Outcome of patients with sepsis and septic shock after ICU treatment

Loss of plasma fibrinogen contributes to platelet hyporeactivity in rats with septic shock

INTRODUCTION

Dysregulated host response to infection causes life-threatening organ dysfunction. Excessive inflammation and abnormal blood coagulation can lead to disseminated intravascular coagulation (DIC) and multiple-organ failure in the late sepsis stages. Platelet function impairment in sepsis contributes to bleeding, secondary infection, and tissue injury. Platelet transfusion is considered in patients with sepsis with DIC and bleeding; however, its benefits are limited and of low quality. Fibrinogen plays a crucial role in platelet function, and establishing a fibrin network binds to activated integrin αIIbβ3 and promotes outside-in signaling that amplifies platelet functions. However, the role of fibrinogen in sepsis-induced platelet dysfunction remains unclear.

MATERIALS AND METHODS

We evaluated the effects of fibrinogen on platelet hyporeactivity during septic shock in adult male Wistar rats using lipopolysaccharide (LPS) injection and cecal ligation and puncture (CLP) surgery. Changes in the hemodynamic, biochemical, and coagulation parameters were examined. Platelet activation and aggregation were measured using whole-blood assay, 96-well plate-based aggregometry, and light-transmission aggregometry. Additionally, platelet adhesion, spreading, and fibrin clot retraction were evaluated.

RESULTS

Rats with LPS- and CLP-induced sepsis displayed considerable decreases in plasma fibrinogen levels and platelet aggregation, adhesion, spreading, and clot retraction. The aggregation of platelets obtained from rats with sepsis was markedly augmented by fibrinogen supplementation. Additionally, fibrinogen administration improved platelet adhesion, spreading, and clot retraction in rats with sepsis.

CONCLUSIONS

Fibrinogen supplementation could serve as a potential therapeutic intervention for alleviating platelet hyporeactivity in patients with sepsis and bleeding.

Exploring the Efficacy of Midodrine for Tapering Off Vasopressors

Sepsis and septic shock represent critical conditions, often necessitating vasopressor support in the intensive care unit (ICU). Midodrine, an oral vasopressor, has gathered attention as a potential adjunct to vasopressor therapy, aiming to facilitate weaning and improve clinical outcomes. However, the efficacy of midodrine remains questionable, with conflicting evidence from clinical trials and meta-analyses. This article provides a comprehensive review of the literature on midodrine's role in ICU settings by gathering evidence from multicenter trials, retrospective studies, and meta-analyses. While some studies suggest a limited benefit of midodrine in expediting vasopressor weaning and reducing ICU/hospital stays, others report potential advantages, particularly in reducing mortality rates among septic shock patients. Ongoing efforts aim to address knowledge gaps surrounding midodrine's efficacy and safety.

Organ support in sepsis: A panoramic view from infection to death

Despite significant advancements in medical research, sepsis persists as a leading cause of mortality in intensive care units (ICUs). Sepsis intricately contributes to organ failure, amplifying both morbidity and mortality. In these instances, a comprehensive comprehension of the physiology of each organ is imperative for accurate diagnosis and effective management. Within the context of an ICU clinical scenario, a meticulous evaluation and monitoring of six pivotal organ systems cardiovascular, renal, respiratory, neurological, hematological, and hepatic are essential. The primary objective in managing sepsis-induced organ failure is the early detection and intervention, encompassing timely administration of antibiotics, identification and control of the infection source, and implementation of supportive therapy. Despite the extensive body of medical literature, there is a conspicuous absence of evidence-based multi-organ management strategies for such patients. The intricate interplay between organs, commonly referred to as organ crosstalk, presents a formidable challenge in navigating the complexities of sepsis management.

Exploring Neuroprotective Agents for Sepsis-Associated Encephalopathy: A Comprehensive Review

Sepsis is a life-threatening condition resulting from an inflammatory overreaction that is induced by an infectious factor, which leads to multi-organ failure. Sepsis-associated encephalopathy (SAE) is a common complication of sepsis that can lead to acute cognitive and consciousness disorders, and no strict diagnostic criteria have been created for the complication thus far. The etiopathology of SAE is not fully understood, but plausible mechanisms include neuroinflammation, blood-brain barrier disruption, altered cerebral microcirculation, alterations in neurotransmission, changes in calcium homeostasis, and oxidative stress. SAE may also lead to long-term consequences such as dementia and post-traumatic stress disorder. This review aims to provide a comprehensive summary of substances with neuroprotective properties that have the potential to offer neuroprotection in the treatment of SAE. An extensive literature search was conducted, extracting 71 articles that cover a range of substances, including plant-derived drugs, peptides, monoclonal antibodies, and other commonly used drugs. This review may provide valuable insights for clinicians and researchers working in the field of sepsis and SAE and contribute to the development of new treatment options for this challenging condition.

Model-interpreted outcomes of artificial neural networks classifying immune biomarkers associated with severe infections in ICU

Introduction

Millions of deaths worldwide are a result of sepsis (viral and bacterial) and septic shock syndromes which originate from microbial infections and cause a dysregulated host immune response. These diseases share both clinical and immunological patterns that involve a plethora of biomarkers that can be quantified and used to explain the severity level of the disease. Therefore, we hypothesize that the severity of sepsis and septic shock in patients is a function of the concentration of biomarkers of patients.

Methods

In our work, we quantified data from 30 biomarkers with direct immune function. We used distinct Feature Selection algorithms to isolate biomarkers to be fed into machine learning algorithms, whose mapping of the decision process would allow us to propose an early diagnostic tool.

