Neutrophil extracellular traps promote intestinal barrier dysfunction by regulating macrophage polarization during trauma/hemorrhagic shock via the TGF-β signaling pathway

The mechanism by which neutrophil extracellular traps (NETs) may cause intestinal barrier dysfunction in response to trauma/hemorrhagic shock (T/HS) remains unclear. In this study, the roles and mechanisms of NETs in macrophage polarization were examined to determine whether this process plays a role in tissue damage associated with T/HS. Rat models of T/HS and macrophage polarization were developed and the levels of NETs formation in the intestinal tissue of T/HS rats were assessed. NET formation was inhibited in models of T/HS to examine the effect on intestinal inflammation and barrier injury. The proportions of pro-inflammatory and anti-inflammatory macrophages in the damaged intestinal tissues were measured. Finally, high-throughput sequencing was performed to investigate the underlying mechanisms involved in this process. The study revealed that the level of NETs formation was increased and that inhibition of NETs formation alleviated the intestinal inflammation and barrier injury. Moreover, the number of pro-inflammatory macrophages increased and the number of anti-inflammatory macrophages decreased. RNA sequencing analysis indicated that NETs formation decreased the expression of transforming growth factor-beta receptor 2 (TGFBR2), bioinformatic analyses revealed that TGFBR2 was significantly enriched in the transforming growth factor-beta (TGF-β) signaling pathway. Verification experiments showed that NETs impeded macrophage differentiation into the anti-inflammatory/M2 phenotype and inhibited TGFBR2 and TGF-β expression in macrophages. However, treatment with DNase I and overexpression of TGFBR2, and inhibition of TGF-β promoted and prevented this process, respectively. NETs may regulate the macrophage polarization process by promoting intestinal barrier dysfunction in T/HS rats through the TGFBR2-mediated TGF-β signaling pathway.

Neutrophil extracellular traps aggravate intestinal epithelial necroptosis in ischaemia-reperfusion by regulating TLR4/RIPK3/FUNDC1-required mitophagy

Neutrophil extracellular trap (NET) has been confirmed to be related to gut barrier injury during intestinal ischaemia-reperfusion (II/R). However, the specific molecular regulatory mechanism of NETs in II/R-induced intestinal barrier damage has yet to be fully elucidated. Here, we reported increased NETs infiltration accompanied by elevated inflammatory cytokines, cellular necroptosis and tight junction disruption in the intestine of human II/R patients. Meanwhile, NETs aggravated Caco-2 intestinal epithelial cell necroptosis, impairing the monolayer barrier in vitro. Moreover, Pad4-deficient mice were used further to validate the role of NETs in II/R-induced intestinal injury. In contrast, NET inhibition via Pad4 deficiency alleviated intestinal inflammation, attenuated cellular necroptosis, improved intestinal permeability, and enhanced tight junction protein expression. Notably, NETs prevented FUN14 domain-containing 1 (FUNDC1)-required mitophagy activation in intestinal epithelial cells, and stimulating mitophagy attenuated NET-associated mitochondrial dysfunction, cellular necroptosis, and intestinal damage. Mechanistically, silencing Toll-like receptor 4 (TLR4) or receptor-interacting protein kinase 3 (RIPK3) via shRNA relieved mitophagy limitation, restored mitochondrial function and reduced NET-induced necroptosis in Caco-2 cells, whereas this protective effect was reversed by TLR4 or RIPK3 overexpression. The regulation of TLR4/RIPK3/FUNDC1-required mitophagy by NETs can potentially induce intestinal epithelium necroptosis.

Open or Not Open the Retroperitoneum: A Pandora's Box for Blunt High-Grade Pancreatic Trauma?

INTRODUCTION

The optimal management strategy for pancreatic trauma remains unclear. We aimed to determine whether the initial nonoperative management (NOM) strategy based on percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement would improve outcomes for blunt high-grade pancreatic trauma.

METHODS

Patients with blunt abdominal trauma who were hemodynamically stable without signs of diffuse peritonitis were consecutively enrolled at a high-volume center. The primary outcome was the occurrence of severe complications (Clavien‒Dindo classification ≥ Ⅲb) for patients who underwent initial laparotomy (LAP) versus NOM. Modified Poisson regression was used to model the primary outcome. Propensity score matching and weighting models were included into a regression-based sensitivity analysis.

RESULTS

Of 119 patients with grade III/IV pancreatic trauma, 29 patients underwent initial NOM, and 90 underwent initial LAP. The incidence of severe complications in the LAP group was higher than that in the NOM group (65/90 [72.2%] versus 9/29 [31.0%], P < 0.001). In the multivariable modified Poisson regression model, the relative risk for severe complications was decreased in the NOM group (relative risk, 0.52; 95% confidence interval, 0.30-0.90; P = 0.020). The results of the sensitivity analysis were consistent with those of the multivariable analysis. The mean number of reinterventions per patient was 1.8 in the NOM group and 2.6 in the LAP group (P = 0.067).

CONCLUSIONS

For blunt high-grade pancreatic trauma patients with stable hemodynamics and no diffuse peritonitis, the NOM strategy was associated with a lower risk of severe complications (Clavien‒Dindo classification ≥ Ⅲb) and did not require more invasive reintervention procedures. In high-volume centers with sufficient expertise, percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement may serve as an initial reasonable option for selected patients.

