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Background The aim of the present study was to compare the experience elderly and younger patients in terms of emotional status, disease perception, methods of coping with the end-stage renal disease (ESRD) stress, and health-related quality of life in 2 different settings of renal replacement therapy: hemodialysis (HD) and continuous ambulatory peritoneal dialysis programs (CAPD). Specifically, we hypothesized that younger people will more frequently use goal-oriented strategies to cope with illness-related stress and elderly patients will use more strategies related to the control of emotion. Material and methods A total of 69 HD patients, 40 CAPD patients, and 89 healthy volunteers were analyzed. The Situation and Trait Anxiety Inventory, the Profile of Mood States, the Cognitive Stress Appraisal Questionnaire, and the Nottingham Health Profile were used to assess anxiety, long-term emotional status, coping mechanisms, and health-related quality of life. Data were collected on several biochemical and demographic variables. Results Our study revealed that younger and elderly people on dialysis faced quite different problems. Younger people in both RRT groups had statistically higher assessment of ESRD as loss or challenge and they more frequently used distractive and emotional preoccupation coping strategies. Depression, confusion, and bewilderment dominate the emotional status of both patient populations, especially in the younger cohort. Both HD(young) and CAPD(young) patients complained more about lack of energy, mobility limitations, and sleep disturbances as compared to their elderly HD and CAPD counterparts. Conclusions There are different needs and problems in younger and elderly patients on renal replacement therapy. Younger people required more ESRD-oriented support to relieve their health-related complaints to the level observed in their peers and needed extensive psychological assistance in order to cope with negative emotions related to their disease.

Alongside the known direct, short-term effects of anesthesia in general, there is emerging evidence of an immunomodulatory effect with specific anesthetics that may decrease patient’s defences against malignant neoplastic growths. This effect is especially important in the setting of surgical management of neoplasms, which is often the best option for long-term survival in patients with solid neoplasm. Many studies have speculated on the best anesthetic technique to reduce the neoplasm recurrence and promote patient survival, however, we often neglect the sympathetic stress response to neoplasia and how anesthetics modulate this effect. In this review, we study the evidence as it pertains to anesthetic techniques and pain control, particularly general vs. regional anesthesia, and opioid analgesia. At this time there is not enough evidence to support that regional anesthesia has a more favorable outcome than general anesthesia, or that opioids should not be used in neoplasm-related pain management because of their potential pro-metastatic properties secondary to opioid-induced immunosuppression. Instead, the debate over anesthetic use should be centered on adequate pain control since overwhelming evidence have shown that pain-related stress reaction mediated via β-adrenergic activation, promotes neoplastic propagation and metastasis, hence decreasing survival rates.

Patients with end stage renal disease (ESRD) suffer from many disturbances of the immune system. These immunopathologies are related to the higher failure of vaccination, and increased prevalence of infections and neoplasms. In the presented article, we review the current data regarding the role of monocytes in immune dysfunctions which are observed in terminal renal failure. As monocytes play a pivotal role in regulating the function of the immune system, their dysfunction can have a profound effect on the immune system and may lead to accelerated arteriosclerosis and deteriorating overall health conditions. More specifically, we suggest that peripheral blood monocytes in patients with ESRD are chronically activated, and their functional and phenotypical features resemble those of inflammatory macrophages. This state of chronic inflammation is unfavorable for dendritic cells and consequently, the prevalence of dendritic cells is reduced. As these effects are consistent across different modes of dialysis, they are probably mediated by the uremia itself.

Myocardial ischemia in pregnancy poses a significant challenge for the anesthesiologist. It is a relatively rare disorder (approximately 180 cases published in the indexed literature since 1922) but it carries high mortality. Diagnosis is frequently hampered by diminished sensitivity of several testing modalities conventionally used to diagnose myocardial ischemia. The etiology of cardiac ischemia also is multifactorial and occurs during a very dynamic period. A case of acute coronary syndrome in a parturient during urgent cesarean delivery for placental abruption is presented, followed by a brief review of the topic.

Fire in the operating room is a rare but potentially devastating event. In this case report, we describe 2 separate fires of a Westmed heated humidification circuit. We conducted a detailed analysis of potential causes of the fires, including a simulation and series of experiments. Our conclusions were (1) a combination of factors led to the fires; and (2) substantial changes in the design could decrease, but may not completely eliminate, the risk of operating room fire.

