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Ying Q, Rong J, Hong M, Heng Z, Zhang Z, Xu Y. The emerging role of adaptor proteins in regulating innate immunity of sepsis. Pharmacol Res 2024; 205:107223. [PMID: 38797359 DOI: 10.1016/j.phrs.2024.107223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 05/18/2024] [Accepted: 05/19/2024] [Indexed: 05/29/2024]
Abstract
Sepsis is a life-threatening syndrome caused by a dysregulated immune response. A large number of adaptor proteins have been found to play a pivotal role in sepsis via protein-protein interactions, thus participating in inflammatory cascades, leading to the generation of numerous inflammatory cytokines, as well as oxidative stress and regulated cell death. Although available strategies for the diagnosis and management of sepsis have improved, effective and specific treatments are lacking. This review focuses on the emerging role of adaptor proteins in regulating the innate immunity of sepsis and evaluates the potential value of adaptor protein-associated therapeutic strategy for sepsis.
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Affiliation(s)
- Qiaoyu Ying
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Jiabing Rong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Min Hong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zetao Heng
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhaocai Zhang
- Department of Intensive Care Unit, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
| | - Yinchuan Xu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
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McWhinney B, Ungerer J, LeMarsey R, Phillips N, Raman S, Gibbons K, Schlapbach LJ. Serum Levels of Vitamin C and Thiamin in Children With Suspected Sepsis: A Prospective Observational Cohort Study. Pediatr Crit Care Med 2024; 25:171-176. [PMID: 38240538 PMCID: PMC10793743 DOI: 10.1097/pcc.0000000000003349] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Vitamin C and thiamin have been trialed as adjunctive therapies in adults with septic shock but their role in critically ill children is unclear. We assessed serum levels of vitamin C and thiamin in children evaluated for sepsis. DESIGN Single-center prospective observational study. Serum levels of vitamin C and thiamin were measured on admission and association with multiple organ dysfunction syndrome (MODS) was explored using logistic regression. SETTING Emergency department and PICU in a tertiary children's hospital, Queensland, Australia. PATIENTS Children greater than 1 month and less than 17 years evaluated for sepsis. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS Vitamin levels were determined in 221 children with a median age of 3.5 (interquartile range [IQR] 1.6, 8.3) years. Vitamin C levels were inversely correlated with severity as measured by pediatric Sequential Organ Failure Assessment (Spearman's rho = -0.16, p = 0.018). Median (IQR) vitamin C levels on admission were 35.7 (17.9, 54.1) µmol/L, 36.1 (21.4, 53.7) µmol/L, and 17.9 (6.6, 43.0) µmol/L in children without organ dysfunction, single organ dysfunction, and MODS, respectively (p = 0.017). In multivariable analyses, low levels of vitamin C at the time of sampling were associated with greater odds of MODS (adjusted odds ratio [aOR] 3.04; 95% CI, 1.51-6.12), and vitamin C deficiency was associated with greater odds of MODS at 24 hours after sampling (aOR 3.38; 95% CI, 1.53-7.47). Median (IQR) thiamin levels were 162 (138, 192) nmol/L, 185 (143, 200) nmol/L, and 136 (110, 179) nmol/L in children without organ dysfunction, single organ dysfunction, and MODS, respectively (p = 0.061). We failed to identify an association between thiamin deficiency and either MODS at sampling (OR 2.52; 95% CI, 0.15-40.86) or MODS at 24 hours (OR 2.96; 95% CI, 0.18-48.18). CONCLUSIONS Critically ill children evaluated for sepsis frequently manifest decreased levels of vitamin C, with lower levels associated with higher severity.
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Affiliation(s)
- Brett McWhinney
- Pathology Queensland, Queensland Health, Brisbane, QLD, Australia
| | - Jacobus Ungerer
- Pathology Queensland, Queensland Health, Brisbane, QLD, Australia
| | - Renate LeMarsey
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children`s Hospital, Brisbane, QLD, Australia
| | - Natalie Phillips
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children`s Hospital, Brisbane, QLD, Australia
- Emergency Department Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Sainath Raman
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children`s Hospital, Brisbane, QLD, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children`s Hospital, Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children`s Hospital, Brisbane, QLD, Australia
- Department of Intensive Care and Neonatology, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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Hitosugi N, Hotta K, Taketa Y, Takamizawa R, Fujii Y, Ikegami R, Tamiya H, Inoue T, Tsubaki A. The effect of sepsis and reactive oxygen species on skeletal muscle interstitial oxygen pressure during contractions. Microcirculation 2024; 31:e12833. [PMID: 37800537 DOI: 10.1111/micc.12833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/09/2023] [Accepted: 09/23/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE This study aims to examine the effect of sepsis on the dynamics of skeletal muscle partial oxygen pressure during muscle contractions as well as the effect of reactive oxygen species (ROS) scavenger (ascorbic acid, Asc). METHODS Twenty-seven male Sprague-Dawley rats (2-3 months old) were randomly assigned to three groups; sham, cecal ligation and puncture (CLP), or CLP plus ascorbic acid treatment group (CLP + Asc). Electrical stimuli-induced muscle contractions and partial oxygen pressure measurements were performed at 3 h after CLP. The interstitial oxygen pressure (PO2 is) in the spinotrapezius muscle was measured by the phosphorescence quenching method. RESULTS The PO2 is at rest was not different between the three groups. The PO2 is decreased from rest to contraction in all groups. Compared to the sham, the time to decrease PO2 is was significantly faster in CLP but not in CLP + Asc (p < .05). Compared to the sham, the PO2 is during muscle contractions was significantly lower in both CLP and CLP + Asc (p < .05, respectively). CONCLUSIONS Our results suggest that CLP-induced sepsis accelerated the decay of PO2 is at the onset of muscle contractions and maintained a low level of PO2 is during muscle contractions.
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Affiliation(s)
- Naoki Hitosugi
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Kazuki Hotta
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, Sagamihara, Japan
- Department of Rehabilitation, Kitasato University School of Allied Health Sciences, Sagamihara, Japan
| | - Yoshikazu Taketa
- Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Japan
| | - Ren Takamizawa
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Yutaka Fujii
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
- Department of Clinical Engineering and Medical Technology, Niigata University of Health and Welfare, Niigata, Japan
| | - Ryo Ikegami
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
- Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Japan
| | - Hajime Tamiya
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
- Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Japan
| | - Tatsuro Inoue
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
- Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Japan
| | - Atsuhiro Tsubaki
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
- Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Japan
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Gajate L, de la Hoz I, Espiño M, Martin Gonzalez MDC, Fernandez Martin C, Martín-Grande A, Parise Roux D, Pastor O, Villahoz J, Rodriguez-Gandía MÁ, Nuño Vazquez J. Intravenous Ascorbic Acid for the Prevention of Postreperfusion Syndrome in Orthotopic Liver Transplantation: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e50091. [PMID: 38100226 PMCID: PMC10757222 DOI: 10.2196/50091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/23/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Liver transplantation is the last therapeutic option for patients with end-stage liver disease. Postreperfusion syndrome (PRS), defined as a fall in mean arterial pressure of more than 30% within the first 5 minutes after reperfusion of at least 1 minute, can occur in liver transplantation as a deep hemodynamic instability with associated hyperfibrinolysis immediately after reperfusion of the new graft. Its incidence has remained unchanged since it was first described in 1987. PRS is related to ischemia-reperfusion (I/R) injury, whose pathophysiology involves the release of several mediators from both the donor and the recipient. The antioxidant effect of ascorbic acid has been studied in resuscitating patients with septic shock and burns. Even today, there are publications with conflicting results, and there is a need for further studies to confirm or rule out the usefulness of this drug in this group of patients. The addition of ascorbic acid to preservation solutions used in solid organ transplantation is under investigation to harness its antioxidant effect and mitigate I/R injury. Since PRS could be considered a manifestation of I/R injury, we believe that the possible beneficial effect of ascorbic acid on the occurrence of PRS should be investigated. OBJECTIVE The aim of this randomized controlled trial is to assess the benefits of ascorbic acid over saline in the development of PRS in adult liver transplantation. METHODS We plan to conduct a single-center randomized controlled trial at the Hospital Universitario Ramón y Cajal in Spain. A total of 70 participants aged 18 years or older undergoing liver transplantation will be randomized to receive either ascorbic acid or saline. The primary outcome will be the difference between groups in the incidence of PRS. The randomized controlled trial will be conducted under conditions of respect for fundamental human rights and ethical principles governing biomedical research involving human participants and in accordance with the international recommendations contained in the Declaration of Helsinki and its subsequent revisions. RESULTS The enrollment process began in 2020. A total of 35 patients have been recruited so far. Data cleaning and analysis are expected to occur in the first months of 2024. Results are expected around the middle of 2024. CONCLUSIONS We believe that this study could be particularly relevant because it will be the first to analyze the clinical effect of ascorbic acid in liver transplantation. Moreover, we believe that this study fills an important gap in the knowledge of the potential benefits of ascorbic acid in the field of liver transplantation, particularly in relation to PRS. TRIAL REGISTRATION European Union Drug Regulating Authorities Clinical Trials Database 2020-000123-39; https://tinyurl.com/2cfzddw8; ClinicalTrials.gov NCT05754242; https://tinyurl.com/346vw7sm. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50091.
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Affiliation(s)
- Luis Gajate
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Inés de la Hoz
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Mercedes Espiño
- Department of Immunology, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Maria Del Carmen Martin Gonzalez
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Cristina Fernandez Martin
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Ascensión Martín-Grande
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Diego Parise Roux
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Oscar Pastor
- Department of Biochemistry, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Judith Villahoz
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Miguel Ángel Rodriguez-Gandía
- Department of Digestive Diseases, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Javier Nuño Vazquez
- Department of Liver Surgery, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
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Anstey MH, Aljeaidi MS, Palmer R, Jacques A, Mevavala B, Litton E, Wibrow B. Intravenous vitamin C for vasoplegia: A double-blinded randomised clinical trial (VALENCIA trial). J Crit Care 2023; 78:154369. [PMID: 37478532 DOI: 10.1016/j.jcrc.2023.154369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/14/2023] [Accepted: 07/05/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To determine whether intravenous vitamin C compared with placebo, reduces vasopressor requirements in patients with vasoplegic shock. METHODS Double-blinded, randomised clinical trial (RCT) conducted in two intensive care units in Perth, Australia. Vasopressor requirements at enrolment needed to be >10 μg/min noradrenaline after hypovolaemia was clinically excluded. Patients received either intravenous 1.5 g sodium ascorbate in 100 ml normal saline every 6 h for 5 days, or placebo (100 ml normal saline). The primary outcome was duration of vasopressor usage in hours. Secondary outcomes were ICU and hospital length of stay, and 28-day, ICU and hospital mortality. RESULTS Of the 71 patients randomised (35 vitamin C, 36 placebo group), the median vasopressor duration was 44 h [95% CI, 37-54 h] and 55 h [95% CI, 33-66 h]) in the vitamin C and placebo groups (p = 0.057). ICU and hospital length of stay, mortality outcomes were similar between groups. CONCLUSIONS In this RCT of patients with vasoplegic shock of at least moderate severity, the use of IV vitamin C compared with placebo did not significantly reduce the duration of vasopressors. TRIAL REGISTRATION Prospective registration - trial number ACTRN12617001392358.
