Development of a novel, nearly insoluble antiadhesive membrane.

BACKGROUND: Sodium hyaluronate/carboxymethylcellulose (HA/CMC) is difficult to use in a moist environment because of its susceptibility to moisture. METHODS: We developed the three-layered nDM-14R membrane. The surface layers are composed of 1-lactide, glycolide and e-caprolactone copolymers. HA/CMC and nDM-14R were used in all these studies. (1) The central region of 1 × 10 cm specimens (n = 5) was moistened for 0, 5, 10, 20, 30 or 60 s, after which the tensile strength was determined; (2) one side of specimens of 1 × 10 cm (n = 5) was moistened with agar gel for 5, 10, 15 or 30 s, after which the adhesion strength was determined, and (3) Rat cecum (n = 10) was scratched, 3 × 3 cm specimens were placed on the scratched area, and adhesions were evaluated on postoperative day 14. RESULTS AND CONCLUSION: (1) The tensile strength of nDM-14R after contact for 10-30 s was greater than that of HA/CMC. (2) The adhesive strength of HA/CMC after contact for 5-10 s was greater than that of nDM-14R. (3) Adhesion scores in treatment groups were significantly lower than in the control group. The results suggest that nDM-14R has the same antiadhesive effect and allows easier placement under moist conditions than HA/CMC.

The clinical significance of serum procalcitonin levels following direct hemoperfusion with polymyxin B-immobilized fiber column in septic patients with colorectal perforation.

BACKGROUND: The efficacy of direct hemoperfusion with polymyxin B-immobilized fiber columns (PMX) has already been demonstrated in clinical studies for the treatment of septic shock. However, serum procalcitonin levels following PMX remain unknown. METHODS: This prospective, multicenter, nonrandomized clinical study was performed at 12 institutions. Forty-five patients with severe sepsis or septic shock due to colorectal perforation underwent PMX. Patients' outcome as well as circulating levels of endotoxin, procalcitonin and IL-6 were monitored. RESULTS: Before surgery, procalcitonin level, but not endotoxin and IL-6 levels, was elevated according to patients' septic conditions. Procalcitonin was significantly and positively correlated with sequential organ failure assessment score. Circulating levels of procalcitonin peaked 24 h after PMX treatment. Change in serum procalcitonin level was significantly higher in nonsurvivors than survivors. Nine mortalities were observed within 28 days. The best predictor for 28-day mortality was procalcitonin >85.7 ng/ml at 24 h after PMX (area under the receiver operating characteristic curve: 0.808 +/- 0.105). CONCLUSIONS: Procalcitonin may be a good indicator of severity of sepsis secondary to colorectal perforation. Furthermore, procalcitonin level at 24 h after PMX appears to predict outcome after PMX. Therefore, procalcitonin may be a useful diagnostic marker to evaluate patients' condition in candidates for PMX treatment.

Bile salt tauroursodeoxycholic acid modulation of Bax translocation to mitochondria protects the liver from warm ischemia-reperfusion injury in the rat.

BACKGROUND: Tauroursodeoxycholic acid (TUDC) is a hydrophilic bile acid that has a cytoprotective effect in primary biliary cirrhosis and primary sclerosing cholangitis. TUDC also protects hepatocytes from hydrophobic bile acid-induced apoptosis. The aim of this study was to determine whether TUDC ameliorates hepatocyte apoptosis during ischemia-reperfusion injury. METHODS: We used a rat model of hepatic warm ischemia-reperfusion injury to assess the effects of TUDC. Male Sprague-Dawley rats were subjected to 1 or 2 hr of normothermic ischemia followed by 3 or 6 hr of reperfusion. The treatment group received TUDC (50 mg/kg) by bolus intravenous injection 30 min before initiation of ischemia, whereas the control group received saline only. Blood samples for biochemical analysis were obtained after 6 hr of reperfusion. Liver biopsies for histological assessment were obtained 3 and 6 hr after reperfusion. Hepatocyte apoptosis was determined by terminal dUTP nick-end labeling. The pro-apoptotic protein Bax was quantified at the mRNA and protein level. RESULTS: Treatment with TUDC significantly reduced serum transaminase levels. This was associated with a significant amelioration in the levels of hepatocyte apoptosis in the TUDC-treated group compared with control. Furthermore, Western blot analysis of Bax expression in liver tissue indicated that TUDC inhibited the translocation of Bax from the cytosol to the mitochondria. CONCLUSIONS: TUDC significantly reduced hepatic injury in this model. The beneficial effects of TUDC upon hepatocyte apoptosis were related to the modulation of Bax protein translocation.

