Impacto de una estrategia multifacética para prevenir la neumonía asociada a la ventilación mecánica en una Unidad de Cuidados Intensivos Pediátricos polivalente: un estudio antes-después / Impact of a strategy multifaceted to prevent pneumonia associated with mechanical ventilation in a Intensive care unit Pediatric multipurpose: a before-after study

Objetivo: Valorar el impacto de la implementación de un programa de medidas de prevención de la neumonía asociada a la ventilación mecánica durante 12 meses. Diseño: Estudio de implementación de estrategias de mejora cuasiexperimental, de intervención antes-después sin población de control. La intervención consistió en la aplicación de un paquete de medidas para prevenir la neumonía asociada a la ventilación mecánica. Ámbito: Unidad de Cuidados Intensivos Pediátricos del Hospital Abete, Buenos Aires, Argentina. Pacientes: Niños de entre 30 días de vida y 16 años de edad, con requerimiento de ventilación mecánica invasiva por, al menos, 48 horas. Intervenciones: Las estrategias de prevención se aplicaron desde el 1 de enero hasta el 31 de diciembre de 2014. Variable de interés: Episodio de neumonía asociada a la ventilación mecánica, según los criterios de diagnóstico consensuados. Resultados: La tasa de uso de ventilación mecánica se mantuvo estable durante el período 2013-2014 (55,9% y 55%, respectivamente). A partir de la implementación del paquete de medidas de prevención, se observó una disminución de los episodios de neumonía asociada a la ventilación mecánica en 2014 (tasa de neumonía asociada a la ventilación mecánica del 0,7‰ comparada con una tasa del 3,8‰ en 2013).Conclusiones: Todas las estrategias de prevención han tenido un efecto significativo en la disminución de los episodios de neumonía asociada a la ventilación mecánica. Su presencia se asocia a mayor morbilidad, aumento de la estadía hospitalaria, incremento de los días de ventilación mecánica y de los costos hospitalarios.(AU)

Objective: To evaluate the effect of a bundle of strategies for prevention of ventilator-associated pneumonia during a period of 12 months. Design: Implementation study of quasi experimental improvement strategies, before-after intervention with no control group. The intervention consisted in the implementation of a bundle of strategies for the prevention of ventilator-associated pneumonia. Setting: Pediatric Intensive Care Unit, Hospital Abete, Buenos Aires, Argentina. Patients: Children between 30 days of life and 16 years with mechanical ventilation requirement of at least 48 hours. Interventions: Prevention strategies were implemented from January 1st to December 31st, 2014. Variable of interest: The primary outcome measured was the development of ventilator-associated pneumonia, according to the agreed diagnostic criteria. Results: The mechanical ventilation use rate remained stable during the period 2013-2014 (55.9% and 55%, respectively). After the development of prevention strategies, a decrease in ventilator-associated pneumonia events was observed in 2014 (ventilator-associated pneumonia rate of 0.7‰ in comparison to 3.8‰ in 2013). Conclusions: All prevention strategies have shown a significant effect in reducing events of ventilator-associated pneumonia. It contributes to a higher morbidity leading to longer hospital stay, duration of mechanical ventilation and higher costs of hospitalization(AU)

Sucralose sweetener in vivo effects on blood constituents radiolabeling, red blood cell morphology and radiopharmaceutical biodistribution in rats.

Effects of sucralose sweetener on blood constituents labelled with technetium-99m ((99m)Tc) on red blood cell (RBC) morphology, sodium pertechnetate (Na(99m)TcO(4)) and diethylenetriaminepentaacetic acid labeled with (99m)Tc ((99m)Tc-DTPA) biodistribution in rats were evaluated. Radiolabeling on blood constituents from Wistar rats was undertaken for determining the activity percentage (%ATI) on blood constituents. RBC morphology was also evaluated. Na(99m)TcO(4) and (99m)Tc-DTPA biodistribution was used to determine %ATI/g in organs. There was no alteration on RBC blood constituents and morphology %ATI. Sucralose sweetener was capable of altering %ATI/g of the radiopharmaceuticals in different organs. These findings are associated to the sucralose sweetener in specific organs.

Cinnamomum zeylanicum extract on the radiolabelling of blood constituents and the morphometry of red blood cells: in vitro assay.

