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VHRG ジャーナルクラブ 2011年9月討論  TNF death signal;TIMP/TACE pathwayの関与について

2011年09月27日 23時03分09秒 | 論文紹介 細胞内情報伝達
Vascular Health Research Group(VHRG) ジャーナルクラブミーティング


文献 1 miRNA-206によるTIMP3のdownregulation

Liu H, Chen SE, Jin B, Carson JA, Niu A, Durham W, Lai JY, Li YP. TIMP3: a physiological regulator of adult myogenesis. J Cell Sci. 2010 Sep 1;123(Pt 17):2914-21.

Abstract
Myogenic differentiation in adult muscle is normally suppressed and can be activated by myogenic cues in a subset of activated satellite cells. The switch mechanism that turns myogenesis on and off is not defined. In the present study, we demonstrate that tissue inhibitor of metalloproteinase 3 (TIMP3), the endogenous inhibitor of TNFalpha-converting enzyme (TACE), acts as an on-off switch for myogenic differentiation by regulating autocrine TNFalpha release. We observed that constitutively expressed TIMP3 is transiently downregulated in the satellite cells of regenerating mouse hindlimb muscles and differentiating C2C12 myoblasts. In C2C12 myoblasts, perturbing TIMP3 downregulation by overexpressing TIMP3 blocks TNFalpha release, p38 MAPK activation, myogenic gene expression and myotube formation. TNFalpha supplementation at a physiological concentration rescues myoblast differentiation. Similarly, in the regenerating soleus, overexpression of TIMP3 impairs release of TNFalpha and myogenic gene expression, and delays the formation of new fibers. In addition, downregulation of TIMP3 is mediated by the myogenesis-promoting microRNA miR-206. Thus, TIMP3 is a physiological regulator of myogenic differentiation.

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Muscle regeneration entails the activation, proliferation and differentiation of mononucleated satellite cells (muscle stem cells) that are associated with muscle fibers. Myogenic differentiation is a carefully controlled process that is normally suppressed until it is activated at an appropriate time in a subset of proliferating satellite cells. The remaining satellite cell pool stays undifferentiated and serves as the reserve for future regeneration events (Charge and Rudnicki, 2004). Although myogenic gene expression requires the reactivation of the myogenic program involving the expression of such transcription factors as Pax7, Myf5, MyoD, myogenin, MRF4 and MEF2, it is clear now that epigenetic regulations also have a pivotal role in mediating myogenesis in regenerating muscle (Guasconi and Puri, 2009).

Before myogenic gene expression, the SWI/SNF chromatin-remodeling complex first has to be activated to allow access of myogenic transcription factors to the muscle-specific gene promoters. Activation of the SWI/SNF chromatin-remodeling complex is mediated by coordinated activation of both p38 MAPK and AKT (Serra et al., 2007). Blockade of either kinase abolishes myogenesis (Cuenda and Cohen, 1999; de Angelis et al., 2005; Jiang et al., 1999; Perdiguero et al., 2007; Puri et al., 2000; Wu et al., 2000; Zetser et al., 1999). It has been known for sometime that myogenic activation of AKT is induced by IGF-I (Lawlor et al., 2000; Rommel et al., 2001; Tureckova et al., 2001). However, the signaling mechanism of myogenic activation of p38, particularly in adult muscle, emerged only recently. It was demonstrated in adult muscle that myogenic activation of p38 requires TNFα-receptor-mediated signaling (Chen et al., 2005). In addition, authors showed that in response to diverse myogenic cues, myoblasts release autocrine TNFα, which is crucial to myogenic activation of the MKK6–p38 pathway and ensuing myogenesis (Chen et al., 2007; Zhan et al., 2007). Moreover, TNFα-converting enzyme (TACE, also known as ADAM17), the disintegrin metalloproteinase (Black, 2002) that cleaves plasma membrane-anchored pro-TNFα (26 kDa) to release free TNFα (17 kDa), is rate limiting for myogenic activation of p38 (Zhan et al., 2007). These findings revealed a new signaling paradigm through which myogenic cues are transduced to activate myogenic gene expression via the activation of p38. In this study, they address the question of how myogenic cues stimulate TACE release of TNFα.

