Cardiac-specific overexpression of thioredoxin 1 attenuates mitochondrial and myocardial dysfunction in septic mice.

Sepsis-induced myocardial dysfunction is associated with increased oxidative stress and mitochondrial dysfunction. Current evidence suggests a protective role of thioredoxin-1 (Trx1) in the pathogenesis of cardiovascular diseases. However, it is unknown yet a putative role of Trx1 in sepsis-induced myocardial dysfunction, in which oxidative stress is an underlying cause. Transgenic male mice with Trx1 cardiac-specific overexpression (Trx1-Tg) and its wild-type control (wt) were subjected to cecal ligation and puncture or sham surgery. After 6, 18, and 24h, cardiac contractility, antioxidant enzymes, protein oxidation, and mitochondrial function were evaluated. Trx1 overexpression improved the average life expectancy (Trx1-Tg: 36, wt: 28h; p=0.0204). Sepsis induced a decrease in left ventricular developed pressure in both groups, while the contractile reserve, estimated as the response to ß-adrenergic stimulus, was higher in Trx1-Tg in relation to wt, after 6h of the procedure. Trx1 overexpression attenuated complex I inhibition, protein carbonylation, and loss of membrane potential, and preserved Mn superoxide dismutase activity at 24h. Ultrastructural alterations in mitochondrial cristae were accompanied by reduced optic atrophy 1 (OPA1) fusion protein, and activation of dynamin-related protein 1 (Drp1) (fission protein) in wt mice at 24h, suggesting mitochondrial fusion/fission imbalance. PGC-1α gene expression showed a 2.5-fold increase in Trx1-Tg at 24h, suggesting mitochondrial biogenesis induction. Autophagy, demonstrated by electron microscopy and increased LC3-II/LC3-I ratio, was observed earlier in Trx1-Tg. In conclusion, Trx1 overexpression extends antioxidant protection, attenuates mitochondrial damage, and activates mitochondrial turnover (mitophagy and biogenesis), preserves contractile reserve and prolongs survival during sepsis.

The pan-caspase inhibitor Emricasan (IDN-6556) decreases liver injury and fibrosis in a murine model of non-alcoholic steatohepatitis.

BACKGROUND & AIMS: Hepatocyte apoptosis, the hallmark of non-alcoholic steatohepatitis (NASH) contributes to liver injury and fibrosis. Although, both the intrinsic and extrinsic apoptotic pathways are involved in the pathogenesis of NASH, the final common step of apoptosis is executed by a family of cysteine-proteases termed caspases. Thus, our aim was to ascertain if administration of Emricasan, a pan-caspase inhibitor, ameliorates liver injury and fibrosis in a murine model of NASH. METHODS: C57/BL6J-mice were fed regular chow or high fat diet (HFD) for 20 weeks. All mice were treated with vehicle or Emricasan. RESULTS: Mice fed a HFD diet demonstrate a five-fold increase in hepatocyte apoptosis by the TUNEL assay and a 1.5-fold and 1.3-fold increase in caspase-3 and-8 activities respectively; this increase in apoptosis was substantially attenuated in mice fed a HFD treated with Emricasan (HFD-Em). Likewise, liver injury and inflammation were reduced in mice fed HFD-Em as compare to HFD by measuring serum aspartate aminotransferase and alanine aminotransferase levels, NAS histological score and IL 1-ß, TNF-α, monocyte chemoattractant protein (MCP-1) and C-X-C chemokine ligand-2 (CXCL2) quantitative reverse-transcription polymerase chain reaction (qPCR). These differences could not be attributed to differences in hepatic steatosis as liver triglycerides content were similar in both HFD groups. Hepatic fibrosis was reduced by Emricasan in HFD animals by decreasing αSMA (a marker for hepatic stellate cell activation), fibrosis score, Sirius red staining, hydroxyproline liver content and profibrogenic cytokines by qPCR. CONCLUSION: In conclusion, these data demonstrate that in a murine model of NASH, liver injury and fibrosis are suppressed by inhibiting hepatocytes apoptosis and suggests that Emricasan may be an attractive antifibrotic therapy in NASH.

