Sepsis-induced organ failure is associated with high morbidity and mortality rates. The onset of an exaggerated host response to microbial invasion and/or trauma, is believed to be the primary cause of excessive inflammation and the subsequent tissue hypoperfusion observed in patients with severe sepsis. In our mouse model of sepsis induced by cecal ligation and perforation (CLP), symptoms indicative of the disease, including diarrhea, increased ventilation and persistent hypothermia, are present at six hours after the surgery (T6). In the untreated CLP mice, mortality occurs starting at T15. As induced hypothermia has shown to exert immunomodulatory effects, this study is aimed at assessing its potential in attenuating inflammation and improving survival in experimental sepsis. Our data has shown that deep hypothermia initiated at T6, by means of cold chamber-induced cooling, prolongs survival. Plasma cytokine quantification by enzyme-linked immunosorbent assays (ELISA) also reveals that induced deep hypothermia reduces tumour necrosis factor(TNF)-α and interleukin (IL)-6 production in untreated CLP mice. In contrast, induced moderate hypothermia does not have such effect. Antibiotic (cefotaxime) and saline resuscitation initiated immediately following CLP ensures survival. However, when these supportive treatments are initiated at T6, >50% mortality is observed in the CLP mice with or without induced hypothermia. In summary, this preliminary study provides proof for a downregulated inflammatory response mediated by external cooling. However, to achieve a survival benefit, treatment strategies in addition to cooling and antibiotics may be required.

Orientador: Francisco Hideo Aoki / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T19:53:42Z (GMT). No. of bitstreams: 1 Sauer_CarlosRobertodeOliveira_M.pdf: 4893312 bytes, checksum: 191dcebcc690c95e22eb505e300a4963 (MD5) Previous issue date: 2014 / Resumo: Introdução: Síndrome da resposta inflamatória sistêmica (SRIS) é uma situação clínica na qual ocorrem as alterações fisiológicas da sepse, mas que é desencadeada por uma agressão não infecciosa ao organismo. Foi definida em 1991, em consenso internacional, e, assim como a sepse, está associada à insuficiência de múltiplos órgãos e sistemas (IMOS) e à mortalidade. Não há muitos dados epidemiológicos a respeito da SRIS, mas sabe-se que a sepse grave e choque séptico são juntos a principal causa de morte nas unidades de terapia intensiva (UTIs) não coronarianas nos EUA e,no Brasil, são responsáveis por mais de 54.000 internações anualmente, com uma mortalidade associada de 32,9% e 64,1%, para sepse grave e choque séptico, respectivamente. Após documentar, em estudo fisiológico com cateter de artéria pulmonar, um caso de choque distributivo com depressão do miocárdio no pós-operatório imediato de uma cirurgia redutora de mama, sem qualquer associação a quadro infeccioso, foi feita, sem sucesso, uma extensa busca de casos semelhantes na literatura médica. Inclusive, nesta revisão, foi encontrada uma grande incidência de cirurgias estéticas de mama no Brasil: quase 280.000 por ano, dentre as quais 131.000 são mamoplastias redutoras. Objetivos: avaliar a prevalência de SRIS e SRIS grave no pós-operatório da cirurgia estética de mama e, secundariamente, avaliar os fatores de risco associados a sua ocorrência e discutir as possíveis implicações da SRIS nos cuidados peri-operatórios das cirurgias estéticas de mama. Casuística e método: foram realizados dois estudos epidemiológicos, um retrospectivo no Hospital Estadual de Sumaré¿UNICAMP (HES), a mesma instituição onde foi verificado esse caso de SRIS grave, envolvendo todas as pacientes que foram submetidas somente a mamoplastia redutora (de 2001 a 2012, com 154 pacientes) e outro estudo prospectivo no Hospital do Instituto do Coração de Campinas (Hospital ICC), onde também foram avaliadas pacientes submetidas à inserção e à troca de próteses mamárias, associadas ou não à lipoaspiração (primeiro semestre de 2012, com 24 pacientes). Resultados: no HES