Automated preoperative assessment of endothelial dysfunction and risk stratification for perioperative myocardial injury in patients undergoing non-cardiac surgery.

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) is a common complication with associated serious morbidity and mortality. Endothelial dysfunction might play an important role in MINS, and its rapid assessment could provide a novel method of risk stratification before surgery. METHODS: We studied 238 subjects scheduled to undergo intermediate or high-risk surgery in a two-centre prospective study to determine whether preoperative endothelial dysfunction identified by a reactive hyperaemia-peripheral arterial tonometry (RH-PAT) index could provide effective risk stratification for MINS, defined as serum troponin ≥0.04 µg litre(-1), within 3 postoperative days. RESULTS: The primary outcome occurred in 35 subjects (14.7%). Endothelial dysfunction was defined as an RH-PAT index of ≤1.22. Adjusted for age, Lee index and a composite measure of the extent of surgery, endothelial dysfunction was associated with MINS [odds ratio 10.1, 95% confidence interval (CI) 3.3-30.9, P=0.001] and increased time to discharge from hospital after surgery (hazard ratio 0.39, 95% CI 0.23-0.65, P=0.001). Endothelial dysfunction identified MINS with a sensitivity of 31%, a specificity of 96%, and a positive diagnostic likelihood ratio of 8.0. Risk classification for MINS was improved by the addition of RH-PAT-defined endothelial dysfunction to the Lee index (c-statistic increased from 0.69 to 0.77; integrated discrimination improvement 0.11, P=0.003). However, prognostic utility varied widely between sites. CONCLUSIONS: For patients undergoing non-cardiac surgery, non-invasive assessment of endothelial function might enhance preoperative risk stratification for perioperative myocardial injury. However, unexplained large inter-site variation in prognostic utility could limit widespread application and needs to be further understood.

Purification and characterization of a novel soluble receptor for interleukin 1.

Affinity chromatography and reverse-phase high-performance liquid chromatography was used to purify a soluble interleukin 1 beta (IL-1 beta) specific binding protein from the supernatant of a human B cell line, Raji. The purified protein specifically bound 125I IL-1 beta forming a 60-kD complex in nonreducing conditions and a 70-kD complex in reducing conditions. Binding was found to be displaceable by mature human and murine IL-1 beta and human 31-kD IL-1 beta propeptide, but not displaceable by human and murine IL-1 alpha or human IL-1 receptor (IL-1R) antagonist. Ligand blotting revealed a 47-kD molecule that specifically bound IL-1 beta. Measurement of binding affinity of the cell surface Raji IL-1R (Kd = 2.2 nm) and the Raji soluble (s)IL-1R (Kd = 2.7 nm) demonstrated a similar affinity for 125I IL-1 beta. Purified sIL-1R inhibited binding of IL-1 beta to cell lines with both type I (80 kD) and type II (65 kD) IL-1Rs, but did not interfere with IL-1 alpha binding. This natural sIL-1R may function as an important regulatory molecule of IL-1 beta in vivo.

A soluble form of the interleukin-1 receptor produced by a human B cell line.

A soluble protein that binds specifically to interleukin-1 (IL-1)beta was released from a B cell line (Raji). The covalently cross-linked binding protein/[125I]IL-1 beta migrated at 60 kDa by SDS-PAGE. The IL-1 receptor (IL-1R) on Raji cells had the same ligand specificity. Stimulation of Raji with dexamethasone increased surface expression of the IL-1R and the rate of release of soluble binding protein. A serine protease inhibitor prevented release of the binding protein and increased IL-1R expression on the cells. These results suggest that the soluble IL-1 beta binding protein is a proteolytically cleaved form of the novel B cell IL-1R.

Identification of an interleukin-1 beta binding protein in human plasma.

