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Resumo Objetivo A sindrome de esmagamento e caracterizada por lesoes musculares traumaticas com graves repercussoes clinicas sistemicas. A reacao inflamatoria sistemica, caracterizada agudamente por infiltracao de neutrofilos nos pulmoes, tem sido estudada como parte do espectro da sindrome de esmagamento. A pesquisa experimental pode demonstrar opcoes de tratamento para a sindrome de esmagamento. Os autores estudaram a hipotese de que solucao salina hipertonica (NaCl 7,5%) pudesse minimizar os efeitos locais e sistemicos da sindrome de esmagamento em um modelo de compressao muscular e choque hemorragico. Metodos Coelhos foram submetidos a um novo modelo de compressao muscular associado ao choque hemorragico. A compressao foi feita por uma faixa de Esmarch aplicada por uma hora em todo membro inferior direito. O choque hemorragico foi induzido durante uma hora por disseccao e cateterizacao da arteria carotida. O choque foi tratado com reposicao de sangue ou solucao salina hipertonica. Foram feitas analises bioquimicas do plasma, quantificacao do edema muscular e infiltracao de celulas inflamatorias nos pulmoes. Resultados Os animais tratados com solucao hipertonica apresentaram a mesma resposta hemodinâmica observada naqueles tratados com sangue, menor quantidade de agua nos musculos comprimidos e menor infiltracao de celulas inflamatorias nos pulmoes. O grupo tratado com sangue apresentou hipocalcemia, caracteristica da sindrome de esmagamento. Conclusoes O modelo proposto mostrou‐se efetivo para o estudo da sindrome de esmagamento associada ao choque hemorragico. O tratamento com solucao hipertonica apresentou beneficios quando comparado com a reposicao volemica com sangue.

Antimicrobial peptides are an ancient family of molecules that emerged millions of years ago and have been strongly conserved during the evolutionary process of living organisms. Recently, our group described that the human antimicrobial peptide LL-37 migrates to the nucleus, raising the possibility that LL-37 could directly modulate transcription under certain conditions. Here, we showed evidence that LL-37 binds to gene promoter regions, and LL-37 gene silencing changed the transcriptional program of melanoma A375 cells genes associated with histone, metabolism, cellular stress, ubiquitination and mitochondria.

Purpose Intensive care unit (ICU) admission triage occurs frequently and often involves highly subjective decisions that may lead to potentially inappropriate ICU admissions. In this study, we evaluated the effect of implementing a decision-aid tool for ICU triage on ICU admission decisions. Methods This was a prospective, before-after study. Urgent ICU referrals to ten ICUs in a tertiary hospital in Brazil were assessed before and after the implementation of the decision-aid tool. Our primary outcome was the proportion of potentially inappropriate ICU referrals (defined as priority 4B or 5 referrals, accordingly to the Society of Critical Care Medicine guidelines of 1999 and 2016, respectively) admitted to the ICU within 48 h. We conducted multivariate analyses to adjust for potential confounders and evaluated the interaction between phase and triage priority. Results Of the 2201 patients analyzed, 1184 (53.8%) patients were admitted to the ICU. After adjustment for confounders, implementation of the decision-aid tool was associated with a reduction in potentially inappropriate ICU admissions using either the 1999 [adjOR (95% CI) = 0.36 (0.13–0.97)] or 2016 [adjOR (95%CI) = 0.35 (0.13–0.96)] definitions. Conclusion Implementation of a decision-aid tool for ICU triage was associated with a reduction in potentially inappropriate ICU admissions.

Objective: Crush syndrome is characterized by traumatic muscular injuries with severe systemic clinical repercussions. The systemic inflammatory reaction characterized acutely by infiltration of neutrophils in the lungs has been studied as part of the spectrum of crush syndrome. Experimental research may demonstrate alternative treatments for crush syndrome. The authors studied the hypothesis that hypertonic saline solution (7.5% NaCl) could minimize the local and systemic effects in a model of muscular compression and hemorrhagic shock. Methods: Rabbits were submitted to a new model of muscle compression associated with hemorrhagic shock. Compression was applied through an Esmarch bandage, used for 1 h on the entire right lower limb. Hemorrhagic shock was induced for 1 h by dissection and catheterization of the carotid artery. Blood replacement or hypertonic saline solution was used to treat the shock. Biochemical analysis of plasma, quantification of muscular edema, and infiltration of inflammatory cells in the lungs were carried out. Results: Animals treated with hypertonic solution presented the same hemodynamic response as the blood treated patients, less water in the compressed muscles and less infiltration of inflammatory cells in the lungs. The blood group presented hypocalcemia, a facet of crush syndrome. Conclusions: The proposed model was effective for the study of crush syndrome associated with hemorrhagic shock. The treatment with hypertonic solution showed benefits when compared with blood volume replacement. RESUMO Objetivo: A síndrome de esmagamento é caracterizada por lesões musculares traumáticas com graves repercussões clínicas sistêmicas. A reação inflamatória sistêmica, caracterizada agudamente por infiltração de neutrófilos nos pulmões, tem sido estudada como parte do espectro da síndrome de esmagamento. A pesquisa experimental pode demonstrar opções de tratamento para a síndrome de esmagamento. Os autores estudaram a hipótese de que solução salina hipertônica (NaCl 7,5%) pudesse minimizar os efeitos locais e sistêmicos da síndrome de esmagamento em um modelo de compressão muscular e choque hemorrágico. Métodos: Coelhos foram submetidos a um novo modelo de compressão muscular associado ao choque hemorrágico. A compressão foi feita por uma faixa de Esmarch aplicada por uma hora em todo membro inferior direito. O choque hemorrágico foi induzido durante uma hora por dissecção e cateterização da artéria carótida. O choque foi tratado com reposição de sangue ou solução salina hipertônica. Foram feitas análises bioquímicas do plasma, quantificação do edema muscular e infiltração de células inflamatórias nos pulmões. Resultados: Os animais tratados com solução hipertônica apresentaram a mesma resposta hemodinâmica observada naqueles tratados com sangue, menor quantidade de água nos músculos comprimidos e menor infiltração de células inflamatórias nos pulmões. O grupo tratado com sangue apresentou hipocalcemia, característica da síndrome de esmagamento. Conclusões: O modelo proposto mostrou-se efetivo para o estudo da síndrome de esmagamento associada ao choque hemorrágico. O tratamento com solução hipertônica apresentou benefícios quando comparado com a reposição volêmica com sangue.