[Tumor ablation with MRI navigation--a novel method of microwave coagulation therapy for hepatic tumor].

Fifty-eight patients with hepatic tumor which consisted of 22 hepatocellular carcinomas and 36 metastatic liver tumors were treated by microwave coagulation therapy with MRI navigation. The tumors were located in all segments of liver except S1. In 24 cases among them, the abdominal approach was difficult, because the tumors were located just below the diaphragm. These cases were selected for thoracoscope-assisted microwave ablation under MR-guidance across the diaphragm. All MR data were collected on a vertically oriented open MRI system (0.5 T SIGNA SP/i system: GE Medical Systems). The microwave electrode was introduced into the liver through a 14G needle via a percutaneous puncture with real-time MR image navigation. Microwave ablations at 60 W for 60 seconds were repeated several times depending on the tumor size. MR imaging may be employed as a reliable guide for percutaneous puncture. Moreover, sufficient safety margin could be obtained for hepatic tumor ablation. MR-guided microwave thermoablation therapy is a feasible method of treatment for hepatic tumors.

The role of bacterial translocation on neutrophil activation during hemorrhagic shock in rats.

Some biological responses to hemorrhage have been reported to be associated with bacterial translocation (BT). While the relationship between peripheral blood neutrophils and BT in the late phase of hemorrhagic shock or burn injury has been reported, this relationship in the early phase has not been fully elucidated. We investigate the role of BT in neutrophil activation and priming during hemorrhagic shock. The experimental rats were divided into three groups: a group with normal intestinal flora (NF group), an antibiotic-decontaminated group (AD group), and a sham shock group with normal intestinal flora (sham group). Hemorrhagic shock was induced in the NF and AD groups (MAP 30 mm Hg for 30-90 min). The rats were sacrificed at 30, 60, or 90 min following the shock induction. Cultures were taken from the liver, spleen, mesenteric lymph nodes (MLNs), and systemic blood to assess the occurrence of BT. Hydrogen peroxide generation and CD11b/c expression were assayed by flow cytometry to evaluate peripheral blood neutrophil activation and priming, respectively. In the NF group, significant BT to the MLNs and spleen was noted from 30 min after the shock induction, and significant hydrogen peroxide generation was also noted from 30 min. The expression of CD11b/c on neutrophils was significantly up-regulated at 90 min after the shock induction. Furthermore, BT, as also the aforementioned parameters of neutrophil function, was significantly suppressed in the AD group. We, therefore, concluded that neutrophil activation and priming during hemorrhagic shock might be closely related to BT, and that infectious factors possibly influence the host responses starting from the early phase of damage, even in noninfectious stress-inducing conditions.

Effects of zinc deficiency and corticosterone elevation on bone marrow in rats.

OBJECTIVE: The effects of zinc deficiency and serum corticosterone elevation, in a zinc-deficient state, on rat bone marrow were studied. MATERIALS AND METHODS: Male Sprague-Dawley rats were divided into the following four groups: zinc-adequate (ZA), restricted ZA (RZA), zinc-deficient (ZD) and ZD with the injection of Mifepristone (ZD+Mife). Platelet and reticulocyte counts, levels of serum zinc and corticosterone, bone marrow cellularity and morphological alterations of marrow were examined in all rats. RESULTS: Decreased marrow cellularity, decreased numbers of peripheral platelets and reticulocytes, and increased adipocytes in the marrow were observed in ZD rats. The injection of Mifepristone improved marrow cellularity, and increased the number of platelets, while decreasing adipocytes in the marrow in ZD rats. CONCLUSION: Both zinc deficiency itself and the associated serum corticosterone elevation induced bone marrow suppression in rats.