A covalent cross-linking technique was used to bind iodinated interleukin-1 (IL1) alpha and beta to plasma proteins. One specific IL1 beta binding protein was observed, that when cross-linked to 125I-IL1 beta migrated to approximately 60 kDa on SDS-PAGE. The protein did not bind IL1 alpha. The 43 -kDa protein was partially purified using a wheat germ agglutinin affinity column. The isolated factor again specifically bound IL1 beta, and appeared to consist of single chain glycoprotein. The protein was heat stable and had a rapid association time with IL1 beta. This protein may be an important carrier molecule for IL1 beta in vivo.

Chronic relapsing experimental allergic encephalomyelitis. Inhibition of lymphocyte mitogenesis by disease-related serum factors.

Peripheral blood mononuclear cells (PBMC) from strain 13 guinea pigs at various stages of chronic relapsing experimental allergic encephalomyelitis (CREAE) showed significantly reduced reactivity to the polyclonal T cell mitogens, phytohaemagglutinin and concanavalin A. Serum taken at the same time revealed an increase in inhibitors of lymphocyte mitogenesis. The factors identified appeared to inhibit the initial stages of lymphocyte proliferation: they were not cytotoxic for lymphocytes nor were they complement-dependent.

Lymphocytic activation in peripheral blood and cerebrospinal fluid during the course of chronic relapsing experimental allergic encephalomyelitis.

A monoclonal antibody against the human interleukin-2 receptor (anti-Tac) has been found to cross-react with an antigen on the surface of guinea pig leucocytes. Cells marking with anti-Tac and with an anti-pan T cell monoclonal antibody have been quantitated in the peripheral blood and cerebrospinal fluid (CSF) of guinea pigs with chronic relapsing experimental allergic encephalomyelitis (CR-EAE). T cells account for about 90% of peripheral blood leucocytes in all animals whilst in the CSF, T cells are the major contributor only when there is a pleocytosis. The proportion of T cells marking with anti-Tac, a measure of T cell activation, in blood and CSF of control animals is 12%, rising to 23% in blood in the post-acute phase of the disease. However, a fall in the blood Tac/T ratio to 13% occurs during the first 10 days of relapse with a subsequent rise to 30-35%. This change is related to the time after onset of relapse irrespective of the subsequent course of the disease. From first relapse onwards CSF lymphocytes show a greater level of activation than lymphocytes from paired peripheral blood samples but the proportion of Tac+ cells in CSF does not increase with increasing CSF pleocytosis. The data is consistent with migration of activated T cells from blood to CSF at the onset of relapse.

Kinetics of IL1 beta mRNA and protein accumulation in human mononuclear cells.

Interleukin 1 beta (IL1 beta) is an inducible polypeptide with many roles in host defence and homoeostasis. It has also been implicated as a mediator of infectious, inflammatory and autoimmune diseases, and the kinetics of its production are relevant to an understanding of the pathogenesis of these conditions. We report here the time-course of IL1 beta production in human adherent monocytes. Both IL1 beta protein and mRNA were measured following cell activation with bacterial endotoxin (lipopolysaccharide; LPS), and pro-inflammatory crystals of monosodium urate (MSU), which cause arthritis and kidney disease. We also tested other crystal types associated with arthritis, namely hydroxylapatite and calcium pyrophosphate dihydrate. IL1 was absent from unstimulated cells, but IL1 beta mRNA accumulated rapidly after LPS or MSU stimulation and was associated with the later appearance of intracellular IL1 beta protein which was subsequently released from the cells (60% at 9 h). The other crystals failed to induce significant IL1 production. Our findings support the view that production of IL1 beta in human mononuclear cells is based on rapid translation of an inducible pool of mRNA and that no pre-formed mRNA or intracellular protein exists in normal blood monocytes. Further, although IL1 beta is translated without a conventional leader sequence, it is translocated extracellularly with the kinetics of a secretory protein.

Interaction between HLA-DR and HLA-DP, and between HLA and interleukin 1 alpha in juvenile rheumatoid arthritis indicates heterogeneity of pathogenic mechanisms of the disease.

