RESUMO
Tumor-associated immune cells play a crucial role in cancer progression. Myeloid-derived suppressor cells (MDSCs), for example, are immature innate immune cells that infiltrate the tumor to exert immunosuppressive activity and protect cancer cells from the host's immune system and/or cancer-specific immunotherapies. While tumor-associated immune cells have emerged as a promising therapeutic target, efforts to counter immunosuppression within the tumor niche have been hampered by the lack of approaches that selectively target the immune cell compartment of the tumor, to effectively eliminate "tumor-protecting" immune cells and/or drive an "anti-tumor" phenotype. Here we report on a novel nanotechnology-based approach to target tumor-associated immune cells and promote "anti-tumor" responses in a murine model of breast cancer. Engineered extracellular vesicles (EVs) decorated with ICAM-1 ligands and loaded with miR-146a and Glut1, were biosynthesized (in vitro or in vivo) and administered to tumor-bearing mice once a week for up to 5 weeks. The impact of this treatment modality on the immune cell compartment and tumor progression was evaluated via RT-qPCR, flow cytometry, and histology. Our results indicate that weekly administration of the engineered EVs (i.e., ICAM-1-decorated and loaded with miR-146a and Glut1) hampered tumor progression compared to ICAM-1-decorated EVs with no cargo. Flow cytometry analyses of the tumors indicated a shift in the phenotype of the immune cell population toward a more pro-inflammatory state, which appeared to have facilitated the infiltration of tumor-targeting T cells, and was associated with a reduction in tumor size and decreased metastatic burden. Altogether, our results indicate that ICAM-1-decorated EVs could be a powerful platform nanotechnology for the deployment of immune cell-targeting therapies to solid tumors.
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Vasculogenic cell therapies have emerged as a powerful tool to increase vascularization and promote tissue repair/regeneration. Current approaches to cell therapies, however, rely mostly on progenitor cells, which pose significant risks (e.g., uncontrolled differentiation, tumorigenesis, and genetic/epigenetic abnormalities). Moreover, reprogramming methodologies used to generate induced endothelial cells (iECs) from induced pluripotent stem cells rely heavily on viral vectors, which pose additional translational limitations. This work describes the development of engineered human extracellular vesicles (EVs) capable of driving reprogramming-based vasculogenic therapies without the need for progenitor cells and/or viral vectors. The EVs were derived from primary human dermal fibroblasts (HDFs), and were engineered to pack transcription factor genes/transcripts of ETV2, FLI1, and FOXC2 (EFF). Our results indicate that in addition of EFF, the engineered EVs were also loaded with transcripts of angiogenic factors (e.g., VEGF-A, VEGF-KDR, FGF2). In vitro and in vivo studies indicate that such EVs effectively transfected HDFs and drove direct conversions towards iECs within 7-14 days. Finally, wound healing studies in mice indicate that engineered EVs lead to improved wound closure and vascularity. Altogether, our results show the potential of engineered human vasculogenic EVs to drive direct reprogramming processes of somatic cells towards iECs, and facilitate tissue repair/regeneration.
RESUMO
Acute respiratory distress syndrome (ARDS) represents a significant burden to the healthcare system, with ≈200 000 cases diagnosed annually in the USA. ARDS patients suffer from severe refractory hypoxemia, alveolar-capillary barrier dysfunction, impaired surfactant function, and abnormal upregulation of inflammatory pathways that lead to intensive care unit admission, prolonged hospitalization, and increased disability-adjusted life years. Currently, there is no cure or FDA-approved therapy for ARDS. This work describes the implementation of engineered extracellular vesicle (eEV)-based nanocarriers for targeted nonviral delivery of anti-inflammatory payloads to the inflamed/injured lung. The results show the ability of surfactant protein A (SPA)-functionalized IL-4- and IL-10-loaded eEVs to promote intrapulmonary retention and reduce inflammation, both in vitro and in vivo. Significant attenuation is observed in tissue damage, proinflammatory cytokine secretion, macrophage activation, influx of protein-rich fluid, and neutrophil infiltration into the alveolar space as early as 6 h post-eEVs treatment. Additionally, metabolomics analyses show that eEV treatment causes significant changes in the metabolic profile of inflamed lungs, driving the secretion of key anti-inflammatory metabolites. Altogether, these results establish the potential of eEVs derived from dermal fibroblasts to reduce inflammation, tissue damage, and the prevalence/progression of injury during ARDS via nonviral delivery of anti-inflammatory genes/transcripts.