El estado nutricional, la respuesta inflamatoria sistémica y la mortalidad en el anciano internado / Nutritional status, systemic inflammatory response and mortality in the elderly hospitalized patient

La desnutrición en el anciano involucra un estado inflamatorio. Con el objetivo de evaluar en el paciente internado la relación con la respuesta inflamatoria sistémica y la mortalidad desarrollamos un estudio de cohortes prospectivo en el que evaluamos un score nutricional (SGA), años de instrucción, capacidad funcional, falla orgánica (Marshall), presencia de sepsis, comorbilidades (Charlson), estado cognitivo (MMSE), albúmina, eritrosedimentación y mortalidad. Se incluyeron 52 pacientes, 19 hombres (36.5%) y 33 mujeres (63.5%) con una mediana de edad de 80 (RI 12.5) años. Los pacientes normonutridos fueron 29 (55.8%) y los desnutridos 23 (44.2%).El 53.8% de los pacientes desarrollaron sepsis al ingreso o en la internación. La mortalidad intrahospitalaria en toda la muestra fue 7.7% (n = 4) y al año fue del 31.8% (n = 14). En el análisis comparativo se evidenció mayor edad (80 vs. 78; p = 0.012), menos años de instrucción (7 vs. 8; p = 0.027), un MMST menor (14 vs. 27; p = 0.017), menor capacidad funcional previa (21 vs. 32; p < 0.0001), menor valor de albumina (3 vs. 3.35; p = 0.014) y mayor score de falla orgánica de ingreso (3 vs. 1; p = 0.01) con mayor número de órganos afectados (2 vs. 1; p = 0.003) en los desnutridos con respecto a los normonutridos. También se observó mayor incidencia de sepsis -al ingreso o durante la internación- (73.9% vs. 37.9%; p = 0.01) y niveles de sepsis más graves en desnutridos. La mortalidad al año fue significativamente mayor en los desnutridos (52.2% vs. 9.5%, log rank test = 0.002). En conclusión, los pacientes desnutridos presentaron mayor respuesta inflamatoria sistémica.

In order to evaluate the relationship between systemic inflammatory response and mortality in the older hospitalized patient, we developed a prospective cohort study in which we evaluated a nutritional score (SGA), years of instruction, functional status, organic failure (Marshall), presence of sepsis, comorbidities (Charlson), cognitive state (MMSE), albumin, erythrocyte sedimentation rate and mortality. Fifty two patients were included, 19 men (36.5%) and 33 women (63.5%), mean age was 80 (Interquartile Range 12.5) years. 29 (55.8%) patients were well-nourished and 23 (44.2%) malnourished, 53.8% of patients developed sepsis at admission or during hospitalization. Total nosocomial mortality was 7.7 % (n = 4) and one-year mortality was 31.8% (n = 14). Comparative analyses showed older age (80 vs. 78; p = 0.012), less years of instruction (7 vs. 8; p = 0.027), lower MMST (14 vs. 27; p = 0.017), lower previous functional status (21 vs. 32; p < 0.0001), lower albumin (3 vs. 3.35; p = 0.014) and higher organic failure score at admission (3 vs. 1; p = 0.01) with more number of affected organs (2 vs. 1; p = 0.003) in malnourished patients compared to well nourished ones. Higher incidence of sepsis -at admission or during hospitalization- (73.9% vs. 37.9%; p = 0.01) and more severe stages of sepsis were also observed in malnourished patients. One-year mortality was significantly higher in malnourished (52.2% vs. 9.5%, log rank test = 0.002). In conclusion, malnourished patients presented greater systemic inflammatory response.

Conceptos emergentes de tolerancia y autoinmunidad: Nuevos enfoques terapéuticos / Tolerance and autoimmunity: Novel therapeutic approaches

La función primaria del sistema inmune es resguardar al individuo de los patógenos potencialmente dañinos que invaden el medio ambiente en el cual nos desarrollamos. Este cuenta con dos grandes ramas, la inmunidad innata y la adaptativa, ambas con la propiedad de diferenciar lo peligroso de aquello inofensivo. Estos procesos se hallan regulados por mecanismos homeostáticos que constituyen la tolerancia inmunológica, a los fines de limitar aquellos procesos prolongados y silenciar los potencialmente autoagresivos. Ante la falla de estos mecanismos de control, surgen las enfermedades autoinmunes. Avances en el conocimiento de la fisiopatología de estas entidades, han abierto un nuevo capítulo en el terreno de la inmunofarmacología. Su prometedor potencial actualmente nos ofrece novedosas herramientas terapéuticas para controlar y atenuar el daño causado por este tipo de respuestas. No obstante, debe continuarse la investigación en el campo de los agentes biológicos, ya que ninguno de ellos se encuentra libre de inconvenientes. Seguramente, futuros hallazgos se concretarán en futuros aciertos. Y los aciertos, en Medicina, equivalen a esperanza.

