O sistema apelinérgico: papel na fisiologia e patologia humanas e potenciais aplicações terapêuticas

A apelina é um peptídeo recentemente descoberto e identificado como o ligando endógeno do receptor APJ. A apelina e o receptor APJ são expressos numa grande variedade de tecidos, tais como coração, cérebro, rins e pulmões, onde a sua interação pode ter importantes efeitos fisiopatológicos. Com efeito, a última década foi fértil no esclarecimento de possíveis papéis desempenhados pela apelina na fisiologia humana, nomeadamente como peptídeo regulador dos sistemas cardiovascular, hipotálamo-hipófisário, gastrointestinal e imunitário. Um possível envolvimento da apelina na patogênese de doenças com elevada prevalência e co-morbilidades, como a hipertensão arterial, a insuficiência cardíaca e o diabete melito tipo 2, perspectivam-na como um possível alvo terapêutico a explorar no futuro. Este trabalho fornece uma visão geral dos efeitos fisiológicos da apelina e apresenta o possível papel desse peptídeo na patogênese de várias doenças, associado a implicações terapêuticas que poderão vir a ser, assim, exploradas.

Linfocitos th 17: moduladores o reguladores de la infección por VIH (Programa: enfermedades transmisibles y emergentes).

Los linfocitos T-CD4+ llamados helper (LTH) o cooperadores, componen una población heterogénea de células constituidas por LTH naive y células efectoras: TH1, TH2, TH17, TH1/TH17 y células regulatorias LT reguladores (T-reg). Ellas desempeñan un rol central en la defensa inmune y adquieren distintas propiedades funcionales en respuesta a señales que genera el sistema inmune innato. Los TH17 cumplen un rol crítico en la interrelación entre la inmunidad innata y adaptativa, en la inflamación crónica y en el mantenimiento de la esterilidad de la mucosa gastrointestinal. La infección por el virus de la inmunodeficiencia humana (VIH-1) se caracteriza por una gradual y progresiva disfunción del sistema inmune, con su consecuencia final el Síndrome de Inmuno Deficiencia Adquirida (SIDA). La infección viral involucra la interacción de proteínas virales con la molécula de superficie celular CD4 y el receptor de quimiocinas CCR5 o CXCR4. Nuestro objetivo es evaluar cualitativamente y cuantitativamente los TH17 en relación con los subtipos de LTH en pacientes con infección por VIH-1 en distintos estadios de la infección y correlacionarlos con la clínica del paciente. Para ello se estudiarán individuos con infección por VIH-1 en distintos estadios de la infección sin tratamiento antirretroviral a los que se evaluarán cuantitativamente los niveles de LTH y las subpoblaciones TH17, TH1 y Treg. Además, se estudiarán las características funcionales de los TH17 cuantificando los niveles de IL-17, IL-10 e INF-γ en suero y sobrenadante de cultivos celulares y los niveles de granulocitos. La evaluación de los TH17, en relación con la etapa inmune, virológica y con la clínica del paciente nos permitirá detectar subgrupos de pacientes y nuevos marcadores de progresión de la enfermedad.

Desarrollo de Sistemas Innovadores de Transporte y Liberación Destinados a la Optimización de la Actividad Terapéutica de Fármacos

Existen numerosos fármacos con atributos terapéuticos relevantes que presentan propiedades físicoquímicas o biológicas desfavorables, las que comprometen su eficacia o seguridad y en consecuencia requieren nuevas estrategias de formulación para superar tales deficiencias. Debido a lo expuesto, el objetivo general de este proyecto es diseñar, desarrollar y evaluar nuevos sistemas de transporte y liberación de fármacos que presentan baja biodisponibilidad cuando son administrados por vía oral, 4 debido a su escasa solubilidad y/o permeación a través del epitelio gastrointestinal. Como objetivos específicos se proponen: - Obtención de nuevos sistemas portadores que incidan sobre la efectividad del proceso de absorción de fármacos modelos, facilitando su disolución y/o permeación en el tracto gastrointesinal. - Evaluación de la eficacia de los sistemas obtenidos, en el transporte y pasaje de los fármacos a través de las mucosas del tracto gastrointestinal, mediante metodologías in situ e in vitro, que contribuyan a la determinación de los parámetros biofarmacéuticos de relevancia. La metodología de trabajo propuesta contempla la formación de complejos ternarios utilizando ciclodextrinas (ß-ciclodextrina, hidroxipropil-ß-ciclodextrina y metil- ß-ciclodextrina) y etanolaminas, aminoácidos o meglumina; la incorporación en microemulsiones de los complejos con ciclodextrina obtenidos; así como la obtención de pellets por extrusión-esferonización. Para los estudios biofarmacéuticos, de los principios activos en los sistemas de transporte y liberación desarrollados, se diseñarán estudios de permeación, in situ, a través del método de perfusión de paso simple en ratas e in vitro, utilizando membranas artificiales y cultivos de células Caco-2. Se desarrollarán y validarán procedimientos analíticos adecuado para las determinaciones de los fármacos en todos los estudios implementados.