Assuntos
Lesão Pulmonar Aguda , Vesículas Extracelulares , Síndrome do Desconforto Respiratório , Humanos , Camundongos , Animais , Modelos Animais de Doenças , Lesão Pulmonar Aguda/terapia , Lesão Pulmonar Aguda/metabolismo , Inflamação/metabolismo , Síndrome do Desconforto Respiratório/terapia , Anti-Inflamatórios , Vesículas Extracelulares/metabolismo , Fibroblastos/metabolismoRESUMO
Direct nuclear reprogramming has the potential to enable the development of ß cell replacement therapies for diabetes that do not require the use of progenitor/stem cell populations. However, despite their promise, current approaches to ß cell-directed reprogramming rely heavily on the use of viral vectors. Here we explored the use of extracellular vesicles (EVs) derived from human dermal fibroblasts (HDFs) as novel non-viral carriers of endocrine cell-patterning transcription factors, to transfect and transdifferentiate pancreatic ductal epithelial cells (PDCs) into hormone-expressing cells. Electrotransfection of HDFs with expression plasmids for Pdx1, Ngn3, and MafA (PNM) led to the release of EVs loaded with PNM at the gene, mRNA, and protein level. Exposing PDC cultures to PNM-loaded EVs led to successful transfection and increased PNM expression in PDCs, which ultimately resulted in endocrine cell-directed conversions based on the expression of insulin/c-peptide, glucagon, and glucose transporter 2 (Glut2). These findings were further corroborated in vivo in a mouse model following intraductal injection of PNM- vs sham-loaded EVs. Collectively these findings suggest that dermal fibroblast-derived EVs could potentially serve as a powerful platform technology for the development and deployment of non-viral reprogramming-based cell therapies for insulin-dependent diabetes.
RESUMO
Gene/oligonucleotide therapies have emerged as a promising strategy for the treatment of different neurological conditions. However, current methodologies for the delivery of neurogenic/neurotrophic cargo to brain and nerve tissue are fraught with caveats, including reliance on viral vectors, potential toxicity, and immune/inflammatory responses. Moreover, delivery to the central nervous system is further compounded by the low permeability of the blood brain barrier. Extracellular vesicles (EVs) have emerged as promising delivery vehicles for neurogenic/neurotrophic therapies, overcoming many of the limitations mentioned above. However, the manufacturing processes used for therapeutic EVs remain poorly understood. Here, we conducted a detailed study of the manufacturing process of neurogenic EVs by characterizing the nature of cargo and surface decoration, as well as the transfer dynamics across donor cells, EVs, and recipient cells. Neurogenic EVs loaded with Ascl1, Brn2, and Myt1l (ABM) are found to show enhanced neuron-specific tropism, modulate electrophysiological activity in neuronal cultures, and drive pro-neurogenic conversions/reprogramming. Moreover, murine studies demonstrate that surface decoration with glutamate receptors appears to mediate enhanced EV delivery to the brain. Altogether, the results indicate that ABM-loaded designer EVs can be a promising platform nanotechnology to drive pro-neuronal responses, and that surface functionalization with glutamate receptors can facilitate the deployment of EVs to the brain.
Assuntos
Vesículas Extracelulares , Animais , Barreira Hematoencefálica , Comunicação Celular , Sistema Nervoso Central , Vesículas Extracelulares/metabolismo , Camundongos , NeurôniosRESUMO
Ischemic stroke causes vascular and neuronal tissue deficiencies that could lead to substantial functional impairment and/or death. Although progenitor-based vasculogenic cell therapies have shown promise as a potential rescue strategy following ischemic stroke, current approaches face major hurdles. Here, we used fibroblasts nanotransfected with Etv2, Foxc2, and Fli1 (EFF) to drive reprogramming-based vasculogenesis, intracranially, as a potential therapy for ischemic stroke. Perfusion analyses suggest that intracranial delivery of EFF-nanotransfected fibroblasts led to a dose-dependent increase in perfusion 14 days after injection. MRI and behavioral tests revealed ~70% infarct resolution and up to ~90% motor recovery for mice treated with EFF-nanotransfected fibroblasts. Immunohistological analysis confirmed increases in vascularity and neuronal cellularity, as well as reduced glial scar formation in response to treatment with EFF-nanotransfected fibroblasts. Together, our results suggest that vasculogenic cell therapies based on nanotransfection-driven (i.e., nonviral) cellular reprogramming represent a promising strategy for the treatment of ischemic stroke.
