Glutamine and alanine-induced differential expression of intracellular IL-6, IL-8, and TNF-α in LPS-stimulated monocytes in human whole-blood.

To investigate the effects of the commonly-used immunomodulators l-glutamine, l-alanine, and the combination of both l-alanyl-l-glutamine (Dipeptamin(®)) on intracellular expression of IL-6, IL-8, and TNF-α during endotoxemia, lipopolysaccharide (LPS)-stimulated human monocytes in a whole blood system were investigated by flow cytometry. Whole blood of twenty-seven healthy volunteers was stimulated with LPS and incubated with three different amino acid solutions (1. l-glutamine, 2. l-alanine, 3. l-alanyl-l-glutamine, each concentration 2 mM, 5 mM, incubation time 3 h). CD14(+) monocytes were phenotyped in whole-blood and intracellular expression of cytokines was assessed by flow cytometry. Our investigations showed for the first time in whole blood probes, imitating best physiologically present cellular interactions, that l-glutamine caused a dose-independent inhibitory effect on IL-6 and TNF-α production in human monocytes stimulated with LPS. However, l-alanine had contrary effects on IL-6 expression, significantly upregulating expression of IL-6 in LPS-treated monocytes. The impact of l-alanine on the expression of TNF-α was comparable with glutamine. Neither amino acid was able to affect IL-8 production in LPS-stimulated monocytes. The combination of both did not influence significantly IL-6 and IL-8 expression in monocytes during endotoxemia, however strongly reduced TNF-α production. For the regulation of TNF-α, l-glutamine, l-alanine and the combination of both show a congruent and exponentiated downregulating effect during endotoxemia, for the modulation of IL-6, l-glutamine and l-alanine featured opposite regulation leading to a canceling impact of each other when recombining both amino acids.

[Sepsis and multiple organ dysfunctions--pathophysiology and the topical concepts of treatment].

Severe sepsis with multiple organ dysfunctions is still the leading cause of death in non-cardiac intensive care units (ICU). The incidence is expected to rise in the future due to the growing number of older and immunocompromized patients, the use of invasive procedures, and an increase in the percentage of aggressive or resistant microorganisms. Despite the enormous investment in critical care resources, severe sepsis mortality remains to be high and ranges from 28 to 50%. Based on the disappointing experiences with anti-inflammatory strategies, the authors now realize that sepsis is more than just an inflammation. By taking into account pathophysiological changes, the new therapeutic concepts combine successful modulation with an improvement of the ICU management of multiple organ dysfunctions. This review discusses the actual sepsis intensive care concepts that may be useful in reducing unacceptable high mortality rates in patients with severe sepsis.

E5564 (Eritoran) inhibits lipopolysaccharide-induced cytokine production in human blood monocytes.

OBJECTIVE AND DESIGN: In this ex vivo laboratory study, we investigated the effects of E5564 (eritoran), a toll-like receptor 4-directed endotoxin antagonist, on intracellular expression of interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha in lipopolysaccharide (LPS)-stimulated human monocytes assessed by flow cytometry. MATERIAL AND METHOD: Whole blood samples from 10 healthy volunteers (average age: 32 +/- 2 years) were pre-incubated with 0.001, 0.003, 0.01, 0.03, 0.1, 0.3, 1 and 10 ng/ml E5564 for 45 min and after this stimulated with LPS (0.2 ng/ml), a dose we found to be the most effective for stimulation. Samples were incubated for 3 h at 37 degrees C and 5% CO(2). Intracellular expression of IL-6 and TNF-alpha was assessed by flow cytometry. RESULTS: Our investigation showed that E5564 (0.03 ng/ml up to 10 ng/ml) caused a dose-dependent inhibitory effect on IL-6 and TNF-alpha production in LPS-stimulated human monocytes. CONCLUSIONS: The results of this investigation led us to conclude that E5564 has a remarkable LPS inhibitory activity manifested via down-regulation of the intracellular generation of pro-inflammatory cytokines IL-6 and TNF-alpha in human monocytes.

[Sepsis and multiple organ failure - update of current therapeutic concepts]. / Sepsis und Multiorganversagen - Update der aktuellen Therapiekonzepte.