EOP-JRA is an autoimmune disease that displays associations with DPB1*0201, DR8, DR5, and DR6, as well as an association with IL1A2 (a variant of IL1 alpha gene, not HLA linked). The purpose of this study was to analyze interactions between these genetic factors. We studied 103 EOP-JRA patients, 181 random controls, and 69 DR8-positive controls. We found a positive interaction between DPB1*0201 and the DRB1 alleles encoding DR3, DR5, or DR6, but not DR8. In addition, we found evidence for an interaction between IL1A2 and DR(3, 5, or 6) and DP2, but not DR8. We interpret the data to suggest heterogeneity in the HLA-associated pathogenic mechanisms of EOP-JRA.

An AP-1 site is involved in the NGF induction of IL-1 alpha in PC12 cells.

The nerve growth factor which induces phenotypic changes in PC12 pheochromocytoma cells also induces the expression of the proinflammatory cytokine interleukin 1 alpha in these cells. We have studied the signal transduction and transcriptional mechanisms involved in this induction of interleukin 1 alpha by nerve growth factor. The nerve growth factor induction of interleukin 1 alpha transcription in PC12 cells is exerted via the TrkA receptor, as demonstrated by inhibition of the nerve growth factor stimulated increases in the interleukin 1 alpha mRNA levels by the TrkA specific alkaloid K-252a. The promoter region(s) involved in induction of interleukin 1 alpha expression by nerve growth factor in PC12 pheochromocytoma cells were studied by deletion mutagenesis in a part of the 5' regulatory region of the human interleukin 1 alpha gene (bases -163 to +64). This promoter region was inserted into the promoterless pBLCAT3 plasmid, using the interleukin 1 alpha 5' fragment as the promoter to drive nerve growth factor inducible expression of the CAT (chloramphenicol acetyl transferase) reporter gene. Four mutants, with deletions of 9-15 bases in the 5' regulatory region of the human interleukin 1 alpha gene, were constructed: three deleted stretches correspond to regions with high sequence similarity to regions in other genes, coding for nerve growth factor-induced proteins, e.g. NGFI-A, NGFI-B, NGFI-C, ERK2 and VGF gene. These deletions, of which some reduced the basal, non-nerve growth factor stimulated expression of the CAT reporter protein, do not prevent the two- to threefold induction by nerve growth factor. The deletion which eliminated a putative AP-1 binding site, immediately upstream of the transcription start site in the interleukin 1 alpha promoter, almost completely prevented the nerve growth factor mediated induction of CAT reporter gene expression, suggesting that in PC12 cells the major site of nerve growth factor regulation of interleukin 1 alpha expression is at this AP-1 site.

Immune modulation by proteins secreted from cells infected by vaccinia virus.

Vaccinia virus comprises the live vaccine that was used for vaccination against smallpox. Following the eradication of smallpox, vaccinia virus was developed as an expression vector that is now used widely in biological research and vaccine development. In recent years vaccinia virus and other poxviruses have been found to express a collection of proteins that block parts of the host response to infection. Some of these proteins are secreted from the infected cell where they bind and neutralise host cytokines, chemokines and interferons (IFN). In this paper three such proteins that bind interleukin (IL)-1 beta, type I IFNs and CC chemokines are described. The study of these immunomodulatory molecules is enhancing our understanding of virus pathogenesis, yielding fundamental information about the immune system, and providing new molecules that have potential application for the treatment of immunological disorders or infectious diseases.

Soluble interleukin 2 receptor in atopic eczema.

