Nepalese undergraduate nursing students' perceptions of the clinical learning environment, supervision and nurse teachers: A questionnaire survey.

BACKGROUND: Clinical practice enables nursing students to acquire essential professional skills, but little is known about nursing students' perceptions of the clinical learning environment (CLE) in Nepal. OBJECTIVES: To examine Nepalese nursing students' perceptions regarding the CLE and supervision. DESIGN: A cross-sectional questionnaire design was used. SETTINGS: Government and private hospitals in Nepal where the undergraduate nursing college students undertook their clinical practice. PARTICIPANTS: Students with clinical practice experience were recruited from years 2-4 of the B.Sc. nursing program in Nepal (n=350). The final sample comprised 263 students. METHODS: A self-administered questionnaire including demographic characteristics, latest clinical practice site, and general satisfaction was administered February-March 2014. The previously validated Clinical Learning Environment, Supervision and Nurse Teacher evaluation scale was used in the questionnaire. The analytical approach used exploratory factor analysis, assessments of the scale and sub-dimension reliability, correlations of factors between scale sub-dimensions, and multiple regression analysis. RESULTS: Students' practicum satisfaction level at government hospitals was significantly higher than those at private hospitals (p<0.0001). Five factors explained 85.7% of the variance, with minor factorial structure differences compared with the original scale. Reliability was confirmed (Cronbach's alpha=0.93 for total scale, 0.76-0.92 for sub-dimensions). Inter-correlations between the five original sub-dimensions were 0.27-0.68 (p<0.0001). Students undertaking their practicum in private hospitals evaluated their clinical placements significantly more negatively on most sub-dimensions than those in government hospitals. Multiple regression analysis revealed a significant positive relationship between satisfaction and pedagogical atmosphere (p<0.0001). CONCLUSION: This is the first study to investigate nursing students' perceptions of the CLE in undergraduate nursing programs in Nepal. Students were satisfied with the CLE overall, but satisfaction varied by practicum hospital sector. The most influential factor explaining satisfaction was pedagogical atmosphere.

Osteopontin Exacerbates Pulmonary Damage in Influenza-Induced Lung Injury.

The level of osteopontin (OPN) increases during bacterial lung infection. However, the OPN level in virus-induced lung injury is unclear, and the relationship between the hyer-production of OPN and lung injury remains to be thoroughly understood. Therefore, we sought to determine whether a relationship exists between OPN and pulmonary damage. Particularly, pulmonary edema and the destruction of pulmonary tissue. In this study, we found that the OPN level was significantly elevated in patients with pulmonary damage, and there was a positive correlation between the OPN serum level and disease severity in influenza lung injury. The epithelial sodium channel (ENaC) is the main mechanism of clearance of pulmonary edema fluid, and matrix metalloproteinase 7 (MMP7) can degrade the extracellular matrix. In lung epithelial cells, OPN markedly decreased the mRNA expression of the α-subunit of ENaC through integrin ß3 and CD44 (OPN receptors); however, the expression of MMP7 was promoted by OPN interaction with integrin ß1 and CD44. In addition, OPN increased the levels of tumor necrosis factor-α and interleukin-6. These findings suggested that OPN might increase influenza virus-induced lung injury by augmenting lung epithelial cell apoptosis and impairing ENaC and extracellular matrix destruction.

Regulatory effect of interleukin-4 in the innate inflammatory response to Rhodococcus aurantiacus infection in mice.

Interleukin (IL)-4 promotes the regression of granulomas during the late phase of Rhodococcus aurantiacus infection. In this study, the contribution of IL-4 to the initial response against this bacterium was investigated using IL-4-deficient mice. Compared with wild-type (WT) mice, IL-4-deficient mice displayed remarkably lower tumor necrosis factor (TNF)-α and IL-6 secretion in the liver, spleen, and blood at the initial phase of infection, along with improved survival. IL-4-deficient mice also showed diminished IL-10 secretion in the spleen and blood; however, hepatic IL-10 levels were similar to those observed in WT animals, and were concomitant with augmented interferon (IFN)-γ production and decreased bacterial burden in the liver at the early infection phase. Histological examination revealed reduced hepatic granuloma formation in infected IL-4-deficient mice. On challenge with heat-killed R. aurantiacus, IL-4-deficient mouse macrophages showed reduced expression of TNF-α, IL-6, and IL-10 at both the gene and protein levels compared with WT mouse cells. These findings indicate that during the initiation of R. aurantiacus-induced inflammation, IL-4 deficiency attenuates cytokine responses in macrophages, which contributes to amelioration in mouse survival and reduction of granulomatous inflammation, and augments a hepatic IFN-γ response which transiently accelerates bacterial elimination.