The main function of the immune system is to protect the individual against potentially dangerous pathogens. It comprises innate and adaptive cellular and soluble components, both with the capacity to discriminate between harmful and harmless. These processes are regulated by homeostatic mechanisms that constitute the so-called immunological tolerance, which aims to limit the prolonged action of immune mediators and to silence the generation of potentially autoaggressive components. Failure to silence self-reactive T and B cells results in the generation of autoimmune disease. Recent advances in our knowledge of these pathological entities have opened a new chapter in the pharmacology of the immune system. Its promising potential currently offers new therapeutic agents to control and attenuate pathological tissue damage. Nevertheless, further research regarding these biologic agents is required, since they are not free from inconveniences. It is without question that upcoming findings in this field will instill hope into the quest for the "magic bullet".

Detection of a mitochondrial kinase complex that mediates PKA-MEK-ERK-dependent phosphorylation of mitochondrial proteins involved in the regulation of steroid biosynthesis.

In order to achieve the goal of this article, as an example we will describe the strategies followed to analyze the presence of the multi-kinase complex at the mitochondria and the posttranslational modification of two key mitochondrial proteins, which participate in the regulation of cholesterol transport across the mitochondrial membranes and in the regulation of steroid biosynthesis. Hormones, ions or growth factors modulate steroid biosynthesis by the posttranslational phosphorylation of proteins. The question still remains on how phosphorylation events transmit a specific signal to its mitochondrial site of action. Cholesterol transport requires specific interactions in mitochondria between several proteins including a multi-kinase complex. The presence of this multi-kinase complex at the mitochondria reveals the importance of the posttranslational modification of mitochondrial proteins for its activity and functions. The activation of PKA triggers the posttranslational modification of the mitochondrial acyl-CoA thioesterase (Acot2), which releases arachidonic acid (AA) in the mitochondria, and the activation of a kinase cascade that leads to the phoshorylation of the steroidogenic acute regulatory (StAR) protein. The function of StAR is to facilitate the access of cholesterol to the first enzyme of the biosynthesis process and its induction is dependent on Acot2 and intramitochondrial AA release. Truncation of the StAR protein is associated with the steroid deficiency disease, congenital lipoid adrenal hyperplasia.

Control of muscle mitochondria by insulin entails activation of Akt2-mtNOS pathway: implications for the metabolic syndrome.

BACKGROUND: In the metabolic syndrome with hyperinsulinemia, mitochondrial inhibition facilitates muscle fat and glycogen accumulation and accelerates its progression. In the last decade, nitric oxide (NO) emerged as a typical mitochondrial modulator by reversibly inhibiting citochrome oxidase and oxygen utilization. We wondered whether insulin-operated signaling pathways modulate mitochondrial respiration via NO, to alternatively release complete glucose oxidation to CO(2) and H(2)O or to drive glucose storage to glycogen. METHODOLOGY/PRINCIPAL FINDINGS: We illustrate here that NO produced by translocated nNOS (mtNOS) is the insulin-signaling molecule that controls mitochondrial oxygen utilization. We evoke a hyperinsulinemic-normoglycemic non-invasive clamp by subcutaneously injecting adult male rats with long-lasting human insulin glargine that remains stable in plasma by several hours. At a precise concentration, insulin increased phospho-Akt2 that translocates to mitochondria and determines in situ phosphorylation and substantial cooperative mtNOS activation (+4-8 fold, P<.05), high NO, and a lowering of mitochondrial oxygen uptake and resting metabolic rate (-25 to -60%, P<.05). Comparing in vivo insulin metabolic effects on gastrocnemius muscles by direct electroporation of siRNA nNOS or empty vector in the two legs of the same animal, confirmed that in the silenced muscles disrupted mtNOS allows higher oxygen uptake and complete (U-(14)C)-glucose utilization respect to normal mtNOS in the vector-treated ones (respectively 37+/-3 vs 10+/-1 micromolO(2)/h.g tissue and 13+/-1 vs 7.2+/-1 micromol (3)H(2)O/h.g tissue, P<.05), which reciprocally restricted glycogen-synthesis by a half. CONCLUSIONS/SIGNIFICANCE: These evidences show that after energy replenishment, insulin depresses mitochondrial respiration in skeletal muscle via NO which permits substrates to be deposited as macromolecules; at discrete hyperinsulinemia, persistent mtNOS activation could contribute to mitochondrial dysfunction with insulin resistance and obesity and therefore, to the progression of the metabolic syndrome.

