Os mecanismos fisiopatológicos associados aos efeitos benéficos da reanimação guiada pela saturação venosa mista de oxigênio (SvO2) durante a sepse não são claros. Nosso objetivo foi avaliar os efeitos de um algoritmo de reanimação guiado pela SvO2 incluindo fluidos, noradrenalina e dobutamina na hemodinâmica, resposta inflamatória e estresse oxidativo cardiovascular durante um modelo experimental que se assemelha clinicamente ao choque séptico. Dezoito porcos anestesiados e cateterizados (35-45 kg) foram submetidos à peritonite por inoculação fecal (0,75 g/Kg). Depois de permanecerem hipotensos, antibióticos foram administrados e os animais foram randomizados em dois grupos: controle (n=9), com suporte hemodinâmico visando pressão venosa central de 8-12 mmHg, débito urinário de 0,5 ml/kg por hora, e pressão arterial média acima de 65 mmHg; e grupo SvO2 (n=9), com os objetivos acima referidos, além de SvO2 acima de 65%. As intervenções duraram 12 hs e incluíram Ringer Lactato e norepinefrina (ambos os grupos) e dobutamina (grupo SvO2). A resposta inflamatória foi avaliada pela concentração plasmática de citocinas, expressão de CD14 de neutrófilos, geração de espécies reativas de oxigênio e apoptose. O estresse oxidativo foi avaliado pelas concentrações de nitratos no miocárdio e no plasma, a atividade miocárdica e vascular de NAD(P)H oxidase, conteúdo de glutationa do miocárdio e expressão de nitrotirosina. A reanimação guiada por SvO2 foi associada com melhor índice sistólico, oferta de oxigênio e diurese. A sepse induziu em ambos os grupos um aumento significativo na concentração de IL-6, nas concentrações de nitrato de plasma e diminuição persistente na expressão de CD14 em neutrófilos. A apoptose e a geração de espécies reativas de oxigênio por neutrófilos não foram diferentes entre os grupos. As estratégias de tratamento não alteraram significativamente os parâmetros de estresse oxidativo. Assim, uma abordagem destinada a otimizar a SvO2 durante a sepse melhora a hemodinâmica, porém sem qualquer efeito significativo sobre a resposta inflamatória e estresse oxidativo. Os efeitos benéficos associados a esta estratégia podem estar relacionados a outros mecanismos. / The pathogenetic mechanisms associated to the beneficial effects of mixed venous oxygen saturation (SvO2)-guided resuscitation during sepsis are unclear. Our purpose was to evaluate the effects of an algorithm of SvO2-driven resuscitation including fluids, norepinephrine and dobutamine on hemodynamics, inflammatory response and cardiovascular oxidative stress during a clinically resembling experimental model of septic shock. Eighteen anesthetized and catheterized pigs (35-45 Kg) were submitted to peritonitis by fecal inoculation (0.75 g/Kg). After hypotension, antibiotics were administered, and the animals were randomized to two groups: control (n=9), with hemodynamic support aiming central venous pressure 8 to 12 mmHg, urinary output 0.5 ml/Kg per hour, and mean arterial pressure greater than 65 mmHg; and group SvO2 (n =9), with the goals above, plus SvO2 greater than 65%. The interventions lasted 12 h, and lactated Ringer\'s and norepinephrine (both groups) and dobutamine (SvO2 group) were administered. Inflammatory response was evaluated by plasma concentration of cytokines, neutrophil CD14 expression, oxidant generation, and apoptosis. Oxidative stress was evaluated by plasma and myocardial nitrate concentrations, myocardial and vascular NAD(P)H oxidase activity, myocardial glutathione content, and nitrotyrosine expression. Mixed venous oxygen saturation-driven resuscitation was associated with improved systolic index, oxygen delivery, and diuresis. Sepsis induced in both groups a significant increase on IL-6 concentrations and plasma nitrate concentrations and persistent decrease in neutrophil CD14 expression. Apoptosis rate and neutrophil oxidant generation were not different between groups. Treatment strategies did not significantly modify oxidative stress parameters. Thus, an approach aiming SvO2 during sepsis improves hemoynamics, without any significant effect on inflammatory response and oxidative stress. The beneficial effects associated with this strategy may be related to other mechanisms