A possible role for NKT-like cells in patients with chronic hepatitis B during telbivudine treatment.

Natural killer T-like (NKT-like) cells are a source of different pro-inflammatory cytokines and therefore may be involved in inflammatory processes. However, little is known about NKT-like cells during antiviral therapy. In this study, we observed significantly higher numbers of CD3(+)CD56(+) cells in patients with chronic hepatitis B (CHB) than healthy controls. Importantly, CD3(+)CD56(+) NKT-like cells markedly decreased during telbivudine treatment in patients with CHB, and a positive correlation between NKT-like cell frequency and the serum HBV DNA level was observed during early antiviral therapy. Interestingly, NKT-like cell frequency significantly reduced in well-responders at week 12 of telbivudine therapy compared to baseline, but did not significantly change in non-responders after treatment. Previous studies have shown that interleukin (IL)-17 plays a role in the pathogenesis of CHB. Serum IL-17 levels reduced significantly during early antiviral therapy, however, interferon (IFN)-γ, IL-6 and tumor necrosis factor (TNF)-α levels did not change significantly. A positive correlation was observed between the NKT-like cell frequency and serum IL-17 level in CHB patients, and NKT-like cells isolated from patients with CHB secreted substantial amounts of IL-17 in vitro. These results suggest that the NKT-like cell frequency may be one of useful immunologic marker for evaluating the efficacy of anti-HBV therapy, and that NKT-like cells are also an important source of IL-17 (in addition to conventional T cells) in patients with CHB.

Contribution of toll-like receptor 2 to the innate response against Staphylococcus aureus infection in mice.

Staphylococcus aureus is a common pathogen that causes a wide range of infectious diseases. The function of TLRs, specifically TLR2, during S. aureus infection is still debated. In this study, we investigated the extent to which TLR2 contributes to the host innate response against the bacterial infection using TLR2-deficient mice. Intravenous inoculation with S. aureus resulted in all TLR2-deficient mice dying within 4 d, along with a high bacterial burden in the livers. However, histological examination showed the same degree of macrophage and neutrophil accumulation in the livers of infected TLR2-deficient mice as that in infected wild-type (WT) mice. TLR2-deficient mouse macrophages also showed normal phagocytic activity, although they failed to express CD36 that appeared on the surface of WT mouse cells upon challenge with heat-killed S. aureus. These data indicate that TLR2, as well as CD36, does not directly affect S. aureus clearance and that CD36 expression on macrophages depends on the presence of TLR2. In vivo infection with S. aureus caused significantly elevated production of TNF-α and IL-6 in the livers and blood of TLR2-deficient mice compared with those in WT mice, while the hepatic and serum levels of IL-10 decreased in these mice. In contrast, lower expression of IL-6 and IL-10, but not of TNF-α, at both the gene and protein levels was found in TLR2-deficient mouse macrophages compared to that in WT mouse cells, in response to challenge with heat-killed S. aureus. These findings suggest that the S. aureus-induced pro-inflammatory cytokine response is not dependent on macrophages and that TLR2 deficiency results in decreased IL-10 release by macrophages, which contributes to dysregulated cytokine balance, impaired bacterial clearance, and mouse death. Therefore, TLR2 possesses a protective function during S. aureus infection by regulating pro- and anti-inflammatory cytokine responses.

Ferrous ferric chloride downregulates the inflammatory response to Rhodococcus aurantiacus infection in mice.

The healthy drink Pairogen is mainly composed of ferrous ferric chloride water that reportedly changes the status of intracellular water from oxidative to antioxidative. Here, we investigated whether Pairogen affects host immune function in a murine model of granulomatous inflammation in response to Rhodococcus aurantiacus (R. aurantiacus) infection. Longitudinal ingestion of Pairogen markedly improved the survival of infected mice in a concentration-dependent manner. Compared to mice received water, mice that ingested 10-fold-diluted Pairogen displayed rapid bacterial elimination, decreased production of tumor necrosis factor (TNF)-α and interleukin (IL)-6, and high levels of IL-10 in organs during the initial phase of infection. Moreover, histological studies showed significant reduction in the number and size of granulomas as well as amelioration of oxidative stress in the livers of mice ingested 10-fold-diluted Pairogen at 14 d post-infection. These characteristics were further pronounced in first-generation (F1) mice that also ingested 10-fold-diluted Pairogen. Following stimulation with heat-killed R. aurantiacus, the production of TNF-α, IL-6, and IL-10 by macrophages from F1 mice was similar to that detected in vivo, while their gene expression levels in these cells were significantly lower than the levels in macrophages from mice received water. Heat-killed R. aurantiacus also induced the expression of heme oxygenase-1 mRNA in the cells from F1 mice. Taken together, these results indicate that Pairogen contributes to the negative regulation of the immuno-inflammatory response to R. aurantiacus infection in mice by modulating the cellular redox state. Longitudinal ingestion of Pairogen further enhances the defense function in mouse progeny.

