Contribuição ao entendimento da patogenia da sepse

The most frequent cause of vasodilatory shockis outcome from sepsis, a systemic inflammatory response to infection, characterized by hypotension, hyporeactivity to the catecholamines and disseminated intravascular coagulation. The commonest cause of sepsis has reported to be infection with Gram-negative bacteria, typically E. coli, resulting in the release of lipopolysaccharide (endotoxin) from the bacterial outer membrane during autolysis or death of these microorganisms, with the involvement of many mediators, including nitric oxide. Later it was found that plasma levels of vasopressin in sepsis patients were abnormally low and observed that some patients with advanced septic shock were extremely sensitive to the activity actions of exogenous vasopressin.

Quantificação de proteínas de fase aguda em éguas doadoras de embrião da raça quarto de milha

Pós-graduação em Ciência Animal - FMVA

N-acetylglucosaminidase, myeloperoxidase and vascular endothelial growth factor serum levels in breast cancer patients

Inflammatory cells surround breast carcinomas and may act promoting tumor development or stimulating anti-tumor immunity. N-acetylglucosaminidase (NAG) has been employed to detect macrophage accumulation/activation. Myeloperoxidase (MPO) is considered a marker for neutrophils activity/accumulation. Vascular Endothelial Growth Factor (VEGF) is as strong pro-angiogenic cytokine. The aim of this study was to measure the systemic inflammatory response by measuring serum levels of NAG, MPO and VEGF in women diagnosed with breast cancer and associate this response to the peritumoral inflammatory infiltrate and to prognostic factors. Serum samples obtained from women with no evidence of disease (n = 31) and with breast cancer (n = 68) were analyzed for the activities of NAG, MPO and VEGF by enzymatic assay. Serum levels of NAG and VEGF were higher in healthy volunteers (P < 0.0001) and serum levels of MPO were higher in patients with breast cancer (P = 0.002). Serum levels of NAG were positively correlated to serum levels of MPO and VEGF (P < 0.0001 and P = 0.0012, respectively) and MPO and VEGF serum levels had also a positive correlation (P = 0.0018). The inflammatory infiltrate was not associated to serum levels of the inflammatory markers, and higher levels of MPO were associated to lymphovascular invasion negativity (P = 0.0175). (C) 2013 Elsevier Masson SAS. All rights reserved.

Associação entre a concentração de selênio, o polimorfismo Pro198Leu da glutationa peroxidase 1 e a mortalidade em pacientes com choque séptico

Pós-graduação em Fisiopatologia em Clínica Médica - FMB

Estudo da capacidade imunomoduladora in vivo de células-tronco mesenquimais obtidas da matriz do cordão umbilical equino

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Is there a therapeutic window for pentoxifylline after the onset of acute pancreatitis?

PURPOSE: To investigate the effects of pentoxifylline (PTX) in experimental acute pancreatitis (AP) starting drug administration after the induction of the disease. METHODS: One hundred male Wistar rats were submitted to taurocholate-induced AP and divided into three groups: Group Sham: sham-operated rats, Group Saline: AP plus saline solution, and Group PTX: AP plus PTX. Saline solution and PTX were administered 1 hour after induction of AP. At 3 hours after AP induction, peritoneal levels of tumor necrosis factor (TNF)-alpha, and serum levels of interleukin (IL)-6 and IL-10 levels were assayed by Enzyme-Linked Immunosorbent Assay (ELISA). Determinations of lung myeloperoxidase activity (MPO), histological analysis of lung and pancreas, and mortality study were performed. RESULTS: PTX administration 1 hour after induction of AP caused a significant decrease in peritoneal levels of TNF-alpha and in serum levels of IL-6 and IL-10 when compared to the saline group. There were no differences in lung MPO activity between the two groups with AP. A decrease in mortality was observed in the PTX treatment compared to the saline group. CONCLUSIONS: Administration of PTX after the onset of AP decreased the systemic levels of proinflammatory cytokines, raising the possibility that there is an early therapeutic window for PTX after the initiation of AP.

