Kazuyoshi Hanasawa

Treatment of sepsis by extracorporeal elimination of endotoxin using polymyxin B-inimobilized fiber

Despite the use of potent antibiotics and intensive supportive care, mortality remains high among septic shock patients, especially those with endotoxemia. To remove endotoxin directly from the blood, a material consisting of polymyxin B that is immobilized on fibers (PMX-F) and that can selectively detoxify endotoxin was developed. In a preliminary clinical study, 16 patients with septic multiple organ failure were treated with direct hemoperfusion using a PMX-F column. This therapy significantly decreased the endotoxin level from 76 pg/mL to 21 pg/mL after 2 hours of direct hemoperfusion. The hyperdynamic state of the cardiac index, which is a characteristic of endotoxic shock, returned to normal levels after treatment. In septic shock patients with a systolic pressure of less than 100 mm Hg, the systolic arterial pressure increased significantly from the pretreatment level. The alleviation of fever caused by this therapy continued until the day after treatment. Of the 16 patients who underwent this therapy, 9 were alive 2 weeks after this therapy and 7 patients were discharged from the hospital alive. Hemoperfusion with PMX may be an effective treatment for sepsis and septic shock.

Correlation between plasma endotoxin, plasma cytokines, and plasminogen activator inhibitor-1 activities in septic patients.

The objective of this study was to evaluate the relation between the clinical and plasma parameters and the changes in plasma endotoxin activity with 2 hours of endotoxin-adsorbing therapy using polymyxin B (PMX). A total of 88 consecutive patients were admitted for PMX treatment of severe sepsis or septic organ failure. Standard supportive care was continued without alteration during PMX treatment. Endotoxin, tumor necrosis factor-alpha (TNFalpha), interleukin-6 (IL-6), IL-10, and plasminogen activator inhibitor-1 (PAI-1) activities and clinical parameters were measured before, immediately after, and the day after PMX treatment. The mean APACHE II and III scores were 24.2 +/- 1.0 and 85.8 +/- 3.0, respectively. The 2-week survival rate was 51.1%. In survivors, TNFalpha, IL-6, IL-10, and PAI-1 activities were significantly decreased during the 2-hour PMX treatment, the following day, or both times. There was no significant change in the parameters, except for TNFalpha, after PMX in nonsurvivors. In the subgroup whose plasma endotoxin decreased more than 30%, IL-6, TNFalpha, and PAI-1 significantly decreased after 2 hours of PMX or the following day (or both), but all four parameters in nonsurvivors showed no significant change. Hence PMX adsorbed plasma endotoxins and contributed to reductions in plasma proinflammatory cytokine levels and to improved clinical parameters during the 2-hour treatment. Changes in these parameters correlated with changes in plasma endotoxin activity in survivors whose plasma endotoxin levels were adequately reduced.

Elevation of plasma peptidoglycan and peripheral blood neutrophil activation during hemorrhagic shock: plasma peptidoglycan reflects bacterial translocation and may affect neutrophil activation.

