RESUMO
INTRODUCTION: Since the beginning of the pandemic in spring 2020, inpatient healthcare has been under enormous burden, which is reflected especially in overworked staff, imprecise bed planning and/or data transfer. According to the recommendation of the Science Council, university clinics should play a controlling role in regional healthcare and act in conjunction with surrounding hospitals and practices. METHODS: In September 2021, 31 representatives from 18 university hospitals were invited to a hybrid Delphi study with a total of 4 survey rounds to discuss criteria for effective inpatient care in a pandemic situation, which were extracted from previous expert interviews. Criteria that were classified as very important/relevant by≥75% of the participants in the first round of the survey (consensus definition) were then further summarized in 4 different small groups. In a third Delphi round, all participants came together again to discuss the results of the small group discussions. Subsequently, these were prioritized as Optional ("can"), Desirable ("should") or Necessary ("must") recommendations. RESULTS: Of the invited clinical experts, 21 (67.7%) participated in at least one Delphi round. In an online survey (1st Delphi round), 233 criteria were agreed upon and reduced to 84 criteria for future pandemic management in four thematic small group discussions (2nd Delphi round) and divided into the small groups as follows: "Crisis Management and Crisis Plans" (n=20), "Human Resources Management and Internal Communication" (n=16), "Regional Integration and External Communication" (n=24) and "Capacity Management and Case & Care" (n=24). In the following group discussion (3rd Delphi round), the criteria were further modified and agreed upon by the experts, so that in the end result, there were 23 essential requirements and recommendations for effective inpatient care in a pandemic situation. CONCLUSION: The results draw attention to key demands of clinical representatives, for example, comprehensive digitization, standardization of processes and better (supra) regional networking in order to be able to guarantee needs-based care even under pandemic conditions. The present consensus recommendations can serve as guidelines for future pandemic management in the inpatient care sector.
Assuntos
Pacientes Internados , Pandemias , Humanos , Técnica Delphi , Alemanha/epidemiologia , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Melatonin is known to influence immune functions and to ameliorate outcome after septic challenge but it is unknown whether this is mediated by melatonin receptor activation. This study aimed to elucidate molecular differences in spleen and ex vivo splenocytes of wild-type (WT) and melatonin receptor double knockout mice (KO) after polymicrobial sepsis. SUBJECTS AND METHODS: C3H/HeN wild-type and MT1-/-/MT2-/- mice underwent sham operation or cecum ligation and incision (CLI) and remained anesthetized for 1 h. Splenocytes were isolated and treated in culture with physiological melatonin concentrations (1 nM). RESULTS: Plasma TNFα levels were consistently high after 1 h of CLI. Basal circulating leukocyte numbers were slightly higher in KO animals. We detected transcriptional differences in splenocytes of the knockout strain concerning proinflammatory mediators. Expression levels of IL-1ß, IL-2, CXCR2, L-Selectin, TNFα, CXCL2 and ICAM-1 were strongly increased in splenocytes of KO mice. Splenocytes of KO mice displayed reduced ERK and p38 as well as increased JNK phosphorylation. None of the analyzed factors were influenced by melatonin in the culture medium. CONCLUSIONS: The results of this study indicate an increased proinflammatory status of mice deficient in both membrane-bound melatonin receptors reflected by altered activation of MAPK cascades and transcriptional activation of proinflammatory mediators.
Assuntos
Deleção de Genes , Receptor MT1 de Melatonina/genética , Receptor MT2 de Melatonina/genética , Sepse/metabolismo , Sepse/microbiologia , Baço/metabolismo , Animais , Sequência de Bases , Sítios de Ligação , Primers do DNA/química , Ensaio de Imunoadsorção Enzimática , MAP Quinases Reguladas por Sinal Extracelular/metabolismo , Feminino , Perfilação da Expressão Gênica , Sistema Imunitário , Inflamação , Contagem de Leucócitos , Melatonina/metabolismo , Camundongos , Camundongos Endogâmicos C3H , Camundongos Knockout , Dados de Sequência Molecular , Fosforilação , Transdução de Sinais , Baço/citologia , Fator de Necrose Tumoral alfa/metabolismoRESUMO
BACKGROUND & AIMS: Melatonin's hepatoprotective actions have numerously been demonstrated in the past but the underlying molecular mechanisms are widely unknown. For a better understanding of melatonin's effects on hepatic stress response this study aimed to elucidate alterations in oxidative stress, unfolded protein response and acute phase response in septic mice. METHODS: Male C3H/HeN mice underwent sham operation or cecal ligation and incision and remained anesthetized for 5h. Production of reactive oxygen species was determined by electron spin resonance spectroscopy. Protein and mRNA expression levels were determined by western blot analysis and quantitative real-time PCR, respectively. RESULTS: Production of reactive oxygen species was strongly increased in the aorta and liver after 5h of polymicrobial sepsis which was entirely inhibited by treatment with melatonin. SOD-1 levels did not differ between the groups. Sepsis also induced the upregulation of VCAM-1 and ICAM-1 independent of melatonin treatment but probably regulated via ERK1/2 signaling. Melatonin triggered the transcriptional upregulation of PERK in septic animals which seems to be independent on ERK1/2 signaling and NR4A1 activation. Melatonin therapy also engendered an increased expression of CHOP, but apoptosis was not initiated. Furthermore, sepsis reduced the expression of the transcription factor CREBH which was entirely suppressed by melatonin. CONCLUSIONS: This study gives new insight into the mechanisms by which melatonin might confer its hepatoprotective actions during polymicrobial sepsis. The results clearly show the melatonin-mediated amelioration of oxidative stress as well as alterations in the cellular stress mechanisms via the unfolded protein response and the acute phase response.
