Introdução: o uso de drogas vasoativas para restaurar a pressão arterial em pacientes com choque séptico é frequentemente utilizada em medicina intensiva. No entanto, os agentes vasopressores podem acentuar a hipoperfusão esplâncnica durante o choque séptico facilitando a translocação bacteriana e endotoxemia. Neste estudo foram comparados os efeitos de diferentes drogas vasoativas na microcirculação intestinal e nos parâmetros de oxigenação tecidual independentemente de reposição volêmica, num modelo experimental de choque séptico. Métodos: Ratos Wistar Kyoto anestesiados com pentobarbital foram submetidos a choque endotoxêmico através da administração de 2mg/Kg IV de lipopolissacarídeo da Escherichia Coli. A pressão arterial média foi restaurada através da administração de diversas drogas vasoativa, incluindo adrenalina, noradrenalina, fenilefrina, dopamina, dobutamina e uma combinação de noradrenalina com dobutamina. A densidade capilar funcional (DCF) da camada muscular do intestino delgado foi avaliada através de microscopia intravital. Gasometria e concentração de lactato da veia mesentérica superior também foram analisadas. Resultados: A DCF diminui aproximadamente 25% a 60% após a administração intravenosa de adrenalina, noradrenalina e fenilefrina. A administração de dopamina, dobutamina e da associação de noradrenalina com dobutamina não reduziu significativamente a DCF intestinal. A concentração de lactato da veia mesentérica aumentou após a administração de fenilefrina e mostrou uma tendência de aumentar após o uso de adrenalina e noradrenalina enquanto não se observou aumento de lactato após o uso de dopamina, dobutamina e da associação entre noradrenalina e dobutamina. Conclusões: O estudo confirma a presença de uma dissociação entre alterações hemodinâmicas sistêmicas e alterações microcirculatórias num modelo experimental de choque séptico. Os resultados indicam que o uso de dopamina, dobutamina e da associação entre noradrenalina e dobutamina apresentam um efeito de proteção na microcirculação da camada muscular intestinal de ratos submetidos a choque endotoxêmico. / Background: The use of vasoactive drugs to restore arterial blood pressure in patients with septic shock remains a cornerstone of intensive care medicine. However, vasopressors can accentuate the hypoperfusion of the gut during septic shock, allowing bacterial translocation and endotoxemia. In this study, we compared the effects of different vasoactive drugs on intestinal microcirculation and tissue oxygenation, independent of the effects of fluid therapy, in a rat model of endotoxemic shock. Methods: Pentobarbital-anesthetized Wistar Kyoto rats were submitted to endotoxemic shock induced by Escherichia coli lipopolysaccharide (2 mg/kg IV). Arterial blood pressure was normalized by a continuous infusion of different vasoactive drugs, including epinephrine, norepinephrine, phenylephrine, dopamine, dobutamine, or a combination of dobutamine and norepinephrine. The functional capillary density (FCD) of the muscular layer of the small intestine was evaluated by intravital video-microscopy. Mesenteric venous blood gases and lactate concentrations were also analyzed. Results: FCD decreased by approximately 25% to 60% after the IV infusion of epinephrine, norepinephrine, and phenylephrine. Administration of dopamine, dobutamine, and the combination of dobutamine and norepinephrine did not induce significant alterations in gut FCD. In addition, the mesenteric venous lactate concentration increased in the presence of phenylephrine and showed a tendency to increase after the administration of epinephrine and norepinephrine, whereas there was no observable increase after the administration of dopamine, dobutamine, and the combination of dobutamine with norepinephrine. Conclusion: This study confirms dissociation of the systemic hemodynamic and microvascular alterations in an experimental model of septic shock. Moreover, the results indicate that the use of dopamine, dobutamine, and dobutamine in combination with norepinephrine yields a protective effect on the microcirculation of the intestinal muscular layer in endotoxemic rats.