Effects of Cinnamomum zeylanicum (cinnamon) on the labelling of blood constituents with technetium-99m(99mTc) and on the morphology of red blood cells were studied. Blood samples from Wistar rats were incubated with cinnamon extract for 1 hour or with 0.9% NaCl, as control. Labelling of blood constituents with 99mTc was performed. Plasma (P) and blood cells (BC), soluble (SF-P and SF-BC) and insoluble (IF-P and IF-BC) fractions were separated. The radioactivity in each fraction was counted and the percentage of radioactivity incorporated (%ATI) was calculated. Blood smears were prepared, fixed, stained and the qualitative and quantitative morphological analysis of the red blood cells was evaluated. The data showed that the cinnamon extract decreased significantly (p<0.05) the %ATI on BC, IF-P and IF-BC. No modifications were verified on shape of red blood cells. Cinnamon extracts could alter the labelling of blood constituents with 99mTc, and although our results were obtained with animals, precaution is suggested in interpretations of nuclear medicine examinations involving the labelling of blood constituents in patients who are using cinnamon.

Acetylsalicylic acid decreases the labeling of blood constituents with technetium-99M.

Acetylsalicylic acid is the most widely used drug as antipyretic, analgesic, anti-inflammatory agent and for secondary prevention of thrombotic phenomena in the heart, brain and peripheral circulation. Drugs can modify the labeling of blood constituents with technetium-99m (99mTc). This work has evaluated the effect of in vivo treatment with acetylsalicylic acid on the in vitro labeling of the blood constituents with 99mTc. Wistar rats were treated with different doses (1.5, 3.0 and 6.0 mg/kg) of acetylsalicylic acid during 1 hour. At higher dose used (6.0 mg/kg) animals were treated during different period of time (0.25, 1.0 and 4.0 hours). Animals treated with physiologic saline solution were used as control. After the labeled process; plasma (P), blood cells (BC), insoluble (IF-P, IF-BC) and soluble (SF-P, SF-BC) fractions were separated. Afterwards, the percentage of radioactivity (%ATI) in each fraction was calculated. The treatment during 1 hour with acetylsalicylic acid at higher dose has significantly (p < 0.05) modified the fixation of 99mTc on blood cells. Considering the results, we suggest that acetylsalicylic acid used at therapeutic doses may interfere with the nuclear medicine procedures related to these blood constituents.

Influence of antipyretic drugs on the labeling of blood elements with technetium-99m.

Acetaminophen (AAP), acetylsalicylic acid (ASA) and dipyrone (DIP) are antipyretic and analgesics drugs that have wide use in health sciences. Some drugs can modify the labeling of blood elements with technetium-99m (99mTc). This work has evaluated the effect of AAP, ASA and DIP on the labeling of the blood elements with 99mTc. Blood was incubated with different concentrations of the drugs before the 99mTc-labeled process. Plasma (P), blood cells (BC), insoluble (IF-P, IF-BC) and soluble (SF-P, SF-BC) fractions were separated and percentage of radioactivity (%ATI) in each fraction was determined. Data have shown that the antipyretic drugs used in this study did not significantly modify the fixation of 99mTc on the blood elements when the experiments were carried out with the doses usually used in human beings. Although the experiments were carried out with rats, it is possible to suggest that AAP, ASA or DIP should not interfere with the procedures in nuclear medicine involving the labeling of blood elements with 99mTc.

Review: cellular substrates of the eukaryotic chaperonin TRiC/CCT.

The TCP-1 ring complex (TRiC; also called CCT, for chaperonin containing TCP-1) is a large (approximately 900 kDa) multisubunit complex that mediates protein folding in the eukaryotic cytosol. The physiological substrate spectrum of TRiC is still poorly defined. Genetic and biochemical data show that it is required for the folding of the cytoskeletal proteins actin and tubulin. Recent years have witnessed a steady stream of reports that describe other proteins that require TRiC for proper folding. Furthermore, analysis of the transit of newly synthesized proteins through TRiC in intact cells suggests that the chaperonin contributes to the folding of a distinct subset of cellular proteins. Here we review the current understanding of a role for TRiC in the folding of newly synthesized polypeptides, with a focus on some of the individual proteins that require TRiC.

Folding of newly translated proteins in vivo: the role of molecular chaperones.

