Sirish Maddali

The Effects of Time Course after Anterior Cruciate Ligament Injury in Correlation with Meniscal and Cartilage Loss

In this study, 130 consecutive patients with anterior cruciate ligament insufficiency who were undergoing ligament reconstruction underwent arthroscopic examination at the time of reconstruction, and any loss of meniscal or chondral integrity was documented in a systematic fashion. In these patients, a greater proportion of the medial meniscus was lost compared with the lateral meniscus (16% versus 5%). On average, 6 cm2 of the articular cartilage was damaged (5.2 cm 2) or lost (0.8 cm2), with the area of damage and loss greatest on the medial femoral condyle. Patients whose injuries had occurred more than 2 years before the examination had more than sixfold greater cartilage loss and damage compared with those whose injuries had occurred within the past 2 months. Meniscal loss was associated with a threefold increase in cartilage damage or loss. The group of patients with meniscal loss whose initial anterior cruciate ligament injury occurred more than 2 years before examination exhibited 18 times the amount of cartilage loss or damage as did the group that had no meniscal loss and whose injury occurred less than 1 month before examination.

Renal Cell Carcinoma Induces Prostaglandin E2 and T-Helper Type 2 Cytokine Production in Peripheral Blood Mononuclear Cells

AbstractBackground: Patients with renal cell carcinoma (RCC) do not develop an effective antitumor immune response, despite significant infiltration by lymphocytes. Tumor production of immunosuppressive factors may account for this failure. The object of this study was to investigate the production of immunosuppressive mediators, especially prostaglandin E2 (PGE2), by RCC. Methods: Peripheral blood mononuclear cells (PBMC) were cocultured with conditioned medium (CM) from human RCC cell lines in the presence or absence of NS-398, a selective cyclooxygenase 2 (COX-2) inhibitor. Supernatants were analyzed for levels of PGE2, interleukin (IL)-10, IL-6, IL-2, interferon-γ, and IL-12. The effects of RCC CM on PBMC proliferation were also examined. The expression of basal and stimulated COX-2 messenger RNA in the cell lines was assessed by reverse transcriptase-polymerase chain reaction. Results: RCC CM significantly increased PGE2 production by PBMC. T-helper type 2 (Th2) cytokine production was also significantly increased. Th1 cytokines were unchanged or decreased. RCC CM increased proliferation of PBMC. Coculture with NS-398 reduced PBMC PGE2 production to below control levels and significantly decreased IL-6 production and PBMC proliferation. NS-398 had no effect on cellular production of IL-10 or Th1 cytokines. Conclusions:Human RCC inhibits the host antitumor immune response by promoting PGE2 production and Th2 cytokines in PBMC. Selective inhibition of COX-2 may have a role in abrogating this effect.

Glucocorticoid pretreatment induces cytokine overexpression and nuclear factor-κB activation in macrophages

BACKGROUND Glucocorticoids are widely used in treating inflammatory diseases. The contribution of adrenal glucocorticoids to inflammatory regulation is unknown. Endogenous glucocorticoids, as distinct from synthetic analogues, not only suppress but also enhance immune functions. Elevated circulating cortisol levels are characteristic of injured patients. In a model of trauma, an early glucocorticoid surge occurs concomitantly with decreased cellular cytokine responses. Cytokine production elevated late after injury is associated with increased mortality. We hypothesized that this glucocorticoid surge mediates the later heightened macrophage responses. MATERIALS AND METHODS The murine macrophage like cells RAW 264.7 were incubated with corticosterone (35 ng/mL), or vehicle control, for 1 h, after which the cells were washed and corticosterone-free medium added. At 0, 3, 6, 12, and 24 h after removal of the corticosterone, the cells were stimulated with lipopolysaccharide (LPS) and interferon-gamma. Supernatant tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and nitrite levels were measured. In separate experiments the effect of pretreatment with corticosterone on TNF-alpha, IL-6, and nitrite mRNA expression as well as nuclear factor-kappaB and glucocorticoid receptor activity was determined. CD14 receptor expression was determined by flow cytometry. RESULTS Glucocorticoid pretreatment caused significantly increased RAW 264.7 cell production of nitrite, IL-6 and TNF-alpha. mRNA for these inflammatory mediators was induced 6 h after the corticosterone pretreatment, and was associated with activation of nuclear factor-kappaB in the presence of activated glucocorticoid receptor. Cell surface-expression of CD14 was likewise increased. CONCLUSIONS The results of this study demonstrate a novel role for glucocorticoids and provide a mechanism for the late upregulation in macrophage function after injury.

