Jukka Tolonen

A controlled immunohistochemical study of inflammatory cells in disc herniation tissue

Study Design The presence and abundance of inflammatory cells was studied immunocytochemically in lumbar disc herniations (DH) and macroscopically normal discs for comparison. Objectives The objective of the study was to characterize inflammatory cells that appear in herniated disc tissue and to study the relative abundance of various types of inflammatory cells. Summary of Background Data Only few macrophages were observed in control discs, whereas abundant macrophages were present in half of the DH.Other types of inflammatory cells were less often abundant in the present material. In about a third of the DH interleukin-1 beta-expressing cells were also observed. Methods Twenty-four DH and control tissue from five discs were studied immunocytochemically, using specific monoclonal antibodies to various types of inflammatory cells and interleukin-1 beta. The results were compared with corresponding clinical data. Macrophages were studied with an antibody to CD68 antigen and Ber-MAC3 antibody separately. Results The obtained results suggest a variable inflammatory cell response in DH, which seems to be often dominated by macrophages at the time of operation. Thus previous suggestions of sometimes very active inflammation in DH tissue are supported. Conclusions Inflammation may be important in disc tissue pathophysiology, possibly also in discogenic pain mechanisms.

Basic fibroblast growth factor immunoreactivity in blood vessels and cells of disc herniations.

Study Design Basic fibroblast growth factor immunoreactivity was studied in disc herniation tissue. Objectives The first objective was to analyze in which tissue components, if any, fibroblast growth factor is expressed in the disc herniation. The second objective was to compare such expression with that in fresh cadaver disc tissue. Summary of Background Data Disc herniation tissue contains vasular ingrowth, which promotes the formation of granulation tissue. Fibroblast growth factor is a potent inducer of angiogenesis and also regulates extracellular proteolysis. Methods Twenty-seven disc herniation tissue and five macroscopically normal fresh cadaver discs were treated with an identical immuunohistochemical protocol. Serial frozen sections were stained with a polyclonal basic fibroblast growth factor antibody and a polyclonal antibody to von Willebrand factor, which localizes endothelial cells. The immunostaining data were compared with relevant clinical data. Results Histologically, 74% of the samples contained anulus fibrosus and 59% nucleus pulposus. Basic fibroblast growth factor immunoreactivity was detected in 81% of the samples. There were immunopositive small blood vessels and scattered immunopositive disc cells(67%). Not all observed blood vessels were basic fib roblast, growth factor immunopositive. I control discs, no immunoreactivity was observed. Conclusions The observed presence of fibroblast growth factor in small blood vessels suggests an active angiogenesis as a result of disc injury. Cellular expression of fibroblast growth factor may be linked to proteolytia activity in disc extracellular matrix.

Transforming growth factor β receptor induction in herniated intervertebral disc tissue: an immunohistochemical study

Transforming growth factor β (TGF-β) is a potent inducer of angiogenesis and fibrogenesis. There is presently little information about the pathophysiological function of TGF-β in herniated disc tissue. In order to analyze the cellular role and activation of TGF-β after disc herniation we immunostained frozen material from 38 disc herniation operations and from eight macroscopically normal discs from organ donors. Polyclonal TGF-β-I, TGF-β-II and TGF-β receptor type II antibodies were used with the avidin biotin complex (ABC-) immunoperoxidase method. All the herniated discs were TGF-β immunopositive. Such immunoreactivity was mainly associated with disc cells. In a few samples, capillaries were also TGF-β immunopositive. Immunopositivity was similarly observed in the control discs. To analyze possible differences between the two groups, we calculated the ratio of immunopositive disc cells. For all three antibodies, a statistically significantly (Mann-Whitney test, P=0.0001) higher number of disc cells showed immunopositivity in the herniated discs. The increase in TGF-β receptor immunopositivity suggested induction of TGF-β receptors in herniated discs. Our results support an active regulatory role for TGF-β in disc cell metabolism.

Inflammatory cells in experimental intervertebral disc injury.