Química y actividad biológica en Huperzia saururus. Chemistry and biological activity in Huperzia saururus.

El presente proyecto apunta a buscar una posible solución a dos problemáticas de salud que afectan a un importante grupo de la población mundial y son los asociados a la enfermedad de Alzheimer (EA) y a la disfunción eréctil. La EA es una enfermedad neurodegenerativa progresiva caracterizada por la pérdida de memoria a corto plazo, entre otras manifestaciones. En la actualidad la terapia más utilizada son los inhibidores de la acetilcolinesterasa (AChE), ya que acetilcolina es el principal neurotransmisor afectado. No obstante, los agentes terapéuticos utilizados presentan efectos no deseados a nivel gastrointestinal, lo que motiva la búsqueda de nuevos agentes. A partir del estudio de la especie autóctona Huperzia saururus aislamos hasta el presente 10 alcaloides, algunos de los cuales resultaron activos sobre la retención de memoria, investigación realizada mediante ensayos tanto in vitro como in vivo. A partir de los promisorios resultados obtenidos se continuarán profundizando estos estudios y también se buscará el farmacóforo, la parte de la estructura responsable de la actividad. Para ello, se realizarán modificaciones químicas de los grupos funcionales y los productos obtenidos serán igualmente evaluados por su actividad sobre memoria. Los que resulten activos serán investigados en relación a su toxicidad, en la búsqueda de potenciales agentes terapéuticos. Paralelamente se estudiarán las diferentes familias de compuestos presentes en la especie, dado que el uso popular proclama su efecto afrodisíaco. La búsqueda de un afrodisíaco perfecto que incremente el deseo sexual, el placer y el desempeño, ha sido una constante desde los tiempos remotos. En todos los casos, se ha buscado mejorar el rendimiento sexual o combatir la disfunción eréctil (DE). Este término se describe como “la incapacidad constante para alcanzar o mantener una erección que es satisfactoria para el rendimiento sexual”. Para investigar la actividad biológica de H. saururus, los extractos y compuestos aislados serán evaluados por la generación de NO que produzcan, la que será estimada mediante la acumulación de nitrito, metabolito estable del NO, en sobrenadantes de cultivo de células endoteliales (HUVEC). Los que resulten efectivos serán evaluados mediante ensayos in vivo tales como, el de conducta sexual en machos y de comportamiento de monta. Del mismo modo que para los alcaloides, se estudiará la toxicidad de los compuestos que resulten activos a los fines de proseguir la metodología en la investigación preclínica de potenciales medicamentos. The present Project aims to look for a possible solution for two health problems that affect an important group of world population and they are those associated to Alzheimer Disease (AD) and Erectile Dysfunction. AD is a neurodegenerative progressive disease characterized by short term memory loss, among other signs. Nowadays the most used therapy are the acethylcholinesterase inhibitors (AChE), in view that the acethylcholine is the main neurotransmitter affected. Nevertheless, the therapeutic agents used present collateral effects at gastrointestinal level, so it motivates the search for new agents. From the autochthonous species Huperzia saururus we have isolated 10 alkaloids until the present, some of which were active on memory retention, investigation developed in vitro and in vivo. After these promising results, these studies will be continued, as well as the search for the pharmacophore. For this reason, chemical modifications on functional groups will be done and the obtained products will be evaluated on their activity on memory as well. In line with this, the different families of compounds present in H. saururus will be studied in view that the popular use claims its aphrodisiac effect. The search for a perfect aphrodisiac that increase the sexual desire, the pleasure and performance was a constant since the old times. In all the cases it was looked a better sexual performance or fight against the erectile dysfunction (DE). For investigate the biological activity of H. saururus, the extracts and the isolated compounds will be evaluated on the NO generation, which will be estimated by means of nitrite accumulation, stable metabolite of NO, in supernatants of endothelial cell cultures (HUVEC). The compounds that appear effectives will be evaluated by in vivo assays such as sexual male behavior, and mount behavior. As for alkaloids, toxicity of active compounds will be studied to follow the pre-clinic methodology research of potential medicines.