Neutrophil extracellular traps drive intestinal microvascular endothelial ferroptosis by impairing Fundc1-dependent mitophagy

Microvascular endothelial damage caused by intestinal ischemia‒reperfusion (II/R) is a primary catalyst for microcirculation dysfunction and enterogenous infection. Previous studies have mainly focused on how neutrophil extracellular traps (NETs) and ferroptosis cause intestinal epithelial injury, and little attention has been given to how NETs, mainly from circulatory neutrophils, affect intestinal endothelial cells during II/R. This study aimed to unravel the mechanisms through which NETs cause intestinal microvascular dysfunction. We first detected heightened local NET infiltration around the intestinal microvasculature, accompanied by increased endothelial cell ferroptosis, resulting in microcirculation dysfunction in both human and animal II/R models. However, the administration of the ferroptosis inhibitor ferrostatin-1 or the inhibition of NETs via neutrophil-specific peptidylarginine deiminase 4 (Pad4) deficiency led to positive outcomes, with reduced intestinal endothelial ferroptosis and microvascular function recovery. Moreover, RNA-seq analysis revealed a significant enrichment of mitophagy- and ferroptosis-related signaling pathways in HUVECs incubated with NETs. Mechanistically, elevated NET formation induced Fundc1 phosphorylation at Tyr18 in intestinal endothelial cells, which led to mitophagy inhibition, mitochondrial quality control imbalance, and excessive mitochondrial ROS generation and lipid peroxidation, resulting in endothelial ferroptosis and microvascular dysfunction. Nevertheless, using the mitophagy activator urolithin A or AAV-Fundc1 transfection could reverse this process and ameliorate microvascular damage. We first demonstrate that increased NETosis could result in intestinal microcirculatory dysfunction and conclude that suppressed NET formation can mitigate intestinal endothelial ferroptosis by improving Fundc1-dependent mitophagy. Targeting NETs could be a promising approach for treating II/R-induced intestinal microcirculatory dysfunction.

IL-1β-pretreated bone mesenchymal stem cell-derived exosomes alleviate septic endoplasmic reticulum stress via regulating SIRT1/ERK pathway

Background

Endoplasmic reticulum (ER) plays a crucial role in the development of organ injury caused by sepsis. Therefore, it is highly important to devise strategies that specially target ER stress for the treatment of sepsis. Previous research has shown that priming chemokines can enhance the therapeutic effects of mesenchymal stem cells (MSCs). In this study, we aimed to investigate the function and mechanism of exosomes derived from MSCs that were pretreated with IL-1β (IB-exos) in the context of septic ER stress.

Methods

Mouse bone MSCs were preconditioned with or without IL-1β and the supernatant was used for exosome extraction. In vitro sepsis cell mode was induced by treating HUVECs with LPS, while in vivo sepsis model was established through cecal ligation and puncture (CLP) operation in mice. Cell viability, apoptosis, motility, and tube formation were assessed using the EDU proliferation assay, flow cytometry analysis, migration assay, and tube formation assay, respectively. The molecular mechanism was investigated using ELISA, qRT-PCR, Western blot, and immunofluorescence staining.

Results

Pretreatment with IL-1β enhanced the positive impact of MSC-exos on the viability, apoptosis, motility, and tube formation ability of HUVECs. The administration of LPS or CLP increased ER stress response, but this effect was blocked by the treatment of IB-exos. Additionally, IB-exos reversed the inhibitory effects of LPS or CLP on the expression levels of SIRT1 and ERK phosphorylation. Knockdown of SIRT1 counteracted the effects of IB-exos on HUVEC cellular function and ER stress. In a mouse model, the injection of IB-exos mitigated sepsis-induced lung injury by inhibiting ER stress response through the activation of SIRT1.

Conclusion

IB-exos have been found to alleviate sepsis-induced lung injury via inhibiting ER stress through the SIRT1/ERK pathway. These findings indicated that IB-exos could potentially be used as a strategy to mitigate lung injury caused by sepsis.

Initial suction drainage decreases severe postoperative complications after pancreatic trauma: A cohort study

BACKGROUND

Few studies have addressed the question of which drain types are more beneficial for patients with pancreatic trauma (PT).

AIM

To investigate whether sustained low negative pressure irrigation (NPI) suction drainage is superior to closed passive gravity (PG) drainage in PT patients.

METHODS

PT patients who underwent pancreatic surgery were enrolled consecutively at a referral trauma center from January 2009 to October 2021. The primary outcome was defined as the occurrence of severe complications (Clavien-Dindo grade ≥ Ⅲb). Multivariable logistic regression was used to model the primary outcome, and propensity score matching (PSM) was included in the regression-based sensitivity analysis.

RESULTS

In this study, 146 patients underwent initial PG drainage, and 50 underwent initial NPI suction drainage. In the entire cohort, a multivariable logistic regression model showed that the adjusted risk for severe complications was decreased with NPI suction drainage [14/50 (28.0%) vs 66/146 (45.2%); odds ratio (OR), 0.437; 95% confidence interval (CI): 0.203-0.940]. After 1:1 PSM, 44 matched pairs were identified. The proportion of each operative procedure performed for pancreatic injury-related and other intra-abdominal organ injury-related cases was comparable in the matched cohort. NPI suction drainage still showed a lower risk for severe complications [11/44 (25.0%) vs 21/44 (47.7%); OR, 0.365; 95%CI: 0.148-0.901]. A forest plot revealed that NPI suction drainage was associated with a lower risk of Clavien-Dindo severity in most subgroups.

