The future of intensive care: the study of the microcirculation will help to guide our therapies.

The goal of hemodynamic resuscitation is to optimize the microcirculation of organs to meet their oxygen and metabolic needs. Clinicians are currently blind to what is happening in the microcirculation of organs, which prevents them from achieving an additional degree of individualization of the hemodynamic resuscitation at tissue level. Indeed, clinicians never know whether optimization of the microcirculation and tissue oxygenation is actually achieved after macrovascular hemodynamic optimization. The challenge for the future is to have noninvasive, easy-to-use equipment that allows reliable assessment and immediate quantitative analysis of the microcirculation at the bedside. There are different methods for assessing the microcirculation at the bedside; all have strengths and challenges. The use of automated analysis and the future possibility of introducing artificial intelligence into analysis software could eliminate observer bias and provide guidance on microvascular-targeted treatment options. In addition, to gain caregiver confidence and support for the need to monitor the microcirculation, it is necessary to demonstrate that incorporating microcirculation analysis into the reasoning guiding hemodynamic resuscitation prevents organ dysfunction and improves the outcome of critically ill patients.

A review of therapeutic attempts to recruit the microcirculation in patients with sepsis.

Microcirculatory dysfunction is a pivotal element of the pathogenesis of severe sepsis and septic shock. Technological development, including sidestream darkfield videomicroscopy, now allows for bedside assessment of the microcirculation. A number of clinical studies have established the importance of the microcirculation in sepsis. The objective of this review is to discuss human trials that have assessed interventions aimed at improving microcirculatory flow in patients with sepsis.

Influence of diabetes on endothelial cell response during sepsis.

AIMS/HYPOTHESIS: Several endothelial pathways of cell adhesion, coagulation and vascular endothelial growth factor (VEGF) signalling are activated during sepsis. The objective of this analysis was to investigate the influence of diabetes on biomarkers of endothelial cell activation in sepsis. METHODS: This was a prospective observational cohort study of a convenience sample of adult patients (age ≥ 18 years) for whom infection was clinically suspected and who presented to an urban tertiary care emergency department between February 2005 and November 2008. We investigated the association of diabetes and sepsis with various endothelial activation biomarkers of cell adhesion (E-selectin, vascular cell adhesion molecule 1 [VCAM-1] and intercellular adhesion molecule 1 [ICAM-1]), coagulation (plasminogen activator inhibitor 1 [PAI-1]) and VEGF signalling (soluble fms-like tyrosine kinase-1 [sFLT-1]). RESULTS: A total of 207 patients (34% with sepsis, 32% with severe sepsis and 34% with septic shock) were studied, including 63 (30%) with diabetes. Compared with patients without diabetes, patients with diabetes had significantly increased E-selectin and sFLT-1 levels overall; this was most pronounced during septic shock in the stratified analysis. Multivariate models including age, sex, sepsis severity and other variables as potential covariates confirmed the association of diabetes with elevated circulating plasma levels of E-selectin (standardised ß 0.24, p < 0.001) and sFLT-1 (standardised ß 0.19, p < 0.01), but there was no significant association with VCAM-1, ICAM-1 or PAI-1. CONCLUSIONS/INTERPRETATION: During septic shock, patients with diabetes had higher levels of circulating biomarkers of endothelial cell adhesion (E-selectin) and VEGF signalling (sFLT-1). Future studies should address whether enhanced activation of the endothelium places patients with diabetes at increased risk for the development of sepsis and worsening morbidity and mortality.

[Trends in the spread of pandemic influenza A(H1N1) swl in the Far East in 2009].

The paper describes the trend in the spread of pandemic influenza A(H1N1) swl virus in the Far East, which started in this region 2-3 months later than that in the European part of Russia. By mid-October seasonal epidemic influenza was practically displaced by pandemic one.

The yield of head CT in syncope: a pilot study.

