Epidemiologia, diagnóstico, marcadores de imunocompetência e prognóstico da sepse / Epidemiology, diagnosis, markers of immunocompetence and prognosis of sepsis

Apesar de uma diversidade de estudos científicos, em que dezenas de milhares de pacientes foram analisados e tratados, a sepse continua sendo um grande desafio para a medicina contemporânea. Investigações bem conduzidas levaram a uma reavaliação do modelo clássico da sepse, tradicionalmente vista como um processo descontrolado de hiperinflamação sistêmica, uma vez que observou-se a existência de uma atividade antiinflamatória ao longo do seu curso evolutivo. Nesse contexto, o comportamento do sistema imune inato se assemelha ao de indivíduos idosos submetidos ao fenômeno da imunossenescência, interseção ainda mais relevante ao considerarmos o crescente incremento na faixa etária média dos pacientes internados em UTI. O presente estudo visou a estabelecer a epidemiologia da sepse em um hospital público de um país de renda media, como é o caso do Brasil. Ademais, através de citometria de fluxo, buscamos definir a cinética da expressão monocitária de moléculas HLA-DR e CD64 ao longo do processo de envelhecimento humano. Comparamos essas observações com o comprometimento do sistema imune inato visto na sepse visando discriminar as alterações da senescência do sistema imune associada ao envelhecimento daquelas associadas ao fenômeno da imunoparalisia da sepse. Na investigação epidemiológica, nós encontramos uma taxa de ocorrência de 5,9 casos de sepse por 100 pacientes e uma densidade de incidência de 6,4 casos por 1000 pacientes-dia. Documentamos ainda sua associação com uma elevada incidência de sepse e documentamos sua associação com uma elevada taxa de comorbidades crônicas. A sepse foi diagnosticada tardiamente (72% dos casos após 12 horas de evolução) e em estágio avançado como atestado pelos elevados escores de gravidade de doença e de disfunção orgânica. O presente estudo identificou vários obstáculos à efetiva implementação das recomendações da Surviving Sepsis Campaign. No segundo estudo, observamos correlações negativas significativas entre idade...

Insulin in the critically ill with focus on cytokines, reactive oxygen species, HLA-DR expression.

Insulin is essential for glucose homeostasis. Insulin/glucose-insulin-potassium (GIK) regimen suppresses the production of tumor necrosis factor-alpha (TNF-alpha), interleukins-6 (IL-6), macrophage migration inhibitory factor (MIF) and other pro-inflammatory cytokines and reactive oxygen species (ROS), enhances the synthesis of endothelial nitric oxide (eNO), and anti-inflammatory cytokines interleukins-4 (IL-4) and interleukin-10 (IL-10). In subjects who are critically ill, monocyte HLA-DR expression was significantly decreased with a concomitant increase in plasma IL-10 and IL-4 concentrations. Large increases in the plasma concentrations of TNF-alpha, IL-6, sustained increase in the expression of leukocyte CD11b/CD18, and ROS generation following surgery and infections were found to be associated with increased mortality. By virtue of its actions on pro- and anti-inflammatory cytokines and ROS, insulin may have the ability to alter HLA-DR expression in the critically ill and thus bring about its beneficial actions in sepsis/septic shock, myocardial recovery following acute myocardial infarction, improve prognosis of those who are critically ill, and suppress inflammation.

Immunohistochemical localization of macrophage CD68+, HLA-DR+, L1+ and CD44+ subsets in uterine endometrium during different phases of menstrual cycle.

Different tissue macrophage subsets were immunohistochemically examined in normal endometrial samples collected from proliferative (n=4), peri-ovulatory (n=6) and secretory (n=8) phases of menstrual cycles in women. The different macrophage subsets, namely CD68 (pan macrophage marker), CD44 (transmembrane adhesion molecule), HLA-DR (transmembrane heterodimeric protein involved in antigen presentation) and L1 (calprotectin)-positive cells, as well as, CD45 (common leucocytic antigen)-positive cells were examined on the basis of immunohistochemical staining, and areas of immunoprecipitation were analyzed morphometrically using computer-assisted video imaging system. The stage-specific distribution of receptors for estrogen (ER) and progesterone (PR) in endometrial cells were examined and morphometrically analyzed. There was an increase in the number of CD45+ cells (P < 0.01) and CD68+ cells (P < 0.05) in secretory phase endometrium compared with proliferative and peri-ovulatory phases. There was no remarkable cycle dependent pattern in HLA-DR+ and L1+ cells. However, there was an increase in CD44 immunopositive area in peri-ovulatory (P < 0.05) and in secretory (P < 0.01) phases of endometrium compared with proliferative phase endometrium. A higher (P < 0.01) degree of immunopositivity for ER was observed during peri-ovulatory phase, and for PR, during peri-ovulatory (P < 0.05) and secretory (P < 0.01) phases compared with proliferative phase of cycle. Positive correlations between areas occupied by (i) CD68+ cells and PR (P < 0.01), (ii) HLA-DR+ and L1+ cells (P < 0.05), (iii) CD45+ and CD68+ cells (P < 0.01), (iv) CD45+ and L1+ cells (P < 0.05), and (v) PR and L1+ cells (P < 0.05) were obtained. It appears that the recruitment of different macrophage subsets in human endometrium involves a complex set of endocrine and paracrine factors.

Increased numbers of Langerhans cell and expression of HLA-Dr antigen in the giant papilla of patients with giant papillary conjunctivitis

A study of histopathologic changes, ultrastructure, and expression of the HLA-Dr antigen within the giant papillae of patients with giant papillary conjunctivitis was performed to determine whether cell-mediated immune response is related to this condition. Conjunctival giant papillae from ten patients with giant papillary conjunctivitis were examined by light and electron microscopy and by the indirect immunofluorescent staining method with HLA-Dr antibody. The infiltration of eosinophilic neutrophils and granules was most prominent, with the occasional infiltration of mast cells, as shown by light microscopy. The infiltration of activated fibroblasts and Langerhans cells was also observed. Cells expressing HLA-Dr antigen were also markedly increased, as shown by the immunofluorescent method. These findings suggest that delayed hypersensitivity may, along with the processes of antigen presentation by HLA-Dr-expressing (including Langerhans) cells, contribute to the pathogenesis of giant papillary conjunctivitis.