Results

We isolated two biomarkers, i.e., Programmed Death Ligand-1 and Myeloperoxidase, that were flagged by the interpretation of an Artificial Neural Network. The upregulation of both biomarkers was indicated as contributing to increase the severity level in sepsis (viral and bacterial induced) and septic shock patients.

Discussion

In conclusion, we built a function considering biomarker concentrations to explain severity among sepsis, sepsis COVID, and septic shock patients. The rules of this function include biomarkers with known medical, biological, and immunological activity, favoring the development of an early diagnosis system based in knowledge extracted from artificial intelligence.

A Pilot Study on Human Circulating System Indicated That Regenerating Islet-Derived Protein 3 Gamma (REG3A) is a Potential Prognostic Biomarker for Sepsis

It is critical to find fast and robust biomarkers for sepsis to reduce the patient's risk for morbidity and mortality. In this work, we compared serum protein expression levels of regenerating islet-derived protein 3 gamma (REG3A) between patients with sepsis and healthy controls and found that serum REG3A protein was significantly elevated in patients with sepsis. In addition, expression level of serum REG3A protein was markedly correlated with the Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation II score, and C-reactive protein levels of patients with sepsis. Serum REG3A protein expression level was also confirmed to have good diagnostic value to differentiate patients with sepsis from healthy controls. Finally, serum REG3A protein expression level was found to have good prognostic value to predict the 28-day survival rate of patients with sepsis. In conclusion, our work indicated that serum REG3A may be a novel biomarker for sepsis.

A Rare Presentation of Tuberculosis-Related Septic Shock

Septic shock with multi-organ dysfunction is an exceedingly rare, but known complication of untreated Mycobacterium tuberculosis (TB) infection. TB-associated cases of septic shock are predominantly reported in immunocompromised patients; however, it can manifest in a healthy individual if the infection is not treated. Through the interaction of lipoarabinomannan (LAM) on the mycobacterium cell wall with antigen-presenting cells, the bacteria may be able to survive in host cells for long periods of time. Without prompt treatment, TB may cause bronchiectasis and multi-organ failure. We report a case of a 24-year-old woman with untreated TB who developed widespread bronchiectasis and septic shock.

Identifying survival protective factors for chronic dialysis patients with surgically confirmed acute mesenteric ischemia

BACKGROUND

Mesenteric ischemia is significantly more common in end-stage kidney disease patients undergoing chronic dialysis than in the general population and is associated with high morbidity and mortality. However, reports on prognostic factors in this population are limited.

AIM

To elucidate the in-hospital outcomes of acute mesenteric ischemia in chronic dialysis patients and to analyze protective factors for survival.

METHODS

The case data of 426 chronic dialysis patients who were hospitalized in a tertiary medical center for acute mesenteric ischemia over a 14-year period were retrospectively reviewed. Of these cases, 103 were surgically confirmed, and the patients were enrolled in this study. A Cox regression analysis was used to evaluate the protective factors for survival.

RESULTS

The in-hospital mortality rate among the 103 enrolled patients was 46.6%. Univariate analysis was performed to compare factors in survivors and nonsurvivors, with better in-hospital outcomes associated with a surgery delay (defined as the time from onset of signs and symptoms to operation) < 4.5 d, no shock, a higher potassium level on day 1 of hospitalization, no resection of the colon, and a total bowel resection length < 110 cm. After 1 wk of hospitalization, patients with lower white blood cell count and neutrophil counts, higher lymphocyte counts, and lower C-reactive protein levels had better in-hospital outcomes. Following multivariate adjustment, a higher potassium level on day 1 of hospitalization (HR 1.71, 95%CI 1.19 to 2.46; P = 0.004), a lower neutrophil count (HR 0.91, 95%CI 0.84 to 0.99; P = 0.037) at 1 wk after admission, resection not involving the colon (HR 2.70, 95%CI 1.05 to 7.14; P = 0.039), and a total bowel resection length < 110 cm (HR 4.55, 95%CI 1.43 to 14.29; P = 0.010) were significantly associated with survival.

CONCLUSION

A surgery delay < 4.5 d, no shock, no resection of the colon, and a total bowel resection length < 110 cm predicted better outcomes in chronic dialysis patients with acute mesenteric ischemia.

Optimizing the First Response to Sepsis: An Electronic Health Record-Based Markov Decision Process Model

Sepsis is considered a medical emergency where delays in initial treatment are associated with increased morbidity and mortality, yet there is no gold standard for identifying sepsis onset and thus treatment timing. We leverage electronic health record (EHR) data with clinical expertise to develop a continuous-time Markov decision process (MDP) optimal stopping model that identifies the optimal first intervention action (anti-infective, fluid, or wait). To study the impact of initial treatment of patients at risk for developing sepsis, we define the delayed treatment population who received delayed treatment upon admission or during hospitalization and serves as an approximation of the natural history of sepsis. We apply the optimal first treatment policy to sample patient visits from the nondelayed treatment population. This analysis indicates the average risk of death could be reduced by approximately 2.2%, the average time until treatment could be reduced by 106 minutes, and the average severity of the treatment state could be reduced by 15.5% compared with the treatment they received in the hospital. We study the properties of the optimal policy to define an easily interpretable initial treatment heuristic that considers a patient’s organ dysfunction, location, and septic shock status. This generalizable framework can inform personalized treatment of patients at risk for sepsis.