Objective To investigate the relations among bacterial translocation, plasma peptidoglycan elevation, and peripheral blood neutrophil activation during hemorrhagic shock. Design Prospective, randomized, unblinded animal study. Setting Surgical research laboratories of Shiga University of Medical Science. Subjects Male, specific pathogen–free Sprague-Dawley rats. Interventions The rats were randomly divided into three groups: a conventional group with normal intestinal flora (NF), an antibiotic (streptomycin and penicillin G) decontaminated group (AD), and a sham shock group with normal intestinal flora. The NF and AD groups were subjected to hemorrhagic shock (mean arterial pressure 30 mm Hg, for 30 to 90 mins). Rats were killed at 30, 60, and 90 mins after shock induction. Systemic blood and mesenteric lymph nodes (MLNs) were cultured for the determination of bacterial translocation (BT). Systemic plasma peptidoglycan and endotoxin concentrations were measured. To evaluate peripheral blood neutrophil activation, phagocytosis and hydrogen peroxide generation were assayed by flow cytometry. Measurements and Main Results In the NF group, BT to MLNs was significantly increased from 30 mins after shock induction. Blood culture and plasma endotoxin were positive at 90 mins but there were no significant differences. Assayed plasma peptidoglycan was significantly increased at 90 mins. Phagocytosis and hydrogen peroxide generation were significantly increased. Assayed plasma peptidoglycan concentrations showed significant positive correlations with the magnitude of BT to MLNs (r2 = .54) and hydrogen peroxide generation (r2 = .22) in individual animals. Furthermore, BT and these parameters were significantly suppressed in the AD group. Conclusions First, we concluded that assayed plasma peptidoglycan reflects BT induced by hemorrhage because the increase in assayed plasma peptidoglycan was suppressed, as was BT, by antibiotic decontamination. Second, peripheral blood neutrophil activation was also suppressed when BT was prevented. We concluded BT to be involved in neutrophil activation. Our findings suggest hydrogen peroxide generation by neutrophils to be involved in plasma peptidoglycan elevation.

Bacterial translocation and peptidoglycan translocation by acute ethanol administration.

Background: We examined bacterial translocation (BT) by acute ethanol administration, using a peptidoglycan detecting system. Methods: Rats were given 20% (v/w) ethanol (10 ml/kg body weight), and heparinized samples of portal blood were collected at specific time points after administration. Plasma peptidoglycan, β-glucan, and endotoxin concentrations of portal blood were measured. The rats were divided into three groups: a 20% ethanol group (20ET group), a 5% ethanol group (5ET group), and a control group. The groups were given 10 ml/kg body weight of either 20% (v/w) ethanol (20ET group), 5% (v/w) ethanol (5ET group), or distilled water (control group). Femoral arterial blood, portal blood, mesenteric lymph nodes (MLNs), spleen, and liver were cultured to assess BT. Plasma peptidoglycan, β-glucan, and endotoxin concentrations of femoral arterial blood and portal blood were measured. Results: The plasma peptidoglycan concentration of portal blood was significantly increased 24 h after the administration of 20% ethanol. There was no significant difference in the incidence and magnitude of viable BT to the MLNs, spleen, and liver among any of the groups at this time point. The rate of plasma peptidoglycan positivity and the plasma peptidoglycan concentration were increased significantly in the portal blood of the 20ET group 24 h after administration. Conclusions: Peptidoglycan was translocated into the portal blood by acute administration of 20% ethanol. Our findings suggest that viable bacterial flora may translocate from the intestine under the influence of ethanol, and BT may be one of the causes of chronic alcoholic liver disease.

The role of bacterial translocation on neutrophil activation during hemorrhagic shock in rats

Some biological responses to hemorrhage have been reported to be associated with bacterial translocation (BT). While the relationship between peripheral blood neutrophils and BT in the late phase of hemorrhagic shock or burn injury has been reported, this relationship in the early phase has not been fully elucidated. We investigate the role of BT in neutrophil activation and priming during hemorrhagic shock. The experimental rats were divided into three groups: a group with normal intestinal flora (NF group), an antibiotic-decontaminated group (AD group), and a sham shock group with normal intestinal flora (sham group). Hemorrhagic shock was induced in the NF and AD groups (MAP 30 mm Hg for 30-90 min). The rats were sacrificed at 30, 60, or 90 min following the shock induction. Cultures were taken from the liver, spleen, mesenteric lymph nodes (MLNs), and systemic blood to assess the occurrence of BT. Hydrogen peroxide generation and CD11b/c expression were assayed by flow cytometry to evaluate peripheral blood neutrophil activation and priming, respectively. In the NF group, significant BT to the MLNs and spleen was noted from 30 min after the shock induction, and significant hydrogen peroxide generation was also noted from 30 min. The expression of CD11b/c on neutrophils was significantly up-regulated at 90 min after the shock induction. Furthermore, BT, as also the aforementioned parameters of neutrophil function, was significantly suppressed in the AD group. We, therefore, concluded that neutrophil activation and priming during hemorrhagic shock might be closely related to BT, and that infectious factors possibly influence the host responses starting from the early phase of damage, even in noninfectious stress-inducing conditions.

