Jean A. Nemzek

Six at six: Interleukin-6 measured 6 H after the initiation of sepsis predicts mortality over 3 days

Virtually of the all recent therapeutic interventions for treating sepsis have failed to improve survival. One potential explanation is that the heterogeneity of the immune response to the septic challenge is such that only a portion of the patients die as a result of excessive inflammation. The clinical trials lacked power because traditional measurements do not accurately identify these patients. Previous work has shown that higher levels of interleukin (IL)-6 are found in those mice that die from septic peritonitis; therefore, we sought to determine whether IL-6 measured 6 h after surgery could predict outcome. Adult, female BALB/c mice (n = 79) were subjected to cecal ligation and puncture with a 21-gauge needle and treated with imipenem in D5W every 12 h for 5 days, resulting in a homogenous population at the outset. Six hours after surgery, 20 &mgr;L of blood was obtained from the tail vein to measure IL-6. Mortality was followed for 21 days. Overall 3-day survival was 77%, and 21-day mortality was 56%. Plasma IL-6 levels >2000 pg/mL were determined to predict mortality within the first 3 days with a sensitivity of 58% and specificity of 97%. To further refine the mortality prediction, body weight and a complete blood count were performed 24 hours after cecal ligation and puncture. Discriminate analysis indicated that a weighted formula combining body mass, lymphocyte, and platelet count would predict death with sensitivity of 83% and a specificity of 79%. We tested the value of the IL-6 prediction by surgically resecting the cecum in those animals with IL-6 > 2000 pg/mL, which resulted in a significant improvement in survival. These data demonstrate that IL-6 measured 6 h after injury accurately predicts mortality resulting from experimental sepsis. This measurement may be determined quickly so that therapy may be targeted only to those individuals at significant risk of dying and initiated within sufficient time to be effective.

Aspiration-Induced lung injury

Objective:Aspiration of oropharyngeal or gastric contents into the lower respiratory tract is a common event in critically ill patients and can lead to pneumonia or pneumonitis. Aspiration pneumonia is the leading cause of pneumonia in the intensive care unit and is one of the leading risk factors for acute lung injury and acute respiratory distress syndromes. Despite its frequency, it remains largely a disease of exclusion characterized by ill-defined infiltrates on the chest radiograph and hypoxia. An accurate ability to diagnose aspiration is paramount because different modalities of therapy, if applied early and selectively, could change the course of the disease. This article reviews definitions, diagnosis, epidemiology, pathophysiology, including animal models of aspiration-induced lung injury, and evidence-based clinical management. Additionally, a review of current and potential biomarkers that have been tested clinically in humans is provided. Data Sources:Data were obtained from a PubMed search of the medical literature. PubMed “related articles” search strategies were used. Summary and Conclusions:Aspiration in the intensive care unit is a clinically relevant problem requiring expertise and awareness. A definitive diagnosis of aspiration pneumonitis or pneumonia is challenging to make. Advances in specific biomarker profiles and prediction models may enhance the diagnosis and prognosis of clinical aspiration syndromes. Evidence-based management is supportive, including mechanical ventilation, bronchoscopy for particulate aspiration, consideration of empiric antibiotics for pneumonia treatment, and lower respiratory tract sampling to define pathogenic bacteria that are causative.

Development and optimization of cytokine ELISAs using commercial antibody pairs

The measurement of cytokines in plasma and other fluids often requires the use of an enzyme-linked immunosorbant assay (ELISA). In the research environment, a valuable assay is one that yields reliable results in the shortest amount of time for the least cost. To achieve this goal, a protocol has been outlined to develop sandwich ELISAs for cytokines using commercial antibodies. These guidelines for ELISA development include selecting antibody concentrations, choosing an appropriate buffer, reducing plasma interference and evaluating the optimal length for incubation periods. In addition, the protocol for a rapid IL-6 ELISA is presented. This ELISA allows measurement of IL-6 in a reduced amount of time by raising the concentration of antibodies used and increasing the temperature for incubation. By following the guidelines presented, cost-effective, cytokine ELISAs can be developed that yield low background, detect a wide range of concentrations, and are suitable for use in the research setting.

Humane endpoints in shock research.