Effects of Renin-Angiotensin-Aldosterone System Inhibitors on Long-Term Major Adverse Cardiovascular Events in Sepsis Survivors

Background Sepsis is known to increase morbidity and duration of hospital stay and is a common cause of mortality worldwide. Renin-angiotensin-aldosterone system inhibitors (RAASis) are commonly used to treat hypertension but are usually discontinued during hospitalization for sepsis because of concerns about renal hypoperfusion. The aim of our study was to investigate whether RAASis should be continued after discharge in sepsis survivors and to identify the effects on the clinical outcomes. Methods and Results A total of 9188 sepsis survivors aged 20 years and older who were discharged from January 1, 2012 to December 31, 2019 were included in our analyses. We further divided sepsis survivors into RAASi users and nonusers. These groups were matched by propensity scores before the outcomes of interest, including all-cause mortality and major adverse cardiac events (MACE), were examined. After propensity score matching, 3106 RAASi users and 3106 RAASi nonusers were included in our analyses. Compared with RAASi nonusers, RAASi users had lower risks of all-cause mortality (hazard ratio [HR], 0.68; 95% CI, 0.62-0.75), MACEs (HR, 0.87; 95% CI, 0.81-0.94), ischemic stroke (HR, 0.85; 95% CI, 0.76-0.96), myocardial infarction (HR, 0.74; 95% CI, 0.61-0.90), and hospitalization for heart failure (HR, 0.84; 95% CI, 0.77-0.92). Subgroup analyses stratified by admission to the ICU and the use of inotropes showed similar results. Conclusions In our study, we found that RAASi users had reduced risks of all-cause mortality and MACEs. These findings suggested a beneficial effect of RAASi use by sepsis survivors after discharge.

Yunnan Black Tea Flavonoids Can Improve Cognitive Dysfunction in Septic Mice by Activating SIRT1

This study explored the effect and mechanism of Yunnan black tea flavonoids (YBTF) on cognitive dysfunction in septic mice. The mice were induced sepsis, the serum was determined using kits, and the tissue was determined by qPCR assay. The Yunnan black tea flavonoids were checked using HPLC. The test results showed that compared with the model group, YBTF could increase the survival rate of the mice; meanwhile, YBTF could also increase the total distance travelled, number of stands, and number of groomings, as well as the number of times crossing the area in the target quadrant. Detection of nerve cells showed that YBTF could reduce the rate of nerve cell apoptosis caused by sepsis. YBTF also reduced the levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-1 beta (IL-1β), and malondialdehyde (MDA) in the hippocampus of septic mice and increased the activity of superoxide dismutase (SOD) and catalase (CAT) enzymes. YBTF could also upregulate the mRNA expression of SOD1, SOD2, CAT, and forkhead box O1 (FOXO1) and downregulate the mRNA expression of TNF-α, IL-1β, nuclear factor kappa-B (NF-κB), p53, and SIRT1 in the hippocampus of septic mice. The animal experiment results showed that YBTF could improve the cognitive dysfunction of septic mice. The effect of YBTF was weaker than that of dexamethasone, but it could enhance the improvement effect when used in conjunction with dexamethasone. The component analysis results showed that YBTF contained 9 compounds, including catechin, gallocatechin gallate, rutin, hyperoside, epicatechin gallate, dihydroquercetin, quercetin, myricetin, and sulphuretin. From these results, YBTF could activate SIRT1 through its active compound components to improve the cognitive dysfunction of septic mice.

Outcome following surgery to treat septic peritonitis in 95 cats in the United Kingdom

OBJECTIVES

To review the cause, management and outcome in cats with septic peritonitis within the United Kingdom (2008 to 2018) and to identify if previously identified prognostic factors were associated with survival in this population.

MATERIALS AND METHODS

Clinical records from 10 referral hospitals in United Kingdom were reviewed. Data collected included signalment, clinicopathological data and management techniques. Serum albumin, glucose, lactate and ionised calcium concentration; presence of intraoperative hypotension and correct empirical antibiosis were analysed via logistic regression for association with survival.

RESULTS

Ninety-five cats were included. The overall survival rate was 66%. Lethargy (89%) and anorexia (75%) were the most common clinical signs, with abdominal pain and vomiting in 44% and 27% of cases, respectively. Gastro-intestinal leakage was the most common source of contamination. The presence of an abdominal mass on clinical examination was not strongly predictive of the presence of neoplasia on histology and did not confer a worse prognosis. Cats presenting with dehiscence of a previous enterotomy/enterectomy did not have a worse prognosis than those presenting with other aetologies. Intraoperative hypotension (adjusted odds ratio 0.173, 95% confidence intervals 0.034 to 0.866, P=0.033) was associated with non-survival. Cats that survived beyond 1 day postoperatively had an improved likelihood of survival (87.5%). All cats that survived beyond 6 days were successfully discharged.

CLINICAL SIGNIFICANCE

This study describes the largest group of cats with septic peritonitis with an overall survival rate of 66%. The presence of an abdominal mass on clinical examination or having dehiscence of a previous gastrointestinal surgery did not confer a worse prognosis.

Efficacy of 4-hour rescue therapeutic plasma exchange in severe septic shock patients

BACKGROUND

Early intervention for septic shock is crucial to reduce mortality and improve outcome. There is still a great debate over the exact time of therapeutic plasma exchange (TPE) administration in septic shock patients. This study aims to investigate the effect of early initiation (within 4 hours) of TPE in severe septic shock on hemodynamics & outcome.

METHODS

We conducted a prospective, before-after case series study on 16 septic shock patients requiring high doses of vasopressors admitted in two ICUs from Cairo, Egypt. All of our patients received TPE within 4 hours of ICU admission. The fresh frozen plasma exchange volume = 1.5 × plasma volume.