Severe sepsis with multiple organ dysfunctions is still the leading cause of death in non-cardiac intensive care units. The incidence is expected to rise in the future due to the growing number of older and immuno-compromized patients, the use of invasive procedures, and an increase in the percentage of aggressive or resistant microorganisms. Despite the enormous investment in critical care resources, mortality of severe sepsis remaines on a high level and ranges from 28 - 50 %. Based on the disappointing experiences with anti-inflammatory strategies, we now realize that sepsis is more than just inflammation. The new therapeutic approaches take account of this more sophisticated view of pathophysiologic changes, resulting in the modulation of the coagulation in combination with an improvement of the ICU-management of organ dysfunctions. This review discusses the therapeutic concepts, reported es exciting new interventions in the ICU setting to decrease the inacceptable high mortality in patients with severe sepsis.

Inhibition of intracellular tumour necrosis factor (TNF)-alpha and interleukin (IL)-6 production in human monocytes by iloprost.

BACKGROUND: To investigate the effects of iloprost as a stable prostacyclin analogue on intracellular expression of IL-6 and TNF-alpha of lipopolysaccharide (LPS)-stimulated human monocytes in a whole blood system assessed by flow cytometry. MATERIAL AND METHODS: Whole blood of six healthy volunteers processed immediately after withdrawal and twice on different days (six measurements per experiment) was stimulated in two different settings with LPS (final concentrations 0.2 ng mL(-1) and 10 ng mL(-1)) and incubated with iloprost (final concentrations in each experiment were 0.01 nm, 0.1 nm, 0.3 nm, 1 nm, 3 nm, 10 nm, 30 nm and 100 nm) for 3 h at 37 degrees C and 5% CO2. Intracellular expression of IL-6 and TNF-alpha was assessed by flow cytometry. RESULTS: Our investigations showed, for the first time, that iloprost (0.1 nm up to 100 nm) caused a dose-dependent inhibitory effect of IL-6 production in human monocytes stimulated with LPS (10 ng mL(-1)), which was even more obvious in monocytes stimulated with lower concentrated LPS (0.2 ng mL(-1)). Iloprost (0.1 nm up to 100 nm) was found to inhibit TNF-alpha production of LPS-stimulated monocytes in a dose-dependent fashion not influenced by LPS concentration. CONCLUSIONS: Apart from the vasodilatory and antithrombotic effects, iloprost may also down-regulate the intracellular expression of IL-6 and TNF-alpha in human monocytes.

[Treatment of emergencies in the hospital--problems and management]. / Die Behandlung von Notfällen im Krankenhaus--Probleme und Management.

Due to the growing number of high-risk patients, the increasing proportion of geriatric patients and the expansion of surgical and invasive-diagnostic procedures, medical stuff in hospitals are confronted with a rising number of emergency situations. Nearly 50% are of cardio-circulatory origin and occur during surgical interventions or immediately afterwards. Another cause of life-threatening complications are side-effects of orally or intravenously administered agents, especially after treatment with antibiotics, anaesthetics, analgetics and sedatives. Due to a lack of emergency training and management in most hospitals, the survival rate after cardiopulmonary resuscitation in general wards lies between just two and 35%. Thus it seems necessary to perform special training in CPR procedures and emergency management at regular intervals for the entire medical stuff. In addition, a special infrastructure for giving sufficient treatment in emergencies has to be established (emergency team, emergency telephone number, intra-hospital emergency car). The second part of this review presents current diagnostic and therapeutic strategies for the most common emergency situations, e.g. anaphylaxis, myocardial infarction, pulmonary embolism, gastrointestinal bleeding, and heparin-induced thrombocytopenia (HIT).

Different expression of cytokines in survivors and non-survivors from MODS following cardiovascular surgery.