Sepsis, a syndrome characterized by systemic inflammation during infection, continues to be one of the most common causes of patient mortality in hospitals across the United States. While standardized treatment protocols have been implemented, wide variability in clinical outcomes persist across racial groups. Specifically, Black and Hispanic populations are frequently associated with higher rates of morbidity and mortality in sepsis compared to the Caucasian population. While this is often attributed to systemic bias against minority groups, a growing body of literature has found patient, community, and hospital-based factors to be driving racial differences. In this article, we provide a focused review on some of the factors driving racial disparities in sepsis. We also suggest potential interventions aimed at reducing health disparities in the prevention, early identification, and clinical management of sepsis.

Psycho logical aspects of renal replacement therapy have been studied by numerous researchers. However, many of these studies are of poor quality, involve small study groups, or focus only on a narrowly defined hypothesis. Due to a lack of general conceptual framework, it is difficult to generalize and inter pret the data, especially in terms of the cause-and-effect relationship. Further research is required to assess how patients with end-stage renal disease cope with dialysis-related stress. Particular emphasis should be placed on the preparation of experimental studies and clinical trials with a longer follow-up.

Background It is a struggle to identify the most adaptive coping strategies with disease-mediated stress. Here, we hypothesize that intensity of coping strategies, including denial, in patients with end-stage renal disease (ESRD), varies with type of renal replacement therapy (RRT). Material and methods We enrolled 60 in-center hemodialyzed patients (HD) and 55 patients treated with continuous ambulatory peritoneal dialysis (CAPD). We administered the Coping Inventory with Stressful Situation, Profile of Mood States, and Stroop Anxiety Inventory to measure patient coping strategies in the context of their ESRD. Denial defense mechanism was measured via the IBS-R/ED. The Nottingham Health Profile was used to evaluate self-perceived quality of life. Serum potassium, urea, creatinine, phosphorus, calcium, albumin, and hematocrit were utilized as the measurements of adequacy of dialysis. Results HD patients had higher self-reported intensity of denial mechanism and avoidance-oriented strategies versus CAPD patients. Because a single strategy is almost never employed, we conducted cluster analysis. We identify 3 patterns of coping strategies using cluster analysis. "Repressors" employed denial and avoidance strategies and were predominant in HD. The second cluster consists of subjects employing predominantly task-oriented strategies with equal distribution among dialyzed patients. The third cluster encompassed a small group of patients who shared higher intensity of both denial and task-oriented strategies. Health-related outcome, anxiety, and mood profile were similar across all patients. Conclusions HD patients predominantly used "repressive" strategies. Patients on RRT utilized denial and avoidance-based strategies to achieve satisfactory outcome in terms of perceived quality of life. We conclude that these coping mechanisms that were previously thought to be inferior are beneficial to patient compliance with RRT.

Possible defective trauma patients' Mphi-T-cell feedback interactions between T cell IL-13 production and IL-1beta and IL-18 Mphi secretion were assessed. Mphi produced IL-1 and IL-18 augment T cell IL-13, which in turn limits excessive macrophage activation. Immunodepressed patients' T cells (depressed proliferation to alphaCD3 + alphaCD4) had decreased IL-13 production concomitant to aberrant Mphi activities ( upward arrow mTNFalpha, downward arrow IL-10) and consequent multiple organ failure (MOF). Decreased IL-13 levels in patients' T cell and diminished Mphi supernatant augmentation of healthy controls' T cell IL-13 production appeared concomitantly, suggesting patients' aberrant monokine levels might intensify in vivo T cell dysfunction severity. Patients' Mphi supernatants, which failed to augment controls' T cell IL-13 production, had depressed IL-1beta and lower induction of IL-18 than immunocompetent patients' Mphi, but combined addition of IL-1beta and IL-18 restored these Mphis' IL-13 enhancing activity. These data suggest that immunodepressed patients' aberrant monokine and depressed T cell IL-13 production are independent but synergistic contributors to emergence of MOF.