encontrou-se 17 casos de SRIS (11,0%) e três casos de SRIS grave (1,9%), sendo verificado, dentre estes, um caso de SRIS grave com choque. Não houve diferença entre os grupos de pacientes com e sem SRIS para 29 variáveis clínicas,-epidemiológicas e farmacológicas analisadas. Observou-se uma tendência a maior frequência de SRIS em pacientes submetidas a anestesia por halogenados, mas sem significância estatística (p>0,05). No estudo do Hospital ICC foi verificada uma prevalência de SRIS 29,2%. Nesse segundo estudo, além de se aproximar da realidade das cirurgias estéticas de nosso país, pois foi feito em um hospital particular não ligado a qualquer universidade, pudemos contar com o critério do leucograma, colhido após a cirurgia. Após exaustiva revisão da literatura médica, foram encontrados alguns possíveis fatores confundidores da análise, a saber:os anestésicos inalatórios (halogenados e óxido nitroso), o propofol, a anestesia peridural, o próprio tecido mamário (em sua anatomia e fisiologia apresenta interfaces com sistema imune) e o órgão adiposo (participa da constituição da mama e possui funções endócrinas, além de ser ontologicamente ligado ao sistema imune). Ao revisar o tipo de cirurgia realizado e a fisiopatogenia da SRIS, encontramos mais duas questões com relevância em termos saúde coletiva: a imunossupressão e a ativação da cascata de coagulação associadas à SRIS poderiam gerar uma população de mulheres mais suscetíveis às complicações infecciosas, à trombose venosa profunda (TVP) e ao trombo-embolismo pulmonar (TEP). Novamente, foram feitos novos levantamentos bibliográficos para abordar estas questões, sendo encontradas inúmeras referências associando o uso inadequado de antibióticos a complicações bacterianas (superinfecções) e artigos descrevendo, nesta situação específica de pós-operatório, o frequente descumprimento dos protocolos de profilaxia de TVP/TEP. Conclusão: na cirurgia estética de mama ocorre uma incidência de SRIS próximo a 30% (quando são utilizados os 4 critérios diagnósticos de SRIS) e uma incidência de SRIS grave de quase 2%. Também foi descrito um caso clínico de SRIS grave com choque no pós-operatório da cirurgia estética de mama, algo presente no dia a dia dos profissionais que atendem estas pacientes, mas sem prévio relato na literatura médica. Não foi encontrada qualquer associação entre SRIS e os fatores de risco analisados. É necessário estarmos atentos para uma melhor definição da importância deste quadro em termos de saúde pública, com um olhar protetor para a população de mulheres submetidas à cirurgia estética de mama, vulneráveis às complicações do pós-operatório numa frequência que pode ser maior que a esperada / Abstract: Introduction : SIRS is a clinical situation where the physiological changes due to sepsis occur, but triggered by a noninfectious aggression to the organism. It was defined in 1991, with international consensus, and like sepsis it is associated to multiple system organ failure (MSOF) and mortality. There is not much epidemiological data related to SIRS but it is known that severe sepsis and septic shock are together the leading cause of death in non-coronary ICUs in the U.S. and, In Brazil, they are responsible for more than 54,000 hospitalizations annually, with an associated mortality of 32.9% and 64.1% for severe sepsis and septic shock, respectively. After reporting, in a physiological study of pulmonary artery catheter, a case of septic shock with myocardial depression in the immediate postoperative of reductive mammoplasty, without any sign of infection, an extensive literature review was done without success, seeking similar cases in the medical literature. Moreover, in this review, a high frequency of cosmetic surgery in breast were found in Brazil: almost 280,000 per year, of which 131,000 were reductive mammoplasties. Objective: Assess the prevalence of SIRS and severe SIRS in the postoperative of cosmetic breast surgery and , secondarily , assess the risk factors associated to its occurrence and discuss the possible implications