Study Design. Inflammatory cells were located by immunocytochemistry in areas of experimental intervertebral disc injury in pigs. Objectives. To study the occurrence of T lymphocytes and macrophages 1 week, 1 month, and 3 months after partial‐thickness transverse scalpel injuries in pig lumbar discs. Summary of Background Data. Inflammatory cells and mediators recently have been observed in disc herniation tissue that was removed at disc prolapse surgery. The prevalence of inflammatory cell infiltrates in such clinical disc tissue material also has been studied. There are no studies, however, that have analyzed, using immunocytochemical methodology, the occurrence of, types of, and time dependence of inflammatory cells in an experimental disc injury model. The role of inflammation in intervertebral disc injury and repair has not been determined. Methods. Transverse scalpel injuries 5‐mm long and 4‐mm deep were cut in the anterolateral anulus of L5‐L6 and L4‐L5 discs in 16 pigs. The cuts in the center of the anulus did not reach the nucleus pulposus and never produced a disc prolapse. In every pig, two non‐adjacent lumbar discs (L1‐L2 and L2‐L3) were used as controls. Four discs per animal were studied in parallel by two different complementary immunohistochemical staining protocols. T lymphocytes and macrophages were located immunohistochemically using CD3 and CD68 antibodies, respectively. Discs were removed for analysis from four pigs at 1 week, from six pigs at 1 month, and from six pigs at 3 months. Inflammatory cells were categorized by two independent observers as being entirely absent (−), only few scattered cells (+), and at least one larger cellular infiltrate (++). Results. In none of the discs could extensive inflammatory cell infiltration be observed. T lymphocytes were present in significantly more sections cut from injured discs than in sections cut from control discs. The difference was highly significant particularly at 1 week and 1 month after disc removal. Only the 1‐month‐after‐injury sections from injured discs exhibited significantly more macrophages than those from control discs. Conclusions. The results suggest the presence of only modest inflammatory cell infiltration in experimental intervertebral disc injury at all follow‐up times. The inflammatory response in partial‐thickness anterior experimental intervertebral disc injury, in the absence of disc prolapse, seems to be dominated by a T lymphocyte response. The macrophage response is apparently strongest at 1 month after such injury. These findings differ from what has been observed in herniated disc tissue.

Concomitant immunocytochemical study of macrophage cells and blood vessels in disc herniation tissue

SummaryTwenty disc herniations (DH) were studied immunocytochemically for macrophages and blood vessels. Serial thin frozen sections were immunostained with an antibody specific for tissue macrophages (monoclonal antibody to CD68 antigen) and the endothelium of blood vessels (polyclonal antibody to von Willebrand factor). With this method, blood vessels, often abundant, were observed in as many as 16/20 (80%) of the DH studied, 12 disc extrusions and 8 sequestrated discs, whereas abundant macrophages were noted in 11/20 (55%) of the DH. Macrophages were present only in areas with blood vessels and had presumably infiltrated the tissue from them. As has been noted previously, some blood vessels are apparently newly formed as a result of tissue injury, whereas others were present in the disc prior to herniation. This is suggested by the lack of a clear correlation between the presence or absence of blood vessels and the preoperative duration of radicular pain. In areas of the DH where cartilage fragments occurred, both macrophages and blood vessels were particularly abundant.

Dexmedetomidine in addition to benzodiazepine-based sedation in patients with alcohol withdrawal delirium.

Alcohol withdrawal delirium (AWD) is often refractory to conventional medication. We report a prospective series of patients treated with &agr;2-agonist dexmedetomidine added to conventional sedation. Eighteen patients with AWD were diagnosed by Confusion assessment method for ICU score. Treatment, complications, length of stay (LOS) in ICU and hospital were recorded. In addition, hospital and 1-year mortality were assessed. Dexmedetomidine was given for 23.9 (18.4) h [mean (SD)]. All the patients also received benzodiazepines but three patients were given haloperidole. No patient was intubated. The maximum infusion rate of dexmedetomidine was 1.5 (1.2) µg/kg/h. Time to resolution of AWD was 3.8 (1.3) days. The ICU LOS was 7.1 (2.7) days and in-hospital LOS 12.1 (4.5) days. No adverse events were observed although one patient died from acute pancreatitis. The use of dexmedetomidine in AWD seems safe but warrants further studies.

Long-term survival after hospitalization for acute heart failure — Differences in prognosis of acutely decompensated chronic and new-onset acute heart failure

AIMS To analyze the five-year mortality after hospitalization for acute heart failure (AHF) and compare predictors of prognosis in patients with and without a previous history of heart failure. METHODS Patients with AHF (n=620) from the prospective multicenter FINN-AKVA study were classified as acutely decompensated chronic heart failure (ADCHF) or de-novo AHF if no previous history of heart failure was present. Both all-cause mortality during five years of follow-up and prognostic factors were determined. RESULTS The overall mortality was 60.3% (n=374) at five years. ADCHF was associated with significantly poorer outcome compared to de-novo AHF; five-year mortality rate 75.6% vs. 44.4% (p<0.001). Initially, mortality was high (33.5% in ADCHF and 21.7% in de-novo AHF after 12 months), but in de-novo AHF the annual mortality declined markedly already after the first year. Compared to de-novo AHF, patients with ADCHF had an increased risk of death for several years after the index hospitalization. A previous history of heart failure was an independent predictor of five-year mortality (adjusted hazard ratio 1.8 (95% CI 1.4-2.2; p<0.001). Older age and impaired renal function were associated with adverse long-term prognosis in both ADCHF and de-novo AHF, while higher systolic blood pressure on admission predicted better outcome. CONCLUSION The long-term prognosis after hospitalization for AHF is poor, with a significantly different survival observed in patients with de-novo AHF compared to ADCHF. A previous history of heart failure is an independent predictor of five-year mortality. Distinction between ADCHF and de-novo AHF may improve our understanding of patients with AHF.