Some trauma patients' monocytes (MO) increase TNF-alpha levels concomitant to augmenting production of the TNF-alpha inhibitor prostaglandin E2 (PGE2), suggesting posttrauma MO insensitivity to PGE2 effects. This study assesses additional posttrauma MO PGE2 insensitivity effects on altering TNF-alpha form (membrane versus secreted), down-regulating MO receptor expression, and depressing MO APC function. Posttrauma MO TNF-alpha insensitivity to exogenous and autocrine PGE2 correlated to accumulation of TNF-alpha primarily as a membrane-bound cytokine (mTNF-alpha). MO retention of mTNF-alpha correlated with unfavorable clinical outcomes and loss of antigen-presenting cell (APC) function as assessed by depressed MLR and dendritic cell (DC) differentiation. MO TNF-alpha sensitivity to down-regulation by IL-10 was retained, suggesting that PGE2-related functions are specifically altered in these patients' MO. Freshly isolated MO from all trauma patients had decreased expression of Toll-like receptor 4 (TLR4) for gram-negative bacteria. Exogenous PGE2 at high (10 (-6) M) or low (10 (-8) M) concentrations decreased normals' and further decreased APC-competent patients' MO TLR4 expression but had no effect on TLR2. Patients' APC-dysfunctional MO failed to further down-regulate their TLR4 expression in response to additional PGE2, demonstrating another form of PGE2 insensitivity. One of the primary MO prostaglandin receptors, eicosanoid receptor 4 (EP4), was decreased on patients' APC dysfunctional MO, suggesting that depressed EP4 expression could contribute to PGE2 insensitivity in patients' MO. The APC dysfunctional MO's dysregulation of TLR4 expression paralleled increased macrophage-like characteristics such as increased CD64 expression density, elevated mTNF-alpha production, and increased PGE2 levels. Increased PGE2 levels still decreased patients' MO APC functions but failed to depress either MO TLR4 expression or mTNF-alpha levels, suggesting differential involvement of EP receptors in postinjury PGE2-mediated effects.

The presented case study describes the beneficial results of the neuropsychological rehabilitation of a gunshot victim, even with late initialization of the therapy--over 1 year after head trauma.A case study of DE, a victim with bilateral damage of the parietal-occipital regions of the brain due to a gunshot.Neuropsychological rehabilitation, first preceded by an initial neuropsychological examination (standard psychological tests: WAIS-R, RAVLT, Rey's CFT, BVRT and clinical experiments tailored to DE's condition), was initiated 1 year after trauma. The rehabilitation programme consisted of computer-based tasks, paper-and-pencil exercises, and occupational therapy. The patient's progress was assessed as improvement in performance in standardized tests and computer-based tasks.DE was diagnosed with complex cognitive deficits syndrome, including visual associative agnosia, apraxia, visuospatial and constructive disorders and linguistic defects. After 1 year of rehabilitation the patient's functioning significantly improved as measured by psychological tests and computer-based tasks (p0.05) as well as the evaluation of the patient's quality of life.The case study demonstrates beneficial effects of neurorehabilitation even initialized at the so-called 'late stage' after a brain injury.

Sepsis triggers a coordinated and thorough immune system response with long-term unfavorable sequelae after the initial insult. Long-term recovery from sepsis has garnered increasing attention recently, but a lack of suitable animal models impairs progress in this area. Our study, therefore, aimed to address the performance of the immune system in a survivable model of sepsis (cecal ligation and sepsis; CLP) for up to 28 d after the initial injury in humanized mice. Our model mimics human sepsis with weight loss and post-sepsis hypothermia. Within the first 7 d of sepsis, the M1 inflammatory cell subtype predominated, as evidenced by increased CD16 expression, but at 28 d, a mixed population of M1 and M2 inflammatory cells emerged, as evidenced by increased secretion of transforming growth factor TGFβ and CD206 expression. This change was accompanied by normalized production of interleukin (IL)-6, tumor necrosis factor TNFα and IL-10 at 28 d. Furthermore, the ability of MO to become regulatory DC or the frequency of endogenous DC were severely affected at 28 days. Thus, sepsis results in profound and persistent changes in the function of myeloid cells up to 28 days after CLP demonstrating the persistence of the new acquired immunological features long after resolution of the sepsis.

Fluid resuscitation in sepsis is the subject of long and complicated debate. Recent research has called into question several entrenched clinical positions. Currently, crystalloid, titrated to specific hemodynamic parameters is the leading modality of resuscitation in early shock. Central venous pressure, mean arterial pressure, and oxygen saturation of mixed venous blood are the indices which measure the adequacy of fluid resuscitation therapy. Lack of more accurate and earlier predictors of sufficient fluid resuscitation precludes even more effective therapeutic measures. In this review we examine the current evidence that drives fluid resuscitation therapy.