of SIRS in the perioperative care of cosmetic breast surgery. Patients and Methods: Two epidemiological studies were conducted, one was a retrospective epidemiological survey which took place at the Sumaré State Hospital ¿ UNICAMP, the same institution where this case was found, involving all patients who underwent reduction mammoplasty ( from 2001 to 2012, with 154 patients) and the other was a prospective study developed at the Campinas Heart Institute Hospital, where patients subjected to placement and replacement of breast implants, associated or not to liposuction were assessed (first semester of 2012, with 24 patients). Results At the Sumaré State Hospital 17 cases of SIRS were found (11.0%), and three cases of severe SIRS (1.9%), among which there was one case of severe SIRS with shock. There was no difference between the group of patients with and without SIRS, regarding the 29 clinical, epidemiological and pharmacological variables that were analyzed. A tendency for a higher frequency of SIRS in patients undergoing anesthesia by halogenated substances was observed, but without statistical significance (p>0.05).At the Campinas Heart Institute Hospital, the prevalence of SIRS was of 29.2%. In this second study, in addition to being similar to the reality of cosmetic surgeries of our country, because it was conducted in a private hospital not related to any university, we could rely on the leucocyte count, collected after surgery. After an exhaustive review of the medical literature, some possible confounding analysis factors were found, namely: inhalational anesthetics (nitrous oxide as the halogenated), propofol, epidural anesthesia, the breast tissue itself (in their anatomy physiology presents interfaces with the immune system) and the adipose organ (part of the constitution of the breast, it has endocrine functions and is ontologically linked to the immune system). When reviewing the type of surgery performed and the pathophysiology of sepsis, we found two other relevant issues: immunosuppression and activation of the coagulation cascade associated to SIRS could generate a population of women transiently more susceptible to infectious complications, Deep Vein Thrombosis (DVT) and Pulmonary Thromboembolism (PTE). Again, we reviewed the literature to address these issues, numerous references were found involving the inappropriate use of antibiotics for bacterial complications (superinfection) and articles describing the incorrect use of the protocols for prophylaxis of DVT / PTE. Conclusion: In cosmetic breast surgery there is an incidence of SIRS close to 30% ( when the four diagnostic criteria for SIRS are used) and an incidence of severe SIRS close to 2%. Moreover, a clinical case of SIRS was described in the postoperative of cosmetic breast surgery, which is present in the everyday routine of the professionals that work with these patients but has not previously been related in the medical literature. No association was found between SIRS and the analyzed risk factors / Mestrado / Clinica Medica / Mestre em Clinica Medica

O escorpião Tityus serrulatus é considerado uma das espécies mais perigosas para os seres humanos no Brasil, e sua peçonha induz resposta inflamatória local e sistêmica. Neste projeto, tivemos como objetivo estudar a produção de mediadores inflamatórios, as vias de ativação celular e os receptores da imunidade inata responsáveis pelo reconhecimento da peçonha do escorpião T. serrulatus (TsV), bem como de suas toxinas. Nós demonstramos que TsV, e suas toxinas Ts1 e Ts6 induzem a produção de NO, IL-6 e TNF-? por células J774.1, as quais podem ser potencializadas pela presença de LPS. No entanto, Ts2 apresenta atividade anti-inflamatória por induzir produção de IL-10 e inibe a liberação de NO, IL-6 e TNF-?, induzida pelo LPS. Mostramos ainda que Ts2 ou Ts6 isoladas do TsV, além das citocinas, induzem a produção dos mediadores lipídicos (LTB4 e PGE2), e estes contribuem para o recrutamento de leucócitos para a cavidade peritoneal. Em conjunto, os nossos dados demonstraram