Interleukin-8 as a predictor of the severity of bacteremia and infectious disease.

The relationship between cytokines and sepsis has been studied frequently in the intensive care unit (ICU). However, the determination of cytokines in patients as they enter the emergency department (ED) would be more meaningful in predicting the outcome of infection. This study investigated plasma interleukin-8 in the ED as the predictor of bacteremia and sepsis. One hundred patients admitted through the ED with signs of systemic inflammatory response syndrome were studied. Plasma IL-8, IL-6, and tumor necrosis factor (TNF) were assayed by enzyme-linked immunosorbent assay. Patients data were evaluated using the APACHE II scoring system as predictive factors of morbidity and mortality. Plasma IL-8 (149 pg/mL) detected bacteremia with a positive predictive value of 90.9% and a specificity of 98.7%. Results indicated that the odds ratios (ORs) of bacteremia were 24.78 (P < 0.01, CI = 2.27-270.8), 5.42 (P < 0.05, CI = 1.37-21.4), and 6.05 (P < 0.05, CI = 1.36-26.8) for IL-8, IL-6, and APACHE II, respectively. Occurrence of bacteremia was highly correlated with increases in plasma IL-8 (P < 0.01). IL-8 (OR = 8.25, CI = 1.03-65.9) and APACHE II scores (OR = 12.6, CI = 2.24-70.4) were found to be significantly better predictive factors of mortality (P < 0.01) than IL-6 (OR = 3.60, CI = 0.57-22.7), TNF (OR = 0.24, CI = 0.01-11.0) and age (OR = 1.02, CI = 0.98-1.06). During bacteremia, IL-8 also correlated well with patient use of a ventilator (P < 0.01, OR = 2.43, CI = 2.41-311.19), use of vasopressors (P < 0.05, OR = 2.67, CI = 1.79-370.78), length of stay in the hospital (P < 0.01, OR = 3.14, CI = 1.87-988.31), and stay in the ICU (P < 0.01, OR = 2.51, CI = 2.98-449.80). Measuring IL-8 on patients in the ED with apparent bacterial infections appears to be a reliable predictor of bacteremia and the severity of disease.

Effects of a urinary trypsin inhibitor on acute circulatory insufficiency after surgical operation

OBJECTIVE To assess the effectiveness of an urinary trypsin inhibitor (UTI) on a surgical stress, particularly the influences on cytokines and diuretic hormones. SUBJECTS AND METHODS Sixteen patients with carcinoma of the digestive system and predicted to suffer from circulatory insufficiency were enrolled. Selection of group was divided alternatively. UTI was administered for 5 consecutive days, at a dose of 300,000 units per day. Urine and blood specimens were collected before, immediately after, and 1, 3, and 5 days after surgery. Interleukin 8 (IL-8), polymorphonuclear leukocyte elastase (PMNE), vasopressin (ADH), atrial natriuretic peptide (ANP), angiotensin II (AT-II), and endothelin 1 (ET-1) in the blood, and N-acetyl-D-glucosaminidase (NAG) in the urine, were determined. RESULTS A UTI group was 9 patients, and a control group was 7 patients. The operation time was significantly longer in the UTI group than in the control group. In the UTI group, the elevation of IL-8, PMNE/WBC, ADH, urinary NAG, and BUN were significantly inhibited. AT-II and ET-1, in the UTI group, tended to be suppressed, and ANP showed the similar changes in the two groups. CONCLUSION UTI is considered effective in the prevention of excessive reaction against major surgery.