The goal of this study was to build on the historic use of the avian model of development and also to further the knowledge of autonomic nervous system (ANS) regulation of cardiovascular function in vertebrates. Vasoactive drugs sodium nitroprusside, a vasodilator and phenylephrine, a vasoconstrictor were used to study the correlation of cardiovascular function relationship with nerve activity, both sympathetic and parasympathetic (vagal). Additionally, ANG II was used to assess its effects on vagal inhibition. The present study shows that pharmacologically-induced hypertension is associated with a fall in mSNA, indicating that the capacity for sympathetic autonomic cardiovascular regulation is established by late incubation however, late-stage embryonic chickens did not show a significant increase in mSNA during hypotension. The hypotensive response of the embryo was not accompanied by the expected inhibition of vagal discharge; however a slight but insignificant reduction in vagal discharge was noted. When vagal efferent output was isolated, a significant drop in vagal efferent activity was noted in response to hypotension. The present study showed late-stage embryonic chickens lack a vagal response to hypertension in both efferent and sensory limbs. In this study, vagal discharge was reduced from baseline levels in response to Ang II. Collectively, the present study indicates that the lack of a decreased heart rate, in response to increases in Pm caused by Ang II, is due to a central inhibitory action of Ang II on the vagus. Data from the present study suggests that although autonomic interaction with the cardiovascular system in present in late-stage chicken embryos, it is still underdeveloped and possesses a limited capacity.

Ultraljudsundersökningar av arteria carotis communis (CCA) utförs med ultraljud vid bedömning av kärlförändringar och flödeshastigheter (FH) samt utredning av sjukdomar i CCA. Lumendiameter (LD) i CCA är en markör för riskfaktorer som leder till stroke, hjärtinfarkt och ateroskleros. Syftet med den aktuella studien är att studera om det sker någon vasoaktiv förändring i CCA vid konsumtion av koffein hos unga vuxna. Det var 33 försökspersoner som delades upp i grupper beroende på deras koffeinkonsumtionsvanor och undersöktes med ultraljud. Försökspersonerna hade innan undersökning inte konsumerat koffein på 12 timmar. Undersökningen utfördes innan konsumtion av koffeindryck och 45 minuter efter koffeinkonsumtion. En signifikant skillnad efter konsumtion av koffein påvisades i lågkonsument gruppen (grupp 1) (p.0,06) och högkonsument gruppen (grupp 3) (p=0,05). En positiv korrelation mellan LD innan och efter konsumtion (r=0,955; p <0,01) samt FH innan och efter konsumtion (r=0,393; p <0,01) av koffein kunde påvisas. Nyckelord: Carotisduplex, Kaffe, Vasoaktiv, CCA.

Bakgrund: Vasoaktiva läkemedel är vanligt förekommande hjälpmedel inom intensivvården. Denna läkemedelskategori beskrivs som förstahandsval vid svår cirkulatorisk svikt. De har ett smalt terapeutiskt spektrum och utsätter patienter för potentiellt livshotande komplikationer samtidigt som de är nödvändiga för överlevnad. Att vara specialistsjuksköterska på en intensivvårdsavdelning innefattar avancerad vård och omvårdnad av kritiskt sjuka patienter. Här ställs höga krav gällande ansvar och kompetens inom en rad komplexa områden. I Sverige är det framför allt specialistsjuksköterskor som hanterar och administrerar vasoaktiva läkemedel efter ordination. Det kräver sakkunnighet inom det medicinska området gällande verkningsmekanism, interaktioner och biverkningar. Det erfordras även individuell skicklighet för att motsvara intensivvårdens kompetenskrav och inte riskera patientsäkerheten. Syfte: Syftet med denna studie var att beskriva intensivvårdssjuksköterskors erfarenheter av att vårda patienter som behandlas med vasoaktiva läkemedel. Metod: En kvalitativ intervjustudie har genomförts där data samlats in genom individuella, semistrukturerade intervjuer med 10 intensivvårdssjuksköterskor. Intervjuerna analyserades enligt en kvalitativ innehållsanalys med manifest ansats. Resultat: Analysen resulterade i fyra kategorier: att ha ett omvårdnadsperspektiv, att ha kliniskt handhavande, att ha en patientsäkerhetskultur och att upprätthålla klinisk kompetens. Det resulterade i ett gemensamt tema för samtliga kategorier: ett livslångt lärande. Lärande beskrivs som en dynamisk process vilket främst tillhandahålls genom klinisk praxis. Erfarenhet av att arbeta med cirkulatoriskt instabila patienter medför en trygghet och säkerhet i hanteringen av vasoaktiva läkemedel. Det leder också till att omvårdnaden och patientsäkerheten kan förbättras. Lärande beskrivs som ett eget och gemensamt ansvar för samtliga professioner. Slutsats: Det krävs att intensivvårdssjuksköterskan har teoretisk kunskap för att hantera vasoaktiva läkemedel. Det är dock genom kliniskt handhavande och praktisk erfarenhet som trygghet och skicklighet skapas.