RESULTS

In the 16 patients included in the study, mean arterial pressure was significantly improved after the initial TPE (p < 0.002) and norepinephrine dose which significantly reduced post TPE (p < 0.001). In addition, norepinephrine dose to mean arterial pressure significantly improved (p < 0.001). There was reduction of a net 6 hours fluid balances following the first TPE were observed in all the patients (p < 0.03) by a mean of 757 ml. Systemic vascular resistance index was markedly improved post-TPE along with statistically improved cardiac index (p < 0.01). Stroke volume variance was also significantly decreased after the TPE sessions (p < 0.01). C-reactive protein significantly improved after TPE (P < 0.01).

CONCLUSION

Early initiation of TPE in severe septic shock patients might improve hemodynamic measures.

In-Hospital and Long-Term Outcomes of Infective Endocarditis in Chronic Dialysis Patients

Purpose

To elucidate the in-hospital and long-term outcomes of infective endocarditis (IE) in end-stage kidney disease (ESKD) patients on chronic dialysis and to analyze the risk factors of mortality.

Patients and Methods

The case files of 1,817 patients who were hospitalized for IE over a 14-year period were retrospectively reviewed. Of these, 116 ESKD patients on chronic dialysis were enrolled in this study. Cox’s proportional hazard model was used to evaluate the risk factors of mortality and long-term outcomes.

Results

The in-hospital mortality rate of the 116 enrolled patients was as high as 43.1%. Patients who survived the index admission had a three-year mortality rate of 33%. Univariate analysis was used to compare survivors and non-survivors; poor in-hospital outcomes were associated with the use of a tunneled cuffed catheter for dialysis access, a shorter duration hospitalization, shock or respiratory failure during hospitalization, a higher white blood count, a higher percentage of polymorphonuclear leukocytes, a higher C-reactive protein level, a lower serum albumin level, and a higher total bilirubin level. Following multivariate adjustment, shock (odds ratio, 9.29, with a 95% confidence interval [CI] of 2.78 to 34.24; p<0.001) or respiratory failure (odds ratio, 25.16, with a 95% CI of 5.63 to 153.54; p<0.001) during hospitalization was strongly associated with increased in-hospital mortality. Patients who underwent cardiac operations (odds ratio, 0.22, with a 95% CI of 0.052 to 0.86; p=0.031) had better in-hospital outcomes. Heart failure reduced ejection fraction (HFrEF) at the time of initial hospitalization was an independent risk factor for 3-year mortality (hazard ratio, 3.48, with a 95% CI of 1.09 to 11.09; p=0.035).

Conclusion

The outcomes of IE for ESKD patients on chronic dialysis were poor. Only 56.9% of these patients survived the index admission and their mortality rate over three years was 33%. Shock or respiratory failure during hospitalization was associated with increased in-hospital mortality. Patients who underwent cardiac operations had better in-hospital outcomes. HFrEF at the time of initial hospitalization was an independent risk factor for three-year mortality.

Early Detection of Septic Shock Onset Using Interpretable Machine Learners

BACKGROUND

Developing a decision support system based on advances in machine learning is one area for strategic innovation in healthcare. Predicting a patient's progression to septic shock is an active field of translational research. The goal of this study was to develop a working model of a clinical decision support system for predicting septic shock in an acute care setting for up to 6 h from the time of admission in an integrated healthcare setting.

METHOD

Clinical data from Electronic Health Record (EHR), at encounter level, were used to build a predictive model for progression from sepsis to septic shock up to 6 h from the time of admission; that is, T = 1, 3, and 6 h from admission. Eight different machine learning algorithms (Random Forest, XGBoost, C5.0, Decision Trees, Boosted Logistic Regression, Support Vector Machine, Logistic Regression, Regularized Logistic, and Bayes Generalized Linear Model) were used for model development. Two adaptive sampling strategies were used to address the class imbalance. Data from two sources (clinical and billing codes) were used to define the case definition (septic shock) using the Centers for Medicare & Medicaid Services (CMS) Sepsis criteria. The model assessment was performed using Area under Receiving Operator Characteristics (AUROC), sensitivity, and specificity. Model predictions for each feature window (1, 3 and 6 h from admission) were consolidated.

RESULTS

Retrospective data from April 2005 to September 2018 were extracted from the EHR, Insurance Claims, Billing, and Laboratory Systems to create a dataset for septic shock detection. The clinical criteria and billing information were used to label patients into two classes-septic shock patients and sepsis patients at three different time points from admission, creating two different case-control cohorts. Data from 45,425 unique in-patient visits were used to build 96 prediction models comparing clinical-based definition versus billing-based information as the gold standard. Of the 24 consolidated models (based on eight machine learning algorithms and three feature windows), four models reached an AUROC greater than 0.9. Overall, all the consolidated models reached an AUROC of at least 0.8820 or higher. Based on the AUROC of 0.9483, the best model was based on Random Forest, with a sensitivity of 83.9% and specificity of 88.1%. The sepsis detection window at 6 h outperformed the 1 and 3-h windows. The sepsis definition based on clinical variables had improved performance when compared to the sepsis definition based on only billing information.

CONCLUSION

This study corroborated that machine learning models can be developed to predict septic shock using clinical and administrative data. However, the use of clinical information to define septic shock outperformed models developed based on only administrative data. Intelligent decision support tools can be developed and integrated into the EHR and improve clinical outcomes and facilitate the optimization of resources in real-time.

Sesamin attenuates intestinal injury in sepsis via the HMGB1/TLR4/IL-33 signalling pathway

CONTEXT

Sepsis is currently one of the leading causes of death in intensive care units (ICUs). Sesamin was previously reported to inhibit inflammation. However, no studies have revealed the impact of sesamin on sepsis.