A sepse causa uma alta taxa de mortalidade no mundo. A fisiopatologia da doença envolve uma rede complexa de mediadores inflamatórios que promovem a lesão de diversos tecidos, além de diversas alterações hemodinâmicas e disfunção do sistema nervoso autonômico (SNA). Assim sabe-se que o sistema nervoso cumpre um papel importante no controle da inflamação sistêmica mediante a via colinérgica anti-inflamatória (VCA) através do receptor nicotínico de acetilcolina alfa7 (alfa7nAChR). O uso das células-tronco mesenquimais (CTM) tem mostrado efeitos benéficos em diversos ensaios clínicos de doenças inflamatórias. Neste contexto, as células-tronco mesenquimais derivadas da geleia de Wharton do cordão umbilical (CTM-GW) tornam-se promissórias, uma vez que essas células são reconhecidas pela regulação da resposta imunológica, reparação neural, efeito anti-apoptose, assim como a melhora da sobrevida na sepse, em modelos experimentais. Nossa hipótese foi de que as CTM-GW poderiam cumprir um papel neuroimunomodulador através da VCA e atenuar a disfunção de múltiplos órgãos em um modelo animal de sepse de ligadura e punção do ceco (LPC). Inicialmente células da matriz do cordão umbilical foram isoladas e caracterizadas de acordo com o consenso internacional vigente. Ratos Wistar machos adultos foram subdivididos em grupos: 1) sham (operação simulada); 2) LPC; 3) LPC+CTM-GW (injetado 106 CTM-GW via intraperitoneal, i.p. 6 h após LPC) e 4) LPC+MLA+CTM-GW (MLA: Metillicaconitine, antagonista do alfa7nAChR, i.p., 5:30 h após LPC e 106 CTM-GW 6h após). Às 24 horas após LPC, foram avaliadas a função cardiovascular, hemodinâmica assim como os outros parâmetros. Interessantemente, o tratamento com CTM-GW na sepse atenuou a disfunção diastólica e protegeu a sensibilidade baroreflexa. Além disso, as CTM-GW estimularam a atividade autonômica, simpática e parassimpática no coração. Observamos que o tratamento celular induziu uma regulação da expressão do receptor alfa7nAChR e TLR4 no baço e no coração, assim como a redução da relação p-STAT3TYR705 e STAT3 total no baço. Outros efeitos importantes e adicionais foram a diminuição da infiltração de leucócitos e a regulação das citocinas pró-inflamatórias pelas células. O bloqueio da VCA usando MLA confirmou que o receptor alfa7nAChR pode ser um provável alvo, chave da ação das CTM entre vários outros mecanismos envolvidos na resposta imune. Finalmente, as CTM-GW conseguiram reduzir a apoptose no pulmão e no baço independentemente da VAC reforçando o conceito de que as células-tronco tem efeitos diversos além da imuno-regulação. Em conclusão, as CTM-GW na sepse foram capazes de atenuar a lesão cardiopulmonar assim como modular a atividade autonômica, reduzindo a inflamação sistêmica, pelo menos em parte, através da via colinérgica anti-inflamatória. Indubitavelmente todos estes efeitos anteriormente descritos e em associação se demonstraram fundamentais no mecanismo de reparo e proteção tecidual em resposta a sepse. Mais estudos pré-clínicos e futuros testes clínicos precisam ser realizados para maior compreensão destes mecanismos bem como uma possível validação terapêutica / Sepsis induces organ dysfunction due to overexpression of the inflammatory host response, involving cardiorespiratory and autonomic dysregulation, thus increasing the associated morbidity and mortality. The cholinergic anti-inflammatory pathway (CAP) is mediated by nervous system through alpha7 nicotinic acetylcholine receptor (alpha7nAChR). This receptor has an important role in systemic inflammation control. Wharton\'s jelly-derived mesenchymal stem cells (WJ-MSCs) are known to express genes and secreted factors related to neurological and immunological protection, as well as to improve survival in experimental sepsis. We hypothesized that WJ-MSCs play a modulatory role through the CAP and attenuate sepsis-induced organ injury in a cecal ligation and puncture (CLP) model. Rats were randomly divided into 4 groups: 1) Control (sham-operated); 2) submitted to CLP without treatment; 3) submitted to CLP and treated with 106 WJ-MSCs 6 h later and 4) CLP+MLA+WJ-MSC group (MLA: Methyllycaconitine, alpha7nAChR antagonist). All experiments were performed 24 h post-surgery. Echocardiographic parameters and heart rate variability were assessed. Importantly, treatment with WJ-MSCs attenuated diastolic heart failure and recovered barorreflex sensitivity. Moreover, WJ-MSCs injection increased cardiac sympathetic and cardiovagal activity. In cardiac and splenic tissue, WJ-MSC treatment downregulated TLR4 and alpha7nAChR expression, as well as it reduced p-STAT3/Total STAT3 ratio in the spleen. In addition, WJ-MSC reduced leukocyte infiltration and pro-inflammatory cytokines, which only were abolished by MLA treatment. Finally, WJ-MSC treatment diminished apoptosis in lung and spleen tissue. Together these findings suggest that treatment with WJ-MSCs appears to protect against sepsis-induced organ injury reducing systemic inflammation, at least in part, through cholinergic anti-inflammatory pathway