Acute respiratory distress syndrome (ARDS) is the most severe lung inflammatory manifestation and has no effective therapy nowadays. Sepsis is one of the main illnesses among ARDS causes. The use of fluid resuscitation is an important treatment for sepsis, but positive fluid balance may induce pulmonary injury. As an alternative, fluid resuscitation with hypertonic saline ((HS) NaCl 7.5%) has been described as a promising therapeutical agent in sepsis-induced ARDS by the diminished amount of fluid necessary. Thus, we evaluated the effect of hypertonic saline in the treatment of LPS-induced ARDS. We found that hypertonic saline (NaCl 7.5%) treatment in rat model of LPS-induced ARDS avoided pulmonary function worsening and inhibited type I collagen deposition. In addition, hypertonic saline prevented pulmonary injury by decreasing metalloproteinase 9 (MMP-9) activity in tissue. Focal adhesion kinase (FAK) activation was reduced in HS group as well as neutrophil infiltration, NOS2 expression and NO content. Our study shows that fluid resuscitation with hypertonic saline decreases the progression of LPS-induced ARDS due to inhibition of pulmonary remodeling that is observed when regular saline is used.

ResumoObjetivosa lesão muscular por esmagamento (lesão por compressão muscular) está associada a manifestações sistêmicas conhecidas como síndrome do esmagamento. A reação inflamatória sistêmica pode também ser desencadeada pela lesão muscular isolada. O objetivo deste estudo foi investigar os níveis plasmáticos de interleucinas (IL) 1, 6, 10 e TNF‐α, marcadores de uma possível reação inflamatória sistêmica, após a lesão muscular isolada resultante da compressão de membros inferiores de ratos.Métodosratos Wistar machos foram submetidos a uma hora de compressão dos membros inferiores por uma faixa de borracha. Os níveis plasmáticos de IL 1, 6, 10 e TNF‐α foram medidos uma, duas e quatro horas após a liberação da compressão.Resultadosos níveis plasmáticos de IL 10 diminuíram quando comparados com outros grupos com diferença estatisticamente significante (p

Endotoxin tolerance is defined as a reduced capacity of the host to respond to LPS activation following a first exposure to this stimulus. It affects all leukocytes and regarding macrophages, most studies focus on the reduced ability of these cells to secrete pro-inflammatory cytokines. Therefore, we evaluated other macrophages functions (fungicidal capacity, reactive oxygen species production and antigen presentation) in cells from tolerant mice. We have performed a tolerance model in our laboratory that does not stimulate directly the place from where the cells will be removed (peritoneal cavity). Mouse received subcutaneous injections of LPS in the scruff for 5 days and we analyze the capacity of peritoneal macrophages to phagocyte using three different receptors: Fc, C3b and mannose receptors. We found a reduction in the phagocytosis of erythrocytes and Candida albicans related to the Fc and mannose receptors. These differences can be due to a macrophage reprogramming, as demonstrated by altered expression of cytokines and chemokines. Despite this reduction in phagocytosis capacity, macrophages from tolerant animals exhibited enhanced hydrogen peroxide production and expression of antigen presentation molecules, suggesting that their ability to combat an infection is improved. In summary, our data indicates that LPS tolerance drives macrophages from a predominant release of proinflammatory mediators that amplify inflammation and host damage toward a better killing and antigen presentation state.

Introduction: Hypocalcemia is a common and poorly understood finding in critically ill patients. The current study was designed to assess the association of ionized calcium, vitamin D, phosphorus and Parathyroid hormone levels in a cohort of patients with and without kidney dysfunction admitted for sepsis or non-infectious causes. Methods: Prospective cohort clinical and biochemical study. Results: We confirmed that hypocalcemia and hypovitaminosis D are a common finding in critically ill patients. Parathyroid hormone levels significantly rise in septic shock. In the recovery phase, however, despite persistent hypocalcemia, Parathyroid hormone levels abruptly decrease in patients with kidney dysfunction, but not in patients with normal renal function. Conclusions: The systemic inflammatory response syndrome probably leads to inappropriately high Parathyroid hormone levels during septic shock. In the recovery phase, Parathyroid hormone levels decrease, but calcium levels remain low, displaying evidence that the parathyroid is not responding as expected. Since Parathyroid hormone receptors and calcium-sensing receptors have been described in immune cells and other cell types, we propose that these effects may have a plethora of other deleterious effects, with important implications to the pathogenesis of septic shock.