CONCLUSION

This study, based on one of the largest PT populations in a single high-volume center, revealed that initial NPI suction drainage could be recommended as a safe and effective alternative for managing complex PT patients.

Allogeneic platelet gel therapy for refractory abdominal wound healing: A preliminary study

BACKGROUND

Refractory abdominal wounds are commonly complicated by surgical site infections, which prolong hospital stays and increase medical costs. There is little clinical data on the use of allogeneic platelet gel (PG) therapy for refractory infected wounds.

OBJECTIVES

This study aimed to evaluate the efficacy and safety of allogeneic PGs in the treatment of refractory abdominal wounds.

MATERIAL AND METHODS

A prospective single-center study was performed in a national abdominal trauma referral center between June 2019 and June 2021. A total of 11 patients with refractory abdominal wounds were treated with allogeneic PGs after the failure of standard medical treatments. The PGs were derived from platelets collected from healthy donors using apheresis, and each PG was tested for platelet count, transfusion-related diseases, aerobic and anaerobic bacteria, and growth factor concentration. Clinical efficacy was evaluated by assessing the wound surface and observing the condition of the wound, including wound area and percentage of granulation.

RESULTS

The median age of the patients was 37 years (1st quartile, 3rd quartile (Q1, Q3): 31-55 years), median (Q1, Q3) hemoglobin level was 95 g/L (78-120 g/L) and median (Q1, Q3) serum albumin level was 39.9 g/L (34.9-42.7 g/L). The PG platelet count was 976.5 ±174.9×109/L. Results of transfusion-associated contagion tests for aerobic and anaerobic bacteria were negative. Growth factor contents (pg/mL) were: for transforming growth factor beta 1 (TGF-β1); 2542.39 ±430.60, for platelet-derived growth factor BB (PDGF-BB); 23230.03 ±4236.14 and FOR vascular endothelial growth factor (VEGF); 91.41 ±23.31. The rate of wound healing was 100%, and the median (Q1, Q3) healing time was 30 days (18-40 days). The follow-up period was 5-27 months, during which no recurrence of the wounds was found.

CONCLUSIONS

The present study demonstrated that allogeneic PGs are a safe and effective treatment for refractory abdominal wounds.

CircSNX25 mediated by SP1 promotes the carcinogenesis and development of triple-negative breast cancer

Circular RNAs (circRNAs), according to a growing body of research, are thought to be important in the initiation and development of a number of cancers. However, more research is needed to fully understand how circRNAs work at the molecular level in triple-negative breast cancer (TNBC). RNA sequencing was conducted on four sets of TNBC samples and their corresponding adjacent noncancerous tissues (ANTs). The circSNX25 expression was assessed using quantitative real-time PCR in TNBC tissues and cells. Several in vitro and in vivo experiments were conducted in order to examine the function of circSNX25 in TNBC carcinogenesis. Through luciferase reporter and chromatin immunoprecipitation (ChIP) assays, we also investigated the potential regulation of circSNX25 biogenesis by specificity protein 1 (SP1). To further validate the relationship between circSNX25 and COPI coat complex subunit beta 1 (COPB1) in TNBC, we conducted circRNA pull-down and RNA immunoprecipitation (RIP) assays using the MS2/MS2-CP system. Online databases were analyzed to examine the clinical implications and prognostic value of COPB1 in TNBC. A higher circSNX25 expression levels were observed in tissues and cells of TNBC. Silencing circSNX25 notably inhibited TNBC cell proliferation, triggered apoptosis, and hindered tumor growth in vivo. Conversely, upregulation of circSNX25 had the opposite effects. Mechanistically, circSNX25 was found to physically interact with COPB1. Importantly, we identified that SP1 may enhance circSNX25 biogenesis. COPB1 levels were markedly higher in TNBC cells. Analysis of online databases revealed that TNBC patients with elevated COPB1 levels had a poorer prognosis. Our findings demonstrate that SP1-mediated circSNX25 promotes TNBC carcinogenesis and development. CircSNX25 may therefore serve as both a diagnostic and therapeutic biomarker for TNBC patients.

Association of longitudinal changes in skeletal muscle mass with prognosis and nutritional intake in acutely hospitalized patients with abdominal trauma: a retrospective observational study

Background

The objective of this study was to explore whether longitudinal changes in skeletal muscle mass, from hospital admission to 3  weeks post-trauma, are associated with poor prognosis and nutritional intake in acutely hospitalized patients with abdominal trauma.

Methods

A single-center retrospective observational review was conducted on 103 patients with abdominal trauma admitted to the Affiliated Jinling Hospital, Medical School of Nanjing University between January 2010 and April 2020. Skeletal muscle mass was assessed by abdominal computed tomography (CT) performed within 14 days before surgery and on post-trauma days 1-3 (week 0), 7-10 (week 1), 14-17 (week 2), and 21-24 (week 3). The skeletal muscle index (SMI) at L3, change in SMI per day (ΔSMI/day), and percent change in SMI per day (ΔSMI/day [%]) were calculated. The receiver-operating characteristic (ROC) curve was used to evaluate the discriminatory performance of ΔSMI/day (%) for mortality. Linear correlation analysis was used to evaluate the associations between ΔSMI/day (%) and daily caloric or protein intake.