TACE activity is normally repressed by its physiological inhibitor tissue inhibitor of metalloproteinase 3 (TIMP3). TIMP3 is a member of the tissue inhibitor of metalloproteinase family that uniquely inhibits TACE (Amour et al., 1998). As a transmembrane protein, TACE is structurally related to the matrix metalloproteinases (MMPs) (Black, 2002). TIMP3 appears to inhibit TACE in the same way the TIMPs inhibit MMPs: by chelating the extracellular active-site zinc with its N-terminus (Gomis-Ruth et al., 1997; Lee et al., 2005). TIMP3 is the only one of four TIMPs that binds to the extracellular matrix (Mohammed et al., 2003) and possesses an amino acid sequence (PFG) necessary for inhibiting TACE (Lee et al., 2005). TIMP3 suppresses inflammation (Black, 2004; Smookler et al., 2006) and impedes cell migration (van der Laan et al., 2003). These effects of TIMP3 could be attributed to its inhibition of TACE release of TNFα, which mediates inflammation (Tracey and Cerami, 1992) and stimulates the chemotactic response (Torrente et al., 2003). Because TIMP3 is constitutively expressed in muscle cells of mice (Leco et al., 1994) and humans (Apte et al., 1994), this article hypothesized that it has a physiological role in suppressing myogenesis as an inhibitor of TACE, and that it has to be downregulated in response to myogenic cues to allow TACE release of autocrine TNFα and the ensuing activation of p38-dependent myogenesis. This study demonstrates that TIMP3 is downregulated in regenerating mouse muscle, particularly, myogenic progenitor cells (MPCs). Furthermore, downregulation of TIMP3 is required for release of TNFα, activation of p38 and ensuing myogenesis. This article also demonstrate that the downregulation of TIMP3 is mediated by microRNA-206 (miR-206).

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Specific primer sets for mouse Timp3:Forward: 5′-AAGGTACTAGAAACAGACTCCTCCAG-3′, and Reverse: 5′-TTGATACAGGACAAGAACTTGAGTG-3′
Duplexes of miR-1 and miR-206 microRNA : from Dharmacon

As with miR-1, miR-206 is induced in differentiating myoblasts (Rao et al., 2006) and regenerating muscle (Yuasa et al., 2008) by the muscle regulatory factors (MRFs) MyoD and Myf5 (Rosenberg et al., 2006; Sweetman et al., 2008); and has a crucial role in the promotion of myogenesis (Chen et al., 2006; Kim et al., 2006). However, the mechanism through which miR-206 promotes myogenesis is just emerging, despite the fact that miR-206 is predicted to target a long list of genes which includes Timp3 (McCarthy, 2008). This article indicates that miR-206 is the primary microRNA that downregulates TIMP3 expression during myogenesis. TIMP3 downregulation is part of the intrinsic myogenic program that activates myogenesis. In addition, a mechanism for miR-206 promotion of myogenesis is that miR-206 promotes myogenesis by serving as an upstream signal for myogenic activation of p38, a key mediator of cell cycle exit (Perdiguero et al., 2007), chromatin remodeling (Simone et al., 2004) and the activation of myogenic gene expression (de Angelis et al., 2005; Lluis et al., 2005; Wu et al., 2000).


文献2 TIMP3による糸球体・尿細管障害
Kassiri Z, Oudit GY, Kandalam V, Awad A, Wang X, Ziou X, Maeda N, Herzenberg AM, Scholey JW. Loss of TIMP3 enhances interstitial nephritis and fibrosis. J Am Soc Nephrol. 2009 Jun;20(6):1223-35.

Abstract
The balance of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) determines the integrity of the extracellular matrix. TIMP3 is the most highly expressed tissue inhibitor of metalloproteinase (TIMP) in the kidney, but its function in renal disease is incompletely understood. In this study, TIMP3-/- mice demonstrated an age-dependent chronic tubulointerstitial fibrosis. After unilateral ureteral obstruction (UUO), young TIMP3-/- mice exhibited increased renal injury (tubular atrophy, cortical and medullary thinning, and vascular damage) compared with wild-type mice. In addition, TIMP3-/- mice had greater interstitial fibrosis; increased synthesis and deposition of type I collagen; increased activation of fibroblasts; enhanced apoptosis; and greater activation of MMP2, but not MMP9, after UUO. TIMP3 deficiency also led to accelerated processing of TNFalpha, demonstrated by significantly higher TACE activity and greater soluble TNFalpha levels by 3 d after UUO. The additional deletion of TNFalpha markedly reduced inflammation, apoptosis, and induction of a number of MMPs. Moreover, inhibition of MMPs in TIMP3-/-/TNFalpha-/- mice further abrogated postobstructive injury and prevented tubulointerestitial fibrosis. In humans, TIMP3 expression increased in the renal arteries and proximal tubules of subjects with diabetic nephropathy or chronic allograft nephropathy. Taken together, these results provide evidence that TIMP3 is an important mediator of kidney injury, and regulating its activity may have therapeutic benefit for patients with kidney disease.