Assuntos
Reprogramação Celular , AVC Isquêmico , Animais , Diferenciação Celular , Modelos Animais de Doenças , Fibroblastos/metabolismo , AVC Isquêmico/terapia , CamundongosRESUMO
OBJECTIVES: Endoscopic pancreatic function tests are used to diagnose pancreatic diseases and are a viable source for the discovery of biomarkers to better characterize pancreatic disorders. However, pancreatic fluid (PF) contains active enzymes that degrade biomolecules. Therefore, we tested how preservation methods and time to storage influence the integrity and quality of proteins and nucleic acids. METHODS: We obtained PF from 9 subjects who underwent an endoscopic pancreatic function test. Samples were snap frozen at the time of collection; after 1, 2, and 4 hours on ice; or after storage overnight at 4°C with or without RNase or protease inhibitors (PIs). Electrophoresis and mass spectrometry analysis determined protein abundance and quality, whereas nucleic acid integrity values determined DNA and RNA degradation. RESULTS: Protein degradation increased after 4 hours on ice and DNA degradation after 2 hours on ice. Adding PIs delayed degradation. RNA was significantly degraded under all conditions compared with the snap frozen samples. Isolated RNA from PF-derived exosomes exhibited similar poor quality as RNA isolated from matched PF samples. CONCLUSIONS: Adding PIs immediately after collecting PF and processing the fluid within 4 hours of collection maintains the protein and nucleic acid integrity for use in downstream molecular analyses.
Assuntos
Ácidos Nucleicos/análise , Pancreatopatias/diagnóstico , Testes de Função Pancreática , Suco Pancreático/química , Proteínas/análise , Manejo de Espécimes , Biomarcadores/análise , Temperatura Baixa , Dano ao DNA , Endoscopia do Sistema Digestório , Congelamento , Humanos , Pancreatopatias/genética , Pancreatopatias/metabolismo , Valor Preditivo dos Testes , Inibidores de Proteases/farmacologia , Estabilidade Proteica , Proteólise , Estabilidade de RNA , Ribonucleases/antagonistas & inibidores , Ribonucleases/metabolismo , Secretina/administração & dosagem , Fatores de Tempo , Fluxo de TrabalhoRESUMO
While gene and cell therapies have emerged as promising treatment strategies for various neurological conditions, heavy reliance on viral vectors can hamper widespread clinical implementation. Here, the use of tissue nanotransfection as a platform nanotechnology to drive nonviral gene delivery to nerve tissue via nanochannels, in an effective, controlled, and benign manner is explored. TNT facilitates plasmid DNA delivery to the sciatic nerve of mice in a voltage-dependent manner. Compared to standard bulk electroporation (BEP), impairment in toe-spread and pinprick response is not caused by TNT, and has limited to no impact on electrophysiological parameters. BEP, however, induces significant nerve damage and increases macrophage immunoreactivity. TNT is subsequently used to deliver vasculogenic cell therapies to crushed nerves via delivery of reprogramming factor genes Etv2, Foxc2, and Fli1 (EFF). The results indicate the TNT-based delivery of EFF in a sciatic nerve crush model leads to increased vascularity, reduced macrophage infiltration, and improved recovery in electrophysiological parameters compared to crushed nerves that are TNT-treated with sham/empty plasmids. Altogether, the results indicate that TNT can be a powerful platform nanotechnology for localized nonviral gene delivery to nerve tissue, in vivo, and the deployment of reprogramming-based cell therapies for nerve repair/regeneration.
Assuntos
Eletroporação/métodos , Técnicas de Transferência de Genes , Nanomedicina/métodos , Nanoestruturas , Animais , Modelos Animais de Doenças , Feminino , Masculino , Camundongos , Traumatismos dos Nervos Periféricos/metabolismo , Nervo Isquiático/lesões , Nervo Isquiático/metabolismoRESUMO
BACKGROUND: Considerable research has increased our understanding of antibiotic prescribing practices in hospital settings when it comes to nosocomial pneumonia. Much less is known about the antibiotic prescribing patterns for hospitalized non-critically ill patients with nursing home-acquired pneumonia (NHAP). OBJECTIVE: As part of a multisite quality improvement project, we sought to examine patterns of antibiotic prescription among healthcare providers as a function of underlying comorbid, functional, and clinical factors. SETTING: Three tertiary care centers. INTERVENTION: Chart reviews of 397 individual admissions were performed on patients admitted from nursing homes with the diagnosis of pneumonia between January 2005 and September 2007. RESULTS: Compliance with national guidelines for the treatment of NHAP was poor. Overall, the 3 most commonly used compounds for inpatient treatment were fluoroquinolones (51.4%), ceftriaxone (45.0%), and azithromycin (42.1%). Monotherapy was prescribed in 57.1%. Fluoroquinolones represented 79.5% of these cases. Patients with higher acuity of illness were more likely to receive a combination of vancomycin plus piperacillin/tazobactam (P < 0.001). Median duration of treatment was 8.0 (range, 3-21) days. Stratified analyses showed that combination therapy was used more often on University-affiliated services than on private service (54% vs. 35%; P < 0.001). CONCLUSIONS: There was poor adherence with antibiotic guidelines for the treatment of NHAP. In the absence of outcome data on guidelines compliance, antibiotic use was influenced by patients' age, severity of illness, and providers' academic affiliation. Future research should focus on outcome measures and physicians factors that influence nonadherence.