A mitochondrial kinase complex is essential to mediate an ERK1/2-dependent phosphorylation of a key regulatory protein in steroid biosynthesis.

ERK1/2 is known to be involved in hormone-stimulated steroid synthesis, but its exact roles and the underlying mechanisms remain elusive. Both ERK1/2 phosphorylation and steroidogenesis may be triggered by cAMP/cAMP-dependent protein kinase (PKA)-dependent and-independent mechanisms; however, ERK1/2 activation by cAMP results in a maximal steroidogenic rate, whereas canonical activation by epidermal growth factor (EGF) does not. We demonstrate herein by Western blot analysis and confocal studies that temporal mitochondrial ERK1/2 activation is obligatory for PKA-mediated steroidogenesis in the Leydig-transformed MA-10 cell line. PKA activity leads to the phosphorylation of a constitutive mitochondrial MEK1/2 pool with a lower effect in cytosolic MEKs, while EGF allows predominant cytosolic MEK activation and nuclear pERK1/2 localization. These results would explain why PKA favors a more durable ERK1/2 activation in mitochondria than does EGF. By means of ex vivo experiments, we showed that mitochondrial maximal steroidogenesis occurred as a result of the mutual action of steroidogenic acute regulatory (StAR) protein -a key regulatory component in steroid biosynthesis-, active ERK1/2 and PKA. Our results indicate that there is an interaction between mitochondrial StAR and ERK1/2, involving a D domain with sequential basic-hydrophobic motifs similar to ERK substrates. As a result of this binding and only in the presence of cholesterol, ERK1/2 phosphorylates StAR at Ser(232). Directed mutagenesis of Ser(232) to a non-phosphorylable amino acid such as Ala (StAR S232A) inhibited in vitro StAR phosphorylation by active ERK1/2. Transient transfection of MA-10 cells with StAR S232A markedly reduced the yield of progesterone production. In summary, here we show that StAR is a novel substrate of ERK1/2, and that mitochondrial ERK1/2 is part of a multimeric protein kinase complex that regulates cholesterol transport. The role of MAPKs in mitochondrial function is underlined.

CO-metal interaction: Vital signaling from a lethal gas.

The past few years have witnessed intense research into the biological significance of carbon monoxide (CO) as an essential signaling mediator in cells and tissues. To transduce the signal properly, CO must react selectively with functional and structural proteins containing moieties that show preferred reactivity towards this gaseous molecule. This selectivity is exemplified by the interaction of CO with iron- and heme-dependent proteins, although systems containing other transition metals can potentially become a preferential target for CO. Notably, transition metal carbonyls, which carry and liberate CO, are also emerging as a pharmacological tool to mimic the bioactivity of endogenously generated CO. Thus, exploring how CO binding to metal complexes is translated into a cytoprotective function is a challenging task and might open up opportunities for therapeutic applications based on CO delivery.

Hypothyroid phenotype is contributed by mitochondrial complex I inactivation due to translocated neuronal nitric-oxide synthase.

Although transcriptional effects of thyroid hormones have substantial influence on oxidative metabolism, how thyroid sets basal metabolic rate remains obscure. Compartmental localization of nitric-oxide synthases is important for nitric oxide signaling. We therefore examined liver neuronal nitric-oxide synthase-alpha (nNOS) subcellular distribution as a putative mechanism for thyroid effects on rat metabolic rate. At low 3,3',5-triiodo-L-thyronine levels, nNOS mRNA increased by 3-fold, protein expression by one-fold, and nNOS was selectively translocated to mitochondria without changes in other isoforms. In contrast, under thyroid hormone administration, mRNA level did not change and nNOS remained predominantly localized in cytosol. In hypothyroidism, nNOS translocation resulted in enhanced mitochondrial nitric-oxide synthase activity with low O2 uptake. In this context, NO utilization increased active O2 species and peroxynitrite yields and tyrosine nitration of complex I proteins that reduced complex activity. Hypothyroidism was also associated to high phospho-p38 mitogen-activated protein kinase and decreased phospho-extracellular signal-regulated kinase 1/2 and cyclin D1 levels. Similarly to thyroid hormones, but without changing thyroid status, nitric-oxide synthase inhibitor N(omega)-nitro-L-arginine methyl ester increased basal metabolic rate, prevented mitochondrial nitration and complex I derangement, and turned mitogen-activated protein kinase signaling and cyclin D1 expression back to control pattern. We surmise that nNOS spatial confinement in mitochondria is a significant downstream effector of thyroid hormone and hypothyroid phenotype.