OBJECTIVE

We studied the mechanism underlying the effect of sesamin on the pathophysiology of sepsis through the HMGB1/TLR4/IL-33 signalling pathway.

MATERIALS AND METHODS

Fifty male BALB/c mice (n = 10 per group) were used to establish a caecal ligation and puncture (CLP) mouse model, and given daily injections of sesamin at a low, middle, or high concentration (25, 50, or 100 μM) during the seven-day study period; survival curves were generated by the Kaplan-Meier method. H&E staining and TUNEL staining were performed to assess changes in intestinal morphology intestinal damage in the mouse intestinal epithelium. Molecules related to the HMGB1/TLR4/IL-33 pathway were assessed by RT-qPCR and Western blotting.

RESULTS

We found mice in the sepsis group survived for only 4 days, while those treated with sesamin survived for 6-7 days. In addition, sesamin significantly relieved the increase in the levels of MPO (21%, 33.3%), MDA (40.5% and 31.6%), DAO (1.24-fold and 2.31-fold), and pro-inflammatory cytokines such as TNF-α (75% and 79%) and IL-6 (1-fold and 1.67-fold) 24 and 48 h after sepsis induction and downregulated the expression of HMGB1, TLR4, and IL-33 while upregulating the expression of ZO-1 and occludin.

DISCUSSION AND CONCLUSIONS

Sesamin improved the 7-day survival rate of septic mice, suppressed the inflammatory response in sepsis through the HMGB-1/TLR4/IL-33 signalling pathway, and further alleviated intestinal injury.

Effect of dilution on sedimentational separation of bacteria from blood

Bacteria must be separated from septic whole blood in preparation for rapid antibiotic susceptibility tests. This work improves upon past work isolating bacteria from whole blood by exploring an important experimental factor: Whole blood dilution. Herein, we use the continuity equation to model red blood cell sedimentation and show that overall spinning time decreases as the blood is diluted. We found that the bacteria can also be captured more efficiently from diluted blood, up to approximately 68 ± 8% recovery (95% confidence interval). However, diluting blood both requires and creates extra fluid that end users must handle; an optimal dilution, which maximizes bacteria recovery and minimizes waste, was found to scale with the square root of the whole blood hematocrit. This work also explores a hypothesis that plasma backflow, which occurs as red cells move radially outward, causes bacterial enrichment in the supernatant plasma with an impact proportional to the plasma backflow velocity. Bacteria experiments carried out with diluted blood demonstrate such bacterial enrichment, but not in the hypothesized manner as enrichment occurred only in undiluted blood samples at physiological hematocrit.

Sepsis in the era of data-driven medicine: personalizing risks, diagnoses, treatments and prognoses

Sepsis is a series of clinical syndromes caused by the immunological response to infection. The clinical evidence for sepsis could typically attribute to bacterial infection or bacterial endotoxins, but infections due to viruses, fungi or parasites could also lead to sepsis. Regardless of the etiology, rapid clinical deterioration, prolonged stay in intensive care units and high risk for mortality correlate with the incidence of sepsis. Despite its prevalence and morbidity, improvement in sepsis outcomes has remained limited. In this comprehensive review, we summarize the current landscape of risk estimation, diagnosis, treatment and prognosis strategies in the setting of sepsis and discuss future challenges. We argue that the advent of modern technologies such as in-depth molecular profiling, biomedical big data and machine intelligence methods will augment the treatment and prevention of sepsis. The volume, variety, veracity and velocity of heterogeneous data generated as part of healthcare delivery and recent advances in biotechnology-driven therapeutics and companion diagnostics may provide a new wave of approaches to identify the most at-risk sepsis patients and reduce the symptom burden in patients within shorter turnaround times. Developing novel therapies by leveraging modern drug discovery strategies including computational drug repositioning, cell and gene-therapy, clustered regularly interspaced short palindromic repeats -based genetic editing systems, immunotherapy, microbiome restoration, nanomaterial-based therapy and phage therapy may help to develop treatments to target sepsis. We also provide empirical evidence for potential new sepsis targets including FER and STARD3NL. Implementing data-driven methods that use real-time collection and analysis of clinical variables to trace, track and treat sepsis-related adverse outcomes will be key. Understanding the root and route of sepsis and its comorbid conditions that complicate treatment outcomes and lead to organ dysfunction may help to facilitate identification of most at-risk patients and prevent further deterioration. To conclude, leveraging the advances in precision medicine, biomedical data science and translational bioinformatics approaches may help to develop better strategies to diagnose and treat sepsis in the next decade.

Early Prediction of Sepsis Incidence in Critically Ill Patients Using Specific Genetic Polymorphisms

Several diagnostic methods for the evaluation and monitoring were used to find out the pro-inflammatory status, as well as incidence of sepsis in critically ill patients. One such recent method is based on investigating the genetic polymorphisms and determining the molecular and genetic links between them, as well as other sepsis-associated pathophysiologies. Identification of genetic polymorphisms in critical patients with sepsis can become a revolutionary method for evaluating and monitoring these patients. Similarly, the complications, as well as the high costs associated with the management of patients with sepsis, can be significantly reduced by early initiation of intensive care.

Mortality Reduction in Septic Shock by Plasma Adsorption (ROMPA): a protocol for a randomised clinical trial

INTRODUCTION

There is a lack of evidence in the efficacy of the coupled plasma filtration adsorption (CPFA) to reduce the mortality rate in septic shock. To fill this gap, we have designed the ROMPA study (Mortality Reduction in Septic Shock by Plasma Adsorption) to confirm whether treatment with an adequate dose of treated plasma by CPFA could confer a clinical benefit.

