At that time, 9 rats from each group were inoculated intraperitoneally with 10(6) erythrocytic parasites (P. berghei ANKA strain), whereas 3 rats from each group remained as noninfected controls. All animals were killed 14 d after inoculation, when significantly lower levels of hemoglobin, serum iron and percent transferrin saturation were found in infected animals from Group D compared with all other groups. However, the time course of parasitemias was similar in all groups. These data indicate that the development of P. berghei was neither suppressed by iron deficiency nor enhanced by iron supplementation in this model. Furthermore, iron repletion during infection did produce a noticeable improvement of hematological variables in previously iron-deficient animals.
Assuntos
Ferro/administração & dosagem , Malária/etiologia , Parasitemia/etiologia , Plasmodium berghei , Anemia Ferropriva/complicações , Anemia Ferropriva/tratamento farmacológico , Animais , Peso Corporal/fisiologia , Modelos Animais de Doenças , Suscetibilidade a Doenças , Ingestão de Alimentos/fisiologia , Eritrócitos/parasitologia , Eritrócitos/patologia , Alimentos Fortificados , Hemoglobinas/análise , Incidência , Ferro/efeitos adversos , Deficiências de Ferro , Malária/complicações , Masculino , Parasitemia/complicações , Ratos , Ratos Wistar , Fatores de Tempo , Transferrina/análiseRESUMO
Sepsis, the leading cause of death in intensive care units, is associated with overproduction of nitric oxide (NO) due to inducible NO synthase (iNOS), responsible for some of the pathologic changes. Aminoguanidine (AG) is a selective iNOS inhibitor with reported inconsistent actions in sepsis. To investigate the influence of iNOS, we studied models of acute bacterial sepsis using acute challenges with aerobic (Escherichia coli) and anaerobic (Bacteroides fragilis) bacteria in the presence of AG. Six-week-old, 23 g, male and female BALB/c and C57Bl/6j mice, in equal proportions, were inoculated (ip) with bacteria in groups of 4 animals for each dose and each experiment in the absence or presence of AG (50 mg/kg, ip, starting 24 h before challenge and daily until day 6) and serum nitrate was measured by chemiluminescence. Both types of bacteria were lethal to mice, with an LD50 of 6 nephelometric units (U) for E. coli and 8 U for B. fragilis. Nitrate production peaked on the second day after E. coli inoculation with 8 and 6 U (P < 0.05), but was absent after non-lethal lower doses. After challenge with B. fragilis this early peak occurred at all tested doses after 24 h, including non-lethal ones (P < 0.05). AG-treated mice challenged with E. coli presented higher survival (P < 0.05) and increased LD50. AG-treated mice challenged with B. fragilis had lower LD50 and higher mortality. Control AG-treated animals presented no toxic effects. The opposite effect of iNOS blockade by AG in these models could be explained by restriction of oxygen for immune cells or an efficient action of NO in anaerobic localized infections. The antagonic role of NO production observed in our bacterial models could explain the reported discrepancy of NO action in sepsis.