文献3 TNFα-mediated epithelial barrier disruption
Fréour T, Jarry A, Bach-Ngohou K, Dejoie T, Bou-Hanna C, Denis MG, Mosnier JF, Laboisse CL, Masson D. TACE inhibition amplifies TNF-alpha-mediated colonic epithelial barrier disruption. Int J Mol Med. 2009 Jan;23(1):41-8.

Abstract
Inflammatory bowel diseases (IBD) are characterized by tumor necrosis factor alpha (TNF-alpha)-mediated epithelial barrier disruption. TNF-alpha production and the bioavailability of its receptors on the cell surface are regulated by TACE (TNF-alpha converting enzyme), a pleiotropic metalloprotease also known as ADAM17, and its specific inhibitor TIMP3. We therefore examined ADAM17 and TIMP3 expression in human intestinal epithelial cells (IEC) using immunohistochemistry on tissue microarrays and real-time PCR on preparations of IEC isolated from human normal and IBD colon. The effects of TACE inhibition by TIMP3 or a pharmacological inhibitor were assessed in inflammatory conditions on a TIMP3-deficient colonic cell line HT29-Cl.16E. Both TACE and TIMP3 were found to be constitutively expressed by intestinal epithelial cells in the normal and inflammatory human intestinal barrier. In the TIMP3-deficient cell line, the addition of recombinant human TIMP3 or of Tapi-2, a pharmacological ADAM17 inhibitor, i) sensitized the cells to TNF-alpha-mediated hyperpermeability, ii) down-regulated tight junction-associated protein expression and iii) inhibited TNFRI shedding. In conclusion, our data showed that TACE and TIMP3 were co-expressed in the human intestinal barrier and that TACE inhibition, either physiologically or pharmacologically, amplified TNF-alpha-mediated hyperpermeability. TIMP3 could thus play a major role in inflammatory conditions by creating an autocrine effect leading to amplified epithelial barrier hyperpermeability.


文献4  Psoriasis-like inflammatory skin disease in sepsis
Guinea-Viniegra J, Zenz R, Scheuch H, Hnisz D, Holcmann M, Bakiri L, Schonthaler HB, Sibilia M, Wagner EF. TNFalpha shedding and epidermal inflammation are controlled by Jun proteins. Genes Dev. 2009 Nov 15;23(22):2663-74.

Abstract
Inducible epidermal deletion of JunB and c-Jun in adult mice causes a psoriasis-like inflammatory skin disease. Increased levels of the proinflammatory cytokine TNFalpha play a major role in this phenotype. Here we define the underlying molecular mechanism using genetic mouse models. We show that Jun proteins control TNFalpha shedding in the epidermis by direct transcriptional activation of tissue inhibitor of metalloproteinase-3 (TIMP-3), an inhibitor of the TNFalpha-converting enzyme (TACE). TIMP-3 is down-regulated and TACE activity is specifically increased, leading to massive, cell-autonomous TNFalpha shedding upon loss of both JunB and c-Jun. Consequently, a prominent TNFalpha-dependent cytokine cascade is initiated in the epidermis, inducing severe skin inflammation and perinatal death of newborns from exhaustion of energy reservoirs such as glycogen and lipids. Importantly, this metabolic "cachectic" phenotype can be genetically rescued in a TNFR1-deficient background or by epidermis-specific re-expression of TIMP-3. These findings reveal that Jun proteins are essential physiological regulators of TNFalpha shedding by controlling the TIMP-3/TACE pathway. This novel mechanism describing how Jun proteins control skin inflammation offers potential targets for the treatment of skin pathologies associated with increased TNFalpha levels.


文献5
Tsakadze NL, Sithu SD, Sen U, English WR, Murphy G, D'Souza SE. Tumor necrosis factor-alpha-converting enzyme (TACE/ADAM-17/CD156q) mediates the ectodomain cleavage of intercellular adhesion molecule-1 (ICAM-1). J Biol Chem. 2006 Feb 10;281(6):3157-64.