Assuntos
Antioxidantes/farmacologia , Fígado/efeitos dos fármacos , Melatonina/farmacologia , Estresse Oxidativo/efeitos dos fármacos , Espécies Reativas de Oxigênio/metabolismo , Sepse/patologia , Resposta a Proteínas não Dobradas/efeitos dos fármacos , Animais , Western Blotting , Modelos Animais de Doenças , Espectroscopia de Ressonância de Spin Eletrônica , Fígado/metabolismo , Fígado/patologia , Masculino , Camundongos , Camundongos Endogâmicos C3H , Reação em Cadeia da Polimerase em Tempo Real , Sepse/metabolismoRESUMO
OBJECTIVE: Melatonin has been demonstrated to attenuate organ damage in models of ischemia and reperfusion. Melatonin treatment before hemorrhagic shock has been shown to improve liver function and hepatic perfusion. Proposed mechanisms of the pineal hormone involve direct inactivation of reactive oxygen species and induction of antioxidative enzymes. However, recent evidence suggests a strong influence of melatonin receptor activation for these effects. Specific protection of organ function by melatonin after hemorrhage has not been investigated yet. In this study, we evaluated whether melatonin therapy after hemorrhagic shock improves liver function and hepatic perfusion, with emphasis on melatonin receptor activation. DESIGN: Prospective, randomized, controlled study. SETTING: University research laboratory. SUBJECTS: Male Sprague-Dawley rats, 200-300 g (n = 10 per group). INTERVENTIONS: Animals underwent hemorrhagic shock (mean arterial pressure, 35 +/- 5 mm Hg for 90 mins) and were resuscitated with shed blood and Ringer's solution. At the end of shock, animals were treated with either melatonin (10 mg/kg, intravenously), melatonin receptor antagonist luzindole (2.5 mg/kg, intravenously) plus melatonin (10 mg/kg, intravenously), luzindole alone (2.5 mg/kg, intravenously), or vehicle. MEASUREMENTS AND MAIN RESULTS: After 2 hrs of reperfusion, either liver function was assessed by plasma disappearance rate of indocyanine green or intravital microscopy of the liver was performed for evaluation of hepatic perfusion, hepatocellular redox state, and hepatic integrity. Compared with vehicle controls, melatonin therapy after hemorrhagic shock significantly improved plasma disappearance rate of indocyanine green, hepatic redox state, hepatocellular injury, and hepatic perfusion index. Coadministration of luzindole completely abolished the protective effect with respect to liver function only, and improvements regarding hepatic redox state, perfusion, and integrity were comparable with melatonin treatment alone. CONCLUSIONS: Melatonin therapy after hemorrhagic shock improves liver function, hepatic perfusion, redox state, and hepatic integrity. With respect to liver function, beneficial effects of the pineal hormone seem to be dependent on melatonin receptor activation.
Assuntos
Antioxidantes/uso terapêutico , Fígado/efeitos dos fármacos , Melatonina/uso terapêutico , Receptores de Melatonina/efeitos dos fármacos , Choque Hemorrágico/tratamento farmacológico , Animais , Corantes/metabolismo , Modelos Animais de Doenças , Verde de Indocianina/metabolismo , Fígado/irrigação sanguínea , Fígado/metabolismo , Fígado/fisiopatologia , Testes de Função Hepática , Masculino , Microcirculação/efeitos dos fármacos , Microcirculação/fisiopatologia , NADP/metabolismo , Estudos Prospectivos , Distribuição Aleatória , Ratos , Ratos Sprague-Dawley , Receptores de Melatonina/metabolismo , Valores de Referência , Choque Hemorrágico/metabolismo , Choque Hemorrágico/fisiopatologia , Resultado do TratamentoRESUMO
OBJECTIVE: Melatonin may attenuate organ damage via direct antioxidative properties, and was recently demonstrated to reduce cardiac and hepatic injury through receptor-dependent effects. However, the relevance of an isolated activation of melatonin receptors for organ protection, excluding direct antioxidant effects, has not been established yet. This study was designed to investigate whether therapy with melatonin receptor agonist and hypnotic substance ramelteon may improve liver function, hepatic perfusion, and hepatic integrity after hemorrhagic shock in rat. DESIGN: Prospective, randomized, controlled study. SETTING: University research laboratory. SUBJECTS: Male Sprague-Dawley rats (n = 10 per group). INTERVENTIONS: Animals underwent hemorrhagic shock (mean arterial pressure 35 +/- 5 mm Hg for 90 mins) and were resuscitated with shed blood and Ringer's lactate (2 hrs). At the end of shock, animals were treated with ramelteon (1.0 mg/kg intravenously), melatonin receptor antagonist luzindole plus ramelteon (each 1.0 mg/kg intravenously), or vehicle. MEASUREMENTS AND MAIN RESULTS: In vitro, ramelteon displayed no relevant antioxidant capacity in an 2,2'-Azino-bis-(3-ethylbenzthiazoline-6-sulfonic acid) assay, compared with melatonin. In vivo, liver function was assessed by plasma disappearance rate of indocyanine green, and intravital microscopy was performed for evaluation of hepatic perfusion index, nicotinamide adenine dinucleotide phosphate autofluorescence, and hepatic integrity. Compared with vehicle controls, ramelteon therapy significantly improved plasma disappearance rate of indocyanine green (7.89 +/- 2.12% vs. 13.67 +/- 2.51%; p = 0.006), hepatic perfusion index (352.04 +/- 111.78 pl/sec/mm vs. 848.81 +/- 181.38 pl/sec/mm; p = 0.002), nicotinamide adenine dinucleotide phosphate autofluorescence and hepatocellular injury. Coadministration of luzindole abolished the protective effect of ramelteon with respect to liver function and nicotinamide adenine dinucleotide phosphate autofluorescence. CONCLUSIONS: Ramelteon therapy improves liver function, hepatic perfusion, and hepatocellular integrity after hemorrhagic shock in rat. This demonstrates that an isolated activation of melatonin receptors may be sufficient for organ protection, independent from direct antioxidant effects. The hypnotic ramelteon could thus play an interesting role in future sedation concepts for critical care patients.
