Maurizio Marandola

Heat shock protein (HSP70) expression in septic patients

PURPOSE This study investigates heat shock protein 70 (HSP70) expression by peripheral blood mononuclear cells (PBMCs) of septic patients admitted to an intensive care unit and examines the possibility of a correlation between HSP70 levels and plasma tumor necrosis factor alpha (TNF-alpha) concentrations. Additionally, we evaluated whether the HSP70 production could be regarded as a prognostic factor for the development of septic shock as well as for patient survival. MATERIALS AND METHODS Blood samples of 29 patients were taken 24 hours after the diagnosis of sepsis. HSP70 expression and TNF-alpha level were measured using indirect immunofluorescent analysis and a commercially available enzyme-linked immunosorbent assay method, respectively. RESULTS PBMCs expressed significantly high levels of HSP70 (11.9 +/- 5.6 [sd]) compared with those of the healthy control group (3.2 +/- 2.1% positive cells). Such enhanced levels were correlated to plasma TNF-alpha concentrations (r = .99, P < .01). This study failed to demonstrate a relationship between HSP70 production and clinical outcome. CONCLUSION These findings give further evidence that also in humans, heat shock response is activated during sepsis. The correlation observed between HSP70 overproduction and TNF-alpha plasma concentrations suggests that HSP70 exerts a possible protective effect against TNF-alpha cytotoxicity. Such hypothesis has not been confirmed by our clinical data.

Interleukin-10 and apoptotic death of circulating lymphocytes in surgical/anesthesia trauma.

OBJECTIVE To examine the relationship between circulating interleukin-10 (IL-10) and the occurrence of lymphocyte apoptosis after surgical/anesthesia trauma. METHODS Data were collected prospectively on 18 adult patients undergoing elective major surgery. Blood sampling for assessment of lymphocyte apoptosis and IL-10 levels was performed on the day before surgery (t(0)) and at 24 and 96 hours after operation (t(1) and t(2), respectively). After lymphocyte isolation, quantification of apoptosis was made by staining apoptotic cells with 7-amino-actinomycin D. Plasma IL-10 concentrations were measured using enzyme-linked immunosorbent assay. RESULTS A significantly increased frequency of apoptotic CD4(+) and CD8(+) cells (p < 0.05) was observed at t1 measurement (8.10% +/- 0.58% and 12.21% +/- 1.47% for CD4(+) and CD8(+), respectively) compared with preoperative values (1.53% +/- 0.38% and 1.32% +/- 0.45% for CD4(+) and CD8(+), respectively). Plasma IL-10 levels showed a significant elevation at both t(1) and t(2) times, peaking at t(1). At t(1), IL-10 levels were correlated with the frequency of CD4(+) and CD8(+) apoptotic lymphocytes (r = 0.78, p = 0.0005 for IL-10 vs. apoptotic CD4(+); r = 0.71, p = 0.003 for IL-10 vs. apoptotic CD8(+)). CONCLUSION Surgical trauma is associated with a significant but transient increase in lymphocyte commitment to apoptosis and IL-10 production. The exact relationship linking the overproduction of IL-10 with lymphocyte apoptosis after a surgical operation is still elusive and requires further investigation.

Plasma levels of IL-10 and nitric oxide under two different anaesthesia regimens.