Abstract
Ectodomain shedding has emerged as an important regulatory step in the function of transmembrane proteins. Intercellular adhesion molecule-1 (ICAM-1), an adhesion receptor that mediates inflammatory and immune responses, undergoes shedding in the presence of inflammatory mediators and phorbol 12-myristate 13-acetate (PMA). The shedding of ICAM-1 in ICAM-1-transfected 293 cells upon PMA stimulation and in endothelial cells upon tumor necrosis factor-alpha stimulation was blocked by metalloproteinase inhibitors, whereas serine protease inhibitors were ineffective. p-Aminophenylmercuric acetate, a mercuric compound that is known to activate matrix metalloproteinases, up-regulated ICAM-1 shedding. TIMP-3 (but not TIMP-1 or -2) effectively blocked cleavage. This profile suggests the involvement of the ADAM family of proteases in the cleavage of ICAM-1. The introduction of enzymatically active tumor necrosis factor-alpha-converting enzyme (TACE) into ICAM-1-expressing cells up-regulated cleavage. Small interfering RNA directed against TACE blocked ICAM-1 cleavage. ICAM-1 transfected into TACE-/- fibroblasts did not show increased shedding over constitutive levels in the presence of PMA, whereas cleavage did occur in ICAM-1-transfected TACE+/+ cells. These results indicate that ICAM-1 shedding is mediated by TACE. Blocking the shedding of ICAM-1 altered the cell adhesive function, as ICAM-1-mediated cell adhesion was up-regulated in the presence of TACE small interfering RNA and TIMP-3, but not TIMP-1. However, cleavage was found to occur at multiple sites within the stalk domain of ICAM-1, and numerous point mutations within the region did not affect cleavage, indicating that TACE-mediated cleavage of ICAM-1 may not be sequence-specific.


文献6
Federici M, Hribal ML, Menghini R, Kanno H, Marchetti V, Porzio O, Sunnarborg SW, Rizza S, Serino M, Cunsolo V, Lauro D, Mauriello A, Smookler DS, Sbraccia P, Sesti G, Lee DC, Khokha R, Accili D, Lauro R. Timp3 deficiency in insulin receptor-haploinsufficient mice promotes diabetes and vascular inflammation via increased TNF-alpha. J Clin Invest. 2005 Dec;115(12):3494-505.

Abstract
Activation of inflammatory pathways may contribute to the beginning and the progression of both atherosclerosis and type 2 diabetes. Here we report a novel interaction between insulin action and control of inflammation, resulting in glucose intolerance and vascular inflammation and amenable to therapeutic modulation. In insulin receptor heterozygous (Insr+/-) mice, we identified the deficiency of tissue inhibitor of metalloproteinase 3 (Timp3, an inhibitor of both TNF-alpha-converting enzyme [TACE] and MMPs) as a common bond between glucose intolerance and vascular inflammation. Among Insr+/- mice, those that develop diabetes have reduced Timp3 and increased TACE activity. Unchecked TACE activity causes an increase in levels of soluble TNF-alpha, which subsequently promotes diabetes and vascular inflammation. Double heterozygous Insr+/-Timp3+/- mice develop mild hyperglycemia and hyperinsulinemia at 3 months and overt glucose intolerance and hyperinsulinemia at 6 months. A therapeutic role for Timp3/TACE modulation is supported by the observation that pharmacological inhibition of TACE led to marked reduction of hyperglycemia and vascular inflammation in Insr+/- diabetic mice, as well as by the observation of increased insulin sensitivity in Tace+/- mice compared with WT mice. Our results suggest that an interplay between reduced insulin action and unchecked TACE activity promotes diabetes and vascular inflammation.


文献7 Preadipocyte factor 1 (Pref-1) & TIMP3-TACE in the preadipocytes
Wang Y, Sul HS. Ectodomain shedding of preadipocyte factor 1 (Pref-1) by tumor necrosis factor alpha converting enzyme (TACE) and inhibition of adipocyte differentiation. Mol Cell Biol. 2006 Jul;26(14):5421-35.