Assuntos
Indenos/farmacologia , Circulação Hepática/efeitos dos fármacos , Hepatopatias/prevenção & controle , Choque Hemorrágico/tratamento farmacológico , Triptaminas/farmacologia , Análise de Variância , Animais , Modelos Animais de Doenças , Infusões Intravenosas , Circulação Hepática/fisiologia , Hepatopatias/etiologia , Testes de Função Hepática , Masculino , Probabilidade , Distribuição Aleatória , Ratos , Ratos Sprague-Dawley , Receptores de Melatonina/efeitos dos fármacos , Sensibilidade e Especificidade , Choque Hemorrágico/complicações , Choque Hemorrágico/fisiopatologiaRESUMO
Exogenous administration of pineal hormone melatonin (MEL) has been demonstrated to attenuate organ damage in models of I/R and inflammation by antioxidative effects. However, specific organ-protective effects of MEL with respect to hemorrhagic shock have not been investigated yet. In the present study, we evaluated the role of MEL pretreatment for hepatic perfusion, redox state, and function after hemorrhage and resuscitation, with emphasis on MEL receptor activation. In a model of hemorrhagic shock (MAP 35 +/- 5 mmHg for 90 min) and reperfusion (2 h), we measured nicotinamide adenine dinucleotide phosphate (reduced form; NADPH) autofluorescence, hepatic microcirculation, and hepatocellular injury by intravital microscopy, as well as plasma disappearance rate of indocyanine green (PDRICG) as a sensitive maker of liver function in rat. Pretreatment with 10 mg kg(-1) MEL (i.v.) 15 min before induction of hemorrhage resulted in a significantly improved PDR(ICG) compared with controls (MEL/shock, 15.02% min(-1) +/- 2.9 SD vs. vehicle/shock, 6.18 +/- 4.6 SD; P = 0.001). Intravital microscopy after reperfusion revealed an improved hepatic perfusion index, redox state, and reduced hepatocellular injury in pretreated animals compared with the vehicle group. Melatonin receptor antagonist luzindole (LZN; 2.5 mg kg(-1)) almost completely abolished the protective effects of MEL pretreatment with respect to liver function (MEL + LZN/shock PDR(ICG), 7.31% min(-1) +/- 3.4 SD). Beneficial effects regarding hepatic perfusion, redox state, and cellular injury were not influenced by LZN, indicating that they may depend on antioxidative effects of MEL. However, liver function after hemorrhage is effectively maintained by MEL pretreatment via receptor-dependent pathways.
Assuntos
Circulação Hepática/efeitos dos fármacos , Fígado/efeitos dos fármacos , Melatonina/farmacologia , Choque Hemorrágico/tratamento farmacológico , Animais , Modelos Animais de Doenças , Verde de Indocianina/farmacocinética , Fígado/enzimologia , Fígado/fisiopatologia , Masculino , Melatonina/administração & dosagem , NADP/metabolismo , Ratos , Ratos Sprague-Dawley , Ressuscitação , Choque Hemorrágico/fisiopatologia , Choque Hemorrágico/prevenção & controle , Choque Hemorrágico/terapiaRESUMO
Microvascular failure is a major determinant for the development of hepatocellular dysfunction after hemorrhagic shock. Induction of heme oxygenase (HO) 1 may confer hepatocellular protection. Hemin arginate (HAR) induces HO-1 and protects against shock-induced organ failure. The mechanisms are not completely understood, but HO-1-mediated protective effects on the microcirculation and on the inflammatory response may contribute. Therefore, the aim of the present study was to investigate the influence of HAR pretreatment on liver microcirculation and cytokine response to assess the role of HO-1-mediated effects under these conditions. Male Sprague-Dawley rats (200-300 g; n=8 per group) were subjected to hemorrhage (MAP, 30-40 mmHg for 1 h) 24 h after pretreatment with vehicle (Ringer solution) or HAR (5 mg kg(-1)), followed by 2 h of resuscitation. The microcirculation and the redox state (nicotinamide adenine dinucleotide phosphate [reduced form; NADPH] autofluorescence) of the liver were assessed using intravital microscopy. Cytokine levels (TNF-alpha and IL-10) were quantified using an enzyme-linked immunosorbent assay. A profound induction of HO-1 was observed 24 h after pretreatment with HAR. Hemorrhage significantly reduced sinusoidal perfusion and increased NADPH autofluorescence and cytokine levels. Hemin arginate pretreatment significantly improved liver microcirculation, reduced NADPH autofluorescence, significantly increased IL-10, and tended to decrease TNF-alpha serum levels compared with shock vehicle. Blockade of the HO pathway with tin-mesoporphyrin-IX after HAR pretreatment abolished the observed beneficial effects, whereas the additional administration of the carbon monoxide donor dichloromethane reversed the tin-mesoporphyrin-IX-mediated changes. These results suggest that HAR pretreatment improves liver microcirculation and mediates an anti-inflammatory cytokine response after hemorrhagic shock through induction of HO-1 and in part through an increased carbon monoxide release.
Assuntos
Anti-Inflamatórios/farmacologia , Arginina/metabolismo , Citocinas/metabolismo , Heme Oxigenase-1/biossíntese , Heme/metabolismo , Fígado/irrigação sanguínea , Fígado/metabolismo , Microcirculação , Choque Hemorrágico/metabolismo , Animais , Proteínas de Choque Térmico/metabolismo , Hemorragia/metabolismo , Interleucina-10/biossíntese , Masculino , Ratos , Ratos Sprague-Dawley , Fator de Necrose Tumoral alfa/sangue , Fator de Necrose Tumoral alfa/metabolismoRESUMO
Induction of heme oxygenase (HO)-1 may confer hepatocellular protection, e.g., in reperfusion injury. Previous reports suggest that intracellular cAMP up-regulates HO-1. The aim of the present study was to assess the role of adrenoceptor agonists as a means to induce HO-1 and to assess molecular mechanisms of HO-1 gene expression by adrenoceptor agonists. Induction of HO-1 in primary cultures of hepatocytes and in rat liver in vivo was assessed by Northern blot, Western blot, and immunohistochemistry. The beta-receptor agonists (+/-)isoproterenol and (-)isoproterenol induced HO-1 in primary cultures of hepatocytes but not the inactive enantiomer (+)isoproterenol. No induction of HO-1 was observed after alpha1, alpha2, beta2, or beta 3 agonists. beta1-Receptor agonists dobutamine and xamoterol induced HO-1 dose dependently, whereas the beta1-receptor antagonist metoprolol attenuated HO-1 induction by beta1-receptor agonists. Furthermore, 8 Br-cAMP and forskolin induced HO-1. Inhibition of protein kinase A (PKA) abolished induction by dobutamine and 8 Br-cAMP. Parallel changes were observed for the transcription factor AP-1. In vivo infusion of dobutamine for 6 h induced HO-1 in rat livers. Immunohistochemical detection of HO-1 revealed a pericentral expression pattern of HO-1 in hepatocytes, i.e., the area at risk for ischemia/reperfusion injury. These results suggest induction of HO-1 by beta1-adrenoceptor agonists via the PKA pathway in hepatocytes, reflecting a potential means for "pharmacological preconditioning."