Following initial episode of sepsis, survivors suffer an increased risk of mortality that persists long-term and remains a significant health care problem. Opportunistic infections and neoplasms are more frequent partially accounting for shorter life expectancy. This suggests that during sepsis the immune system becomes aberrant and is unable to restore its optimal function after the initial insult. Dendritic cells (DC) or their precursors are frequently affected during the initial episode of sepsis as well as after the resolution of symptom. Considering these cells’ pivotal role in regulating innate and acquired immune, they are promising candidates for therapeutic manipulation. Sepsis induces several changes in the populations of DCs via epigenetic, and/or other, mechanisms. Here, we propose that transplantation of ‘naive dendritic cells’ (DCs which are never exposed to sepsis) can reverse several aspects of the long-term post-sepsis immunosuppression. Furthermore, we present advantages of the presented therapeutic approach.

A 45 year-old Asian female presented with new onset of progressive ataxia and underwent resection of a pontocerebellar meningioma. A catastrophic intracranial hemorrhage complicated recovery. Her preoperative coagulation tests were within reference limits. Detailed analysis revealed a very low factor XII level concomitant with prolonged aPTT, but no other coagulation abnormalities were detected. In the discussion, the role of factor XII is described with special emphasize on the novel understanding of the coagulation pathway.

The Inflammation and Host Response to Injury Large-Scale Collaborative Research program, funded by the National Institute of General Medical Sciences of the National Institutes of Health, is the first large-scale interdisciplinary program to attempt to solve the life-threatening problem of inflammation after major trauma or burn injury. One of the main goals of the project was to develop a large clinical database with baseline patient characteristics and well-defined outcomes that pertain to the host inflammatory response after injury. To minimize the impact of practice variation between participating sites, clinical guidelines were developed at the outset of the project, based on the best available evidence in concert with expert consensus.1 The resultant standards of practice guidelines have been provided to the clinical community to ensure transparency of the research initiative, highlight the applicability of these best practices, and to promote the ongoing development of consistent, high-quality care. Recognizing the complexity and heterogeneity of the patient population, the investigators have additionally created a library of standardized diagnostic criteria for complications after traumatic injury. The method used to define these complications incorporated several key components. An expert panel of surgeons who were participating investigators in the Patient-Oriented Research Core was assembled to identify and enumerate the complications that arise after traumatic injury to be included in the study database. Definitions were based on the best available evidence and were clarified to attempt to unambiguously describe complications in such a manner that reliable data could be captured relative to that complication. Input into the consensus process was also obtained from trauma research nurses to modify the definitions to facilitate practical measurement of complications based on information available in the medical record. Although the primary intent was to maintain consistent reporting and quality assessment of treatment and outcomes among participating trauma centers, the compilation of these infectious and noninfectious complication definitions in a single source may serve as a useful reference for the clinician, as well as a framework for future research.

Cardiac arrhythmias are common comorbidities among acutely ill patients admitted to hospitals. An abnormal iron metabolism may contribute to the abnormalities in the conduction and propagation of action potentials through myocardium.To determine whether serum indexes of iron metabolism correlate with electrocardiogram (ECG) changes.In the present retrospective, pilot chart review, serum levels of iron, ferritin, Na(+), K(+), Mg(2+), Ca(2+) and total iron-binding capacity in 77 hospitalized patients with acute illness were correlated with ECG variables.The serum ferritin level correlated strongly (r=0.49) with QT/QTs interval. There were three subjects with QT prolongation (longer than 450 ms) within the high serum ferritin (576 ng/mL or greater) group versus subjects with low ferritin. Multiple regression analysis showed that serum ferritin level and serum iron level contributed to the variance in the QT/QTs prolongation. No other correlation between the studied serum markers and ECG characteristics were found.The present study suggests that serum ferritin and iron levels affect the QT interval in a variety of medical conditions, possibly contributing to the emergence of fatal cardiac arrhythmias.