Objective: The HLA haplotype has been associated with many autoimmune diseases, but no associations have been described in sepsis. This study aims to investigate the HLA system as a possible marker of genetic sepsis susceptibility. Methods: This is a prospective cohort study including patients admitted to an intensive care unit and healthy controls from a list of renal transplant donors. Patients with less 18 years of age; pregnant or HIV positive patients; those with metastatic malignancies or receiving chemotherapy; or with advanced liver disease; or with end-of-life conditions were excluded. The DNA was extracted from the whole blood and HLA haplotypes determined using MiliPlex® technology. Results: From October 2010 to October 2012, 1,121 patients were included (1,078 kidney donors, 20 patients admitted with severe sepsis and 23 with septic shock). HLA-A*31 positive subjects had increased risk of developing sepsis (OR 2.36, 95%CI 1.26-5.35). Considering a p value

Metabolic disturbances are quite common in critically ill patients. Glycemic control appears to be an important adjuvant therapy in such patients. In addition, disorders of lipid metabolism are associated with worse prognoses. The purpose of this study was to investigate the effects that two different glycemic control protocols have on lipid profile and metabolism. We evaluated 63 patients hospitalized for severe sepsis or septic shock, over the first 72 h of intensive care. Patients were randomly allocated to receive conservative glycemic control (target range 140–180 mg/dl) or intensive glycemic control (target range 80–110 mg/dl). Serum levels of low-density lipoprotein, high-density lipoprotein, triglycerides, total cholesterol, free fatty acids, and oxidized low-density lipoprotein were determined. In both groups, serum levels of low-density lipoprotein, high-density lipoprotein, and total cholesterol were below normal, whereas those of free fatty acids, triglycerides, and oxidized low-density lipoprotein were above normal. At 4 h after admission, free fatty acid levels were higher in the conservative group than in the intensive group, progressively decreasing in both groups until hour 48 and continuing to decrease until hour 72 only in the intensive group. Oxidized low-density lipoprotein levels were elevated in both groups throughout the study period. Free fatty acids respond to intensive glycemic control and, because of their high toxicity, can be a therapeutic target in patients with sepsis.

This study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU. Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians’ personal, professional and EOL educational characteristics. The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 ± 8 years, with a mean of 14 ± 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356–0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271–13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply “full code” had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012–0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122–0.361), P

Objective Liver failure can occur as a consequence of the systemic inflammation after acute pancreatitis. We assessed the effect of volume repositioning with hypertonic saline solution or normal saline on hepatic cytokine production and the expression of heat-shock proteins and apoptotic proteins after acute pancreatitis. Methods Wistar rats were divided in four groups: C - control animals that were not subjected to insult or treatment; NT - animals that were subjected to acute pancreatitis and received no treatment; normal saline - animals that were subjected to acute pancreatitis and received normal saline (NaCl 0.9%); and HS - animals that were subjected to acute pancreatitis and received hypertonic saline solution (NaCl 7.5%). Acute pancreatitis was induced by retrograde transduodenal infusion of 2.5% sodium taurocholate into the pancreatic duct. At 4, 12 and 24 h following acute pancreatitis induction, TNF-alpha, IL-1-beta, IL-6 and IL-10, caspase-2 and -7, Apaf-1, AIF and HSP60 and 90 were analyzed in the liver. Results Casp2 decreased in the normal saline and hypertonic saline groups (p

Laser phototherapy emerges as an alternative or auxiliary therapy for acute ischemic stroke, traumatic brain injury, degenerative brain disease, spinal cord injury, and peripheral nerve regeneration, but its effects are still controversial. We have previously found that laser phototherapy immunomodulates the response to focal brain damage. Following direct cortical cryogenic injury the effects of laser phototherapy on inflammation and repair was assessed after cryogenic injury (CI) to the central nervous system (CNS) of rats. The laser phototherapy was carried out with a 780 nm AlGaAs diode laser. The irradiation parameters were: power of 40 mW, beam area of 0.04 cm(2), energy density of 3 J/cm(2) (3s) in two points (0.12 J per point). Two irradiations were performed at 3 h-intervals, in contact mode. Rats (20 non-irradiated - controls and 20 irradiated) were used. The wound healing in the CNS was followed in 6 h, 1, 7 and 14 days after the last irradiation. The size of the lesions, the neuron cell viability percentages and the amount of positive GFAP labeling were statistically compared by ANOVA complemented by Tukey's test (p

Sepsis syndrome is caused by inappropriate immune activation due to bacteria and bacterial components released during infection. This syndrome is the leading cause of death in intensive care units. Specialized B-lymphocytes located in the peritoneal and pleural cavities are known as B-1 cells. These cells produce IgM and IL-10, both of which are potent regulators of cell-mediated immunity. It has been suggested that B-1 cells modulate the systemic inflammatory response in sepsis. In this study, we conducted in vitro and in vivo experiments in order to investigate a putative role of B-1 cells in a murine model of LPS-induced sepsis. Macrophages and B-1 cells were studied in monocultures and in co-cultures. The B-1 cells produced the anti-inflammatory cytokine IL-10 in response to LPS. In the B-1 cell-macrophage co-cultures, production of proinflammatory mediators (TNF-α, IL-6 and nitrite) was lower than in the macrophage monocultures, whereas that of IL-10 was higher in the co-cultures. Co-culture of B-1 IL-10(-/-) cells and macrophages did not reduce the production of the proinflammatory mediators (TNF-α, IL-6 and nitrite). After LPS injection, the mortality rate was higher among Balb/Xid mice, which are B-1 cell deficient, than among wild-type mice (65.0% vs. 0.0%). The Balb/Xid mice also presented a proinflammatory profile of TNF-α, IL-6 and nitrite, as well as lower levels of IL-10. In the early phase of LPS stimulation, B-1 cells modulate the macrophage inflammatory response, and the main molecular pathway of that modulation is based on IL-10-mediated intracellular signaling.