Abstract
Preadipocyte factor 1 (Pref-1), an epidermal growth factor repeat containing transmembrane protein found in the preadipocytes, inhibits adipocyte differentiation in vitro and in vivo. Here, we examined the processing of membrane form of Pref-1A to release the 50-kDa soluble form that inhibits adipocyte differentiation. The ectodomain cleavage of Pref-1 is markedly enhanced by phorbol 12-myristate 13-acetate in a dose- and time-dependent manner. The basal and stimulated cleavage is inhibited by the broad metalloproteinase inhibitor GM6001, a fact that suggests that cleavage of membrane Pref-1A is dependent on a metalloproteinase. Next, we showed that release of soluble Pref-1A is inhibited by TAPI-0 and by a tissue inhibitor of metalloproteinase-3, TIMP-3, that can inhibit tumor necrosis factor alpha converting enzyme (TACE), but not by TIMP-1 or TIMP-2. On the other hand, overexpression of TACE increases Pref-1 cleavage to produce the 50-kDa soluble form. Furthermore, this cleavage was not detected in cells with TACE mutation or with TACE small interfering RNA. TACE-mediated shedding of Pref-1 ectodomain inhibits adipocyte differentiation of 3T3-L1 cells and in Pref-1-null mouse embryo fibroblasts transduced with Pref-1A. Identification of TACE as the major protease responsible for conversion of membrane-bound Pref-1 to the biologically active diffusible form provides a new insight into Pref-1 function in adipocyte differentiation.


文献8
Dada LA, Sznajder JI. Mitochondrial Ca²+ and ROS take center stage to orchestrate TNF-α-mediated inflammatory responses. J Clin Invest. 2011 May 2;121(5):1683-5.

Abstract
Proinflammatory stimuli induce inflammation that may progress to sepsis or chronic inflammatory disease. The cytokine TNF-α is an important endotoxin-induced inflammatory glycoprotein produced predominantly by macrophages and lymphocytes. TNF-α plays a major role in initiating signaling pathways and pathophysiological responses after engaging TNF receptors. In this issue of JCI, Rowlands et al. demonstrate that in lung microvessels, soluble TNF-α (sTNF-α) promotes the shedding of the TNF-α receptor 1 ectodomain via increased mitochondrial Ca²+ that leads to release of mitochondrial ROS. Shedding mediated by TNF-α-converting enzyme (TACE) results in an unattached TNF receptor, which participates in the scavenging of sTNF-α, thus limiting the propagation of the inflammatory response. These findings suggest that mitochondrial Ca²+, ROS, and TACE might be therapeutically targeted for treating pulmonary endothelial inflammation.


文献9 Erica MartinのLungにおけるTIMP3研究
Martin EL, Sheikh TA, Leco KJ, Lewis JF, Veldhuizen RA. Contribution of alveolar macrophages to the response of the TIMP-3 null lung during a septic insult. Am J Physiol Lung Cell Mol Physiol. 2007 Sep;293(3):L779-89.

Abstract
Mice deficient in tissue inhibitor of metalloproteinase-3 (TIMP-3) develop an emphysema-like phenotype involving increased pulmonary compliance, tissue degradation, and matrix metalloproteinase (MMP) activity. After a septic insult, they develop a further increase in compliance that is thought to be a result of heightened metalloproteinase activity produced by the alveolar macrophage, potentially modeling an emphysemic exacerbation. Therefore, we hypothesized that TIMP-3 null mice lacking alveolar macrophages would not be susceptible to the altered lung function associated with a septic insult. TIMP-3 null and wild-type (WT) mice were depleted of alveolar macrophages before the induction of a septic insult and assessed for alteration in lung mechanics, alveolar structure, metalloproteinase levels, and inflammation. The results showed that TIMP-3 null mice lacking alveolar macrophages were protected from sepsis-induced alterations in lung mechanics, particularly pulmonary compliance, a finding that was supported by changes in alveolar structure. Additionally, changes in lung mechanics involved primarily peripheral tissue vs. central airways as determined using the flexiVent system. From investigation into possible molecules that could cause these alterations, it was found that although several proteases and inflammatory mediators were increased during the septic response, only MMP-7 was attenuated after macrophage depletion. In conclusion, the alveolar macrophage is essential for the TIMP-3 null sepsis-induced compliance alterations. This response may be mediated in part by MMP-7 activity but occurs independently of inflammatory cytokine and/or chemokine concentrations.


