[Intrathoracic blood volume index as an indicator of fluid management in septic shock].

OBJECTIVE: To investigate the value of intrathoracic blood volume index (ITBVI) monitoring in fluid management strategy in septic shock patients. METHODS: In a prospective study, 33 patients who were diagnosed to be suffering from septic shock in the intensive care unit (ICU) were enrolled . Seventeen patients who received pulse indicator continuous cardiac output (PiCCO) monitoring, and ITBVI was used as indicator of fluid management, were enrolled into ITBVI group; 16 patients who received traditional fluid management strategy [directed by central venous pressure (CVP)] were enrolled into control group. Acute physiology and chronic health evaluation II (APACHEII) score, sepsis related organ failure assessment (SOFA) score and vasopressor score were compared between 1 day and 3 days of treatment. The characteristics of fluid management were recorded and compared within 72 hours. RESULTS: (1)In 3 days of treatment, APACHEII, SOFA and vasopressor score were significantly lower in ITBVI group compared with that of in 1 day of treatment[21.3±6.2 vs. 25.4±7.2, 6.1±3.4 vs. 9.0±3.5, 5 (0, 8.0) vs. 20.0 (8.0, 35.0), respectively, all P<0.01], whereas there were no changes in control group. (2)Although fluid output (ml) was higher in ITBVI group during 48-72 hours period (2 421± 868 vs. 1 721±934, P=0.039), there was no difference in fluid intake, fluid output or fluid balance (ml) within 0-72 hours between two groups (fluid intake: 9 918±137 vs. 10 529±1 331, fluid output : 6 035±1 739 vs. 5 827±2 897, fluid balance: 3 882±1 889 vs. 4 703±2 813, allP>0.05). (3)Comparing the fluid volume (ml) used for fluid replacement period, except that there was no significance in fluid challenge with colloid during 0-6 hours between two groups [ml: 250 (125, 500) vs. 250 (69,250), P>0.05], more fluid intake (ml) was found in ITBVI group [0-6 hours crystalloid: 250(150,250) vs. 125 (105,125), 6-72 hours crystalloid: 125 (125, 250) vs. 100 (56, 125), 0-72 hours crystalloid: 250(125, 250) vs. 125 (75, 125), 6-72 hours colloid: 125 (106, 250) vs. 75 (50, 125), 0-72 hours colloid: 200 (125, 250) vs. 100 (50, 125),all P<0.01]. CONCLUSION: Clinical picture in patients with septic shock is improved after 3 days of treatment than 1 day of treatment under fluid management directed by ITBVI, compared with by CVP. This improvement may be attributable to accurate assessment of preload and appropriate infusion rate in fluid challenge.

HSP70 and mucin 5B: novel protein targets of N,N'-dinitrosopiperazine-induced nasopharyngeal tumorigenesis.

N,N'-Dinitrosopiperazine (DNP) induces nasopharyngeal carcinoma (NPC) and shows organ specificity to the nasopharyngeal epithelium. To investigate its mechanism, the rat NPC model was induced using DNP. Rat NPC and normal nasopharyngeal cells were obtained from the NPC model using laser capture. The total proteins from these cell samples were separated with two-dimension polyacrylamide gel electrophoresis techniques, and highly expressed proteins (> five-fold) were analyzed using matrix-assisted laser desorption/ionization time of flight and bioinformatics. The results showed that HSP70 and mucin 5B expression increased not only in rat NPC but also in atypical hyperplasia nasopharyngeal tissues, a precancer stage of NPC. High-expression of heat shock protein 70 (HSP70) and mucin 5B was further supported by western blot analysis. The immunofluorescence and western-blotting studies further showed that DNP induced the expression of HSP70 and mucin 5B in a dosage-dependent manner in normal nasopharyngeal epithelia cells. Our data indicate that DNP triggers over-expression of HSP70 and mucin 5B, and is involved in nasopharyngeal tumorigenesis. HSP70 and mucin 5B may be important targets in nasopharyngeal tumorigenesis induced by DNP.

Calcitonin gene-related peptide increases proliferation of human HaCaT keratinocytes by activation of MAP kinases.

Psoriasis is a chronic disease characterized by keratinocyte hyperproliferation and inflammation. It has been demonstrated that the expression of calcitonin gene-related peptide (CGRP) is elevated in psoriasis lesions and CGRP-containing neuropeptide nerve fibers are denser in the psoriatic epidermis. CGRP has been previously described to influence proliferation of several cell types, such as Schwann cell, tracheal epithelial cells, and human gingival fibroblasts. In the present study, we determined the effect of CGRP on HaCaT keratinocyte proliferation and the role of mitogen-activated protein kinases (MAPKs) in CGRP induced keratinocyte proliferation. Our data indicate CGRP increased [(3)H]-thymidine incorporation and MTT activity of HaCaT in a concentration-dependent manner. CGRP also enhanced serum-induced HaCaT cell proliferation. HaCaT cells cultured with CGRP had a significant increase in phosphorylated ERK1/2, p38 and JNK, and CGRP induced DNA synthesis was inhibited by PD 98059 or SB 203580, selective inhibitors of MAP kinase kinase (MEK, which is upstream from ERK) and p38, respectively. These findings suggest that HaCaT cell proliferate in response to CGRP, which is mediated by phosphorylation of ERK1/2 and p38 MAPK.