The effects of HSP27 on human monocytes (MO) are predominantly antiinflammatory through preferential interleukin (IL)10 induction and by alteration of MO to immature dendritic cells (iDCs) or MO to macrophage (Mac) differentiation. Initial HSP27 inclusion in IL4+GM-CSF MO to iDC induction cultures allows Mac differentiation (CD14++, CD16+), decreases iDC (CD1a+) differentiation, and depresses DC induction of allogeneic T lymphocyte proliferation (MLR). HSP27 increased MO IL10 and M-CSF production but subsequent increased Mac differentiation isn't responsible for depressed MO to iDC differentiation and function. Mac function after IL10 induced MO to Mac differentiation is also altered by HSP27 inclusion so that Mac phagocytic activity and scavenger receptor expression (CD163) are depressed. HSP27, in addition to immature DCs, doesn't increase Mac differentiation but instead generates inhibitory DCs, which depress rather than stimulate T cell proliferation even during anti CD3+CD28 induction. Upon maturation, these HSP27-altered inhibitory DCs have increased production of the T cell and DC suppressive mediator, thrombospondin 1. HSP27's anti-inflammatory and immunodepressive effects include deranging MO differentiation to both Mac and DCs, altering their receptor expression, and inducing production of inhibitory mediators such as thrombospondin-1 as well as IL10. These data suggest HSP27 belongs to a new group of 'anti-danger signals'.

Circulating heat shock protein (HSP)-27 is associated with tumor progression and increased post-injury infection. Extracellular HSP-27 might alter monocyte (MO)-derived DC and/or MPhi function to mediate immunosuppression. HSP-27 treatment inhibited expression of CD1a and CD1b/c, antigen uptake, and allogeneic T cell induction (MLR) by IL-4 + GM-CSF-differentiated human DC while increasing some MPhi characteristics ( upward arrowCD14, upward arrowCD16, upward arrowCD163). MO cytokine receptor profiles elicited by 24-h exogenous HSP-27 treatment remained supportive of immature DC (iDC) emergence ( upward arrowIL-4R, downward arrowIL-6R, downward arrowM-CSFR). IL-10, IL-6, and M-CSF (which promote MPhi differentiation) were significantly increased in IL-4 + GM-CSF + HSP-27 MO-->iDC differentiation cultures. However, HSP-27 treatment during MO differentiation to DC increased programmed cell death ligand 1 coinhibitor and depressed CD86 costimulator expression in parallel to decreased iDC MLR activity. This suggested that increased MPhi differentiation was not solely responsible for HSP-27 reduction of differentiating DC activity. HSP-27 treatment actually depressed the phagocytic capacity of MO differentiated to MPhi by IL-10 or M-CSF culture. CD163 (hemoglobin receptor) expression was depressed on M-CSF + HSP-27 MO-derived MPhi. HSP-27-mediated inhibition of MO-->iDC differentiation was reversed by p38alpha & beta inhibitor (SB202190) addition or TLR4 receptor modulation. HSP-27 impaired appropriate MO-->iDC and MO-->MPhi differentiation modulating expression of receptors necessary for their proper functions. This suggests that endogenous HSP-27 has immunoregulatory activities which could contribute to immunopathology.

Maintenance of postinjury T-lymphocyte immune paralysis or anergy could result from failure to activate costimulatory receptors during T-cell receptor activation and/or from chronic stimulation of a competing set of elevated corepressor receptors. Our objective was to assess whether elevated posttrauma T-lymphocyte surface expression of corepressor receptors was associated with immunodepressed lymphocyte responses and corresponded to increased inhibitory and decreased activating signal transduction molecules.Prospective observational study.University trauma intensive care unit and research laboratory.Sixty-one severe thermal and mechanical trauma patients.None.Isolated trauma patients' and controls' peripheral blood T cells were assayed for negative and positive costimulation receptor expression. These receptor expression levels were compared (flow cytometry) between the two groups and correlated to T-cell levels of inhibitory and activating signal transduction molecules and proliferation capacity. Patients' proliferation hyporesponsive (anergic) T cells had increased expression of novel inhibitory receptors (corepressors) PD-1 (p.05) and CD47 (p.05) vs. patients' T-cell proliferation competent or controls' T cells. Patients' T-cell CD152 (CTLA-4) expression was also elevated vs. controls. Only patients' anergic T cells had simultaneously increased levels of the inhibitory signal transduction proteins, c-Cbl, a ubiquitin-ligase (p.01) and SHP-1, a phosphatase (p.01), concomitant to depressed phosphorylation of the activating signal kinases Erk, Zap70, and CD3Euro. T-cell receptor complex phosphorylation and activation of the interleukin-2 pivotal transcriptional complex protein CREB were also simultaneously depressed as c-Cbl and SHP-1 were elevated.Up-regulated corepressor receptor expression is novelly shown to characterize trauma patients' anergic T cells and correlate with predominance of inhibitory overactivating signal transduction molecules during T-cell stimulation. This could contribute to postinjury immunosuppression.