Background and objective: An alteration in production of both interleukin‐10 (IL‐10) and nitric oxide (NO) has been found following surgical/anaesthesia trauma. It is also suggested that IL‐10 could be an important factor in regulating NO metabolism during the postoperative period. Furthermore, NO seems to play a crucial role in the anaesthetic state. The purpose of this study was to investigate plasma levels of IL‐10 and NO following surgery, any possible correlation between these two variables and whether anaesthesia technique could influence NO and IL‐10 circulating concentrations. Methods: Thirty‐two patients scheduled to undergo elective major surgery were enrolled in the study and allocated into two groups to receive two different techniques of anaesthesia, total intravenous (i.v.) anaesthesia (Group I) and inhalational anaesthesia (Group II). Blood samples were drawn before (t0), at the end (t1) of operation and after 24 h (t2). Plasma IL‐10 and NO levels were measured by using an enzyme‐linked‐immunosorbent assay (ELISA) and a total NO assay kit, respectively. Results: In both patient groups there was a significant decrease of plasma NO levels at the end of surgery (30.35 ± 2.70 mmol L−1 at t0 to 13.76 ± 1.51 mmol L−1 at t1 in Group I, P < 0.0001; 28.23 ± 2.50 mmol L−1 at t0 to 11.38 ± 0.95 mmol L−1 at t1 in Group II, P < 0.0001). This reduction remained at 24 h postoperatively (14.33 ± 1.52 mmol L−1 in Group I, P < 0.0001; 12.52 ± 1.11 mmol L−1 in Group II, P < 0.0001, both vs. t0). There was an increase in IL‐10 concentrations (26.35 ± 3.42 pg mL−1 and 75.39 ± 8.33 pg mL−1 at t1 and t2, respectively, vs. 4.93 ± 0.31 pg mL−1 at t0, P = 0.03 and P < 0.0001, respectively, in Group I; 26.18 ± 3.22 pg mL−1 and 69.91 ± 7.33 pg mL−1 at t1 and t2, respectively, vs. 5.50 ± 0.33 pg mL−1 at t0, P = 0.02 and P < 0.0001, respectively, in Group II). No relationship was found between circulating IL‐10 and NO. Conclusions: During the postoperative period, IL‐10 overproduction does not correlate with the decrease in systemic NO concentration.

Anesthesia and Pain Management: Techniques and Practice

Surgery for pancreatic cancer (PC) is widely viewed as a complex procedure associated with considerable perioperative morbidity and mortality. Many aspects of surgery for pancreatic cancer, such as the extent of resection, the value of vascular resection, the use of laparoscopy and the importance of treatment at high-volume centers are currently under debate. PC is the fourth leading cause of cancer related mortality in the United States with an estimated 42500 new cases and 35000 deaths from the disease each year (Jemal, 2009). Analysis of overall survival shows that the prognosis of PC is still quite poor despite the fact that 1-year survival has increased from 15.2% to 21.6% and 5-year survival has increased from 3% to 5% (ShaibYH et al., 2006). Surgery is the only chance of cure and the presence of negative resection margins of the primary tumor represent the strongest prognostic factor. Preoperative staging modalities include the combination of several imaging techniques such as computed tomography (CT scan), magnetic resonance imaging (MRI), endoscopic ultrasounds (EUS), staging laparoscopy and laparoscopic ultrasound which aim to identify patients with resectable disease. There is consensus that patients with distant metastases (liver, lung, peritoneum) or local invasion of the surrounding organs (stomach, colon, small bowel) are usually not surgical candidates. A decision analysis demonstrated that the best strategy to assess tumor resectability was based on CT as an initial test and the use of EUS to confirm the results of resectability by CT (Delbecke et al., 1999). Laparoscopic ultrasonography (LUS) has been introduced as an additional procedure to increase the detection of intrahepatic metastases, identify enlarged and suspicious lymph nodes and to evaluate local growth in the vascular structures (Tilleman et al., 2004). The routine use of staging laparoscopy and LUS in patients with radiographically resectable PC remains controversial as imaging modalities has significantly improved, thus reducing the risk of discovering non resectable disease at the time of surgery. Surgery for the PC can be considered an high-risk surgery. This term is rarely explicitly defined in scientific articles. There seems to be a common understanding among surgeons and anesthesiologists of what major surgery means. It can be defined as a surgical procedure that is extensive, involves removal of whole or parts of organs and/or is lifethreatening. It has also been defined as a surgical procedure with >1 mortality (Ghaferi et al., 2009). One possibility of evaluating the perioperative risk is the use of 1 of several risk scores. The American Society of Anesthesiologists score is widely used and easy to apply, but excludes age from its risk analysis (Kullavanijaya et al., 2001). Age is securely one of the most important, if not the single most predictive, risk factors for morbidity and mortality after major surgery, including major pancreatic surgery (Riall et al., 2008).