[Evaluation of compliance with bundle treatment in the management of severe infection].

OBJECTIVE: To evaluate compliance with bundle treatment in the management of severe infection in a tertiary hospital, aiming at analyzing clinical data in order to popularize guidelines for management of severe sepsis and septic shock. METHODS: A 14-month (from November 1, 2006 to December 31, 2007) prospective observational study of a group of 43 patients admitted to the respiratory intensive care unit in First Affiliated Hospital (tertiary hospital) of Guangzhou Medical College meeting the criteria for severe pneumonia and septic shock was carried out. Implementation of 6-hour and 24-hour bundle treatment for severe infection was divided into three phases consisting of education, trial, and application. A cohort of 43 patients with matched disease history admitted during January 1, 2004 to October 31, 2006 were enrolled as control group. RESULTS: (1) In 6-hour bundle treatment for severe infection, 20.9% (9/43) had serum lactate measured, blood culture was obtained prior to antibiotic administration in 7.0% (3/43) of patients, 100% (43/43) had empirical antibiotics administration within 1 hour, an infusion of an initial minimum of 20 ml/kg of crystalloid or colloid equivalent (1.1 ml/kg of 20% albumin or 4.8 ml/kg of 6% hydroxyethyl starch) was given in 44.2% (19/43), with infused fluid (converted into 6% hydroxyethyl starch) reaching (503.95+/-176.19) ml within 6 hours, in 94.7% (18/19) of patients had received vasopressors , and inotropic dobutamine and/or transfusion of packed red blood cells were administered in 7.0% (3/43). (2) In 24-hour bundle treatment for severe infection group, 31.6% (6/19) had received low-dose steroids, 34.9% (15/43) had their blood glucose controlled<8.3 mmol/L, mechanical ventilation with inspiratory plateau pressures maintained<30 cm H(2)O (1 cm H(2)O=0.098 kPa, 6 ml/kg tidal volume) was instituted in 97.6% (40/41) of patients. (3) The percentage of compliance with 6-hour and 24-hour bundle treatment for severe infection were 0 and 21.4% respectively, total compliance was also 0. (4) As compared with control group, a 23.30% absolute mortality reduction was found in bundle group (18.6% vs. 41.9%, P=0.019). CONCLUSION: Bundle treatment for severe infection is complied with partially in our hospital, suggesting that it is still quite arduous to popularize guidelines for management of severe sepsis and septic shock in our country.

[Severe respiratory failure after injection of botulinum toxin: case report and review of the literature].

OBJECTIVE: To describe the manifestations and management of respiratory failure caused by cosmetic injections of botulinum toxin type A (BTA). METHODS: A case of severe respiratory failure after cosmetic injections of BTA was reported and the literature was reviewed. RESULTS: A 24 year old female, seeking leg cosmetic therapy, received multiple point dorsal intramuscular injection of BTA (200 Units) in the legs. Two days later, 100 unit BTA was injected in the same sites. After the first injection, the patient felt no discomfort. But after the second injection, the patient developed diplopia and malaise but without breathlessness. Gradually, ptosis, dysphagia, and tetraparesis developed, and the patient felt difficult in raising her head, followed by systemic muscle paralysis and severe respiratory failure. After admission, the patient received mechanical ventilation, supportive therapies, active muscle functional exercise and she recovered slowly. The double proximal and distal upper limb strength were class III and V(-), and the double proximal and distal lower limb muscle strength were class IV and V(-). Cough reflex and deglutition reflex recovered gradually. The patient was successfully weaned off mechanical ventilation, and was able to walk on discharge. CONCLUSION: Even conventional doses of BTA injection could increase the risk of developing systemic muscle weakness and respiratory failure. Clinical application of botulinum toxin treatment should be strictly controlled.

Inhibiting interleukin-18 production through the mitogen-activated protein kinase pathway, a potential role of corticotropin-releasing hormone in chronic plaque psoriasis.

Corticotropin-releasing hormone (CRH) and CRH receptors (CRH-Rs) are expressed in the skin; CRH-R1 is the predominant receptor. Whether the CRH/CRH-R1 system plays a role in psoriasis has not yet been assessed. Immunohistochemistry, real-time RT-PCR, ELISA assay, and Western blot analysis were used to investigate the expression of CRH/CRH-R1 in patients with chronic plaque psoriasis and that of IL-18 in CRH-treated HaCaT cells. CRH and CRH-R1 were downregulated in patients with chronic plaque psoriasis. In vitro, CRH attenuated the expression of IL-18 by a mitogen-activated protein kinase signaling pathway through CRH-R1 in HaCaT cells. Thus, an aberrant cutaneous CRH/CRH-R1 system exists in lesions from chronic plaque psoriasis which might play a role in psoriasis and offers further evidence for the study of CRH in the skin.

