Sphingosine-1-Phosphate (S1P) Is a Feasible Biomarker in Predicting the Efficacy of Polymyxin B-Immobilized Fiber Direct Hemoperfusion (PMX-DHP) in Patients with Septic Shock.

PURPOSE: The aim of this study was to identify a useful biomarker to predict the efficacy of polymyxin B-immobilized fiber direct hemoperfusion (PMX-DHP) in patients with septic shock. METHODS: The 44 patients included in this study were divided into two groups. Group A had an increase in systolic blood pressure (SBP) over 30 mmHg after PMX-DHP treatment. Group B had an increase in SBP less than 30 mmHg after PMX-DHP treatment. We evaluated the clinical characteristics and demographics of both groups. We also assessed whether the cause of sepsis affected the efficacy of PMX-DHP and compared the prognosis of both groups. Finally, we investigated whether there were any significant differences in the levels of sepsis-related biomarkers, including sphingosine-1-phosphate (S1P), between both groups before PMX-DHP in an effort to identify a biomarker that could predict the efficacy of PMX-DHP. RESULTS: PMX-DHP significantly increased SBP regardless of the cause of sepsis. Although there was some tendency, PMX-DHP did not significantly improve the prognosis of effective cases in comparison with non-effective cases, probably because of the limited number of patients included. Among the sepsis-related biomarkers, only S1P values were significantly different between the two groups before PMX-DHP, and S1P levels were significantly increased after treatment in the effective cases. CONCLUSION: S1P levels prior to PMX-DHP can be used to predict its efficacy. In addition, continuous monitoring of S1P levels can indicate the effectiveness of PMX-DHP in patients with septic shock.

Acceleration of small bowel motility after oral administration of dai-kenchu-to (TJ-100) assessed by cine magnetic resonance imaging.

Dai-kenchu-to (TJ-100) is an herbal medicine used to shorten the duration of intestinal transit by accelerating intestinal movement. However, intestinal movement in itself has not been evaluated in healthy volunteers using radiography, fluoroscopy, and radioisotopes because of exposure to ionizing radiation. The purpose of this study was to evaluate the effect of TJ-100 on intestinal motility using cinematic magnetic resonance imaging (cine MRI) with a steady-state free precession sequence. Ten healthy male volunteers received 5 g of either TJ-100 or lactose without disclosure of the identity of the substance. Each volunteer underwent two MRI examinations after taking the substances (TJ-100 and lactose) on separate days. They drank 1200 mL of tap water and underwent cine MRI after 10 min. A steady-state free precession sequence was used for imaging, which was performed thrice at 0, 10, 20, 30, 40, and 50 min. The bowel contraction frequency and distention score were assessed. Wilcoxon signed-rank test was used, and differences were considered significant at a P-value <0.05. The bowel contraction frequency tended to be greater in the TJ-100 group and was significantly different in the ileum at 20 (TJ-100, 8.95 ± 2.88; lactose, 4.80 ± 2.92; P < 0.05) and 50 min (TJ-100, 9.45 ± 4.49; lactose, 4.45 ± 2.65; P < 0.05) between the groups. No significant differences were observed in the bowel distention scores. Cine MRI demonstrated that TJ-100 activated intestinal motility without dependence on ileum distention.

Combination therapy of 15-epi-lipoxin A4 with antibiotics protects mice from Escherichia coli-induced sepsis*.

