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Ein Schlüsselereignis, welches dem prognosebestimmenden Organversagen bei systemi-schen Entzündungsprozessen und Sepsis vorangeht, ist die Entwicklung einer mikrovas-kulären endothelialen Schrankenstörung. Das vaskuläre endotheliale (VE-) Cadherin als mechanischer Stabilisator der Endothelbarriere spielt dabei eine wichtige Rolle. In der Inflammation werden Spaltprodukte von VE-Cadherin (sVE-Cadherin) gebildet. Ge-genstand der vorliegenden Arbeit war die Untersuchung der Hypothese ob diese Spalt-produkte selbst an der Störung der endothelialen Barrierefunktion beteiligt sind. Es wurde hierfür humanes sVE-Cadherin bestehend aus den extrazellulären Domänen EC1-5 (sVE-CadherinEC1-5) generiert. In Messungen des transendothelialen elektrischen Widerstands (TER), mit Immunfluoreszenzfärbungen und Western Blot Analysen wird gezeigt, dass sVE-Cadherin dosisabhängig die Barriere Integrität in primären humanen dermalen Endothelzellen stört. Dies führt zu einer Reduktion von VE-Cadherin und den assoziierten Proteinen α-, γ- und δ-Catenin und ZO-1, die nach der Applikation von sVE-Cadherin an den Zellgrenzen reduziert sind. Die Interaktion zwischen VE-PTP und VE-Cadherin wird durch sVE-CadherinEC1-5 reduziert. Durch pharmakologische Hem-mung der Phosphataseaktivität von VE-PTP mittels AKB9778 wird der durch sVE-CadherinEC1-5-induzierte Verlust der Endothelbarriere aufgehoben. Dagegen zeigt die direkte Aktivierung von Tie-2 mittels Angiopoetin-1 keinen protektiven Effekt auf die durch sVE-CadherinEC1-5 gestörte Endothelbarriere. Weitere Analysen zeigen eine erhöh-te Expression von GEF-H1 durch sVE-CadherinEC1-5. Diese ist ebenfalls durch AKB9778 hemmbar. Zusätzlich zu diesen Untersuchungen wurden die Konstrukte EC1-4 und EC3-5 in ver-schiedene Vektoren kloniert, um zu bestimmen, ob die extrazelluläre Domäne 5 von VE-Cadherin die dominante Rolle bei den sVE-Cadherin-vermittelten Effekten spielt. Zusammenfassend zeigen diese Untersuchungen zum ersten Mal, dass sVE-CadherinEC1-5 unabhängig von proinflammatorischen Auslösern über die Aktivierung des VE-PTP/RhoA-Signalweges den Zusammenbruch der Endothelbarriere mitversursacht. Dies stellt einen neuen pathophysiologischer Mechanismus dar, der zum Gesamtverständnis der entzündungsinduzierten Barriereveränderungen des Endothels beiträgt. / A key prognostic event preceding organ failure in sepsis and systemic inflammatory pro-cesses is dysfunction of the microvascular endothelial barrier. The transmembrane pro-tein vascular endothelial (VE-) cadherin is an important prerequisite to stabilize endothe-lial barrier. VE-cadherin is cleaved under inflammatory conditions which results in the release of soluble VE-cadherin (sVE-cadherin). The main hypothesis of this thesis is to investigate whether sVE-cadherin itself directly disrupts the endothelial barrier in the absence of proinflammatory stimuli. Human sVE-cadherin consisting of extracellular domains EC1-5 (sVE-cadherinEC1-5) was generated and applied onto primary human dermal endothelial cells (HDMECs) for structural and functional analysis. Measurements of transendothelial electrical resistance (TER) and 4 kDa FITC-dectran flux revealed that sVE-cadherinEC1-5 dose-dependently disrupts endothelial barrier integrity. This was confirmed by immunostaining and im-munoblotting analysis which showed that sVE-cadherinEC1-5 treatment reduced overall levels of VE-cadherin and the associated proteins α-, γ- and δ-catenin and ZO-1 as well as their distribution at the cell border of HDMECs. sVE-cadherinEC1-5 treatment reduced the interaction between the phosphatase VE-PTP and VE-cadherin. Accordingly, phar-macological inhibition of VE-PTP using AKB9778 reversed sVE-cadherinEC1-5-induced endothelial barrier loss. Further analysis showed that the increased expression of