Assuntos
Antibacterianos/administração & dosagem , Infecção Hospitalar/tratamento farmacológico , Hospitalização , Pneumonia/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Feminino , Fidelidade a Diretrizes , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Casas de Saúde , Guias de Prática Clínica como Assunto , Garantia da Qualidade dos Cuidados de Saúde/métodos , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
RATIONALE: Pseudomonas aeruginosa is one of the leading causes of gram-negative ventilator-associated pneumonia (VAP) associated with a mortality rate of 34 to 68%. Recent evidence suggests that P. aeruginosa in patients with VAP may persist in the alveolar space despite adequate antimicrobial therapy. We hypothesized that failure to eradicate P. aeruginosa from the lung is linked to type III secretory system (TTSS) isolates. OBJECTIVES: To determine the mechanism by which infection with P. aeruginosa in patients with VAP may evade the host immune response. METHODS: Thirty-four patients with P. aeruginosa VAP underwent noninvasive bronchoalveolar lavage (BAL) at the onset of VAP and on Day 8 after initiation of antibiotic therapy. Isolated pathogens were analyzed for secretion of type III cytotoxins. Neutrophil apoptosis in BAL fluid was quantified by assessment of nuclear morphology on Giemsa-stained cytocentrifuge preparations. Neutrophil elastase was assessed by immunoenzymatic assay. MEASUREMENTS AND MAIN RESULTS: Twenty-five out of the 34 patients with VAP secreted at least one of type III proteins. There was a significant difference in apoptotic rate of neutrophils at VAP onset between those strains that secreted cytotoxins and those that did not. Neutrophil elastase levels were positively correlated with the rate of apoptosis (r = 0.43, P < 0.01). Despite adequate antimicrobial therapy, 13 out of 25 TTSS(+) isolates were recovered at Day 8 post-VAP, whereas eradication was achieved in all patients who had undetectable levels of type III secretion proteins. CONCLUSIONS: The increased apoptosis in neutrophils by the TTSS(+) isolates may explain the delay in eradication of Pseudomonas strains in patients with VAP. Short-course antimicrobial therapy may not be adequate in clearing the infection with a TTSS secretory phenotype.
Assuntos
Antibacterianos/farmacologia , Proteínas de Bactérias/metabolismo , Farmacorresistência Bacteriana/fisiologia , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Infecções por Pseudomonas/tratamento farmacológico , Apoptose , Proteínas de Bactérias/genética , Toxinas Bacterianas/genética , Toxinas Bacterianas/metabolismo , Líquido da Lavagem Broncoalveolar/química , Líquido da Lavagem Broncoalveolar/microbiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neutrófilos/metabolismo , Fenótipo , Pseudomonas aeruginosa/genética , Pseudomonas aeruginosa/metabolismo , RecidivaRESUMO
OBJECTIVE: To investigate the potential role of serum and alveolar soluble triggering receptor expressed on myeloid cells (sTREM-1) as a biological marker of pulmonary aspiration syndromes. DESIGN: Prospective cohort study. SETTING: University-affiliated intensive care unit. PATIENTS: Seventy-five patients with pulmonary aspiration and 13 controls receiving mechanical ventilation. INTERVENTIONS: Blood and bronchoalveolar lavage (BAL) fluid samples were collected on enrollment. Soluble TREM-1 levels were measured by an enzyme-linked immunosorbent assay. MEASUREMENTS AND RESULTS: Thirty-eight of 75 participants had documented BAL culture-positive pulmonary aspiration. While circulating levels of sTREM-1 were comparable between those with aspiration syndromes (19.81 +/- 12.09 pg/ml) and controls (15.96 +/- 11.16 pg/ml) (p=0.27), the alveolar levels of sTREM-1 were higher in patients with culture-positive pulmonary aspiration (344.41 +/- 152.82 pg/ml) compared with those culture-negative pulmonary aspiration (142.76 +/- 89.88 pg/ml; p < 0.001). A cut-off value of 250 pg/ml for alveolar sTREM-1 achieved a sensitivity of 65.8% (95% CI 48.6-80.4) and a specificity of 91.9% (95% CI 78.1-98.2) with an area under the curve of 0.87 (95% CI 0.78-0.94). CONCLUSIONS: Alveolar sTREM-1 levels can be a potential biomarker for distinguishing BAL culture-positive from BAL culture-negative pulmonary aspiration.