UNLABELLED: Although head CT is often routinely performed in emergency department (ED) patients with syncope, few studies have assessed its value. OBJECTIVES: To determine the yield of routine head CT in ED patients with syncope and analyse the factors associated with a positive CT. METHODS: Prospective, observational, cohort study of consecutive patients presenting with syncope to an urban tertiary-care ED (48,000 annual visits). INCLUSION CRITERIA: age >or=18 and loss of consciousness (LOC). Exclusion criteria included persistent altered mental status, drug-related or post-trauma LOC, seizure or hypoglycaemia. Primary outcome was abnormal head CT including subarachnoid, subdural or parenchymal haemorrhage, infarction, signs of acute stroke and newly diagnosed brain mass. RESULTS: Of 293 eligible patients, 113 (39%) underwent head CT and comprise the study cohort. Ninety-five patients (84%) were admitted to the hospital. Five patients, 5% (95% CI=0.8%-8%), had an abnormal head CT: 2 subarachnoid haemorrhage, 2 cerebral haemorrhage and 1 stroke. Post hoc examination of patients with an abnormal head CT revealed focal neurologic findings in 2 and a new headache in 1. The remaining 2 patients had no new neurologic findings but physical findings of trauma (head lacerations with periorbital ecchymoses suggestive of orbital fractures). All patients with positive findings on CT were >65 years of age. Of the 108 remaining patients who had head CT, 45 (32%-51%) had signs or symptoms of neurologic disease including headache, trauma above the clavicles or took coumadin. Limiting head CT to this population would potentially reduce scans by 56% (47%-65%). If age >60 were an additional criteria, scans would be reduced by 24% (16%-32%). Of the patients who did not have head CT, none were found to have new neurologic disease during hospitalisation or 30-day follow-up. CONCLUSIONS: Our data suggest that the derivation of a prospectively derived decision rule has the potential to decrease the routine use of head CT in patients presenting to the ED with syncope.

Early goal-directed therapy: a UK perspective.

The surviving sepsis campaign developed guidelines in 2003 that were designed to increase physician awareness of sepsis and to develop a series of recommendations for the management of the patient with sepsis. The guidelines had the support of 11 international professional organisations across a variety of specialties, and advocate aggressive, early goal-oriented resuscitation in appropriate patients.

Absolute lymphocyte count as a predictor of CD4 count.

STUDY OBJECTIVE: To determine whether the absolute lymphocyte count (ALC) (white blood count x lymphocyte percentage) can be used to predict a low CD4 count. METHODS: We conducted a retrospective data analysis of consecutive CD4 count analyses performed between January 1, 1995, through December 1, 1995, at an urban university teaching hospital. Results of consecutive CD4 counts and simultaneously measured ALCs were analyzed from samples obtained in inpatient, clinic, and emergency department settings. The ability of ALC to predict a CD4 count less than 200 cells/mm3 was analyzed by calculating sensitivities, specificities, predictive values, and likelihood ratios for a range of ALC values. RESULTS: Among the 807 samples, 322 results (40%) had a CD4 count less than 200 cells/mm3. The ALC and CD4 count were correlated (r=.69, P<.0001). An ALC less than 1,000 cells/mm3 predicted CD4 counts less than 200 cells/mm3 with a sensitivity of .67 (95% confidence interval .62 to .72), specificity of .96 (.94 to .98), positive predictive value of .91 (.87 to .95), and a negative predictive value of .81 (.78 to .84). An ALC less than 2,000 cells/mm3 predicted CD4 counts less than 200 cells/mm3 with a sensitivity of .97 (.95 to .99), specificity of .41 (.37 to .45), positive predictive value of .52 (.48 to .56), and negative predictive value of .95 (.92 to .98). CONCLUSION: A reliable relationship exists between ALC and CD4 count. In a similar population, an ALC less than 1,000 cells/mm3 is predictive of a CD4 count less than 200 cells/mm3, and an ALC greater than or equal to 2,000 cells/mm3 is predictive of a CD4 count greater than or equal to 200 cells/mm3. Physicians may find these criteria useful in identifying patients with increased risk of opportunistic infection.

Reversion to normal phenotype induced by SV40 in a spontaneously transformed malignant Chinese hamster cell line.