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Affiliation(s)
- Matthew H Anstey
- Sir Charles Gairdner Hospital, Australia; Medical School, The University of Western Australia, Perth, WA, Australia; Curtin University, Australia.
| | - Muhamad S Aljeaidi
- Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Angela Jacques
- Sir Charles Gairdner Hospital, Australia; Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
| | | | - Edward Litton
- Medical School, The University of Western Australia, Perth, WA, Australia; Fiona Stanley Hospital, Perth, WA, Australia
| | - Bradley Wibrow
- Sir Charles Gairdner Hospital, Australia; Medical School, The University of Western Australia, Perth, WA, Australia
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Luo X, Zhu Y, Zhang R, Zhu J, Kuang H, Shao Y, Guo X, Ning B. The effect of vitamin C in adults with sepsis: a meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1244484. [PMID: 37720500 PMCID: PMC10502229 DOI: 10.3389/fmed.2023.1244484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/22/2023] [Indexed: 09/19/2023] Open
Abstract
Background The effect of intravenous (IV) vitamin C in the treatment of sepsis remains controversial. We aimed to explore the clinical efficacy of vitamin C in the treatment of sepsis. Methods Electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) were searched from inception through November 15th, 2022, for randomized controlled trials evaluating the effect of IV vitamin C treatment in patients with sepsis. The primary outcome was short-term mortality, secondary outcomes included duration of vasopressor use, length of intensive care unit (ICU) stay, and Sequential Organ Failure Assessment (SOFA) score after vitamin C treatment. Subgroup analyses were performed based on the dose and duration of IV vitamin C and region to determine whether vitamin C benefited patients with sepsis. Results A total of 10 studies including 1,426 patients fulfilled the predefined criteria and were analyzed. Overall, there were no significant differences between the vitamin C group and the control group regarding short-term mortality [odds ratio (OR), 0.61; 95% confidence interval (CI) 0.37-1.01; p = 0.05], ICU length of stay [mean difference (MD), -1.24; 95% CI -3.54 to 1.05, p = 0.29] and SOFA score (MD, -0.85, 95% CI -2.38 to 0.67, p = 0.27). However, vitamin C significantly reduced the duration of vasopressor use (MD, -14.36, 95% CI -26.11 to -2.61, p = 0.02). Furthermore, subgroup analysis found that in developing countries, vitamin C was associated with a significant reduction in short-term mortality (OR, 0.33; 95% CI 0.12-0.90; p = 0.03), duration of vasopressor use (MD, -24.37, 95% CI -33.72 to -15.02, p < 0.001) and SOFA score (MD, -2.55, 95% CI -4.81 to -0.28, p = 0.03). Conclusion In our study, vitamin C administration for sepsis patients was not associated with a significant reduction in short-term mortality, length of ICU stay or SOFA score. However, we observed that vitamin C could reduce the duration of vasopressor use. Furthermore, sepsis patients in developing countries may benefit more from vitamin C administration than those in developed countries.Systematic review registration: Identifier CRD42022380958, https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=380958.
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Affiliation(s)
- Xing Luo
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Youfeng Zhu
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Rui Zhang
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - JianQiu Zhu
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Huanming Kuang
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Yuebin Shao
- Department of Traditional Chinese Medicine, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Xinmin Guo
- Department of Ultrasonography, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Bo Ning
- Department of Neurosurgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
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Polcz VE, Barrios EL, Chapin B, Price C, Nagpal R, Chakrabarty P, Casadesus G, Foster T, Moldawer L, Efron PA. Sex, sepsis and the brain: defining the role of sexual dimorphism on neurocognitive outcomes after infection. Clin Sci (Lond) 2023; 137:963-978. [PMID: 37337946 PMCID: PMC10285043 DOI: 10.1042/cs20220555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023]
Abstract
Sexual dimorphisms exist in multiple domains, from learning and memory to neurocognitive disease, and even in the immune system. Male sex has been associated with increased susceptibility to infection, as well as increased risk of adverse outcomes. Sepsis remains a major source of morbidity and mortality globally, and over half of septic patients admitted to intensive care are believed to suffer some degree of sepsis-associated encephalopathy (SAE). In the short term, SAE is associated with an increased risk of in-hospital mortality, and in the long term, has the potential for significant impairment of cognition, memory, and acceleration of neurocognitive disease. Despite increasing information regarding sexual dimorphism in neurologic and immunologic systems, research into these dimorphisms in sepsis-associated encephalopathy remains critically understudied. In this narrative review, we discuss how sex has been associated with brain morphology, chemistry, and disease, sexual dimorphism in immunity, and existing research into the effects of sex on SAE.
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Affiliation(s)
- Valerie E. Polcz
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Evan L. Barrios
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Benjamin Chapin
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Catherine C. Price
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions, Gainesville, Florida, U.S.A
| | - Ravinder Nagpal
- Florida State University College of Health and Human Sciences, Tallahassee, Florida, U.S.A
| | - Paramita Chakrabarty
- Department of Neuroscience, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Gemma Casadesus
- Department of Pharmacology and Therapeutics, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Thomas Foster
- Department of Neuroscience, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Lyle L. Moldawer
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, U.S.A
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Xu C, Yi T, Tan S, Xu H, Hu Y, Ma J, Xu J. Association of Oral or Intravenous Vitamin C Supplementation with Mortality: A Systematic Review and Meta-Analysis. Nutrients 2023; 15:nu15081848. [PMID: 37111066 PMCID: PMC10146309 DOI: 10.3390/nu15081848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/21/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
Mortality is the most clinically serious outcome, and its prevention remains a constant struggle. This study was to assess whether intravenous or oral vitamin C (Vit-C) therapy is related to reduced mortality in adults. Data from Medline, Embase, and the Cochrane Central Register databases were acquired from their inception to 26 October 2022. All randomized controlled trials (RCTs) involving intravenous or oral Vit-C against a placebo or no therapy for mortality were selected. The primary outcome was all-cause mortality. Secondary outcomes were sepsis, COVID-19, cardiac surgery, noncardiac surgery, cancer, and other mortalities. Forty-four trials with 26540 participants were selected. Although a substantial statistical difference was observed in all-cause mortality between the control and the Vit-C-supplemented groups (p = 0.009, RR 0.87, 95% CI 0.78 to 0.97, I2 = 36%), the result was not validated by sequential trial analysis. In the subgroup analysis, mortality was markedly reduced in Vit-C trials with the sepsis patients (p = 0.005, RR 0.74, 95% CI 0.59 to 0.91, I2 = 47%), and this result was confirmed by trial sequential analysis. In addition, a substantial statistical difference was revealed in COVID-19 patient mortality between the Vit-C monotherapy and the control groups (p = 0.03, RR 0.84, 95% CI 0.72 to 0.98, I2 = 0%). However, the trial sequential analysis suggested the need for more trials to confirm its efficacy. Overall, Vit-C monotherapy does decrease the risk of death by sepsis by 26%. To confirm Vit-C is associated with reduced COVID-19 mortality, additional clinical random control trials are required.
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Affiliation(s)
- Chongxi Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Wuhou District, Chengdu 610000, China
| | - Tong Yi
- Department of Neurology, The Second People's Hospital of Deyang City, No. 340 Minjiang West Road, Deyang 618000, China
| | - Siwen Tan
- Outpatient Department, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Wuhou District, Chengdu 610000, China
| | - Hui Xu
- Department of Neurosurgery, The Second People's Hospital of Liangshan Yi, Autonomous Prefecture, Liangshan 615000, China
| | - Yu Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Wuhou District, Chengdu 610000, China
| | - Junpeng Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Wuhou District, Chengdu 610000, China
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Wuhou District, Chengdu 610000, China
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Li M, Ching TH, Hipple C, Lopez R, Sahibzada A, Rahman H. Use of Intravenous Vitamin C in Critically Ill Patients With COVID-19 Infection. J Pharm Pract 2023; 36:60-66. [PMID: 34098784 DOI: 10.1177/08971900211015052] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The pathophysiology for Coronavirus Disease 2019 (COVID-19) infection is characterized by cytokine oxidative stress and endothelial dysfunction. Intravenous (IV) vitamin C has been utilized as adjuvant therapy in critically ill patients with sepsis for its protective effects against reactive oxygen species and immunomodulatory effects. The primary objective of this study was to evaluate the effects of IV vitamin C in critically ill patients with COVID-19 infection. METHODS Retrospective observational cohort study with propensity score matching of intensive care unit (ICU) patients who received 1.5 grams IV vitamin C every 6 hours for up to 4 days for COVID-19 infection. The primary study outcome was in-hospital mortality. Secondary outcomes included vasopressor requirements in norepinephrine equivalents, ICU length of stay, and change in Sequential Organ Failure Assessment (SOFA) score. RESULTS Eight patients received IV vitamin C and were matched to 24 patients. Patients in the IV vitamin C group had higher rates of hospital mortality [7 (88%) vs. 19 (79%), P = 0.049]. There was no difference in the daily vasopressor requirement in the treatment group or between the 2 groups. The mean SOFA scores post-treatment was higher in the IV vitamin C group (12.4 ± 2.8 vs. 8.1 ± 3.5, P < 0.005). There was no difference in ICU length of stay between the treatment and control groups. CONCLUSION Adjunctive IV vitamin C for the management of COVID-19 infection in critically ill patients may not decrease the incidence of mortality, vasopressor requirements, SOFA scores, or ventilator settings.
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Affiliation(s)
- Matthew Li
- New York City Health + Hospitals/Queens, Jamaica, NY, USA
| | - Tsung Han Ching
- New York City Health + Hospitals/Queens, Jamaica, NY, USA.,5925Icahn School of Medicine at Mount Sinai, NY, USA
| | | | - Ricardo Lopez
- New York City Health + Hospitals/Queens, Jamaica, NY, USA.,5925Icahn School of Medicine at Mount Sinai, NY, USA
| | - Asad Sahibzada
- New York City Health + Hospitals/Queens, Jamaica, NY, USA.,5925Icahn School of Medicine at Mount Sinai, NY, USA
| | - Habibur Rahman
- New York City Health + Hospitals/Queens, Jamaica, NY, USA.,5925Icahn School of Medicine at Mount Sinai, NY, USA
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10
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Zhang H, Wang Y, Qu M, Li W, Wu D, Cata JP, Miao C. Neutrophil, neutrophil extracellular traps and endothelial cell dysfunction in sepsis. Clin Transl Med 2023; 13:e1170. [PMID: 36629024 PMCID: PMC9832433 DOI: 10.1002/ctm2.1170] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023] Open
Abstract
Sepsis is a persistent systemic inflammatory condition involving multiple organ failures resulting from a dysregulated immune response to infection, and one of the hallmarks of sepsis is endothelial dysfunction. During its progression, neutrophils are the first line of innate immune defence against infection. Aside from traditional mechanisms, such as phagocytosis or the release of inflammatory cytokines, reactive oxygen species and other antibacterial substances, activated neutrophils also release web-like structures composed of tangled decondensed DNA, histone, myeloperoxidase and other granules called neutrophil extracellular traps (NETs), which can efficiently ensnare bacteria in the circulation. In contrast, excessive neutrophil activation and NET release may induce endothelial cells to shift toward a pro-inflammatory and pro-coagulant phenotype. Furthermore, neutrophils and NETs can degrade glycocalyx on the endothelial cell surface and increase endothelium permeability. Consequently, the endothelial barrier collapses, contributing to impaired microcirculatory blood flow, tissue hypoperfusion and life-threatening organ failure in the late phase of sepsis.
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Affiliation(s)
- Hao Zhang
- Department of AnesthesiologyZhongshan HospitalFudan UniversityShanghaiChina
- Shanghai Key laboratory of Perioperative Stress and ProtectionShanghaiChina
- Department of AnesthesiologyShanghai Medical CollegeFudan University, Shanghai, China
| | - Yanghanzhao Wang
- Department of AnesthesiologyZhongshan HospitalFudan UniversityShanghaiChina
- Shanghai Key laboratory of Perioperative Stress and ProtectionShanghaiChina
- Department of AnesthesiologyShanghai Medical CollegeFudan University, Shanghai, China
| | - Mengdi Qu
- Department of AnesthesiologyZhongshan HospitalFudan UniversityShanghaiChina
- Shanghai Key laboratory of Perioperative Stress and ProtectionShanghaiChina
- Department of AnesthesiologyShanghai Medical CollegeFudan University, Shanghai, China
| | - Wenqian Li
- Department of AnesthesiologyZhongshan HospitalFudan UniversityShanghaiChina
- Shanghai Key laboratory of Perioperative Stress and ProtectionShanghaiChina
| | - Dan Wu
- Department of AnesthesiologyZhongshan HospitalFudan UniversityShanghaiChina
- Shanghai Key laboratory of Perioperative Stress and ProtectionShanghaiChina
- Department of AnesthesiologyShanghai Medical CollegeFudan University, Shanghai, China
| | - Juan P. Cata
- Department of Anesthesiology and Perioperative MedicineThe University of Texas‐MD Anderson Cancer CenterHoustonTexasUSA
- Anesthesiology and Surgical Oncology Research GroupHoustonTexasUSA
| | - Changhong Miao
- Department of AnesthesiologyZhongshan HospitalFudan UniversityShanghaiChina
- Shanghai Key laboratory of Perioperative Stress and ProtectionShanghaiChina
- Department of AnesthesiologyShanghai Medical CollegeFudan University, Shanghai, China
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11
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Hwang NC, Sivathasan C. Review of Postoperative Care for Heart Transplant Recipients. J Cardiothorac Vasc Anesth 2023; 37:112-126. [PMID: 36323595 DOI: 10.1053/j.jvca.2022.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022]
Abstract
The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.
