Kupffer cell blockade reduces hepatic and systemic cytokine levels and lung injury in hemorrhagic pancreatitis in rats.

Severe acute pancreatitis (AP) is associated with both the local (pancreatic) release of cytokines and an elevation in their systemic plasma concentrations. This may lead to organ dysfunction and death of the patient. The aims of this study were to investigate the source(s) of systemic cytokine production during experimental AP. Forty-two rats were allocated to five groups (control, sham operation and saline injection, sham operation and gadolinium chloride injection, intraductal sodium-taurocholate infusion and saline injection, or intraductal sodium-taurocholate infusion and gadolinium chloride injection). Blood from the iliac artery, portal vein, and hepatic vein, along with tissue from the pancreas, liver, and lung, were collected. Serum levels of TNFalpha, IL-1beta, IL-6, and IL-10 were determined by enzyme-linked immunosorbent assay. Tissue mRNA for IL-1beta and IL-10 was assessed by reverse-transcription polymerase chain reaction. In untreated animals with AP, the lowest serum cytokine levels were found in the portal vein. In the hepatic vein, the levels of TNFalpha, IL-1beta, and IL-6 were higher. The highest serum levels were detected in the systemic circulation. In the gadolinium chloride-treated group, there was no increase in hepatic or systemic cytokine levels and less lung injury was observed. Extrapancreatic cytokine production from both the liver and the lung contributed significantly to systemic levels of TNFalpha, IL-1beta, IL-6, and IL-10 in this experimental model of AP.

Activation of pancreatic acinar cells on isolation from tissue: cytokine upregulation via p38 MAP kinase.

Cytokines produced by pancreatic acinar cells may mediate cell death and recruitment of inflammatory cells into pancreas in pancreatitis and other disorders. Here, we demonstrate mRNA expression for a number of cytokines in acini isolated from rat pancreas. Using RNA from microscopically selected individual cells, we confirmed the acinar cell as a source for cytokine expression. Competitive RT-PCR, Western blot analysis, and immunocytochemistry showed large amounts of monocyte chemotactic protein-1 and interleukin-6 compared with other cytokines. Cytokine expression was inhibited by either inhibitors of p38 mitogen-activated protein kinase (MAPK), SB-202190 and SB-203580, or (less strongly) by the transcription factor nuclear factor (NF)-kappaB inhibitor MG-132. A combination of SB-203580 and MG-132 inhibited mRNA expression of all cytokines by >90%. The results suggest a major role for p38 MAPK and involvement of NF-kappaB in cytokine expression in pancreatic acinar cells. In contrast to isolated acini, we detected no or very low cytokine expression in normal rat pancreas. Our results indicate that activation of p38 MAPK, transcription factors, and cytokines occurs during removal of the pancreas from the animal and isolation of acini.

Antisense blockade of p21/WAF1 decreases radiation-induced G2 arrest in esophageal squamous cell carcinoma.

Introduction. The p21 cyclin-dependent kinase inhibitor arrests the cell cycle following DNA damage at the G1-S checkpoint. Recent literature has also demonstrated a role for p21 in G2 arrest. Studies with esophageal squamous cell carcinoma (ESSC) lines have shown that radiation-induced p21 protein induction is associated with G2 arrest. The aim of this study was to determine if p21 blockade would affect this G2 arrest pattern. Method. We transfected the ESSC line KYSE 170 with antisense p21 mRNA oligonucleotides or scrambled 20-mer p21 control oligonucleotides using a lipofectant reagent. Cells were exposed to 6 Gy or used as controls. p21 levels were determined by ELISA. Cell cycle arrest pattern was determined via flow cytometry. Student's t test and ANOVA were used to compare p21 levels and percentages of G2 arrest. Results. Irradiated/scrambled cells expressed 10.1 ng/ml of p21 protein compared to irradiated/antisense cells at 2.1 ng/ml (P < 0.05), demonstrating successful blockade of p21. Irradiated cells displayed prominent G2 arrest following 6 Gy doses, but there was a decrease from 65 to 44% G2 phase when p21 was blocked (P < 0.05). Conclusions. We have demonstrated that G2 arrest accompanying irradiation of ESSC cells decreases when p21 protein production is blocked via antisense oligonucleotides. These data support a role for p21 in mediating G2 arrest in these cells.

Early NF-kappaB activation is associated with hormone-induced pancreatitis.

Inflammation and cell death are critical to pathogenesis of acute pancreatitis. Here we show that transcription factor nuclear factor-kappaB (NF-kappaB), which regulates these processes, is activated and plays a role in rat cerulein pancreatitis. NF-kappaB was strongly activated in the pancreas within 30 min of cerulein infusion; a second phase of NF-kappaB activation was prominent at 3-6 h. This biphasic kinetics could result from observed transient degradation of the inhibitory protein IkappaBalpha and slower but sustained degradation of IkappaBbeta. The hormone also caused NF-kappaB translocation and IkappaB degradation in vitro in dispersed pancreatic acini. Both p65/p50 and p50/p50, but not c-Rel, NF-kappaB complexes were manifest in pancreatitis and in isolated acini. Coinfusion of CCK JMV-180, which abolishes pancreatitis, prevented cerulein-induced NF-kappaB activation. The second but not early phase of NF-kappaB activation was inhibited by a neutralizing tumor necrosis factor-alpha antibody. Antioxidant N-acetylcysteine (NAC) blocked NF-kappaB activation and significantly improved parameters of pancreatitis. In particular, NAC inhibited intrapancreatic trypsin activation and mRNA expression of cytokines interleukin-6 and KC, which were dramatically induced by cerulein. The results suggest that NF-kappaB activation is an important early event that may contribute to inflammatory and cell death responses in acute pancreatitis.