In biomedical research using animal models, the phrase “humane endpoints” refers to predetermined criteria used to judge when the research animals should be humanely euthanized. The intended goal of humane endpoints is to minimize the distress or suffering of research animals; however, if applied incorrectly, this well-intended concept could lead to premature decisions and inaccurate data, resulting in a waste of animal life. A concensus on specific endpoints for shock and inflammation research is not available but several biochemical, physical and behavioral parameters have been suggested for other research models. In addition, the authors have found, in the studies presented here, that increasing body weight, decreased body temperature, and inability to ambulate are important parameters in a model of cecal ligation and puncture. However, it is clear that the applicability of these endpoints may change with the model of disease, intensity of insults, experimental treatments and other factors. Consequently, humane endpoints should be assigned cautiously and preferably after preliminary studies to prevent aberrant research results. In order to accomplish this, investigators must become aware of certain concepts including: when to implement endpoints, what endpoints to consider, and how to establish the endpoints for their studies. Equipped with the basic principles of humane endpoints, investigators can make informed decisions that meet current standards of animal care while still achieving the scientific goals of their research studies.

Differences in normal values for murine white blood cell counts and other hematological parameters based on sampling site.

Abstract.Objective and design: The effect of blood sampling site on the hemogram and neutrophil adhesion molecules was examined in BALB/c mice.¶Materials and methods: Blood samples were drawn from the tail, eye, and heart during anesthesia with ketamine and xylazine. Cell numbers were quantified with an automated counter and flow cytometry was used to quantify CD11b and CD18.¶Results: Total white blood cell (WBC) counts were highest from tail, lower from eye, and significantly lower from heart blood. In general, differences between tail and heart counts reflected changes in all cell types. RBCs, platelets and hematocrits were significantly increased in tail compared to heart blood. Although CD18 levels were not different, CD11b was significantly higher on neutrophils from tail compared to heart blood.¶Conclusions: In anesthetized BALB/c mice, sampling site readily influences blood counts and neutrophil CD11b. The findings underscore the need to standardize sampling site when measuring these parameters.

Ratio of Local to Systemic Chemokine Concentrations Regulates Neutrophil Recruitment

CXC chemokines are important regulators of local neutrophil recruitment. In this study, we examined the role of the ratio of local to systemic chemokine concentrations as a significant factor determining local neutrophil recruitment. Thioglycollate was injected intraperitoneally into BALB/c mice resulting in a dose-dependent increase in neutrophil recruitment and local inflammation, as measured by peritoneal levels of interleukin 6. At the high dose of 3% thioglycollate, antibody inhibition of the murine chemokines KC and macrophage inflammatory protein-2 caused a reduction in peritoneal neutrophil recruitment by as much as 93%. A paradoxical effect was observed with a 0.3% thioglycollate intraperitoneal challenge. In this situation, inhibition of KC resulted in a significant increase in peritoneal neutrophils, and inhibition of macrophage inflammatory protein-2 also resulted in increased peritoneal neutrophils. These results were consistent with a reverse chemotactic gradient as described by the ratio of peritoneal to plasma KC levels. A higher ratio (ie, increased peritoneal chemokines compared to plasma) resulted in increased neutrophil recruitment after either the 3% or 0.3% thioglycollate challenge. Our results demonstrate that whereas sufficient local concentrations of chemokines are necessary, a critical factor dictating local neutrophil recruitment is the ratio of the local to the systemic chemokine concentrations.

Differential local and systemic regulation of the murine chemokines KC and MIP2.

We characterized the relative biological activity and expression of two murine chemokines that may serve as functional homologues for human IL-8, KC, and macrophage inflammatory protein 2 (MIP2). Recombinant chemokines were produced in bacterial expression systems and antibodies specific for KC or MIP2 were raised. In vitro assays showed that KC elicited 4-fold greater neutrophil chemotaxis compared with MIP2, while MIP2 elicited significantly greater release of elastase. Lipopolysaccharide- (LPS) stimulated macrophages (8 h) secreted more MIP2 (approximately 10 ng/mL) compared with KC (approximately 4 ng/ml) and expression of either murine chemokine was independent of TNFalpha or IL-1beta production. Thioglycollate (thio) and glycogen (gly) induced peritonitis produced more KC (thio = 7.1 and gly = 2.5 ng/mL) in the peritoneum compared with MIP2 (thio = 4.5 and gly = 0.3 ng/mL). Plasma KC levels were very high after either challenge (approximately 24 ng/mL), which was >50-fold more than the systemic increase in MIP2 (approximately 0.3 ng/mL). Our data demonstrate that while KC and MIP2 have similar in vitro production characteristics, KC appears to be a more potent and systemically distributed chemokine during acute in vivo inflammation, while MIP2 expression appears limited to localized expression.