Correlation between plasma endotoxin, plasma cytokines, and plasminogen activator inhibitor-1 activities in septic patients.

The objective of this study was to evaluate the relation between the clinical and plasma parameters and the changes in plasma endotoxin activity with 2 hours of endotoxin-adsorbing therapy using polymyxin B (PMX). A total of 88 consecutive patients were admitted for PMX treatment of severe sepsis or septic organ failure. Standard supportive care was continued without alteration during PMX treatment. Endotoxin, tumor necrosis factor-alpha (TNFalpha), interleukin-6 (IL-6), IL-10, and plasminogen activator inhibitor-1 (PAI-1) activities and clinical parameters were measured before, immediately after, and the day after PMX treatment. The mean APACHE II and III scores were 24.2 +/- 1.0 and 85.8 +/- 3.0, respectively. The 2-week survival rate was 51.1%. In survivors, TNFalpha, IL-6, IL-10, and PAI-1 activities were significantly decreased during the 2-hour PMX treatment, the following day, or both times. There was no significant change in the parameters, except for TNFalpha, after PMX in nonsurvivors. In the subgroup whose plasma endotoxin decreased more than 30%, IL-6, TNFalpha, and PAI-1 significantly decreased after 2 hours of PMX or the following day (or both), but all four parameters in nonsurvivors showed no significant change. Hence PMX adsorbed plasma endotoxins and contributed to reductions in plasma proinflammatory cytokine levels and to improved clinical parameters during the 2-hour treatment. Changes in these parameters correlated with changes in plasma endotoxin activity in survivors whose plasma endotoxin levels were adequately reduced.

Off-line leukapheresis using leukofiltration for active ulcerative colitis: a case report.

The method of leukocytapheresis for ulcerative colitis (UC) by using extracorporeal circulation (on-line system) has been reported. To perform leukocytapheresis, we have applied leukocyte elimination filters for blood transfusion to leukocytapheresis without using extracorporeal circulation (off-line leukocytapheresis system). Four hundred milliliters of peripheral blood was collected and reinfused through a leukocyte elimination filter. This procedure was repeated 5 times, and up to 2,000 ml of peripheral blood was treated. This method has been applied once a week for 5 weeks. We applied the off-line leukapheresis system to a 31-year-old male ulcerative colitis patient. As a result, the frequency of defecation and the dose of medicine were effectively decreased, and endoscopic finding was also improved. Because of the absence of complications observed with the on-line system, the off-line leukocytapheresis system that we have applied to the clinical patient is simple, safe, and useful.

Bacterial translocation and tumor necrosis factor-alpha gene expression in experimental hemorrhagic shock.

OBJECTIVE: To investigate whether bacterial translocation is the causative mechanism underlying cytokine production during hemorrhagic shock. DESIGN: Prospective, randomized, unblinded animal study. SETTING: Surgical research laboratories of Shiga University of Medical Science. SUBJECTS: Male Sprague-Dawley rats. INTERVENTIONS: The rats were randomly divided into three groups. Each animal was anesthetized with pentobarbital, given a continuous infusion of 0.9% saline, and monitored for blood pressure. The normoxic and sham shock groups breathed room air, whereas the hyperoxic shock group was administered 100% oxygen. Except in the sham shock group, blood was withdrawn to induce a hemorrhagic shock state, then the shed blood was reinfused. Sixty minutes after the induction of hemorrhagic shock, arterial blood cultures were performed in all three groups. The animals were then killed, and their mesenteric lymph nodes (MLNs) were harvested for bacterial culture. The terminal ileum, liver, spleen, kidney, lung, and MLNs were also collected for histologic study by in situ hybridization. MEASUREMENTS AND MAIN RESULTS: In the bacteriologic study, the prevalence of bacterial translocation was 0% (0/11) in the hyperoxic shock group, 55% (6/11) in the normoxic shock group, and 0% (0/9) in the sham shock group. In the in situ hybridization study, tumor necrosis factor-alpha gene expression was detected only in the ileal tissue, MLNs, and spleens of the normoxic shock group. Blood cultures were sterile in all three groups. CONCLUSIONS: Bacterial translocation occurred in MLNs within 1 hr of hemorrhage. Hemorrhagic shock causes tumor necrosis factor-alpha gene expression as well as bacterial translocation in MLNs, but not in the liver, in this model. Bacterial translocation was prevented by hyperoxia early in the course of hemorrhagic shock. Hyperoxia also prevented tumor necrosis factor-alpha gene expression along the bacterial invasion route.