GEF-H1 by sVE-cadherinEC1-5 is also attenuated by AKB9778. In addition to these studies, the constructs EC1-4 and EC3-5 were cloned into different vectors to determine wheth-er the extracellular domain 5 of VE-cadherin plays the dominant role in sVE-cadherin-mediated effects. In summary, these studies show for the first time that sVE-cadherinEC1-5 actively con-tributes to breakdown of the endothelial barrier independently of proinflammatory stim-uli via activation of the VE-PTP/RhoA signaling pathway. This represents a new patho-physiological mechanism that adds to the understanding of inflammation-induced endo-thelial barrier changes.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23753号 / 医博第4799号 / 新制||医||1055(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 中本 裕士, 教授 松田 秀一, 教授 山本 洋介 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Sepsis is a dysregulated systemic response to infection and is one of the leading causes of in-hospital mortality in Canada. Accurate distinction between survivors and non-survivors of sepsis has recently been demonstrated through quantification of cell-free DNA (cfDNA) concentration in blood. In an analysis of 80 septic patients, non-survivors of sepsis had significantly higher cfDNA concentration levels than that of survivors or healthy patients. Real time separation of cfDNA from contaminants in blood has also been done using a cross channel microfluidic device. Current methods for DNA quantification utilize time consuming and complicated laboratory equipment and therefore are not suitable for bedside real-time testing. Thus a handheld cfDNA fluorescence device coined the Sepsis Check was designed that can perform DNA characterization in a reservoir device and DNA detection in a microfluidic cross channel device. The goal is to use this system along with the cross channel devices to set apart survivors or healthy donors from non-survivors in patients with sepsis. The design consists of a 470𝑛𝑚 light emitting diode (LED) with 170𝑚𝑊 of optical power (LED470L – ThorLabs), an aspherical uncoated lens with a focal length of 15𝑚𝑚 (LA1540-ML – ThorLabs), a 488𝑛𝑚 bandpass filter with a 3𝑛𝑚 full width at half maximum (FWHM) (FL05488-3 – ThorLabs), an aspherical uncoated lens with a focal length of 25𝑚𝑚 (LA1560-ML – ThorLabs), an aspherical uncoated lens with a focal length of 35𝑚𝑚 (LA1027-ML – ThorLabs), a 525𝑛𝑚 longpass filter with an optical density >4.0 (F84744 – Edmund Optics), and a Raspberry Pi Camera V2 (Raspberry Pi Foundation). The Sepsis Check is made to excite the dsDNA specific PicoGreen fluorophore which has a peak absorbance at 502𝑛𝑚 and a peak emission at 523𝑛𝑚. In summary, the Sepsis Check in this thesis is capable of calibrating dsDNA concentration from 1𝜇𝑔/𝑚𝐿 to 10𝜇𝑔/𝑚𝐿 and detect DNA accumulation of 5𝜇𝑔/𝑚𝐿 and 10𝜇𝑔/𝑚𝐿 in the cross channel device. This tool can be a valuable addition to the ICU to rapidly assess the severity of sepsis for informed decision making. / Thesis / Master of Applied Science (MASc)

Introduction: Sepsis is a major source of morbidity and mortality in neonates; however, identification of the causative pathogens can be challenging. Next generation sequencing (NGS) is a high-throughput, parallel sequencing technique for DNA. Pathogen-targeted enrichment followed by NGS has the potential to be more sensitive and faster than current gold-standard blood culture. In this pilot study, we will test the feasibility and pathogen detection patterns of pathogen-targeted NGS in neonates with suspected sepsis. Additionally, the distribution and diagnostic accuracy of cell-free DNA and protein C levels at two time points will be explored. Methods: We will conduct a prospective, pilot observational study. Neonates over 1 kg with suspected sepsis from a single tertiary care children’s hospital will be recruited for the