OBJECTIVE: To determine whether serum soluble interleukin 2 receptor concentrations are related to disease activity in atopic eczema. DESIGN: Single cohort longitudinal study with controls. SETTING: Outpatient and general medicine departments in secondary referral centre. PATIENTS: Of 15 patients aged 17-57 with severe atopic eczema, all with acute exacerbations of disease, 13 were admitted to hospital and two treated as outpatients until the skin lesions had resolved or greatly improved. Nineteen controls gave single blood samples. INTERVENTIONS: Daily skin dressing with betamethasone valerate (0.025%) and ichthammol paste and tubular dressings. END POINT: Resolution of or considerable improvement in skin lesions. MEASUREMENTS AND MAIN RESULTS: Enzyme linked immunosorbent assays (ELISA) were used to measure serum soluble interleukin 2 receptor concentrations in blood samples taken on admission, at intervals subsequently, and on discharge. Clinical scores of disease activity were also made. Median concentrations on admission were significantly higher (770 U/ml) in the patients than the controls (300 U/ml). Concentrations fell significantly during treatment. In 25 assessments made at different times in 13 patients serum soluble interleukin 2 receptor concentration correlated significantly (R = 0.73) with clinical disease activity. CONCLUSIONS: Cellular immunopathogenic mechanisms contribute to atopic eczema. Immune activation can be measured in atopic eczema by measurements of soluble interleukin 2 receptor, and this should facilitate assessment of response to treatment.

Volatile anaesthetic myocardial protection: a review of the current literature.

Ischaemic preconditioning is a powerful innate adaptive phenomenon whereby brief periods of sublethal ischaemia result in marked tolerance to subsequent lethal ischaemia. Halogenated anaesthetics have been shown to mimic ischaemic preconditioning, modifying and attenuating ischaemia reperfusion injury. This review aims to present the current animal and human data, discuss the possible mechanisms of action and review the clinical evidence for volatile anaesthetic-induced myocardial protection. There is class Ia evidence for the myocardial protective properties of sevoflurane and desflurane in low risk patients undergoing coronary artery bypass grafting surgery. These volatile anaesthetics have been shown to improve clinical outcomes and health economics following cardiac surgery, reducing intensive care and hospital stay. The evidence for the benefit of volatile anaesthetics in non-cardiac surgery is less robust and further large randomized controlled trials are required to elucidate this question.

Myocardial protection with volatile anaesthetic agents during coronary artery bypass surgery: a meta-analysis.

Previous studies have investigated the role of volatile anaesthetic agents in myocardial protection during coronary artery bypass graft (CABG) surgery, and some have identified beneficial effects. However, these studies have been too small to identify a significant effect on myocardial infarction (MI) or mortality. We undertook a systematic overview and meta-analysis of all randomized trials comparing volatile with non-volatile anaesthesia in CABG surgery. We identified 27 trials that included 2979 patients. There was no significant difference in myocardial ischaemia, MI, intensive care unit length of stay or hospital mortality between the groups (all P>0.05). Post-bypass, patients randomized to receive volatile anaesthetics had 20% higher cardiac indices (P=0.006), significantly lower troponin I serum concentrations (P=0.002) and lesser requirement for inotropic support (P=0.004) compared with those randomized to receive i.v. anaesthetics. Duration of mechanical ventilation was reduced by 2.7 h (P=0.04), and there was a 1 day decrease in hospital length of stay (P<0.001). Some of these outcomes were based on a smaller number of trials because of incomplete data, largely because the individual trials focused on one or more surrogate endpoints. We found some evidence that volatile anaesthetic agents provide myocardial protection in CABG surgery, but larger adequately powered trials with agreed, defined outcomes need to be done to fully assess a possible beneficial effect of volatile anaesthetic agents on the risk of MI and mortality.

The vaccinia virus soluble alpha/beta interferon (IFN) receptor binds to the cell surface and protects cells from the antiviral effects of IFN.