Assuntos
Biomarcadores/metabolismo , Glicoproteínas de Membrana/metabolismo , Células Mieloides/metabolismo , Pneumonia Aspirativa/diagnóstico , Pneumonia/diagnóstico , Receptores Imunológicos/metabolismo , Líquido da Lavagem Broncoalveolar/química , Líquido da Lavagem Broncoalveolar/citologia , Estudos de Casos e Controles , Distribuição de Qui-Quadrado , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia/metabolismo , Pneumonia/microbiologia , Pneumonia Aspirativa/metabolismo , Pneumonia Aspirativa/microbiologia , Estudos Prospectivos , Curva ROC , Respiração Artificial , Estatísticas não Paramétricas , Receptor Gatilho 1 Expresso em Células MieloidesRESUMO
OBJECTIVE: To evaluate the effect of obesity on intensive care unit mortality, duration of mechanical ventilation, and intensive care unit length of stay among critically ill medical and surgical patients. DESIGN: Meta-analysis of studies comparing outcomes in obese (body mass index of > or = 30 kg/m2) and nonobese (body mass index of < 30 kg/m2) critically ill patients in intensive care settings. DATA SOURCE: MEDLINE, BIOSIS Previews, PubMed, Cochrane library, citation review of relevant primary and review articles, and contact with expert informants. SETTING: Not applicable. PATIENTS: A total of 62,045 critically ill subjects. INTERVENTIONS: Descriptive and outcome data regarding intensive care unit mortality and morbidity were extracted by two independent reviewers, according to predetermined criteria. Data were analyzed using a random-effects model. MEASUREMENTS AND MAIN RESULTS: Fourteen studies met inclusion criteria, with 15,347 obese patients representing 25% of the pooled study population. Data analysis revealed that obesity was not associated with an increased risk of intensive care unit mortality (relative risk, 1.00; 95% confidence interval, 0.86-1.16; p = .97). However, duration of mechanical ventilation and intensive care unit length of stay were significantly longer in the obese group by 1.48 days (95% confidence interval, 0.07-2.89; p = .04) and 1.08 days (95% confidence interval, 0.27-1.88; p = .009), respectively, compared with the nonobese group. In a subgroup analysis, an improved survival was observed in obese patients with body mass index ranging between 30 and 39.9 kg/m2 compared with nonobese patients (relative risk, 0.86; 95% confidence interval, 0.81-0.91; p < .001). CONCLUSION: Obesity in critically ill patients is not associated with excess mortality but is significantly related to prolonged duration of mechanical ventilation and intensive care unit length of stay. Future studies should target this population for intervention studies to reduce their greater resource utilization.
Assuntos
Cuidados Críticos/estatística & dados numéricos , Obesidade/epidemiologia , Adulto , Idoso , Causalidade , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Viés de Publicação , Respiração Artificial/estatística & dados numéricos , Risco , Análise de SobrevidaRESUMO
OBJECTIVES: To evaluate the effect on 28-day mortality of implementation of a sepsis "bundle" protocol for the treatment of older adults with septic shock. DESIGN: Observational prospective study with a historical control group. SETTING: Tertiary care center. PARTICIPANTS: Eighty-seven consecutive patients recruited between May 2004 and February 2007 matched to a historic group identified between March 2001 and April 2004. INTERVENTIONS: Implementation of a sepsis protocol for the management of septic shock. RESULTS: Subjects who were treated according to the sepsis "bundle" had an absolute risk reduction in 28-day mortality of 16% (95% confidence interval (CI)=-31% to -2%). The treatment group received a larger volume of fluid in the first 6 hours of presentation (3,960 +/- 1,990 vs 2,490 +/- 1,020 mL; P<.001) and lower doses of vasopressors (maximum dosage of norepinephrine 0.51 microg/kg per min (range 0.12-1.7) vs 0.98 microg/kg per min (range 0.15-3.1) P=.009). A high prevalence of adrenal insufficiency (86%) was identified in the study population. There were no significant differences between the treatment and control groups in the surviving patients with respect to duration of mechanical ventilation (median 8.5 vs 12.0, respectively; P=.07) or intensive care unit length of stay (median 12 days vs 15 days; P=.08). According to Cox regression analysis, implementation of the sepsis bundle protocol was independently associated with better 28-day survival (hazard ratio=0.54, 95% CI=0.33-0.86; P=.01). CONCLUSION: Older patients with septic shock had a better 28-day survival rate when treated with a comprehensive sepsis "bundle" protocol.