By using a selection procedure that excluded the transforming effect of SV40, reversions to several properties of normal phenotype were for the first time obtained in a transformed Chinese hamster cell line after SV40 infection. The value of induction to recovery of contact inhibition was typical for SV40-induced reverse gene mutations. Thirteen of 15 isolated revertant clones were T-antigen positive, thus synthesizing the product of viral oncogene. Therefore, in the majority of clones reversion occurred in spite of the presence of viral transforming protein. Dot hybridization revealed the presence of SV40 DNA in all revertants including those expressing no T antigen. The virus rescued from one T-antigen positive and two negative clones proved to be infectious. Reversion to contact inhibition was followed by reversion as regards serum requirements and growth in soft agar. However, in all cases reversion was partial. Karyologic analysis of revertant clones showed that six clones maintained the hypodiploid karyotype of the parental clone, six revertants were near-tetraploid, and one was near triploid. The possible events underlying the SV40-induced reversions to normal phenotype and the role of virus-induced mutations in viral carcinogenesis are discussed.

[Chinese hamster cells mutant at the hypoxanthine-guanine phosphoribosyltransferase (GPRT) locus. V. Complementation analysis of ts mutants]. / Issledovanie kletok kitaiskogo khomiachka, mutantnykh po lokusu gipoksantin-gunainfosforiboziltransferazy (GFRT). Soobshchenie V. Komplementatsionnyi analiz ts-mutantov.

Four temperature-sensitive HPRT clones were used for hybridological analysis, which led to increase in complementation rate about 5 times. The probability of complementation, in respect of the HPRT locus proved to be rather high: 14 of 45 hybridization-tested mutants had complementation ability (including 3 ts mutants). Analysis of the complementation rate among mutants revealed clear-cut dependence on the selection conditions: clones grown in a medium with 8-azaguanine showed most frequent complementation. The use of mutants with a new phenotype in hybridization analysis revealed four additional complementation groups, three of which are made of temperature-sensitive clones. Biochemical analysis revealed the presence of hybrid forms of the HPRT enzyme in all hybrids tested. This confirms the intragenic character of complementation. At present, the functional map of the HPRT locus is represented by 9 groups, including a group of mutants with no complementation ability.

[Reversibility of malignant transformation as affected by the oncogenic virus SV40. II. The characteristics of virus-induced revertant clones]. / Obratimost' zlokachestvennoi transformatsii pod vliianiem onkogennogo virusa SV40. Soobshchenie II. Kharakteristika virusindutsirovannykh revertantnykh klonov.

Fifteen revertant clones exhibiting contact inhibition, one of the typical characteristics of normal cells, were studied after treatment of spontaneously transformed Chinese hamster fibroblasts with SV40. The clones proved to be partial revertants, as regards to other properties of the normal phenotype--loss of the ability to grow in a medium with a low serum content and anchorage-dependence. Viral DNA was detected in all revertant clones. The expression of T-antigen--the product of viral oncogene, was observed in 13 of 15 revertants analyzed. The study of SV40 "rescued" from several revertants in permissive monkey cells has shown that the virus is non-defective. In 7 clones, reversion was accompanied with polyploidization. In the cases, reversion could be due to changes in the balance between oncogenes and suppressor genes (anti-oncogenes). The possibility of induction by SV40 of mutations in anti-oncogenes suppressing the expression of both cellular and viral oncogenes is discussed. It is suggested that reversion to the normal phenotype in clones with a near-diploid karyotype could result from such virus-induced suppressor mutations.

The action of the tumour promoter, TPA, on mutagenesis induced by different agents (UV light, chemical and viral mutagens).

The present paper deals with effects of 12-O-tetradecanoylphorbol-13-acetate (TPA) on the frequency of induced mutations to 6-mercaptopurine (6MP) and ouabain resistance in Chinese hamster and mouse cells. UV light, bovine adenovirus 3(BAV-3) and 5-bromodeoxyuridine (BrdU) were used as mutagens. TPA was shown to raise the frequency of gene mutations induced by UV light and BAV-3 but it did not enhance the mutagenic effect of BrdU. We also examined the ability of BAV-3 and BrdU to induce tumours in mice. BrdU was shown to have no carcinogenic effect. The results suggest that TPA enhances the mutagenic effect only for carcinogenic mutagens.

[Delayed-type hypersensitivity reaction induced in mice by the administration of an inactivated influenza vaccine]. / Izuchenie reaktsii povyshennoi chuvstvitel nosti zamedlennogo tipa pri vaktsinatsii myshei inaktivirovannoi grippoznoi vaktsinoi.