Assuntos
Agonistas Adrenérgicos/farmacologia , Regulação Enzimológica da Expressão Gênica/efeitos dos fármacos , Heme Oxigenase (Desciclizante)/biossíntese , Heme Oxigenase (Desciclizante)/genética , Hepatócitos/efeitos dos fármacos , Hepatócitos/metabolismo , Receptores Adrenérgicos beta/metabolismo , Animais , Artérias/efeitos dos fármacos , Proteínas Quinases Dependentes de AMP Cíclico , Dobutamina/farmacologia , Relação Dose-Resposta a Droga , Frequência Cardíaca/efeitos dos fármacos , Heme Oxigenase-1 , Isoproterenol/farmacologia , Fígado/metabolismo , Masculino , Metoprolol , RatosRESUMO
Ischemia and reperfusion may cause liver injury and are characterized by hepatic microperfusion failure and a decreased hepatocellular function. Inhibition of glycogen synthase kinase (GSK)-3ß, a serine-threonine kinase that has recently emerged as a key regulator in the modulation of the inflammatory response after stress events, may be protective in conditions like sepsis, inflammation and shock. Therefore, aim of the study was to assess the role of GSK-3ß in liver microcirculation and hepatocellular function after hemorrhagic shock and resuscitation (H/R). Anesthetized male Sprague-Dawley rats underwent pretreatment with Ringer´s solution, vehicle (DMSO) or TDZD-8 (1 mg/kg), a selective GSK-3ß inhibitor, 30 min before induction of hemorrhagic shock (mean arterial pressure 35±5 mmHg for 90 min) and were resuscitated with shed blood and Ringer´s solution (2h). 5h after resuscitation hepatic microcirculation was assessed by intravital microscopy. Propidium iodide (PI) positive cells, liver enzymes and alpha-GST were measured as indicators of hepatic injury. Liver function was estimated by assessment of indocyanine green plasma disappearance rate. H/R led to a significant decrease in sinusoidal diameters and impairment of liver function compared to sham operation. Furthermore, the number of PI positive cells in the liver as well as serum activities of liver enzymes and alpha-GST increased significantly after H/R. Pretreatment with TDZD-8 prevented the changes in liver microcirculation, hepatocellular injury and liver function after H/R. A significant rise in the plasma level of IL-10 was observed. Thus, inhibition of GSK-3ß before hemorrhagic shock modulates the inflammatory response and improves hepatic microcirculation and hepatocellular function.
Assuntos
Quinase 3 da Glicogênio Sintase/antagonistas & inibidores , Fígado/irrigação sanguínea , Choque Hemorrágico/fisiopatologia , Tiadiazóis/farmacologia , Alanina Transaminase/sangue , Animais , Aspartato Aminotransferases/sangue , Glutamato Desidrogenase/sangue , Glutationa Transferase/sangue , Quinase 3 da Glicogênio Sintase/metabolismo , Glicogênio Sintase Quinase 3 beta , Hepatócitos/efeitos dos fármacos , Hepatócitos/patologia , Interleucina-10/sangue , Fígado/efeitos dos fármacos , Masculino , Microcirculação/efeitos dos fármacos , Ratos , Ratos Sprague-Dawley , Fluxo Sanguíneo Regional/efeitos dos fármacos , Choque Hemorrágico/sangue , Fator de Necrose Tumoral alfa/sangueRESUMO
BACKGROUND: Only 2-5% of patients who have a stroke receive thrombolytic treatment, mainly because of delay in reaching the hospital. We aimed to assess the efficacy of a new approach of diagnosis and treatment starting at the emergency site, rather than after hospital arrival, in reducing delay in stroke therapy. METHODS: We did a randomised single-centre controlled trial to compare the time from alarm (emergency call) to therapy decision between mobile stroke unit (MSU) and hospital intervention. For inclusion in our study patients needed to be aged 18-80 years and have one or more stroke symptoms that started within the previous 2·5 h. In accordance with our week-wise randomisation plan, patients received either prehospital stroke treatment in a specialised ambulance (equipped with a CT scanner, point-of-care laboratory, and telemedicine connection) or optimised conventional hospital-based stroke treatment (control group) with a 7 day follow-up. Allocation was not masked from patients and investigators. Our primary endpoint was time from alarm to therapy decision, which was analysed with the Mann-Whitney U test. Our secondary endpoints included times from alarm to end of CT and to end of laboratory analysis, number of patients receiving intravenous thrombolysis, time from alarm to intravenous thrombolysis, and neurological outcome. We also assessed safety endpoints. This study is registered with ClinicalTrials.gov, number NCT00153036. FINDINGS: We stopped the trial after our planned interim analysis at 100 of 200 planned patients (53 in the prehospital stroke treatment group, 47 in the control group), because we had met our prespecified criteria for study termination. Prehospital stroke treatment reduced the median time from alarm to therapy decision substantially: 35 min (IQR 31-39) versus 76 min (63-94), p<0·0001; median difference 41 min (95% CI 36-48 min). We also detected similar gains regarding times from alarm to end of CT, and alarm to end of laboratory analysis, and to intravenous thrombolysis for eligible ischaemic stroke patients, although there was no substantial difference in number of patients who received intravenous thrombolysis or in neurological outcome. Safety endpoints seemed similar across the groups. INTERPRETATION: For patients with suspected stroke, treatment by the MSU substantially reduced median time from alarm to therapy decision. The MSU strategy offers a potential solution to the medical problem of the arrival of most stroke patients at the hospital too late for treatment. FUNDING: Ministry of Health of the Saarland, Germany, the Werner-Jackstädt Foundation, the Else-Kröner-Fresenius Foundation, and the Rettungsstiftung Saar.