Interleukin-8 as a predictor of the severity of bacteremia and infectious disease.

The relationship between cytokines and sepsis has been studied frequently in the intensive care unit (ICU). However, the determination of cytokines in patients as they enter the emergency department (ED) would be more meaningful in predicting the outcome of infection. This study investigated plasma interleukin-8 in the ED as the predictor of bacteremia and sepsis. One hundred patients admitted through the ED with signs of systemic inflammatory response syndrome were studied. Plasma IL-8, IL-6, and tumor necrosis factor (TNF) were assayed by enzyme-linked immunosorbent assay. Patient's data were evaluated using the APACHE II scoring system as predictive factors of morbidity and mortality. Plasma IL-8 (149 pg/mL) detected bacteremia with a positive predictive value of 90.9% and a specificity of 98.7%. Results indicated that the odds ratios (ORs) of bacteremia were 24.78 (P < 0.01, CI = 2.27-270.8), 5.42 (P < 0.05, CI = 1.37-21.4), and 6.05 (P < 0.05, CI = 1.36-26.8) for IL-8, IL-6, and APACHE II, respectively. Occurrence of bacteremia was highly correlated with increases in plasma IL-8 (P < 0.01). IL-8 (OR = 8.25, CI = 1.03-65.9) and APACHE II scores (OR = 12.6, CI = 2.24-70.4) were found to be significantly better predictive factors of mortality (P < 0.01) than IL-6 (OR = 3.60, CI = 0.57-22.7), TNF (OR = 0.24, CI = 0.01-11.0) and age (OR = 1.02, CI = 0.98-1.06). During bacteremia, IL-8 also correlated well with patient use of a ventilator (P < 0.01, OR = 2.43, CI = 2.41-311.19), use of vasopressors (P < 0.05, OR = 2.67, CI = 1.79-370.78), length of stay in the hospital (P < 0.01, OR = 3.14, CI = 1.87-988.31), and stay in the ICU (P < 0.01, OR = 2.51, CI = 2.98-449.80). Measuring IL-8 on patients in the ED with apparent bacterial infections appears to be a reliable predictor of bacteremia and the severity of disease.

The prevention of bile duct injury during laparoscopic cholecystectomy from the point of view of anatomic variation.

The aim of this study was to evaluate ways to prevent bile duct injury during laparoscopic cholecystectomy in patients with anomalous biliary tract anatomy. The biliary tract was studied using cholangiograms of 511 patients who had gallbladder disease and was dissected in 92 cadaveric specimens. The authors classified confluent forms of the cystic duct and the bile duct into five different types, including four anomalous types. Sixteen instances (3.13%) of anatomic variation of the biliary tract were found among the patients, and four cases (4.35%) were found in the cadavers. Among the 511 patients, there were 495 cases of type C anatomy, three cases of type A, seven cases of type R, six cases of type P, and zero cases of type L; among the 92 cadaveric specimens, there were 88 cases of type C anatomy, one case of type R, two cases of type P, and one case of type L. For anatomic types A, P, and R, there is a high probability of risk of cutting the wrong duct. Therefore, it is important to clarify the anatomy of the biliary tract by preoperative examination and to carefully dissect the cystic duct close to the neck of the gallbladder during laparoscopic cholecystectomy. Anatomic variation of the biliary tract is common and can create a rare pitfall during laparoscopic cholecystectomy.

New method for the detection of bacterial translocation using intestinal permeability with polyethylene glycol 4000.