Clinical, virological and immunological features from patients infected with re-emergent avian-origin human H7N9 influenza disease of varying severity in Guangdong province.

BACKGROUND: The second wave of avian influenza H7N9 virus outbreak in humans spread to the Guangdong province of China by August of 2013 and this virus is now endemic in poultry in this region. METHODS: Five patients with H7N9 virus infection admitted to our hospital during August 2013 to February 2014 were intensively investigated. Viral load in the respiratory tract was determined by quantitative polymerase chain reaction (Q-PCR) and cytokine levels were measured by bead-based flow cytometery. RESULTS: Four patients survived and one died. Viral load in different clinical specimens was correlated with cytokine levels in plasma and broncho-alveolar fluid (BALF), therapeutic modalities used and clinical outcome. Intravenous zanamivir appeared to be better than peramivir as salvage therapy in patients who failed to respond to oseltamivir. Higher and more prolonged viral load was found in the sputum or endotracheal aspirates compared to throat swabs. Upregulation of proinflammatory cytokines IP-10, MCP-1, MIG, MIP-1α/ß, IL-1ß and IL-8 was found in the plasma and BALF samples. The levels of cytokines in the plasma and viral load were correlated with disease severity. Reactivation of herpes simplex virus type 1(HSV-1) was found in three out of five patients (60%). CONCLUSION: Expectorated sputum or endotracheal aspirate specimens are preferable to throat swabs for detecting and monitoring H7N9 virus. Severity of the disease was correlated to the viral load in the respiratory tract as well as the extents of cytokinemia. Reactivation of HSV-1 may contribute to clinical outcome.

Vasoactive intestinal peptide induces vascular endothelial growth factor production in human HaCaT keratinocytes via MAPK pathway.

Psoriasis is a chronic skin disease characterized by abnormal keratinocyte proliferation and differentiation, inflammation, and angiogenesis. Although dysfunction of the immune system is known to be an important factor in the pathogenesis of psoriasis, there is also strong evidence that psychological stresses are involved. Neuropeptides are thought to be main mediators of neurogenic inflammation, presumably involved in the pathogenesis of psoriasis. Vasoactive intestinal peptide (VIP) is one of the major neuropeptides in human and rodent skin. In the present study, we examined the effect and mechanism of VIP on vascular endothelial growth factor (VEGF) production by HaCaT cells which is a spontaneous, immortalized, human keratinocyte cell line. Our data indicate the mRNA and protein levels of VEGF by VIP were increased in a concentration-dependent manner. However, this increase was abrogated by pretreatment with an extracellular signal-regulated kinase (ERK) inhibitor PD98059 or p38MAPK inhibitor SB203580; pretreatment with c-Jun N-terminal kinase (JNK) inhibitor SP600125 did not attenuate the effects of VIP on the expression of VEGF. In addition, VIP treatment induced rapid phosphorylation of ERK1/2 and p38MAPK, and PD98059 and SB203580 were able to inhibit VIP-induced phosphorylation of ERK1/2 and p38MAPK, respectively. These results suggest that VIP increases the expression of VEGF through the ERK1/2 and p38MAPK signaling pathway in human HaCaT cells.

Expression and localization of the activated mitogen-activated protein kinase in lesional psoriatic skin.

Abnormalities in several signaling pathways and in the expression and/or activation of different transcription factors in psoriatic keratinocytes have been hypothesized to play a role in the pathophysiology of psoriasis. The mitogen-activated protein kinase (MAPK) cascades are among the best characterized of intracellular signaling pathways, and they play important roles in cell proliferation, differentiation, gene expression, and inflammation. We investigated the expression, activation and distribution of extracellular signal-regulated kinases (ERKs), p38 mitogen-activated protein kinases (p38 MAPK) and c-Jun N-terminal kinases (JNKs), using immunohistochemistry and Western blot in lesional psoriatic skin and normal control skin, to clarify the possible roles of these kinases involved in the pathogenesis of psoriasis. The immunoblot analysis demonstrated that activation of ERK1/2 and p38 MAPK increased in the lesional psoriatic skin. In addition, a significant increase in p-MEK (the upstream activator of ERK), and p-CREB (a downstream transcription factor of active ERK) was also found in our experiment. The immunohistochemical study showed that the levels of phosphorylated ERK1/2 and p38 MAPK were enhanced in lesional psoriatic skin compared with controls. Phosphorylated ERK1/2 and p38 exhibited clear nuclear localization throughout the epidermal part of lesional psoriatic skin. These findings suggested that ERK1/2 and p38 pathways were involved in the pathophysiology of psoriasis.