Results

Among the included patients, there were 91 males and 12 females (mean age ± standard deviation 43.74 ± 15.53 years). ΔSMI_4-1/d (%) had a ROC-area under the curve of 0.747 (p = 0.048) and a cut-off value of -0.032 for overall mortality. There were significant positive correlations between ΔSMI_4-1/d (%) and daily caloric intake and protein intake (Y = 0.0007501*X - 1.397, R² = 0.282, R = 0.531, p < 0.001; Y = 0.008183*X - 0.9228, R² = 0.194, R = 0.440, p < 0.001). Δ SMI/day (%) was positively correlated with daily caloric intake ≥80% of resting energy expenditure in weeks 2, 3, and 1-3 post-trauma and with protein intake >1.2 g/kg/d in weeks 3 and 1-3 post-trauma.

Conclusion

Loss of skeletal muscle mass is associated with poor prognosis and nutritional intake in patients admitted to hospital with abdominal trauma.

Bioinspired Hemostatic Strategy via Pulse Ejections for Severe Bleeding Wounds

Efficient hemostasis during emergency trauma with massive bleeding remains a critical challenge in prehospital settings. Thus, multiple hemostatic strategies are critical for treating large bleeding wounds. In this study, inspired by bombardier beetles to eject toxic spray for defense, a shape-memory aerogel with an aligned microchannel structure was proposed, employing thrombin-carrying microparticles loaded as a built-in engine to generate pulse ejections for enhanced drug permeation. Bioinspired aerogels, after contact with blood, can rapidly expand inside the wound, offering robust physical barrier blocking, sealing the bleeding wound, and generating a spontaneous local chemical reaction causing an explosive-like generation of CO₂ microbubbles, which provide propulsion thrust to accelerate burst ejection from arrays of microchannels for deeper and faster drug diffusion. The ejection behavior, drug release kinetics, and permeation capacity were evaluated using a theoretical model and experimentally demonstrated. This novel aerogel showed remarkable hemostatic performance in severely bleeding wounds in a swine model and demonstrated good degradability and biocompatibility, displaying great potential for clinical application in humans.

Hesperetin attenuates sepsis-induced intestinal barrier injury by regulating neutrophil extracellular trap formation via the ROS/autophagy signaling pathway

Background: Hesperetin (HES), one of the major flavonoids that has various biological activities, such as anti-inflammatory and antioxidant activities, may preserve the intestinal barrier during sepsis. However, the detailed mechanism remains unclear. Our previous studies confirmed that neutrophil extracellular traps (NETs) may jeopardize the intestinal barrier via a reactive oxygen species (ROS)-dependent pathway during sepsis. Therefore, we hypothesized that HES may inhibit NET formation and protect the intestinal barrier function during sepsis. Methods: Mice were pretreated with HES (50 mg kg^-1) intraperitoneally for one week, and sepsis models were then induced using lipopolysaccharides (LPS) (10 mg kg^-1). The mice were randomly divided into three groups: (1) sham group; (2) LPS group; and (3) HES + LPS group. Twenty-four hours after LPS injection, the serum and terminal ileum specimens were collected for subsequent studies. To detect ROS production and NET formation in vitro, human neutrophils were collected and incubated with phorbol-12-myristate-13-acetate (PMA) and various concentrations of HES. The level of autophagy was measured by an immunofluorescence assay and western blot analysis. TUNEL staining was utilized to analyze cell apoptosis. Results: The outcomes demonstrated that HES decreased inflammatory cytokine and myeloperoxidase (MPO) levels in serum and attenuated distant organ dysfunction in LPS-induced septic mice. Meanwhile, HES treatment reversed intestinal histopathological damage in septic mice, improving intestinal permeability and enhancing tight junction expression. Moreover, we found that neutrophil infiltration and NET formation in the intestine were suppressed during sepsis after HES pretreatment. In vitro, HES treatment reduced PMA-induced ROS production and NET formation, which were reversed by hydrogen peroxide (H₂O₂) administration. Notably, HES also inhibited NET formation by reducing the microtubule-associated protein light chain 3 (LC3)-II/LC3-I ratio (an indicator of autophagy) in PMA-induced neutrophils, which was reversed by rapamycin. Moreover, when autophagy was suppressed by chloroquine or induced by rapamycin, apoptosis in cells will be switched with autophagy. Conclusion: Taken together, these findings suggest that HES may inhibit NET formation in a ROS/autophagy-dependent manner and switch neutrophil death from NETosis to apoptosis, which reduced NETs-related intestinal barrier damage, providing a novel protective role in intestinal barrier dysfunction during sepsis.

Sequential Changes in the Body Composition and Metabolic Response after Pancreatic Trauma

OBJECTIVES

Pancreatic trauma and subsequent pancreatic operation result in early pathophysiologic alterations. Understanding changes in energy expenditure and body composition is essential for optimal management. This study aims to observe changes in energy expenditure and body composition in patients during the early postoperative days (PODs) after pancreatic trauma.

METHODS

This is a retrospective review of patients who underwent surgery for blunt pancreatic trauma in a single trauma center. Data of body composition by bioimpedance spectroscopy and energy expenditure by indirect calorimetry were collected and analyzed in patients during the early PODs. The association of body composition parameters with major complications was analyzed.