A novel murine model for non-alcoholic steatohepatitis developed by combination of a high-fat diet and oxidized low-density lipoprotein.

Non-alcoholic steatohepatitis (NASH) is the hepatic manifestation of metabolic syndrome that is characterized by steatosis, inflammation, and fibrosis, and may progress to cirrhosis and carcinoma. To investigate its pathogenic processes, we established a novel murine model for NASH by combination of a high-fat diet (HFD) and oxidized low-density lipoprotein (oxLDL). Mice that received HFD for 23 weeks showed hepatic steatosis, slight fibrosis, and a high level of lipid peroxidation compared with a regular diet (RD)-fed mice. Hepatic injury and elevated tumor necrosis factor (TNF)-α mRNA expression were also detected in these mice. Moreover, oxLDL administration to HFD-fed mice during weeks 21-23 not only aggravated hepatic steatosis, fibrosis, and lipid metabolism, but also resulted in intense inflammation, including severe hepatic injury and inflammatory cell infiltration, which are the typical histological features of NASH. Inflammation was accompanied by increased gene expression of TNF-α and interleukin (IL)-6. Additionally, the livers of RD-fed animals treated with oxLDL during weeks 21-23 were characterized by foamy macrophages and inflammatory cell infiltration along with an elevated IL-6 mRNA level. These results suggest that an increased oxidative state, including HFD-induced intracellular lipid peroxidation and its extracellular source from oxLDL, is the actual trigger for hepatic inflammation in which liver injury is mediated by TNF-α and inflammatory cell accumulation is dependent on IL-6. HFD and oxLDL also induced insulin resistance in mice; additionally, oxLDL downregulated insulin secretion. In this model, CD36 overexpression was observed in the hepatocytes of HFD-fed mice and those treated with HFD and oxLDL, and in the hepatic macrophages of RD-fed mice immediately after oxLDL treatment. In vitro experiments indicated a rapid and transient elevation of CD36 on macrophage plasma membrane in response to oxLDL. Our findings demonstrate that CD36 expressed on hepatocytes and hepatic macrophages mediates the pathophysiology of NASH.

Dynamic 11C-methionine PET analysis has an additional value for differentiating malignant tumors from granulomas: an experimental study using small animal PET.

PURPOSE: We evaluated whether the dynamic profile of L-(11)C-methionine (11C-MET) may have an additional value in differentiating malignant tumors from granulomas in experimental rat models by small animal positron emission tomography (PET). METHODS: Rhodococcus aurantiacus and allogenic rat C6 glioma cells were inoculated, respectively, into the right and left calf muscles to generate a rat model bearing both granulomas and tumors (n=6). Ten days after the inoculations, dynamic 11C-MET PET was performed by small animal PET up to 120 min after injection of 11C-MET. The next day, after overnight fasting, the rats were injected with 18F-2-deoxy-2-fluoro-D-glucose (18F-FDG), and dynamic 18F-FDG PET was performed up to 180 min. The time-activity curves, static images, and mean standardized uptake value (SUV) in the lesions were calculated. RESULTS: 11C-MET uptake in the granuloma showed a slow exponential clearance after an initial distribution, while the uptake in the tumor gradually increased with time. The dynamic pattern of 11C-MET uptake in the granuloma was significantly different from that in the tumor (p<0.001). In the static analysis of 11C-MET, visual assessment and SUV analysis could not differentiate the tumor from the granuloma in all cases, although the mean SUV in the granuloma (1.48±0.09) was significantly lower than that in the tumor (1.72±0.18, p<0.01). The dynamic patterns, static images, and mean SUVs of 18F-FDG in the granuloma were similar to those in the tumor (p=NS). CONCLUSION: Dynamic 11C-MET PET has an additional value for differentiating malignant tumors from granulomatous lesions, which deserves further elucidation in clinical settings.