METHODS AND ANALYSIS

Our study is a multicentric randomised clinical trial with a 28-day and 90-day follow-up and allocation ratio 1:1. Its aim is to clarify whether the application of high doses of CPFA (treated plasma ≥0.20 L/kg/day) in the first 3 days after randomisation, in addition to the current clinical practice, is able to reduce hospital mortality in patients with septic shock in intensive care units (ICUs) at 28 and 90 days after initiation of the therapy. The study will be performed in 10 ICUs in the Southeast of Spain which follow the same protocol in this disease (based on the Surviving Sepsis Campaign). Our trial is designed to be able to demonstrate an absolute mortality reduction of 20% (α=0.05; 1-β=0.8; n=190(95×2)). The severity of the process, ensuring the recruitment of patients with a high probability of death (50% in the control group), will be achieved through an adequate stratification by using both severity scores and classical definitions of severe sepsis/septic shock and dynamic parameters. Our centres are fully aware of the many pitfalls associated with previous medical device trials. Trying to reduce these problems, we have developed a training programme to improve the CPFA use (especially clotting problems).

ETHICS AND DISSEMINATION

The protocol was approved by the Ethics Committees of all the participant centres. The findings of the trial will be disseminated through peer-reviewed journals, as well as national and international conference presentations.

TRIAL REGISTRATION NUMBER

NCT02357433; Pre-results.

Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

IMPORTANCE

Septic shock currently refers to a state of acute circulatory failure associated with infection. Emerging biological insights and reported variation in epidemiology challenge the validity of this definition.

OBJECTIVE

To develop a new definition and clinical criteria for identifying septic shock in adults.

DESIGN, SETTING, AND PARTICIPANTS

The Society of Critical Care Medicine and the European Society of Intensive Care Medicine convened a task force (19 participants) to revise current sepsis/septic shock definitions. Three sets of studies were conducted: (1) a systematic review and meta-analysis of observational studies in adults published between January 1, 1992, and December 25, 2015, to determine clinical criteria currently reported to identify septic shock and inform the Delphi process; (2) a Delphi study among the task force comprising 3 surveys and discussions of results from the systematic review, surveys, and cohort studies to achieve consensus on a new septic shock definition and clinical criteria; and (3) cohort studies to test variables identified by the Delphi process using Surviving Sepsis Campaign (SSC) (2005-2010; n = 28,150), University of Pittsburgh Medical Center (UPMC) (2010-2012; n = 1,309,025), and Kaiser Permanente Northern California (KPNC) (2009-2013; n = 1,847,165) electronic health record (EHR) data sets.

MAIN OUTCOMES AND MEASURES

Evidence for and agreement on septic shock definitions and criteria.

RESULTS

The systematic review identified 44 studies reporting septic shock outcomes (total of 166,479 patients) from a total of 92 sepsis epidemiology studies reporting different cutoffs and combinations for blood pressure (BP), fluid resuscitation, vasopressors, serum lactate level, and base deficit to identify septic shock. The septic shock-associated crude mortality was 46.5% (95% CI, 42.7%-50.3%), with significant between-study statistical heterogeneity (I2 = 99.5%; τ2 = 182.5; P < .001). The Delphi process identified hypotension, serum lactate level, and vasopressor therapy as variables to test using cohort studies. Based on these 3 variables alone or in combination, 6 patient groups were generated. Examination of the SSC database demonstrated that the patient group requiring vasopressors to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L (18 mg/dL) after fluid resuscitation had a significantly higher mortality (42.3% [95% CI, 41.2%-43.3%]) in risk-adjusted comparisons with the other 5 groups derived using either serum lactate level greater than 2 mmol/L alone or combinations of hypotension, vasopressors, and serum lactate level 2 mmol/L or lower. These findings were validated in the UPMC and KPNC data sets.

CONCLUSIONS AND RELEVANCE

Based on a consensus process using results from a systematic review, surveys, and cohort studies, septic shock is defined as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone. Adult patients with septic shock can be identified using the clinical criteria of hypotension requiring vasopressor therapy to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L after adequate fluid resuscitation.

Cerium oxide nanoparticle treatment ameliorates peritonitis-induced diaphragm dysfunction

The severe inflammation observed during sepsis is thought to cause diaphragm dysfunction, which is associated with poor patient prognosis. Cerium oxide (CeO2) nanoparticles have been posited to exhibit anti-inflammatory and antioxidative activities suggesting that these particles may be of potential use for the treatment of inflammatory disorders. To investigate this possibility, Sprague Dawley rats were randomly assigned to the following groups: sham control, CeO2 nanoparticle treatment only (0.5 mg/kg iv), sepsis, and sepsis+CeO2 nanoparticles. Sepsis was induced by the introduction of cecal material (600 mg/kg) directly into the peritoneal cavity. Nanoparticle treatment decreased sepsis-associated impairments in diaphragmatic contractile (P(o)) function (sham: 25.6±1.6 N/cm(2) vs CeO2: 23.4±0.8 N/cm(2) vs Sep: 15.9±1.0 N/cm(2) vs Sep+CeO2: 20.0±1.0 N/cm(2), P<0.05). These improvements in diaphragm contractile function were accompanied by a normalization of protein translation signaling (Akt, FOXO-1, and 4EBP1), diminished proteolysis (caspase 8 and ubiquitin levels), and decreased inflammatory signaling (Stat3 and iNOS). Histological analysis suggested that nanoparticle treatment was associated with diminished sarcolemma damage and diminished inflammatory cell infiltration. These data indicate CeO2 nanoparticles may improve diaphragmatic function in the septic laboratory rat.

