Monocytes maintain tissue factor activity after cytolysis of bacteria-infected endothelial cells in an in vitro model of bacterial endocarditis

Crosslinking of dialdehyde heparin: a new strategy for improving the anticoagulant properties of porcine acellular dermal matrix

The anticoagulant properties of valve materials are essential to maintain blood patency after artificial valve implantation. Porcine acellular dermal matrix (pADM) has low immunogenicity, good biocompatibility, and can reduce calcification by eliminating heterogeneous cells. However, its main component is collagen, which has strong coagulation function and poor anticoagulant activity. When used in heart valve materials, it can easily coagulate and form a life-threatening thrombus. Therefore, it is necessary to improve its anticoagulant performance. The glutaraldehyde (GA) cross-linked valves widely used clinically are easy to calcify with poor anticoagulant performance and cytotoxicity. In this study, dialdehyde heparin containing cross-linking active aldehyde groups was prepared by sodium periodate oxidation, then it was used for crosslinking with pADM to chemically modify its anticoagulant performance. Compared with GA cross-linked pADM (GA-pA), dialdehyde heparin cross-linked pADM (OL-pA) has better thermal stability and biocompatibility, especially its anticoagulant and antiplatelet adhesion were significantly improved, which can reduce the incidence of coagulation, thrombocytopenia and bleeding. In summary, dialdehyde heparin is expected to be applied to modify the anticoagulant properties of pADM and has great potential for the preparation and clinical application of anticoagulant materials such as heart valves and artificial blood vessels.

Dialdehyde heparin containing cross-linking active aldehyde groups was prepared by sodium periodate oxidation. It was used as a cross-linking agent and the anticoagulant performance of modified porcine acellular dermal matrix was much improved.

Coagulation: At the heart of infective endocarditis

Infective endocarditis is a life-threatening and enigmatic disease with a mortality of 30% and a pathophysiology that is poorly understood. However, at its core, an endocarditis lesion is mainly a fibrin and platelet blood clot infested with bacteria, clinging at the cardiac valves. Infective endocarditis therefore serves as a paradigm of immunothrombosis gone wrong. Immunothrombosis refers to the entanglement of the coagulation system with innate immunity and the role of coagulation in the isolation and clearance of invading pathogens. However, in the case of infective endocarditis, instead of containing the infection, immunothrombosis inadvertently creates the optimal shelter from the immune system and allows some bacteria to grow almost unimpeded. In every step of the disease, the coagulation system is heavily involved. It mediates the initial adhesion of bacteria to the leaflets, fuels the growth and maturation of a vegetation, and facilitates complications such as embolization and valve destruction. In addition, the number one cause of infective endocarditis, Staphylococcus aureus, has proven to be a true manipulator of immunothrombosis and thrives in the fibrin rich environment of an endocarditis vegetation. Considering its central role in infective endocarditis, the coagulation system is an attractive therapeutic target for this deadly disease. There is, however, a very delicate balance at play and the use of antithrombotic drugs in patients with endocarditis is often accompanied with a high bleeding risk.

Propofol attenuates monocyte-endothelial adhesion via modulating connexin43 expression in monocytes

AIMS

Monocyte-endothelial adhesion is considered to be the primary initiator of inflammatory vascular diseases, such as atherosclerosis. Connexin 43 (Cx43) has been reported to play an important part in this process, however, the underlying mechanisms are not fully understood. Intravenous anesthetics, propofol is commonly used in the perioperative period and in the intensive care unit, and considered to have good anti-inflammatory and antioxidant effects. Thus, we speculate that propofol could influence monocyte-endothelial adhesion, and explore whether its possible mechanism is relative with Cx43 expression in U937 monocytes influencing cell adhesion of U937 monocytes to human umbilical vein endothelial cells (HUVEC).

MAIN METHODS

Cx43-siRNAs or pc-DNA-Cx43 were used to alter Cx43 expression in U937 monocytes. Propofol was given as pretreatments to U937 monocytes. Then, cell adhesion, ZO-1, LFA-1, VLA-4, COX and MCP-1 were determined. PI3K/AKT/NF-κB signaling pathway was explored to clarify the possible mechanism.

KEY FINDINGS

Alternation of Cx43 expression affects cell adhesion and adhesion molecules significantly, such as ZO-1, LFA-1, VLA-4, COX-2 and MCP-1, the mechanism of which is relative with Cx43 influencing the activation of PI3K/AKT/NF-κB signaling pathway. Preconditioning with propofol at its clinically relevant anesthesia concentration attenuates cell adhesion. Propofol not only decreases Cx43 expression in U937 monocytes, but also depresses the activation of PI3K/AKT/NF-κB signaling pathway.