OBJECTIVES: In this study, we tested the hypothesis that hypertonic saline exerts anti-inflammatory effects by modulating hepatic oxidative stress in pancreatitis. INTRODUCTION: The incidence of hepatic injury is related to severe pancreatitis, and hypertonic saline reduces pancreatic injury and mortality in pancreatitis. METHODS: Wistar rats were divided into four groups: control (not subjected to treatment), untreated pancreatitis (NT, pancreatitis induced by a retrograde transduodenal infusion of 2.5% sodium taurocholate into the pancreatic duct with no further treatment administered), pancreatitis with normal saline (NS, pancreatitis induced as described above and followed by resuscitation with 0.9% NaCl), and pancreatitis with hypertonic saline (HS, pancreatitis induced as described above and followed by resuscitation with 7.5% NaCl). At 4, 12, and 24 h after pancreatitis induction, liver levels of inducible nitric oxide synthase (iNOS), heat-shock protein 70, nitrotyrosine (formation of peroxynitrite), nitrite/nitrate production, lipid peroxidation, and alanine aminotransferase (ALT) release were determined. RESULTS: Twelve hours after pancreatitis induction, animals in the HS group presented significantly lower iNOS expression (P

Sepsis induces a systemic inflammatory response leading to tissue damage and cell death. LPS tolerance affects inflammatory response. To comprehend potential new mechanisms of immune regulation in endotoxemia, we examined macrophage mRNA expression by macroarray affected by LPS tolerance. LPS tolerance was induced with subcutaneous administration of 1 mg/kg/day of LPS over 5 days. Macrophages were isolated from the spleen and the expression of 1200 genes was quantitatively analyzed by the macroarray technique. The tolerant group displayed relevant changes in the expression of 84 mRNA when compared to naïve mice. A functional group of genes related to cell death regulation was identified. PARP-1, caspase 3, FASL and TRAIL genes were confirmed by RT-PCR to present lower expression in tolerant mice. In addition, reduced expression of the pro-inflammatory genes TNF-α and IFN-γ in the tolerant group was demonstrated. Following this, animals were challenged with polymicrobial sepsis. Flow cytometry analysis showed reduced necrosis and apoptosis in macrophages from the tolerant group compared to the naïve group. Finally, a survival study showed a significant reduction in mortality in the tolerant group. Thus, in the current study we provide evidence for the selective reprogramming of the gene expression of cell death pathways during LPS tolerance and link these changes to protection from cell death and enhanced survival rates.

Extensive lymphocyte apoptosis may be an important cause of immune suppression in sepsis. Here we investigated the effect of LPS tolerance on lymphocyte apoptosis in an experimental model of polymicrobial infection. Tolerance was induced by the injection of lipopolysaccharide (1.0mg/kg/subcutaneously) once a day for 5 days. Macroarray analysis of mRNA isolated from T-(CD4) lymphocytes was used to identify genes that are differentially expressed during LPS tolerance. In addition, assessment of the expression of apoptosis-associated lymphocyte gene products and apoptotic events was performed on the 8th day; 6h after the terminal challenge with polymicrobial infection or high-dose LPS administration. Survival studies with polymicrobial infection were also conducted. LPS tolerance induced a broad reprogramming of cell death pathways, including a suppression of receptor-mediated and mitochondrial apoptotic pathways, inflammatory caspases, alternate apoptotic pathways, as well as reduced expression of genes involved in necrosis. These alterations led to a marked resistance of lymphocytes against cell death during the subsequent period of sepsis. In addition, LPS tolerance produced an increased differentiation of T-lymphocytes to T(H)1 and T(H)2, with a T(H)1 differentiation predominance. Thus, in the current study we provide an evidence for a marked reprogramming of gene expression of multiple cell death pathways during LPS tolerance. These alterations may play a significant role in the observed protection of the animals from a subsequent lethal polymicrobial sepsis challenge.

Signal transduction through the surface molecule CD40 is critical for cellular activation in immunoinflammatory states such as sepsis. The mechanisms regulating this pathway are not completely understood. Because CD40 displays potentially regulatory cysteine residues and CD40 is probably exposed to NO in the inflammatory milieu, we hypothesized that S-nitrosylation, the interaction of NO with cysteines residues, acts as a post-translational modification on CD40, coregulating the signaling activity and, therefore, the level of cellular activation. As assessed by the biotin switch and the reduction/chemiluminescence S-nitrosylation detection techniques, CD40 was found to be S-nitrosylated endogenously and upon exposure to NO donors in both human and murine macrophages. S-nitrosylation of CD40 was associated with milder activation by its ligand (CD40L), leading to reduced in vitro cytokine (IL-1beta, IL-12, and TNF-alpha) production, which was reversed in the presence of inhibitors of NO synthesis. S-nitrosylated CD40 was found in resting RAW 246.7 macrophages and BALB/c mice peritoneal macrophages, turning into the denitrosylated state upon in vitro or systemic exposure, respectively, to LPS. Moreover, monocytes from patients with sepsis displayed denitrosylated CD40 in contrast to the CD40 S-nitrosylation measured in healthy individuals. Finally, in an attempt to explain how S-nitrosylation regulates CD40 activation, we demonstrate that NO affects the redistribution of CD40 on the cell surface, which is a requirement for optimal signal transduction. Our results support a novel post-translational regulatory mechanism in which the CD40 signal may be, at least in part, dependent on cellular activation-induced receptor denitrosylation.