Ecoepidemiología de Chlamydophila psittaci, pecorum, pneumoniae, abortus en Córdoba. Eco-epidemiology of Chlamydophila psittaci, pecorum, pneumoniae, abortus in Córdoba.

Las Clamidias son bacterias patógenas de los animales de producción, de vida silvestre y de compañía. Además de las pérdidas económicas que producen las infecciones en los planteles de producción bovina, ovina, caprina, porcina y aves de corral, la mayoría de las especies tienen importancia zoonótica, pudiendo dar origen a infecciones graves, potencialmente letales en el ser humano. El orden Chlamydiales está integrado por bacterias que actúan como parásitos intracelulares obligados que desarrollan su ciclo de vida únicamente dentro de inclusiones citoplasmáticas. En este orden se encuentra la familia Chlamydiaceae que comprende dos géneros, Chlamydia y Chlamydophila; y las especies, Chlamydia trachomatis, C. suis, C. muridarum, Chlamydophila psittaci, C. abortus, C. felis, C. caviae, C. pecorum, y C. pneumoniae. C. psittaci causa psitacosis o clamidiosis aviar. En Argentina, los primeros casos clínicos de psitacosis fueron reportados en 1929. Los criadores de aves y quienes las poseen como mascotas, representan el grupo de mayor riesgo; pero también las personas que trabajan en pajarerías y aquellas que por su empleo se ven expuestas a contraer la enfermedad (empleados en peladeros donde se carnean y procesan pollos y otras aves para consumo, veterinarios, empleados de zoológicos, etc.). La infección en humanos se presenta como una neumonía severa; con fiebre alta, escalofríos, dolor de cabeza, mialgia y dificultad respiratoria. Ocasionalmente puede presentarse vómitos, dolor abdominal, diarrea y complicaciones como miocarditis, endocarditis, encefalitis, ictericia y fallas multiorgánicas, que pueden ser fatales sino se le administra el tratamiento adecuado. La infección en las mujeres embarazadas puede producir neumonía, hepatitis, insuficiencia renal, sepsis, parto prematuro y muerte fetal. Existen más de 465 especies de aves en las que se registró C. psittaci, incluyendo ornamentales, de corral, silvestres, acuáticas y palomas. Las patologías que pueden producir en estos animales son neumonitis, conjuntivitis, encefalomielitis, placentopatías, fetopatías, anorexia, diarrea e infecciones persistentes asintomáticas u oligosintomáticas. En bovinos, C. pecorum, C. abortus y C. psittaci producen infecciones respiratorias y genitales; que se presentan como cuadros de enteritis, artritis, encefalomielitis, endometritis e hipofertilidad. En Argentina, la infección clamidial en el ganado caprino fue asociada a daños en el tejido uterino, abortos, partos prematuros y crías débiles. En equinos, C. psittaci y C. pneumoniae producen abortos y desórdenes respiratorios, con un gran impacto en ganadería que redunda en pérdidas económicas. Considerando que existen escasos estudios eco-epidemiológicos y clínicos que reporten el estado de situación de estas infecciones en nuestro medio, es que el presente trabajo propone actualizar y profundizar el conocimiento de las especies de Clamidias de importancia médico-veterinaria presentes en la provincia de Córdoba, Argentina. El desarrollo de este proyecto aportará la implementación de técnicas que mejorarán el diagnóstico microbiológico, confirmarán los cuadros clínicos; y por lo tanto contribuirá al conocimiento de estos agentes infecciosos en nuestra región. Esta información es indispensable para los organismos responsables de la Salud Pública (Ministerios de Salud y Educación, Municipios, etc.) para que puedan obrar en consecuencia y generar sistemas de alerta temprana, tomar medidas de prevención y medidas de control frente a la presencia de un brote epidémico por alguna cepa clamidial. "Eco epidemiology of Chlamydophila psittaci, C. pecorum and C. pneumoniae: Impact on public health "The Chlamydiae are bacterial pathogens of farm animals, wildlife and pets. Besides the economic losses that occur on campuses infections of cattle, sheep, goats, swine and poultry, most species are zoonotic, infections potentially fatal can cause in humans. The order Chlamydiales is composed of the family Chlamydiaceae comprising two genera, Chlamydia and Chlamydophila, and nine species, Chlamydia trachomatis, C. suis, C. muridarum, Chlamydophila psittaci, C. abortus, C. felis, C. caviae, C. pecorum, and C. pneumoniae. The clinical manifestations in humans are associated with severe pneumonia. Also, nonspecific gastrointestinal symptoms, and complications such as myocarditis, endocarditis, encephalitis, jaundice and multiple organ failure. There are over 465 species of birds where recorded C. psittaci, including ornamental plants, poultry, wild waterfowl and pigeons. Sick birds eliminate chlamydia in all secretions, asymptomatic birds can develop the disease through contact with other infected birds. The human infection occurs by inhalation of aerosolized secretions of infected birds. The prevalence of C. psittaci records in humans, birds, horses, goats and cattle are scarce in Latin America. In Argentina it has been detected chlamydial antibody prevalence in cattle in Buenos Aires and La Pampa (5) and Rockhopper Penguins (Eudyptes chrysocome) in the town of Santa Cruz (11). Detect this pathogen in these birds and learn about potential sources of infection would be of great public health significance. To develop an efficient system of medical and veterinary surveillance is essential to have reliable diagnostic techniques for detection and identification of Chlamydia in birds, animals and humans.