Poxviruses encode a broad range of proteins that interfere with host immune functions, such as soluble versions of receptors for the cytokines tumor necrosis factor, interleukin-1 beta, gamma interferon (IFN-gamma), IFN-alpha/beta, and chemokines. These virus-encoded cytokine receptors have a profound effect on virus pathogenesis and enable the study of the role of cytokines in virus infections. The vaccinia virus (VV) Western Reserve gene B18R encodes a secreted protein with 3 immunoglobulin domains that functions as a soluble receptor for IFN-alpha/beta. We have found that after secretion B18R binds to both uninfected and infected cells. The B18R protein present at the cell surface maintains the properties of the soluble receptor, binding IFN-alpha/beta with high affinity and with broad species specificity, and protects cells from the antiviral state induced by IFN-alpha/beta. VV strain Wyeth expressed a truncated B18R protein lacking the C-terminal immunoglobulin domain. This protein binds IFN with lower affinity and retains its ability to bind to cells, indicating that the C-terminal region of B18R contributes to IFN binding. The replication of a VV B18R deletion mutant in tissue culture was restricted in the presence of IFN-alpha, whereas the wild-type virus replicated normally. Binding of soluble recombinant B18R to cells protected the cultures from IFN and allowed VV replication. This represents a novel strategy of virus immune evasion in which secreted IFN-alpha/beta receptors not only bind the soluble cytokine but also bind to uninfected cells and protect them from the antiviral effects of IFN-alpha/beta, maintaining the cells' susceptibility to virus infections. The adaptation of this soluble receptor to block IFN-alpha/beta activity locally will help VV to replicate in the host and spread in tissues. This emphasizes the importance of local effects of IFN-alpha/beta against virus infections.

Soluble type II interleukin 1 (IL-1) receptor binds and blocks processing of IL-1 beta precursor and loses affinity for IL-1 receptor antagonist.

Two IL-1 receptors have been identified, termed type I and type II. The extracellular domain of the type II IL-1 receptor is released from certain cells and can function as a specific inhibitor of IL-1 beta activity. We assessed the ligand-binding properties of the type II membrane-bound and soluble IL-1 receptor (sIL-1R) from the human B cell line Raji by competition. Upon release, the affinity of sIL-1R for IL-1 alpha and IL-1 beta remained constant, and both soluble and cell surface IL-1 receptors bound to the same regions on the IL-1 beta molecule as defined by binding of a series of IL-1 beta mutant molecules. However, the affinity of sIL-1R for the IL-1 receptor antagonist (IL-1ra) decreased by a factor of 2000 when compared with the cell surface receptor. Type II sIL-1R and IL-1ra had an additive effect in inhibiting the binding of IL-1 beta to cell surface IL-1 receptors. In contrast, the combination of recombinant type 1 sIL-1R with IL-1ra abrogated the inhibition seen with each of the individual agents alone. The type II cell surface IL-1 receptor failed to bind the biologically inactive IL-1 beta precursor molecule, but binding to the IL-1 beta precursor was observed on cellular release of the receptor; this was confirmed with 35S-labeled IL-1 beta. Binding of IL-1 beta precursor by sIL-1R inhibited the precursor's ability to be processed to the mature, biologically active 17-kDa species. These observations suggest that the type II sIL-1R inhibits IL-1 beta at two steps, by preventing processing of propeptide and by blocking the interaction of mature IL-1 beta with type I IL-1 receptor. In addition, type II sIL-1R does not interfere with inhibition mediated by IL-1ra.

Vaccinia virus encodes a soluble type I interferon receptor of novel structure and broad species specificity.

Vaccinia virus (VV) and other orthopoxviruses express a soluble type I interferon (IFN) receptor that for VV strain Western Reserve is encoded by gene B18R. The 60-65 kDa glycoprotein is related to the interleukin-1 receptors and is a member of the immunoglobulin superfamily, unlike other type I IFN receptors, which belong to the class II cytokine receptor family. The receptor has high affinity (KD, 174 pM) for human IFN alpha and, unlike other type I IFN receptors, has broad species specificity, binding to human, rabbit, bovine, rat, and mouse type I IFNs. This may have aided VV replication in multiple host species during evolution. A VV B18R deletion mutant is attenuated in a murine intranasal model. This type I IFN receptor represents the fourth VV protein that interferes with IFN and the fourth soluble cytokine receptor expressed by poxviruses.

Serum interleukin-2-receptor in rheumatoid arthritis: a prognostic indicator of disease activity?