The conditions of delayed-type hypersensitivity induction following immunization with an inactivated influenza vaccine in BALB/c and CBA/H mice treated with cyclophosphane were studied. The results showed that the delayed-type hypersensitivity reaction had no type specificity when revealing preparation injected to immunized mice is a vaccine prepared with chorioallantoic fluid, but it is specific when a tissue vaccine is used. The use of inactivated influenza viruses cultivated on different cell-types for sensitization and revelation of the hypersensitivity state allowed to evaluate the level of the delayed-type hypersensitivity induced by untreated virus.

[Reversal of malignant transformation induced by the oncogenic virus SV40. I. Induction of reversal to normal type for the contact inhibition trait]. / Obratimost' zlokachestvennoi transformatsii pod vliianiem onkogennogo virusa SV40. Soobshchenie I. Induktsiia reversii k norme po priznaku kontaktnogo razmnozheniia.

The possibility of induction by the oncogenic DNA-containing virus SV40 of reversions to normal phenotype as regards contact inhibition ("flat" revertants), was studied in spontaneously transformed chinese hamster fibroblasts. Negative selection was used for detection of revertants. The method adopted allowed to study the mutagenic activity of the virus, while excluding its transforming effect. In all experiments the frequency of revertants after infection exceeded that in control series. The value of induction varied from 1.2 to 28.4 X 10(-6). The tumor promoter 12-O-tetradecanoyl-phorbol-13-acetate (TPA) known to increase the frequency of mutations induced by carcinogens in vitro, displayed no enhancing effect on the frequency of revertants induced by SV40. The lack of enhancement of virus-induced reversions after TPA treatment might be explained by the lack of the transforming effect of SV40 in the system studied. Some of the normal "flat" colonies were T-antigen positive, i. e. the viral oncogene was expressed. The role of mutations induced by SV40 in cellular genes controlling malignancy is discussed.

[Integration of SV40 DNA into the cell genome and viral mutagenesis]. / Integratsiia DNK SV40 v genom kletok i virusnyi mutagenez.

Integration of DNA of a temperature-sensitive SV40 mutant (tsA239) into the cell genome was studied. The viral A gene (the oncogene) encodes the tumour T antigen which is ts in the mutant and is devoid of mutagenic and transforming activity under non-permissive conditions (40 degrees C). Clones of Chinese hamster cells infected by tsA239 mutant were analysed. Those infected by wild-type SV40 served as controls. As shown by dot-hybridization, SV40 DNA was detected in cells of 14 out of 18 clones infected by tsA mutant and incubated at 40.5 degrees C, and in all 20 clones infected by tsA mutant and incubated under permissive conditions (33 degrees C), the difference between the two groups being insignificant (p greater than 0.05). By means of blot-hybridization it was established that viral DNA was integrated into the cell genome of all 12 clones analysed, belonging to the three experimental series: infection by tsA mutant, incubation at 40.5 and 33 degrees C, infection by wt SV40, incubation at 40.5 degrees C. The number of integration sites ranged from one to four in different clones. Integration of SV40 DNA in tandems was observed. The data presented allow to conclude that integration per se does not play a crucial role in determining the mutagenic and transforming effect of the virus. Obviously, what matters is the activity of viral oncogene product - the T antigen.

[Allergenic action of inactivated influenza vaccines]. / Izuchenie allergiziruiushchego deistviia inaktivirovannykh grippoznykh vaktsin.

The allergenic action of influenza vaccines was evaluated by the determination of the capacity of sera, taken before and after immunization, for inducing the degranulation of rat mast cells in the presence of the vaccine preparation. In this test sera from three groups of volunteers immunized with experimental and commercial batches of influenza inactivated vaccines, purified and concentrated by gradient centrifugation, was studied. The absence of immediate-type allergization after a single administration of the vaccines under study was shown.

[Mutagenic effect of the SV40 oncogene: induction of resistance to 6-mercaptopurine and serum independence]. / Mutagennoe deistvie onkogena SV40: induktsiia rezistentnosti k 6-merkaptopurinu i nezavisimost' ot syvorotki.