A ventilação mecânica é uma terapia importante, mas pode resultar em complicações. Uma das mais relevantes é a lesão pulmonar induzida por ventilador. Devido à hiperdistensão alveolar, o pulmão inicia um processo inflamatório, com infiltrado neutrofílico, formação de membrana hialina, fibrogênese e prejuízo de troca gasosa. Nesse processo, a mecanotransdução da hiperdistensão celular é mediada através do citoesqueleto da célula e de suas interações com a matriz extracelular e com as células vizinhas, de modo que o estímulo mecânico da ventilação se traduz em sinalização bioquímica intracelular, desencadeando ativação endotelial, permeabilidade vascular pulmonar, quimiotaxia leucocitária, produção de citocinas e, possivelmente, lesão de órgãos à distância. Estudos clínicos demonstram essa relação entre distensão pulmonar e mortalidade em pacientes com lesão pulmonar induzida por ventilador. Entretanto, apesar de o citoesqueleto ter um papel fundamental na patogênese da lesão pulmonar induzida por ventilador, a literatura carece de estudos utilizando modelos in vivo sobre as alterações do citoesqueleto e de suas proteínas associadas durante esse processo patológico. Although mechanical ventilation is an important therapy, it can result in complications. One major complication is ventilator-induced lung injury, which is caused by alveolar hyperdistension, leading to an inflammatory process, with neutrophilic infiltration, hyaline membrane formation, fibrogenesis and impaired gas exchange. In this process, cellular mechanotransduction of the overstretching stimulus is mediated by means of the cytoskeleton and its cell-cell and cell-extracellular matrix interactions, in such a way that the mechanical stimulus of ventilation is translated into an intracellular biochemical signal, inducing endothelial activation, pulmonary vascular permeability, leukocyte chemotaxis, cytokine production and, possibly, distal organ failure. Clinical studies have shown the relationship between pulmonary distension and mortality in patients with ventilator-induced lung injury. However, although the cytoskeleton plays a fundamental role in the pathogenesis of ventilator-induced lung injury, there have been few in vivo studies of alterations in the cytoskeleton and in cytoskeleton-associated proteins during this pathological process.

Shock and resuscitation render patients more susceptible to acute lung injury due to an exacerbated immune response to subsequent inflammatory stimuli. To study the role of innate immunity in this situation, we investigated acute lung injury in an experimental model of ischemia-reperfusion (I-R) followed by an early challenge with live bacteria. Conscious rats (N = 8 in each group) were submitted to controlled hemorrhage and resuscitated with isotonic saline (SS, 0.9% NaCl) or hypertonic saline (HS, 7.5% NaCl) solution, followed by intratracheal or intraperitoneal inoculation of Escherichia coli. After infection, toll-like receptor (TLR) 2 and 4 mRNA expression was monitored by RT-PCR in infected tissues. Plasma levels of tumor necrosis factor alpha and interleukins 6 and 10 were determined by ELISA. All animals showed similar hemodynamic variables, with mean arterial pressure decreasing to nearly 40 mmHg after bleeding. HS or SS used as resuscitation fluid yielded equal hemodynamic results. Intratracheal E. coli inoculation per se induced a marked neutrophil infiltration in septa and inside the alveoli, while intraperitoneal inoculation-associated neutrophils and edema were restricted to the interseptal space. Previous I-R enhanced lung neutrophil infiltration upon bacterial challenge when SS was used as reperfusion fluid, whereas neutrophil influx was unchanged in HS-treated animals. No difference in TLR expression or cytokine secretion was detected between groups receiving HS or SS. We conclude that HS is effective in reducing the early inflammatory response to infection after I-R, and that this phenomenon is achieved by modulation of factors other than expression of innate immunity components.

Objectives: Acute pancreatitis (AP) protease release induces lung parenchymal destruction via matrix metalloproteinases (MMPs), a neutrophil (polymorphonuclear leukocyte)-dependent process. Recent studies in hemorrhagic shock revealed that hypertonic saline (HTS) has an anti-inflammatory effect and can inhibit a variety of neutrophil functions. The aim of this study was to determine whether HTS and its actions in the pathway of neutrophil migration, MMPs, and heat shock proteins (HSPs) are effective in protecting the lung from injury associated with AP. Methods: We determined neutrophil infiltration and expressions of MMPs and HSPs in the lung tissue after AP induced by retrograde infusion of 2.5% of sodium taurocholate. Results: Animals submitted to AP that received HTS compared with those who received normal saline presented with increased HSP70 and HSP90 expressions and reduced myeloperoxidase levels and MMP-9 expression and activity. Conclusions: Our data raised the hypothesis that a sequence of HTS lung protection events increases HSP70 and HSP90, inhibiting infiltration of neutrophils and their protease actions in the lung.

Background Obesity is associated with increased sympathetic activity and higher mortality. Treatment of this condition is often frustrating. Roux-en-Y gastric bypass is the most effective technique nowadays for treatment of obesity. The aim of the present study is to assess the effects of this surgery on the cardiac autonomic activity, including the influence of gender and age, through heart rate variability (HRV) analysis. Methods The study group consisted of 71 obese patients undergoing gastric bypass. Time domain measures of HRV, obtained from 24-h Holter recordings, were evaluated before and 6 months after surgery, and the results were compared. Percentage of interval differences of successive normal sinus beats greater than 50 ms (pNN50) and square root of the mean squared differences of successive normal sinus beat intervals (rMSSD) was used to estimate the short-term components of HRV, related to the parasympathetic activity. Standard deviation of intervals between all normal sinus beats (SDNN) was related to overall HRV. Results SDNN, pNN50, and rMSSD showed significant increase 6 months after surgery (p