study. Recruitment will be censored at 200 events or 6 months duration. Two blood study samples will be taken: the first simultaneous to the blood culture (time = 0 hr, for NGS and biomarkers) via an exception to consent (deferred consent) and another 24 hours later after prospective consent (biomarkers only). Neonates will be adjudicated into those with clinical sepsis, culture-proven sepsis and without sepsis based on clinical criteria. Feasibility parameters (e.g. recruitment) and NGS process time will be reported. Analysis: NGS results will be described in aggregate, compared to the simultaneous blood culture (sensitivity and specificity) and reviewed via expert panel for plausibility. Pilot data for biomarker distribution and diagnostic accuracy (sensitivity and specificity) for distinguishing between septic and non-septic neonates will be reported. Study amendment and interim results: After obtaining ethics approval, study enrolment started October 15, 2020. Interim feasibility results showed successful deferred consent, but low enrolment. A study amendment was used to increase enrolment, create pre-packaged blood kits and implement a substitute decision maker Notification form. / Thesis / Master of Health Sciences (MSc)

Sepsis drabbar varje år miljontals människor och skapar stort lidande och kan i värsta fall leda till döden. Sepsis är ett tillstånd där kroppens eget immunförsvar överreagerar och om det går obehandlat kommer det leda till en livshotande organsvikt. Sjuksköterskan har en viktig roll och ett stort ansvar när det kommer till att identifiera och behandla sepsis och dennes kunskap och kompetens att utföra dessa uppgifter påverkar utfallet för patienten. Sepsis slår brett över alla patientgrupper och är ett tillstånd som kan komma plötsligt och om det inte tidigt identifieras kan det skapa ett stort lidande för den drabbade patienten. Detta examensarbete hade som syfte att beskriva sjuksköterskors kunskap och kompetens samt vad som påverkar den i samband med vård av patienter med sepsis på somatisk vårdavdelning och akutmottagning. För att undersöka detta ämne har en litteraturöversikt med en mixad metod valts. Efter att ha sökt i två databaser hittades 8 artiklar som inkluderades i resultatet. Dessa artiklar bearbetades och tre teman identifierades; Kunskapsläget, erfarenhet och Utbildning ihop med ytterligare sju underteman som var brist på kunskap om patofysiologi och symtom vid sepsis, behov av mer kunskap, vikten av erfarenhet, vilken erfarenhet höjer kompetensen, brist på utbildning ett hinder för god vård, utbildningen ökar kompetensen och vikten av screening och vitala parametrar. Det som framkom i resultatet var att det finns vissa brister i sjuksköterskans kunskap och kompetens när det kom till sepsis men också att med hjälp av utbildning kunde man höja kompetensen inom professionen.

Yes / Women are discharged home from hospital increasingly early, but there is little evidence examining the postnatal hospital discharge process and how this may impact on the health of women and babies. In particular, there is little on sepsis prevention advice, despite it being the biggest direct cause of maternal mortality. Aim To explore the perceptions of women and senior student midwives related to the postnatal hospital discharge process and maternal sepsis prevention advice. Methods Three focus group interviews were undertaken, involving 9 senior student midwives and 14 women attending paid or specialist classes for vulnerable migrant women. Findings All participants believed that the postnatal hospital discharge process was inadequate, rushed and inconsistent. Sepsis advice was patchy and the condition underplayed. Conclusions Cost effective, time-efficient and innovative ways to impart vital information are required to support the postnatal hospital discharge process.

