In vitro and in vivo protein sampling by combined microdialysis and ultrafiltration.

Cytokines, chemokines and growth factors regulate inflammation, resistance to infection and tissue repair. Understanding their function within tissues is a priority in evolving therapy for a number of disease processes. Yet, the existence of complex networks of these factors in the tissue microenvironment has made understanding of their interactions difficult. We demonstrate the capability of microdialysis probes to recover small proteins efficiently in vitro. Further we show that microdialysis of human tissues allows for protein recovery from tissue interstitial fluid. This technology, combined with a multiplexed immunoassay, facilitates the simultaneous measurement of cytokines and chemokines in response to injury in the oral mucosa of human subjects in vivo.

Nanoporous SiC: a candidate semi-permeable material for biomedical applications.

We have fabricated free-standing SiC nanoporous membranes in both p -type and n -type material. We showed that these membranes will permit the diffusion of proteins up to 29000 Daltons, while excluding larger proteins. By using radioactively labeled albumin, we also show that porous SiC has very low protein adsorption, comparable to the best commercially available polymer nanoporous membrane.

Safety observations in phase I clinical evaluation of the Excorp Medical Bioartificial Liver Support System after the first four patients.

A Phase I clinical safety evaluation of the Excorp Medical, Inc, Bioartificial Liver Support System (BLSS) is in progress. Inclusion criteria are patients with acute liver failure of any etiology, presenting with encephalopathy deteriorating beyond Parson's Grade 2. The BLSS consists of a blood pump, heat exchanger to control blood temperature, oxygenator to control oxygenation and pH, bioreactor, and associated pressure and flow alarm systems. Patient liver support is provided by 70-100 g of porcine liver cells housed in the hollow fiber bioreactor. A single support period evaluation consists of 12 hour extracorporeal perfusion with the BLSS sandwiched between 12 hours of pre (baseline) and 12 hours of post support monitoring. Blood chemistries and hematologies are obtained every 6 hours during monitoring periods and every 4 hours during perfusion. Physiologic parameters are monitored continuously. The patient may receive a second treatment at the discretion of the clinical physician. Preliminary evaluation of safety considerations after enrollment of the first four patients (F, 41, acetaminophen induced, two support periods; M, 50, Wilson's disease, one support period; F, 53, acute alcoholic hepatitis, two support periods; F, 24, chemotherapy induced, one support period) is presented. All patients tolerated the extracorporeal perfusion well. All patients presented with hypoglycemia at the start of perfusion, treatable by IV dextrose. Transient hypotension at the start of perfusion responded to an IV fluid bolus. Only the second patient required heparin anticoagulation. No serious or unexpected adverse events were noted. Moderate biochemical response to support was noted in all patients. Completion of the Phase I safety evaluation is required to fully characterize the safety of the BLSS.

Suppression of cytokine-mediated beta2-integrin activation on circulating neutrophils in critically ill patients.

The beta2 integrin CD11b plays a central role in inflammation and the systemic inflammatory response syndrome (SIRS). The CD11b molecule activates in two ways: the density of membrane-bound CD11b up-regulates and the molecule undergoes a conformational change that confers adhesiveness to counter-receptors. We studied the kinetics of CD11b activation in patients with SIRS. We found a significantly diminished CD11b activation in response to tumor necrosis factor alpha (TNF-alpha). This affected all circulating polymorphonuclear neutrophils (PMN) and was an intrinsic property of the cells and not due to antagonism by soluble TNF-alpha receptors or loss of cellular receptors for TNF-alpha. Diminished responsiveness correlated with the severity of organ failure and lasted for months in some patients but had no impact on mortality. We speculate that reduced CD11b responsiveness in SIRS contributes to the high risk of recurrent infection, but that it may also be protective against excessive PMN activation within the vascular space.

Leukocyte activation in the peripheral blood of patients with cirrhosis of the liver and SIRS. Correlation with serum interleukin-6 levels and organ dysfunction.

OBJECTIVE: Leukocyte adhesion plays an important role in inflammation. Adhesion molecules such as CD11b on polymorphonuclear neutrophil leukocytes (PMNs) up-regulate in response to tumor necrosis factor-alpha, interleukin-8 (IL-8), and other mediators that are involved in systemic inflammatory response syndrome (SIRS). This study examined the behavior of CD11b and other membrane molecules in SIRS in relation to serum cytokines and the severity of illness. DESIGN: Survey study. SETTING: Liver transplantation intensive care unit at a tertiary care center. PATIENTS: A consecutive sample of 22 patients admitted to the liver transplantation intensive care unit for complications related to cirrhosis of the liver in the absence of other disease. Sixteen of the patients developed SIRS and multiple organ dysfunction syndrome with suspected bacterial infections. Seven control subjects were also studied. MAIN OUTCOME MEASURES: Modified Goris organ failure score and Acute Physiology and Chronic Health Evaluation II score. RESULTS: Mean serum IL-6 levels, but not IL-1 beta or tumor necrosis factor-alpha levels, correlated with organ failure (r = 0.79, P < .001). Leukocyte cell-surface markers fluctuated from day to day. The mean of several values was more stable. Mean CD11b and CD35 on PMNs correlated with serum IL-6 level (r = 0.75, P < .001, and r = 0.77, P < .005, respectively). Up-regulation of both CD11b and CD35 display on PMNs correlated with organ failure (r = 0.74, P < .001, and r = 0.71, P < .01, respectively). Polymorphonuclear neutrophil leukocyte L-selectin, CD31, and CD16 were simultaneously decreased, consistent with PMN activation. Monocytes appeared to be activated, but the pattern of surface molecule display was different. CONCLUSIONS: In human SIRS, the circulating monocyte and PMN pools undergo alterations suggestive of leukocyte activation, including up-regulation of PMN CD11b in correlation with the serum IL-6 level and severity of organ dysfunction.

Massive ST-segment elevation without myocardial injury in a patient with fulminant hepatic failure and cerebral edema.

A 49-year-old woman presented in fulminant hepatic failure. The ECG showed dramatic ST-segment elevation, suggesting diffuse myocardial injury. However, echocardiography, creatine phosphokinase enzyme determinations, and examination of the heart at autopsy (six days later) failed to demonstrate any physiologic, anatomic, or histologic evidence of abnormality. The appearance of ST-segment elevation in this setting should not prompt treatment for cardiac disease or limit the candidacy for liver transplantation of such critically ill patients.

Optimizing drug treatment of alcohol withdrawal.

A number of complications can arise during the drug treatment of alcohol withdrawal, which can be serious or even fatal. Patients who are elderly, have renal or hepatic disease, or are poorly monitored during treatment are particularly prone to problems. By consideration of pharmacologic principles and clinical experience, an optimal drug treatment regimen is formulated that minimizes these risks, while remaining highly effective.