SIGNIFICANCE

Modulation Cx43 expression in U937 monocytes could affect cell adhesion via regulating the activation of PI3K/AKT/NF-κB signaling pathway. Propofol attenuates cell adhesion via inhibiting Cx43 and its downstream signaling pathway of PI3K/AKT/NF-κB.

Inflammatory Response in Infective Endocarditis

Endocarditis remains a devastating disease with a high mortality despite timely diagnosis and treatment. The mainstays of treatment include appropriate antibiotics and when indicated, removal of the septic focus. This sounds extremely simple and belies the necessity for a sophisticated multidisciplinary approach to its treatment, the success of which depends not just on the right antibiotic at the right dosage via the right portal, but also on a profound understanding of the inflammatory and infective pathophysiology at work. This review aims at assisting both the clinician and the lab-based physician in the task.

Monocyte-endothelial adhesion is modulated by Cx43-stimulated ATP release from monocytes

Adhesion of circulating monocytes to vascular endothelial cells is a crucial event in development of vascular inflammatory conditions, including atherosclerosis. We investigated the roles of connexin43 (Cx43) and ATP release on monocyte-endothelial adhesion. Cx43 function and expression were manipulated by connexin channel inhibitors, overexpression and siRNA. Connexin channel inhibitors rapidly decreased ATP release from U937 monocytes and increased adhesion to human umbilical vein endothelial cells (HUVEC). Monocyte ATP release correlated with Cx43 expression, not with Cx37 expression. Exogenous adenosine (ADO) or ATP decreased adhesion, and inhibition of ATP conversion to ADO increased adhesion. We infer that monocyte Cx43 channel activity causes ATP release, likely via Cx43-containing hemichannels, and that ATP decreases adhesion via conversion to ADO. Inhibition of HUVEC connexin channel activity did not affect ATP release or adhesion. In contrast, expression of Cx43 protein in U937 cells enhanced adhesion. Thus, Cx43 channel function and expression have opposite effects: Cx43 channel function in monocytes, but not in HUVEC, rapidly decreases adhesion via ATP release and conversion to ADO, whereas Cx43 expression itself enhances adhesion. These studies suggest that local regulation of monocyte Cx43 activity within the vasculature can dynamically modulate the monocyte-endothelial adhesion that is an initiating event in vascular inflammatory pathologies, with the baseline adhesion set by Cx43 expression levels. This balance of rapid and tonic influences may be crucial in development of vascular pathologies.

Anti-thrombotic therapy in infective endocarditis

Despite advances in medical and surgical treatment, infective endocarditis (IE) still carries a high risk of morbidity and mortality. One of the determinants of an adverse outcome is the presence of systemic embolization and in particular, of CNS embolization. IE vegetations consist of bacteria, platelets and inflammatory cells in a fibrin mesh. The interactions between pathogens, platelets and the coagulation system are critical to vegetation initiation and growth. This understanding has led to the study of the effect of anti-thrombotic treatment on IE vegetation formation and embolization. Although it has been demonstrated that antiplatelet and anticoagulant strategies have an impact on in vitro and animal models of IE, results from the available clinical studies are conflicting. In this article, we provide an overview of the available experimental and clinical data on anti-thrombotic treatment in IE and summarize the current guidelines. An early diagnosis, prompt empiric antibiotic treatment and a careful selection of patients who benefit from early surgical intervention remain essential in the prevention of embolic complications. In patients who have other indications for antiplatelet or anticoagulant treatment, the continuation of this treatment is deemed safe in the absence of hemorrhagic complications.

Staphylococcal endocarditis presenting with a renal infarct in a patient with acute lymphoblastic leukemia

We present here a patient with acute lymphoblastic leukemia (ALL) and who developed infective endocarditis during induction chemotherapy with prednisolone, L-asparaginase (Leunase), vincristine and adriamycin. The patient did not have a history of a central venous catheter. Sharp flank pain and fever occurred on the 25(th) day of induction chemotherapy. In addition, a renal infarct and movable vegetations on the mitral valve were detected on the abdominal computed tomography (CT) and echocardiography. S. aureus was identified in the cultured blood. While the patient achieved remission, follow-up echocardiography revealed the vegetation had increased in size and an abscess pocket had developed despite the antibiotics and heparin therapy. Consequently, ten days after the diagnosis of infective endocarditis, a successful mitral valvuloplasty was performed without complications. The patient is currently on maintenance chemotherapy while in remission.

The role of endothelial cell biology in endocarditis

The treatment of endocarditis remains a challenge for physicians, even in times of modern antibiotic treatment. Depending on its cause, endocarditis can either be of infectious or non-infectious origin. Infective endocarditis is caused by bacterial (or fungal) pathogens, and the clinical course is critically dependent on the virulence factors of the specific microorganisms involved. Therefore, the clinical type of endocarditis can be divided into an acute and more aggressive form and a subacute form (endocarditis lenta). Much of our knowledge regarding the pathogenesis of infective endocarditis is based on studies of the virulence of Staphylococcus aureus, which has become the most frequent cause of infective endocarditis nowadays. However, independently of the underlying cause of endocarditis (infectious or noninfectious), the pathogenesis involves the damage and disturbance of endothelial function and the formation of associated "vegetation". Surprisingly little is known about the specific role of the endothelium in the pathogenesis of endocarditis. This review will thus give insights into current knowledge of the pathogenesis of endocarditis with a focus on the role of the endothelium.