Hypertonic saline solution (HS solution, NaCl 7.5%) has shown to restore hemodynamic parameters in hemorrhagic shock and to decrease the inflammation triggered by ischemia-reperfusion injury (I-R). Therefore, our objective was to investigate the effects of HS solution on the mechanisms involved in I-R, in an experimental model of controlled hemorrhagic shock. Wistar rats (280-350 g) were submitted to controlled bleeding, keeping the mean arterial pressure around 40 mmHg, for 1 h. After that, rats were randomized and treated with HS solution (4 mL/kg) or normal saline (34 mL/kg). There were no differences in hemodynamic parameters between both groups for at least 2 h after shock. No difference either was observed in reactive oxygen species generation (measured indirectly by malondialdehyde concentration) or cytokines (interleukins 6 and 10) production (measured by enzyme-linked immunosorbent assay). Quantitative analysis of lung tissue showed a smaller neutrophil infiltration in animals that received HS solution. Moreover, the animals in the HS group showed an increased expression of heat shock protein 70. Therefore, we concluded that treatment of hemorrhagic shock with HS solution can decrease pulmonary inflammation and increase cellular protection by up-regulating heat shock protein 70 expression.

Acute lung injury (ALI) is a common complication associated with septic shock that directly influences the prognosis of sepsis patients. Currently, one of the main supportive treatment modalities for septic shock is fluid resuscitation. The use of hypertonic saline (HS: 7.5% NaCl) for fluid resuscitation has been described as a promising therapy in experimental models of sepsis-induced ALI, but it has failed to produce similar results in clinical practice. Thus, we compared experimental timing versus clinical timing effectiveness (i.e., early vs. late fluid resuscitation) after the inflammatory scenario was established in a rat model of bacterial lipopolysaccharide-induced ALI. We found that late fluid resuscitation with hypertonic saline (NaCl 7.5%) did not reduce the mortality rates of animals compared with the mortality late associated with early treatment. Late fluid resuscitation with both hypertonic and normal saline increased pulmonary inflammation, decreased pulmonary function, and induced pulmonary injury by elevating metalloproteinase-2 and metalloproteinase-9 activity and collagen deposition in the animals, unlike early treatment. The animals with lipopolysaccharide-induced ALI that received late resuscitation with any kind of fluids demonstrated aggravated pulmonary injury and respiratory function. Moreover, we showed that the therapeutic window for a beneficial effect of fluid resuscitation with hypertonic saline is very narrow.

Sepsis is a devastating disease that can affect humans at any time between neonates and the elderly and is associated with mortality rates that range from 30 to 80%. Despite intensive efforts, its treatment has remained the same over the last few decades. Fc receptors regulate multiple immune responses and have been investigated in diverse complex diseases. FcγRIIA (CD32A) is an immunoreceptor, tyrosine-based activation motif-bearing receptor that binds immunoglobulin G and C-reactive protein, important opsonins in host defense. We conducted a study of 702 patients (184 healthy individuals, 171 non-infected critically ill patients, and 347 sepsis patients) to investigate if genetic polymorphisms in the CD32A coding region affect the risk of septic shock. All individuals were genotyped for a variant at position 131 of the FcγRIIA gene. We found that allele G, associated with the R131 genotype, was significantly more frequent in septic patients than in the other groups (p = 0.05). Our data indicate that FcγRIIA genotyping can be used as a marker of genetic susceptibility to sepsis.

Introduction: An ischemic stroke is a clinical condition that affects thousands of people worldwide. As a result of this injury, neuronal death can be observed, and in the natural course of recovery, the individual may develop sepsis. Sepsis is a systemic inflammatory response that can lead the patient to death. To assess the clinical condition of a patient with this condition, the Auditory Brainstem Response (ABR) can be useful, since it is not an invasive procedure, it is a fast technique and it can be done at the bedside. Purpose: To assess auditory brainstem response (ABR) latency values in gerbils subjected to ischemia and sepsis. Methods: ABR values were collected from 72 adult male gerbils, which were divided into six groups: control, sepsis, ischemia, sham, ischemia with sepsis, and sham with sepsis. For the induction of sepsis, lipopolysaccharide (LPS) was applied intraperitoneally in gerbils. The animals were anesthetized with a ketamine/xylazine combination before collection; their ABR were collected before any procedure (base collection), after ischemia, and 24 hours after the application of LPS. The absolute latency of wave IV was evaluated, and the values were compared between groups. Results: There were significant differences in the groups submitted to sepsis in the latency value of wave IV in relation with the other groups. Conclusion: ABR was sensitive to sepsis with the increase in latency of wave IV during the development of the disease in the experimental model used. Introdução: O acidente vascular cerebral do tipo isquêmico é um quadro clínico que afeta milhares de pessoas no mundo. Como resultado dessa injúria observamos morte neuronal, e no decorrer natural de recuperação o indivíduo pode desenvolver a sepse. A sepse é uma resposta inflamatória sistêmica que pode levar o indivíduo à morte. Para avaliar as condições clínicas de um paciente com esse quadro, o potencial evocado auditivo de tronco encefálico (PEATE) pode ser útil, uma vez que ele não é um procedimento invasivo, sua técnica é rápida e pode ser feita à beira do leito. Objetivo: Verificar os valores de latência do PEATE em gerbils submetidos à isquemia e sepse. Métodos: Foram coletados os PEATEs de 72 gerbils machos adultos que foram distribuídos em 6 grupos: controle, sepse, isquemia, sham, isquemia com sepse e sham com sepse. Para a indução de sepse, foi aplicado lipopolissacarídeo (LPS) intraperitoneal nos gerbils. Os animais foram anestesiados antes das coletas com ketamina associada à xilazina, seus PEATEs foram coletados antes de qualquer procedimento (coleta base), após isquemia e 24 horas após a aplicação de LPS. Foi avaliada a latência absoluta da onda IV, e os valores foram comparados intergrupos. Resultados: Houve diferença significativa nos grupos submetidos à sepse no valor da latência da onda IV em relação aos demais grupos. Conclusão: O PEATE se mostrou sensível à sepse com aumento de latência da onda IV no desenvolver da doença no modelo experimental utilizado.