Recent years have witnessed dramatic advances in our understanding of how newly translated proteins fold in the cell and the contribution of molecular chaperones to this process. Folding in the cell must be achieved in a highly crowded macromolecular environment, in which release of nonnative polypeptides into the cytosolic solution might lead to formation of potentially toxic aggregates. Here I review the cellular mechanisms that ensure efficient folding of newly translated proteins in vivo. De novo protein folding appears to occur in a protected environment created by a highly processive chaperone machinery that is directly coupled to translation. Genetic and biochemical analysis shows that several distinct chaperone systems, including Hsp70 and the cylindrical chaperonins, assist the folding of proteins upon translation in the cytosol of both prokaryotic and eukaryotic cells. The cellular chaperone machinery is specifically recruited to bind to ribosomes and protects nascent chains and folding intermediates from nonproductive interactions. In addition, initiation of folding during translation appears to be important for efficient folding of multidomain proteins.

The interaction of the chaperonin tailless complex polypeptide 1 (TCP1) ring complex (TRiC) with ribosome-bound nascent chains examined using photo-cross-linking.

The eukaryotic chaperonin tailless complex polypeptide 1 (TCP1) ring complex (TRiC) (also called chaperonin containing TCP1 [CCT]) is a hetero-oligomeric complex that facilitates the proper folding of many cellular proteins. To better understand the manner in which TRiC interacts with newly translated polypeptides, we examined its association with nascent chains using a photo-cross-linking approach. To this end, a series of ribosome-bound nascent chains of defined lengths was prepared using truncated mRNAs. Photoactivatable probes were incorporated into these (35)S- labeled nascent chains during translation. Upon photolysis, TRiC was cross-linked to ribosome-bound polypeptides exposing at least 50-90 amino acids outside the ribosomal exit channel, indicating that the chaperonin associates with much shorter nascent chains than indicated by previous studies. Cross-links were observed for nascent chains of the cytosolic proteins actin, luciferase, and enolase, but not to ribosome-bound preprolactin. The pattern of cross-links became more complex as the nascent chain increased in length. These results suggest a chain length-dependent increase in the number of TRiC subunits involved in the interaction that is consistent with the idea that the substrate participates in subunit-specific contacts with the chaperonin. Both ribosome isolation by centrifugation through sucrose cushions and immunoprecipitation with anti-puromycin antibodies demonstrated that the photoadducts form on ribosome-bound polypeptides. Our results indicate that TRiC/CCT associates with the translating polypeptide shortly after it emerges from the ribosome and suggest a close association between the chaperonin and the translational apparatus.

Protein folding in vivo: the importance of molecular chaperones.

The contribution of the two major cytosolic chaperone systems, Hsp70 and the cylindrical chaperonins, to cellular protein folding has been clarified by a number of recent papers. These studies found that, in vivo, a significant fraction of newly synthesized polypeptides transit through these chaperone systems in both prokaryotic and eukaryotic cells. The identification and characterization of the cellular substrates of chaperones will be instrumental in understanding how proteins fold in vivo.

Co-translational domain folding as the structural basis for the rapid de novo folding of firefly luciferase.

The 62 kDa protein firefly luciferase folds very rapidly upon translation on eukaryotic ribosomes. In contrast, the chaperone-mediated refolding of chemically denatured luciferase occurs with significantly slower kinetics. Here we investigate the structural basis for this difference in folding kinetics. We find that an N-terminal domain of luciferase (residues 1-190) folds co-translationally, followed by rapid formation of native protein upon release of the full-length polypeptide from the ribosome. In contrast sequential domain formation is not observed during in vitro refolding. Discrete unfolding steps, corresponding to domain unfolding, are however observed when the native protein is exposed to increasing concentrations of denaturant. Thus, the co-translational folding reaction bears more similarities to the unfolding reaction than to refolding from denaturant. We propose that co-translational domain formation avoids intramolecular misfolding and may be critical in the folding of multidomain proteins.

In vivo newly translated polypeptides are sequestered in a protected folding environment.

Molecular chaperones play a fundamental role in cellular protein folding. Using intact mammalian cells we examined the contribution of cytosolic chaperones to de novo folding. A large fraction of newly translated polypeptides associate transiently with Hsc70 and the chaperonin TRiC/CCT during their biogenesis. The substrate repertoire observed for Hsc70 and TRiC is not identical: Hsc70 interacts with a wide spectrum of polypeptides larger than 20 kDa, while TRiC associates with a diverse set of proteins between 30 and 60 kDa. Overexpression of a bacterial chaperonin 'trap' that irreversibly captures unfolded polypeptides did not interrupt the productive folding pathway. The trap was unable to bind newly translated polypeptides, indicating that folding in mammalian cells occurs without the release of non-native folding intermediates into the bulk cytosol. We conclude that de novo protein folding occurs in a protected environment created by a highly processive chaperone machinery and is directly coupled to translation.