Toll-like receptor 9 activation in neutrophils impairs chemotaxis and reduces sepsis outcome

Objectives: To investigate the role of toll-like receptor 9 on sepsis-induced failure of neutrophil recruitment to the site of infection. Design: Prospective experimental study. Setting: University research laboratory. Interventions: Model of polymicrobial sepsis induced by cecal ligation and puncture in wild-type and toll-like receptor 9-deficient mice. Measurements and Main Results: Toll-like receptor 9-deficient mice with cecal ligation and puncture-induced severe sepsis did not demonstrate failure of neutrophil migration and consequently had a low systemic inflammatory response and a high survival rate. Upon investigating the mechanism by which toll-like receptor 9-deficiency prevents the failure of neutrophil migration, it was found that neutrophils derived from toll-like receptor 9-deficient mice with cecal ligation and puncture induced severe sepsis expressed high levels of chemokine C-X-C motif receptor 2 (CXCR2) and had reduced induction of G-protein-coupled receptor kinase 2. Conclusions: These findings suggest that the poor outcome of severe sepsis is associated with toll-like receptor 9 activation in neutrophils, which triggers G-protein-coupled receptor kinase 2 expression and CXCR2 downregulation. These events account for the reduction of neutrophil migration to the site of infection, with consequent spreading of the infection, onset of the systemic inflammatory response, and a decrease in survival. (Crit Care Med 2012; 40:2631-2637)

Dano muscular: resposta inflamatória sistêmica após ações excêntricas máximas

O objetivo deste estudo foi analisar a resposta inflamatória induzida por grande número de ações excêntricas (AE) máximas realizadas pelos flexores do cotovelo. Participaram do estudo nove homens jovens, que realizaram 35 séries de seis AE nos flexores de cotovelo, com intervalo de um minuto, utilizando um dinamômetro isocinético em uma velocidade de 210º.s-1. As variáveis mensuradas foram: a contração isométrica voluntaria máxima (CIVM), a amplitude de movimento (AM), a dor muscular de inicio tardio (DMIT), a interleucina-6 (IL-6) e o fator de necrose tumoral alfa (TNF-α). Alterações significantes foram observadas para os marcadores indiretos de dano muscular (CIVM, AM e DMIT), entretanto não houve modificações para os marcadores inflamatórios (IL-6 e TNF-α). Em conclusão, os resultados demonstraram que mesmo com alterações nos marcadores indiretos de dano muscular após a realização de um grande número de AE não foram observadas alterações na resposta inflamatória sistêmica.

Valutazione clinica, clinicopatologica e quantificazione di IgG e IgM in corso di leishmaniosi canina: studio retrospettivo

La leishmaniosi canina (LCan) causata da Leishmania infantum rappresenta un’importante zoonosi in molte aree del mondo ed il cane rappresenta il principale reservoir del parassita per l’uomo. Il tipo di risposta immunitaria che i soggetti colpiti mettono in atto condiziona fortemente la progressione della malattia: animali che non sviluppano un’adeguata risposta immunitaria cellulo-mediata mostrano la sintomatologia clinica nonostante abbiano una forte ma inefficace risposta umorale che contribuisce al peggioramento della sintomatologia clinica. L’obbiettivo dello studio è stato quello valutare da un punto di vista descrittivo il segnalamento, i segni clinici e clinicopatologici dei pazienti affetti da leishmaniosi portati in visita presso il Dipartimento di Scienze Mediche Veterinarie nel periodo compreso da Gennaio 2002 a Marzo 2012 con particolare attenzione sull’impatto della patologia renale e dell’anemia nel quadro clinico della LCan. In base ai risultati ottenuti è stato possibile affermare che la leishmaniosi canina è una patologia relativamente frequente nella nostra realtà clinica universitaria e che presenta caratteristiche cliniche e clinicopatologiche simili a quelle riportate in letteratura. I nostri risultati preliminari suggeriscono che in questa malattia il coinvolgimento renale e le conseguenze sistemiche che ne derivano possono essere predominanti a livello clinico e laboratoristico. La gravità del quadro clinico appare associata in maniera significativa all’entità della risposta umorale e del successivo coinvolgimento glomerulare nel contesto di una risposta infiammatoria sistemica cronica. Successivamente, sono state misurate le concentrazioni di IgG ed IgM in corso di follow-up in alcuni dei soggetti inclusi nello studio e sottoposti a differenti trattamenti anti-leishmania. Dai risultati preliminari ottenuti nel nostro lavoro è stato possibile affermare che in corso di trattamento le concentrazioni di tali immunoglobuline subiscono una riduzione progressiva confermando pertanto l’efficacia del trattamento anti-leishmania non solo nella remissione della sintomatologia clinica ma anche nel ripristino della normale risposta umorale.