OBJECTIVE: Cardiopulmonary bypass is often associated with pathophysiological changes in form of systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS). In the present study, we investigated plasma levels of pro- and anti-inflammatory cytokines in survivors and non-survivors from MODS in the early postoperative course following open heart surgery. DESIGN: Prospective clinical study. SETTING: A University Cardiothoracic Intensive Care Unit. METHODS: Levels of cytokines (IL-6, IL-8, IL-10, IL-18, and TGF- ) and procalcitonin (PCT) were measured at the first four postoperative days in 16 adult male patients with an Apache II-score >24 and two or more organ dysfunctions after myocardial revascularization. MAIN RESULTS: All pro-inflammatory cytokines, except for IL-6, were significantly elevated in non-survivors from MODS, with peak values at the first two postoperative days. The plasma levels of immunoinhibitory cytokines showed no differences between the groups. CONCLUSIONS: The results of our study show a different expression of pro-inflammatory cytokines in survivors and non-survivors from MODS following operations with extracorporeal circulation. In addition to Apache-II score, especially IL-8, IL-18, and PCT may be used as parameters for the prognosis of patients with organ dysfunctions after cardiac surgery.

Lipopolysaccharide-binding protein (LBP) and markers of acute-phase response in patients with multiple organ dysfunction syndrome (MODS) following open heart surgery.

Cardiopulmonary bypass (CPB) is associated with an immunological injury that may cause pathophysiological alterations in the form of a systemic inflammatory response syndrome (SIRS) or a multiple organ dysfunction syndrome (MODS). Previous studies on this issue have reported different changes of immunological parameters during and after CPB, but there are no reports about the lipopolysaccharide-binding protein (LBP) in relationship to other markers of inflammation in patients with MODS following cardiovascular surgery. In the present study, we investigated the acute-phase response of patients with MODS of infectious and non-infectious origin following open-heart-surgery. Plasma levels of procalcitonin (PCT), c-reactive protein (CRP), interleukin-6 (IL-6), and LBP were measured in the first four postoperative days in 12 adult male patients with the signs of SIRS and two or more organ dysfunctions after myocardial revascularization (MODS-group), and 12 patients without organ insufficiencies (SIRS-group). There were no significant differences regarding age, weight, height, preoperative NYHA-classification, preoperative LVEDP, or the number of anastomosis. Patients with MODS had a significantly longer operation time, duration of ischemia, and duration of extracorporeal circulation. None of the patients in the SIRS group died, whereas in the MODS group, 4 patients died due to septic multiorgan failure. Plasma PCT and IL-6 concentrations were significantly elevated in all MODS patients. CRP and LBP showed no differences between the MODS and the SIRS group. Comparing the MODS patients with and without positive microbial findings, we found significantly elevated levels of PCT and LBP in those patients with documented infections. Our results indicate that LBP may be a new marker for the differentiation between a severe non-infectious SIRS and an ongoing bacterial sepsis in the early postoperative course following CPB, while a microbiological result is still missing.

[Changes in the cytokine network through escalating SIRS after heart surgery]. / Veränderungen des Zytokin-Netzwerkes bei eskalierendem SIRS nach herzchirurgischen Operationen*

Changes in the Cytokine Network Through Escalating SIRS After Heart Surgery. Cardiopulmonary bypass is associated with an injury that may cause pathophysiological changes in form of systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS). There is a lot of information about the immunologic alterations in patients undergoing cardiopulmonary bypass, but only little is known about the expression of cytokines in patients with severe SIRS or MODS following cardiovascular surgery. In the present study, we investigated the inflammatory response of patients with an escalating SIRS following open heart surgery. Plasma levels of cytokines (IL-1beta, IL-6, IL-8, IL-10, IL-12, IL-18, GM-CSF and TGF-beta) were measured at the first four postoperative days in 12 adult male patients with severe SIRS (SIRS-group), and 15 patients with uncomplicated course (control-group) following myocardial revascularization. All cytokines (except IL-1beta) were significantly elevated in SIRS-patients, the analysis of differences between the survivors and non-survivors within the SIRS-group showed dramatically elevated levels of IL-8 and IL-18 in non-survivors. From the results of our investigation we can conclude that monitoring of immunologic parameters, e.g. IL-8 and/or IL-18 may be helpful for the early detection and prognosis of high-risk patients with severe SIRS and MODS following cardiac surgery.