Assuntos
Protocolos Clínicos , Choque Séptico/mortalidade , Choque Séptico/terapia , APACHE , Idoso , Estudos de Casos e Controles , Distribuição de Qui-Quadrado , Feminino , Hidratação/métodos , Humanos , Masculino , Modelos de Riscos Proporcionais , Estudos Prospectivos , Comportamento de Redução do Risco , Estatísticas não Paramétricas , Taxa de SobrevidaRESUMO
OBJECTIVES: To compare the clinical presentation, microbiological features, and outcomes of patients with community-acquired empyema (CAE) with those of patients with nursing home-acquired empyema (NHAE). DESIGN: A retrospective observational study. SETTING: Three tertiary care centers. PARTICIPANTS: One hundred fourteen patients admitted from the community and 55 patients transferred from nursing homes. MEASUREMENTS: Baseline sociodemographic information, activities of daily living, Charlson Comorbidity Index score, and clinica, and microbiologic data were obtained. Outcome was assessed at hospital discharge and 6 months postdischarge. RESULTS: Patients admitted from nursing homes had a delayed presentation, with dyspnea, weight loss, and anemia as the predominant manifestation. Patients with CAE presented more acutely, with fever, cough, and chest pain. Anaerobic organisms were more commonly isolated from patients with NHAE. The success rate of nonsurgical intervention was significantly lower for the NHAE patients than for the CAE group (39% vs 63; P=.01). In-hospital mortality was not significantly different between the two groups (NHAE, 18%; CAE, 8%; P=.09). In a Cox regression analysis, preadmission functional status (hazard ratio (HR)=1.26, 95% confidence interval (CI)=1.19-1.4; P<.001) and surgical intervention (HR=0.47, 95% CI=0.24-0.92; P=.03) were the only variables highly correlated with long-term outcome. CONCLUSION: Patients admitted with NHAE have distinctly different clinical and microbiological presentation from that of patients with CAE. Because of the delayed presentation in patients with NHAE, medical treatment alone may be associated with higher rate of failure. Surgical therapy should be considered for selected cases, with the aim of improving long-term survival.
Assuntos
Infecções Bacterianas/diagnóstico , Infecções Comunitárias Adquiridas/diagnóstico , Infecção Hospitalar/diagnóstico , Empiema Pleural/diagnóstico , Instituição de Longa Permanência para Idosos , Casas de Saúde , Atividades Cotidianas/classificação , Idoso , Idoso de 80 Anos ou mais , Infecções Bacterianas/microbiologia , Infecções Bacterianas/mortalidade , Infecções Bacterianas/cirurgia , Técnicas Bacteriológicas , Infecções Comunitárias Adquiridas/microbiologia , Infecções Comunitárias Adquiridas/mortalidade , Comorbidade , Infecção Hospitalar/microbiologia , Infecção Hospitalar/mortalidade , Infecção Hospitalar/cirurgia , Estudos Transversais , Diagnóstico Precoce , Empiema Pleural/microbiologia , Empiema Pleural/mortalidade , Empiema Pleural/cirurgia , Feminino , Avaliação Geriátrica , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , New York , Avaliação de Resultados em Cuidados de Saúde , Admissão do Paciente , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Choque Séptico/diagnóstico , Choque Séptico/microbiologia , Choque Séptico/mortalidadeRESUMO
INTRODUCTION: Diagnostic strategies based on tracheal aspirates in patients with severe nursing home-acquired pneumonia have not previously been evaluated. The objectives of the study were to investigate, in patients with severe nursing home-acquired pneumonia, the diagnostic value of quantitative endotracheal aspirate (QEA) cultures using increasing interpretative cutoff points, as compared with bronchoalveolar lavage (BAL) and protected specimen brush (PSB) quantitative cultures. METHODS: Seventy-five nursing home patients requiring mechanical ventilation for suspected pneumonia were studied. Endotracheal aspirate, PSB, and BAL samples were obtained consecutively. The diagnostic yield of QEA at thresholds raging from 10(3) to 10(7) colony-forming units (cfu)/ml was assessed by calculating sensitivities, specificities, and accuracy rates. A receiver operator characteristic curve for the series of cutoff points was constructed. RESULTS: Forty-nine patients were diagnosed with pneumonia either by BAL (Assuntos
Infecção Hospitalar/diagnóstico
, Instituição de Longa Permanência para Idosos
, Casas de Saúde
, Pneumonia Bacteriana/diagnóstico
, Manejo de Espécimes/métodos
, Traqueia/microbiologia
, Idoso
, Lavagem Broncoalveolar
, Infecção Hospitalar/microbiologia
, Escherichia coli/isolamento & purificação
, Feminino
, Humanos
, Masculino
, Pneumonia Bacteriana/microbiologia
, Curva ROC
, Respiração Artificial
, Staphylococcus aureus/isolamento & purificação
, Streptococcus pneumoniae/isolamento & purificação
RESUMO
Despite substantial progress in therapeutic options, severe community-acquired pneumonia (CAP) remains a significant cause of morbidity and mortality worldwide. Recognising the clinical importance of CAP over the past several years, different medical societies and health organisations in different countries have proposed specific guidelines for the management of CAP. Early and rapid initiation of antimicrobial therapy has been advocated for a favourable outcome. Treatment is empirical as the diagnostic yield for potential pathogens does not exceed 50%. Dual therapy is emerging as the preferred therapy for severe CAP. The regimen is based on an epidemiological approach with emphasis on covering both typical and atypical pathogens. Non-antimicrobial adjuvant therapies including non-invasive ventilation and immunomodulatory agents are emerging as promising area for future development.