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Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
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12
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Muacevic A, Adler JR, Sevilla L, Garza J, Rashid H, Benitez AC, Shipotko M, Ali Z. A Systematic Review and Meta-Analysis on Possible Role of Vitamin C in Sepsis. Cureus 2022; 14:e32886. [PMID: 36699754 PMCID: PMC9867929 DOI: 10.7759/cureus.32886] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 12/24/2022] Open
Abstract
Sepsis is a substantial healthcare burden, and its management continues to be a major challenge. Prior studies demonstrate conflicting evidence regarding the utility of vitamin C in sepsis. This systematic review and meta-analysis aim to collect data among critically ill patients (sepsis/septic shock), comparing the efficacy of parenteral vitamin C with standard care. A literature review was conducted using databases including PubMed, Web of Science, Google Scholar, and the Cochrane Library to identify randomized controlled trials (RCTs) and observational studies comparing intravenous vitamin C alone or in combination with thiamine or glucocorticoids to the standard of care. We identified 11 RCTs and seven retrospective cohort studies. The primary outcome was 28-day mortality. Secondary outcomes included intensive care unit (ICU) length of stay, change in Sequential Organ Failure Assessment (SOFA) score, duration of vasopressor use, and duration of mechanical ventilation. A total of 18 studies with 4078 patients were included in our final analysis. Overall, we found no mortality reduction in patients treated with vitamin C compared to standard of care (odds ratio (OR) 0.92; 95% confidence interval (CI) 0.78 to 1.09; p = 0.34). Studies that reported a change in SOFA scores, ICU length of stay, duration of mechanical ventilation, or duration of vasopressor use did not show any significant difference between groups. Subgroup analysis with RCT versus observational studies and vitamin C dosage regimens did not show any difference. Among patients with sepsis or septic shock, treatment with vitamin C was not associated with a reduction in mortality, ICU length of stay, change in SOFA score, duration of vasopressor use, or duration of mechanical ventilation. Further studies are needed to demonstrate the potential role of vitamin C in the management of sepsis.
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13
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Abstract
Ascorbic acid, as one of the basic exogenous vitamins, is known for its tremendous antioxidant properties. This review has been prepared to show not only the importance of ascorbic acid as a free radical scavenger, but also to summarize its antioxidant action based on other mechanisms, including activation of intracellular antioxidant systems. Ascorbic acid interacts with small molecule antioxidants, including tocopherol, glutathione and thioredoxin, but also can stimulate the biosynthesis and activation of antioxidant enzymes, such as superoxide dismutase, catalase or glutathione peroxidase. Moreover, ascorbic acid promotes the activity of several transcription factors (Nrf2, Ref-1, AP-1), which enables the expression of genes encoding antioxidant proteins. Additionally, it supports the action of other exogenous antioxidants, mainly polyphenols. In this connection, both DNA, protein and lipids are protected against oxidation. Although ascorbic acid has strong antioxidant properties, it can also have pro-oxidant effects in the presence of free transition metals. However, its role in prevention of DNA mutation and cellular apoptosis, especially in relation to cancer cells is controversial.
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Affiliation(s)
- Agnieszka Gęgotek
- Department of Inorganic and Analytical Chemistry, Medical University of Bialystok, Bialystok, Poland
| | - Elżbieta Skrzydlewska
- Department of Inorganic and Analytical Chemistry, Medical University of Bialystok, Bialystok, Poland.
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14
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Song SH, Sankary KM, Burns SP. Vital sign differences between septic patients with tetraplegia and paraplegia. Spinal Cord Ser Cases 2022; 8:87. [PMID: 36433952 PMCID: PMC9700738 DOI: 10.1038/s41394-022-00553-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022] Open
Abstract
STUDY DESIGN Retrospective chart review. OBJECTIVES Sepsis is a leading preventable cause of death in patients with chronic spinal cord injury (SCI). Individuals with tetraplegia may exhibit different signs and symptoms of infection compared to those with paraplegia. In this study, we examine differences in vital signs (VS) and mental status between septic patients with tetraplegia and paraplegia with the goal of improving early identification of sepsis in this population. SETTING Veterans hospital in Washington, USA. METHODS Participants consisted of 19 patients with tetraplegia and 16 with paraplegia who were transferred from an SCI Service to a higher level of care with sepsis between June 1, 2010 and June 1, 2018 (n = 35). We compared VS between patients with tetraplegia and paraplegia at baseline and during sepsis including temperature, heart rate (HR), and blood pressure as well as presence/absence of altered mental status (AMS). RESULTS While there were no significant VS differences between groups at baseline, septic patients with tetraplegia had lower maximum temperature (38.2 °C versus 39.2 °C, p = 0.003), lower maximum HR (106 versus 124 beats/minute, p = 0.004), and more frequent AMS compared to septic patients with paraplegia (79% versus 31%, p = 0.007). CONCLUSION Patients with tetraplegia may not be able to mount fever and tachycardia to the same degree as patients with paraplegia and may be more prone to developing AMS during sepsis. These findings suggest that changes to VS parameter cut-offs may improve sensitivity and be useful in identifying sepsis earlier in the tetraplegic population.
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Affiliation(s)
- Shawn H Song
- Spinal Cord Injury Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.
| | - Kendl M Sankary
- Spinal Cord Injury Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Stephen P Burns
- Spinal Cord Injury Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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15
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Juneja D, Nasa P, Jain R. Current role of high dose vitamin C in sepsis management: A concise review. World J Crit Care Med 2022; 11:349-363. [PMID: 36439321 PMCID: PMC9693906 DOI: 10.5492/wjccm.v11.i6.349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/08/2022] [Accepted: 09/09/2022] [Indexed: 02/05/2023] Open
Abstract
Sepsis and septic shock are common diagnoses for patients requiring intensive care unit admission and associated with high morbidity and mortality. In addition to aggressive fluid resuscitation and antibiotic therapy, several other drugs have been tried as adjuvant therapies to reduce the inflammatory response and improve outcomes. Vitamin C has been shown to have several biological actions, including anti-inflammatory and immunomodulatory effects, which may prove beneficial in sepsis management. Initial trials showed improved patient outcomes when high dose vitamin C was used in combination with thiamine and hydrocortisone. These results, along with relative safety of high-dose (supra-physiological) vitamin C, encouraged physicians across the globe to add vitamin C as an adjuvant therapy in the management of sepsis. However, subsequent large-scale randomised control trials could not replicate these results, leaving the world divided regarding the role of vitamin C in sepsis management. Here, we discuss the rationale, safety profile, and the current clinical evidence for the use of high-dose vitamin C in the management of sepsis and septic shock.
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Affiliation(s)
- Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | - Ravi Jain
- Department of Critical Care Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur 302022, Rajasthan, India
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16
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Gęgotek A, Skrzydlewska E. Antioxidative and Anti-Inflammatory Activity of Ascorbic Acid. Antioxidants (Basel) 2022; 11:1993. [PMID: 36290716 PMCID: PMC9598715 DOI: 10.3390/antiox11101993] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 07/24/2023] Open
Abstract
Ascorbic acid, as a one of the basic exogenous vitamins, occurs in the body in the form of ascorbate, known for its strong antioxidant and anti-inflammatory properties. The presented review shows not only the importance of ascorbate as a free radical scavenger but also summarizes its antioxidant action based on other mechanisms, including the activation of intracellular antioxidant systems and its effect on the NFκB/TNFα pathway and apoptosis. Ascorbate interacts with small-molecule antioxidants, including tocopherol, glutathione, and thioredoxin; it can also stimulate biosynthesis and the activation of antioxidant enzymes, such as superoxide dismutase, catalase, or glutathione peroxidase. Moreover, ascorbate promotes the activity of transcription factors (Nrf2, Ref-1, AP-1), which enables the expression of genes encoding antioxidant proteins. Additionally, it supports the action of other exogenous antioxidants, mainly polyphenols. In this regard, both DNA, proteins, and lipids are protected against oxidation, leading to an inflammatory reaction and even cell death. Although ascorbate has strong antioxidant properties, it can also have pro-oxidant effects in the presence of free transition metals. However, its role in the prevention of DNA mutation, inflammation, and cell apoptosis, especially in relation to cancer cells, is controversial.
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17
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Zhu H, Xu X, Zhang K, Ye Q. The effect of intravenous vitamin C on clinical outcomes in patients with sepsis or septic shock: A meta-analysis of randomized controlled trials. Front Nutr 2022; 9:964484. [PMID: 35967816 PMCID: PMC9366349 DOI: 10.3389/fnut.2022.964484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/06/2022] [Indexed: 12/05/2022] Open
Abstract
Objectives Vitamin C deficiency is common among patients with sepsis and has been associated with poor clinical outcomes. Nevertheless, the effect of intravenous (IV) vitamin C for the treatment of sepsis remains controversial. The purpose of this meta-analysis was to evaluate the effect of IV vitamin C in patients with sepsis or septic shock. Methods Electronic databases (PubMed, Embase, Scopus, and Cochrane Library) were searched from inception through May 25, 2022 for randomized controlled trials evaluating the effect of IV vitamin C treatment in patients with sepsis. The primary outcome was short-term mortality, and secondary outcomes including the duration of vasopressor, length of intensive care unit (ICU) stay, and Sequential Organ Failure Assessment (SOFA) score after vitamin C treatment. Subgroup analyses were performed based on the type of disease, dose and duration of IV vitamin C. Results A total of 10 studies were included, with a total sample of 755 septic patients. The IV vitamin C was associated with a significant reduction in the short-term mortality (OR 0.51, 95% CI 0.37–0.69, I2 = 0%) and duration of vasopressor (MD −27.88, 95% CI −49.84 to −5.92, I2 = 95%). The length of ICU stay (MD −0.68, 95% CI −2.13 to 0.78, I2 = 74%) and SOFA score (MD −0.05, 95% CI −1.69 to 1.58, I2 = 86%) were not significantly different between two groups. Conclusion In patients with sepsis or septic shock, the IV vitamin C reduced the short-term mortality rate and duration of vasopressor, with no effect on the length of ICU stay and SOFA score. Further trials are required to explore the optimal dosage and duration of IV vitamin C. Systematic Review Registration https://inplasy.com/inplasy-2022-6-0013/, identifier INPLASY202260013.
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Affiliation(s)
- Huiyan Zhu
- Department of General Surgery, Lishui People's Hospital, Lishui, China
| | - Xiaoya Xu
- Department of General Surgery, Lishui People's Hospital, Lishui, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiaoping Ye
- Department of General Surgery, Lishui People's Hospital, Lishui, China
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18
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Li Y, Xie HQ, Liu Y, Xu L, Zheng L, Yu S, Chen G, Ji J, Jiang S, Guo TL, Zhao B. Subacute effects of the chlorinated flame retardant dechlorane 602 on intestinal microenvironment in mice. ENVIRONMENT INTERNATIONAL 2022; 166:107394. [PMID: 35820366 DOI: 10.1016/j.envint.2022.107394] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Chlorinated flame retardant Dechlorane 602 (Dec 602) has been detected in daily food, indicating that it may pose a risk to intestinal health. The intestinal microenvironment plays an important role in intestinal health. Intestinal microbiota and metabolites are two important factors for maintaining the microenvironment. However, little is known about the effects of Dec 602 on intestinal microbiota and metabolites. OBJECTIVES We aimed to probe the effects of Dec 602 on the intestine by revealing the changes that Dec 602 caused to the intestinal microbiota and metabolites. METHODS Adult female C57BL/6 mice were exposed to Dec 602 (low/high doses: 1.0/10.0 μg/kg body weight per day) orally for 7 consecutive days, and sacrificed after 7 days of recovery. The composition of colonic microbiota was measured by 16S rRNA gene sequencing, and the colonic metabolites were determined by LC-ESI-MS/MS. Finally, the effects of Dec 602 on the colon were validated by histopathological analysis. RESULTS The intestinal microbiota composition was altered toward a pro-inflammatory status after exposure to Dec 602. Dec 602 exposure also up-regulated oxidative metabolites (glutathione disulfide, taurine and retinoic acid) and pro-inflammatory metabolites (prostaglandin E2). On the other hand, antioxidative metabolites (s-adenosylmethionine and 11-cis-retinol) and anti-inflammatory metabolites (alpha-linolenic acid, eicosapentaenoic acid and docosahexaenoic acid) were down-regulated after exposure to Dec 602. Infiltration of lymphocytes in the colonic lamina propria was observed in the mice treated with Dec 602 for 7 days, and it was not recovered after another 7 days without further treatment. CONCLUSION Dec 602 interfered with the colonic microbiota and metabolome, and exhibited inflammatory features. Histopathological studies confirmed that Dec 602 exposure did induce colonic inflammation.