The KATP channels play an important role in the membrane excitability and vascular tone regulation. Previous studies indicate that the function of KATP channels is disrupted in oxidative stress seen in a variety of cardiovascular diseases, while the underlying mechanism remains unclear. Here, we demonstrate S-glutathionylation to be a modulation mechanism underlying the oxidant-mediated vascular KATP channel inhibition, the molecular basis for the channel inhibition and the alleviation of the channel inhibition by vasoactive intestinal peptide (VIP). We found that an exposure of isolated mesenteric rings to H2O2 impaired the KATP channel-mediated vascular dilation. In whole-cell recordings and inside-out patches, micromolar H2O2 or diamide caused a strong inhibition of the vascular KATP channel (Kir6.1/SUR2B) in the presence, but not in the absence, of glutathione (GSH), indicating S-glutathionylation. By co-expressions of Kir6.1 or Kir6.2 with SUR2B subunits, we found that the oxidant sensitivity of the KATP channel relied on the Kir6.1 subunit. Systematic mutational analysis revealed three cysteine residues (Cys43, Cys120 and Cys176) to be important. Among them, Cys176 was prominent, contributing to >80% oxidant sensitivity. Biochemical pull-down assay with biotinylated glutathione ethyl ester (BioGEE) showed that mutations of Cys176 impaired the oxidant-induced incorporation of GSH to the Kir6.1 subunit. Simulation modeling of Kir6.1 S-glutathionylation revealed that after incorporation to residue 176, the GSH moiety occupied a space between slide helix and two transmembrane helices. This prevented the necessary conformational change of the inner helix for channel gating, and retained the channel in its closed state. VIP is a potent vasodilator, and is shown to have protective role against oxidative stress. We found that the channel was strongly augmented by VIP and the channel activation relied on PKA phosphorylation. These results therefore indicate that 1) the vascular KATP channel is strongly inhibited in oxidative stress, 2) S-glutathionylation underlies the oxidant-mediated KATP channel inhibition, 3) Cys176 in the Kir6.1 subunit is the major site for S-glutathionylation, and 4) the Kir6.1/SUR2B channel is activated in a PKA-dependent manner by VIP that has been previously shown to alleviate oxidative stress.