The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis

Introduction

Sepsis and septic shock are leading causes of intensive care unit (ICU) mortality. They are characterized by excessive inflammation, upregulation of procoagulant proteins and depletion of natural anticoagulants. Plasma exchange has the potential to improve survival in sepsis by removing inflammatory cytokines and restoring deficient plasma proteins. The objective of this study is to evaluate the efficacy and safety of plasma exchange in patients with sepsis.

Methods

We searched MEDLINE, EMBASE, CENTRAL, Scopus, reference lists of relevant articles, and grey literature for relevant citations. We included randomized controlled trials comparing plasma exchange or plasma filtration with usual care in critically ill patients with sepsis or septic shock. Two reviewers independently identified trials, extracted trial-level data and performed risk of bias assessments using the Cochrane Risk of Bias tool. The primary outcome was all-cause mortality reported at longest follow-up. Meta-analysis was performed using a random-effects model.

Results

Of 1,957 records identified, we included four unique trials enrolling a total of 194 patients (one enrolling adults only, two enrolling children only, one enrolling adults and children). The mean age of adult patients ranged from 38 to 53 years (n = 128) and the mean age of children ranged from 0.9 to 18 years (n = 66). All trials were at unclear to high risk of bias. The use of plasma exchange was not associated with a significant reduction in all-cause mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.45 to 1.52, I² 60%). In adults, plasma exchange was associated with reduced mortality (RR 0.63, 95% CI 0.42 to 0.96; I² 0%), but was not in children (RR 0.96, 95% CI 0.28 to 3.38; I² 60%). None of the trials reported ICU or hospital lengths of stay. Only one trial reported adverse events associated with plasma exchange including six episodes of hypotension and one allergic reaction to fresh frozen plasma.

Conclusions

Insufficient evidence exists to recommend plasma exchange as an adjunctive therapy for patients with sepsis or septic shock. Rigorous randomized controlled trials evaluating clinically relevant patient-centered outcomes are required to evaluate the impact of plasma exchange in this condition.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0699-2) contains supplementary material, which is available to authorized users.

Role of prostaglandins in determining the increased cardiac sympathetic nerve activity in ovine sepsis

Effective treatment of sepsis remains a significant challenge in intensive care units. During sepsis, there is widespread activation of the sympathetic nervous system, which is thought to have both beneficial and detrimental effects. The sympathoexcitation is thought to be partly due to the developing hypotension, but may also be a response to the inflammatory mediators released. Thus, we investigated whether intracarotid infusion of prostaglandin E2 (PGE2) induced similar cardiovascular changes to those caused by intravenous infusion of Escherichia coli in sheep and whether inhibition of prostaglandin synthesis, with the nonselective cyclooxygenase inhibitor indomethacin, administered at 2 and 8 h after the onset of sepsis, reduced sympathetic nerve activity (SNA), and heart rate (HR). Studies were performed in conscious sheep instrumented to measure mean arterial pressure (MAP), HR, cardiac SNA (CSNA), and renal SNA (RSNA). Intracarotid infusion of PGE2 (50 ng·kg−1·min−1) increased temperature, CSNA, and HR, but not MAP or RSNA. Sepsis, induced by infusion of E. coli, increased CSNA, but caused an initial, transient inhibition of RSNA. At 2 h of sepsis, indomethacin (1.25 mg/kg bolus) increased MAP and caused reflex decreases in HR and CSNA. After 8 h of sepsis, indomethacin did not alter MAP, but reduced CSNA and HR, without altering baroreflex control. These findings indicate an important role for prostaglandins in mediating the increase in CSNA and HR during the development of hyperdynamic sepsis, whereas prostaglandins do not have a major role in determining the early changes in RSNA.

Epidemiologic features, risk factors, and outcome of sepsis in stroke patients treated on a neurologic intensive care unit

PURPOSE

Because of the immune-suppressive effect of cerebral damage, stroke patients are at high risk for infections. These might result in sepsis, which is the major contributor to intensive care unit (ICU) mortality. Although there are numerous studies on infections in stroke patients, the role of sepsis as a poststroke complication is unknown.

METHODS

We retrospectively analyzed incidence of and risk factors for sepsis acquisition as well as outcome parameters of 238 patients with ischemic or hemorrhagic strokes consecutively admitted to the neurologic ICU in a tertiary university hospital between January 1, 2009, and December 31, 2010. Basic demographic and clinical data including microbiological parameters as well as factors describing stroke severity (eg, lesion volume and National Institute of Health stroke scale score) were recorded and included into the analysis. The diagnosis of sepsis was based on the criteria of the German Sepsis Society.

RESULTS

We identified 30 patients (12.6%) with sepsis within the first 7 days from stroke onset. The lungs were the most frequent source of infection (93.3%), and gram-positive organisms were dominating the microbiologic spectrum (52.4%). Comorbidities (chronic obstructive pulmonary disease and immunosuppressive disorders) and Simplified Acute Physiology Score II but none of the factors describing stroke severity were independent predictors of sepsis acquisition. Sepsis was associated with a significantly worse prognosis, leading to a 2-fold increased mortality rate during in-hospital care (36.7% vs 18.8%) and after 3 months (56.5% vs 28.5%), but only in the subgroup of supratentorial hemorrhages, it was an independent predictor of in-hospital and 3-month mortality. Other factors significantly associated with death in a multivariate analysis were chronic obstructive pulmonary disease, malignancies (in-hospital mortality only), and Simplified Acute Physiology Score II (3-month mortality only) for ischemia and heart failure (in-hospital mortality only), National Institute of Health stroke scale score (in-hospital mortality only), and stroke volume for hemorrhages, respectively.