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Affiliation(s)
- Yunping Li
- School of Environment, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Hangzhou, Zhejiang 310024, China; State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
| | - Heidi Qunhui Xie
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Yin Liu
- School of Environment, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Hangzhou, Zhejiang 310024, China
| | - Li Xu
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Liping Zheng
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Shuyuan Yu
- Environment and Health Department, Shenzhen Center for Disease Control and Prevention, Shenzhen, Guangdong 518055, China
| | - Guomin Chen
- Environment and Health Department, Shenzhen Center for Disease Control and Prevention, Shenzhen, Guangdong 518055, China
| | - Jiajia Ji
- Environment and Health Department, Shenzhen Center for Disease Control and Prevention, Shenzhen, Guangdong 518055, China
| | - Shuai Jiang
- Environment and Health Department, Shenzhen Center for Disease Control and Prevention, Shenzhen, Guangdong 518055, China
| | - Tai L Guo
- Department of Veterinary Biomedical Sciences, University of Georgia, Athens, GA 30602, USA.
| | - Bin Zhao
- School of Environment, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Hangzhou, Zhejiang 310024, China; State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China.
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19
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Burgunder L, Heyrend C, Olson J, Stidham C, Lane RD, Workman JK, Larsen GY. Medication and Fluid Management of Pediatric Sepsis and Septic Shock. Paediatr Drugs 2022; 24:193-205. [PMID: 35307800 DOI: 10.1007/s40272-022-00497-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 01/02/2023]
Abstract
Sepsis is a life-threatening response to infection that contributes significantly to neonatal and pediatric morbidity and mortality worldwide. The key tenets of care include early recognition of potential sepsis, rapid intervention with appropriate fluids to restore adequate tissue perfusion, and empiric antibiotics to cover likely pathogens. Vasoactive/inotropic agents are recommended if tissue perfusion and hemodynamics are inadequate following initial fluid resuscitation. Several adjunctive therapies have been suggested with theoretical benefit, though definitive recommendations are not yet supported by research reports. This review focuses on the recommendations for medication and fluid management of pediatric sepsis and septic shock, highlighting issues related to antibiotic choices and antimicrobial stewardship, selection of intravenous fluids for resuscitation, and selection and use of vasoactive/inotropic medications. Controversy remains regarding resuscitation fluid volume and type, antibiotic choices depending upon infectious risks in the patient's community, and adjunctive therapies such as vitamin C, corticosteroids, intravenous immunoglobulin, and methylene blue. We include best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices.
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Affiliation(s)
- Lauren Burgunder
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Caroline Heyrend
- Division of Primary Children's Hospital Pharmacy, Salt Lake City, UT, USA
| | - Jared Olson
- Division of Primary Children's Hospital Pharmacy, Salt Lake City, UT, USA.,Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Chanelle Stidham
- Division of Primary Children's Hospital Pharmacy, Salt Lake City, UT, USA
| | - Roni D Lane
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jennifer K Workman
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Gitte Y Larsen
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
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20
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High Dose Intravenous Vitamin C as Adjunctive Therapy for COVID-19 Patients with Cancer: Two Cases. Life (Basel) 2022; 12:life12030335. [PMID: 35330086 PMCID: PMC8953706 DOI: 10.3390/life12030335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Related to the SARS-CoV-2 pandemic leading to COVID-19 illness, patients with cancer comorbidity are known to have a higher risk of developing severe viral-related events, including death. To date, there are few treatments with proven efficacy for COVID-19. Vitamin C administered intravenously (IVC) has been extensively investigated in cancer treatment with a known safety profile and has been proposed to play a role in managing COVID-19. IVC was used to treat COVID-19 patients in hospitals in China, USA, and Europe with reported benefits. We report here unexpected beneficial results from the use of IVC in two severely ill oncology patients with documented COVID-19 lung disease. Case Report: two oncology patients were diagnosed with SARS-CoV-2 infection. Prior to receiving IVC, lung infiltrates and systemic inflammation in both patients were progressing despite multiple anti-viral, antibiotic, and anti-inflammatory treatments with intensive supportive care. Both patients subsequently received 12 g of IVC delivered intravenously over 30 min, given 2 times daily for 7 days. Serial SARS-CoV-2 nucleic acid tests showed that the viral load was negative only after the 7-day IVC treatment. In both patients after receiving IVC infusions, imaging by chest CT or X-ray showed improving lung infiltrates. There were reductions in systematic inflammation by high-sensitivity C-reactive protein (hsCRP), and Interleukin-6 (IL-6) testing. No adverse events were observed related to IVC treatment. Conclusion: the use of high-dose IVC demonstrated unexpected clinical benefits in treating COVID-19 in two cancer patients presenting with complicated severe comorbidities where an unfavorable prognosis was anticipated.
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21
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Shokri-Mashhadi N, Aliyari A, Hajhashemy Z, Saadat S, Rouhani MH. Is it time to reconsider the administration of thiamine alone or in combination with vitamin C in critically ill patients? A meta-analysis of clinical trial studies. J Intensive Care 2022; 10:8. [PMID: 35177121 PMCID: PMC8851730 DOI: 10.1186/s40560-022-00594-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 01/04/2022] [Indexed: 01/21/2023] Open
Abstract
Background Although the effect of thiamine alone or in combination with vitamin C has been studied in multiple trials (RCT and interventional studies), their results are inconsistent. This meta-analysis aimed to assess impact of thiamine administration alone, thiamine in combination with vitamin C, and co-administration of low-dose hydrocortisone, vitamin C and thiamine (HVT) on clinical outcomes in critically ill patients. Methods and materials After electronic searches on PubMed, Scopus, Cochrane Library, and Web of Science databases, initially 3367 papers were found, and 20 interventional studies were included in our analysis. We assessed the risk-difference between treatment and control (standard treatment) groups by pooling available data on ICU length of stay, number of ventilator free days, mortality, and changes in Sequential Organ Failure Assessment (SOFA) scores. Results The results of present studies revealed no significant effect of thiamine in combination with vitamin C, and HVT on number of free days of ventilation. Thiamine alone supplementation was associated with high mortality percentage (WMD: 5.17%; 95% CI: 2.67, 7.67). Thiamine in combination with vitamin C had no significant impact on mortality rate. In contrast, HVT could decrease mortality rate (WMD: − 7.23%; 95% CI: − 10.31, − 4.16; I-square: 0.0%). There was no significant effect of thiamine alone, co-administration of thiamine and vitamin C, and HVT on ICU length of stay. The results of the meta-analysis showed that thiamine alone and HVT supplementation had no significant effect on SOFA score. Interestingly, co-supplementation of thiamine and vitamin C had a significant decreasing effect on SOFA score (WMD: − 0.73; 95% CI: − 1.29, − 0.17; I-square: 0.0%). Conclusion In contrast to HVT, thiamine supplementation alone was associated with increased mortality rate in ICU. However, co-supplementation of thiamine and vitamin C had a significant decreasing effect on SOFA score. Thiamine, co-supplementation of thiamine and vitamin C and co-administration of hydrocortisone, vitamin C and thiamine (HVT) had no significant effect on free days of ventilation and ICU length of stay. HVT could decrease and thiamine supplementation could increase mortality rate in ICU. Co-supplementation of thiamine and vitamin C could decrease SOFA score.
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Affiliation(s)
- Nafiseh Shokri-Mashhadi
- Food Security Research Center and Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Aliyari
- Food Security Research Center and Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Hajhashemy
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Saadat
- Faculty of Mathematics and Natural Sciences, Department of Computer Sciences, Heinrich Heine Universität, Düsseldorf, Germany
| | - Mohammad Hossein Rouhani
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
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Kory P, Meduri GU, Iglesias J, Varon J, Cadegiani FA, Marik PE. "MATH+" Multi-Modal Hospital Treatment Protocol for COVID-19 Infection: Clinical and Scientific Rationale. J Clin Med Res 2022; 14:53-79. [PMID: 35317360 PMCID: PMC8912998 DOI: 10.14740/jocmr4658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
In December 2019, coronavirus disease 2019 (COVID-19), a severe respiratory illness caused by the new coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies recommended "supportive care only" avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of "what was working and what wasn't working", the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and non-antiviral co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically.
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Affiliation(s)
- Pierre Kory
- Front Line Critical Care Consortium (FLCCC.org), Washington DC, USA
| | | | - Jose Iglesias
- Jersey Shore University Medical Center, Hackensack School of Medicine at Seton Hall, NJ, USA
| | - Joseph Varon
- University of Texas Health Science Center, Houston, TX, USA
| | | | - Paul E. Marik
- Front Line Critical Care Consortium (FLCCC.org), Washington DC, USA
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Lavillegrand JR, Raia L, Urbina T, Hariri G, Gabarre P, Bonny V, Bigé N, Baudel JL, Bruneel A, Dupre T, Guidet B, Maury E, Ait-Oufella H. Vitamin C improves microvascular reactivity and peripheral tissue perfusion in septic shock patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2022; 26:25. [PMID: 35062987 PMCID: PMC8781452 DOI: 10.1186/s13054-022-03891-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/08/2022] [Indexed: 12/29/2022]
Abstract
Background Vitamin C has potential protective effects through antioxidant and anti-inflammatory properties. However, the effect of vitamin C supplementation on microvascular function and peripheral tissue perfusion in human sepsis remains unknown. We aimed to determine vitamin C effect on microvascular endothelial dysfunction and peripheral tissue perfusion in septic shock patients. Methods Patients with septic shock were prospectively included after initial resuscitation. Bedside peripheral tissue perfusion and skin microvascular reactivity in response to acetylcholine iontophoresis in the forearm area were measured before and 1 h after intravenous vitamin C supplementation (40 mg/kg). Norepinephrine dose was not modified during the studied period. Results We included 30 patients with septic shock. SOFA score was 11 [8–14], SAPS II was 66 [54–79], and in-hospital mortality was 33%. Half of these patients had vitamin C deficiency at inclusion. Vitamin C supplementation strongly improved microvascular reactivity (AUC 2263 [430–4246] vs 5362 [1744–10585] UI, p = 0.0004). In addition, vitamin C supplementation improved mottling score (p = 0.06), finger-tip (p = 0.0003) and knee capillary refill time (3.7 [2.6–5.5] vs 2.9 [1.9–4.7] s, p < 0.0001), as well as and central-to-periphery temperature gradient (6.1 [4.9–7.4] vs 4.6 [3.4–7.0] °C, p < 0.0001). The beneficial effects of vitamin C were observed both in patients with or without vitamin C deficiency. Conclusion In septic shock patients being resuscitated, vitamin C supplementation improved peripheral tissue perfusion and microvascular reactivity whatever plasma levels of vitamin C. ClinicalTrials.gov Identifier: NCT04778605 registered 26 January 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03891-8.
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Yu F, Tian W, Dong J. Anagliptin prevents lipopolysaccharide (LPS)- induced inflammation and activation of macrophages. Int Immunopharmacol 2022; 104:108514. [PMID: 35045357 DOI: 10.1016/j.intimp.2021.108514] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/11/2021] [Accepted: 12/30/2021] [Indexed: 11/17/2022]
Abstract
Sepsis is a multiple organ dysfunction syndrome (MODS) induced by infection, which significantly threatens public health. The overactivation of inflammatory reactions and oxidative stress participate in the pathogenesis of sepsis. Anagliptin, a novel anti-diabetic agent widely applied for the treatment of type II diabetes, has been recently claimed to possess anti-inflammatory properties. Here, the protective effects of anagliptin on lipopolysaccharide (LPS)- stimulated macrophages will be checked to explore the possible pharmacological property of anagliptin on sepsis. The state of oxidative stress was dramatically activated by LPS, accompanied by the upregulation of toll-like receptor 4 (TLR4) and high mobility group box-1 (HMGB-1), as well as the elevated expression of inducible nitric oxide synthase (iNOS) and production of nitric oxide (NO). After treatment with anagliptin, the state of oxidative stress in macrophages was alleviated, with the downregulation of TLR4, HMGB-1, iNOS, and the declined release of NO. The excessive secretion of inflammatory factors, activation of the NF-κB pathway, and promoted expression level of receptor-interacting protein 1 (RIP1) were observed in LPS- stimulated macrophages, all of which were greatly reversed by the introduction of anagliptin. Lastly, the protective properties of anagliptin on LPS- treated macrophages, including the inhibitory effects on inflammation and the NF-κB pathway, were dramatically abolished by the overexpression of RIP1 in macrophages. Collectively, anagliptin prevented LPS-induced inflammation and activation of P338D1 macrophages by repressing the expression level of RIP1.