que Ts2 e Ts6 induzem inflamação por mecanismos dependentes da produção de citocinas e mediadores lipídicos, e que Ts2 pode desempenhar papel regulador da resposta. No entanto, os mecanismos responsáveis pelo reconhecimento da peçonha e indução da liberação de mediadores inflamatórios por células de mamíferos, são desconhecidos. Assim, dando continuidade aos nossos estudos, demonstramos que os receptores TLR2, TLR4 e CD14 reconhecem TsV, e medeiam a produção de citocinas e mediadores lipídicos. Além disso, nós demonstramos que TsV ativa NF-?B dependente de MyD88, e o fator c-Jun, independente de MyD88. Semelhante ao TsV, a sua toxina majoritária, Ts1, induz a fosforilação de NF-?B dependente de MyD88, via reconhecimento por TLR2 e TLR4, enquanto a ativação c-Jun é via TLR4, mas independente de MyD88. Dentro deste contexto, nós propusemos o termo Padrões Moleculares Associados à Venenos (VAMP) para se referir às moléculas que são introduzidas no hospedeiro por picadas e são reconhecidas por receptores de reconhecimento padrão (PRRs), resultando em inflamação. Demonstramos ainda, a formação de corpúsculos lipídios (CLs) e a geração de eicosanóides, após o reconhecimento do TsV por TLR2 e TLR4. Nossos dados mostraram que a formação de eicosanóides se correlaciona com a formação dos CLs, que por sua vez são dependentes de TLR2 e TLR4, e da ativação de PPAR?, sugerindo que este receptor nuclear pode modular a produção de citocinas pró-inflamatórias. Assim, concluímos que PPAR? pode ser um candidato-alvo atrativo para novas estratégias terapêuticas para prevenção dos efeitos deletérios resultantes da intensa liberação sistêmica de mediadores inflamatórios após envenenamento. / Tityus serrulatus is the scorpion considered one of the most dangerous species to humans in Brazil, which venom induces local and systemic inflammatory response. In this project, we aimed to study In this project, we aimed to study the inflammatory mediators production, cell activation and receptors of innate immunity responsible for recognition of the venom of the scorpion T. serrulatus (TsV) as well as their toxins. We have demonstrated that TsV and their toxins Ts1 and Ts6 induce NO, IL-6 and TNF-? production in J774.1 cells, which may be potentiated by presence of LPS. However, Ts2 exhibits anti-inflammatory activity due induction of IL-10 production and inhibits the release of NO, IL- 6 and TNF-? induced by LPS. We also show that Ts2 or Ts6 isolated of TsV, besides of the cytokines, induce the production of lipid mediators (LTB4 and PGE2), and these mediators contribute to leukocytes recruitment into the peritoneal cavity. Taken together, our data demonstrated that Ts2 and Ts6 induce inflammation by mechanisms dependent on the production of cytokines and lipid mediators, and that Ts2 may play regulatory role on the cell response. Furthermore, continuing our studies, we demonstrated that TLR2, TLR4 and CD14 receptors recognize TsV, mediating cytokines and lipid mediators production. We also showed TsV MyD88- dependent activation of NF-?B, and a MyD88-independent activation of the factor c-Jun. Similar to TsV, the majority toxin Ts1 induces MyD88-dependent phosphorylation of NF-kB via TLR2 and TLR4 recognition, while the c-Jun activation is through TLR4 recognition, but independent of MyD88. Within this context, we propose the term Venom-Associated Molecular Pattern (VAMP), to refer molecules that are introduced into the host by st ings and recognized by PRRs, resulting in inflammation. Finally, we investigated the formation of lipid bodies (LBs) and generation of eicosanoids, through TsV recognition by TLR2 and TLR4. Our data showed that eicosanoid production correlates with the LBs formation, which are dependent on TLR2, TLR4 and PPAR? activation, suggesting that this nuclear receptor can modulate cytokines inflammatory. Thus, we suggest that PPAR? may be an attractive candidate target for novel therapeutic strategies to prevent the deleterious effects of intense systemic release of inflammatory mediators after envenomation.