Cancer patients with septic shock: mortality predictors and neutropenia.

GOALS OF WORK: To study outcome and its predictive factors in cancer patients admitted to the ICU with septic shock, and the implications of neutropenia as a risk factor in this advanced stage of systemic inflammatory response. PATIENTS AND METHODS: A prospective consecutive observational cohort study was conducted in 73 adults with cancer and septic shock admitted to the ICU at the Cancer Medical Center associated with the University of Buenos Aires. MAIN RESULTS: The mortality rate from septic shock was 53.4% (95%CI 41.9 to 64.8%). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission, the mean number of organ dysfunctions on admission or during the ICU stay, liver dysfunction, respiratory dysfunction, and the need for mechanical ventilation were predictive of mortality in a univariate analysis. Neutropenia was not associated with a worse prognosis in terms of mortality (56%) or mean days of ICU stay (6.64 days) in comparison with nonneutropenic patients (52.1% and 6.8 days) in the univariate analysis. In the logistic regression model only the need for mechanical ventilation and liver dysfunction remained independent predictors of mortality. CONCLUSIONS: Septic shock among cancer patients admitted to the ICU has a mortality rate similar to that reported for mixed populations, and it is particularly increased when hepatic or respiratory dysfunction develop. Neutropenia on admission does not seem to modify outcome.

Mitochondrial nitric oxide synthase drives redox signals for proliferation and quiescence in rat liver development.

Mitochondrial nitric oxide synthase (mtNOS) is a fine regulator of oxygen uptake and reactive oxygen species that eventually modulates the activity of regulatory proteins and cell cycle progression. From this perspective, we examined liver mtNOS modulation and mitochondrial redox changes in developing rats from embryonic days 17-19 and postnatal day 2 (proliferating hepatocyte phenotype) through postnatal days 15-90 (quiescent phenotype). mtNOS expression and activity were almost undetectable in fetal liver, and progressively increased after birth by tenfold up to adult stage. NO-dependent mitochondrial hydrogen peroxide (H(2)O(2)) production and Mn-superoxide dismutase followed the developmental modulation of mtNOS and contributed to parallel variations of cytosolic H(2)O(2) concentration ([H(2)O(2)](ss)) and cell fluorescence. mtNOS-dependent [H(2)O(2)](ss) was a good predictor of extracellular signal-regulated kinase (ERK)/p38 activity ratio, cyclin D1, and tissue proliferation. At low 10(-11)-10(-12) M [H(2)O(2)](ss), proliferating phenotypes had high cyclin D1 and phospho-ERK1/2 and low phospho-p38 mitogen-activated protein kinase, while at 10(-9) M [H(2)O(2)](ss), quiescent phenotypes had the opposite pattern. Accordingly, leading postnatal day 2-isolated hepatocytes to embryo or adult redox conditions with H(2)O(2) or NO-H(2)O(2) scavengers, or with ERK inhibitor U0126, p38 inhibitor SB202190 or p38 activator anisomycin resulted in correlative changes of ERK/p38 activity ratio, cyclin D1 expression, and [(3)H] thymidine incorporation in the cells. Accordingly, p38 inhibitor SB202190 or N-acetyl-cysteine prevented H(2)O(2) inhibitory effects on proliferation. In conclusion, the results suggest that a synchronized increase of mtNOS and derived H(2)O(2) operate on hepatocyte signaling pathways to support the liver developmental transition from proliferation to quiescence.

Nitric oxide, complex I, and the modulation of mitochondrial reactive species in biology and disease.