Linfocitos TH 17: moduladores o reguladores de la infección por VIH-1.

Los linfocitos T-CD4+ llamados helper (LTh) o cooperadores, componen una población heterogénea de células constituidas por LTh naive y células efectoras: Th1, Th2, Th17, Th1/Th17 y células regulatorias LT reguladores (T-reg). Ellos desempeñan un rol central en la defensa inmune y adquieren distintas propiedades funcionales en respuesta a señales que genera el sistema inmune innato. Los Th17 cumplen un rol crítico en la interrelación entre la inmunidad innata y adaptativa, en la inflamación crónica y en el mantenimiento de la esterilidad de la mucosa gastrointestinal. La infección por el virus de la inmunodeficiencia humana (VIH-1) se caracteriza por una gradual y progresiva disfunción del sistema inmune, con su consecuencia final el Síndrome de Inmuno Deficiencia Adquirida (SIDA). La infección viral involucra la interacción de proteínas virales con la molécula de superficie celular CD4 y el receptor de quimiocinas CCR5 o CXCR4. Nuestro objetivo es evaluar cualitativamente y cuantitativamente los Th17 en relación con los subtipos de LTh en pacientes con infección por VIH-1 en distintos estadios de la infección y correlacionarlos con la clínica del paciente. Para ello se estudiarán individuos con infección por VIH-1 en distintos estadios de la infección sin tratamiento antirretroviral a los que se evaluarán cuantitativamente los niveles de LTh y las subpoblaciones Th17, Th1 y Treg. Además, se estudiarán las características funcionales de los TH17 cuantificando los niveles de IL-17, IL10 e INF-G; en suero y sobrenadante de cultivos celulares y los niveles de granulocitos. La evaluación de los Th17, en relación con el fase inmune, virológico y con la clínica del paciente nos permitirá detectar subgrupos de pacientes y nuevos marcadores de progresión de la enfermedad.

Alterações gastrointestinais associadas a insuficiência cardíaca

Na última década, foram realizados vários estudos sobre alterações gastrointestinais associadas a insuficiência cardíaca crônica. Neste artigo, apresentamos revisão da literatura sobre a fisiopatologia e consequências clínicas das alterações patológicas digestivas de pacientes com insuficiência cardíaca. Anormalidades estruturais e funcionais do trato gastrointestinal, como edema da mucosa absortiva e hipercrescimento bacteriano intestinal, têm sido responsabilizadas por graves consequências clínicas. Entre essas, destacam-se caquexia cardíaca, ativação inflamatória sistêmica e anemia. Essas condições, isoladamente ou em combinação, podem levar a piora da disfunção ventricular preexistente. Embora atualmente não haja terapêutica específica direcionada às alterações gastrointestinais associadas a insuficiência cardíaca, o entendimento das anormalidades digestivas é fundamental para sua prevenção e manejo das consequências sistêmicas.