Assuntos
Cuidados Críticos/organização & administração , Serviços Médicos de Emergência/organização & administração , Unidades Móveis de Saúde/organização & administração , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Idoso , Angioplastia , Diagnóstico Diferencial , Intervenção Médica Precoce/organização & administração , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/mortalidade , Análise de Sobrevida , Terapia Trombolítica , Estudos de Tempo e MovimentoRESUMO
BACKGROUND: Delayed gastric emptying (DGE) is still a common postoperative complication after pancreaticoduodenectomy (PD). Because different reconstruction techniques after PD and the influence of motilin receptor expression are controversially discussed, the present study analyzed the influence of a total orthotopic reconstruction technique on DGE after PD. METHODS: Data from patients undergoing PD and reconstruction using a total orthotopic technique were reviewed, and correlations between DGE and clinico-pathological variables were analyzed. Motilin receptor expression was measured within the duodenum, jejunum, and terminal ileum. RESULTS: Three hundred seven patients received orthotopic reconstruction using a single jejunal loop. DGE grade B or C could be observed in 16.6% of the patients. DGE was significantly associated with the severity of a postoperative pancreatic fistula, the need for a reoperation, wound infections, and vascular complications. Furthermore, these parameters correlated significantly with the grade of DGE. The density of motilin receptor expression decreased significantly behind the duodenum in aboral direction. CONCLUSIONS: The orthotopic reconstruction after PD is the shortest distance without resection of a jejunal segment, preserves the greatest length of jejunum and thus the highest density of motilin receptors, and should therefore be recommended to reduce the incidence of DGE after PD.
Assuntos
Esvaziamento Gástrico/fisiologia , Gastroparesia/etiologia , Jejuno/metabolismo , Pancreaticoduodenectomia/efeitos adversos , Procedimentos de Cirurgia Plástica/efeitos adversos , Receptores dos Hormônios Gastrointestinais/biossíntese , Receptores de Neuropeptídeos/biossíntese , Biomarcadores/metabolismo , Feminino , Seguimentos , Gastroparesia/metabolismo , Gastroparesia/fisiopatologia , Humanos , Imuno-Histoquímica , Jejuno/cirurgia , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/métodos , Estudos Prospectivos , Procedimentos de Cirurgia Plástica/métodosRESUMO
BACKGROUND: Early treatment with rt-PA is critical for favorable outcome of acute stroke. However, only a very small proportion of stroke patients receive this treatment, as most arrive at hospital too late to be eligible for rt-PA therapy. METHODS AND FINDINGS: We developed a "Mobile Stroke Unit", consisting of an ambulance equipped with computed tomography, a point-of-care laboratory system for complete stroke laboratory work-up, and telemedicine capabilities for contact with hospital experts, to achieve delivery of etiology-specific and guideline-adherent stroke treatment at the site of the emergency, well before arrival at the hospital. In a departure from current practice, stroke patients could be differentially treated according to their ischemic or hemorrhagic etiology even in the prehospital phase of stroke management. Immediate diagnosis of cerebral ischemia and exclusion of thrombolysis contraindications enabled us to perform prehospital rt-PA thrombolysis as bridging to later intra-arterial recanalization in one patient. In a complementary patient with cerebral hemorrhage, prehospital diagnosis allowed immediate initiation of hemorrhage-specific blood pressure management and telemedicine consultation regarding surgery. Call-to-therapy-decision times were 35 minutes. CONCLUSION: This preliminary study proves the feasibility of guideline-adherent, etiology-specific and causal treatment of acute stroke directly at the emergency site.
Assuntos
Tratamento de Emergência , Acidente Vascular Cerebral/terapia , Humanos , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
Hemoglobin glutamer-200 (HbG) might be an alternative to human blood. However, artificial oxygen carriers are initially successful to restore oxygen supply but may induce organ dysfunction and increase mortality several days after application in terms of delayed side effects. Impairment of microcirculation and an inflammatory cytokine response through induction of endothelin (ET) 1 may contribute. We investigated the role of HbG for the therapy of hemorrhagic shock and for delayed side effects in a model of hemorrhagic shock and reperfusion (H/R). To analyze early effects, Sprague-Dawley rats (n = 8/group) were resuscitated after hemorrhagic shock (1 h) with shed blood or HbG followed by reperfusion (2 h). Hemorrhagic shock and reperfusion decreased liver microcirculation and hepatic function in both shock groups to the same extent. Thus, HbG was not superior to shed blood regarding resuscitation end points after hemorrhagic shock. To determine delayed effects, rats (n = 8/group) were pretreated with Ringer's solution (vehicle) or HbG (1 g/kg) 24 h before H/R. Endothelin receptors were blocked with bosentan. Subsequently, ET-1 expression, inflammatory response, sinusoidal perfusion, hepatocellular function (plasma disappearance rate of indocyanine green [PDRICG]), and redox state [NAD(P)H] were analyzed. After vehicle pretreatment, H/R increased ET-1, hepatocellular injury, NAD(P)H, and cytokine levels. Sinusoidal perfusion and PDRICG decreased. After HbG pretreatment, a further increase of ET-1 and hepatocellular injury was observed, whereas PDRICG further decreased. Application of bosentan after HbG but not after vehicle pretreatment significantly improved PDRICG and liver perfusion, whereas NAD(P)H and hepatocellular injury decreased. Furthermore, cytokine release changed to an anti-inflammatory response. These data suggest an HbG-dependent increase of ET-1, which may contribute to delayed side effects under shock conditions.