Early administration of broad-spectrum antibiotics is the first goal in sepsis treatment. Besides from bacteriostatic/bactericidal effects, some antibiotics may also modify the host´s response to infection. The novel antibiotic tigecycline may exert such properties; however, this property has not been evaluated in large-animal trials. We compared tigecycline with doxycycline and placebo in relation to anti-inflammatory, circulatory and organ dysfunction effects in a sterile pig model of sepsis. Doxycycline, but not tigecycline, reduced the inflammatory response as manifested by tumor necrosis factor alpha levels in plasma. Tigecycline, however, had a stabilizing effect on the circulation not exerted by doxycycline or placebo. To achieve rapid restoration of the circulating blood volume - another major goal in sepsis treatment - fluid bolus administration of is some-times practiced. In addition to crystalloids, albumin-containing solutions are suggested. Yet, some animal-experimental data suggests that rapid bolus administration of albumin reduces albumin’s plasma-expanding effect. We compared a rapid intravenous bolus of radiolabeled albumin with a slow infusion in a sterile pig model of sepsis. Rapid bolus of administration did not reduce plasma levels of albumin following administration and did not increase the amount of albumin that left the circulation. Inadequate oxygen delivery (DO2) by the circulation to the tissues may cause increased plasma lactate, which is the most striking effect of sepsis on the metabolism. However, experimental data and clinical trials refute this link, instead, suggesting other mechanisms, including impaired oxygen extraction, mitochondrial dysfunction and accelerated aerobic glycolysis. We investigated the impact of DO2, oxygen consumption (VO2), hemodynamic parameters and inflammatory response on plasma lactate and organ dysfunction in two experimental sepsis models. In the most severe cases of shock, with DO2, there was an increase in plasma lactate, but without a decrease in VO2, invalidating the assumption that the increase in lactate is due to anaerobic metabolism. To identify critical steps in the sepsis-induced increase in lactate, we inhibited the major energy-producing step in the electron transport chain (ETC). The combination of sepsis and ETC inhibition led to a cellular energy crisis. This finding suggests that early sepsis induces a partial mitochondrial dysfunction.

<p>Veno-arterijski gradijent ugljen-dioksida (Pv-aCO2) se smatra pokazateljem adekvatnosti microcirculatornog venskog protoka. U stanjima usporenog protoka dolazi do povećavanja Pv-aCO2 zbog fenomena zadržavanja CO2. Vrednost Pv-aCO2 predložena je kao dodatni cilj rane usmerene terapije kod pacijenata sa septičnim &scaron;okom. Cilj rada bilo je utvrditi postojanje korelacije promene Pv-aCO2 s promenom SOFA (&ldquo;Sequential Organ Failure Assessment&rdquo;) skora (delta SOFA) nakon primene rane ciljane terapije, kao i korelacije vrednosti različitih pokazatelja krvnog protoka unutar prvih 12 sati od početka lečenja pacijenata sa sepsom. Sekundarni cilj bilo je utvrditi postojanje korelacije Pv-aCO2 6 sati nakon početka rane ciljane terapije (T6) s dužinom boravka u intenzivnoj jedinici i ishodom lečenja. Prospektivnim, neintervencijskim ispitivanjem obuhvaćeno je 150 pacijenata sa sepsom ili septičnim &scaron;okom. Merenja serumskog laktata, saturacije kiseonikom me&scaron;ane venske krvi (ScvO2) i Pv-aCO2 vr&scaron;ena su na početku rane ciljane terapije (T0), posle 6 i 12 sati (T6, T12). Pv-aCO2 se računao kao razlika između parcijalnog pritiska ugljen dioksida arterijske i me&scaron;ane venske krvi. Vrednost SOFA skora određivana je u vremenu T0 i nakon 48 časova (T48). Pacijenti su za potrebe analize podeljeni u dve grupe na osnovu promene SOFA skora [(1) pacijenti kod kojih je do&scaron;lo do smanjenja SOFA skora (delta SOFA &lt; 