Monitoring genome-wide, cell-specific responses to human disease, although challenging, holds great promise for the future of medicine. Patients with injuries severe enough to develop multiple organ dysfunction syndrome have multiple immune derangements, including T cell apoptosis and anergy combined with depressed monocyte antigen presentation. Genome-wide expression analysis of highly enriched circulating leukocyte subpopulations, combined with cell-specific pathway analyses, offers an opportunity to discover leukocyte regulatory networks in critically injured patients. Severe injury induced significant changes in T cell (5,693 genes), monocyte (2,801 genes), and total leukocyte (3,437 genes) transcriptomes, with only 911 of these genes common to all three cell populations (12%). T cell-specific pathway analyses identified increased gene expression of several inhibitory receptors (PD-1, CD152, NRP-1, and Lag3) and concomitant decreases in stimulatory receptors (CD28, CD4, and IL-2Rα). Functional analysis of T cells and monocytes confirmed reduced T cell proliferation and increased cell surface expression of negative signaling receptors paired with decreased monocyte costimulation ligands. Thus, genome-wide expression from highly enriched cell populations combined with knowledge-based pathway analyses leads to the identification of regulatory networks differentially expressed in injured patients. Importantly, application of cell separation, genome-wide expression, and cell-specific pathway analyses can be used to discover pathway alterations in human disease.

Recently, the role of small heat shock proteins (HSPs) has been widely recognized in cancer research. Small HSPs are tumorprotective via numerous, independent mechanisms such as: oxidative stress, protection preventing protein denaturation, anti-apoptotic activity, and likely direct suppression of the immune system. However, it is unclear whether they play any role in the initial steps in carcinogenesis. This article seeks to familiarize the reader with general characteristics of small HSPs (especially HSP-27, alphaA/B-crystallins), their tissue distribution with special regard on expression in malignant specimens, and biological properties of intracellular HSP-27 and alphaA/B-crystallins promoting tumor genesis and growth. A separate chapter describes immunomodulatory characteristics of extracellular HSP-27 with special emphasis on their plausible effect on the neoplasm development.

Although activation of human innate immunity after endotoxin administration is well established, in vivo endotoxin effects on human T cell responses are not well understood. Most naive human T cells do not express receptors for LPS, but can respond to endotoxin-induced mediators such as chemokines. In this study, we characterized the in vivo response of peripheral human T cell subsets to endotoxin infusion by assessing alterations in isolated T cells expressing different phenotypes, intracellular cytokines, and systemic chemokines concentration, which may influence these indirect T cell responses. Endotoxin administration to healthy subjects produced T cell activation as confirmed by a 20% increase in intracellular IL-2, as well as increased CD28 and IL-2R α-chain (CD25) expression. Endotoxin induced indirect activation of T cells was highly selective among the T cell subpopulations. Increased IL-2 production (36.0 ± 3.7 to 53.2 ± 4.1) vs decreased IFN-γ production (33.8 ± 4.2 to 19.1 ± 3.2) indicated selective Th1 activation. Th2 produced IL-13 was minimally increased. Differentially altered chemokine receptor expression also indicated selective T cell subset activation and migration. CXCR3+ and CCR5+ expressing Th1 cells were decreased (CXCR3 44.6 ± 3.2 to 33.3 ± 4.6 and CCR5 24.8 ± 2.3 to 12 ± 1.4), whereas plasma levels of their chemokine ligands IFN-γ-inducible protein 10 and MIP-1α were increased (61.4 ± 13.9 to 1103.7 ± 274.5 and 22.8 ± 6.2 to 55.7 ± 9.5, respectively). In contrast, CCR4+ and CCR3 (Th2) proportions increased or remained unchanged whereas their ligands, eotaxin and the thymus and activation-regulated chemokine TARC, were unchanged. The data indicate selective activation among Th1 subpopulations, as well as differential Th1/Th2 activation, which is consistent with a selective induction of Th1 and Th2 chemokine ligands.