Neuropeptides are present in nerve fibers of the upper and lower airways. Local release of these substances may be of importance for the pathophysiology of airway disorders and may play a role in responses to different stimuli. However, little is known about the distribution of neuropeptides in the larynx. The superior laryngeal nerve is one of the vagal branches supplying the larynx. The aim of the present study was to investigate the fiber composition of this nerve and to analyse the distribution of different neuropeptides and mast cells in the larynx. The internal and the external branches of the superior laryngeal nerve had a similar number and size of the nerve fibers. Numerous unmyelinated fibers were evenly distributed in the branches. A large majority of the fibers were sensory myelinated and unmyelinated fibers; only a few of the myelinated fibers of the external branch ( 2-10 %) were motor. About a quarter of the unmyelinated fibers of the internal and the external branches had their cell bodies in the brainstem, and single myelinated and unmyelinated fibers emanated from the superior cervical ganglion. In every superior laryngeal nerve examined one to three spherical paraganglia were observed. These paraganglia contained cells which were similar to the type I and type II cells found in the carotid body and the paraganglia of the recurrent laryngeal nerve. Thin-walled sinusoidal blood vessels which were sometimes fenestrated were also present The laryngeal mucosa was supplied with nerve fibers exhibiting substance P- and calcitonin gene-related peptide-like immunoreactivity with regional differences in the distribution. The laryngeal side of the epiglottis and the ventral recess were richly supplied, and the vocal cords showed no evidence of immunoreactive nerve fibers. The distribution of connective tissue mast cells and mucosal mast cells/globular leucocytes was similar to that of nerve fibers displaying substance P- and calcitonin gene-related peptide-like immunoreactivity. These cells were found in close approximation to nerve fibers. Acetylcholinesterase-positive ganglionic cells in the larynx showed vasoactive intestinal polypeptide-, neuropeptide Y-and enkephalin-like immunoreactivity. Neuropeptide Y-like immunoreactivity was co-localized with tyrosine-hydroxylase/dopamine beta-hydroxylase-like immunoreactivity in nerve fibers in some blood vessel walls. Enkephalin-like immunoreactivity was rarely found in this location and co-localization with tyrosine- hydroxylase-like immunoreactivity was not detected. In glands and some blood vessel walls neuropeptide Y- and enkephalin-like immunoreactivity were localized in nerve fibers showing a positive acetylcholinesterase reaction and vasoactive intestinal polypeptide-like immunoreactivity. Thus, this indicates that neuropeptide Y is present in both the sympathetic and parasympathetic nervous systems, while enkephalin and vasoactive intestinal polypeptide are confined to the parasympathetic nervous system in the rat larynx. The present study shows that the superior laryngeal nerve is mainly sensory, and the study also provides a morphological basis for neuropeptide effects in laryngeal physiology/pathophysiology. / <p>S. 1-27: sammanfattning, s. 29-97: 6 uppsatser</p> / digitalisering@umu

Le tissu adipeux sous-cutané (TAsc) est le site préférentiel du stockage postprandial des triglycérides (TG). Quand les capacités d’accrétion sont dépassées, le stockage des TG se fait dans des sites ectopiques du TA et dans des tissus non adipocytaires, par exemple foie et muscles, ce qui entraine de multiples dysfonctionnements dans ces organes et tissus, et permet le développement du syndrome d’insulinorésistance. Chez les sujets obèses, la période postprandiale est caractérisée par des anomalies métaboliques, immunitaires, hormonales, et également par une diminution importante du flot sanguin dans le tissu adipeux (FSTA) sous-cutané. Ce blocage de la perfusion postprandiale du TA a aussi été montrée chez des individus minces qui avaient de très lourds antécédents familiaux de maladies cardiométabolique (obésité, diabète de type 2, maladies cardiovasculaires). Dans cette thèse, on classifiera ces individus comme « non-répondeurs ». À ce jour, peu d’attention a été accordée à ce phénomène. L’hypothèse qui sous-tend cette thèse est que les anomalies du FSTA sont innées ou primaires et sont impliquées très tôt dans le développement de la résistance à l’insuline (RI), du diabète de