BACKGROUND: Currently, there is no method of accurately diagnosing bacterial translocation (BT) in humans. BT may be related to changes in intestinal permeability. In this study, we examined the correlation between intestinal permeability using polyethylene glycol (PEG) 4000 and BT. MATERIALS AND METHODS: Under general anesthesia, laparotomy was done in rats, and PEG4000 was administered to the small intestine. We prepared models of invasive stimulation in which lipopolysaccharide (LPS) was intravenously administered, and a hemorrhagic shock model in which blood pressure was decreased to 30 mm Hg. Blood PEG4000 levels were measured. We also measured blood PEG levels in a model in which oxygen was administered to treat hemorrhagic shock. In all models, the presence or absence of BT development was evaluated. RESULTS: In groups given LPS, mean blood PEG levels were significant higher than in the group treated with saline solution. In the hemorrhagic shock group, the mean PEG level was increased but was slightly inhibited by oxygen administration. In the LPS and hemorrhagic shock groups, the incidene of BT was significantly greater than in the control group. In the hemorrhagic shock group, the incidence of BT was 0% after oxygen administration. There was a correlation between the incidence of BT and changes in the intestinal permeability of PEG4000 (R(2) = 0.824). CONCLUSIONS: LPS stimulation enhanced intestinal permeability in a dose-dependent manner. An increase in intestinal permeability was correlated with the incidence of BT. Blood PEG4000 levels correlated positively with the grade of invasion and the incidence of BT.

[Sepsis and organ failure--its pathogenesis and treatment].

Sepsis, septic shock, and multiple organ dysfunction are heterogeneous and sophisticated clinical syndromes which result from the interplay of mediators of cellular function and inflammation. Secondary mediators such as lipids (prostaglandin, thromboxane, platelet-activating factor), peptides (bradykinin, vasoactive intestinal peptide), amines (histamine, serotonin) and complements are key mediators which lead to the state of shock in human sepsis. Endotoxin may also cause multiple organ dysfunction syndrome (MODS). New antiendotoxin treatment and the strategy for sepsis including endotoxemia are reviewed. Monoclonal antibodies directed at core epitopes and lipid A (E5, HA1-A) could not reproduce the beneficial effects. Bactericidal/permeability increasing protein (BPI)). Endotoxin neutralizing protein (ENP)) and E5531 may have potential in the treatment of sepsis. Another treatment using extracorporeal endotoxin removal is reported. Polymyxin B immobilized fiber (PMX), commercialized as Toraymyxin, is now widely used in Japan for severe sepsis and septic MODS. PMX treatment improves the symptoms related to the septic state, a hemodynamic disorders, and cytokine levels including tumor mecrosis factor, interleukin (IL)-6, and IL-10, with a decrease in endotoxin levels. Phase II, III, and IV clinical trials with extracorporeal endotoxin removal by PMX revealed that endotoxin removal is helpful in the treatment of septic patients.

Effects of a urinary trypsin inhibitor on acute circulatory insufficiency after surgical operation.

OBJECTIVE: To assess the effectiveness of an urinary trypsin inhibitor (UTI) on a surgical stress, particularly the influences on cytokines and diuretic hormones. SUBJECTS AND METHODS: Sixteen patients with carcinoma of the digestive system and predicted to suffer from circulatory insufficiency were enrolled. Selection of group was divided alternatively. UTI was administered for 5 consecutive days, at a dose of 300,000 units per day. Urine and blood specimens were collected before, immediately after, and 1, 3, and 5 days after surgery. Interleukin 8 (IL-8), polymorphonuclear leukocyte elastase (PMNE), vasopressin (ADH), atrial natriuretic peptide (ANP), angiotensin II (AT-II), and endothelin 1 (ET-1) in the blood, and N-acetyl-D-glucosaminidase (NAG) in the urine, were determined. RESULTS: A UTI group was 9 patients, and a control group was 7 patients. The operation time was significantly longer in the UTI group than in the control group. In the UTI group, the elevation of IL-8, PMNE/WBC, ADH, urinary NAG, and BUN were significantly inhibited. AT-II and ET-1, in the UTI group, tended to be suppressed, and ANP showed the similar changes in the two groups. CONCLUSION: UTI is considered effective in the prevention of excessive reaction against major surgery.