OBJECTIVES: Inflammation occurs along with infection during sepsis. 15-Epi-lipoxin A4 has protective and resolving effects in experimental models of infection. In this study, we examined the effects of 15-epi-lipoxin A4 combined with antibiotics on Escherichia coli-induced peritonitis. DESIGN: Prospective experimental study. SETTING: University research laboratory. SUBJECTS: Male C57BL/6 mice. INTERVENTIONS: Mice were injected with E. coli to induce peritonitis and were given either 15-epi-lipoxin A4 (1 µg/mouse) or placebo (saline) with antibiotics (ceftazidime). The effects of 15-epi-lipoxin A4 on peritoneal cell populations, bacterial burden, and cytokine production were assessed. Survival rates were observed for up to 7 days. In addition, we examined the effects of 15-epi-lipoxin A4 on peritoneal macrophages stimulated with lipopolysaccharide, CpG DNA, or live E. coli. MEASUREMENTS AND MAIN RESULTS: Treatment with 15-epi-lipoxin A4 significantly reduced the number of neutrophils in the peritoneum, inhibited production of cytokines and chemokines, and decreased bacterial load in the serum. Combined treatment of 15-epi-lipoxin A4 with antibiotics significantly improved survival in E. coli-infected mice. 15-Epi-lipoxin A4 also attenuated the production of interleukin-6 and tumor necrosis factor-α by lipopolysaccharide- or CpG DNA-stimulated peritoneal macrophages. Furthermore, 15-epi-lipoxin A4 combined with antibiotics synergistically reduced the production of interleukin-6 and tumor necrosis factor-α by peritoneal macrophages stimulated with live E. coli. CONCLUSIONS: 15-Epi-lipoxin A4 combined with antibiotics attenuated systemic inflammation, inhibited bacteria dissemination, and improved survival in E. coli-infected mice. The reduced production of interleukin-6 and tumor necrosis factor-α by peritoneal macrophages suggested that 15-epi-lipoxin A4 blocked the initial proinflammatory response. Taken together, these data suggested that 15-epi-lipoxin A4 combined with antibiotics was beneficial in regulating the proinflammatory response in sepsis without exacerbating infection.

Diagnostic potential of endotoxin scattering photometry for sepsis and septic shock.

Endotoxin scattering photometry (ESP) is a novel Limulus amebocyte lysate (LAL) assay that uses a laser light-scattering particle-counting method. In the present study, we compared ESP, standard turbidimetric LAL assay, and procalcitonin assay for the evaluation of sepsis after emergency gastrointestinal surgery. A total of 174 samples were collected from 40 adult patients undergoing emergency gastrointestinal surgery and 10 patients with colorectal cancer undergoing elective surgery as nonseptic controls. Plasma endotoxin levels were measured with ESP and turbidimetric LAL assay, and plasma procalcitonin levels were assessed with a standard procalcitonin assay. Plasma endotoxin and procalcitonin levels increased corresponding to the degree of sepsis. Endotoxin scattering photometry significantly discriminated between patients with or without septic shock: sensitivity, 81.1%; specificity, 76.6%; positive predictive value, 48.4%; negative predictive value, 93.8%; and accuracy, 77.6%. The area under the receiver operating characteristic curve for septic shock with the ESP assay (endotoxin cutoff value, 23.8 pg/mL) was 0.8532 ± 0.0301 (95% confidence interval, 0.7841-0.9030; P < 0.0001). The predictive power of ESP was superior to that of turbidimetric assay (difference, 0.1965 ± 0.0588; 95% confidence interval, 0.0812-0.3117; P = 0.0008). There was no significant difference in predictive power between ESP and procalcitonin assay. Endotoxin scattering photometry also discriminated between patients with and without sepsis. Area under the receiver operating characteristic curve analysis showed that ESP had the best predictive power for diagnosing sepsis. In conclusion, compared with turbidimetric LAL assay, ESP more sensitively detected plasma endotoxin and significantly discriminated between sepsis and septic shock in patients undergoing gastrointestinal emergency surgery.

The ability of endotoxin adsorption during a longer duration of direct hemoperfusion with a polymyxin B-immobilized fiber column in patients with septic shock.

The patients' hemodynamic conditions of septic shock due to intra-abdominal infection were improved by the longer duration of direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX), reducing plasma endotoxins measured by the novel endotoxin detection method, named endotoxin scattering photometry (ESP) method; however, turbidimetric method could not detect endotoxins. We also observed the reduction in the endotoxin after passing through column by ESP method even after the longer duration of PMX. ESP method may more sensitively detect endotoxins than the ordinary turbidimetric method. Moreover, we demonstrated the ability of endotoxin adsorption in spite of the longer duration of PMX.

Time to initiation of treatment with polymyxin B cartridge hemoperfusion in septic shock patients.

BACKGROUND: We investigated whether early initiation of hemoperfusion with a polymyxin B cartridge (PMX) after the diagnosis of septic shock could improve the clinical outcome. METHODS: A prospective, open-labeled, multicenter cohort study was performed at intensive care units in Japan. 41 patients received PMX within 6 h after the diagnosis of septic shock (early group) and 51 patients were treated after 6 h (late group). RESULTS: The early group had a significantly shorter duration of ventilator support and also had a lower catecholamine requirement. PMX was effective for improvement of hypotension, hypoperfusion, the sequential organ failure assessment score, and pulmonary oxygenation regardless of the timing of its initiation. The 28-day mortality rate did not differ between the two groups. CONCLUSIONS: Early initiation of PMX shortened the duration of ventilator support and also reduced the catecholamine requirement, so early treatment of septic shock should achieve a better outcome.