type 2 et du syndrome métabolique. Le but de notre recherche était donc de vérifier si les altérations du FSTA sont présentes chez les personnes saines et minces, mais à très haut risque de développer une RI ou une maladie cardiométabolique. Nous avons aussi cherché à déterminer les facteurs liés à la non-réponse. Pour cela il nous a fallu explorer certains facteurs hormonaux impliqués dans la régulation du FSTA. Nos résultats montrent que le FSTA est très diminué, à jeun et en postprandial, chez les sujets à haut risque de maladies cardiométaboliques mais encore minces et métaboliquement sains, sans RI. Nous avons aussi montré, pour la première fois, l’effet vasodilatateur du peptide intestinal vasoactif (VIP) dans le TAsc, tout comme le rôle stimulant du système cholinergique dans la régulation postprandiale du FSTA. Cependant, aucun de ces facteurs ne participe au dysfonctionnement du FSTA postprandial chez les non-répondeurs. Des taux répétés de TG plus élevés chez les non-répondeurs et l’association du FSTA avec certains indices de la RI décrits dans la littérature suggèrent que l’altération du métabolisme lipidique suite à la diminution du FSTA puisse servir de médiateur à la détérioration de la sensibilité à l’insuline. / Abstract : Subcutaneous adipose tissue (SCAT) is the preferential site of triacylglycerols (TAG) postprandial disposal. When the buffering capacity of SCAT for lipids is exceeded, TAG are disposed in ectopic adipose tissue depots and in non-adipose tissues, such as liver and muscles. Consequently, multiple dysfunctions of these organs and tissues develop including insulin resistance (IR). In obese people, the postprandial period is characterized by metabolic, immune and hormonal alterations, but also by severely altered adipose tissue blood flow (ATBF). Nevertheless, significant alteration of postprandial ATBF was also found in lean individuals with highly positive familiar history of cardiometabolic diseases (obesity, type 2 diabetes, cardiovascular diseases). In the thesis, we term them as "non-responders". Up to date, little attention has been payed to this phenomenon. The underlying hypothesis of this thesis is that alterations in ATBF are inborne or very early and that they participate on the development of IR, type 2 diabetes and metabolic syndrome. Consequently, the aim of our research was to verify if the alterations in ATBF are present in healthy, normal-weight subjects, but at very high risk for development of IR or cardiometabolic diseases. Simultaneously, we searched for factors linked with nonresponsiveness phenomenon. To do this, we examined some hormonal factors in ATBF regulation. Our results confirm the presence of altered fasting and postprandial ATBF in at highrisk subjects for cardiometabolic diseases, but still lean and metabolically healthy, without IR. For the first time, we have also demonstrated the role of cholinergic system in postprandial ATBF regulation, and vasodilatory effect of vasoactive intestinal peptide (VIP) in SCAT. However, none of these factors takes part in postprandial ATBF dysfunction in non-responders. Higher TAG levels repeatedly found in non-responders and the association of ATBF with some indices of insulin sensitivity described in the literature suggest that alteration of lipid metabolism as a result of low ATBF may mediate deterioration of insulin sensitivity.

Cortical malformations as a result of altered development are a common cause of human epilepsy. The cellular mechanisms that render neurons of malformed cortex epileptogenic remain unclear. Using a rat model of the malformation of microgyria, a previous study showed an alteration in the number of immunocytochemically-identified parvalbumin cells, a GABAergic inhibitory interneurons subtype (Rosen et al., 1998). A second study showed no change in the total number of GABAergic neurons (Schwarz et al., 2000). Consequently, we hypothesize that interneuron subtypes are differentially affected by maldevelopment. The present study investigated (1) whether interneuron subtype identity is retained in malformed cortex, based on chemical content, and (2) whether the proportion of three chemical subtypes is altered in malformed cortex. Here we demonstrate that three non-overlapping subtype markers remain non-overlapping in malformed cortex, but show altered distributions. These findings suggest that an increase in one subpopulation of interneurons may compensate for a corresponding decrease in a second subset.