Gamma interferon confers resistance to infection with Staphylococcus aureus in human vascular endothelial cells by cooperative proinflammatory and enhanced intrinsic antibacterial activities

Vascular endothelium is an exposed target in systemic endovascular Staphylococcus aureus infections. We reported earlier that the proinflammatory and procoagulant activities of primary human umbilical vein endothelial cells (ECs) after binding and ingestion of S. aureus organisms provide the cells effective means for leukocyte-mediated bacterial elimination. Expanding on this, we now show that these ECs exhibit a modest intrinsic capacity for eliminating intracellular S. aureus that was influenced by cytokines relevant to S. aureus infections. Using various EC infection assays, we showed that gamma interferon (IFN-gamma), applied to cultures of ECs prior to or after infection with S. aureus, markedly reduced the level of infection, illustrated by lower percentages of S. aureus-infected ECs and less intracellular bacteria per infected cell. IFN-gamma-activated ECs had unaltered abilities to bind S. aureus and processed ingested bacteria by a seemingly conventional phagocytic pathway. IFN-gamma treatment rescued EC monolayers from severe injury by virulent clinical S. aureus strains or excessive bacterial numbers. Mechanistically, IFN-gamma controls S. aureus infection via IFN-gamma receptor, most likely through stimulation of intrinsic endothelial antibacterial mechanisms but independent of processes that deprive bacteria of intracellular L-tryptophan or iron. The antibacterial activity of IFN-gamma-stimulated ECs coincided with sustained or slightly elevated endothelial proinflammatory responses that supported monocyte recruitment. In conclusion, we identify IFN-gamma as a potent regulatory Th1 cytokine possessing exclusive abilities to augment intrinsic antistaphylococcal effector mechanisms in human ECs without ablating the S. aureus-induced proinflammatory EC responses and, as such, coordinating a protective efficacy of ECs against blood-borne S. aureus infection.

Immunologic quantitation of tissue factors

The large number of conflicting reports on the presence and concentration of circulating tissue factor (TF) in blood generates uncertainties regarding its relevance to hemostasis and association with specific diseases. We believe that the source of these controversies lies in part in the assays used for TF quantitation. We have developed a highly sensitive and specific double monoclonal antibody fluorescence-based immunoassay and integrated it into the Luminex Multi-Analyte Platform. This assay, which uses physiologically relevant standard and appropriate specificity controls, measures TF antigen in recombinant products and natural sources including placenta, plasma, cell lysates and cell membranes. Comparisons of reactivity patterns of various full-length and truncated TFs on an equimolar basis revealed quantitative differences in the immune recognition of TFs by our antibodies in the order of TF 1-263 > 1-242 > 1-218 > placental TF. Despite this differential recognition, all TF species are quantifiable at concentrations < or = 2 pM. Using a calibration curve constructed with recombinant TF 1-263 and plasma from healthy individuals (n = 91), we observed the concentration of TF antigen in plasma to be substantially lower than that generally reported in the literature: TF antigen in plasma of 72 individuals (79%) was below 2 pM (quantitative limit of our assay); TF antigen levels between 2.0 and 5.0 pM could be detected in six individuals (7%); and in 14% (13 plasmas), the non-specific signal was higher than the specific signal, and thus TF levels could not be determined. These differential recognition patterns affect TF quantitation in plasma and should be considered when evaluating plasma TF-like antigen concentrations.

Endothelial cells, tissue factor and infectious diseases

Tissue factor is a transmembrane procoagulant glycoprotein and a member of the cytokine receptor superfamily. It activates the extrinsic coagulation pathway, and induces the formation of a fibrin clot. Tissue factor is important for both normal homeostasis and the development of many thrombotic diseases. A wide variety of cells are able to synthesize and express tissue factor, including monocytes, granulocytes, platelets and endothelial cells. Tissue factor expression can be induced by cell surface components of pathogenic microorganisms, proinflammatory cytokines and membrane microparticles released from activated host cells. Tissue factor plays an important role in initiating thrombosis associated with inflammation during infection, sepsis, and organ transplant rejection. Recent findings suggest that tissue factor can also function as a receptor and thus may be important in cell signaling. The present minireview will focus on the role of tissue factor in the pathogenesis of septic shock, infectious endocarditis and invasive aspergillosis, as determined by both in vivo and in vitro models.