ABSTRACT
Triggering receptor expressed on myeloid cells-1 (TREM-1) is produced and up-regulated by exposure of myeloid cells to lipopolysaccharides or other components of either bacterial or fungal origin, which causes it to be strongly expressed on phagocytes that accumulate in inflamed areas. Because TREM-1 participates in septic shock and in amplifying the inflammatory response to bacterial and fungal infections, we believe it could be an immunohistochemical marker for postmortem diagnosis of sepsis. We tested the anti-TREM-1 antibody in 28 cases of death by septic shock and divided them into two groups. The diagnosis was made according to the criteria of the Surviving Sepsis Campaign. In all cases, blood cultures were positive. The first group was comprised subjects that presented high ante-mortem serum procalcitonin and the soluble form of TREM-1 (s-TREM-1) values. The second group comprised subjects in which s-TREM-1 was not measured ante-mortem. We used samples of brain, heart, lung, liver and kidney for each case to test the anti-TREM-1 antibody. A semiquantitative evaluation of the immunohistochemical findings was made. In lung samples, we found immunostaining in the cells of the monocyte line in 24 of 28 cases, which suggests that TREM-1 is produced principally by cells of the monocyte line. In liver tissue, we found low TREM-staining in the hepatocyte cytoplasm, duct epithelium, the portal-biliary space and blood vessel. In kidney tissue samples, we found the TREM-1 antibody immunostaining in glomeruli and renal tubules. We also found TREM-1 staining in the lumen of blood vessels. Immunohistochemical staining using the anti-TREM-1 antibody can be useful for postmortem diagnosis of sepsis.
Subject(s)
Immunohistochemistry , Shock, Septic/metabolism , Shock, Septic/mortality , Triggering Receptor Expressed on Myeloid Cells-1/metabolism , Antibodies , Biomarkers , Female , Humans , Male , Middle Aged , Tissue Distribution , Triggering Receptor Expressed on Myeloid Cells-1/geneticsABSTRACT
Any discussion of the delicate subject of a doctor's autonomy in the choice and management of therapy entails addressing the intimate question of professional and ethical conduct. The professional freedom to choose which therapy to use continues to be the most quintessential expression of the medical professional and, in respect of the primary purpose of safeguarding health, must be aligned with: the choices of the informed patient or his/her legal representatives, existing guidelines and the equitable allocation of resources. On these grounds, the author sets out brief considerations regarding a number of issues frequently raised in the everyday work of the pediatrician and neonatologist: from the doctor's autonomy to adopt a diagnostic-therapeutic approach, with special reference to the prescription of drugs and the subtle differences compared to pharmacological trials, to the promotion and protection of breastfeeding, with explicit reference to the Ministry of Health's recent Circular no. 16 of 24.10.2000 ("Promotion and protection of breastfeeding") which, following a cursory reading of the text, appears to highlight restrictions to the pediatrician's decision-making autonomy. Special emphasis is also given to the medicolegal problems of caring for high-risk neonates. The clinical practice of neonatology often places the doctor in "critical" decision-making situations, with far from negligible ethical and moral implications, not to mention juridical and forensic ones. The author sets out a number of decision-making parameters for use as guidelines: the statistical criterion, the legal criterion and the clinical criterion, the only one capable of adjusting to scientific progress and to the specific technical and professional resources of the medical centre where the doctor is required to intervene in order to preserve even the simple "possibility" of autonomous life for the fetus. From this point of view, the so-called chronological vitality and scientifically proven statistics form part of the numerous criteria available for clinical evaluation. If the clinical criterion is not met, namely if the product of conception is not vital and has never been fully alive in the biologically complete sense of the term, then the omission of therapeutic support is not particularly important in professional and juridical terms. On the contrary, it would show an obstinate persistence of therapy, which would be both ethically and professionally incorrect. Lastly, even during the final stages of life, the doctor must play a participatory role not only by providing palliative treatment but also, and above all, offering moral assistance to sanction the ineluctable end of the therapeutic alliance, that "feeling together" which is the most literal and profound meaning of the word "consent", indicating both "information" but to an even greater extent "discussion" and "empathy" with the patient and his/her family.