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Affiliation(s)
- Fangfang Yu
- Department of Clinical Laboratory, YanTai Yuhuangding Hospital, Yantai, Shandong 264000, China
| | - Wenxia Tian
- Department of Clinical Laboratory, Jinan Health Promotion and Education Center, Jinan, Shandong 250002, China
| | - Jie Dong
- Department of Clinical Laboratory, YanTai Yuhuangding Hospital, Yantai, Shandong 264000, China.
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Jung SY, Lee MT, Baek MS, Kim WY. Vitamin C for ≥ 5 days is associated with decreased hospital mortality in sepsis subgroups: a nationwide cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2022; 26:3. [PMID: 34983595 PMCID: PMC8728994 DOI: 10.1186/s13054-021-03872-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/11/2021] [Indexed: 12/29/2022]
Abstract
Background Previous randomized trials of vitamin C, hydrocortisone, and thiamine on sepsis were limited by short-term vitamin C administration, heterogeneous populations, and the failure to evaluate each component’s effect. The purpose of this study was to determine whether vitamin C alone for ≥ 5 days or in combination with corticosteroids and/or thiamine was associated with decreased mortality across the sepsis population and subpopulation.
Methods Nationwide population-based study conducted using the Korean National Health Insurance Service database. A total of 384,282 adult patients with sepsis who were admitted to the intensive care unit were enrolled from January 2017 to December 2019. The primary outcome was hospital mortality, while the key secondary outcome was 90-day mortality. Results The mean [standard deviation] age was 69.0 [15.4] years; 57% were male; and 36,327 (9%) and 347,955 did and did not receive vitamin C, respectively. After propensity score matching, each group involved 36,327 patients. The hospital mortality was lower by − 0.9% in the treatment group (17.1% vs 18.0%; 95% confidence interval, − 1.3 to − 0.5%; p < 0.001), a significant but extremely small difference. However, mortality decreased greater in patients who received vitamin C for ≥ 5 days (vs 1–2 or 3–4 days) (15.8% vs 18.8% vs 18.3%; p < 0.001). Further, vitamin C was associated with a lower hospital mortality in patients with older age, multiple comorbidities, pneumonia, genitourinary infection, septic shock, and mechanical ventilation. Consistent findings were found for 90-day mortality. Moreover, vitamin C alone or in combination with thiamine was significantly associated with decreased hospital mortality. Conclusions Intravenous vitamin C of ≥ 5 days was significantly associated with decreased hospital and 90-day mortality in sepsis patients. Vitamin C combined with corticosteroids and/or thiamine in specific sepsis subgroups warrants further study. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03872-3.
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Affiliation(s)
- Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea.,Department of Global Innovative Drugs, The Graduate School of Chung-Ang University, Chung-Ang University, Seoul, Republic of Korea
| | - Min-Taek Lee
- Department of Global Innovative Drugs, The Graduate School of Chung-Ang University, Chung-Ang University, Seoul, Republic of Korea
| | - Moon Seong Baek
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Won-Young Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea.
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Abstract
Vitamins are essential micronutrients with key roles in many biological pathways relevant to sepsis. Some of these relevant biological mechanisms include antioxidant and anti-inflammatory effects, protein and hormone synthesis, energy generation, and regulation of gene transcription. Moreover, relative vitamin deficiencies in plasma are common during sepsis and vitamin therapy has been associated with improved outcomes in some adult and pediatric studies. High-dose intravenous vitamin C has been the vitamin therapy most extensively studied in adult patients with sepsis and septic shock. This includes three randomized control trials (RCTs) as monotherapy with a total of 219 patients showing significant reduction in organ dysfunction and lower mortality when compared to placebo, and five RCTs as a combination therapy with thiamine and hydrocortisone with a total of 1134 patients showing no difference in clinical outcomes. Likewise, the evidence for the role of other vitamins in sepsis remains mixed. In this narrative review, we present the preclinical, clinical, and safety evidence of the most studied vitamins in sepsis, including vitamin C, thiamine (i.e., vitamin B1), and vitamin D. We also present the relevant evidence of the other vitamins that have been studied in sepsis and critical illness in both children and adults, including vitamins A, B2, B6, B12, and E. IMPACT: Vitamins are key effectors in many biological processes relevant to sepsis. We present the preclinical, clinical, and safety evidence of the most studied vitamins in pediatric sepsis. Designing response-adaptive platform trials may help fill in knowledge gaps regarding vitamin use for critical illness and association with clinical outcomes.
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Oxidation and “Unconventional” Approaches to Infection. ENCYCLOPEDIA OF INFECTION AND IMMUNITY 2022. [PMCID: PMC8575407 DOI: 10.1016/b978-0-12-818731-9.00182-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Nonpharmacological approaches can be useful to control infectious diseases. Historically infection has been successfully managed with oxidation therapy methods that support the body's own innate defenses. Several modalities include ozone and hyperbaric oxygen therapy, ultraviolet blood irradiation (UBI), intravenous hydrogen peroxide, and ascorbate therapies. Oxidation therapies are virtually 100% safe, and repeatedly reported as highly and quickly effective in quelling infection (bacterial and viral) either as stand-alone therapies or adjunctive with drugs. They are directly and indirectly germicidal, and modulate the immune system via pro-oxidant signaling molecules. Oxidation therapies especially enhance oxygen delivery and metabolism, critical for all infection defenses. Ozone has remitted Ebola, COVID-19, and bacterial infections. UBI defeated most preantibiotic era infections in hospitals. Not being drug therapy, the effects of oxidation defenses, used by planetary animal life for millions of years, are not diminished by antibiotic-resistant organisms. Oxidation, depending on delivery method, can be very inexpensive and third world adaptable. This chapter summarizes the use of these key modalities, by exploring known published literature.
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Yao R, Zhu Y, Yu Y, Li Z, Wang L, Zheng L, Li J, Huang H, Wu G, Zhu F, Xia Z, Ren C, Yao Y. Combination therapy of thiamine, vitamin C and hydrocortisone in treating patients with sepsis and septic shock: a meta-analysis and trial sequential analysis. BURNS & TRAUMA 2021; 9:tkab040. [PMID: 34901285 PMCID: PMC8660008 DOI: 10.1093/burnst/tkab040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/12/2021] [Indexed: 12/29/2022]
Abstract
Background The objective of this study was to evaluate the clinical efficacy of thiamine and vitamin C with or without hydrocortisone coadministration on the treatment of sepsis and septic shock. Methods MEDLINE, EMBASE and CENTRAL databases were searched for randomized controlled trials (RCTs) that made a comparative study between the combination therapy of vitamin C and thiamine with or without hydrocortisone and the administration of placebo in patients with sepsis or septic shock. Two reviewers independently performed study selection, data extraction and quality assessment. Both short-term mortality and change in the sequential organ failure assessment (SOFA) score from baseline (delta SOFA) were set as the primary outcomes. Secondary endpoints included intensive care unit (ICU) mortality, new onset of acute kidney injury, total adverse events, ICU and hospital length of stay, duration of vasopressor usage and ventilator-free days. Meanwhile, trial sequential analysis was conducted for primary outcomes. Results Eight RCTs with 1428 patients were included in the current study. The results showed no significant reduction of short-term mortality in sepsis and septic shock patients who received combination therapy of vitamin C and thiamine with or without hydrocortisone compared to those with placebo {risk ratio (RR), 1.02 [95% confidence interval (CI), 0.87 to 1.20], p = 0.81, I2 = 0%; risk difference (RD), 0 [95% CI, −0.04 to 0.05]}. Nevertheless, the combination therapy was associated with significant reduction in SOFA score [mean difference (MD), −0.63, (95% CI, −0.96 to −0.29, p < 0.001, I2 = 0%] and vasopressors duration (MD, −22.11 [95% CI, −30.46 to −13.77], p < 0.001, I2 = 6%). Additionally, there were no statistical differences in the pooled estimate for other outcomes. Conclusions In the current meta-analysis, the combination therapy of vitamin C and thiamine, with or without hydrocortisone had no impact on short-term mortality when compared with placebo, but was associated with significant reduction in SOFA score among patients with sepsis and septic shock.
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Affiliation(s)
- Renqi Yao
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Yibing Zhu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yue Yu
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Zhixuan Li
- International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Institute, Second Military Medical University, Shanghai 200082, China
| | - Lixue Wang
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Liyu Zheng
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Jingyan Li
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Huibin Huang
- Department of Critical Care Medicine, Beijing Tsinghua Chang Gung Hospital, Beijing 102218, China
| | - Guosheng Wu
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Shanghai 200433, China
| | - Feng Zhu
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Zhaofan Xia
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Shanghai 200433, China
| | - Chao Ren
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Yongming Yao
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
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Vandervelden S, Wauters L, Breuls J, Fieuws S, Vanhove P, Hubloue I, Bartiaux M, Creteur J, Stifkens F, Monsieurs K, Desruelles D. Early administration of Vitamin C in patients with sepsis or septic shock in emergency departments: A multicenter, double blinded, randomized controlled trial: The C-EASIE trial protocol. PLoS One 2021; 16:e0259699. [PMID: 34739527 PMCID: PMC8570477 DOI: 10.1371/journal.pone.0259699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Sepsis is a potentially life-threatening condition characterized by a deregulated body's response to infection causing injury to its own tissues and organs. Sepsis is the primary cause of death from infection. If not recognized and treated timely, it can evolve within minutes/hours to septic shock. Sepsis is associated with an acute deficiency of Vitamin C. Despite the proof-of-concept of the benefit of administering Vitamin C in patients with sepsis or septic shock, Vitamin C administration is not yet current practice. OBJECTIVE To investigate the potential benefit of early administration of high doses of Vitamin C in addition to standard of care in patients with sepsis or septic shock. METHODS This phase 3b multi-center trial is conducted in 8 hospitals throughout Belgium. In total 300 patients will be randomly assigned to one of two groups in a 1:1 allocation ratio. The intervention group will receive 1.5 g Vitamin C 4 times a day during 4 days, started within 6 hours after admission. The primary outcome is the average post-baseline patient SOFA score. CONCLUSION This trial will determine whether the early administration of Vitamin C in patients with sepsis or septic shock can lead to a more rapid solution of shock and less deterioration from sepsis to septic shock, hereby reducing morbidity and mortality as well as the length of hospital stay in this patient population. TRIAL REGISTRATION The C-EASIE trial has been registered on the ClinicalTrials.gov website on 10 February 2021 with registration number NCT04747795. TRIAL SPONSOR UZ Leuven (sponsor's reference S63213).
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Affiliation(s)
| | - Lina Wauters
- Department of Emergency Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jan Breuls
- Department of Emergency Medicine, Algemeen Ziekenhuis Turnhout, Rubensstraat, Turnhout, Belgium
| | - Steffen Fieuws
- Leuven Biostatistics and Statistical Bioinformatics Center (L-BioStat), Kapucijnenvoer, Leuven, Belgium
| | - Philippe Vanhove
- Department of Intensive Care, GZA Ziekenhuizen, Antwerpen, Belgium
| | - Ives Hubloue
- Department of Emergency Medicine, University Hospitals Brussel, Jette, Belgium
| | - Magali Bartiaux
- Department of Emergency Medicine, University Medical Center Saint Pierre, Bruxelles, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital Brussels, Bruxelles, Belgium
| | - François Stifkens
- Department of Emergency Medicine, Center Hospitalier Universitaire de Liège, Liège, Belgium
| | - Koen Monsieurs
- Department of Emergency Medicine, University Hospitals Antwerp, Edegem, Belgium
| | - Didier Desruelles
- Department of Emergency Medicine, University Hospitals Leuven, Leuven, Belgium
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30
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Iglesias J. Response. Chest 2021; 159:882. [PMID: 33563443 DOI: 10.1016/j.chest.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/02/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Jose Iglesias
- Departments of Critical Care and Nephrology, Community Medical Center; Department of Nephrology, Jersey Shore University Medical Center, Hackensack Meridian School of Medicine at Seton Hall, Neptune, NJ.