A matched case-control study was carried out at a Brazilian academic medical emergency department to identify the occurrence of adverse events (AEs) in patients with community- acquired pneumonia (CAP) and disclose their association with in- hospital death. The cases comprised 101 consecutive deaths and the controls 101 discharged patients admitted for CAP from March 1996 to September 1999. Adverse events were classified according to severity, potential causes, the occurrence of nosocomial in- fections, and the related professional category. A total of 603 AEs were identified, predominating among the deceased patients: 456 events (75.6%) in 85 cases and 147 (24.4%) in 55 controls. Severe AEs also predominated among the cases. Procedures and nursing activities were the main AE-related potential causes. The oc- currence of at least 1 AE was associated with a higher risk of death (3.25-fold). This association was stronger when either severe AEs (8.37-fold) or medical AEs (4.23-fold) were analyzed. (Infect Dis Clin Pract 2006;14:350- 359)

A solução hipertônica de cloreto de sódio 7,5% (SSH) é eficaz em restaurar os parâmetros hemodinâmicos e reduzir a inflamação em modelos experimentais de choque hemorrágico. Assim, foi nosso objetivo investigar a ação da SSH sobre os mecanismos envolvidos na lesão de isquemia e reperfusão (I/R) em um modelo de choque hemorrágico controlado. Ratos Wistar (280-350 g) foram submetidos à hemorragia controlada, mantendo-se a pressão arterial média em 40 mmHg por 1 h. Após esse período, os animais foram randomizados e receberam SSH (4 ml/kg) ou solução salina isotônica (SSI-34 ml/kg). Não foram observadas diferenças na resposta hemodinâmica nos dois grupos. Também não foram observadas diferenças na geração espécies reativas de oxigênio (medida indiretamente pela concentração de malondialdeído) ou das citocinas IL-6 e IL-10 (medidas por ELISA). A análise histológica qualitativa dos pulmões mostrou que os animais do grupo SSH apresentaram um menor influxo tecidual de neutrófilos. Esses animais também mostraram maior expressão de proteínas do choque térmico 70 (HSP70). Assim, concluímos que o tratamento do choque hemorrágico com SSH pode diminuir o processo inflamatório pulmonar e aumentar a proteção celular, devido ao aumento da expressão de HSP70.

Severe acute pancreatitis (AP) is characterized by hemodynamic alterations and a systemic inflammatory response, leading to a high mortality rate. Treatment of hemorrhagic shock with hypertonic saline solutions significantly reduces mortality through an improvement in the hemodynamic conditions and possibly by an anti-inflammatory effect. Therefore, hypertonic solutions could be effective in AP.Wistar rats were divided in 4 groups: group C, control, without AP; group NT, AP, without treatment; group NS, treatment with normal saline solution (NaCl 0.9%) 1 hour after AP; group HTS, treatment with hypertonic saline solution (NaCl 7.5%) 1 hour after AP. AP was induced by injection of 2.5% sodium taurocholate into the pancreatic duct. Mean arterial blood pressure (MAP) and heart rate were recorded at 0 and 2, 4, 24, and 48 hours after AP. After induction of AP, animals were killed at 2, 12, 24, and 48 hours for serum amylase, interleukin (IL)-6, and IL-10 analysis, pancreatic tissue culture and histologic analysis, oxidation and phosphorylation of liver mitochondria, pulmonary myeloperoxidase activity (MPO), and mortality study.In animals of groups NS and NT, a significant decrease of MAP was observed 48 hours after AP (NS: 91 +/- 3 mm Hg; NT: 89 +/- 3 mm Hg) compared with baseline (C: 105 +/- 2 mm Hg) and to HTS group (HTS: 102 +/- 2 mm Hg; P0.05). In animals of group NT, NS, and HTS, serum IL-6 and IL-10 levels were significantly higher at 2 hours after AP compared with the control group. However, IL-6 levels at 12 hours after AP and IL-10 levels at 2 and 12 hours after AP were significant lower in group HTS compared with NS and NT groups (P0.05). In group HTS, a decrease of pulmonary MPO activity and of pancreatic infection was observed 24 hours after AP compared with NT and NS groups (P0.05). A significant reduction on pancreatic acinar necrosis and mitochondrial dysfunction was observed after 48 hours of AP in animals of group HTS compared with groups NT and NS (P0.05). A significant reduction on mortality was observed in HTS (0/14) compared with NS (6/17; 35%) and NT (7/20; 35%).The administration of hypertonic saline solution in experimental AP attenuated hemodynamic alterations, decreased inflammatory cytokines, diminished systemic lesions and pancreatic acinar necrosis, prevented pancreatic infection, and reduced the mortality rate.