Bacterial translocation and tumor necrosis factor-α gene expression in experimental hemorrhagic shock

ObjectiveTo investigate whether bacterial translocation is the causative mechanism underlying cytokine production during hemorrhagic shock. DesignProspective, randomized, unblinded animal study. SettingSurgical research laboratories of Shiga University of Medical Science. SubjectsMale Sprague-Dawley rats. InterventionsThe rats were randomly divided into three groups. Each animal was anesthetized with pentobarbital, given a continuous infusion of 0.9% saline, and monitored for blood pressure. The normoxic and sham shock groups breathed room air, whereas the hyperoxic shock group was administered 100% oxygen. Except in the sham shock group, blood was withdrawn to induce a hemorrhagic shock state, then the shed blood was reinfused. Sixty minutes after the induction of hemorrhagic shock, arterial blood cultures were performed in all three groups. The animals were then killed, and their mesenteric lymph nodes (MLNs) were harvested for bacterial culture. The terminal ileum, liver, spleen, kidney, lung, and MLNs were also collected for histologic study by in situ hybridization. Measurements and Main ResultsIn the bacteriologic study, the prevalence of bacterial translocation was 0% (0/11) in the hyperoxic shock group, 55% (6/11) in the normoxic shock group, and 0% (0/9) in the sham shock group. In the in situ hybridization study, tumor necrosis factor-&agr; gene expression was detected only in the ileal tissue, MLNs, and spleens of the normoxic shock group. Blood cultures were sterile in all three groups. ConclusionsBacterial translocation occurred in MLNs within 1 hr of hemorrhage. Hemorrhagic shock causes tumor necrosis factor-&agr; gene expression as well as bacterial translocation in MLNs, but not in the liver, in this model. Bacterial translocation was prevented by hyperoxia early in the course of hemorrhagic shock. Hyperoxia also prevented tumor necrosis factor-&agr; gene expression along the bacterial invasion route.

Invasive ductal carcinoma within a fibroadenoma of the breast

A rare case of invasive ductal carcinoma within a fibroadenoma of the breast in a 42-year-old woman is reported. The patient had a well-defined mass, measuring 6.0 × 5.0 cm, in the upper lateral quadrant of the left breast. Physical examination suggested fibroadenoma. Ultraso-nography and mammography revealed some malignant findings. Needle biopsy demonstrated fibroadenoma. Frozen section revealed invasive ductal carcinoma, scirrhous type, arising in a fibroadenoma; muscle-preserving mastectomy was performed. Only 16 cases of carcinoma within a fibroadenoma of the breast have been reported in the literature in Japan. Carcinoma in a fibroadenoma should be treated on the basis of the therapeutic criteria for ordinary carcinoma.

Direct hemoperfusion with polymyxin-B-immobilized fiber columns improves septic hypotension and reduces inflammatory mediators in septic patients with colorectal perforation

PurposeAlthough some studies have reported favorable effects of direct hemoperfusion with polymyxin-B-immobilized fiber columns (PMX) for the treatment of septic shock, few studies have demonstrated the efficacy of PMX in studies with a uniform case definition and without any other blood purification techniques.Materials and methodsFifty-two patients with severe sepsis or septic shock secondary to colorectal perforation were treated with PMX. Hemodynamic alterations and plasma concentrations of endotoxin, interleukin (IL)-1β, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-8, and IL-10 were evaluated following PMX treatment.ResultsWe observed a significant reduction in plasma endotoxin in the nonsurvivors immediately after PMX treatment compared to before treatment. Systolic blood pressure was markedly increased and circulating levels of IL-1β, IL-1Ra, and IL-8 were significantly reduced during a 2-h interval of PMX.ConclusionsOur findings suggested that PMX treatment appears to adsorb endotoxin and also modulates circulating cytokine during a 2-h interval of direct hemoperfusion in septic patients with such condition.