Osteopontin expression and relation to streptococcal disease severity in mice.

Osteopontin (OPN) is a phosphorylated glycoprotein that has been implicated in a number of infectious diseases. However, the role of OPN in Streptococcus pyogenes infection is unknown. To investigate whether OPN is involved in S. pyogenes infection, we first examined the plasma OPN levels after local injection of S. pyogenes. OPN expression was significantly increased at 2 h post-infection and increased thereafter. A correlation was found between plasma OPN levels and the development of S. pyogenes infection. The plasma OPN level in severe S. pyogenes infection was higher than during a normal infection. Levels of OPN were found to correlate with the severity of S. pyogenes infection. We also found that OPN production was suppressed by interleukin-6 and enhanced by tumour necrosis factor-alpha in immunocompetent cells. Collectively, these findings demonstrate that the OPN level may provide clues to the severity of S. pyogenes infection in the early phase of the infection.

Mutual modulation between interleukin-10 and interleukin-6 induced by Rhodococcus aurantiacus infection in mice.

The interaction between interleukin-10 (IL-10) and interleukin-6 (IL-6) was investigated in the inflammatory response to Rhodococcus aurantiacus (R. aurantiacus) infection, in which both cytokines act as anti-inflammatory cytokines. Compared with wild-type (WT) counterparts, IL-6 gene-deficient (IL-6(-)/(-)) mice mounted a more robust production of IL-10 and tumor necrosis factor-alpha (TNF-alpha) during the initial phase of infection. Administration of anti-IL-10 antibody resulted in all the mice dying within 3 days post-infection as well as a further elevated TNF-alpha release. In vitro challenge of the macrophages from IL-6(-)/(-) and WT mice with heat-killed R. aurantiacus also showed similar results. Addition of exogenous IL-6 depressed IL-10 and TNF-alpha production by either IL-6(-)/(-) mice or IL-6(-)/(-) mouse macrophages. Likewise, WT mouse macrophages pretreated with anti-IL-10 or anti-IL-6 antibody exhibited increased production of TNF-alpha and IL-6 or IL-10 respectively. Moreover, neutralization of both IL-10 and IL-6 induced a further increase in TNF-alpha production by WT mouse cells. Overall, we conclude that IL-10 is a key element in protecting mice against mortality, and that IL-10 and IL-6 production are negatively regulated by each other although they are additive in suppressing TNF-alpha release in R. aurantiacus-infected mouse model.

Usefulness of 11C-methionine for differentiating tumors from granulomas in experimental rat models: a comparison with 18F-FDG and 18F-FLT.

UNLABELLED: Many clinical PET studies have shown that increased (18)F-FDG uptake is not specific to malignant tumors. (18)F-FDG is also taken up in inflammatory lesions, particularly in granulomatous lesions such as sarcoidosis or active inflammatory processes after chemoradiotherapy, making it difficult to differentiate malignant tumors from benign lesions, and is the main source of false-positive (18)F-FDG PET findings in oncology. These problems may be overcome by multitracer studies using 3'-deoxy-3'-(18)F-fluorothymidine ((18)F-FLT) or l-(11)C-methionine. However, (18)F-FLT or (11)C-methionine uptake in granulomatous lesions remains unclarified. In this study, the potentials of (18)F-FLT and (11)C-methionine in differentiating malignant tumors from granulomas were compared with (18)F-FDG using experimental rat models. METHODS: Dual-tracer tissue distribution studies using (18)F-FDG and (3)H-FLT (groups I and III) or (18)F-FDG and (14)C-methionine (groups II and IV) were performed on rats bearing both granulomas (Mycobacterium bovis bacillus Calmette-Guérin [BCG]-induced) and hepatomas (KDH-8-induced) (groups I and II) or on rats bearing both turpentine oil-induced inflammation and hepatomas (groups III and IV). One hour after the injection of a mixture of (18)F-FDG and (3)H-FLT or of (18)F-FDG and (14)C-methionine, tissues were excised to determine the radioactivities of (18)F-FDG, (3)H-FLT, and (14)C-methionine (differential uptake ratio). RESULTS: Mature epithelioid cell granuloma formation and massive lymphocyte infiltration were observed in the granuloma tissue induced by BCG, histologically similar to sarcoidosis. The granulomas showed high (18)F-FDG uptake comparable to that in the hepatomas (group I, 8.18 +/- 2.40 vs. 9.13 +/- 1.52, P = NS; group II, 8.43 +/- 1.45 vs. 8.91 +/- 2.32, P = NS). (14)C-Methionine uptake in the granuloma was significantly lower than that in the hepatoma (1.31 +/- 0.22 vs. 2.47 +/- 0.60, P < 0.01), whereas (3)H-FLT uptake in the granuloma was comparable to that in the hepatoma (1.98 +/- 0.70 vs. 2.30 +/- 0.67, P = NS). Mean uptake of (18)F-FDG, (3)H-FLT, and (14)C-methionine was markedly lower in the turpentine oil-induced inflammation than in the tumor. CONCLUSION: (14)C-Methionine uptake was significantly lower in the granuloma than in the tumor, whereas (18)F-FDG and (3)H-FLT were not able to differentiate granulomas from tumors. These results suggest that (14)C-methionine has the potential to accurately differentiate malignant tumors from benign lesions, particularly granulomatous lesions, providing a biologic basis for clinical PET studies.