Assuntos
Corticosteroides/uso terapêutico , Antibacterianos/uso terapêutico , Anti-Infecciosos/uso terapêutico , Hospitalização/estatística & dados numéricos , Pneumonia Bacteriana/tratamento farmacológico , Proteína C/uso terapêutico , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/microbiologia , Quimioterapia Combinada , Humanos , Incidência , Pneumonia Bacteriana/etiologia , Pneumonia Bacteriana/mortalidade , Guias de Prática Clínica como Assunto , Proteínas Recombinantes/uso terapêutico , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: To determine pathogen-specific kinetic changes in the alveolar procoagulant (PC) activity, tissue factor (TF), and tissue factor pathway inhibitor (TFPI) expression during the course of ventilator-associated pneumonia (VAP) and to assess the relationship between clinical resolution, intra-alveolar bacterial eradication, and restoration of hemostatic balance. DESIGN: Prospective, multiple-center study in a cohort of VAP patients. SETTING: Two university-affiliated intensive care units. PATIENTS: Thirty-five patients with microbiologically documented VAP who received adequate antimicrobial coverage and 13 controls. INTERVENTIONS: Nonbronchoscopic bronchoalveolar lavage was performed at the onset of VAP and on days 4 and 8 after initiation of antibiotic therapy. Samples were assayed for PC, TF, TFPI, and thrombin-antithrombin complex (TATc). The corresponding Clinical Pulmonary Infection Score (CPIS) was collected simultaneously. MEASUREMENTS AND MAIN RESULTS: Isolated pathogens included Pseudomonas aeruginosa (n=13), methicillin-resistant Staphylococcus aureus (MRSA) (n=8), methicillin-sensitive S. aureus (MSSA) (n=7), and Escherichia coli (n=7). Although PC activity and TF were increased among the various pathogens at the onset of VAP, the levels of those with P. aeruginosa remained elevated at the end of treatment compared with controls and other etiological agents. TFPI levels were elevated for the duration of the study for all pathogens. A universal increase in TATc was noted at the onset of VAP, but the difference among the group of pathogens was significant at days 4 and 8 posttherapy. Despite the persisting hemostatic imbalance and incomplete intra-alveolar eradication of P. aeruginosa at end of therapy, the CPIS fell comparably at each time point irrespective of the etiological agents. CONCLUSIONS: Alveolar activation of the TF-dependent pathway may be species-specific in VAP and may not be adequately balanced by TFPI. The disparity between clinical response and eradication of P. aeruginosa from the intra-alveolar space suggests the need for biological markers to guide response to therapy.
Assuntos
Hemostasia , Pneumonia Associada à Ventilação Mecânica/sangue , Pneumonia Associada à Ventilação Mecânica/microbiologia , Idoso , Líquido da Lavagem Broncoalveolar/química , Líquido da Lavagem Broncoalveolar/microbiologia , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Alvéolos PulmonaresRESUMO
BACKGROUND: Hospitalization for older patients with community-acquired pneumonia (CAP) is associated with functional decline. Little is know about the relationship between inflammatory markers and determinants of functional status in this population. The aim of the study is to investigate the association between tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP) and Activities of Daily Living, and to identify risk factors associated with one year mortality or hospital readmission. METHODS: 301 consecutive patients hospitalized for CAP (mean age 73.9 +/- 5.3 years) in a University affiliated hospital over 18 month period were included. All patients were evaluated on admission to identify baseline demographic, microbiological, cognitive and functional characteristics. Serum levels for TNF-alpha and CRP were collected at the same time. Reassessment of functional status at discharge, and monthly thereafter till 3 months post discharge was obtained and compared with preadmission level to document loss or recovery of functionality. Outcome was assessed by the composite endpoint of hospital readmission or death from any cause up to one year post hospital discharge. RESULTS: 36% of patients developed functional decline at discharge and 11% had persistent functional impairment at 3 months. Serum TNF-alpha (odds ratio [OR] 1.12, 95% CI 1.08-1.15; p < 0.001) and the Charlson Index (OR = 1.39, 95% CI 1.14 to 1.71; p = 0.001) but not age, CRP, or cognitive status were independently associated with loss of functionality at the time of hospital discharge. Lack of recovery in functional status at 3 months was associated with impaired cognitive ability and preadmission comorbidities. In Cox regression analysis, persistent functional impairment at 3 months, impaired cognitive function, and the Charlson Index were highly predictive of one year hospital readmission or death. CONCLUSION: Serum TNF-alpha levels can be useful in determining patients at risk for functional impairment following hospitalization from CAP. Old patients with impaired cognitive function and preexisting comorbidities who exhibit delay in functional recovery at 3 months post discharge may be at high risk for hospital readmission and death. With the scarcity of resources, a future risk stratification system based on these findings might be proven helpful to target older patients who are likely to benefit from interventional strategies.