0); (2) pacijenti kod kojih je smanjenje SOFA skora izostalo (delta SOFA &ge; 0)] i na osnovu vrednosti Pv-aCO2 u vremenu T6 [(1) pacijenti sa visokim Pv-aCO2 (&ge; 0.8 kPa); (2) pacijenti sa normalnim Pv-aCO2 (&lt; 0.8 kPa)]. Između dve grupe pacijenata, sa normalnim i visokim Pv-aCO2, statistički značajne razlike uočene su samo u odnosu na najvi&scaron;u vrednost respiratorne komponente SOFA skora (p=0.01). Uočena je statistički značajna korelacija između vrednosti Pv-aCO2 i laktata u vremenu T6 (r=0.2), Pv-aCO2 i ScvO2 u vremenu T0 (r=-0.4) i T12 (r=-0.24) kao i laktata i ScvO2 u vremenu T0 (r=-0.26) i T12 (r=-0.18). Analizom ponavljanih merenja nije utvrđena statistički značajna korelacija između promene vrednosti Pv-aCO2 unutar prvih 6 sati s promenom SOFA skora unutar prvih 48 sati nakon početka rane ciljane terapije (p=0.12). Utvrđeno je da su vrednosti Pv-aCO2 u vremenu T6 bile lo&scaron; prediktor smrtnog ishoda. Nisu utvrđene statistički značajne razlike u dužini boravka u intenzivnoj jedinici i ishodu lečenja u zavisnosti od vrednosti Pv-aCO2.</p> / <p>Central venous-arterial CO2 difference (Pv-aCO2) reflects adequacy of microcirculatory venous flow. Widening of Pv-aCO2 due to CO2-stagnant phenomenon is described in the low flow states. Pv-aCO2 was proposed as an additional resuscitation target for patients with septic shock.The aim of this study was to examine correlation between changes in Pv-aCO2 and SOFA score as well as different blood flow indices (lactate, mixed venous oxygen saturation) 12 hours after onset of resuscitation in patients with sepsis or septic shock. Secondary aim was to evaluate association of delta CO2 6 hours after onset of resuscitation and patient outcomes (length of stay in the ICU, mortality). Prospective observational study included 150 patients with sepsis. Simultaneous measurements of lactate, mixed venous oxygen saturation (ScvO2) and delta PCO2 were performed at onset of resuscitation (T0) and after 6 hours (T6). Delta PCO2 was calculated as a difference between arterial PCO2 and PCO2 from mixed venous blood. Organ dysfunction was evaluated with the Sequential Organ Failure Assessment (SOFA) score at T0 and after 48 hours (T48). Mortality was assessed after 28 days. For data analysis purposes two groups were created based on delta SOFA [(1) patients with SOFA score decrease (delta SOFA &lt;0); (2) patients without SOFA score decrease (delta SOFA &ge; 0)] and based on Pv-aCO2 [(1) patients with high Pv-aCO2 (&ge;0.8 kPa); (2) patients with normal Pv-aCO2 (&lt;0.8 kPa). Patients with high and normal Pv-aCO2 differed only with respect to highest respiratory SOFA score (p=0.01) Change in Pv-aCO2 between T0 and T6 was not in correlation with change in SOFA score between T0 and T48 (p=0.12). Moderate statistically significant correlation was found between Pv-aCO2 and lactate at T6 (r=0.2), and moderate inverse correlation between Pv-aCO2 and ScvO2 at T0 (r=-0.4) and T12 (r=-0.25) and ScvO2 and lactate at T0 (r=-0.27) and T12 (r=-0.18). Pv-aCO2 at T6 was not associated with 28-day mortality and length of stay in the ICU.</p>

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-01-11T17:31:37Z No. of bitstreams: 1 lidiamariacarneirodafonseca.pdf: 814638 bytes, checksum: 8aa87e2816d8e7e5c474900ab0798b04 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-01-25T17:10:03Z (GMT) No. of bitstreams: 1 lidiamariacarneirodafonseca.pdf: 814638 bytes, checksum: 8aa87e2816d8e7e5c474900ab0798b04 (MD5) / Made available in DSpace on 2016-01-25T17:10:03Z (GMT). No. of bitstreams: 1 lidiamariacarneirodafonseca.pdf: 814638 bytes, checksum: 8aa87e2816d8e7e5c474900ab0798b04 (MD5) Previous issue date: 2015-07-16 / FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais / Introdução: A forma como pulmões com enfisema respondem a uma agressão sistêmica como a sepse não é conhecida. É possível que as alterações inflamatórias e estruturais nos pulmões com enfisema alterem a resposta dos mesmos à sepse influenciando no desenvolvimento da síndrome do desconforto respiratório agudo. Objetivo: Comparar a lesão pulmonar secundária à sepse, induzida por lipopolissacarídeo (LPS) intraperitoneal, em ratos com e sem enfisema induzido pela administração intratraqueal de elastase. Métodos: Vinte e quatro ratos Wistar adultos foram randomizados para quatro grupos de seis animais: controle (C-C), enfisema (E-C), controle com sepse (C-LPS) e enfisema com sepse (E-LPS). O enfisema foi induzido pela injeção intratraqueal de elastase pancreática de porco (12 UI/ animal). Após três semanas deste procedimento, a sepse foi induzida pela injeção intraperitoneal de LPS da Escherichia coli (10 mg/Kg). Vinte e quatro horas após a indução da sepse, os animais foram submetidos à ventilação mecânica por 10 minutos para posterior coleta da gasometria arterial. A seguir, foram eutanasiados e as seguintes análises foram realizadas: lavado broncoalveolar (LBA), permeabilidade pulmonar e histologia. Os resultados foram expressos em média ± desvio padrão ou mediana (intervalo interquartil), quando apropriado, e comparados por ANOVA seguida do teste de Tukey, ou por Kruskal-Wallis seguido do teste de Mann-Whitney. Resultados: O escore de lesão pulmonar foi significativamente maior nos grupos C-LPS [0,62 (0,19)] e E-LPS [0,59 (0,13)] em comparação com os grupos C-C [0,11 (0,09)] e E-C [0,15 (0,05)] (p < 0,05). A contagem total de células (C-LPS=2,37 ± 0,74; E-LPS=5,37 ± 0,13; C-C=0,73 ± 0,36; E-C=3,09 ± 7,53 x 105) e de neutrófilos [C-LPS=1,39 (1,48); E-LPS=4,39 (1,95); C-C=0,07 (0,11); E-C=0,68 (0,61) x 105] no LBA foi significativamente maior nos grupos C-LPS e E-LPS comparado aos grupos C-C e E-C (p < 0,05). Animais do grupo E-LPS apresentaram maior contagem de células totais e de neutrófilos no LBA em comparação com o grupo C-LPS (p < 0,05). Na avaliação da razão albumina LBA/soro, o grupo E-LPS apresentou aumento significativo quando comparado ao C-LPS [0,069 (1,243) vs. 0,007 (0,002), respectivamente, p < 0,05]. Não foram observadas diferenças significativas nas trocas gasosas entre os grupos. Conclusões: A presença de enfisema foi acompanhada de maior inflamação pulmonar em resposta à agressão sistêmica induzida pela injeção intraperitoneal de LPS, levando a uma maior lesão da barreira alvéolo-capilar. Palavras-chave: enfisema pulmonar, sepse, lesão pulmonar aguda, síndrome do desconforto respiratório agudo, elastase pancreática, lipopolissacarídeos. / Introduction: The response of lungs with emphysema to a systemic insult such as sepsis is not known. Structural and inflammatory abnormalities in lungs caused by emphysema might alter their response to sepsis and thus influence the incidence and severity of acute respiratory distress syndrome. We therefore aimed to compare the severity and extension of acute lung injury in response to intraperitoneal lipopolysaccharide (LPS) injection in rats with and without emphysema induced by elastase. Methods: Twenty four adult Wistar rats were randomized into 4 groups, each of them with 6 animals: control (C-C), emphysema without sepsis (E-C), control with sepsis (C-LPS) and emphysema with sepsis (E-LPS). Emphysema was induced by intratracheal instillation of pancreatic porcine elastase (12 IU/animal). Three weeks later, sepsis was induced by intraperitoneal Escherichia coli LPS injection (10 mg/kg). Twenty four hours after sepsis induction, animals underwent mechanical ventilation for 10 minutes and then blood was sampled for gasometric analysis. Thereafter, euthanasia and the following analysis were performed: BAL, lung permeability and histology. Results were expressed as mean ± standard deviation or median (interquartile range), when appropriate, and compared using ANOVA followed by Tukey test or Kruskal-Wallis followed by Mann-Whitney test. Results: Significant increase in lung injury score was observed in the C-LPS [0.62 (0.19)] and E-LPS [0.59 (0.13)] compared to the groups C-C [0.11 (0.09)] and E-C [0.15 (0.05)] (p < 0.05). Total cell (C-LPS=2.37 ± 0.74; E-LPS=5.37 ± 0.13; C-C=0.73 ± 0.36; E-C=3.09 ± 7.53 x 105) and neutrophil counts [C-LPS=1.39 (1.48); E-LPS=4.39 (1.95); C-C=0.065 (0.11); E-C=0.68 (0.61) x 105] in the BAL were significantly higher in the groups that received LPS (p < 0.05). Significantly higher total cell and neutrophil counts in the BAL were also observed in the E-LPS group compared to C-LPS (p < 0.05). The group E-LPS showed a significant increase in the BAL/serum albumin ratio compared to C-LPS [0.069 (1.243) vs. 0.007 (0.002), respectively] (p < 0.05). There were no significant differences in the gas exchange levels among the groups. Conclusions: The presence of emphysema increases the inflammatory response in the lungs to a systemic stimulus, represented in this model by the intraperitoneal injection of LPS.