Bacteremia and endotoxemia after endoscopic submucosal dissection for gastric neoplasia: pilot study.

BACKGROUND: Because the invasive procedure of endoscopic submucosal dissection (ESD) entails a large mucosal defect which is left open, with extensive submucosal exposure to the indigenous bacterial flora, the procedure may have a substantial risk for bacteremia. Our aim was to examine gastric ESD-related bacteremia and endotoxemia in gastric neoplasia patients. METHODS: In patients who underwent ESD for superficial gastric neoplasia, blood cultures and plasma endotoxin measurements were done before, immediately after, and on day 2 after ESD. Clinically manifest infections and inflammatory markers, including C-reactive protein (CRP) and white blood cells, were monitored. RESULTS: Fifty patients (aged 69 ± 8 years; mean ± SD) were enrolled. The diameter of the resected specimens was 38 ± 18 mm and the procedure time of ESD was 66 ± 53 min. Two percent (2/100) of blood cultures after ESD were positive, with findings as follows: Propionibacterium species immediately after ESD, and Enterobacter aerogenes on day 2 after ESD, but no clinically manifest infection was observed. In 30% of the enrolled patients, CRP on day 2 after ESD had increased to levels higher than 1.0 mg/l. Plasma endotoxin levels, immediately after and on day 2 after ESD were correlated with CRP levels on day 2 after ESD. CONCLUSIONS: In spite of the invasive procedure with massive submucosal exposure to the indigenous bacterial flora, gastric ESD has a low risk for bacteremia. Gastric ESD-related endotoxemia may be linked to inflammatory reactions such as those shown by the increase of CRP or fever observed after ESD.

Low-grade endotoxemia contributes to chronic inflammation in hemodialysis patients: examination with a novel lipopolysaccharide detection method.

Chronic inflammation has recently been proposed to play a major role in the development of cardiovascular disease and mortality among advanced chronic kidney disease (CKD) patients; however, why advanced CKD promotes chronic inflammation is still unclear. We hypothesized that a very low level of plasma endotoxin (lipopolysaccharide [LPS]) contributes to chronic inflammation in advanced CKD patients. We measured the plasma LPS levels using a novel LPS detection method (ESP method, a method for endotoxin detection using laser scattering photometry) concurrently with serum C-reactive protein (CRP) levels and various blood tests in 17 stable hemodialysis (HD) patients. As a result, the median LPS levels measured by the ESP method was 0.23 pg/mL (range, 0.01-3.89) (inflow, start of HD), 0.22 pg/mL (<0.01-9.97) (outflow, start of HD), 0.37 pg/mL (<0.01-7.42) (inflow, end of HD), and 1.07 pg/mL (<0.01-10.66) (dialysate), respectively; statistically significant differences were not detected between them. The predialysis median CRP level was 0.19 mg/dL (0.04-3.02). The logarithm of plasma LPS independently correlated with serum CRP (R = 0.595, P = 0.0103). In multiple (forward stepwise) regression analysis, in which CRP was determined to be the criterion variable, LPS (log), albumin, and the white blood cell count were adopted as independent explanatory variables (R = 0.401, -0.397 and 0.387, respectively). In conclusion, the present study revealed a significant relationship between LPS and CRP using the novel ESP method, and suggested that very low-grade endotoxemia is contributing to systemic inflammation in HD patients.

Effectiveness of early start of direct hemoperfusion with polymyxin B-immobilized fiber columns judging from stabilization in circulatory dynamics in surgical treatment patients.