Mitochondria are the specialized organelles for energy metabolism but also participate in the production of O(2) active species, cell cycle regulation, apoptosis and thermogenesis. Classically, regulation of mitochondrial energy functions was based on the ADP/ATP ratio, which dynamically stimulates the transition between resting and maximal O(2) uptake. However, in the last years, NO was identified as a physiologic regulator of electron transfer and ATP synthesis by inhibiting cytochrome oxidase. Additionally, NO stimulates the mitochondrial production of O(2) active species, primarily O(2)(-) and H(2)O(2), and, depending on NO matrix concentration, of ONOO(-), which is responsible for the nitrosylation and nitration of mitochondrial components. By this means, alteration in mitochondrial complexes restricts energy output, further increases O(2) active species and changes cell signaling for proliferation and apoptosis through redox effects on specific pathways. These mechanisms are prototypically operating in prevalent generalized diseases like sepsis with multiorgan failure or limited neurodegenerative disorders like Parkinson's disease. Complex I appears to be highly susceptible to ONOO(-) effects and nitration, which defines an acquired group of mitochondrial disorders, in addition to the genetically induced syndromes. Increase of mitochondrial NO may follow over-expression of nNOS, induction and translocation of iNOS, and activation and/or increased content of the newly described mtNOS. Likewise, mtNOS is important in the modulation of O(2) uptake and cell signaling, and in mitochondrial pathology, including the effects of aging, dystrophin deficiency, hypoxia, inflammation and cancer.

Neutropenia and the development of the systemic inflammatory response syndrome.

OBJECTIVE: To determine outcome and natural course of systemic inflammatory response syndrome (SIRS) stages in adult febrile neutropenic patients. DESIGN AND SETTING: Retrospective cohort study in the medicine department and intensive care unit of a university hospital. PATIENT: Adults with cancer-related neutropenia and community-acquired fever. MEASUREMENTS AND RESULTS: Patients were classified on admission according to SIRS parameters, tumor type, and degree of neutropenia. Records of clinical and laboratory data during hospitalization were reviewed. Univariate and logistic regression analyses were performed. Seventy-nine events in 62 patients were analyzed. Overall mortality rate was 20.2% (16/79). Mortality increased as SIRS stage worsened on admission. No patients with stage 2 SIRS died (neutropenia and fever alone) but 11.1% of patients with SIRS 3, 43.4% with SIRS 4, 66.6% with sepsis induced hypotension, and 90% with septic shock. SIRS stage on admission was an independent predictor of death and was related directly to rate of progression to shock, i.e., none of the patients with SIRS 2, 2.7%(1/36) of those with SIRS 3, and 30.4% (7/23) of those admitted with SIRS 4. CONCLUSIONS: Mortality and progression to septic shock increased as more SIRS criteria were met on admission. SIRS stages could serve as a risk-assessing model in febrile neutropenic patients.

Sepsis: citoquinas, radicales libres y óxido nítrico / Sepsis: cytokine, free radicals and nitric oxide

La sepsis y sus complicaciones, el shock séptico y el síndrome de disfunción orgánica múltiple (MODS - multiple organ dysfunction syndrome) mantienen desde hace años el triste privilegio de ser las primeras causas de muerte en las salas de terapia intensiva y postquirúrgica; el aumento de su incidencia está en relación con el desarrollo de procedimientos más invasivos, los tratamientos inmunosupresores, la quimioterapia, la mayor edad de los enfermos, los síndromes de inmunodeficiencia y las floras hospitalarias multirresistentes. Se estima en 400.000 el número de pacientes afectados anualmente en los Estados Unidos y, a pesar de sofisticados y extremadamente caros procedimientos de sostén vital y de los antibióticos, la mortalidad no ha disminuido en los últimos años. Probablemente, esta detención en el progreso terapéutico, se deba a la extrema complejidad de los mecanismos patogénicos en juego y a lo incompleto de su conocimiento y comprensión. El problema de las infecciones graves y de la sepsis (del griego putrefacción), es antiguo y acompaña al hombre desde sus orígenes remotos, como ejemplo de lo cual, basta recordar la peste, la fiebre tifoidea, la gangrena, la peritonitis y las infecciones puerperales. En realidad se trata de un enfrentamiento ancestral entre bacterias y organismos superiores, en el que, desafortunadamente, a menudo triunfan las primeras