The mutagenic and transforming activity of SV40 DNA fragment, corresponding to its oncogene (the gene for large T antigen) was studied in Chinese hamster cells. After expression time of 3 to 4 days, the oncogene induced mutations of resistance to 6-mercaptopurine (6MP), while the DNA encoding the SV40 late genes, as well as DNA of Chinese hamster cells, were devoid of mutagenic activity. The value of induction ranged from 10(-4) to 10(-5). After the same expression time, the oncogene induced a typical character of oncogenic transformation - independence of serum growth factors (ser+). The value of induction of ser+ variants was somewhat higher than for resistance mutations. The study of 12 clones induced by the oncogene has shown the ser+ character to be hereditary, the expression of viral oncogene being not necessary for its maintenance. The data obtained support the hypothesis in favour of the participation of mutations of cellular genes in viral carcinogenesis.

[Adsorbed subunit influenza vaccine: its isolation and characteristics]. / Adsorbirovannaia grippoznaia sub''edinichnaia (AGS)vaktsina: poluchenie i kharakteristika.

Experimental batches of adsorbed subunit influenza vaccine were prepared from the envelope of glycoprotein antigens separated from the influenza virion by treatment with a cationic detergent (cetyltrimethylammonium bromide). Purified and concentrated influenza virus strains A(H1N1) and A(H3N2) were obtained by gradient centrifugation; additional purification, with a view to removing ovalbumin and structural components of the chorioallantoic membrane, was achieved by gelfiltration. The composition and biological properties of the vaccine are described.

The oncogene of BAV-3 as a mutagen.

We studied the mutagenic and carcinogenic effects on mammalian cells of two EcoRI DNA fragments of bovine adenovirus type3 (BAV-3) integrated into the pBR325 plasmid. Fragment D located between 3.6 and 19.7 map units, contains the viral oncogene, fragment C, located between 44.3 and 63.7 map units, has no oncogenic activity. The BAV-3 oncogene was shown to increase significantly the frequency of 6-mercaptopurine (6MP)-resistant mutants in Chinese hamster calls. Fragment C, pBR325 without viral sequences and DNA from normal Syrian hamster cells did not have any mutagenic effect. We also looked at the combined action of the viral DNA fragments and the tumour promoter 12-O-tetradecanoylphorbol-13-acetate (TPA), which enhances the transforming effect of carcinogens. TPA was shown to increase the mutant yield on exposure to the viral oncogene but not to induce mutagenic activity in those types of DNA that are unable to transform cells. Probably TPA does not affect the initiation of the mutation process, but acts on later stages just as it affects carcinogenic activity. Thus the results obtained confirm the existence of parallelism between the mutagenic and transforming effects of viral DNA and show that both activities are mapped in the same region of viral DNA - its oncogene.

[Mutagens and the tumor promoter]. / Mutageny i opukholevyi promotor.

We studied the effect of 12-O-tetradecanoylphorbol-13-acetate (TPA) and saccharin on the frequency of induced mutations of resistance to 6-mercaptopurine and ouabain in Chinese hamster and mouse cells. UV-rays, bovine adenovirus-3 (BAV-3) and 5-bromdeoxyuridine (BrdU) were used as mutagens. In the case of BAV-3 and BrdU, we investigated, apart from the mutagenic effect, the tumor-inducing activity of these mutagens in mice, BrdU proved to have no carcinogenic effect. The data about the influence of TPA on the mutagenic effect of the three different mutagens indicate that TPA increases the frequency of the gene mutations induced by UV-rays and BAV-3. The results of the study of BrdU and TPA combined action revealed the fact that TPA does not increase the mutagenic effect of BrdU. We demonstrated that saccharin also possesses the promoter activity; it increases the mutagenic effect of BAV-3. The results described above lead to the assumption that TPA influence on the mutagenic effect only takes place when carcinogenic mutagens are used.

[Immune response of noninbred mice to subvirion influenza vaccines with various antigen and sorbent loads]. / Izuchenie immunnogo otveta neinbrednykh myshei na subvirionnye gripkoznye vaktsiny s var'iruemoi nagruzkoi antigena i sorbenta.

The variants of splitted and subunit influenza monovaccines from virus strains A/Leningrad/385/80R (H3N2) and A/Kiev/59/79R (H1N1), adsorbed on aluminium hydroxide and having the varying content of hemogglutinin and the carrier, have been studied. The immune response of noninbred mice to a single and double injections of these vaccines have been evaluated, the concentrations of the antigen and the carrier inducing a high response in the animals, have been determined. Differences in the immunological potency of hemagglutinins H1 and H3 have been noted.