次回 VHRG10月予定:'Do'nt eat me'シグナルとニッチ理論 プレゼンテータ 松田直之


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特別講演・公開講演会のお知らせ 成人教育とは何か ―経験を積んだ専門職が共に成長するために―

2011年09月14日 05時12分16秒 | お知らせ 講演会・セミナー

日時 平成23年9月17日(土曜日) 14:20~15:50

会場 兵庫県看護協会 ハーモニーホール
   兵庫県神戸市中央区下山手通5丁目6番24

市民公開講座「臨床指導に関する成人教育」

タイトル 専門職としての共感力の育成 ―経験を積んだ専門職が共に成長するために―

名古屋大学大学院医学系研究科 救急・集中治療医学分野 教授  松田直之


主催 兵庫県看護協会
〒650-0011 兵庫県神戸市中央区下山手通5丁目6番24
担当 : 資格認定教育部


50枚スライドを用いた講演とします。
近代経済哲学における思想を基盤とした教育の変遷や,教育の視点変換における難点を題材とし,VOICE理論についてもふれ,
成人教育における学びの意義と確認,教育者の視点変換,教育者の人的成長・社会的成長についても,できるだけ平易に論じます。広く「成人教育」や「社会教育」を共に考える機会としたいと思います。


【御礼・後記】100名を超える多くの教育者の皆さまにお集まり頂き,どうもありがとうございました。
改めて教育を考えるよい機会となり,私自身が,とても感謝しております。 2011年9月17日 PM 6:30


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文献 Legionella 肺炎と保健所届出の義務

2011年09月06日 12時39分46秒 | 論文紹介 臨床研究
レジオネラ菌は,1976年に米国ペンシルベニア州米国在郷軍人会大会において,参加者や周辺住民221人が原因不明の肺炎にかかり,34人が死亡したことで有名となった菌であり,在郷軍人 (legionnaire) にちなんで Legionella pneumophila と名づけられた。レジオネラ菌は鞭毛を持つちびちびぽつぽつとした大きさ2 - 5µmレベルの桿菌で,アカントアメーバなどのアメーバ類に寄生して増殖する。アカントアメーバは24時間風呂などの浴槽表面に生着しやすく,ここに寄生したレジオネラは37~41℃で繁殖しやすい。
 レジオネラ菌は糖を利用しないため,通常の細菌検査用培地では生育しない。このため,レジオネラ菌の培養には,エネルギー源として利用できるセリン,スレオニンなどの必須アミノ酸を加える必要がある。診断には,尿中レジオネラ抗原の検出,喀痰のヒメネス染色を用いる。レジオネラは肺浸潤において,肺胞上皮細胞や線維芽細胞に細胞内寄生する特徴がある。このため,宿主細胞に浸透することのできる抗菌薬として,ニューキノロン,エリスロマイシン,リファンピシンなどの抗菌薬が推奨されている。現在,低心機能状態でレジオネラ肺炎を併発している患者の治療を行っている。レジオネラ症は4類感染症に定められており,病原体診断や血清学的診断によりレジオネラ症を診断した医師は,直ちに最寄りの保健所に届け出る義務があるほど,劇症化して死に至る可能性のある菌種である。現在ポリクリにきている学生さんは,以下の論文も読んでみて下さい。


文献1. Int J Gen Med. 2011 Jan 6;4:15-9. PCRによるレジオネラ症の血清診断

Community-acquired pneumonia due to Legionella pneumophila, the utility of PCR, and a review of the antibiotics used.

Zarogoulidis P, Alexandropoulou I, Romanidou G, Konstasntinidis TG, Terzi E, Saridou S, Stefanis A, Zarogoulidis K, Constantinidis TC.

Source
Regional Laboratory of Public Health, East Macedonia-Thrace, Komotini, Greece. pzarog@hotmail.com

Abstract
INTRODUCTION:
There are at least 40 types of Legionella bacteria, half of which are capable of producing disease in humans. The Legionella pneumophila bacterium, the root cause of Legionnaires' disease, causes 90% of legionellosis cases.
CASE PRESENTATION:
We describe the case of a 60-year-old woman with a history of diabetes mellitus and arterial hypertension who was admitted to our hospital with fever and symptoms of respiratory infection, diarrhea, and acute renal failure. We used real-time polymerase chain reaction (PCR) to detect L. pneumophila DNA in peripheral blood and serum samples and urine antigen from a patient with pneumonia. Legionella DNA was detected in all two sample species when first collected.
CONCLUSION:
Since Legionella is a cause of 2% to 15% of all community-acquired pneumonias that require hospitalization, legionellosis should be taken into account in an atypical pulmonary infection and not be forgotten. Moreover, real-time PCR should be considered a useful diagnostic method.