The application of genome-wide expression analysis to a large-scale, multicentered program in critically ill patients poses a number of theoretical and technical challenges. We describe here an analytical and organizational approach to a systematic evaluation of the variance associated with genome-wide expression analysis specifically tailored to study human disease. We analyzed sources of variance in genome-wide expression analyses performed with commercial oligonucleotide arrays. In addition, variance in gene expression in human blood leukocytes caused by repeated sampling in the same subject, among different healthy subjects, among different leukocyte subpopulations, and the effect of traumatic injury, were also explored. We report that analytical variance caused by sample processing was acceptably small. Blood leukocyte gene expression in the same individual over a 24-h period was remarkably constant. In contrast, genome-wide expression varied significantly among different subjects and leukocyte subpopulations. Expectedly, traumatic injury induced dramatic changes in apparent gene expression that were greater in magnitude than the analytical noise and interindividual variance. We demonstrate that the development of a nation-wide program for gene expression analysis with careful attention to analytical details can reduce the variance in the clinical setting to a level where patterns of gene expression are informative among different healthy human subjects, and can be studied with confidence in human disease.

Polymorphonuclear leukocytes (PMNs; commonly known as neutrophils) play essential roles in innate immunity and inflammation. Although there are standardized methods for the isolation of human neutrophils, they are time consuming and demand considerable technical expertise, making them unfeasible for many clinical applications. Here, we describe a simple and time-efficient technique for the isolation of human neutrophils, which adapts a readily available commercial cell preparation tube (CPT) currently in use for isolation of peripheral blood mononuclear cells (PBMC) and plasma and is now adapted to also yield neutrophils. The total time required for neutrophil isolation was less than 1 hr. Neutrophils isolated by this method were highly purified (> or =97%) as assessed by surface expression of the neutrophil specific marker, CD66b. Neutrophils isolated by this method were functional as demonstrated by their ability to secrete interleukin-1 receptor antagonist (IL-1RA). Neutrophils isolated using this new technique secreted significant amounts of soluble IL-1RA (929.3+/-197 pg/10(6)cells/mL) in response to lipopolysaccharide (LPS). Use of this adapted CPT method allows simultaneous isolation of functional human neutrophils as well as PBMC and plasma. Adoption of this new method will allow the conduct of different neutrophil assays at any clinical site without requiring trained laboratory personnel or a large staff time commitment.

Mechanical trauma is one of the most important causes of morbidity in the developed world. The response of the immune system to mechanical insult is of paramount importance for the patient's recovery. Shortly after trauma, the indiscriminate systemic inflammatory response syndrome (SIRS) is mediated by circulating monocytes (M Øs) and other innate immunity components. Then acquired immunity, limited to the offending pathogen and the site of injury, gradually preponderates. SIRS is followed by the compensatory anti-inflammatory response syndrome (CARS), where the initial inflammatory response is quenched by anti-inflammatory mediators. This precisely regulated process of immune system activation in response to trauma can be easily deviated, resulting in multiorgan failure (MOF) and increased mortality. Excessive activation of inflammatory M Øs in the SIRS phase, premature or exorbitant CARS, a predominance of macrophages (Macs) in the blood stream and peripheral tissues, as well as a depletion of dendritic cells are often seen in trauma patients and contribute to the development of MOF. Here we explore several mechanisms of pathological MØ; activation in patients with severe mechanical traumatic injury without accompanying sepsis.

The analysis of gene expression data in clinical medicine has been plagued by the lack of a critical evaluation of accepted methodologies for the collection, processing, and labeling of RNA. In the present report, the reliability of two commonly used techniques to isolate RNA from whole blood or its leukocyte compartment was compared by examining their reproducibility, variance, and signal-to-noise ratios. Whole blood was obtained from healthy subjects and was either untreated or stimulated ex vivo with Staphylococcus enterotoxin B (SEB). Blood samples were also obtained from trauma patients but were not stimulated with SEB ex vivo. Total RNA was isolated from whole blood with the PAXgene proprietary blood collection system or from isolated leukocytes. Biotin-labeled cRNA was hybridized to Affymetrix GeneChips. The Pearson correlation coefficient for gene expression measurements in replicates from healthy subjects with both techniques was excellent, exceeding 0.985. Unsupervised analyses, including hierarchical cluster analysis, however, revealed that the RNA isolation method resulted in greater differences in gene expression than stimulation with SEB or among different trauma patients. The intraclass correlation, a measure of signal-to-noise ratio, of the difference between SEB-stimulated and unstimulated blood from healthy subjects was significantly higher in leukocyte-derived samples than in whole blood: 0.75 vs. 0.46 ( P = 0.002). At the P < 0.001 level of significance, twice as many probe sets discriminated between SEB-stimulated and unstimulated blood with leukocyte isolation than with PAXgene. The findings suggest that the method of RNA isolation from whole blood is a critical variable in the design of clinical studies using microarray analyses.