Assuntos
Substitutos Sanguíneos/efeitos adversos , Endotelina-1/sangue , Hemoglobinas/efeitos adversos , Fígado/metabolismo , Choque Hemorrágico/sangue , Choque Hemorrágico/tratamento farmacológico , Animais , Substitutos Sanguíneos/farmacologia , Citocinas/sangue , Modelos Animais de Doenças , Hemoglobinas/farmacologia , Humanos , Soluções Isotônicas/efeitos adversos , Soluções Isotônicas/farmacologia , Fígado/lesões , Masculino , NADP/sangue , Oxigênio/metabolismo , Ratos , Ratos Sprague-Dawley , Traumatismo por Reperfusão/sangue , Solução de Ringer , Choque Hemorrágico/patologia , Fatores de TempoRESUMO
OBJECTIVE: We compared two PK/PD models, one with and one without a plateau effect. Bispectral (BIS, Aspect Medical Systems, Natick, MA, version XP) and Narcotrend (NCT, MonitorTechnik, Bad Bramstedt, Germany, Version 4.0) indices were used as an electroencephalographic measure of desflurane drug effect. METHODS: With IRB approval and informed consent we investigated 20 adult patients scheduled for radical prostatectomy. At least 45 minutes after induction of general anaesthesia, end-tidal concentrations of desflurane was varied between 3 and 10 vol%. To evaluate the relationship between concentrations and EEG indices, two different pharmacodynamic models were applied: A conventional model based on a single sigmoidal curve, and a novel model based on two sigmoidal curves for BIS and NCT values with and without burst suppression. The parameters of the models were estimated by NONMEM V (GloboMax, Hanover, USA) by minimizing log likelihood. Statistical significance between the two models was calculated by the likelihood ratio test. RESULTS: The maximum end-tidal desflurane concentration during the two concentrations ramps was 10.0 +/- 1.4 vol%. The mean BIS and NCT values decreased significantly but slightly with increasing end-tidal desflurane concentrations between 4 and 8 vol%. Therefore a two sigmoidal curves PK/PD model including a plateau describes the effects of desflurane on BIS and Narcotrend better than a single sigmoidal curve model. The difference between the log likelihood values of the new PK/PD model with two connected sigmoidal curves and the classical E (max )model with one sigmoidal curve is 634 (P < 0.001) for the BIS monitor and 4089 (P < 0.001) for the NCT. CONCLUSIONS: BIS and Narcotrend are not useful to differentiate pharmacodynamic changes in the EEG between 4 and 9 vol% desflurane.
Assuntos
Conscientização/efeitos dos fármacos , Eletroencefalografia/efeitos dos fármacos , Isoflurano/análogos & derivados , Processamento de Sinais Assistido por Computador , Adulto , Anestesia Geral/psicologia , Anestésicos Inalatórios , Desflurano , Relação Dose-Resposta a Droga , Alemanha , Humanos , Isoflurano/administração & dosagem , Masculino , Modelos Biológicos , Monitorização Intraoperatória/métodos , Prostatectomia , Pesos e MedidasRESUMO
RATIONALE: Induction of heme oxygenase-1 (HO-1) protects the liver against reperfusion injury after hemorrhagic shock. Previous data suggest that the beta(1)-adrenoceptor agonist dobutamine induces HO-1 in hepatocytes. OBJECTIVES: To investigate the functional significance of dobutamine pretreatment for liver function after hemorrhagic shock in vivo. METHODS: Anesthetized rats received either Ringer's (Vehicle/Shock), 10 microg/kg/min of the beta(1)-adrenoceptor agonist dobutamine (Dob/Shock), or 10 microg/kg/min dobutamine and 500 microg/kg/min of the beta(1)-adrenoceptor antagonist esmolol (Dob/Esmolol/Shock) for 6 h. Hemorrhagic shock was induced thereafter (mean arterial pressure, 35 mm Hg for 90 min). Animals were resuscitated with shed blood and Ringer's. In addition, the HO pathway was blocked after dobutamine pretreatment with 10 micromol/kg tin-mesoporphyrin-IX (Dob/SnMP/Shock) or animals received 100 mg/kg of the carbon monoxide donor dichloromethane (DCM/Shock). MEASUREMENTS: Hepatocellular metabolism and liver blood flow were measured by plasma disappearance rate of indocyanine green (PDR(ICG)) as a sensitive marker of liver function. MAIN RESULTS: Pretreatment with dobutamine induced HO-1 in pericentral hepatocytes and improved PDR(ICG) (Vehicle/Shock: 11.7 +/- 8.12%/min vs. Dob/Shock: 19.7 +/- 2.46%/min, p = 0.006). Blockade of the HO pathway after preconditioning and the combined pretreatment with dobutamine and esmolol decreased PDR(ICG) (Dob/SnMP/Shock: 12.6 +/- 4.24%/min, p = 0.011; Dob/Esmolol/Shock: 10.2 +/- 4.34%/min, p = 0.008). Pretreatment with a carbon monoxide donor improved PDR(ICG) (DCM/Shock: 18 +/- 3.19%/min, p = 0.022) compared with Vehicle/Shock. CONCLUSIONS: These results suggest a beta(1)-adrenoceptor-dependent hepatic up-regulation of HO-1 and a better maintained hepatocellular function after hemorrhagic shock in animals pretreated with dobutamine. The improved hepatocellular function may be in part mediated by carbon monoxide because of up-regulation of HO-1. Pretreatment with dobutamine might be a potential means of pharmacologic preconditioning before ischemia-reperfusion of the liver.