Systemic inflammation is a leading cause of mortality and morbidity in both human and equine intensive care patients. This systemic inflammatory response may be due to insult from bacterial, viral, fungal or parasitic invasion or from trauma or hypoxemia. Local and systemic release of a wide variety of endogenous pro-inflammatory mediators results in activation of the innate immune system in order to resolve the insult. In sepsis this initial appropriate host response becomes amplified and deregulated leading to refractory hypotension and multiple organ dysfunction. The exact incidence of sepsis (SIRS due to bacterial infection) has not been reported in the equine literature (Roy 2004). Since early recognition and treatment of sepsis are associated with improved outcome the search for markers to accurately predict presence of sepsis and likelihood of survival continues. The serum concentration of both procalcitonin and its related molecule CGRP have been documented to increase in humans with SIRS, yet no literature exists as to the production or role of CGRP in equine patients with SIRS. This study showed that equine CGRP was produced in detectable quantities by healthy adult horses and neonatal foals less than two weeks of age using a rat á-CGRP ELISA. The low percentage recovery of CGRP from samples and the high lower limit of detection for the assay prevented establishment of a normal concentration range of CGRP in healthy horses. In both adult horses and foals with documented SIRS, CGRP concentrations were significantly increased at time of presentation to the hospital (p<0.0002, p<0.003 respectively). A trend towards increased serum CGRP concentration was present in anaesethized horses exposed to endotoxin, but this was not statistically significant (p< 0.067). / Master of Science

Die Sepsis ist ein gefürchtetes Krankheitsbild, das in hochentwickelten Industrienationen mit einer hohen Mortalität verknüpft ist und damit zu den häufigsten Todesursachen gehört. Die Pathomechanismen dieses komplexen und heterogenen Krankheitsbildes zu entdecken, gehört momentan zu den Hauptinteressengebieten der Sepsisforschung. Da die Interpretation klinischer Studien aufgrund der Heterogenität des Patientenguts schwierig ist, kommt der Entwicklung adäquater Tiermodelle eine entscheidende Bedeutung zu. Die hierbei gängigen Tiermodelle in Mäusen weisen jedoch Unzulänglichkeiten auf, die die Übertragung der in Tierexperimenten gewonnen Daten auf den klinischen Kontext nur teilweise ermöglichen. Eine Brücke kann hierbei das Tiermodell der humanisierten Maus schlagen, in der, durch Transplantation mit humanen hämatopoetischen Stammzellen, ein humanes Immunsystem reift. Die vorliegende Arbeit beschäftigt sich mit der Fragestellung, inwieweit die humanen Immunzellen in der humanisierten Maus in der Lage sind, auf LPS als Stimmulus zu reagieren. Darüberhinaus wird die Nutzung der Endotoxämie in der humanisierten Maus als alternatives Sepsismodell im Bezug zum klinischen Kontext untersucht. Hierbei ergab sich eine mögliche Nutzung des Endotoxämiemodells in der humanisierten Maus zur genaueren Erforschung des Zytokinmilieus, sowie neuer Surrogatmarker wie Pentraxin 3. Bezüglich der Reaktion einzelner immunologischer Subpopulationen und deren Bedeutung für die Klinik scheint eine Untersuchung an Modellen, die eine B- und T-Zell-Reifung nachvollziehen können und in der murine Residualzellen möglichst gering vorhanden sind, als sinnvoll.

Sammanfattning: I samband med att en patient drabbas av sepsis pågår processer i kroppen som påverkar bland annat hjärnan. Patienterna kan drabbas av ett tillstånd av förvirring som kallas för delirium. Syfte: Syftet med studien var att beskriva intensivvårdssjuksköterskans omvårdnad i samband med sepsisassocierat delirium. Metod: För att genomföra studien valdes systematisk litteraturstudie. Data söktes i tre databaser samt fritextsökningar och manuell sökning i artiklars referenslistor. En integrerad analys genomfördes för att sammanställa resultatet. Resultat: Resultatet baseras på fyra artiklar. I resultatet framträdde tre huvudkategorier: Utföra personcentrerad vård, Utföra målinriktad behandling med läkemedel och Förutsättningar för god omvårdnad. Slutsats: Det råder brist på kunskap om ämnet hos sjukvårdspersonal vilket bidrar till att patienter diagnostiseras sent eller att diagnosen missas, vilket i sin tur leder till ökad morbiditet, mortalitet och förlängda vårdtider. / Introduction: In conjunction with a patient suffering from sepsis, ongoing processes in the body affects the brain. Patients can suffer from a state of confusion known as delirium. Aim: The aim of the study was to describe critical care nursing care associated with sepsis-associated delirium. Method: To conduct the study we selected systematic literature method. To conduct the study were selected systematic literature. Data were searched three databases and free-text search and manual search of reference lists of articles. An integrated analysis was performed to compile the results. Results: The result is based on four articles. The result appeared in three main categories: Perform personcentered care, Perform targeted drug treatment and Conditions for good care. Conclusion: There is a lack of knowledge on the subject of health professionals which leads to patients diagnosed late or missed diagnosis, which in turn leads to increased morbidity, mortality and prolonged hospitalization.