Following trauma, increased inflammatory monokine activation and depressed APC function can occur simultaneously. These contradictory monocyte (Mφ) dysfunctions could result if postinjury Mφ differentiation preferentially favored inflammatory macrophage (Mac) differentiation over development into the most potent APC, dendritic cells (DC). In this report, Mφ of trauma patients with a depressed MLR induction capacity are, for the first time, shown to be unable to differentiate in vitro to immature CD1a+ DC under the influence of GM-CSF and IL-4. Trauma patient Mφ that retained MLR-inducing capacity had a nonsignificant reduction in DC differentiation capacity. Only patient Mφ populations with depressed differentiation to immature DC (iDC) demonstrated depressed IL-12 and IL-15 production and a continued reduced MLR induction capacity. Neither increased IL-10 production nor decreased CD11c+ DC precursor numbers correlated with depressed Mφ-to-DC differentiation. Instead, these patients’ APC-dysfunctional Mφ populations had increased expression of inflammatory Mac phenotypes (CD64+, CD86low, HLA-DRlow) and up-regulated secretion of M-CSF. M-CSF combined with IL-6 inhibits Mφ-to-iDC differentiation and promotes Mφ-to-Mac differentiation by down-regulating GM-CSFR expression and increasing DC apoptosis. Both depressed GM-CSFR expression and increased Mφ iDC apoptosis, as well as increased expression of CD126 (IL-6R) and CD115 (M-CSFR), were detected in APC-defective patient Mφ. In vitro addition of anti-M-CSF enhanced the IL-4 plus GM-CSF-induced Mφ-to-DC differentiation of these patients. This suggests that, in trauma patients, enhanced Mφ-to-Mac differentiation with concomitant inhibited iDC development is partially due to increased circulating Mφ sensitivity to and production of M-CSF and contributes to postinjury immunoaberrations.

Monocytes (MO) can uniquely differentiate in a variety of the offspring cells including dendritic cells (DC). After severe immune insult, like sepsis, ability of MO to differentiate to DC (MO->DC) is significantly diminished immediately after insult and is related to the acquisition of a predominantly macrophage like characteristic of MO thus leaving only few available precursory MO for MO->DC process. Here, we enrolled patients scheduled for non-emergent heart surgery and assessed leukocyte function before surgery (t0), 24hrs (t24h) and 7 days (t7d) after surgery. We hypothesized that immediately after surgery, MO will acquire a persistent macrophage characteristic with subsequent MO->DC defect. MO were isolated and subjected to a DC differentiation&maturation conditions including 5 days in vitro cultures in X-VIVO15 enriched with IL-4 & GM-CSF. The process of MO->DC was significantly diminished in patients but only at the day 7 after the CPB as shown by diminished expression CD83 (%CD83+ [X±SD] t0=24.5±33.81 vs t24hr=8.84±10.71 [p=ns] vs t7d=0.2±0.4 [p

Core tip: Cancer mortality is frequently related to metastatic disease. An altered balance between the tendency of the tumor to spread via metastasis and the body’s anti defense processes is the most plausible mechanism of cancer spread. This comprehensive review summarizes the role of anesthetic technique and perioperative interventions and their influence in cancer recurrence. An exhaustive compilation of the latest research and ongoing clinical trials in this area is presented to the reader.

Introduction: Ketamine is frequently suggested be the anesthetic of choice in sepsis due superior hemodynamic stability and lack of effect on the adrenal axis. Little is known about its immunological properties with some data suggesting immunomodulatory effect on the elements of innate immunity via

Pregnancy in women with Marfan syndrome (MFS) is linked to approximately a 4.4% risk of acute aortic dissection (AAD). The natural history of pregnancy and the ability to deliver a viable fetus depends on the interaction between the pace of changes in the cardiovascular system and the advancement of pregnancy. We report the management of a type B acute aortic dissection in a woman in her 36th week of pregnancy. The anaesthesiologist has the unique task of managing complicated and mutually exclusive physiologic goals and acts as a consultant bridging the mother’s well-being and fetal management.