Wound infection is a major clinical burden that can significantly impede the healing process and cause severe pain. Prolonged wound infection can lead to long-term hospitalization or death. Pre-clinical research to evaluate new drugs or treatment strategies relies on animal studies. However, animal studies have several challenges including interspecies variations, cost, and, ethics question the success of these models. Recent advances in tissue engineering have enabled the development of in vitro human skin models for wound infection modeling and drug testing. The existing skin models are mostly representative of the healthy human skin and its normal functions. However, to study the wound healing process and the response of skin to the infection, there is still a need to develop a skin model mimicking the wound infection. This work presents a simplified functional infected epidermis model, fabricated with enzymatically crosslinked gelatin hydrogel. The immortalized human keratinocytes, HaCaT cells, was successfully cultured and differentiated to a multilayer epidermis structure at the air-liquid interface, and expressed terminal differentiation marker, filaggrin, in the outer layer. The barrier function of the epidermis model was studied by measuring the electrical resistance and tissue permeability across the layer. The results showed that the developed epidermis model offered a higher electrical resistance and a lower drug permeability compared to the cell monolayer on gelatin and cell-free gelatin. To show the capability of the developed epidermis model in wound modeling and drug, the model was infected with Escherichia coli and the inflammatory response of keratinocytes was studied by measuring the level of proinflammatory cytokines, including IL-1β and TNF-α. The results demonstrated the proinflammatory response of the epidermis model to infection by producing a higher level of TNF-α and IL-1β compared to the control group. While treating with antibiotic ciprofloxacin terminated the proinflammatory response and reduced the level of TNF-α and IL-1β. The robust fabrication procedure and functionality of this model suggest that this model has great potential for wound modeling and high throughput drug testing. / Graduate

Current Possibilities in Use of a Centrifugal Pump in the Cardiac Sugery Abstract Currently, the most commonly used technical solution for pumping blood during extracorporeal circulation during cardiac surgery, as well as for some types of ECMO (extracorporeal membrane oxygenation) are either a roller pump or centrifugal pump. Due to its advantages the centrifugal pump is mainly used for prolonged extracorporeal circulation in cardiac surgery and as a heart and / or lung support system. In current literature there is a lack of compelling scientific evidence that would clearly support its use in a routine cardiac surgery. The aim of our study was to compare both types of currently used blood pumps in longer cardiac procedures with deep hypothermic circulation arrest. In a randomized clinical study we had selected a group of patients that underwent a pulmonary endarterectomy (PEA) in order to demonstrate the positive effects of the centrifugal pump on the postoperative inflammatory reactions. There were no statistically significant differences between these two pumps when other clinical and laboratory parameters were observed. Based on the hypothesis that significant temperature changes during cardiac procedure with a deep hypothermia can affect sealing pressure of the endotracheal tube cuff, we performed a...

Current Possibilities in Use of a Centrifugal Pump in the Cardiac Sugery Abstract Currently, the most commonly used technical solution for pumping blood during extracorporeal circulation during cardiac surgery, as well as for some types of ECMO (extracorporeal membrane oxygenation) are either a roller pump or centrifugal pump. Due to its advantages the centrifugal pump is mainly used for prolonged extracorporeal circulation in cardiac surgery and as a heart and / or lung support system. In current literature there is a lack of compelling scientific evidence that would clearly support its use in a routine cardiac surgery. The aim of our study was to compare both types of currently used blood pumps in longer cardiac procedures with deep hypothermic circulation arrest. In a randomized clinical study we had selected a group of patients that underwent a pulmonary endarterectomy (PEA) in order to demonstrate the positive effects of the centrifugal pump on the postoperative inflammatory reactions. There were no statistically significant differences between these two pumps when other clinical and laboratory parameters were observed. Based on the hypothesis that significant temperature changes during cardiac procedure with a deep hypothermia can affect sealing pressure of the endotracheal tube cuff, we performed a...