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Chen C, Sun T, Yin M, Yan Z, Yu W, Long H, Wang L, Liao X, Yan Z, Li W, Lyu Q. Ionomycin-induced mouse oocyte activation can disrupt preimplantation embryo development through increased reactive oxygen species reaction and DNA damage. Mol Hum Reprod 2021; 26:773-783. [PMID: 32697831 DOI: 10.1093/molehr/gaaa056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/01/2020] [Indexed: 12/19/2022] Open
Abstract
Oocyte activation induced by calcium oscillations is an important process in normal fertilization and subsequent embryogenesis. In the clinical-assisted reproduction, artificial oocyte activation (AOA) is an effective method to improve the clinical outcome of patients with null or low fertilization rate after ICSI. However, little is known about the effect of AOA on preimplantation embryo development in cases with normal fertilization by ICSI. Here, we used ionomycin at different concentrations to activate oocytes after ICSI with normal sperm and evaluated energy metabolism and preimplantation embryo development. We found that a high concentration of ionomycin increased the frequency and amplitude of calcium oscillation patterns, affecting the balance of mitochondrial energy metabolism, leading to increased reactive oxygen species (ROS) and decreased ATP. Eventually, it increases DNA damage and decreases blastocyst formation. In addition, the addition of vitamin C to the culture medium ameliorated the increase in ROS and DNA damage and rescued the abnormal embryo development caused by excessive ionomycin activation. This study provides a perspective that the improper application of AOA may have adverse effects on preimplantation embryo development. Thus, clinical AOA treatment should be cautiously administered.
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Affiliation(s)
- Chen Chen
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Tingye Sun
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,Department of Gynaecology, Guangdong Second Provincial General Hospital, Guangzhou, People's Republic of China
| | - Mingru Yin
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Zhiguang Yan
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Weina Yu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Hui Long
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Li Wang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaoyu Liao
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Zheng Yan
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Wenzhi Li
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Qifeng Lyu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Hess EK, Reinhart JM, Anderson MJ, Jannasch AS, Taylor SD. Pharmacokinetics of thiamine (vitamin B1) in adult horses after administration of three single intravenous doses. J Vet Pharmacol Ther 2021; 44:937-944. [PMID: 34407222 DOI: 10.1111/jvp.13007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/08/2021] [Accepted: 08/06/2021] [Indexed: 11/30/2022]
Abstract
Thiamine is a vital co-factor for several anti-inflammatory and antioxidant processes that are critical for mitigation of sepsis-associated inflammation, but pharmacokinetic (PK) analysis has not been reported in horses. We hypothesized that IV thiamine hydrochloride (TH) at increasing dosages would result in corresponding increases in plasma thiamine concentrations without causing adverse effects. A randomized cross-over study was performed in 9 healthy horses that each received TH at 5, 10, and 20 mg/kg IV. Blood was collected immediately prior to drug administration and at several time points thereafter. High-performance liquid chromatography with mass spectrometry was used to quantify thiamine concentrations at each time point. Non-compartmental PK methods showed that IV TH resulted in supraphysiologic plasma concentrations with a short half-life (0.77-1.12 h) and no adverse clinical signs were observed. The terminal rate constant decreased as the dosage increased (p < .0001) and clearance significantly decreased at the 20 mg/kg dosage (p = .0011). The area under the curve (AUC) increased in a non-linear fashion. These findings suggest that thiamine follows non-linear elimination kinetics in horses, which is likely due to saturation of renal elimination. Future studies are needed to identify therapeutic plasma concentrations and develop thiamine dosing recommendations for horses.
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Affiliation(s)
- Emily K Hess
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN, USA
| | - Jennifer M Reinhart
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL, USA
| | - Melinda J Anderson
- Department of Basic Medical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN, USA
| | - Amber S Jannasch
- Bindley Bioscience Center, Purdue University, West Lafayette, IN, USA
| | - Sandra D Taylor
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN, USA
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Efficacy of intravenous vitamin C intervention for septic patients: A systematic review and meta-analysis based on randomized controlled trials. Am J Emerg Med 2021; 50:242-250. [PMID: 34416515 DOI: 10.1016/j.ajem.2021.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/31/2021] [Accepted: 08/04/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The role of vitamin C in sepsis is still controversial, we aimed to systematically review the efficacy of intravenous vitamin C supplementation in the treatment of sepsis. METHODS MEDLINE, EmBase, Web of Science, WanFang Data and CNKI were comprehensively searched to collect randomized controlled trails (RCTs) of vitamin C supplementation for patients with sepsis or sepsis shock from January 2000 to March 2021. Two researchers independently screened the literature, extracted the data and accessed the risk of bias in the included studies; meta-analysis was then performed by using Revman 5.4 software. RESULTS A total of 10 RCTs involving 1400 participants were included. The results of meta-analysis showed that intravenous vitamin C supplementation can improve SOFA (ΔSOFA) within 72 h [RR = 1.32,95% CI(0.80,1.85), P < 0.0001] of septic patients. There were no difference on short term mortality (28-30d)[RR = 0.83,95% CI(0.65,1.05), P = 0.11], long term mortality (90d) [RR = 1.16,95% CI(0.82,1.66), P = 0.40], hospital LOS[RR = 0.15,95% CI(-0.73,1.03), P = 0.55], ventilator-free days[RR = 0.09,95% CI(-0.24,0.42), P = 0.60], ICU-LOS[RR = 0.22,95% CI(-0.13,0.57), P = 0.22], between two groups. The results of Subgroup analysis showed that intravenous vitamin C alone can reduce the risk of short term mortality (28-30d) [RR = 0.61,95% CI(0.47,0.79), P = 0.0002]of sepsis patients. CONCLUSION Based on current RCTs, our work indicated that mono-intravenous vitamin C therapy may reduce short-term mortality of sepsis patients, and it may protect organ functions. Due to the limitation of the quantity and quality of included studies, the above conclusions need to be verified by more large scale and high quality randomized control trials.
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Jamshidi MR, Zeraati MR, Forouzanfar B, Tahrekhani M, Motamed N. Effects of triple combination of hydrocortisone, thiamine, and Vitamin C on clinical outcome in patients with septic shock: A single-center randomized controlled trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2021; 26:47. [PMID: 34484379 PMCID: PMC8383994 DOI: 10.4103/jrms.jrms_593_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 07/30/2020] [Accepted: 01/20/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recent studies suggest that hydrocortisone, Vitamin C, and thiamine alone or in combination may improve the clinical outcomes of patients with septic shock. The aim of this study is the effects of this combination therapy on clinical outcome and sepsis biomarkers in patients with septic shock. MATERIALS AND METHODS Fifty-eight consecutive patients suffering septic shock were randomly assigned into two groups receiving the combination therapy of hydrocortisone (50 mg/6 h, intravenously), Vitamin C (1.5 g/6 h in 100 ml normal saline or DW5%, intravenously), and thiamine (200 mg/12 h in 50 ml normal saline or DW5%, intravenously) or placebo for up to 4 days. RESULTS The decline in procalcitonin, lactate, and leukocyte count 72 h after the initiation of treatment was significantly greater in the intervention as compared to the control group. The intervention group has a significantly lower sequential organ failure assessment score 72 h after treatment (P < 0.001). The mean duration of vasopressor dependency was shorter in the intervention group (P = 0.039). In-hospital death occurred in 10.3% of the patients who received combination therapy and 37.9% in the control group (P = 0.014). CONCLUSION The administration of the triple combination of hydrocortisone, thiamine, and Vitamin C appeared to be effective in improving the clinical outcomes of patients with septic shock and of reducing vasopressor requirements with a significant increase in the rate of improvement of sepsis biomarkers.
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Affiliation(s)
- Mohammad Reza Jamshidi
- Department of Anesthesiology and Critical Care Medcine, Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Mohammad Reza Zeraati
- Department of Anesthesiology and Critical Care Medcine, Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Baharak Forouzanfar
- Department of Anesthesiology and Critical Care Medcine, Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Mehran Tahrekhani
- Department of Nursing Education, Abhar School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Nima Motamed
- Department of Social Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
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Abstract
BACKGROUND Sepsis remains a leading cause of death in the critically ill. The combination of thiamine, vitamin C, and hydrocortisone has recently emerged as a potential adjunctive therapy and supportive care for patients with sepsis and septic shock. AREAS OF UNCERTAINTY Several randomized and observational controlled trials evaluated the role of vitamin C in sepsis and septic shock. However, there are variabilities in the findings of these studies that led to a substantial global debate on incorporating vitamin C therapy in clinical practice. DATA SOURCES A PubMed and Embase English language literature search through April 2021 was performed using the following terms: ascorbic acid, vitamin C, corticosteroid, hydrocortisone, thiamine, HAT, sepsis, and shock. Citations, including controlled trials, observational studies, review articles, guidelines, and consensus statements, were reviewed. The risk of bias for each clinical study was systematically evaluated. Relevant clinical data focusing on efficacy, safety, and special considerations regarding the use of vitamin C with and without thiamine and hydrocortisone in sepsis and septic shock were narratively summarized. RESULTS The most commonly used vitamin C dosing in sepsis and septic shock is 1.5 g every 6 hours with and without thiamine and hydrocortisone. Current literature is limited because of heterogeneity in vitamin C regimen used, initiation time, and duration of treatment. This limitation led to variability in outcomes evaluated. Vitamin C decreases proinflammatory mediators and slows the progression of endothelial injury in severe sepsis. There is an inconsistency between randomized controlled trials and observational controlled trials regarding mortality, resolution in organ failure, hospital and intensive care unit length of stay findings with the use of vitamin C in septic shock. Vitamin C seems to be safe in comparison with placebo. CONCLUSIONS Future studies with consistent end points, initiation time with an emphasis on early initiation, and standard vitamin C dosing regimen are needed to determine the overall benefit of vitamin C in sepsis.
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Somagutta MKR, Pormento MKL, Khan MA, Hamdan A, Hange N, Kc M, Pagad S, Jain MS, Lingarajah S, Sharma V, Kaur J, Emuze B, Batti E, Iloeje OJ. The Efficacy of vitamin C, thiamine, and corticosteroid therapy in adult sepsis patients: a systematic review and meta-analysis. Acute Crit Care 2021; 36:185-200. [PMID: 34185986 PMCID: PMC8435446 DOI: 10.4266/acc.2021.00108] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/04/2021] [Indexed: 12/11/2022] Open
Abstract
Background Previous studies have suggested favorable outcomes of hydrocortisone, ascorbic acid (vitamin C), and thiamine (HAT) therapy in patients with sepsis. However, similar results have not been duplicated in sequential studies. This meta-analysis aimed to reevaluate the value of HAT treatment in patients with sepsis. Methods Electronic databases were searched up until October 2020 for any studies that compared the effect of HAT versus non-HAT use in patients with sepsis. Results Data from 15 studies (eight randomized controlled trials [RCTs] and seven cohort studies) involving 67,349 patients were included. The results from the RCTs show no significant benefit of triple therapy on hospital mortality (risk ratio [RR], 0.99; P=0.92; I2=0%); intensive care unit (ICU) mortality (RR, 0.77; P=0.20; I2=58%); ICU length of stay (weighted mean difference [WMD], 0.11; P=0.86; I2=37%) or hospital length of stay (WMD: 0.57; P=0.49; I2=17%), and renal replacement therapy (RR, 0.64; P=0.44; I2=39%). The delta Sequential Organ Failure Assessment (SOFA) score favored treatment after a sensitivity analysis (WMD, -0.72; P=0.01; I2=32%). However, a significant effect was noted for the duration of vasopressor use (WMD, -25.49; P<0.001; I2=46%). The results from cohort studies have also shown no significant benefit of HAT therapy on hospital mortality, ICU mortality, ICU length of stay, length of hospital stay, the delta SOFA score, the use of renal replacement therapy, or vasopressor duration. Conclusion HAT therapy significantly reduced the duration of vasopressor use and improved the SOFA score but appeared not to have significant benefits in other outcomes for patients with sepsis. Further RCTs can help understand its benefit exclusively.