The effect of sevoflurane and desflurane on upper airway reactivity.

BACKGROUND: Although bronchial reactivity can be assessed by changes in airway resistance, there is no well-accepted measure of upper airway reactivity during anesthesia. The authors used the stimulus of endotracheal tube cuff inflation and deflation to assess changes in airway reactivity in patients anesthetized with sevoflurane and desflurane. METHODS: Sixty-four patients classified as American Society of Anesthesiologists physical status I or II participated in this randomized, double-blind study. Patients were anesthetized with either sevoflurane or desflurane at 1.0 and 1.8 minimum alveolar concentration (MAC). The trachea was stimulated by inflating the endotracheal tube cuff. A blinded observer assessed the severity of patient response to the stimulus and changes in hemodynamic variables. The process was repeated at the second MAC treatment condition. RESULTS: At 1.0 MAC, patients anesthetized with desflurane had a more intense response and a greater likelihood of significant coughing and associated hemodynamic changes (both at P < 0.05). At 1.8 MAC, sevoflurane and desflurane both suppressed clinically significant responses to tracheal stimulation. Interrater reliability was excellent for this measure of upper airway reactivity (P < 0.001). CONCLUSIONS: The assessment of the cough response to tracheal stimulation by endotracheal tube cuff inflation is a reliable and clinically meaningful measure of upper airway reactivity. At 1.0 MAC, sevoflurane is superior to desflurane for suppressing moderate and severe responses to this stimulus.

[Cisatracurium in patients with compromised kidney function. Pharmacodynamic and intubation conditions under isoflurane-nitrous oxide anesthesia]. / Cisatracurium bei Patienten mit eingeschränkter Nierenfunktion. Pharmakodynamik und Intubationsbedingungen unter Isofluran-Lachgas-Anästhesie.

OBJECTIVES: The choice of cisatracurium, especially for patients with organ dysfunction, seems to be beneficial, because of organ-independent Hofmann-elimination and less histamine release propensity. This study was designed to investigate pharmacodynamics and intubating conditions after bolus administration of 0.15 mg/kg cisatracurium (3 x ED95) in patients with renal failure and maintained with isoflurane/N2O in oxygen. METHODS: 20 patients with renal failure and 19 patients with normal renal function were studied. Anaesthesia was induced with fentanyl (2-3 micrograms/kg) and thiophentone (4-7 mg/kg). After rapid bolus administration of 0.15 mg/kg cisatracurium (3 x ED95), onset time and intubating conditions were assessed. Clinical duration (DUR 25%), recovery index and duration 90% were investigated by acceleromyography. Changes of mean arterial blood pressure and/or heart rate > or = 20% were defined as clinically significant. RESULTS: The onset time (3.1 +/- 0.8 min) was shorter in patients without renal failure (Cis-1) than in patients with normal renal function (3.6 +/- 0.8 min), but without statistical significance. Intubating conditions, scored according to a 3-step scale, were slightly better in patients with normal renal function. Other pharmacodynamic parameters did not differ significantly. However, a small tendency to a prolonged recovery with a wide inter-individual variety was characteristic for patients with renal failure. Regarding the hemodynamic actions, only minor individual cardiovascular changes occured. No clinical evidence of histamine release was observed in any patient. CONCLUSIONS: The result of this clinical study suggest, that cisatracurium is a suitable choice for patients with renal failure. The necessity for an intraoperative neuromuscular monitoring is given by the marked heterogeneity in the recovery parameters in patients with renal failure.

Onset time, endotracheal intubating conditions, and plasma histamine after cisatracurium and vecuronium administration.