BACKGROUND: Septic shock remains a major cause of multiple organ failure and is associated with a high mortality rate. In 1994, direct hemoperfusion using a polymyxin B-immobilized fiber column (PMX; Toray Industries Inc., Tokyo Japan) was developed in Japan and has since been used for the treatment of septic shock arising from endotoxemia. MATERIALS AND METHOD: We treated 36 patients with septic shock using direct hemoperfusion with PMX. The patients were analyzed in two groups based on whether they had undergone surgery prior to DHP-PMX treatment (surgical group: surgical treatment before DHP-PMX, medical group: no surgical treatment). In surgical group, DHP-PMX was started within three hours after the surgical treatment. Various factors were measured before and after DHP-PMX. RESULTS: The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 27.4 +/- 8.8, and the mean sepsis-related organ failure assessment (SOFA) score was 11.8 +/- 4.9 before DHP-PMX. The SOFA score was significantly higher (P = 0.0091) and the PaO2/FiO2 ratio (P/F ratio) was significantly lower (P = 0.0037) in medical group than in surgical group prior to DHP-PMX. A chi-square test showed that the survival rate in surgical group was significantly better than in medical group (P = 0.0027). The survival rate of surgical group (84.2%) was judged to be very good because the predicated survival rate based on the APACHE II score (25.0) was only 46.5%. On the other hand, the survival rate of medical group (35.3%) was almost equal to that predicted by the APACHE II score (30.6; predicted survival rate, 27.4%). CONCLUSION: The results of this study suggest the utility of early DHP-PMX in surgical group.

Effectiveness of endotoxin scattering photometry for determining the efficacy of polymyxin B-immobilized fiber treatment in septic shock: report of a case.

The limulus test, which has been established as a test for endotoxin measurement, is associated with problems, including that posed by the presence of a response inhibitor factor and the longer time needed for the measurement of low concentrations. On the other hand, the technique of direct hemoperfusion with a polymyxin B immobilized fiber column (DHP-PMX) was developed in Japan in 1994 and has been used for the control of endotoxemia in septic shock. The limulus test, which is a common endotoxin measurement test, has several problems with regard to sensitivity. Therefore, this test is no longer used to determine the effectiveness of DHP-PMX. Here, we describe a patient presenting with colonic perforation who recovered from septic shock with DHP-PMX. This treatment effect was reflected by a decrease in plasma endotoxin levels as demonstrated more readily with endotoxin scattering photometry assay than with the standard limulus test. We conclude that endotoxin measurement with endotoxin scattering photometry is superior to nephelometry in patients with endotoxemia.

Buccal administration of dexmedetomidine as a preanesthetic in children.

PURPOSE: The objective of this study was to evaluate the efficacy and safety of buccal dexmedetomidine as a preanesthetic in children, to compare it with diazepam, and to investigate the optimal dosage for buccal dexmedetomidine administration by measuring its serum concentration. METHODS: We performed a prospective study with 40 children who were assigned to two groups. The patients underwent an operation for inguinal or umbilical hernia. Twenty children received dexmedetomidine buccally at 3-4 microg/kg (Dex Group) and 20 received a diazepam suppository at 0.7 mg/kg (Diazepam Group) as preanesthetics 1 h before the operation. Heart rate, systolic blood pressure, SpO2, and respiratory rate were measured 1 h after premedication in all children. Sedation level was preoperatively evaluated, and compared with the Ramsay score, in the ward, at the entrance to the main operating rooms, and at anesthesia induction between the two groups. To investigate the optimal dosage of buccal dexmedetomidine, we compared the mean serum concentration of dexmedetomidine at induction between patients with a Ramsay score of 5 or greater and those with a Ramsay score less than 5. The Mann-Whitney U test was used for statistical analysis. RESULTS: There was no significant difference between the two groups in age or body weight. Furthermore, there was no significant difference between the two groups in heart rate, systolic blood pressure, SpO2, or respiratory rate after administration of either medication. The Ramsay score of the Dex Group was significantly higher than that of the Diazepam Group at all times. The mean serum dexmedetomidine concentration at induction in patients with a Ramsay score of 5 or greater (75 +/- 50 pg/ml) was significantly higher than in those with a Ramsay score less than 5 (34 +/- 36 pg/ml, P < 0.05). CONCLUSION: These results suggest that the buccal administration of dexmedetomidine (3-4 microg/kg) 1 h before the operation can be safely and effectively applied as a preanesthetic in children.

Increased isoprostane levels in oleic acid-induced lung injury.

The present study was performed to examine a role of oxidative stress in oleic acid-induced lung injury model. Fifteen anesthetized sheep were ventilated and instrumented with a lung lymph fistula and vascular catheters for blood gas analysis and measurement of isoprostanes (8-epi prostaglandin F2alpha). Following stable baseline measurements, oleic acid (0.08 ml/kg) was administered and observed 4 h. Isoprostane was measured by gas chromatography mass spectrometry with the isotope dilution method. Isoprostane levels in plasma and lung lymph were significantly increased 2 h after oleic acid administration and then decreased at 4 h. The percent increases in isoprostane levels in plasma and lung lymph at 2 h were significantly correlated with deteriorated oxygenation at the same time point, respectively. These findings suggest that oxidative stress is involved in the pathogenesis of the pulmonary fat embolism-induced acute lung injury model in sheep and that the increase relates with the deteriorated oxygenation.