Acute Heart Failure With and Without Concomitant Acute Coronary Syndromes: Patient Characteristics, Management, and Survival

BACKGROUND Acute coronary syndromes (ACS) may precipitate up to a third of acute heart failure (AHF) cases. We assessed the characteristics, initial management, and survival of AHF patients with (ACS-AHF) and without (nACS-AHF) concomitant ACS. METHODS AND RESULTS Data from 620 AHF patients were analyzed in a prospective multicenter study. The ACS-AHF patients (32%) more often presented with de novo AHF (61% vs. 43%; P < .001). Although no differences existed between the 2 groups in mean blood pressure, heart rate, or routine biochemistry on admission, cardiogenic shock and pulmonary edema were more common manifestations in ACS-AHF (P < .01 for both). Use of intravenous nitrates, furosemide, opioids, inotropes, and vasopressors, as well as noninvasive ventilation and invasive coronary procedures (angiography, percutaneous coronary intervention, coronary artery bypass graft surgery), were more frequent in ACS-AHF (P < .001 for all). Although 30-day mortality was significantly higher for ACS-AHF (13% vs. 8%; P = .03), survival in the 2 groups at 5 years was similar. Overall, ACS was an independent predictor of 30-day mortality (adjusted odds ratio 2.0, 95% confidence interval 1.07-3.79; P = .03). CONCLUSIONS Whereas medical history and the manifestation and initial treatment of AHF between ACS-AHF and nACS-AHF patients differ, long-term survival is similar. ACS is, however, independently associated with increased short-term mortality.

Oncoprotein c-Fos and c-Jun immunopositive cells and cell clusters in herniated intervertebral disc tissue

Abstract. The oncoproteins c-Fos and c-Jun create a transcriptional site early response activating protein (AP-1) mediating the regulation of gene expression in response to extracellular signalling by, for example, cytokines. These proteins are important in the signalling pathway from the cell membrane to the nucleus. Previously, oncoproteins have been located in articular synovium and in chondrocytes, participating in transcription. There is, however, no such study of intervertebral disc tissue. In disc degeneration and after herniation, cell proliferation markers have been demonstrated. In the present study we visualize the AP-1 transcriptional site factors c-Fos and c-Jun in 38 human herniated intervertebral disc tissue samples by immunohistochemical staining with monoclonal antibodies. No immunoreactivity could be observed in control disc tissue, indicating that after herniation, disc cells are entering from the resting stage to the cell cycle. Furthermore, c-Jun immunoreactivity was also observed in disc cell clusters, thus demonstrating them to be active transcriptional sites in disc tissue. c-Fos immunoreactivity was seen in 15/38 and c-Jun in 28/38 herniated discs (39% and 74% respectively). Immunopositive groups of disc cells were noted in 7/28 (25%) of the oncoprotein-immunopositive samples. We did not see any difference in immunoreactivity between female and male patients. Furthermore, we did not notice any statistical difference regarding the immunoreaction for proto-oncogenes c-Fos and c-Jun in extrusions, sequesters and protrusions. Nor did immunostaining show any significant relationship with preoperative pain duration. We concluded that, in herniated disc tissue, the oncoproteins c-Fos and c-Jun are activated in disc cells and cell clusters. In the future, learning more about this transcriptional signal pathway may result in new specific treatments for intervertebral disc pathology.

Management of acute heart failure and the effect of systolic blood pressure on the use of intravenous therapies

Aims: To examine the use of the treatments for acute heart failure (AHF) recommended by ESC guidelines in different clinical presentations and blood pressure groups. Methods: The use of intravenous diuretics, nitrates, opioids, inotropes, and vasopressors as well as non-invasive ventilation (NIV) was analysed in 620 patients hospitalized due to AHF. The relation between AHF therapies and clinical presentation, especially systolic blood pressure (SBP) on admission, was also assessed. Results: Overall, 76% of patients received i.v. furosemide, 42% nitrates, 29% opioids, 5% inotropes and 7% vasopressors, and 24% of patients were treated with NIV. Furosemide was the most common treatment in all clinical classes and irrespective of SBP on admission. Nitrates were given most often in pulmonary oedema and hypertensive AHF. Overall, only SBP differed significantly between patients with and without the studied treatments. SBP was higher in patients treated with nitrates than in those who were not (156 vs. 141 mmHg, p<0.001). Still, only one-third of patients presenting acute decompensated heart failure and SBP over 120 mmHg were given nitrates. Inotropes and vasopressors were given most frequently in cardiogenic shock and pulmonary oedema, and their use was inversely related to initial SBP (p<0.001). NIV was used only in half of the cardiogenic shock and pulmonary oedema patients. Conclusions: The management of AHF differs between ESC clinical classes and the use of i.v. vasoactive therapies is related to the initial SBP. However, there seems to be room for improvement in administration of vasodilators and NIV.