Assuntos
Atividades Cotidianas , Proteína C-Reativa/análise , Pneumonia/reabilitação , Recuperação de Função Fisiológica , Fator de Necrose Tumoral alfa/análise , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Infecções Comunitárias Adquiridas , Comorbidade , Feminino , Insuficiência Cardíaca/epidemiologia , Hospitalização , Humanos , Pneumopatias/epidemiologia , Masculino , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/epidemiologia , Pneumonia/imunologia , Pneumonia/mortalidade , Recuperação de Função Fisiológica/fisiologia , Fatores de Risco , Fumar/epidemiologia , Escarro/microbiologia , Análise de SobrevidaRESUMO
INTRODUCTION: Nosocomial pneumonia is a significant cause of in-hospital morbidity and mortality. Oral care interventions have great potential to reduce the occurrence of nosocomial pneumonia. Studies using topical antiseptic agents yielded mixed results. We hypothesized that the use of chlorhexidine for oral decontamination would reduce the incidence of nosocomial pneumonia in patients requiring mechanical ventilation. METHODS: This study is a meta-analysis of randomized controlled trials assessing the effect of chlorhexidine on the incidence of nosocomial pneumonia. Data sources were Medline, EMBASE, Cochrane library, citation review of relevant primary and review articles, and contact with expert informants. Out of 1,251 articles screened, 4 randomized, controlled trials were identified that included a total of 1,202 patients. Descriptive and outcome data were extracted by two reviewers independently. Main outcome measures were the incidence of nosocomial pneumonia, and mortality. A random effects model was used. RESULTS: The incidence of nosocomial pneumonia in the control group was 7% (41 out of 615) compared to 4% (24 out of 587) in the treatment group. Gram-negative bacteria accounted for 78% of the total isolates, with Pseudomonas aeruginosa being the most frequently isolated pathogen irrespective of the intervention provided. Duration of mechanical ventilation and intensive care unit length of stay were comparable between the two groups. Overall, the use of oral decontamination with chlorhexidine did not affect the incidence of nosocomial pneumonia (odds ratio of 0.42; 95% confidence interval 0.16-1.06) or the mortality rate (odds ratio 0.77, 95% confidence interval 0.28-2.11). CONCLUSION: The use of oral decontamination with chlorhexidine did not result in significant reduction in the incidence of nosocomial pneumonia in patients who received mechanical ventilation, nor altered the mortality rate. The lack of benefit may reflect the few studies conducted in this area. Future trials should focus on a combination strategy of mechanical and pharmacological interventions.
Assuntos
Clorexidina/administração & dosagem , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/epidemiologia , Administração Oral , Placa Dentária/tratamento farmacológico , Placa Dentária/epidemiologia , Humanos , Incidência , Pessoa de Meia-Idade , Respiração ArtificialRESUMO
OBJECTIVE: To test the hypothesis that alveolar plasminogen activator inhibitor-1 (PAI-1) can identify patients with witnessed aspiration at risk for progression to acute respiratory distress syndrome (ARDS). DESIGN: Prospective observational study. SETTING: Medical intensive care unit in a tertiary care center. PATIENTS: Fifty-one patients with witnessed aspiration who had a PaO2/FIO2<300 for a period no less than 4 h from admission. INTERVENTIONS: Alveolar fluid sampling was performed within 8 h of intubation via luminal suction of the distal airways using a 13-Fr catheter. Plasma levels were collected simultaneously by venipuncture. MEASUREMENTS AND RESULTS: Alveolar PAI-1 antigen levels were more than five times higher in those who progressed to ARDS than in those with uncomplicated aspiration pneumonitis (2687+/-1498 ng/ml vs. 587+/-535 ng/ml, respectively; p<0.001), while plasma levels of PAI-1 antigen were not significantly different between the two groups. The measured activity of PAI-1 antigen paralleled the levels observed in both media. A cut-off level of alveolar PAI-1 >1518 ng/ml was found to be 82.4% (56.6%-96.0%) sensitive and 97.1% (84.6%-99.5%) specific in predicting progression to ARDS. There was also a significant inverse relationship between elevation of PAI-1 antigen levels and the degree of lung injury as assessed by the days of unassisted ventilation (r2=0.37; p<0.001). CONCLUSIONS: Elevation of alveolar PAI-1 antigen levels postaspiration is the consequence of local rather than systemic activation of the fibrinolytic system. Measurement of alveolar PAI-1 antigen levels can be a useful clinical marker in predicting progression to ARDS after gastric aspiration.