Antimicrobial cathelicidin polypeptide CAP11 suppresses the production and release of septic mediators in D-galactosamine-sensitized endotoxin shock mice.

Endotoxin shock is a severe systemic inflammatory response that is caused by the augmented production and release of septic mediators. Among them, inflammatory cytokines such as tumor necrosis factor-alpha, IL-1beta and IL-6 play a pivotal role. In addition, anandamide, an endogenous cannabinoid and high-mobility group box-1 (HMGB1), a non-histone chromosomal protein has recently been recognized as members of septic mediators. We previously reported that cationic antibacterial polypeptide of 11-kDa (CAP11), an antimicrobial cathelicidin peptide (originally isolated from guinea pig neutrophils), potently neutralizes the biological activity of LPS and protects mice from lethal endotoxin shock. In this study, to clarify the protective mechanism of CAP11 against endotoxin shock, we evaluated the effects of CAP11 on the production and release of septic mediators in vitro and in vivo using a murine macrophage cell line RAW264.7 and a D-galactosamine-sensitized murine endotoxin shock model. LPS stimulation induced the production of inflammatory cytokines and anandamide and release of HMGB1 from RAW264.7 cells. Importantly, CAP11 suppressed the LPS-induced production and release of these mediators by RAW264.7 cells. Moreover, LPS administration enhanced the serum levels of HMGB1, anandamide and inflammatory cytokines in the endotoxin shock model. Of note, CAP11 suppressed the LPS-induced increase of these mediators in sera, and LPS binding to CD14-positive cells (peritoneal macrophages), accompanied with the increase of survival rates. Together these observations suggest that the protective action of CAP11 on endotoxin shock may be explained by its suppressive effect on the production and release of septic mediators by CD14-positive cells possibly via the inhibition of LPS binding to the targets.

Novel endotoxin assay by laser light-scattering particle-counting method.

Exposure of Limulus amoebocyte lysate to endotoxin under stirring produced light-reflective particles that appeared to be coagulin polymers. A laser light-scattering particle counter, the PA-200, detected these particles sensitively. The PA-200 detected endotoxin at a concentration as low as 0.00015 EU/ml in 71 min, whereas the minimum endotoxin concentration measured by a turbidimeter, ET-2000, was 0.0005 EU/ml in 138 min. Moreover, PA-200 was much less affected by the presence of colored substances and refractive materials than was ET-2000. We propose that the high sensitivity, speed, and high interference tolerance of the laser light-scattering particle-counting method make it more useful than the widely used turbidimetric method for quantitative endotoxin assay.

Activated endocannabinoid system in coronary artery disease and antiinflammatory effects of cannabinoid 1 receptor blockade on macrophages.

BACKGROUND: Cannabinoid 1 (CB1) receptor blockade with rimonabant represents a clinical therapeutic strategy for obesity. Recently, the role of the endocannabinoid system has been described in peripheral organs. We sought to determine whether the endocannabinoid system could be involved in human atherosclerosis and whether CB1 receptor blockade could modulate proinflammatory activity in macrophages. METHODS AND RESULTS: mRNA expression levels of CB1 receptor in coronary atherectomy samples were significantly higher in patients with unstable angina than in those with stable angina (3.62+/-2.96-fold; n=7; P<0.05). Immunoreactive area analysis of the coronary artery showed that CB1 receptor expression was greater in lipid-rich atheromatous plaques than in fibrous plaques, especially in CD68 macrophages (9.5+/-1.2% versus 0.6+/-0.6%; n=5; P<0.01). Levels of blood endocannabinoids were significantly higher in patients with coronary artery disease (n=20) than those without coronary artery disease (n=20) (median [interquartile range]: anandamide, 1.048 pmol/mL [0.687 to 1.387 pmol/mL] versus 0.537 pmol/mL [0.468 to 0.857 pmol/mL], P<0.01; 2-arachidonoyl glycerol, 13.30 pmol/mL [6.65 to 16.21 pmol/mL] versus 7.67 pmol/mL [6.39 to 10.03 pmol/mL], P<0.05). In cultured macrophages, expression of CB1 receptor was significantly increased during monocyte-macrophage differentiation (1.78+/-0.13-fold; n=6; P<0.01). CB1 receptor blockade in macrophages induced a significant increase in cytosolic cAMP (29.9+/-13.0%; n=4; P<0.01), inhibited phosphorylation of c-Jun N-terminal kinase (-19.1+/-12.6%, n=4; P<0.05), and resulted in a significant decrease in the production of proinflammatory mediators (interleukin-1beta, -28.9+/-10.9%; interleukin-6, -24.8+/-7.6%; interleukin-8, -22.7+/-5.2%; tumor necrosis factor-alpha, -13.6+/-4.8%; matrix metalloproteinase-9, -16.4+/-3.8%; n=4 to 8; P<0.01). CONCLUSIONS: Patients with coronary artery disease demonstrated the activation of the endocannabinoid system with elevated levels of blood endocannabinoids and increased expression of CB1 receptor in coronary atheroma. CB1 receptor blockade exhibited antiinflammatory effects on macrophages, which might provide beneficial effects on atherogenesis.