Assuntos
Agonistas Adrenérgicos beta/farmacologia , Dobutamina/farmacologia , Heme Oxigenase-1/sangue , Hepatopatias/fisiopatologia , Traumatismo por Reperfusão/fisiopatologia , Choque Hemorrágico/fisiopatologia , Animais , Aorta/metabolismo , Gasometria , Relação Dose-Resposta a Droga , Hemodinâmica/efeitos dos fármacos , Jejuno/metabolismo , Rim/metabolismo , Fígado/irrigação sanguínea , Fígado/efeitos dos fármacos , Fígado/fisiopatologia , Hepatopatias/etiologia , Hepatopatias/prevenção & controle , Masculino , Propanolaminas/farmacologia , Ratos , Ratos Sprague-Dawley , Traumatismo por Reperfusão/etiologia , Traumatismo por Reperfusão/prevenção & controle , Choque Hemorrágico/sangue , Regulação para Cima/fisiologiaRESUMO
OBJECTIVE: Hemoglobin-based oxygen carriers (e.g., diaspirin-cross-linked hemoglobin [DCLHb] and hemoglobin glutamer-200 [HbG]) may have potential in the treatment of hemorrhagic shock. The nitric oxide scavenging and direct vasoconstrictive side effects of free hemoglobin of currently available preparations may increase organ injury after shock in contrast to non-oxygen-carrying heme solutions (e.g., hemin arginate [HAR]). However, both classes of substances might induce the protective enzyme heme oxygenase (HO)-1, particularly in the liver. The aim of the study was to assess the role of pretreatment with DCLHb, HbG, or HAR on HO-1 expression and organ injury after hemorrhagic shock. DESIGN: Prospective controlled laboratory study. SETTING: Animal research laboratory at a university hospital. SUBJECTS: Male Sprague-Dawley rats (200-300 g body weight, n = 5-12/group). INTERVENTIONS: Twenty-four hours after different doses of DCLHb, HbG (each 1, 2, or 3 g/kg of body weight), or HAR (5, 25, or 75 mg/kg of body weight), the protein expression of HO-1 and heat shock protein-70 in liver, kidney, heart, lungs, and aorta was determined. Twenty-four hours after pretreatment with DCLHb, HbG, or HAR, rats were subjected to hemorrhage (mean arterial blood pressure, 35-40 mm Hg for 1 or 2 hrs)/resuscitation (5 or 4 hrs, respectively). Animals treated with Ringer's solution (30 mL/kg of body weight) served as controls. In additional experiments, HO activity was blocked with tin mesoporphyrin-IX. MEASUREMENTS AND MAIN RESULTS: DCLHb, HbG, and HAR dose-dependently induced HO-1 protein but not heat shock protein-70. Pretreatment with DCLHb or HbG shortened the onset of decompensation in shock (DCLHb, 40 +/- 11 mins; HbG, 36 +/- 4 mins) compared with vehicle (68 +/- 4 mins, p < .05) and HAR pretreatment (81 +/- 7 mins, p < .05). High doses of DCLHb pretreatment increased mortality (2 hrs of shock, 80%; p < .05 vs. vehicle or HAR). Pretreatment with HAR led to higher shed blood volumes (p < .05) and higher hepatocellular ATP levels (2 hrs of shock, p < .05 vs. DCLHb and HbG). Blockade of HO activity by tin mesoporphyrin-IX abolished the protection mediated by HAR. CONCLUSIONS: Although DCLHb, HbG, and HAR induce HO-1 in the absence of an unspecific stress response, only HAR pretreatment protects against shock-induced organ failure. Although the underlying mechanisms of positive HAR priming are not completely understood, the induction of HO-1 expression and the lack of nitric oxide scavenging through HAR may play an important role.
Assuntos
Aspirina/análogos & derivados , Aspirina/uso terapêutico , Substitutos Sanguíneos/uso terapêutico , Heme Oxigenase (Desciclizante)/efeitos dos fármacos , Hemina/análogos & derivados , Hemina/uso terapêutico , Hemoglobinas/uso terapêutico , Choque Hemorrágico/tratamento farmacológico , Animais , Aspirina/farmacologia , Substitutos Sanguíneos/farmacologia , Relação Dose-Resposta a Droga , Proteínas de Choque Térmico HSP70/efeitos dos fármacos , Proteínas de Choque Térmico HSP70/metabolismo , Heme Oxigenase (Desciclizante)/metabolismo , Heme Oxigenase-1 , Hemina/farmacologia , Hemoglobinas/farmacologia , Fígado/efeitos dos fármacos , Fígado/metabolismo , Falência Hepática/fisiopatologia , Masculino , Estudos Prospectivos , Ratos , Ratos Sprague-Dawley , Choque Hemorrágico/mortalidade , Análise de SobrevidaRESUMO
Induction of the "delay phenomenon" by chronic ischemia is an established clinical procedure, but the mechanisms conferring tissue protection are still incompletely understood. To elucidate the role of heme oxygenase-1 [HO-1 or heat shock protein-32 (HSP-32)] in delay, we examined in the skin-flap model of the ear of the hairless mouse, 1) whether chronic ischemia (delay) is capable to induce expression of HO-1, and 2) whether delay-induced HO-1 affects skin-flap microcirculation and survival by either its carbon monoxide-associated vasodilatory action or its biliverdin-associated anti-oxidative mechanism. Chronic ischemia was induced by transsection of the central feeding vessel of the ear 7 days before flap creation. The flap was finally raised by an incision through four-fifths of the base of the ear. Microcirculatory dysfunction and tissue necrosis were studied with the use of laser Doppler fluxmetry and intravital fluorescence microscopy. HO-1 protein expression was determined with Western blot analysis. Seven days of chronic ischemia (delay) induced a marked expression of HO-1. This was paralleled by a significant improvement (P <0.05) of microvascular perfusion and a reduction (P <0.05) of flap necrosis when compared with nondelayed controls. Importantly, blockade of HO-1 activity by tin protoporhyrin-IX completely blunted the protection of microcirculation and the improvement of tissue survival. Additional administration of the vitamin E analog trolox after blockade of HO-1 to mimic exclusively the anti-oxidative action of the heat shock protein did not restore the HO-1-associated microcirculatory improvement and only transiently attenuated the manifestation of flap necrosis. Thus our data indicate that the delay-induced protection from tissue necrosis is mediated by HO-1, predominantly through its carbon monoxide-associated action of adequately maintaining nutritive capillary perfusion.