Myeloid-derived suppressor cells (MDSCs) numbers increase significantly in sepsis and are associated with high mortality rates. These myeloid cell precursors promote immunosuppression, especially in the late (post sepsis) stage. However, the mechanisms that underlie MDSC expansion and programming are not completely understood. To investigate these mechanisms, we used a cecal-ligation and puncture (CLP) mouse model of polymicrobial sepsis that progresses from an early/acute proinflammatory phase to a late/chronic immunosuppressive phase. Previous studies in our laboratory showed that microRNA (miR)-21 and miR-181b elevate levels of the transcription factor nuclear factor 1 (NFI-A) that promotes MDSC expansion. We report here that miR-21 and miR-181b regulate NFI-A expression via a post-transcriptional regulatory mechanism by recruiting RNA-binding proteins HuR and Ago1 to stabilize NFI-A mRNA, thus increasing its protein levels. Studies in our laboratory also showed that inflammatory mediator S100A9 accumulates in the nucleus in Gr1+CD11b+ myeloid precursors in the later phases of sepsis and is necessary for their expansion and programming into immunosuppressive MDSCs. We demonstrate here that nuclear S100A9 associates with specific transcription factors that activate miR-21 and miR-181b expressions. In our final manuscript, we uncover another layer of the mechanisms of MDSC expansion and programming. We found that long non-coding RNA (lncRNA) Hotairm1 binds to and recruits S100A9 to the nucleus to program Gr1+CD11b+ myeloid precursors into MDSCs in the later phases of sepsis. Together, our results reveal three regulatory layers involving NFI-A, S100A9 and Hotairm1 in the pathway leading to MDSCs development in sepsis and suggest that therapeutically targeting these molecular switches might improve sepsis survival.

No description available.

In der vorliegenden Arbeit wurde anhand der im Rahmen des Vermont-Oxford-Neonatal-Networks erhobenen Daten an der Berliner Klinik für Neonatologie der Charité Campus Mitte und der Abteilung für neonatologische Intensivmedizin der Universitätskinderklinik in Innsbruck ein Benchmarking-Projekt für die Jahre 1997 bis 2001 durchgeführt. Nach der Analyse des Outcomes wurde eine Analyse der externen Evidenz anhand von Literatursuche in PubMed und der Cochrane Datenbank für systematische Reviews durchgeführt. Danach wurde ein Fragebogen entworfen, der gezielt Handlungsstrategien und -richtlinien bezüglich der relevanten Outcome-Parameter erfragt. Für das Benchmarking-Projekt wurden das Atemnotsyndrom, die nekrotisierende Enterokolitis und die bakteriellen Infektionen ausgewählt. Die Analyse der Handlungsstrategien durch den Fragebogen zeigte, dass in den drei Bereichen respiratorische Interventionen, Nahrung und Ernährung sowie im Infektionsmanagement Unterschiede vorlagen. In der Diskussion zeigte sich, dass in vielen Bereichen noch Bedarf nach guter externer Evidenz und weiterer Forschung besteht. / This dissertation presents the results of a 1997 - 2001 benchmark project in co-operation with the "Berliner Klinik für Neonatologie der Charité Campus Mitte" and the "Abteilung für neonatologische Intensivmedizin der Universitätskinderklinik" in Innsbruck. The study is based on the Vermont-Oxford-Neonatal-Network''s data. After analysing the results, further evidence was analysed by way of literary research in PubMed and the Cochrane Database of Systematic Reviews. Afterwards, a questionnaire was created, lining out the clinical guidelines of the relevant outcome parameters. The respiratory distress syndrom, the necrotising enterocolitis and the bacterial infections were selected for the benchmark. The internal guidelines'' analysis showed that there were differences between the two clinics'' results in respiratory interventions, feeding and the management of infections. The discussion made clear that research based on further evidence is necessary in many fields.