Interleukin-2 (IL-2) is an important growth factor for T lymphocytes. Its effects are mediated by cell surface receptors (IL-2 R) expressed on activated T cells. Receptor protein can be shed from cell membranes and the soluble form (sIL-2 R) is detectable by enzyme linked immunosorbent assay (ELISA). We have studied serial levels of sIL-2 R in the sera of patients with rheumatoid arthritis (RA). In 13 patients with active disease, the mean serum level of sIL-2 R was raised compared to age-matched healthy controls. In 48 samples taken at different times from 13 patients, serum sIL-2 R correlated significantly with Ritchie joint index, duration of early morning stiffness, patient pain score, physician's assessment, erythrocyte sedimentation rate (ESR) and platelet count. In individual patients, serial sIL-2 R serum levels fell with treatment preceding clinical improvement. In four patients where serum sIL-2 R levels fell and clinical improvement occurred, subsequent spontaneous increases of serum sIL-2 R level preceded increased clinical disease activity by up to 2 weeks. Serum sIL-2 R level in RA probably reflects activation of underlying immunopathogenic mechanisms and appears to be an excellent monitor of clinical disease activity. More importantly, a rising level may also predict exacerbation of disease activity.

Interleukin 1 beta in synovial fluid is related to local disease activity in rheumatoid arthritis.

Interleukin 1 beta (IL-1 beta) is a polypeptide with pro-inflammatory and immunopotentiating effects in vivo and in vitro. With relevance to rheumatoid arthritis (RA) IL-1 augments release of prostanoids, proteinases and oxygen metabolites and is a potent inducer of bone and cartilage resorption. Although high levels of IL-1 have been found in rheumatoid synovial fluids, intra-individual variation in IL-1 production has made it difficult to correlate these levels with disease activity. To overcome this problem we have studied patients with symmetrical and asymmetrical knee joint inflammation. Local disease activity was documented using Ritchie score and joint circumference; IL-1 beta levels were quantitated in synovial fluid by ELISA. In patients with symmetrical joint involvement almost identical levels of IL-1 beta were detected in the right and left knee joints. In contrast, in patients exhibiting asymmetrical knee joint involvement, IL-1 beta levels in the inflamed joints were significantly higher than in the contralateral joints. The study provides further evidence for the role of IL-1 in the pathogenesis of rheumatoid inflammation.

A soluble binding protein specific for interleukin 1 beta is produced by activated mononuclear cells.

Soluble interleukin 1 (IL 1) binding proteins were identified by gel filtration and covalent cross-linking of 125I IL 1 in normal human serum and inflammatory exudate. High molecular weight 125I IL 1 protein complexes occurred with both IL 1 alpha and IL 1 beta, however, high molecular weight binding appeared to be non-specific. One specific IL 1 beta binding protein was observed to elute at approximately 100 kDa on gel filtration when bound to 125I IL 1 beta. This complex migrated as a broad band at 60 kDa when covalently cross-linked and analyzed by SDS-PAGE. The protein did not bind 125I IL 1 alpha and 125I IL 1 beta binding was only displaceable by excess cold IL-1 beta. The production of the specific IL 1 beta binding protein was assessed in a number of cell populations. Unstimulated peripheral blood mononuclear cells (PBMNC) did not produce the binding protein, but stimulation with phytohemagglutinin (PHA) caused production within 24 hr and binding protein levels remained elevated for up to 7 days. Stimulation with lipopolysaccharide (LPS) and IL 1 alpha did not consistently induce synthesis of the binding protein. Ligand-binding studies were performed to compare solubilized EL 4 NOB.1 cell membrane IL 1 receptor (sIL 1R) with semi-purified IL 1 beta binding protein from pooled synovial fluid. The sIL 1R preparation bound ligand with an affinity of 168 pM while the IL 1 beta binding protein bound 125I IL 1 beta with an affinity of 370 pM. This protein may function as an important carrier molecule for IL 1 beta and determine its distribution and kinetics in vivo.