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Affiliation(s)
| | | | - Muhammad Adnan Khan
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Alaa Hamdan
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Namrata Hange
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Manish Kc
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Sukrut Pagad
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Molly Sanjay Jain
- Department of Medicine, Saint James School of Medicine, Park Ridge, IL, USA
| | - Sivasthikka Lingarajah
- Department of Medicine, Windsor University School of Medicine, Cayon (St. Kitts and Nevis), USA
| | - Vishal Sharma
- Department of Medicine, Windsor University School of Medicine, Cayon (St. Kitts and Nevis), USA
| | - Jaspreet Kaur
- Department of Medicine, Medical University of Silesia, Katowice, Poland
| | - Bernard Emuze
- Department of Medicine, Saint James School of Medicine, Park Ridge, IL, USA
| | - Erkan Batti
- Department of Medicine, Washington University of Health and Science, San Pedro, Belize
| | - Obumneme Jude Iloeje
- Department of Medicine, University of Health Sciences, Antigua, Antigua and Barbuda
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Molecular Basis of the Therapeutical Potential of Clove ( Syzygium aromaticum L.) and Clues to Its Anti-COVID-19 Utility. Molecules 2021; 26:molecules26071880. [PMID: 33810416 PMCID: PMC8036487 DOI: 10.3390/molecules26071880] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022] Open
Abstract
The current COronaVIrus Disease 19 (COVID-19) pandemic caused by SARS-CoV-2 infection is enormously affecting the worldwide health and economy. In the wait for an effective global immunization, the development of a specific therapeutic protocol to treat COVID-19 patients is clearly necessary as a short-term solution of the problem. Drug repurposing and herbal medicine represent two of the most explored strategies for an anti-COVID-19 drug discovery. Clove (Syzygium aromaticum L.) is a well-known culinary spice that has been used for centuries in folk medicine in many disorders. Interestingly, traditional medicines have used clove since ancient times to treat respiratory ailments, whilst clove ingredients show antiviral and anti-inflammatory properties. Other interesting features are the clove antithrombotic, immunostimulatory, and antibacterial effects. Thus, in this review, we discuss the potential role of clove in the frame of anti-COVID-19 therapy, focusing on the antiviral, anti-inflammatory, and antithrombotic effects of clove and its molecular constituents described in the scientific literature.
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Chuklin S, Chuklin S. Витамин С при критических состояниях: от эксперимента к клинике (часть 2). EMERGENCY MEDICINE 2021; 17:6-13. [DOI: 10.22141/2224-0586.17.1.2021.225708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Витамин С (аскорбиновая кислота) играет важную физиологическую роль в многочисленных метаболических функциях. Он также является кофактором в синтезе важных веществ, в частности катехоламинов и вазопрессина. Снижение уровня аскорбиновой кислоты отмечено при различных заболеваниях и часто сопровождает тяжелое состояние больного. Целью этой статьи является обзор современных представлений о применении высоких доз витамина С при критических состояниях у хирургических больных. Для поиска литературных источников использовалась база Medline на платформе Pubmed по ключевым словам: витамин С, сепсис, шок, травма, ожоги.
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Gao D, Xu M, Wang G, Lv J, Ma X, Guo Y, Zhang D, Yang H, Jiang W, Deng F, Xia G, Lu Z, Lv L, Gong S. The efficiency and safety of high-dose vitamin C in patients with COVID-19: a retrospective cohort study. Aging (Albany NY) 2021; 13:7020-7034. [PMID: 33638944 PMCID: PMC7993712 DOI: 10.18632/aging.202557] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/04/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The inflammatory reaction is the main cause of acute respiratory distress syndrome and multiple organ failure in patients with Coronavirus disease 2019, especially those with severe and critical illness. Several studies suggested that high-dose vitamin C reduced inflammatory reaction associated with sepsis and acute respiratory distress syndrome. This study aimed to determine the efficacy and safety of high-dose vitamin C in Coronavirus disease 2019. METHODS We included 76 patients with Coronavirus disease 2019, classified into the high-dose vitamin C group (loading dose of 6g intravenous infusion per 12 hr on the first day, and 6g once for the following 4 days, n=46) and the standard therapy group (standard therapy alone, n=30). RESULTS The risk of 28-day mortality was reduced for the high-dose vitamin C versus the standard therapy group (HR=0.14, 95% CI, 0.03-0.72). Oxygen support status was improved more with high-dose vitamin C than standard therapy (63.9% vs 36.1%). No safety events were associated with high-dose vitamin C therapy. CONCLUSION High-dose vitamin C may reduce the mortality and improve oxygen support status in patients with Coronavirus disease 2019 without adverse events.
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Affiliation(s)
- Dengfeng Gao
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Min Xu
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Gang Wang
- Department of Critical Care, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Jianrui Lv
- Department of Anesthesiology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Xiaorong Ma
- Department of Hematology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Yonghong Guo
- Department of Infectious Diseases, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Dexin Zhang
- Department of Respiratory and Critical Care, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Huiyun Yang
- Department of Nursing, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Wei Jiang
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Fuxue Deng
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Guozhi Xia
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Ziwei Lu
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Lv Lv
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Shouping Gong
- Department of Neurosurgery, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
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Lankadeva YR, Peiris RM, Okazaki N, Birchall IE, Trask-Marino A, Dornom A, Vale TAM, Evans RG, Yanase F, Bellomo R, May CN. Reversal of the Pathophysiological Responses to Gram-Negative Sepsis by Megadose Vitamin C. Crit Care Med 2021; 49:e179-e190. [PMID: 33239507 PMCID: PMC7803449 DOI: 10.1097/ccm.0000000000004770] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Oxidative stress appears to initiate organ failure in sepsis, justifying treatment with antioxidants such as vitamin C at megadoses. We have therefore investigated the safety and efficacy of megadose sodium ascorbate in sepsis. DESIGN Interventional study. SETTING Research Institute. SUBJECTS Adult Merino ewes. INTERVENTIONS Sheep were instrumented with pulmonary and renal artery flow-probes, and laser-Doppler and oxygen-sensing probes in the kidney. Conscious sheep received an infusion of live Escherichia coli for 31 hours. At 23.5 hours of sepsis, sheep received fluid resuscitation (30 mL/kg, Hartmann solution) and were randomized to IV sodium ascorbate (0.5 g/kg over 0.5 hr + 0.5 g/kg/hr for 6.5 hr; n = 5) or vehicle (n = 5). Norepinephrine was titrated to restore mean arterial pressure to baseline values (~80 mm Hg). MEASUREMENTS AND MAIN RESULTS Sepsis-induced fever (41.4 ± 0.2°C; mean ± se), tachycardia (141 ± 2 beats/min), and a marked deterioration in clinical condition in all cases. Mean arterial pressure (86 ± 1 to 67 ± 2 mm Hg), arterial Po2 (102.1 ± 3.3 to 80.5 ± 3.4 mm Hg), and renal medullary tissue Po2 (41 ± 5 to 24 ± 2 mm Hg) decreased, and plasma creatinine doubled (71 ± 2 to 144 ± 15 µmol/L) (all p < 0.01). Direct observation indicated that in all animals, sodium ascorbate dramatically improved the clinical state, from malaise and lethargy to a responsive, alert state within 3 hours. Body temperature (39.3 ± 0.3°C), heart rate (99.7 ± 3 beats/min), and plasma creatinine (32.6 ± 5.8 µmol/L) all decreased. Arterial (96.5 ± 2.5 mm Hg) and renal medullary Po2 (48 ± 5 mm Hg) increased. The norepinephrine dose was decreased, to zero in four of five sheep, whereas mean arterial pressure increased (to 83 ± 2 mm Hg). We confirmed these physiologic findings in a coronavirus disease 2019 patient with shock by compassionate use of 60 g of sodium ascorbate over 7 hours. CONCLUSIONS IV megadose sodium ascorbate reversed the pathophysiological and behavioral responses to Gram-negative sepsis without adverse side effects. Clinical studies are required to determine if such a dose has similar benefits in septic patients.
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Affiliation(s)
- Yugeesh R Lankadeva
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, VIC, Australia
| | - Rachel M Peiris
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Nobuki Okazaki
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
- Department of Anesthesiology and Resuscitology, Okayama University, Okayama, Japan
| | - Ian E Birchall
- Neuropathology Laboratory, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Anton Trask-Marino
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Anthony Dornom
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Tom A M Vale
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Roger G Evans
- Department of Physiology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University, VIC, Australia
| | - Fumitaka Yanase
- School of Medicine, University of Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, VIC, Australia
- School of Medicine, University of Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Clive N May
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, VIC, Australia
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Dolmatova EV, Wang K, Mandavilli R, Griendling KK. The effects of sepsis on endothelium and clinical implications. Cardiovasc Res 2021; 117:60-73. [PMID: 32215570 PMCID: PMC7810126 DOI: 10.1093/cvr/cvaa070] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/03/2020] [Accepted: 03/20/2020] [Indexed: 12/15/2022] Open
Abstract
ABSTRACT Sepsis accounts for nearly 700 000 deaths in Europe annually and is caused by an overwhelming host response to infection resulting in organ failure. The endothelium is an active contributor to sepsis and as such represents a major target for therapy. During sepsis, endothelial cells amplify the immune response and activate the coagulation system. They are both a target and source of inflammation and serve as a link between local and systemic immune responses. In response to cytokines produced by immune cells, the endothelium expresses adhesion molecules and produces vasoactive compounds, inflammatory cytokines, and chemoattractants, thus switching from an anticoagulant to procoagulant state. These responses contribute to local control of infection, but systemic activation can lead to microvascular thrombosis, capillary permeability, hypotension, tissue hypoxia, and ultimately tissue damage. This review focuses on the role of the endothelium in leucocyte adhesion and transmigration as well as production of reactive oxygen and nitrogen species, microRNAs and cytokines, formation of signalling microparticles, and disseminated intravascular coagulation. We also discuss alterations in endothelial permeability and apoptosis. Finally, we review the diagnostic potential of endothelial markers and endothelial pathways as therapeutic targets for this devastating disease.
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Affiliation(s)
- Elena V Dolmatova
- Division of Cardiology, Department of Medicine, Emory University, 101 Woodruff Circle, Atlanta, GA 30322, USA
| | - Keke Wang
- Division of Cardiology, Department of Medicine, Emory University, 101 Woodruff Circle, Atlanta, GA 30322, USA
| | - Rohan Mandavilli
- Division of Cardiology, Department of Medicine, Emory University, 101 Woodruff Circle, Atlanta, GA 30322, USA
| | - Kathy K Griendling
- Division of Cardiology, Department of Medicine, Emory University, 101 Woodruff Circle, Atlanta, GA 30322, USA
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Kory P, Meduri GU, Iglesias J, Varon J, Marik PE. Clinical and Scientific Rationale for the "MATH+" Hospital Treatment Protocol for COVID-19. J Intensive Care Med 2020; 36:135-156. [PMID: 33317385 DOI: 10.1177/0885066620973585] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In December 2019, COVID-19, a severe respiratory illness caused by the new coronavirus SARS-CoV-2 (COVID-19) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies' recommended "supportive care only" avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of "what was working and what wasn't working," the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically. The review concludes with a comparison of published multi-national mortality data with MATH+ center outcomes.