Formation of the VHL-elongin BC tumor suppressor complex is mediated by the chaperonin TRiC.

von Hippel-Lindau (VHL) disease is caused by loss of function of the VHL tumor suppressor protein. Here, we demonstrate that the folding and assembly of VHL into a complex with its partner proteins, elongin B and elongin C (herein, elongin BC), is directly mediated by the chaperonin TRiC/CCT. Association of VHL with TRiC is required for formation of the VHL-elongin BC complex. A 55-amino acid domain of VHL is both necessary and sufficient for binding to TRiC. Importantly, mutation or deletion of this domain is associated with VHL disease. We identified two mutations that disrupt the normal interaction with TRiC and impair VHL folding. Our results define a novel role for TRiC in mediating oligomerization and suggest that inactivating mutations can impair polypeptide function by interfering with chaperone-mediated folding.

Directionality of polypeptide transfer in the mitochondrial pathway of chaperone-mediated protein folding.

Protein folding in mitochondria depends on the functional cooperation of the Hsp70 and Hsp60 chaperone systems, at least for a subset of mitochondrial polypeptides. As suggested previously, Hsp70 and Hsp60 act sequentially. However, recent proposals that the chaperonin Hsp60 functions by releasing substrate protein in an unfolded state would predict a lateral partitioning of folding intermediates between chaperone systems. Firefly luciferase, carrying a mitochondrial targeting signal, was used as a model protein to analyze the degree of coupling and the directionality of substrate transfer between the Hsp70 and Hsp60 chaperones. In vitro, Hsp60 binds unfolded luciferase with high affinity but is unable to promote its folding, whereas the Hsp70 system assists the folding of luciferase efficiently. Upon import into yeast mitochondria, luciferase interacted first with Hsp70. Surprisingly, most of the protein subsequently accumulated in a complex with Hsp60 and never reached the native state. Import into mitochondria that lack a functional Hsp60 did not result in increased folding, but in the aggregation of luciferase. Thus, in intact organelles the two chaperone systems do not function independently in de novo folding of aggregation-sensitive proteins but rather act in an ordered pathway with substrate transfer predominantly in the direction from Hsp70 to Hsp60.

Chaperones get in touch: the Hip-Hop connection.

Recent findings emphasize that different molecular chaperones cooperate during intracellular protein biogenesis. Mechanistic aspects of chaperone cooperation are now emerging from studies on the regulation of certain signal transduction pathways mediated by Hsc70 and Hsp90 in the eukaryotic cytosol. Efficient cooperation appears to be achieved through a defined regulation of Hsc70 activity by the chaperone cofactors Hip and Hop.

Principles of chaperone-assisted protein folding: differences between in vitro and in vivo mechanisms.

Molecular chaperones in the eukaryotic cytosol were shown to interact differently with chemically denatured proteins and their newly translated counterparts. During refolding from denaturant, actin partitioned freely between 70-kilodalton heat shock protein, the bulk cytosol, and the chaperonin TCP1-ring complex. In contrast, during cell-free translation, the chaperones were recruited to the elongating polypeptide and protected it from exposure to the bulk cytosol during folding. Posttranslational cycling between chaperone-bound and free states was observed with subunits of oligomeric proteins and with aberrant polypeptides; this cycling allowed the subunits to assemble and the aberrant polypeptides to be degraded. Thus, folding, oligomerization, and degradation are linked hierarchically to ensure the correct fate of newly synthesized polypeptides.

Folding of nascent polypeptide chains in a high molecular mass assembly with molecular chaperones.

The folding of polypeptides emerging from ribosomes was analysed in a mammalian translation system using firefly luciferase as a model protein. The growing polypeptide interacts with a specific set of molecular chaperones, including Hsp70, the DnaJ homologue Hsp40 and the chaperonin TRiC. The ordered assembly of these components on the nascent chain forms a high molecular mass complex that allows the cotranslational formation of protein domains and the completion of folding once the chain is released from the ribosome.