Combination immunotherapy with soluble tumor necrosis factor receptors plus interleukin 1 receptor antagonist decreases sepsis mortality

ObjectiveInhibition of tumor necrosis factor (TNF) or interleukin 1 (IL-1) alone has not improved sepsis survival in human clinical trials; therefore, it has been suggested that blockade of both may be successful. We tested whether combination immunotherapy would improve survival in mice subjected to a lethal lipopolysaccharide (LPS) challenge or the sepsis model of cecal ligation and puncture. DesignMice were treated with the combination immunotherapy and challenged with either a lethal dose of lipopolysaccharide or a septic challenge induced by cecal ligation and puncture. SettingUniversity research laboratory. SubjectsAdult, female Balb/c mice. InterventionsMice were treated with the combination of the IL-1 receptor antagonist plus a polyethylene glycol-linked dimer of the TNF soluble receptor. Measurements and Main Results LPS lethality was reduced in the treated mice with a decrease in biologically active TNF in the plasma and peritoneal fluid. In the cecal ligation and puncture (CLP) model of sepsis, this combination immunotherapy for 1 day decreased plasma and peritoneal levels of IL-6 and the murine chemokines KC and MIP-2. However, treatment did not result in a reduction in the hypothermia or peripheral blood alterations that occur after CLP, and the 1-day therapy did not result in an improvement in survival. In contrast, when combination immunotherapy was extended to 3 days there was a significant improvement in survival. ConclusionsThese data demonstrate that inhibition of both TNF and IL-1 will decrease the lethality of sepsis initiated by CLP if the combination immunotherapy is provided for a sufficient amount of time.

An Essential Role for Lipopolysaccharide-binding Protein in Pulmonary Innate Immune Responses

Lipopolysaccharide (LPS)-binding protein (LBP) greatly facilitates LPS activation of monocytic cells through the CD14 receptor, triggering activation of innate immune responses. An acute phase protein, LBP is produced predominantly by the liver; however, we and others have shown that LBP is produced extrahepatically in multiple locations, including the lung. The importance of LBP in the lung has remained unclear. LBP may make the host more acutely sensitive to LPS and development of septic complications; alternatively, it may be protective, aiding in detection, opsonization, and killing of bacteria. Our objective was to determine the role LBP plays in local pulmonary immune defenses to bacterial challenge. LBP knockout mice and age-matched C57BL/6 wild-type controls were challenged with direct intratracheal inoculation of Klebsiella pneumoniae. We observed a significant increase in mortality, earlier onset of bacteremia, and greater pulmonary bacterial loads in LBP knockout mice compared with controls. Total lung myeloperoxidase (MPO) activity, neutrophil recruitment to the alveolar space, and levels of KC—a chemokine involved in neutrophil recruitment—in bronchoalveolar lavage (BAL) fluid and lung homogenates were found to be significantly diminished in knockout mice compared with controls. Together, our findings suggest that LBP is essential in local pulmonary innate immune responses against bacteria.

Keratinocyte growth factor pretreatment is associated with decreased macrophage inflammatory protein-2α concentrations and reduced neutrophil recruitment in acid aspiration lung injury

A two-hit model of acid aspiration was used to examine the effect of keratinocyte growth factor (KGF) on chemokine levels and neutrophil recruitment into the lung. Mice were subjected to cecal ligation and puncture and then either KGF or saline, intratracheally (IT). Forty-eight hours later, the mice were given IT acid. After 8 h, neutrophil counts in bronchoalveolar lavage (BAL) fluid were significantly decreased in animals pretreated with KGF (23 ± 4 × 103/mouse) compared with saline (74 ± 2 × 103/mouse). In addition, the BAL fluid IL-6 levels were decreased in the KGF-treated group (88 ± 44 pg/mL) compared with the saline group (166 ± 34 pg/mL). To examine the mechanism behind the KGF-induced reduction in neutrophil influx, the murine chemokines KC and macrophage inflammatory protein (MIP)-2&agr; were measured. KC levels in plasma and BAL fluid were not significantly different between the treatment groups. Likewise, levels of MIP-2&agr; in plasma were not affected by KGF treatment. However, 8 h after acid aspiration, MIP-2&agr; concentrations were significantly lower in the KGF-treated group. The ratio of MIP-2&agr; in BAL fluid versus plasma was lower in the KGF group (0.72 ± 0.28) than in the saline group at 3 h (2.23 ± 0.93) and also significantly lower in the KGF group (3.02 ± 0.78) compared with the saline group (6.23 ± 1.19) at 8 h. In this study, KGF pretreatment after acid aspiration was associated with reduced neutrophil recruitment into the lung and a decrease in MIP-2&agr; gradients between BAL fluid and plasma.