Crohns sjukdom är en kronisk inflammatorisk tarmsjukdom av okänd orsak. Det tidigaste tecknet på Crohns sjukdom är mikroskopiska sår i det s.k. follikelassocierade epitelet (FAE) som täcker ansamlingar av immunceller i tarmen. FAE är specialiserat för att fånga innehåll från tarmen och transportera det till underliggande immunvävnad. Denna funktion är viktig för att inducera skyddande immunsvar, men den utgör också en ingångsväg för sjukdomsalstrande bakterier. Crohns sjukdom är associerat med ett kraftigt ökat immunsvar mot bakterier, och sjukdomsförloppet kan ändras av stress. Det övergripande syftet med avhandlingen var att studera effekterna av stress på FAE samt att undersöka rollen av FAE vid utvecklingen av tarminflammation, särskilt vid Crohns sjukdom. Inledningsvis studerades effekterna av psykologisk stress på FAE. Stressade råttor uppvisade ökad genomsläpplighet av bakterier efter stress, och passagen var högre i FAE än i vanligt epitel. Efterföljande experiment visade att stressförändringarna i slemhinnan regleras via kortikotropinfrisättande hormon och mastceller. Vidare visade det sig att vasoaktiv intestinal peptid kunde efterlikna stressens effekter på genomsläppligheten, och att detta kunde förhindras genom att blockera mastcellerna. Studier av tunntarmsslemhinna från patienter med icke-inflammatorisk tarmsjukdom och friska kontroller visade en högre passage av bakterier i FAE än i vanligt epitel. Hos patienter med Crohns sjukdom var bakteriepassagen genom FAE betydligt ökad jämfört med kontroller. Resultaten från detta avhandlingsarbete visar att stress kan förändra upptaget av bakterier från tarmen via FAE, med mekanismer som innefattar kortikotropinfrisättande hormon och mastceller. Detta har gett nya kunskaper kring regleringen av slemhinnebarriären. Vidare presenterar denna avhandling nya insikter i sjukdomsuppkomsten vid Crohns sjukdom genom att påvisa en tidigare okänd defekt i barriärfunktionen i FAE. / The earliest observable signs of Crohn’s disease are microscopic erosions in the follicle-associated epithelium (FAE) covering the Peyer’s patches. The FAE, which contains M cells, is specialised in sampling of luminal content and delivery to underlying immune cells. This sampling is crucial for induction of protective immune responses, but it also provides a route of entry for microorganisms into the mucosa. Crohn’s disease is associated with an increased immune response to bacteria, and the disease course can be altered by stress. The overall aim of this thesis was to study the effects of stress on the FAE and elucidate the role of FAE in the development of intestinal inflammation, specifically Crohn’s disease. Initially, rats were submitted to acute and chronic water avoidance stress to study the effects of psychological stress on the FAE. Stressed rats showed enhanced antigen and bacterial passage, and the passage was higher in FAE than in regular villus epithelium (VE). Further, stress gave rise to ultrastructural changes. Subsequent experiments revealed the stress-induced increase in permeability to be regulated by corticotropin-releasing hormone and mast cells. Furthermore, vasoactive intestinal peptide (VIP) mimicked the stress effects on permeability, and the VIP effects were inhibited by a mast cell stabiliser. Human studies of ileal mucosa from patients with non-inflammatory disease and healthy controls showed a higher antigen and bacterial passage in FAE than in VE. In patients with Crohn’s disease, the bacterial passage across the FAE was significantly increased compared to non-inflammatory and inflammatory controls (ulcerative colitis). Furthermore, there was an enhanced uptake of bacteria into dendritic cells, and augmented TNF-α release in Crohn’s disease mucosa. Taken together this thesis shows that stress can modulate the uptake of luminal antigens and bacteria via the FAE, through mechanisms involving CRH and mast cells. It further shows that human ileal FAE is functionally distinct from VE, and that Crohn’s disease patients exhibit enhanced FAE permeability compared to inflammatory and non-inflammatory controls. This thesis presents novel insights into regulation of the FAE barrier, as well as into the pathophysiology of Crohn’s disease by demonstrating a previously unrecognised defect of the FAE barrier function in ileal Crohn’s disease.

名古屋大学博士学位論文 学位の種類 : 博士(医学)(論文) 学位授与年月日:平成4年7月20日 淺田義正氏の博士論文として提出された