Two decades of cervical esophagostomy: indications and outcomes.

Diverting cervical esophagostomy is a surgical procedure generally reserved for extremely ill patients as a life-saving maneuver. However, it is also a procedure that is infrequently performed, such that most centers have limited experience with the operation. To investigate the indications and outcomes of cervical esophagostomy, we reviewed the use of this operation at UCLA Medical Center over the last 20 years as employed for esophageal leaks. Eighteen patients underwent this procedure for the following indications: leak with malignant tracheoesophageal fistula (11%), anastomotic leak (44%), endoscopic injury (18%), gunshot wound (5.5%), operative injury (11%), corrosive ingestion (11%), and spontaneous rupture (5.5%). Overall mortality directly attributable to sepsis was 33 per cent. Of the surviving patients, 67 per cent later underwent reconstruction. Seventy-two per cent of patients had end esophagostomies, and the remainder had loop diversions. The primary indication for operation in these patients was persistent sepsis after initial surgical management of esophageal spillage into the mediastinum or neck. This series suggests that cervical esophagostomy, when applied to the appropriate patient population, can decrease mortality and allow subsequent alimentary reconstruction.

p21 expression is increased by irradiation in esophageal squamous cell carcinoma.

The p21 cyclin-dependent kinase inhibitor blocks cell cycle transition and replication in response to DNA damage. Although required for p53-mediated cell cycle arrest, p21 expression can also be initiated via p53-independent pathways. This study examines the postirradiation expression of p21 in squamous cell carcinoma (SCC) of the esophagus to determine whether this p21 production is p53-dependent or independent. We sequenced p53 exons 5-8 and the exon-intron junctions of four esophageal SCC lines, KYSEs 30, 150, 410, and 960. We exposed these same lines to increasing doses of radiation (3 to 24 Gy) and subsequently extracted their total protein. The p21 content of the protein was then determined via p21 ELISA. The same cell lines were also irradiated for determination of clonogenic survival over the course of 7 days. Cells were counted via a Coulter machine. KYSE 30 and 410 were found to have mutations in their p53 genes, while KYSEs 150 and 960 had wild-type p53 genomes. All cell lines produced basal levels of p21 (from 3.2 to 7.8 ng/ml) and all lines increased production in response to radiation (6.4 to 16.8 ng/ml at 3 Gy, P < 0.05 for all lines vs. their controls). Cells displayed dose-dependent mortality in response to radiation, with only minor differences in survival between two of the lines. All of the esophageal SCC lines studied produced basal p21 and increased p21 with irradiation. p21 production was independent of p53 status. Previous reports have failed to detect elevation of p21 expression in esophageal SCC, and this is the first report of radiation-induced p21 expression in esophageal cell lines.

Preload assessment in trauma patients during large-volume shock resuscitation.

OBJECTIVES: To evaluate the utility of the right ventricular end-diastolic volume index (RVEDVI) as a method of preload assessment in trauma patients during large-volume shock resuscitation, and to compare the RVEDVI with the pulmonary artery occlusion pressure (PAOP) as a predictor of preload in this patient population. DESIGN: Retrospective study of a consecutive series of 46 trauma patients, admitted between June 1, 1992, and June 1, 1993, who received a volumetric oximetry pulmonary artery catheter and greater than 10 L of fluid in 24 hours. SETTINGS: University level 1 trauma center. MAIN OUTCOME MEASURES: Correlations of the RVEDVI and PAOP with the cardiac index (CI) during the defined study period. RESULTS: Three hundred fourteen measurements of the RVEDVI, PAOP, CI, and other hemodynamic variables were evaluated. Patients received a mean +/- SD of 22.1 +/- 13.3 L of blood and fluid during the 24 hours. The RVEDVI correlated better (P < .001) with the CI (r = 0.39) than did the PAOP (R = 0.05). Furthermore, there was a better correlation (P < .04) between the RVEDVI and CI when the RVEDVI was 130 mL/m2 or less (r = 0.54) than when it was greater than 130 mL/m2 (r = 0.30). CONCLUSIONS: The RVEDVI is a better predictor of preload than the PAOP in trauma patients during large-volume shock resuscitation. When the RVEDVI is 130 mL/m2 or less, volume administration will likely increase the CI.

The staged celiotomy for trauma. Issues in unpacking and reconstruction.

OBJECTIVE: This article describes the important clinical events and decisions surrounding the reconstruction/unpacking portion of the staged celiotomy for trauma. METHODS: Of 13,817 consecutive trauma admissions, 1175 received trauma celiotomies. Of these, 107 patients (9.1%) underwent staged celiotomy with abdominal packing. The authors examined medical records to identify and characterize: (1) indications and timing of reconstruction, (2) criteria for emergency return to the operating room, (3) complications after reconstruction, and (4) abdominal compartment syndrome (ACS). RESULTS: Fifty-eight patients (54.2%) survived to reconstruction, 43 (74.1%) survived to discharge; 9 patients (15.5%) were returned to the operating room for bleeding; 13 patients required multiple packing procedures. There were 117 complications; 8 patients had positive blood cultures, abdominal abscesses developed in 6 patients, and ACS developed in 16 patients. CONCLUSIONS: 1. Reconstruction should occur after temperature, coagulopathy, and acidosis are corrected, usually within 36 hours after the damage control procedure. 2. Emergent reoperation should occur in any normothermic patient with unabated bleeding (greater than 2 U packed cells/hr). 3. ACS occurs in 15% of patients and is characterized by high peak inspiratory pressure, CO2 retention, and oliguria. Lethal reperfusion syndrome is common but preventable.