Removal of 2-arachidonylglycerol by direct hemoperfusion therapy with polymyxin B immobilized fibers benefits patients with septic shock.

Arachidonylethanolamide (AEA) and 2-arachidonylglycerol (2-AG) are endocannabinoids involved in septic shock, and 8-epi prostaglandin F2alpha (F2-isoprostane) is a biomarker of oxidative stress in biological systems. Because the antibiotic polymyxin B absorbs endocannabinoids as well as endotoxins, direct hemoperfusion therapy with polymyxin B-immobilized fibers (PMX-DHP) decreases serum levels of endocannabinoids. To investigate the features of sepsis and determine the proper use of PMX-DHP, we measured the changes in levels of endocannabinoids and F2-isoprostane in patients with septic shock. Twenty-six patients with septic shock, including those with septic shock induced by peritonitis, underwent laparotomy for drainage. Endocannabinoids absorption with PMX-DHP was examined in two groups of patients: patients whose mean arterial blood pressure (mABP) had increased more than 20 mm Hg (responder group; N = 13); and patients iwhose mABP did not increase or had increased no more than 20 mm Hg (non-responder group; N = 13). Levels of AEA did not change after PMX-DHP in either the non-responder or responder groups, whereas levels of 2-AG decreased significantly after PMX-DHP in the responder group, but not in the non-responder group. F2-isoprostane gradually increased after PMX-DHP treatment; on the other hand, levels of F2-isoprostane remained constant in the responder group. Patients with septic shock are under considerable oxidative stress, and 2-AG plays an important role in the cardiovascular status of these patients. The removal of 2-AG by PMX-DHP benefits patients with septic shock by stabilizing cardiovascular status and decreasing long-term oxidative stress.

Relationship between treatment resistance to hemoperfusion using a polymyxin B-immobilized fiber column and oxidative stress.

Recently, the existence of a relationship was reported between the severity of lung injury and the serum level of F2-isoprostane, a known oxidative stress marker. Recent reports have suggested that direct hemoperfusion with a polymyxin B-immobilized fiber column (DHP-PMX) may improve the oxygenation in patients with acute lung injury and acute respiratory distress syndrome. Because cases of septic shock associated with respiratory diseases have poor outcomes, we selected cases of septic shock associated with respiratory disease to review the characteristics of the treatment-resistant cases. We treated 13 septic shock cases due to respiratory disease using DHP-PMX. The patients were separated into 2 groups for analysis from oxygenation effect immediately after DHP-PMX: A group (7 cases) PaO2/FiO2 ratio increased more than 20%; B group (6 cases) PaO2/FiO2 ratio did not increase more than 20%. Factors were measured before DHP-PMX. The average Acute Physiology and Chronic Health Evaluation II score was 31.2 +/- 9.4, and the average sequential organ failure assessment score was 15.1 +/- 5.3 before DHP-PMX. Four patients survived and 9 died. Only the F2-Isoprostane level was significantly high in B group (p = 0.0228). A relationship between F2-Isoplostane and rebellious cases by DHP-PMX in severe respiratory disease patients became clear.

Interaction of alpha1-adrenoceptor subtypes with different G proteins induces opposite effects on cardiac L-type Ca2+ channel.