<p>Uvod: Nespecifičnost kliničke slike sepse, velike individualne razlike u odgovoru organizma na infekciju kao i neophodnost adekvatne inicijalne procene težine kliničke slike, toka i ishoda bolesti, čine istraživanja biomarkera koji bi doprineli pravovremenom postavljanju dijagnoze i adekvatnoj prognozi bolesti izuzetno značajnim. Do sada je ispitivano preko 200 biomarkera od kojih ni jedan nije pokazao zadovoljavajuću senzitivnost i specifičnost. Uloga B limfocita u patogenezi sepse pri tome je nedovoljno istražena. Članovi superfamilije tumor-nekrozis faktora alfa: A proliferation inducing ligand (APRIL), Bcell activating factor (BAFF) i solubilni transmembrane activator and calcium modulator cyclophilin ligand interactor (sTACI) su citokini koji imaju ključnu ulogu u homeostazi B limfocita. Cilj istraživanja bio je da se ispita dijagnostički i prognostički značaj citokina članova superfamilije tumor nekrozis faktora alfa (APRIL, BAFF, sTACI) za procenu težine kliničke slike, razvoja multiorganske disfunkcije (MODS) u prvih 48h hospitalizacije i letalnog ishoda sepse. Ispitanici i metode: Istraživanjem je obuhvaćeno 150 obolelih od sepse lečenih na Klinici za infektivne bolesti i Odeljenju anestezije i reanimacije Kliničkog centra Vojvodine i 30 zdravih dobrovljnih davalaca krvi. Kod svih bolesnika evidentirani su demografski i ostali podaci iz istorije bolesti kao i laboratorijske analize u okviru rutinske dijagnostike sepse. Iz dodatnih 5ml venske krvi svim ispitanicima određene su koncentracije APRIL-a, BAFF-a, sTACI-ja ELISA metodom komercijalnim testovima proizvođača R&amp;D Systems. Rezultati pokazuju da su koncentracije sva tri citokina (APRIL, BAFF i sTACI) statistički značajno povi&scaron;ene kod obolelih od sepse u odnosu na zdravu populaciju (p&lt;0.001), pri čemu APRIL pokazuje najveću senzitinvost (99%) i specifičnost (97%). Najveći dijagnostički značaj BAFF-a ogleda se u sposobnosti distinkcije između sepsi uzrokovanih Gram pozitivnim i Gram negativnim bakterijama (p=0,03). U predikciji razvoja MODS-a i letalnog ishoda sepse multivarijantnom regresionom analizom kao nezavisni prediktori pokazali su se jedino antiinflamatorni biomarker sTACI receptor i klinička procena pacijenta iskazana kroz APACHE II i SOFA skor. Senzitivnost i specifilnost sTACI receptora u predikciji razvoja MODS-a i letalnog ishoda daleko nadma&scaron;uje do sada rutinski kori&scaron;ćen prokalcitonin. Zaključak: Dobijeni rezultati ukazuju na to da su citokini koji učestvuju u regulaciji funkcije B limfocita značajni dijagnostički i prognostički parametri u sepsi. Predominacija antiinflamatornog odgovora na koju ukazuju povi&scaron;ene koncentracije sTACI receptora pokazala se pored APACHE II i SOFA skora kao jedini nezavisni prediktor razvoja MODS-a i letalnog ishoda septičnih bolesnika. Neophodna su dalja istraživanja u pravcu određivanja momenta kada u imunskom odgovoru organizam prelazi iz stanja dominacije proniflamatornog u dominaciju antiinflamatornog odgovora radi pravovremenog reagovanja imunomodulatornom terapijom.</p> / <p>Introduction: The nonspecific clinical presentation of sepsis and great individual response variations, as well as huge significance of adequate early prognosis of its clinical course and outcome made sepsis biomarkers research extremely significant. The properties of more than 200 biomarkers have been evaluated for prognostic value, but none have adequate specificity and sensitivity. The role of the B cells in sepsis pathogenesis also remains unclear. Tumor necrosis factor alpha (TNF-&alpha;) superfamily members: A proliferation inducing ligand (APRIL), Bcell activating factor (BAFF) and soluble transmembrane activator and calcium modulator cyclophilin ligand interactor (sTACI) are key factors in B cell biology. The aim of the study was to evaluate the diagnostic and prognostic significance of determining the concentrations of tumor necrosis factor alpha superfamily members for the prediction of MODS development in the first 48h of hospitalization as well as outcome prediction.<br />Subjects and methods: The study included 150 patients suffering from sepsis treated at the Clinic for infectious diseases and Department for anesthesiology and reanimatology of the Clinical center of Vojvodina, and 30 healthy volunteer blood donors. The demographic and other data regarding routine blood analysis performed during sepsis treatment of the patients has been acquired from their hospitalization documentation. Additional 5 ml of venous blood was taken from the patients and the concentrations of APRIL, BAFF and sTACI have been determined using the ELISA method by using R&amp;D Systems commercial kit&rsquo;s. Results: There is a statistically significant difference in concentrations of APRIL, BAFF and sTACI between healthy blood donors and septic patients (p&lt;0.001). APRIL showed the highest sensitivity (99%) and specificity (97%) in distinguishing sepsis from healthy subjects. BAFF showed statistically significant higher concentrations in Gram positive than in Gram negative sepsis (p=0,03). In the multivariate logistic regression analysis, only anti-inflammatory cytokine sTACI and APACHE II or SOFA score remained significant predictors of MODS and lethal outcome. sTACI showed greater sensitivity and specificity for MODS and outcome prediction then the widely used procalcitonin.