RESULTS

Forty-one patients were included. Compared with POD-3, the total body water, extracellular water, fat-free mass, and skeletal muscle mass on POD-7 and -14 decreased significantly (all P < 0.05). The phase angle (PhA) increased significantly from POD-3 to -14 (P < 0.05). Resting energy expenditure was significantly higher than predicted and remained high throughout the study period. Over the 14-d study period, delivered energy was escalated to the level of resting energy expenditure. The PhA was significantly lower in patients with severe morbidity than in those without (3.6 [3.3-4.2] versus 4.5 [4.2-5.0]; P < 0.001). A multivariate analysis found that PhA was the independent variable for severe complications, with an odds ratio of 0.069 (95% CI, 0.011-0.427; P = 0.004). The predictive ability of PhA revealed an area under the receiver operating characteristic curve of 0.837, with an optimal threshold of 4.23.

CONCLUSIONS

Changes in body composition and hypermetabolism state were observed from POD-3 to -14 after pancreatic trauma. A postoperative value of PhA < 4.23 is associated with severe complications.

Persistent fibrinolysis shutdown is associated with increased mortality in traumatic pancreatic injury

PURPOSE

The features of fibrinolytic system modifications and their relationship with prognosis are still unknown in traumatic pancreatic injury. The object of this prospective cohort research was to identify fibrinolytic characteristics in patients with pancreatic trauma and to identify the correlation to mortality.

METHOD

A prospective screening of traumatic pancreatic injury patients was done for five years. The fibrinolytic status of patients was determined by thromboelastography (TEG). The percentage reduction in clot strength 30 min (LY30) after the time of maximal clot strength was utilized to distinguish the fibrinolytic phenotype of individuals, including fibrinolytic shutdown (SD), physiologic fibrinolysis (PHYS) and hyperfibrinolysis (HF). Two cohorts, transient fibrinolytic shutdown (TSD) and persistent fibrinolytic shutdown (PSD), were divided according to whether fibrinolytic shutdown persisted within one week. Demographics, injury severity, characteristics of pancreatic injury, treatment, and outcomes were compared.

RESULT

A total of 180 cases enrolled, aged 42(interquartile range 32-51) years, 88% males, 97% were blunt trauma. The median ISS was 19(IQR 10-25), and 76% were AAST grade III to V (high-grade). At admission, there were 159 cases of SD (88%), 15 cases of PHYS (8%) while 6 cases of HF (3%). Of these, the TSD cohort included 54 patients (34%), while the PSD cohort included 105 patients (66%). Compared with the TSD cohort, the PSD cohort had more severe injury (ISS 21[IQR 12-27] vs 16[IQR 9-22], p = 0.006) and a higher proportion of AAST high-grade (83% vs 67%, p = 0.035). Persistent fibrinolytic shutdown was associated with operative treatment (odds ratio [OR] 3.111; 95%CI 1.146-8.447; p = 0.026), associated intra-abdominal injury (OR 8.331; 95% CI 1.301-53.336; p = 0.025) and admission LY30 (OR 0.016; 95% CI 0.002 - 0.120; p < 0.001). It was an independent predictor of mortality (adjusted odds ratio [AOR] 4.674; 95% CI 1.03 to 21.14; p = 0.045).

CONCLUSION

Fibrinolytic shutdown especially persistence of this phenotype is more common in traumatic pancreatic injury than PHYS and HF, which related with mortality. Risk factors including LY30 at admission, intra-abdominal injury and operative treatment were associated with the persistent fibrinolytic shutdown. Sheltered the patients from these risk factors seems to be beneficial, which need to be confirmed by further large-scale studies.

Multiple portions enteral nutrition and chyme reinfusion of a blunt bowel injury patient with hyperbilirubinemia undergoing open abdomen: A case report

Blunt bowel injury (BBI) is relatively rare but life-threatening when delayed in surgical repair or anastomosis. Providing enteral nutrition (EN) in BBI patients with open abdomen after damage control surgery is challenging, especially for those with discontinuity of the bowel. Here, we report a 47-year-old male driver who was involved in a motor vehicle collision and developed ascites on post-trauma day 3. Emergency exploratory laparotomy at a local hospital revealed a complete rupture of the jejunum and then primary anastomosis was performed. Postoperatively, the patient was transferred to our trauma center for septic shock and hyperbilirubinemia. Following salvage resuscitation, damage control laparotomy with open abdomen was performed for abdominal sepsis, and a temporary double enterostomy (TDE) was created where the anastomosis was ruptured. Given the TDE and high risk of malnutrition, multiple portions EN were performed, including a proximal portion EN support through a nasogastric tube and a distal portion EN via a jejunal feeding tube. Besides, chyme delivered from the proximal portion of TDE was injected into the distal portion of TDE via a jejunal feeding tube. Hyperbilirubinemia was alleviated with the increase in chyme reinfusion. After 6 months of home EN and chyme reinfusion, the patient finally underwent TDE reversal and abdominal wall reconstruction and was discharged with a regular diet. For BBI patients with postoperative hyperbilirubinemia who underwent open abdomen, the combination of multiple portions EN and chyme reinfusion may be a feasible and safe option.