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Affiliation(s)
- Pierre Kory
- 22392Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - G Umberto Meduri
- Memphis VA Medical Center, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jose Iglesias
- Jersey Shore University Medical Center, Hackensack School of Medicine at Seton Hall, NJ, USA
| | - Joseph Varon
- 12340University of Texas Health Science Center, Houston, TX, USA
| | - Paul E Marik
- 6040Eastern Virginia Medical School, Norfolk, VA, USA
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Ganeshkumar A, Suvaithenamudhan S, Rajaram R. In Vitro and In Silico Analysis of Ascorbic Acid Towards Lanosterol 14-α-Demethylase Enzyme of Fluconazole-Resistant Candida albicans. Curr Microbiol 2020; 78:292-302. [PMID: 33170381 DOI: 10.1007/s00284-020-02269-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
Antibiotic resistance is one of the major concerns and the biggest threats to the world population. The incidents of antibiotic resistance in Candida spp. were frequently recorded. In the present investigation, antifungal potential of ascorbic acid (AA) was evaluated. According to the in vitro analysis, the zone of inhibition of AA (24.75 ± 0.35 mm) against C. albicans was greater as compared to other vitamins tested. AA significantly modulate the growth of C. albicans at 25 mg/ml. The highest percentage (94.67%) of cell viability was observed in untreated cells, and low cell viability (29.36%) was observed in cells treated with 50 mg/ml of AA (2 × MIC). Further, AO/EB (acridine orange/ethidium bromide), propidium iodide staining, and real-time qPCR confirmed the loss of membrane integrity due to membrane lesions that caused cell death. Lanosterol 14-α-demethylase (L-14α-DM) is the product of ERG11 and acted as superior drug target of C. albicans. Molecular docking analysis confirmed that active interaction of ascorbic acid with L-14α-DM. Based on the present investigation, the efficiency of AA was effectively proved through the in vitro and in silico analysis. This finding has evidenced the effectiveness of AA as a potential candidate against C. albicans.
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Affiliation(s)
- Arumugam Ganeshkumar
- DNA Barcoding and Marine Genomics Laboratory, Department of Marine Science, Bharathidasan University, Tiruchchirappalli, Tamil Nadu, 620 024, India
| | - Suvaiyarasan Suvaithenamudhan
- Department of Bioinformatics, School of Life Sciences, Bharathidasan University, Tiruchchirappalli, Tamil Nadu, 620 024, India
| | - Rajendran Rajaram
- DNA Barcoding and Marine Genomics Laboratory, Department of Marine Science, Bharathidasan University, Tiruchchirappalli, Tamil Nadu, 620 024, India.
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Anderson MJ, Ibrahim AS, Cooper BR, Woolcock AD, Moore GE, Taylor SD. Effects of administration of ascorbic acid and low-dose hydrocortisone after infusion of sublethal doses of lipopolysaccharide to horses. J Vet Intern Med 2020; 34:2710-2718. [PMID: 33026127 PMCID: PMC7694830 DOI: 10.1111/jvim.15896] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 01/07/2023] Open
Abstract
Background Sepsis is associated with ascorbic acid (AA) depletion and critical illness‐related corticosteroid insufficiency (CIRCI) in humans. Hypotheses Intravenous infusion of lipopolysaccharide (LPS) would (a) decrease endogneous AA concentrations, (b) induce CIRCI and (c) administration of a combination of AA and hydrocortisone (HC) would have decreased indices of inflammation compared to either drug alone. Animals Thirty‐two healthy horses. Methods Randomized placebo‐controlled experimental trial. Horses were assigned to 1 of 4 groups (saline, AA and HC, AA only, or HC only). Treatments were administered 1 hour after completion of LPS infusion. Clinical signs, clinicopathological variables, pro‐inflammatory cytokine gene expression and production, and plasma AA concentrations were assessed at various time points. Serum cortisol concentrations and ACTH stimulation tests were used to detect CIRCI. Results There was no effect of drug on clinical signs or pro‐inflammatory cytokine gene expression or production compared to controls at any time point. Administration of AA was associated with higher blood neutrophil counts 6 hours after LPS infusion (11.01 ± 1.02 K/μl) compared to other groups (8.99 ± 0.94 K/μL; P < .009). Adminstration of HC was associated with higher blood neutrophil counts 12 hours after LPS infusion (10.40 ± 0.75 K/μl) compared to other groups (6.88 ± 0.68 K/μl; P < .001). Serum cortisol increased from 5.11 ± 1.48 μg/dL before LPS administration to 9.59 ± 1.83 μg/dL 1 h after completion of LPS infusion (T1) without an effect of treatment (P = 0.59). Conclusions and Clinical Importance Ascorbic acid and HC appeared to protect against LPS‐induced neutrophil depletion and could be considered as adjunctive therapy in horses with endotoxemia.
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Affiliation(s)
- Melinda J Anderson
- Department of Basic Medical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| | - Alina S Ibrahim
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| | - Bruce R Cooper
- Bindley Bioscience Center, Purdue University, West Lafayette, Indiana, USA
| | - Andrew D Woolcock
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| | - George E Moore
- Department of Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| | - Sandra D Taylor
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
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Wald EL, Sanchez-Pinto LN, Smith CM, Moran T, Badke CM, Barhight MF, Malakooti MR. Hydrocortisone-Ascorbic Acid-Thiamine Use Associated with Lower Mortality in Pediatric Septic Shock. Am J Respir Crit Care Med 2020; 201:863-867. [PMID: 31916841 DOI: 10.1164/rccm.201908-1543le] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Eric L Wald
- Northwestern University Feinberg School of MedicineChicago, Illinoisand
| | | | - Craig M Smith
- Northwestern University Feinberg School of MedicineChicago, Illinoisand
| | - Thomas Moran
- Ann & Robert H. Lurie Children's Hospital of ChicagoChicago, Illinois
| | - Colleen M Badke
- Northwestern University Feinberg School of MedicineChicago, Illinoisand
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46
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Shah S, Brown C, Owen J, Fisher B, Natarajan R, Kates S. Vitamin C and inflammatory cytokine levels in elective total knee arthroplasty. Nutr Health 2020; 26:87-91. [PMID: 32228134 DOI: 10.1177/0260106020910632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Vitamin C levels are decreased in arthritis patients and reduced levels following surgery may impair adequate healing. AIM This study measured changes in vitamin C and inflammatory markers in patients undergoing total knee arthroplasty (TKA). METHODS Venous blood samples were collected from 10 patients during the preoperative to postoperative period. Vitamin C, interleukin-1β, interleukin-6 (IL-6), and C-reactive protein (CRP) levels were measured using various assays. RESULTS No significant changes in vitamin C levels were measured. However, all participants had suboptimal preoperative vitamin C levels and 90% had suboptimal levels postoperatively. IL-6 and CRP levels significantly increased during the immediate postoerative period. CONCLUSION There was a rise in inflammation following TKA while vitamin C levels did not significantly change during this short study period. Of note, every patient had suboptimal vitamin C levels prior to surgery and 90% continued with suboptimal levels two days postoperatively.
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Affiliation(s)
- Shalin Shah
- Virginia Commonwealth University School of Medicine, McGlothlin Medical Education Center (MMEC), USA
| | - Christopher Brown
- Virginia Commonwealth University School of Medicine, McGlothlin Medical Education Center (MMEC), USA
| | - John Owen
- Orthopaedic Research Laboratory, Virginia Commonwealth University, USA
| | - Bernard Fisher
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, USA
| | - Ramesh Natarajan
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, USA
| | - Stephen Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, USA
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Abstract
PURPOSE OF REVIEW The current review discusses the supplemental use of vitamin C as an adjunct in the management of sepsis and septic shock. RECENT FINDINGS The antioxidant properties of vitamin C are touted to be useful in modulating the inflammatory response, decreasing vasopressor requirements, and improving resuscitation. Current resuscitation practices are focused on addressing the hemodynamic instability and ensuring adequate oxygen delivery to tissues. The conceptual framework of the use of vitamin C during a resuscitation is to modulate in a beneficial fashion the inflammatory response to sepsis while concomitantly resuscitating and treating the infection. While there is promising animal and burn-related data on improved fluid resuscitation with the use of vitamin C as an adjunct, the most recent meta-analyses of the available data fail to show a survival benefit in sepsis, and concerns regarding nephrotoxicity remain. SUMMARY Although there are large number of animal studies, only a few small prospective and retrospective studies in humans address the use of vitamin C to treat sepsis. Further research in a controlled and randomized fashion is needed to determine if vitamin C is effective in this role. While there is a promise of ascorbate's addition to the sepsis bundle as an adjunct to resuscitation, the evidence is not conclusive.
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48
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Busse LW, Barker N, Petersen C. Vasoplegic syndrome following cardiothoracic surgery-review of pathophysiology and update of treatment options. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:36. [PMID: 32019600 PMCID: PMC7001322 DOI: 10.1186/s13054-020-2743-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
Vasoplegic syndrome is a common occurrence following cardiothoracic surgery and is characterized as a high-output shock state with poor systemic vascular resistance. The pathophysiology is complex and includes dysregulation of vasodilatory and vasoconstrictive properties of smooth vascular muscle cells. Specific bypass machine and patient factors play key roles in occurrence. Research into treatment of this syndrome is limited and extrapolated primarily from that pertaining to septic shock, but is evolving with the expanded use of catecholamine-sparing agents. Recent reports demonstrate potential benefit in novel treatment options, but large clinical trials are needed to confirm.
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Affiliation(s)
- Laurence W Busse
- Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA. .,Emory Johns Creek Hospital, 6325 Hospital Parkway, Johns Creek, GA, 30097, USA.
| | - Nicholas Barker
- Department of Pharmacy, Emory St. Joseph's Hospital, Atlanta, GA, USA
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Kashiouris MG, L’Heureux M, Cable CA, Fisher BJ, Leichtle SW, Fowler AA. The Emerging Role of Vitamin C as a Treatment for Sepsis. Nutrients 2020; 12:nu12020292. [PMID: 31978969 PMCID: PMC7070236 DOI: 10.3390/nu12020292] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 12/26/2022] Open
Abstract
Sepsis, a life-threatening organ dysfunction due to a dysregulated host response to infection, is a leading cause of morbidity and mortality worldwide. Decades of research have failed to identify any specific therapeutic targets outside of antibiotics, infectious source elimination, and supportive care. More recently, vitamin C has emerged as a potential therapeutic agent to treat sepsis. Vitamin C has been shown to be deficient in septic patients and the administration of high dose intravenous as opposed to oral vitamin C leads to markedly improved and elevated serum levels. Its physiologic role in sepsis includes attenuating oxidative stress and inflammation, improving vasopressor synthesis, enhancing immune cell function, improving endovascular function, and epigenetic immunologic modifications. Multiple clinical trials have demonstrated the safety of vitamin C and two recent studies have shown promising data on mortality improvement. Currently, larger randomized controlled studies are underway to validate these findings. With further study, vitamin C may become standard of care for the treatment of sepsis, but given its safety profile, current treatment can be justified with compassionate use.
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Affiliation(s)
- Markos G. Kashiouris
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University School of Medicine, 1200 E Broad St., P.O. Box 980050, Richmond, VA 23298, USA; (M.L.); (C.A.C.); (B.J.F.); (A.A.F.)
- Correspondence: ; Tel.: +1-(804)-828-9893
| | - Michael L’Heureux
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University School of Medicine, 1200 E Broad St., P.O. Box 980050, Richmond, VA 23298, USA; (M.L.); (C.A.C.); (B.J.F.); (A.A.F.)
| | - Casey A. Cable
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University School of Medicine, 1200 E Broad St., P.O. Box 980050, Richmond, VA 23298, USA; (M.L.); (C.A.C.); (B.J.F.); (A.A.F.)
| | - Bernard J. Fisher
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University School of Medicine, 1200 E Broad St., P.O. Box 980050, Richmond, VA 23298, USA; (M.L.); (C.A.C.); (B.J.F.); (A.A.F.)
| | - Stefan W. Leichtle
- Department of Surgery, Division of Acute Care Surgical Services, Virginia Commonwealth University School of Medicine, 1200 E Broad St., P.O. Box 980454, Richmond, VA 23298, USA;
| | - Alpha A. Fowler
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University School of Medicine, 1200 E Broad St., P.O. Box 980050, Richmond, VA 23298, USA; (M.L.); (C.A.C.); (B.J.F.); (A.A.F.)
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50
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Alkadi H. A Review on Free Radicals and Antioxidants. Infect Disord Drug Targets 2020; 20:16-26. [PMID: 29952268 DOI: 10.2174/1871526518666180628124323] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 05/16/2023]
Abstract
Free radicals are generated in our body by several systems. A balance among free radicals and antioxidants is an important matter for appropriate physiological function. If free radicals become greater than the ability of the body to control them, a case known as oxidative stress appears, as a result of that, a number of human diseases spread in the body. Antioxidants can contribute to facingthis oxidative stress. The present review provides a brief overview of free radicals, oxidative stress, some natural antioxidants and the relationship between them.
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Affiliation(s)
- Hourieh Alkadi
- Department of Pharmaceutical Chemistry & Drug Control, Faculty of Pharmacy, Arab International University, Daraa, Syrian Arab Republic
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