&nbsp; Conclusions: The concentrations of TNF superfamily members, the main regulators of B cell function, have a significant diagnostic and prognostic value in predicting sepsis course and outcome. The predomination of the anti-inflammatory response, as being pointed out by elevated concentrations of sTACI receptors, has proved to be the only independent predictor, besides APACHE II and SOFA score, in MODS and lethal outcome development in sepsis. Further research is needed in order to accurately determine the exact moment when the immunological response shifts from the predominance of the pro-inflammatory response to the predominance of the anti-inflammatory response, so as to ensure the timely application of therapy that modulates the immunological response.</p>

A &#946;2-glicoproteína I (&#946;2GPI) é uma proteína de fase aguda, produzida principalmente no fígado e intestino. Os efeitos dessa proteína sobre células mononucleares foram investigados tanto em monócitos humanos de sangue periférico quanto em células promonocíticas humanas da linhagem celular ATCC THP-1. As correlações entre sua concentração plasmática e a intensidade da inflamação sistêmica foram avaliadas em humanos e em um modelo experimental de infecção sistêmica, em ratos. Nenhum efeito da &#946;2GPI foi observado sobre a resposta oxidativa de monócitos de sangue periférico durante a fagocitose de zymosan opsonisado ou de S. aureus, analisada respectivamente por quimiluminescência amplificada por luminol ou por citometria de fluxo. A &#946;2GPI estimulou a viabilidade celular e estimulou a diferenciação dos promonócitos. As células THP-1 tratadas com &#946;2GPI apresentaram adesão aumentada a placas de cultura bem como expressão aumentada de CD54 e CD14. A suplementação com &#946;2GPI foi suficiente para manter a proliferação das células THP-1 em cultura sem a adição de soro por 72h. Não houve correlações entre a concentração plasmática da &#946;2GPI e indicadores clínicos da resposta inflamatória aguda em pacientes sépticos. A concentração da &#946;2GPI não correlacionou com as concentrações plasmáticas de IL-8, SAA e PCR, que foram encontradas elevadas no sangue de pacientes com sepse. A variação da concentração plasmática de &#946;2GPI foi um fenômeno muito precoce no modelo experimental de sepse e translocação bacteriana. Nas primeiras três horas após a indução da sepse endovenosa, a concentração plasmática de &#946;2GPI diminuiu de forma dependente da intensidade de infecção. Sugere-se que efeitos muito precoces de compartimentalização associados ao sangue portal medeiem esta regulação. As concentrações mais baixas de &#946;2GPI foram observadas nos animais expostos à translocação bacteriana através da mucosa intestinal, associada a uma condição inflamatória leve. A derivação da linfa preveniu completamente a diminuição da concentração plasmática de &#946;2GPI. Em conjunto, os resultados revelaram a relevância combinada de via e de intensidade da infecção para o controle da concentração plasmática de &#946;2GPI no início na resposta inflamatória aguda. / The &#946;2-glycoprotein I (&#946;2GPI) is an acute phase protein, produced mainly in the liver and intestine. The effects of this protein upon mononuclear cells were investigated both in monocytes from human peripheral blood, and in the human promonocytic cells from the ATCC THP-1 cell line. The correlations between its plasma concentration and systemic inflammation intensity were evaluated in humans and in ad experimental model of systemic infection in rats. No &#946;2GPI effects were observed upon the oxidative response of blood monocytes during the phagocytosis of opsonized zymosan or S. aureus as analysed by luminol amplified chemiluminescence and flow cytometry. &#946;2GPI enhanced the cellular viability and stimulated the differentiation of the promonocytes. The THP-1 cells treated with &#946;2GPI presented increased adhesion to the plastic of cell culture plates as well as increased expression of CD54 and CD14 antigens. The supplementation with &#946;2GPI was sufficient to support the proliferation of THP-1 cells in serum free culture conditions for 72 h. There were no correlations between the &#946;2GPI plasma concentration and clinical parameters of the acute inflammatory response in septic patients. The &#946;2GPI concentrations didn\'t correlated with the plasma concentrations of IL-8, SAA and C reactive protein, despite these substances were found increased in the blood of patients with sepsis. The &#946;2GPI plasma concentration response was a very early phenomenon in the experimental sepsis and bacterial translocation model. The &#946;2GPI concentration decreased within the first 3h after endovenous sepsis induction, depending on the infection intensity. Very early compartment effects associated with the portal blood are suggested to mediate such regulation. The lowest &#946;2GPI concentrations were found in the animals exposed to bacterial translocation through the intestinal mucosa, associated with a mild inflammatory condition. The lymph derivation completely prevented the plasma &#946;2GPI decrease. Taken together, the results revealed the relevance of both the infection route and intensity to the control of plasma &#946;2GPI concentrations during the acute phase response.