Mechanisms and prevention of intestinal barrier function damage in traumatic hemorrhagic shock

The intestinal barrier is composed of mechanical barrier, chemical barrier, immune barrier, and microbial barrier, which has an important role in defense against microbial invasion. The components of intestinal barrier coordinate with each other under physiological conditions to maintain the homeostasis of intestinal internal and external environment. In traumatic hemorrhagic shock, intestinal barrier function is prone to be impaired by intestinal hypoperfusion, intestinal ischemia-reperfusion injury, and many other factors. Bacterial translocation and endotoxin entry into the blood may occur, leading to enterogenic infection, multiple organ dysfunction, and even death. At present, there are many conceptual updates and technical progress on the mechanisms, prevention, and treatment of intestinal barrier function injury in traumatic hemorrhagic shock both at home and abroad. This paper intends to make a literature review in this field based on the previous research of our team, in order to provide a systematic and comprehensive theoretical system for the clinical prevention and treatment of post-traumatic intestinal dysfunction related diseases.

Dual-Driven Hemostats Featured with Puncturing Erythrocytes for Severe Bleeding in Complex Wounds

Achieving rapid hemostasis in complex and deep wounds with secluded hemorrhagic sites is still a challenge because of the difficulty in delivering hemostats to these sites. In this study, a Janus particle, SEC-Fe@CaT with dual-driven forces, bubble-driving, and magnetic field– (MF–) mediated driving, was prepared via in situ loading of Fe₃O₄ on a sunflower sporopollenin exine capsule (SEC), and followed by growth of flower-shaped CaCO₃ clusters. The bubble-driving forces enabled SEC-Fe@CaT to self-diffuse in the blood to eliminate agglomeration, and the MF-mediated driving force facilitated the SEC-Fe@CaT countercurrent against blood to access deep bleeding sites in the wounds. During the movement in blood flow, the meteor hammer-like SEC from SEC-Fe@CaT can puncture red blood cells (RBCs) to release procoagulants, thus promoting activation of platelet and rapid hemostasis. Animal tests suggested that SEC-Fe@CaT stopped bleeding in as short as 30 and 45 s in femoral artery and liver hemorrhage models, respectively. In contrast, the similar commercial product Celox™ required approximately 70 s to stop the bleeding in both bleeding modes. This study demonstrates a new hemostat platform for rapid hemostasis in deep and complex wounds. It was the first attempt integrating geometric structure of sunflower pollen with dual-driven movement in hemostasis.

De-escalation antibiotic therapy alleviates organ injury through modulation of NETs formation during sepsis

Empiric broad-spectrum antimicrobials therapy is suggested to be started immediately for sepsis patients. Empiric antimicrobial therapy should be narrowed once pathogen identification and sensitivities are established. However, the detailed mechanisms of de-escalation strategy are still unclear. Here we hypothesized neutrophil extracellular traps (NETs) played an essential role and de-escalation strategy might alleviate organs injury through regulation of NETs formation in sepsis. We evaluated the effect of imipenem and ceftriaxone on NETs formation in vitro and examined the role of reactive oxygen species (ROS). Next, we designed de-escalation and escalation strategy in cecum ligation and puncture (CLP) models. Organ injury, inflammatory cytokines, NETs levels were compared and evaluated. In CLP models, de-escalation therapy resulted in an increased serum MPO-DNA level during the early stage and decreased MPO-DNA level during late stage, which exerted the reverse effects in escalation therapy. Inflammatory response and organ injury exacerbated when eliminated NETs with DNAse I during the early stage of sepsis (p < 0.01). Histopathological analysis showed decreased injury in lung, liver, and intestine in de-escalation therapy compared with escalation therapy (p < 0.01). De-escalation therapy results in the highest 6-day survival rate compared with the control group (p < 0.01), however, no significant difference was found between de-escalation and escalation group (p = 0.051). The in vitro study showed that the imipenem could promote, while the ceftriaxone could inhibit the formation of NETs in PMA-activated PMNs through a ROS-dependent manner. We firstly demonstrate that de-escalation, not escalation, therapy reduces organ injury, decreases inflammatory response by promoting NETs formation in the early stage, and inhibiting NETs formation in the late stage of sepsis.

Neutrophil extracellular traps impair intestinal barrier functions in sepsis by regulating TLR9-mediated endoplasmic reticulum stress pathway

Increased neutrophil extracellular traps (NETs) formation has been found to be associated with intestinal inflammation, and it has been reported that NETs may drive the progression of gut dysregulation in sepsis. However, the biological function and regulation of NETs in sepsis-induced intestinal barrier dysfunction are not yet fully understood. First, we found that both circulating biomarkers of NETs and local NETs infiltration in the intestine were significantly increased and had positive correlations with markers of enterocyte injury in abdominal sepsis patients. Moreover, the levels of local citrullinated histone 3 (Cit H3) expression were associated with the levels of BIP expression. To further confirm the role of NETs in sepsis-induced intestinal injury, we compared peptidylarginine deiminase 4 (PAD4)-deficient mice and wild-type (WT) mice in a lethal septic shock model. In WT mice, the Cit H3-DNA complex was markedly increased, and elevated intestinal inflammation and endoplasmic reticulum (ER) stress activation were also found. Furthermore, PAD4 deficiency alleviated intestinal barrier disruption and decreased ER stress activation. Notably, NETs treatment induced intestinal epithelial monolayer barrier disruption and ER stress activation in a dose-dependent manner in vitro, and ER stress inhibition markedly attenuated intestinal apoptosis and tight junction injury. Finally, TLR9 antagonist administration significantly abrogated NETs-induced intestinal epithelial cell death through ER stress inhibition. Our results indicated that NETs could contribute to sepsis-induced intestinal barrier dysfunction by promoting inflammation and apoptosis. Suppression of the TLR9–ER stress signaling pathway can ameliorate NETs-induced intestinal epithelial cell death.

Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial

BACKGROUND

Fluid overload (FO) after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen (OA) patients. Bioelectrical impedance analysis (BIA) is a promising tool for monitoring fluid status and FO. Therefore, we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.

METHODS

A pragmatic, prospective, randomized, observer-blind, single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center. A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation (BIA) protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level (HL) measured by BIA or a traditional fluid resuscitation (TRD) in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 days of ICU management. The primary outcome was the 30-day primary fascial closure (PFC) rate. The secondary outcomes included the time to PFC, postoperative 7-day cumulative fluid balance (CFB) and adverse events within 30 days after OA. The Kaplan-Meier method and the log-rank test were utilized for PFC after OA. A generalized linear regression model for the time to PFC and CFB was built.

RESULTS

A total of 134 patients completed the trial (BIA, n = 66; TRD, n = 68). The BIA patients were significantly more likely to achieve PFC than the TRD patients (83.33% vs. 55.88%, P < 0.001). In the BIA group, the time to PFC occurred earlier than that of the TRD group by an average of 3.66 days (P < 0.001). Additionally, the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml (P < 0.001) and fewer complications.

CONCLUSION

Among postinjury OA patients in the ICU, the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.

A case-control study of risk factors for survival after laparotomy in patients with pancreatic trauma

BACKGROUND

Pancreatic trauma results in significant morbidity and mortality. However, few studies have investigated the postoperative prognostic factors in patients with pancreatic trauma.

MATERIAL AND METHODS

A retrospective study was conducted on consecutive patients with pancreatic trauma who underwent surgery in a national referral trauma center. Clinical data were retrieved from the electronic medical system. Univariate and binary logistic regression analyses were performed to identify the perioperative clinical parameters that may predict the factors of mortality of the patients.

RESULTS

A total of 150 patients underwent laparotomy due to pancreatic trauma during the study period. 128(85.4%) patients survived and 22 (14.6%) patients died due to pancreatic injury (10 patients died of recurrent intra-abdominal active hemorrhage and 12 died of multiple organ failure). Univariate analysis showed that age, hemodynamic status, and injury severe score (ISS) as well as postoperative serum levels of C-reactive protein (CRP), procalcitonin, albumin, creatinine and the volume of intraoperative blood transfusion remained strongly predictive of mortality (P < 0.05). Binary logistic regression analysis showed that the independent risk factors for prognosis after pancreatic trauma were age (P = 0.010), preoperative hemodynamic instability (P = 0.015), postoperative CRP ≥154 mg/L (P = 0.014), and postoperative serum creatinine ≥177 μmol/L (P = 0.027).

CONCLUSIONS

In this single-center retrospective study, we demonstrated that preoperative hemodynamic instability, severe postoperative inflammation (CRP ≥154 mg/L) and acute renal failure (creatinine ≥177 μmol/L) were associated with a significant risk of mortality after pancreatic trauma.

Low skeletal muscle mass predicts poor clinical outcomes in patients with abdominal trauma

OBJECTIVE

The aim of this study was to investigate whether low skeletal muscle mass is associated with clinical outcomes in patients with abdominal trauma.

METHODS

Patients presenting to our institution with abdominal trauma from January 2010 to April 2020 were retrospectively included. Low skeletal muscle mass was defined, using computed tomography, as skeletal muscle index (SMI) at the third lumbar vertebra below the lowest sex-specific quartile within 1 wk of admission. Clinical outcomes such as complications, hospital stay, and hospital cost were recorded, and univariate and multivariate analyses were performed.

RESULTS

Among 684 patients, 451 were eligible. Of these, 112 (24.8%) were classified as having low skeletal muscle mass, based on SMI diagnostic cutoff values (42.08 cm²/m² for men and 37.35 cm²/m² for women). Low skeletal muscle mass was significantly associated with longer hospital length of stay, longer intensive care length of stay, higher cost, higher frequency of mechanical ventilation, longer duration of vasopressor use, and higher incidence of massive transfusion and overall complications (P < 0.05). Subgroup analysis showed that pneumonia, acute gastrointestinal dysfunction, cholecystitis, digestive tract fistula, gastric fistula, and intestinal fistula were significantly associated with low skeletal muscle mass (P < 0.05). Multivariate analysis showed that low skeletal muscle mass was an independent risk factor for overall complications (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.33-4.49; P = 0.004), hospital length of stay (OR, 3.49; 95% CI, 1.96-6.20; P < 0.001), and hospital cost (OR, 2.67; 95% CI, 1.48-4.80; P = 0.001).

CONCLUSIONS

Low skeletal muscle mass could be an independent predictor of poor clinical outcomes in patients with abdominal trauma.