Extensive FDG uptake and its modification with corticosteroid in a granuloma rat model: an experimental study for differentiating granuloma from tumors.

INTRODUCTION: Increased (18)F-fluorodeoxyglucose (FDG) uptake in inflammatory lesions, particularly in granulomatous inflammation (e.g., sarcoidosis), makes it difficult to differentiate malignant tumors from benign lesions and is the main source of false-positive FDG-PET findings in oncology. Here, we developed a rat granuloma model and examined FDG uptake in the granuloma. The effects of corticosteroid on FDG uptake in the granuloma were compared with those in a malignant tumor. METHODS: Rats were inoculated with Mycobacterium bovis bacillus Calmette-Guérin (BCG) or allogenic hepatoma cells, and subdivided into control and pretreated (methylprednisolone acetate, 8 mg/kg i.m.) groups. Radioactivity in tissues was determined 1 h after the FDG injection. FDG-PET was performed in rats bearing BCG granulomas or tumors before and after prednisolone treatment. RESULTS: Mature epithelioid cell granuloma-formation and massive lymphocyte-infiltration were observed in the control group of granuloma, histologically similar to sarcoidosis. The mean FDG uptake in the granuloma was comparable to that in the hepatoma. Prednisolone reduced epithelioid cell granuloma-formation and lymphocyte-infiltration. Prednisolone significantly decreased the level of FDG uptake in the granuloma (52% of control), but not in the hepatoma. The FDG uptake levels in the granulomas and tumors were clearly imaged with PET. CONCLUSION: We developed an intramuscular granuloma rat model that showed a high FDG uptake comparable to that of the tumor. The effect of prednisolone pretreatment on FDG uptake was greater in the granuloma than in the tumor. These results suggest that BCG-induced granuloma may be a valuable model and may provide a biological basis for FDG studies.

A regulatory effect of the balance between TNF-alpha and IL-6 in the granulomatous and inflammatory response to Rhodococcus aurantiacus infection in mice.

After i.v. inoculation with Rhodococcus aurantiacus, wild-type (WT) mice develop nonnecrotic, epithelioid granulomas. Because a high level of TNF-alpha is observed during the initial phase postinfection, we examined the extent to which TNF-alpha contributes to granulomatous inflammation using TNF-alpha gene-deficient (TNF-alpha(-/-)) mice. Despite a lack of R. aurantiacus proliferation, TNF-alpha(-/-) mice displayed high mortality rates within 5 days postinfection, as well as a high level of IL-6 in their spleens. Histological examination showed an absence of granuloma formation in TNF-alpha(-/-) mice. Pretreatment of TNF-alpha(-/-) mice with rTNF-alpha failed to restore this granuloma formation but accelerated bacterial removal and cellular recruitment. This rTNF-alpha administration also attenuated IL-6 production, resulting in increased survival rates of TNF-alpha(-/-) mice. Heat-killed R. aurantiacus induced in vitro enhanced mRNA expression and production of IL-6 in macrophages and DCs from TNF-alpha(-/-) mice when compared with WT controls, and treatment of TNF-alpha(-/-) mouse cells with rTNF-alpha decreased the IL-6 secretion. Moreover, anti-TNF-alpha or anti-IL-6 treatment increased IL-6 or TNF-alpha production by WT mouse cells, respectively. These data suggest that the production of TNF-alpha and IL-6 can be negatively regulated by each other. Administration of rIFN-gamma to TNF-alpha(-/-) mice caused immature granulomas in livers, and treatment with both rTNF-alpha and rIFN-gamma led to the formation of mature granulomas. Overall, TNF-alpha appears crucial for bacterial clearance, cellular recruitment, and granuloma formation. The balance between TNF-alpha and IL-6 during the early phase of infection controls the development of the inflammatory response to R. aurantiacus infection.