Therapeutic apheresis for septic patients with organ dysfunction: hemoperfusion using a polymyxin B immobilized column.

A prospective clinical study was performed to evaluate a new method of treatment of endotoxin shock, a column containing polystyrene fibers with covalently bound immobile polymyxin B. Direct hemoperfusion using the column removes circulating endotoxin by adsorption. All of the patients studied, 37 in the treatment group and 33 in the control group, had endotoxemia and failure of 1 or more organs. The perfusion was performed 1-7 times per patient, 2 h/session. The survival rate was significantly higher in the treatment group (54%) than in the controls (36.4%). The mean plasma endotoxin concentration was significantly lowered by the treatment from 83.7 pg/ml before perfusion to 56.4 pg/ml immediately after and 28.5 pg/ml the day after the treatment, and the posttreatment level was much lower in those who survived (mean, 18.8 pg/ml) compared to those who died (mean, 88 pg/ml). Various parameters of cardiac function also improved after the treatment.

Blood purification therapy in cancer treatment.

It is well known that cancer patients have specific and nonspecific immunosuppressive substances in their sera that depress cellular immunity. Plasma exchanges have been attempted to remove these immunosuppressive factors and improve the immunity to cancer. Double infiltration plasmapheresis has also been attempted and has been found to remove the immunosuppressive substances efficiently without a large volume substitution. Using these methods, an improvement in performance status and clinical symptoms and reduction of tumor size have been observed. Cancer chemotherapy has several severe side effects. Double filtration plasmapheresis is also clinically applied as a surplus carcinostatic drug adsorption method to alleviate systemic adverse reactions.

Extracorporeal endotoxin removal by polymyxin B immobilized fiber cartridge: designing and antiendotoxin efficacy in the clinical application.

We have developed an extracorporeal hemoadsorption cartridge, the PMX cartridge, to eliminate endotoxin from peripheral blood circulation. As an adsorbent, a polymyxin B covalently immobilized fiber (PMX-F) was developed. After the optimization of the condition of immobilization, fixed polymyxin B maintained its ability to adsorb endotoxin and its bactericidal activity. PMX-F could detoxify many kinds of endotoxin in vitro. Fixed polymyxin B was estimated to interact with the lipid A portion of endotoxin. Utilization of fibrous adsorbents enabled us to design the PMX cartridge with a large surface area and low blood pressure drop in the blood flow compartment and to apply it safely to the direct hemoperfusion procedure. In Japan, the PMX cartridge is now being clinically applied as one of the therapeutical interventions for sepsis, septic shock, and septic multiple organ failure. In multicenter clinical studies, the blood endotoxin level has been significantly decreased. Accompanied with elimination of endotoxin, hemodynamic abnormalities such as low blood pressure and low systemic vascular resistance were significantly improved. In more recent multicenter studies, the average number of failed organs; severity of illness score, such as Goris score; and vasopressor dosage were significantly decreased. The PMX cartridge is expected to be effective in the intervention for the treatment of septic shock. Endotoxin may be one of the therapeutical targets for the treatment of sepsis.

Theoretical background of effect mechanism by extracorporeal immunomodulation.

Therapeutic plasmapheresis has usually been applied to diseases with unknown causes. Clear analysis of the mechanism of the effect that apheresis has on diseases derived from unknown causes has not been completed. The effect of leukocytapheresis on ulcerative colitis (UC) or rheumatoid arthritis (RA) also lacks clear analysis, but removal of 10(10) adhesive cells resulted in the suppression of both acute and chronic inflammatory reactions. The number of cells removed was not unreasonable for efficacy. A quite acceptable explanation is that the cells activated in the inflammatory lesions are more adhesive than nonactivated cells. However, only a few minutes of contact with the surface of the device can activate blood immune cells. All of the apheresis therapies, not only leukocytapheresis, should be evaluated for their efficacies, excluding the effects of contact activation. According to results presently available, the suppressive effect of leukocytapheresis on RA or UC is through to depend upon the removal of activated inflammation related cells that might transfer inflammatory signals. It may be that those cells removed are bound because of cell stimulation caused by microorganisms or foreign bodies.