Data management and data analysis in the large European projects GEHA (GEnetics of Healthy Aging) and NU-AGE (NUtrition and AGEing): a bioinformatic approach

The aging process is characterized by the progressive fitness decline experienced at all the levels of physiological organization, from single molecules up to the whole organism. Studies confirmed inflammaging, a chronic low-level inflammation, as a deeply intertwined partner of the aging process, which may provide the “common soil” upon which age-related diseases develop and flourish. Thus, albeit inflammation per se represents a physiological process, it can rapidly become detrimental if it goes out of control causing an excess of local and systemic inflammatory response, a striking risk factor for the elderly population. Developing interventions to counteract the establishment of this state is thus a top priority. Diet, among other factors, represents a good candidate to regulate inflammation. Building on top of this consideration, the EU project NU-AGE is now trying to assess if a Mediterranean diet, fortified for the elderly population needs, may help in modulating inflammaging. To do so, NU-AGE enrolled a total of 1250 subjects, half of which followed a 1-year long diet, and characterized them by mean of the most advanced –omics and non –omics analyses. The aim of this thesis was the development of a solid data management pipeline able to efficiently cope with the results of these assays, which are now flowing inside a centralized database, ready to be used to test the most disparate scientific hypotheses. At the same time, the work hereby described encompasses the data analysis of the GEHA project, which was focused on identifying the genetic determinants of longevity, with a particular focus on developing and applying a method for detecting epistatic interactions in human mtDNA. Eventually, in an effort to propel the adoption of NGS technologies in everyday pipeline, we developed a NGS variant calling pipeline devoted to solve all the sequencing-related issues of the mtDNA.

Perioperative metabolic changes in patients undergoing cardiac surgery

Perioperative metabolic changes in cardiac surgical patients are not only induced by tissue injury and extracorporeal circulation per se: the systemic inflammatory response to surgical trauma and extracorporeal circulation, perioperative hypothermia, cardiovascular and neuroendocrine responses, and drugs and blood products used to maintain cardiovascular function and anesthesia contribute to varying degrees. The pathophysiologic changes include increased oxygen consumption and energy expenditure; increased secretion of adrenocorticotrophic hormone, cortisol, epinephrine, norepinephrine, insulin, and growth hormone; and decreased total tri-iodothyronine levels. Easily measurable metabolic consequences of these changes include hyperglycemia, hyperlactatemia, increased aspartate, glutamate and free fatty acid concentrations, hypokalemia, increased production of inflammatory cytokines, and increased consumption of complement and adhesion molecules. Nutritional risk before elective cardiac surgery-defined as preoperative unintended pathologic weight loss/low amount of food intake in the preceding week or low body mass index-is related to adverse postoperative outcome. Improvements in surgical techniques, anesthesia, and perioperative management have been designed to minimize the stressful stimulus to catabolism, thereby slowing the wasting process to the point where much less nutrition is required to meet metabolic requirements. Early nutrition in cardiac surgery is safe and well tolerated.

Visual disturbance following sclerotherapy for varicose veins, reticular veins and telangiectasias: a systematic literature review

The objective of the study was to review the literature reporting visual disturbance (VD) following sclerotherapy for varicose veins. Underlying mechanisms will be discussed. A literature search of the databases Medline and Google Scholar was performed. Original articles including randomized trials, case series and case reports reporting VD in humans following sclerotherapy for varicose veins were included. Additional references were also obtained if they had been referenced in related publications. The search yielded 4948 results of which 25 reports were found to meet the inclusion criteria. In larger series with at least 500 included patients the prevalence of VD following sclerotherapy ranges from 0.09% to 2%. In most reports foam sclerotherapy was associated with VD (19); exclusive use of liquid sclerosant was reported in two cases, some reports included foam and liquid sclerosant (4). There were no persistent visual disorders reported. VD occurred with polidocanol and sodium tetradecyl sulphate in different concentrations (0.25-3%). Various forms of foam preparation including various ways of foam production and the liquid - air ratio (1 or 2 parts of liquid mixed with 3, 4 or 5 parts of air) were reported in association with the occurrence of VD. VDs following sclerotherapy for varicose veins are rare and all reported events were transient. Bubble embolism or any kind of embolism seems unlikely to be the only underlying mechanism. A systemic inflammatory response following sclerotherapy has been suggested. Further research to clarify the mechanism of action of sclerosants is required.