[Application of deep learning-based chest CT auxiliary diagnosis system in emergency trauma patients]

Objective: To investigate the diagnostic efficacy and potential application value of deep learning-based chest CT auxiliary diagnosis system in emergency trauma patients. Methods: A total of 403 patients, including 254 males and 149 females aged from 16 to 100 (50±19) years, who received emergency treatment for trauma and chest CT examination in the Eastern Theater General Hospital from September 2019 to November 2019 were retrospectively analyzed. Dr. Wise Lung Analyzer's chest CT auxiliary diagnosis system was applied to detect 5 types of injuries, including pneumothorax, pleural effusion/hemothorax, pulmonary contusion (shown as consolidation and ground glass opacity), rib fractures, and other fractures (including thoracic vertebrae, sternum, scapula and clavicle, etc.) and 6 other abnormalities (bullae, emphysema, pulmonary nodules, stripe, reticulation, pleural thickening). The diagnostic reference standards were labeled by two radiologists independently. The sensitivity and specificity of the auxiliary diagnosis system were evaluated. The imaging diagnostic reports were compared with the results of the auxiliary diagnosis system, and the diagnostic consistency between the two was calculated by using the Kappa test. Results: According to the reference standards, among the 403 patients, 29 were pneumothorax, 75 were pleural effusion/hemothorax, 131 were pulmonary contusion, 124 were rib fractures, and 63 were other fractures. The sensitivity and specificity of the auxiliary diagnosis system for detection of pneumothorax, pleural effusion/hemothorax, rib fractures, and other fractures were 96.6%, 97.6%, 80.0%, 99.7%, 99.2%, 83.9%, 84.1%, and 99.7%, respectively. The sensitivity of detecting lung contusion was 97.7%. There was a high consistency between the auxiliary diagnosis system and imaging diagnosis in the diagnosis of injuries, in which the kappa values of pneumothorax, pleural effusion, rib fracture and other fractures were 0.783, 0.821, 0.706 and 0.813, respectively (all P<0.001). Two cases of pneumothorax, three cases of pleural effusion/hemothorax, nine cases of rib fractures, and six cases of other fractures missed by imaging diagnosis were all detected by the auxiliary diagnosis system. The detection sensitivity of the auxiliary diagnosis system was higher for emphysema, pulmonary nodules and stripe (all>85%), but lower for bullae, reticulation and pleural thickening. Conclusions: The deep learning-based chest CT auxiliary diagnosis system could effectively assist chest CT to detect injuries in emergency trauma patients, which was expected to optimize the clinical workflow.

Protective effect of ethyl pyruvate on gut barrier function through regulations of ROS-related NETs formation during sepsis

BACKGROUND

Sepsis impairs the function of the intestinal barrier through neutrophil extracellular traps (NETs). Reactive oxygen species (ROS)-induced activation of mitogen-activated protein kinase (MAPK) is involved in NET formation. Ethyl pyruvate (EP), a potent and effective ROS scavenger, ameliorates sepsis-associated intestinal barrier dysfunction, but the detailed mechanism is unknown. The current study aimed to explore the eff ;ects of EP on sepsis-induced intestinal barrier dysfunction and whether ROS and NETs were involved.

METHODS

A sepsis model was induced in mice by intraperitoneal injection of LPS (10 mg/kg). The mice were divided into 4 groups: (1) sham group; (2) LPS group; (3) DNase-1 + LPS group; and (4) EP + LPS group. EP or DNase-1 was intraperitoneally injected after the LPS model was established. After 24 h, the small intestine and blood were collected for analysis. Human neutrophils were harvested and incubated with phorbol-12-myristate-13-acetate (PMA) or PMA + EP, and ROS and NET generation was measured.

RESULTS

EP significantly decreased proinflammatory cytokines and MPO-DNA in the LPS model. In addition, EP suppressed NET formation in the intestines of endotoxemic mice. The decrease in NETs induced by EP or DNase-1 alleviated histopathological damage, intestinal cell apoptosis and increased tight junction expression. In vitro, the treatment of EP abolished PMA-induced ROS production and NET formation which could be reversed by H₂O₂ treatment. Meanwhile, EP also abolished MAPK ERK1/2 and p38 activation during PMA-induced NET formation.

CONCLUSION

This study was the first to demonstrate that EP alleviated NET formation and sepsis-induced intestinal damage through blockage of ROS mediated MAPK ERK1/2 and p38 activation.

β-Lactams modulate neutrophil extracellular traps formation mediated by mTOR signaling pathway

BACKGROUND

Some biotics, like β-Lactams, have shown immunomodulation effects during sepsis, but the detailed mechanism was still unclear. Here we postulated that neutrophils play an essential role and β-Lactams exert immunomodulation effects through modulating neutrophil extracellular traps (NETs) formation.

METHODS

NETs formation induced by two β-Lactams, Meropenem (MEM) and ceftazidime/tazobactam (CAZ/TB) in neutrophils from healthy donors and HL-60 cells was performed. Reactive oxygen species (ROS) generation and the activity of nicotinamide adenine dinucleotide phosphate (NAPDH) oxidase were examined. Additionally, the upstream signal pathway of NETs formation, including protein kinase C (PKC), protein kinase B (Akt) and mammalian target of rapamycin (mTOR), were detected.

RESULTS

MEM and CAZ/TB modulate NETs formation in activated PMNs, not resting PMNs. Both reduced ROS generation in resting PMNs and increased in activated PMNs. To test the activity of NADPH oxidase, we detected NADPH in MEM and CAZ/TB pre-cultivated activated PMNs, which showed that MEM and CAZ/TB modulates NETs formation through activation of NADHP oxidase by affecting the subunits of key enzymes. However, MEM reduced levels of phosho-PKC-Akt-mTOR, with no changes in CAZ/TB.

CONCLUSIONS

We firstly demonstrate that β-Lactams showed the definitive immunomodulation effects through modulating NETs formation, which is depended on PKC-Akt-mTOR signal pathway.