UNLABELLED: Cisatracurium is a nondepolarizing muscle relaxant with a slow onset. We performed a prospective, randomized, double-blind clinical trial in 60 patients (ASA physical status I or II) to assess whether cisatracurium (0.15 or 0.25 mg/kg) or vecuronium (0.15 mg/kg), administered as a bolus immediately after induction of anesthesia with fentanyl and thiopental, would provide a faster onset time and better tracheal intubating conditions than previously reported. We sought to determine whether patients given muscle relaxants in this commonly used induction sequence would exhibit cutaneous, systemic, or chemical evidence of histamine release. Onset time of the relaxants was determined by using mechanomyography. Intubating conditions were scored on a defined interval scale by an anesthesiologist blinded to the relaxant administered. Heart rate and arterial blood pressure were measured noninvasively every minute from 10 min before to 5 min after the application of the muscle relaxant. Mean (+/- SD) onset times for 0.25 mg/kg cisatracurium (68.3 +/- 19.5 s) and for 0.15 mg/kg vecuronium (69.5 +/- 29.2 s) were significantly different from those in the 0.15 mg/kg cisatracurium group (105 +/- 41.2 s). The intubating conditions were better with the larger dose of cisatracurium or vecuronium (P < 0.03). Although plasma histamine levels were not statistically different among groups, levels >1 ng/mL were observed in 5 of 40 patients who received cisatracurium but in none of the 20 patients who received vecuronium. There were no significant hemodynamic differences among the groups. In a dose of 0.25 mg/kg, cisatracurium has as rapid an onset time as vecuronium 0.15 mg/kg, but the former shows evidence of histamine release. IMPLICATIONS: Cisatracurium has been considered a drug with a relatively slow onset but that has the significant benefit of being devoid of chemically mediated histamine release. In this study, we describe an onset time faster than previously reported when cisatracurium was given immediately after thiopental. We also note that several patients had abnormal histamine levels after cisatracurium administration.

Growth regulation by cell shape alteration and organization of the cytoskeleton.

The correlation between cellular growth and microfilament-dependent morphology was investigated. It was found that the proliferative growth of various nontransformed cell lines does not only depend on cell adhesion to a suitable substratum and cell flattening but also on intact microfilaments. Disintegration of microfilaments by cytochalasin D (CD) as well as lactrunculin (LAT)-A and LAT-B is correlated with a strong decline of the number of DNA-synthesizing cells during a period of 8 to 12 h after application of the drug. RNA and protein synthesis are reduced already after a preincubation time of 2 h. Although microinjected rhodamine-phalloin is colocalized with microfilaments there is no stabilizing effect against CD even at high phaloidin concentrations. Microinjection of DNAse I results in a strong alteration of the microfilament system. The disorganization of microfilaments was correlated with a moderate decrease of protein synthesis 2 h after microinjection, whereas RNA synthesis remained unchanged, if RNase-free DNase I was used. The number of DNA-synthesizing cells was somewhat diminished 24 h after microinjection. Furthermore, the microfilament system is disorganized by microinjection of gelsolin and gelsolin segment 1 + 2, respectively. The severing the microfilaments by gelsolin is correlated with a significant restriction of RNA and protein synthesis during a period of 2 to 4 h after injection, but the labeling index remaining unchanged. Therefore, we assume that inhibition of the G0-G1-S transition is only caused by a disintegration of microfilaments lasting longer than 4 h. The significance of microfilament organization for growth regulation is discussed.

Significance of the cardioprotective effect of prostanoids and indomethacin.

Recent investigations in several organs indicate cytoprotective effects of prostanoids. For further elucidation of this efficacy the investigations dealt with the cardioprotection of prostanoids (iloprost, PGE1) and the cyclooxygenase inhibitor indomethacin under in vivo- and in vitro-conditions. The experiments were carried out in isolated perfused guinea pig hearts and anaesthetized rabbits. Cardiac damage was induced by chemical substances or loading by aortic constriction or ischemia. In isolated perfused hearts iloprost and indomethacin suppressed the toxic effects of carbon tetrachloride, chloroform, benzene, sodium dithionate and phenylethylbarbituric acid, but not the efficacy of quinine sulfate and 2,4-dinitro-phenol. Cardiac loading by aortic stenosis or ischemia induced a decrease of contractility and blood pressure and changes in the myocardial PGI2-biosynthesis. On the other side application of indomethacin, iloprost or PGE1 diminished the cardiac damage and inhibit the myocardial PGI2-formation. The results show that indomethacin and prostanoids have a protective effect in pathophysiological changes or toxic damage of the heart, possibly caused by a stabilization of the cellular membrane.