Caquexia associada à insuficiência cardíaca

Pacientes com insuficiência cardíaca frequentemente desenvolvem estado de caquexia, que constitui fator independente de redução da sobrevida. Caquexia pode ser diagnosticada quando ocorre perda de peso corporal maior que 6% do peso habitual, na ausência de outras doenças. Embora sua fisiopatologia não esteja completamente esclarecida, vários fatores parecem estar envolvidos, como diminuição da ingestão alimentar, anormalidades do trato gastrointestinal, ativação imunológica e neuro-hormonal e alteração da relação entre processos anabólicos e catabólicos. Como não há terapia específica para a caquexia associada à insuficiência cardíaca, o tratamento baseia-se no suporte nutricional, bloqueio neuro-hormonal, controle do edema e anemia e exercícios físicos. Fármacos com propriedades imunomodulatórias e anabólicas encontram-se em investigação clínica e experimental.

Neural Mechanisms and Delayed Gastric Emptying of Liquid Induced Through Acute Myocardial Infarction in Rats

Background: In pathological situations, such as acute myocardial infarction, disorders of motility of the proximal gut can trigger symptoms like nausea and vomiting. Acute myocardial infarction delays gastric emptying (GE) of liquid in rats. Objective: Investigate the involvement of the vagus nerve, α 1-adrenoceptors, central nervous system GABAB receptors and also participation of paraventricular nucleus (PVN) of the hypothalamus in GE and gastric compliance (GC) in infarcted rats. Methods: Wistar rats, N = 8-15 in each group, were divided as INF group and sham (SH) group and subdivided. The infarction was performed through ligation of the left anterior descending coronary artery. GC was estimated with pressure-volume curves. Vagotomy was performed by sectioning the dorsal and ventral branches. To verify the action of GABAB receptors, baclofen was injected via icv (intracerebroventricular). Intravenous prazosin was used to produce chemical sympathectomy. The lesion in the PVN of the hypothalamus was performed using a 1mA/10s electrical current and GE was determined by measuring the percentage of gastric retention (% GR) of a saline meal. Results: No significant differences were observed regarding GC between groups; vagotomy significantly reduced % GR in INF group; icv treatment with baclofen significantly reduced %GR. GABAB receptors were not conclusively involved in delaying GE; intravenous treatment with prazosin significantly reduced GR% in INF group. PVN lesion abolished the effect of myocardial infarction on GE. Conclusion: Gastric emptying of liquids induced through acute myocardial infarction in rats showed the involvement of the vagus nerve, alpha1- adrenergic receptors and PVN.

First- Versus Second-Generation Drug-Eluting Stents in Acute Coronary Syndromes (Katowice-Zabrze Registry)

Abstract Background: There are sparse data on the performance of different types of drug-eluting stents (DES) in acute and real-life setting. Objective: The aim of the study was to compare the safety and efficacy of first- versus second-generation DES in patients with acute coronary syndromes (ACS). Methods: This all-comer registry enrolled consecutive patients diagnosed with ACS and treated with percutaneous coronary intervention with the implantation of first- or second-generation DES in one-year follow-up. The primary efficacy endpoint was defined as major adverse cardiac and cerebrovascular event (MACCE), a composite of all-cause death, nonfatal myocardial infarction, target-vessel revascularization and stroke. The primary safety outcome was definite stent thrombosis (ST) at one year. Results: From the total of 1916 patients enrolled into the registry, 1328 patients were diagnosed with ACS. Of them, 426 were treated with first- and 902 with second-generation DES. There was no significant difference in the incidence of MACCE between two types of DES at one year. The rate of acute and subacute ST was higher in first- vs. second-generation DES (1.6% vs. 0.1%, p < 0.001, and 1.2% vs. 0.2%, p = 0.025, respectively), but there was no difference regarding late ST (0.7% vs. 0.2%, respectively, p = 0.18) and gastrointestinal bleeding (2.1% vs. 1.1%, p = 0.21). In Cox regression, first-generation DES was an independent predictor for cumulative ST (HR 3.29 [1.30-8.31], p = 0.01). Conclusions: In an all-comer registry of ACS, the one-year rate of MACCE was comparable in groups treated with first- and second-generation DES. The use of first-generation DES was associated with higher rates of acute and subacute ST and was an independent predictor of cumulative ST.