Objective: To describe the clinical features as well as morbidity and mortality of elderly patients submitted to coronary artery bypass graft (CABG). Design: Randomized, single-center, observational study. Methods: A prospective study was carried out in a tertiary referral teaching hospital (Heart Institute-Brazil). A total of 220 inpatients submitted to elective CABG were evaluated and data collected from the pre-, intra- and postoperative periods. Instruments: The patients were assessed according to the Geriatric Depression Scale. A diagnosis of delirium was determined according to DSM-IV criteria. Results: Of these 220 patients 64.5% were males and 35.5% females. The mean age was 71 years. The most important preoperative findings were a higher incidence of comorbidities such as hypertension (73%), diabetes mellitus (35%), dyslipidemia (27%), and previous myocardial infarction (41%).The majority of patients were found to have three or more vessels obstructed at angiography (74%). The major intraoperative findings were that a high number of the patients received more than 3 grafts (74%). A large proportion (72%) of patients needed a blood transfusion and the overall incidence of clinical complications was 33%. The overall postoperative mortality rate for this observational study was 5%. A large number of patients presented complications (56%) such as hypotension (22%), atrial fibrillation (22%), and delirium (34%). Conclusions: Although elderly patients have a somewhat increased, however acceptable, operative mortality rate, we believe that this patient group can benefit from CABG.

Objective: To investigate the risk factors for delirium in the elderly during the post-operative period of coronary artery bypass graft surgery (CABG).Methods: A total of 220 inpatients submitted to CABG were evaluated prior to and after surgery. In order to investigate the possible risk factors, data were collected from pre-intra- and post-operative periods.Instruments: The patients were assessed using the Mini-mental State Examination and to the Geriatric Depression Scale. The diagnosis of delirium was determined according to DSM-IV criteria.Results: Delirium was detected in 74 (33.6%) patients. Increasing age, blood urea level, cardio-thoracic index, hypertension, smoking habits, blood replacement during bypass, atrial fibrillation (AF), pneumonia and blood balance in the post-operative period were the risk factors for delirium selected by the logistic regression analysis. No specific factor associated with the CABG (perfusion pressure, number of grafts) was correlated with an increased risk for delirium post-operatively. The length of stay was twice as long in the delirious group (pConclusions: Delirium in the elderly after CABG is a multifactorial disorder. Nine factors taken together can identify patients at great risk for delirium. No specific factor associated with bypass procedure could be identified as a risk factor for delirium. The control of the risk factors should bring a decrease in delirium morbidity and mortality.

Sepsis is one of the highest causes of mortality in hospitalized people and a common complication in both surgical and clinical patients admitted to hospital for non-infectious reasons. Sepsis is especially common in older people and its incidence is likely to increase substantially as a population ages. Despite its increased prevalence and mortality in older people, immune responses in the elderly during septic shock appear similar to that in younger patients. The purpose of this study was to conduct a genome-wide gene expression analysis of circulating neutrophils from old and young septic patients to better understand how aged individuals respond to severe infectious insult. We detected several genes whose expression could be used to differentiate immune responses of the elderly from those of young people, including genes related to oxidative phosphorylation, mitochondrial dysfunction and TGF-β signaling, among others. Our results identify major molecular pathways that are particularly affected in the elderly during sepsis, which might have a pivotal role in worsening clinical outcomes compared with young people with sepsis.

The objective of this randomized animal study and laboratory investigation was to investigate whether lipopolysaccharide tolerance redirects neutrophil migration between organs. Male BALB/c mice received subcutaneous injections of lipopolysaccharide (1 mg/kg) for 5 days, followed by cecal ligation and puncture (CLP). Cytokines and adhesion molecules were measured after tolerance and CLP challenge. Increased numbers of neutrophils were observed in the peritoneal cavity of tolerant mice, which was associated with increased levels of adhesion molecules and chemokines. In contrast, nontolerant mice accumulated higher numbers of neutrophils in the lungs compared with those in the peritoneal cavity. Neutrophil function accessed by hydrogen peroxide production from neutrophils recovered from peritoneal cavity showed that tolerance increased the capacity to produce hydrogen peroxide. Mortality was reduced in tolerant animals. This study demonstrated that tolerance reduces leukocyte accumulation in the lung after CLP by redirecting neutrophils to the site of infection.

Objetivo: Investigar o papel de duas diferentes solucoes salinas nos mecanismos de lesao apos isquemia intestinal: estresse oxidativo e respostas inflamatorias. Metodos: Ratos Wistar foram submetidos a oclusao transitoria da arteria mesenterica superior e estudados durante as 6 horas seguintes a reperfusao. Apos randomizacao, os animais foram divididos em quatro grupos: Falso; Solucao Hipertonica, os quais receberam infusao de solucao salina hipertonica a 7,5% (4mL/kg de peso corporeo); Solucao Fisiologica, os quais receberam infusao de solucao salina a 0,9% (33mL/kg); e Sem Tratamento. A infusao foi realizada imediatamente antes da reperfusao. Foram realizadas dosagens sequenciais de interleucina 6 e interleucina 10 no plasma. Foram coletadas amostras de tecidos (pulmao, figado e intestino) para medir malondialdeido, mieloperoxidase e interleucina. Resultados: Em comparacao ao Grupo Sem Tratamento, os animais que receberam volume (Grupos Solucao Hipertonica e Solucao Fisiologica) mostraram niveis tissulares mais baixos de malondialdeido, mieloperoxidase, interleucina 6 e interleucina 10. As concentracoes plasmaticas de interleucina 6 e interleucina 10 foram mais altas nos animais tratados com solucao hipertonica do que nos tratados com solucao fisiologica e nos sem tratamento. Conclusao: Neste modelo de isquemia intestinal transitoria, a manutencao adequada de volume intravascular diminuiu o estresse oxidativo e a sintese de marcadores de inflamacao. Tanto a solucao hipertonica quanto a fisiologica atenuaram os efeitos deleterios observados apos isquemia intestinal.