L. pneumophila with a real-time polymerase chain reaction (PCR) kit (Aqua Screen L. pneumophila-detection kit for real-time PCR; Minerva Biolabs, Minerva, OH)を用いたレジオネラ検出。

文献2. Aust Fam Physician. 2008 Oct;37(10):812-5. レジオネラは下痢を合併しやすい

Could it be Legionella?

Darby J, Buising K.

Source
Infectious Diseases Unit, St Vincent's Hospital, Fitzroy, Victoria. jonathan.darby@svhm.org.au

Abstract
BACKGROUND:
Community acquired pneumonia is a common condition presenting to general practitioners and emergency departments across Australia. Legionella is one of many pathogens responsible for community acquired pneumonia. Cases of Legionella may occur sporadically or as part of an outbreak.
OBJECTIVE:
This article describes the clinical manifestations of Legionella infection and provides clinicians with an approach to its diagnosis and management.
DISCUSSION:
Legionella infection is typically associated with community acquired pneumonia, which can be severe. Features pointing to Legionella as a cause of pneumonia include the presence of gastrointestinal symptoms, especially diarrhoea; neurological symptoms, especially confusion; fever up to 40 degrees C; hyponatraemia; and hepatic dysfunction. However, none of these is required to make the diagnosis. Sometimes nonrespiratory symptoms can predominate. Diagnosis requires the use of special tests specific for Legionella, the most clinically useful being urinary antigen tests and serology. Recommended treatments include macrolide therapy or doxycycline.

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文献 特発性肺線維症 Cochrane Database Syst Rev. 2010 Sep 8;(9):CD003134.

2011年09月06日 06時41分39秒 | 論文紹介 臨床研究
Non-steroid agents for idiopathic pulmonary fibrosis

Spagnolo P, Del Giovane C, Luppi F, Cerri S, Balduzzi S, Walters EH, D'Amico R, Richeldi L.

Source
Center for Rare Lung Disease, University of Modena and Reggio Emilia, Modena Italy and Respiratory Disease Section, Department of Oncology, Hematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy.

Abstract
BACKGROUND:
Idiopathic pulmonary fibrosis is a chronic progressive lung disease with poor outcome and no effective treatment to date. This is an update of a Cochrane Review first published in 2003.
OBJECTIVES:
To assess the efficacy of non-steroid agents in adults with idiopathic pulmonary fibrosis.
SEARCH STRATEGY:
We searched the Cochrane Airways Group Register (30 March 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2010), Ovid MEDLINE to March week 5, 2010, EMBASE to week 13, 2010 and PubMed to April 2010, with additional handsearching, including abstracts of international conferences. We also contacted pharmaceutical companies and researchers in the field.
SELECTION CRITERIA:
Randomised studies comparing non-steroid drugs with placebo or steroids in adults with idiopathic pulmonary fibrosis.
DATA COLLECTION AND ANALYSIS:
Two authors independently assessed trial quality, extracted data and assessed risk of bias. We contacted pharmaceutical companies to obtain missing information, if any. We combined survival outcomes using Peto odds ratios or hazard ratios (HR).
MAIN RESULTS:
Fifteen trials involving 10 different drugs were included. Two trials enrolling 1156 patients compared interferon gamma-1beta with placebo: interferon gamma-1beta did not significantly improve survival (HR 0.88, 95% CI 0.47 to 1.64; P = 0.68). Four trials involving 1155 patients compared pirfenidone with placebo. Three trials, conducted in 1046 patients, provided data on progression-free survival: pirfenidone significantly reduced the risk of disease progression by 30% (HR 0.70, 95% CI 0.56 to 0.88, P = 0.002). Data on the effect of pirfenidone on pulmonary function could only be assessed for two studies analysing 314 patients. Forced vital capacity or vital capacity was significantly improved by pirfenidone (mean difference 0.08 L, 95% CI 0.03 to 0.13, P = 0.0006).
AUTHORS' CONCLUSIONS:
Based on available data, partly still unpublished, pirfenidone appears to improve progression-free survival and, to a lesser extent, pulmonary function in patients with idiopathic pulmonary fibrosis. More data are needed on overall survival and quality of life on treatment. From the studies in this review, interferon gamma-1beta has not been shown to affect survival. Other agents evaluated in single studies either failed to provide evidence for a benefit or need to be assessed in larger randomised controlled trials.

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