Overlapping CRE and E-box promoter elements can independently regulate COX-2 gene transcription in macrophages.

Macrophage cyclooxygenase‐2 (COX‐2) transcription is mediated through the collaboration of different promoter elements. Here, the role of an overlapping cyclic AMP responsive element (CRE)/E‐box was investigated. Nuclear proteins bound both the CRE and E‐box, which synergized with other promoter elements to induce COX‐2 transcription. Endotoxin induced binding of nuclear proteins to the CRE and E‐box and each element independently induced higher COX‐2 transcription levels than the overlapping CRE/E‐box. Transcription factors associated with the CRE binding complex included c‐Jun and CRE binding protein and with the E‐box binding complex USF‐1; their overexpression significantly induced COX‐2 transcription. Therefore, both CRE and E‐box promoter elements regulate COX‐2 transcription in macrophages.

Cyclooxygenase-2 Inhibition Improves Macrophage Function in Melanoma and Increases the Antineoplastic Activity of Interferon γ

AbstractBackground: Melanoma inhibits macrophage tumoricidal activity and increases the expression of cyclooxygenase-2 (COX-2). In this study, we sought to determine whether inhibition of COX-2 could restore macrophage function and hence maximize the antitumor activity of the immune stimulant interferon γ (IFNγ). Methods: Peritoneal macrophages were exposed to B16 melanoma-conditioned medium for 24 hours with or without the COX-2 inhibitor NS-398 and then were stimulated with lipopolysaccharide and IFNγ. Cytotoxic activity, nitrite production, and cytokine production by the stimulated macrophages were measured. In addition, B16 melanoma cells were implanted intradermally into mice treated with IFNγ (14,000 U on alternate days) alone or with a combination of IFNγ and a COX-2 inhibitor (NS-398 or nimesulide). Mice were assessed for tumor growth and survival. Results: Macrophage cytotoxicity and nitrite production were significantly suppressed by melanoma-conditioned medium (P < .01). This was prevented by 200 μM of NS-398 (P < .05). In vivo, combined treatment with IFNγ and a COX-2 inhibitor caused a significant inhibition of tumor growth (P < .01) and improved survival (P = .02) compared with controls. Conclusions: COX-2 inhibition reversed melanoma-induced suppression of macrophage function, and combined treatment of IFNγ plus a COX-2 inhibitor was maximally effective in reducing tumor growth and improving survival.

A Cost-Utility Analysis Comparing the Sartorius versus the Rectus Femoris Flap in the Treatment of the Infected Vascular Groin Graft Wound.

Background: The purpose of this study was to examine the sartorius and rectus femoris flaps as reasonable coverage options for the infected vascular groin graft wound. The authors’ goal was to perform a cost-utility analysis of the sartorius flap versus the rectus femoris flap in the treatment of an infected vascular groin graft. Methods: Cost-utility methodology involved a literature review compiling outcomes for specific flap interventions, obtaining utility scores for complications to estimate quality-adjusted life-years, accruing costs using Diagnosis-Related Group and Current Procedural Terminology codes for each intervention, and developing a decision tree that could portray the more cost-effective strategy. The authors also performed sensitivity analysis to check the robustness of their data. Szilyagi III and Samson III and IV grades of infected groin grafts were included in the study. Results: Twenty-six studies were used pooling 296 patients (234 sartorius flaps and 62 rectus flaps). Decision tree analysis noted that the rectus femoris flap was the more cost-effective option. It was the dominant treatment option given that it was more clinically effective by an additional 0.30 quality- adjusted life-years, with the sartorius flap option costing an additional

Altered cyclooxygenase-2 expression and nitric oxide metabolism following major elective surgery.