Endogenous interleukin-6 plays a crucial protective role in streptococcal toxic shock syndrome via suppression of tumor necrosis factor alpha production.

During a Streptococcus pyogenes infection in interleukin-6 (IL-6)-deficient mice, there is elevation of serum tumor necrosis factor alpha (TNF-alpha) levels, muscular necrosis, and death compared with infection of C57BL/6 mice. Anti-TNF-alpha monoclonal antibody treatment decreased mortality and muscular necrosis in the infected IL-6-deficient mice. These results suggest that IL-6 plays a crucial protective role via suppression of TNF-alpha production in S. pyogenes infection.

Up-regulation of granulomatous inflammation in interleukin-6 knockout mice infected with Rhodococcus aurantiacus.

After intravenous injection of Rhodococcus aurantiacus normal mice develop non-necrotic granulomas, the formation of which is dependent on endogenous interferon-gamma (IFN-gamma). In the early phase of R. aurantiacus infection a high level of endogenous interleukin-6 (IL-6) is detected in the spleen extracts, though its importance is unknown. Using IL-6 knockout (IL-6-/-) mice, we studied the role of IL-6 in granulomatous inflammation induced by R. aurantiacus. The size of granulomas generated in IL-6-/- mice was significantly larger than that of wild-type (IL-6+/+) mice at 2 weeks postinjection (p.i). Moreover, central necrosis of the granuloma was observed in IL-6-/- mice but not in IL-6+/+ controls. Titres of endogenous IFN-gamma and tumour necrosis factor-alpha (TNF-alpha) were markedly increased in the spleens and livers of IL-6-/- mice in comparison with IL-6+/+ mice at days 1 through 3 p.i. In vivo administration of either an anti-IFN-gamma monoclonal antibody (mAb) or anti-TNF-alpha mAb to IL-6-/- mice reduced the number and size of granulomas, and prevented formation of necrotic granulomas. In addition, the production of endogenous IFN-gamma and TNF-alpha in the early phase of R. aurantiacus infection by IL-6-/- mice was suppressed by treatment with recombinant IL-6 (rIL-6). This suppression of IFN-gamma and TNF-alpha production was followed by a reduction in the number and size of central necrotic granulomas at 2 weeks p.i. These findings suggest that overproduction of IFN-gamma and TNF-alpha induces central necrotic granuloma formation in IL-6-/- mice, and that IL-6 down-regulates granulomatous inflammation reaction in response to R. aurantiacus infection by modulating production of IFN-gamma and TNF-alpha.

Lipopolysaccharide triggers invasive streptococcal disease in mice through a tumour necrosis factor-alpha-dependent mechanism.

Streptococcus pyogenes sometimes induces invasive streptococcal infection, including streptococcal toxic shock syndrome (STSS). Muscular necrosis is one of the peculiar symptoms of invasive streptococcal infection and STSS. We inoculated S. pyogenes into the muscles of mice. To do so, 5 x 10(8) bacteria in 0.2 ml phosphate-buffered saline were injected into the right hind thigh. None of the mice injected with the bacteria showed muscular necrosis and none died. Tumour necrosis factor-alpha (TNF-alpha) and infiltration of leucocytes were detected in the muscles of infected sites, although the condition of the infected mice did not deteriorate after anti-TNF-alpha monoclonal antibody treatment. The infected mice treated intraperitoneally with Escherichia coli lipopolysaccharide (LPS) showed augmentation of bacterial growth, muscular necrosis and death. TNF-alpha was detected in the sera of the infected mice treated with LPS, but not in the muscles of the infected sites. Infiltration of leucocytes into the infected muscle was not observed in the infected mice treated with LPS. Anti-TNF-alpha monoclonal antibody treatment decreased mortality in the infected mice treated with LPS. Moreover, the infected mice treated with recombinant TNF-alpha showed augmentation of muscular necrosis and death. These results suggest that systemic production of TNF-alpha induced by stimulation with LPS inhibits infiltration of leucocytes into the infected site and exacerbates muscular infection, and that TNF-alpha produced in streptococcal infection is not a defence factor for the host. Invasive streptococcal infection and STSS appear to be induced by both S. pyogenes and the host's immune system.