Assuntos
Citoproteção , Orelha , Heme Oxigenase (Desciclizante)/metabolismo , Pele/patologia , Retalhos Cirúrgicos , Animais , Antioxidantes , Biliverdina , Monóxido de Carbono/metabolismo , Condicionamento Psicológico , Feminino , Expressão Gênica , Heme Oxigenase (Desciclizante)/genética , Heme Oxigenase-1 , Imuno-Histoquímica , Isquemia/enzimologia , Isquemia/patologia , Masculino , Proteínas de Membrana , Camundongos , Camundongos Nus , Microcirculação , Necrose , Pele/irrigação sanguínea , Fatores de Tempo , VasodilataçãoRESUMO
BACKGROUND: Liver dysfunction as a result of impaired oxygen availability frequently occurs following hemorrhage and contributes to delayed mortality. Artificial oxygen carriers may improve oxygen supply to vital organs while avoiding the need for allogeneic transfusion. METHODS: Rats were subjected to hemorrhagic hypotension (mean arterial pressure = 35-40 mmHg for 120 min) and were subsequently resuscitated with (1) stored whole rat blood, (2) pentastarch, or (3) pentastarch combined with perflubron emulsion (PFE; 2.7 or 5.4 g/kg body weight), a second-generation artificial oxygen carrier. Recovery of liver adenosine triphosphate, hepatocellular injury, and expression of glutamine synthetase 1, a gene that is induced by exposure of hepatocytes to low partial pressure of oxygen, were studied at 4 h of resuscitation. RESULTS: Stored whole blood or pentastarch failed to restore liver adenosine triphosphate concentrations after prolonged shock as compared to sham controls and resulted in increased gene expression of glutamine synthetase 1. Addition of 2.7 g PFE/kg restored liver adenosine triphosphate to control, whereas 5.4 g PFE/kg resulted in adenosine triphosphate concentrations significantly above control. Improved hepatocellular oxygen supply was also confirmed by restoration of the physiologic expression pattern of glutamine synthetase 1. Serum enzyme concentrations were highest after resuscitation with stored blood, whereas addition of PFE failed to further decrease enzyme concentrations as compared to pentastarch alone. CONCLUSIONS: Resuscitation with PFE is superior to stored blood or asanguineous resuscitation with respect to restoration of hepatocellular energy metabolism. The improved hepatocellular oxygen availability is reflected in normalization of oxygen-dependent gene expression. However, improved oxygen availability failed to affect early hepatocellular injury.
Assuntos
Substitutos Sanguíneos/uso terapêutico , Metabolismo Energético/efeitos dos fármacos , Fluorocarbonos/uso terapêutico , Expressão Gênica/efeitos dos fármacos , Hepatócitos/metabolismo , Fígado/metabolismo , Oxigênio/fisiologia , Choque Hemorrágico/tratamento farmacológico , Equilíbrio Ácido-Base/efeitos dos fármacos , Trifosfato de Adenosina/metabolismo , Animais , Substitutos Sanguíneos/administração & dosagem , Western Blotting , Emulsões , Fluorocarbonos/administração & dosagem , Glutamato-Amônia Ligase/biossíntese , Glutamato-Amônia Ligase/genética , Hematócrito , Hepatócitos/efeitos dos fármacos , Hepatócitos/enzimologia , Hidrocarbonetos Bromados , Derivados de Hidroxietil Amido/uso terapêutico , Imuno-Histoquímica , Fígado/efeitos dos fármacos , Fígado/enzimologia , Circulação Hepática/efeitos dos fármacos , Masculino , Ratos , Ratos Sprague-Dawley , RessuscitaçãoRESUMO
BACKGROUND: Evidence indicates that hyperthermia preconditioning (HP) can be protective in kidney transplantation, possibly through increased heat shock protein (HSP) expression. A detailed study about individual HSPs and functional preservation is lacking, however. Therefore, we studied the effects of HP on kidney graft survival, function and HSP expression. METHODS: Male Lewis rats were or were not subjected to whole-body hyperthermia 24 h prior to kidney procurement. Kidneys were stored in UW solution at 4 degrees C for 32, 40 or 45 h. Recipient kidneys were both removed and single isografts transplanted orthotopically. RESULTS: HP strongly induced HSP72 and HSP32 expression. Following 32-hour cold ischemia, most animals survived even without prior HP. However, HP strongly reduced functional impairment induced by cold ischemia. Following 40-hour cold ischemia, kidneys from donors without HP did not recover function and all animals died within 3 days. In contrast, HP-exposed kidneys tolerated 40-hour storage significantly better, with 44% of rats surviving until sacrifice on day 7. In these animals, renal function was still better compared to animals with 32-hour-stored kidneys without HP. Histological alterations were also diminished following HP. CONCLUSION: Our data show that HP induces renal HSP72 and, for the first time, HSP32. HP increases survival following transplantation and acts by improving several parameters of kidney function including proteinuria, volume output and creatinine clearance.
Assuntos
Temperatura Baixa , Proteínas de Choque Térmico/metabolismo , Temperatura Alta , Precondicionamento Isquêmico , Transplante de Rim , Rim/metabolismo , Preservação de Órgãos , Animais , Sobrevivência de Enxerto , Rim/irrigação sanguínea , Rim/citologia , Masculino , Ratos , Taxa de Sobrevida , Fatores de TempoRESUMO
The ability of cancer cells to initiate specific fibroblast reactions may subsequently determine tumor evolution. In the present study we examined the coordinated expression of transforming growth factor-beta-1 (TGF-beta1), its signaling receptors, and its downstream mediator-connective tissue growth factor (CTGF)--and their impact on tumor progression and fibrogenesis in esophageal carcinomas. Messenger ribonucleic acid (mRNA) expression of TGF-beta1, CTGF, TGF-beta receptor subtype I ALK5 (TbetaR-IALK5), and TGF-beta receptor type II (TbetaR-II) was studied by Northern blot analysis in esophageal cancer and the normal esophagus. By means of immunohistochemistry and Western blot analysis, the respective proteins were localized in the tissue samples and the protein content was quantitated. Northern blot analysis revealed 3-fold and 4-fold increases (p < 0.05) in TGF-beta1 and CTGF mRNA levels, respectively, in esophageal cancer in comparison with normal controls, whereas TbetaR-I mRNA levels were significantly decreased and TbetaR-II mRNA levels were unchanged in the cancer samples. Immunostaining revealed results similar to those seen on the RNA level. TGF-beta1 and CTGF immunoreactivity were increased, TbetaR-II was unchanged, and TbetaR-IALK5 immunoreactivity was decreased. CTGF immunoreactivity was mainly present in the stroma surrounding the cancer cells but was also present in the cancer cells. The degree of fibrosis was different in squamous and adenocarcinomas and was significantly related to CTGF mRNA expression levels. The presence of CTGF in squamous cell carcinomas was associated with longer survival, whereas in adenocarcinomas it influenced survival negatively. The findings indicate that TGF-beta signaling is disturbed in esophageal cancer. CTGF, a downstream effector of TGF-beta action, differentially influences the composition of tumor microenvironment and distinct cell-matrix interactions in the two histological types of esophageal carcinoma, resulting in differences in tumor progression and patient survival.