2241.88. The sartorius flap had a 13.68 percent major complication rate versus an 8.6 percent major complication rate for the rectus femoris flap. One-way sensitivity analysis showed that the sartorius flap became a cost-effective option if its major complication rate was less than or equal to 8.89 percent. Conclusion: The rectus femoris flap in the treatment of the infected vascular groin graft is a cost-effective option compared with the sartorius flap.

Cost-Utility Analysis: Sartorius Flap versus Negative Pressure Therapy for Infected Vascular Groin Graft Managment

BACKGROUND AND AIMS Postoperative variation in immune function leads to increased susceptibility to infections. Cyclooxygenase-2 (COX-2)-generated Prostaglandin-E(2) (PGE(2)), which signals through the PGE(2) receptor (EP receptor), as well as nitric oxide metabolites (NOx), appear to be important in postoperative immune dysfunction. It is unclear, however, how these substrates and receptors change over time. This study was conducted to evaluate postoperative changes in inflammatory mediator production and monocyte COX-2 and EP receptor expression. MATERIALS AND METHODS Nineteen patients had blood drawn preoperatively and up to 1 week postoperatively. Plasma NOx levels were measured. Peripheral blood mononuclear cell (PBMC) COX-2 and EP receptor mRNA expression were analyzed by reverse transcription-polymerase chain reaction (RT-PCR). PBMC PGE(2), interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-alpha), and IL-10 productions were evaluated by enzyme-linked immunosorbent assay (ELISA) kits. Statistical analyses were by ANOVA and Students t tests. RESULTS Postoperatively, PBMC mean PGE(2) and IL-6 productions were significantly increased at all time points. Mean TNF-alpha production was maximal on postoperative day 2, while mean IL-10 production was unchanged. Mean circulating NOx levels demonstrated a biphasic response decreasing early postoperatively and normalizing at postoperative day (POD) 7. PBMC COX-2 enzyme and EP receptor mRNA expression were unchanged. CONCLUSIONS Altered PBMC PGE(2) production and plasma NOx levels support a role for altered macrophage activity, which may contribute to immune dysfunction in the postoperative period.

Cyclo-oxygenase inhibitor and interferon-γ act synergistically to reduce melanoma growth and improve survival in a murine model

Background: Sartorius flap coverage and adjunctive negative pressure wound therapy (NPWT) have been described in managing infected vascular groin grafts with varying cost and clinical success. We performed a cost–utility analysis comparing sartorius flap with NPWT in managing an infected vascular groin graft. Methods: A literature review compiling outcomes for sartorius flap and NPWT interventions was conducted from peer-reviewed journals in MEDLINE (PubMed) and EMBASE. Utility scores were derived from expert opinion and used to estimate quality-adjusted life years (QALYs). Medicare current procedure terminology and diagnosis-related groups codes were used to assess the costs for successful graft salvage with the associated complications. Incremental cost-effectiveness was assessed at

Melanoma-induced suppression of macrophage nitric oxide production: reversal by a cyclo-oxygenase 2 inhibitor

50,000/QALY, and both univariate and probabilistic sensitivity analyses were conducted to assess robustness of the conclusions. Results: Thirty-two studies were used pooling 384 patients (234 sartorius flaps and 150 NPWT). NPWT had better clinical outcomes (86.7% success rate, 0.9% minor complication rate, and 13.3% major complication rate) than sartorius flap (81.6% success rate, 8.0% minor complication rate, and 18.4% major complication rate). NPWT was less costly (