Plastic ingestion by sea turtles in Paraíba State, Northeast Brazil

ABSTRACT Currently, plastics are recognized as a major pollutant of the marine environment, representing a serious threat to ocean wildlife. Here, we examined the occurrence and effects of plastic ingestion by sea turtles found stranded along the coast of Paraíba State, Brazil from August 2009 to July 2010. Ninety-eight digestive tracts were examined, with plastic found in 20 (20.4%). Sixty five percent (n = 13) of turtles with plastic in the digestive tract were green turtles (Chelonia mydas), 25% (n = 5) were hawksbills (Eretmochelys imbricata), and 10% (n = 2) were olive ridley (Lepidochelys olivacea). More plastic was found in the intestine (85%) than in other parts of the gastrointestinal tract. We observed complete blockage of the gastrointestinal tract due to the presence of plastic in 13 of the 20 turtles that had ingested plastic. No correlation was found between the curved carapace length (CCL) and the number or mass of the plastic ingested items. Significant differences were found between the intake of hard and soft plastic and the ingestion of white/transparent and colored plastic, with soft and white/transparent plastics being more commonly ingested. This study reveals the serious problem of plastic pollution to sea turtles at the area.

Role of secretory immunoglobulin A and secretory component in the protection of mucosal surfaces.

The contribution of secretory immunoglobulin A (SIgA) antibodies in the defense of mucosal epithelia plays an important role in preventing pathogen adhesion to host cells, therefore blocking dissemination and further infection. This mechanism, referred to as immune exclusion, represents the dominant mode of action of the antibody. However, SIgA antibodies combine multiple facets, which together confer properties extending from intracellular and serosal neutralization of antigens, activation of non-inflammatory pathways and homeostatic control of the endogenous microbiota. The sum of these features suggests that future opportunities for translational application from research-based knowledge to clinics include the mucosal delivery of bioactive antibodies capable of preserving immunoreactivity in the lung, gastrointestinal tract, the genito-urinary tract for the treatment of infections. This article covers topics dealing with the structure of SIgA, the dissection of its mode of action in epithelia lining different mucosal surfaces and its potential in immunotherapy against infectious pathogens.

GLUT2 and the incretin receptors are involved in glucose-induced incretin secretion.

Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are incretins secreted in response to oral glucose ingestion by intestinal L and K cells, respectively. The molecular mechanisms responsible for intestinal cell glucose sensing are unknown but could be related to those described for beta-cells, brain and hepatoportal sensors. We determined the role of GLUT2, GLP-1 or GIP receptors in glucose-induced incretins secretion, in the corresponding knockout mice. GLP-1 secretion was reduced in all mutant mice, while GIP secretion did not require GLUT2. Intestinal GLP-1 content was reduced only in GIP and GLUT2 receptors knockout mice suggesting that this impairment could contribute to the phenotype. Intestinal GIP content was similar in all mice studied. Furthermore, the impaired incretins secretion was associated with a reduced glucose-stimulated insulin secretion and an impaired glucose tolerance in all mice. In conclusion, both incretins secretion depends on mechanisms involving their own receptors and GLP-1 further requires GLUT2.

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

OBJECTIVE: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Relationships between imatinib plasma levels and efficacy

Purpose: While imatinib has revolutionized the treatment of chronic myeloid leukaemia (CML) and gastrointestinal stromal tumors (GIST), its pharmacokinetic-pharmacodynamic relationships have been poorly studied. This study aimed to explore the issue in oncologic patients, and to evaluate the specific influence of the target genotype in a GIST subpopulation. Patients and methods: Data from 59 patients (321 plasma samples) were collected during a previous pharmacokinetic study. Based on a population model purposely developed, individual post-hoc Bayesian estimates of pharmacokinetic parameters were derived, and used to estimate drug exposure (AUC; area under curve). Free fraction parameters were deduced from a model incorporating plasma alpha1-acid glycoprotein levels. Associations between AUC (or clearance) and therapeutic response (coded on a 3-point scale), or tolerability (4-point scale), were explored by ordered logistic regression. Influence of KIT genotype on response was also assessed in GIST patients. Results: Total and free drug exposure correlated with the number of side effects (p < 0.005). A relationship with response was not evident in the whole patient set (with good-responders tending to receive lower doses and bad-responders higher doses). In GIST patients however, higher free drug exposure predicted better responses. A strong association was notably observed in patients harboring an exon 9 mutation or a wild type KIT, known to decrease tumor sensitivity towards imatinib (p < 0.005). Conclusions: Our results are arguments to further evaluate the potential benefit of a therapeutic monitoring program for imatinib. Our data also suggest that stratification by genotype will be important in future trials.