Methylprednisolone Fails to Preserve Pulmonary Surfactant and Blood-Air Barrier Integrity in a Porcine Cardiopulmonary Bypass Model

BACKGROUND: Pulmonary inflammation after cardiac surgery with cardiopulmonary bypass (CPB) has been linked to respiratory dysfunction and ultrastructural injury. Whether pretreatment with methylprednisolone (MP) can preserve pulmonary surfactant and blood-air barrier, thereby improving pulmonary function, was tested in a porcine CPB-model. MATERIALS AND METHODS: After randomizing pigs to placebo (PLA; n = 5) or MP (30 mg/kg, MP; n = 5), animals were subjected to 3 h of CPB with 1 h of cardioplegic cardiac arrest. Hemodynamic data, plasma tumor necrosis factor-alpha (TNF-alpha, ELISA), and pulmonary function parameters were assessed before, 15 min after CPB, and 8 h after CPB. Lung biopsies were analyzed for TNF-alpha (Western blot) or blood-air barrier and surfactant morphology (electron microscopy, stereology). RESULTS: Systemic TNF-alpha increased and cardiac index decreased at 8 h after CPB in PLA (P < 0.05 versus pre-CPB), but not in MP (P < 0.05 versus PLA). In both groups, at 8 h after CPB, PaO(2) and PaO(2)/FiO(2) were decreased and arterio-alveolar oxygen difference and pulmonary vascular resistance were increased (P < 0.05 versus baseline). Postoperative pulmonary TNF-alpha remained unchanged in both groups, but tended to be higher in PLA (P = 0.06 versus MP). The volume fraction of inactivated intra-alveolar surfactant was increased in PLA (58 +/- 17% versus 83 +/- 6%) and MP (55 +/- 18% versus 80 +/- 17%) after CPB (P < 0.05 versus baseline for both groups). Profound blood-air barrier injury was present in both groups at 8 h as indicated by an increased blood-air barrier integrity score (PLA: 1.28 +/- 0.03 versus 1.70 +/- 0.1; MP: 1.27 +/- 0.08 versus 1.81 +/- 0.1; P < 0.05). CONCLUSION: Despite reduction of the systemic inflammatory response and pulmonary TNF-alpha generation, methylprednisolone fails to decrease pulmonary TNF-alpha and to preserve pulmonary surfactant morphology, blood-air barrier integrity, and pulmonary function after CPB.

Minimized cardiopulmonary bypass combined with a smart suction device: the future of cardiopulmonary bypass?

OBJECTIVE: The standard heart-lung machine is a major trigger of systemic inflammatory response and the morbidity attributed to conventional extracorporeal circulation (CECC) is still significant. Reduction of blood-artificial surface contact and reduction of priming volume are principal aims in minimized extracorporeal circulation (MECC) cardiopulmonary bypass systems. The aim of this paper is to give an overview of the literature and to present our experience with the MECC-smart suction system. METHODS AND RESULTS: At our institution, 1799 patients underwent isolated coronary artery bypass grafting (CABG) surgery, 1372 with a MECC-smart suction system and 427 with CECC. All in-hospital data were assessed and the results were compared between the 2 groups. Patient characteristics and the distribution of EuroSCORE risk profile in our collective were similar between both groups. Average age in the MECC collective was 67.5 +/- 11.4 years and average EuroSCORE was 5.0 +/- 1.5. Average number of distal anastomoses was similar to the average number encountered in patients undergoing CABG surgery with CECC (3.3 +/- 1.0 for MECC versus 3.2 +/- 1.1 for CECC; P = ns). Myocardial protection is superior in MECC patients with lower postoperative maximal cTnI values (11.0 +/- 10.8 micromol/L for MECC versus 24.7 +/- 25.3 micromol/L for CECC; P < .05). Postoperative recovery was faster in patients operated on with the MECC-smart suction system and discharge from the hospital was earlier than for CECC patients (7.4 +/- 1.9 days for MECC versus 8.8 +/- 3.8 days for CECC; P < .05). CONCLUSIONS: The MECC-smart suction system is a safe perfusion technique for CABG surgery. In patients operated on with this system, the clinical outcome seems to be better than in patients operated on with CECC. This promising and less damaging perfusion technology has the potential to replace CECC systems in CABG surgery.

Acute pancreatitis and thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) has multiple clinical manifestations and risk factors, but the events that actually trigger acute episodes of TTP are often unclear. We describe the case of a 56-year-old woman who presented with clinical signs and symptoms of TTP and acute pancreatitis. We discuss whether pancreatitis was due to ischemic pancreatic damage caused by microvascular platelet clumping in the frame of TTP, or whether acute pancreatitis, a disorder that results in an intense systemic inflammatory response, may be a triggering event for acute episodes of TTP.