We examined the effect of alpha(1)-adrenoceptor subtype-specific stimulation on L-type Ca2+ current (I(Ca)) and elucidated the subtype-specific intracellular mechanisms for the regulation of L-type Ca2+ channels in isolated rat ventricular myocytes. We confirmed the protein expression of alpha(1A)- and alpha(1B)-adrenoceptor subtypes at the transverse tubules (T-tubules) and found that simultaneous stimulation of these 2 receptor subtypes by nonsubtype selective agonist, phenylephrine, showed 2 opposite effects on I(Ca) (transient decrease followed by sustained increase). However, selective alpha(1A)-adrenoceptor stimulation (> or =0.1 micromol/L A61603) only potentiated I(Ca), and selective alpha(1B)-adrenoceptor stimulation (10 mumol/L phenylephrine with 2 micromol/L WB4101) only decreased I(Ca). The positive effect by alpha(1A)-adrenoceptor stimulation was blocked by the inhibition of phospholipase C (PLC), protein kinase C (PKC), or Ca2+/calmodulin-dependent protein kinase II (CaMKII). The negative effect by alpha(1B)-adrenoceptor stimulation disappeared after the treatment of pertussis toxin or by the prepulse depolarization, but was not attributable to the inhibition of cAMP-dependent pathway. The translocation of PKCdelta and epsilon to the T-tubules was observed only after alpha(1A)-adrenoceptor stimulation, but not after alpha(1B)-adrenoceptor stimulation. Immunoprecipitation analysis revealed that alpha(1A)-adrenoceptor was associated with G(q/11), but alpha(1B)-adrenoceptor interacted with one of the pertussis toxin-sensitive G proteins, G(o). These findings demonstrated that the interactions of alpha(1)-adrenoceptor subtypes with different G proteins elicit the formation of separate signaling cascades, which produce the opposite effects on I(Ca). The coupling of alpha(1A)-adrenoceptor with G(q/11)-PLC-PKC-CaMKII pathway potentiates I(Ca). In contrast, alpha(1B)-adrenoceptor interacts with G(o), of which the betagamma-complex might directly inhibit the channel activity at T-tubules.

Effectiveness of continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter after polymyxin B-immobilized fiber column therapy of septic shock.

Septic shock is a condition associated with diffuse coagulopathy and multiple organ failure, and frequently ends in death. Direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) was first developed in Japan in 1994 and has since been used for the treatment of septic shock. On the other hand, the effectiveness of continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA- CHDF) for critically ill patients has also been reported. We treated 27 septic shock patients by DHP-PMX. The patients, except for the nine in whom CHDF was not performed after DHP-PMX, were divided into two groups: namely, a group in which PMMA-CHDF therapy was added after DHP-PMX (11 cases), and a group in which continuous hemodiafiltration using a polyacrylonitrile membrane hemofilter (PAN-CHDF) therapy was added after DHP-PMX (7 cases). The outcomes in the two groups were compared. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score and the average sepsis-related organ failure assessment (SOFA) score were not significantly different between the two groups. The PMMA-CHDF group showed significantly better outcomes, with significant improvements of the serum PAI-1, protein C, IL-6 and N-arachidonoylethanolamine (AEA) levels. We conclude that PMMA-CHDF may be more effective than PAN-CHDF in the management of septic shock.

Clinical responses and improvement of some laboratory parameters following polymyxin B-immobilized fiber treatment in septic shock.

Direct hemoperfusion using a polymyxin B-immobilized fiber column (PMX; Toray Industries Inc., Tokyo, Japan) was first developed in 1994 and has since been used for the treatment of septic shock. Positive clinical data, such as an increase in systolic blood pressure (SBP) and an improved Pao2/Fio2 ratio, have also been reported. We treated 27 septic shock patients using DHP-PMX. The patients were separated into two groups for analysis: those whose Pao2/Fio2 ratio increased after DHP-PMX (9 cases) and those whose Pao2/Fio2 ratio did not increase after DHP-PMX (18 cases). The patients were also separated into two other groups for analysis: those whose SBP increased by more than 30 mm Hg immediately after DHP-PMX (15 cases) and those whose SBP did not increase by more than 30 mm Hg after DHP-PMX (12 cases). The Pao2/Fio2 ratio increased significantly after DHP-PMX in the groups showing improved 2AG and PAI-1 levels (p = 0.0040). The SBP increased significantly in the group showing improved HMGB-1 levels (p < 0.0001). We observed a relationship between hemodynamic improvement and increase of the serum HMGB-1 levels and between improvement of respiratory functions and increase of the serum 2-AG and PAI-1 levels in septic shock patients treated with DHP-PMX.