Zymosan-induced peritonitis is a model commonly used to study systemic inflammatory response syndrome and multiple organ dysfunction syndrome. However, effects of zymosan on cardiac function have not been reported. We evaluated cardiac responses to zymosan in mice and the role of β-Glucan and dectin-1 in mediating these responses. Temperature and cardiac function were evaluated before and after intraperitoneal (i.p.) injection of zymosan (100 or 500 mg/kg) or saline. Chronotropic and dromotropic functions were measured using electrocardiograms (ECGs) collected from conscious mice. Cardiac inotropic function was determined by echocardiography. High-dose zymosan caused a rapid and maintained hypothermia along with visual signs of illness. Baseline heart rate (HR) was unaffected but HR variability (HRV) increased, and there was a modest slowing of ventricular conduction. High-dose zymosan also caused prominent decreases in cardiac contractility at 4 and 24 h. Because zymosan is known to cause gastrointestinal tract pathology, peritoneal wash and blood samples were evaluated for bacteria at 24 h after zymosan or saline injection. Translocation of bacterial occurred in all zymosan-treated mice (n=3), and two had bacteremia. Purified β-Glucan (50 and 125 mg/kg, i.p.) had no effect on temperature or ECG parameters. However, deletion of dectin-1 modified the ECG responses to high-dose zymosan; slowing of ventricular conduction and the increase in HRV were eliminated but a marked bradycardia appeared at 24 h after zymosan treatment. Zymosan-treated dectin-1 knockout mice also showed hypothermia and visual signs of illness. Fecal samples from dectin-1 knockout mice contained more bacteria than wild types, but zymosan caused less translocation of bacteria. Collectively, these findings demonstrate that zymosan-induced systemic inflammation causes cardiac dysfunction in mice. The data suggest that dectin-1-dependent and -independent mechanisms are involved. Although zymosan treatment causes translocation of bacteria, this effect does not have a major role in the overall systemic response to zymosan.

The use of degradable biomedical materials has during the past decades indeed modernized medical science, finding applications in e.g. tissue engineering and drug delivery. The key question is to adapt the material with respect to mechanical properties, surface characteristics and degradation profile to suit the specific application. Degradation products are generally considered non-toxic and they are excreted from the human body. However, large amounts of hydroxy acids may induce a pH decrease and a subsequent inflammatory response at the implantation site. In this study, macromolecular design and a combination of cross-linking and adjusted hydrophilicity are utilized as tools to control and tailor degradation rate and subsequent release of degradation products from biomedical polyester-ethers. A series of different homo- and copolymers of -caprolactone (CL) and 1,5-dioxepan-2-one (DXO) were synthesized and their hydrolytic degradation was monitored in phosphate buffer solution at pH 7.4 and 37 °C for up to 546 days. The various materials comprised linear DXO/CL triblock and multiblock copolymers, PCL linear homopolymer and porous structure, and random cross-linked homo- and copolymers of CL/DXO using 2,2’-bis-(ε-caprolactone-4-yl) propane (BCP) as a cross-linking agent. The results showed that macromolecular engineering and controlled hydrophilicity of cross-linked networks were useful implements for customizing the release rate of acidic degradation products in order to prevent the formation of local acidic environments and thereby reduce the risk of inflammatory responses in the body. / QC 20101109

Background: Systemic inflammation can occur after transcatheter aortic valve replacement (TAVR) and correlates with adverse outcome. The impact of remote ischemic preconditioning (RIPC) on TAVR associated systemic inflammation is unknown and was focus of this study. Methods: We performed a prospective controlled trial at a single center and included 66 patients treated with remote ischemic preconditioning (RIPC) prior to TAVR, who were matched to a control group by propensity score. RIPC was applied to the upper extremity using a conventional tourniquet. Definition of systemic inflammation was based on leucocyte count, C-reactive protein (CRP), procalcitonin (PCT) and interleukin-6 (IL-6), assessed in the first 5 days following the TAVR procedure. Mortality was determined within 6 months after TAVR. RIPC group and matched control group showed comparable baseline characteristics. Results: Systemic inflammation occurred in 66% of all patients after TAVR. Overall, survival after 6 months was significantly reduced in patients with systemic inflammation. RIPC, in comparison to control, did not significantly alter the plasma levels of leucocyte count, CRP, PCT or IL-6 within the first 5 days after TAVR. Furthermore, inflammation associated survival after 6 months was not improved by RIPC. Of all peri-interventional variables assessed, only the amount of the applied contrast agent was connected to the occurrence of systemic inflammation. Conclusions: Systemic inflammation frequently occurs after TAVR and leads to increased mortality after 6 months. RIPC neither reduces the incidence of systemic inflammation nor improves inflammation associated patient survival within 6 months.

No description available.