CONCLUSIONS

Sepsis seems to be a frequent complication of stroke patients requiring neurologic ICU treatment. Predictors of sepsis acquisition in our study were comorbidities and severity of deterioration of physiological status, but not stroke severity. A better understanding of risk factors is important for prevention and early recognition, whereas knowledge of outcome may help in prognosis prediction. Further studies are needed to clarify the optimal preventive treatment for these patients.

Revisiting the white blood cell count: immature granulocytes count as a diagnostic marker to discriminate between SIRS and sepsis--a prospective, observational study

Background

Sepsis is a serious disease condition and a major cause of intensive care unit (ICU) admission. Its diagnosis in critically ill patients is complicated. To diagnose an infection rapidly, and to accurately differentiate systemic inflammatory response syndrome (SIRS) from sepsis, is challenging yet early diagnosis is vital for early induction of an appropriate therapy. The aim of this study was to evaluate whether the immature granulocyte (IG) count is a useful early diagnostic marker of sepsis compared to other markers. Therefore, a total of 70 consecutive surgical intensive care patients were assessed. IGs were measured from whole blood samples using an automated analyzer. C-reactive protein (CRP), lipopolysaccharide binding protein (LBP) and interleukin-6 (IL-6) concentrations were also determined. The observation period was a maximum of 21 days and ended with the patients’ discharge from ICU or death. Receiver operating characteristic (ROC) analyses were conducted and area under the curve (AUC) was calculated to determine sensitivities and specificities for the parameters.

Results

We found that the IG count significantly discriminates between infected and non-infected patients (P < 0.0001) with a sensitivity of 89.2% and a specificity of 76.4%, particularly within the first 48 hours after SIRS onset. Regarding the discriminative power for infection, the IG count was more indicative than other clinical parameters such as CRP, LBP and IL-6, which had a sensitivity of less than 68%. Additionally, the highest diagnostic odds ratio (DOR) with 26.7 was calculated for the IG count within the first 48 hours. During the course of the disease ROC curve analyses showed a superior positive predictive value of the IG count compared to the other measured parameters during the first five days following the fulfillment of SIRS criteria. However, the number of IGs was not correlated with ICU mortality.

Conclusions

The total number of IG in peripheral blood from ICU patients is a good marker to discriminate infected and non-infected patients very early during SIRS. However, the IG count is not suitable as a prognostic marker for mortality. Routine and serial measurement of IGs may provide new possibilities for rapid screening of SIRS patients on ICU with suspected infections.

Lipopolysaccharide-induced mitochondrial DNA depletion

Hepatic energy depletion has been described in severe sepsis, and lipopolysaccharide (LPS) has been shown to cause mitochondrial DNA (mtDNA) damage. To clarify the mechanisms of LPS-induced mtDNA damage and mitochondrial alterations, we treated wild-type (WT) or transgenic manganese superoxide dismutase-overerexpressing (MnSOD(+++)) mice with a single dose of LPS (5 mg/kg). In WT mice, LPS increased mitochondrial reactive oxygen species formation, hepatic inducible nitric oxide synthase (NOS) mRNA and protein, tumor necrosis factor-alpha, interleukin-1 beta, and high-mobility group protein B1 concentrations. Six to 48 h after LPS administration (5 mg/kg), liver mtDNA levels, respiratory complex I activity, and adenosine triphosphate (ATP) contents were decreased. In addition, LPS increased interferon-β concentration and decreased mitochondrial transcription factor A (Tfam) mRNA, Tfam protein, and mtDNA-encoded mRNAs. Morphological studies showed mild hepatic inflammation. The LPS (5 mg/kg)-induced mtDNA depletion, complex I inactivation, ATP depletion, and alanine aminotransferase increase were prevented in MnSOD(+++) mice or in WT mice cotreated with 1400W (a NOS inhibitor), (2-(2,2,6,6-tetramethylpiperidin-1-oxyl-4-ylamino)-2-oxoethyl)triphenylphosphonium chloride, monohydrate (a superoxide scavenger) or uric acid (a peroxynitrite scavenger). The MnSOD overexpression delayed death in mice challenged by a higher, lethal dose of LPS (25 mg/kg). In conclusion, LPS administration damages mtDNA and alters mitochondrial function. The protective effects of MnSOD, NOS inhibitors, and superoxide or peroxynitrite scavengers point out a role of the superoxide anion reacting with NO to form mtDNA- and protein-damaging peroxynitrite. In addition to the acute damage caused by reactive species, decreased levels of mitochondrial transcripts contribute to mitochondrial dysfunction.

C1-esterase inhibitor attenuates the inflammatory response during human endotoxemia

OBJECTIVE

Besides its role in regulation of the complement and contact system, C1-esterase inhibitor has other immunomodulating effects that could prove beneficial in patients with acute inflammation such as during sepsis or after trauma. We examined the immunomodulating properties of C1-esterase inhibitor during human experimental endotoxemia, in which the innate immune system is activated in the absence of activation of the classic complement pathway.

DESIGN

Double-blind placebo-controlled study.

SETTING

Research intensive care unit of the Radboud University Nijmegen Medical Centre.

SUBJECTS

Twenty healthy volunteers.

INTERVENTIONS

Intravenous injection of 2 ng/kg Escherichia coli lipopolysaccharide. Thirty minutes thereafter (to prevent binding of lipopolysaccharide), C1-esterase inhibitor concentrate (100 U/kg, n = 10) or placebo (n = 10) was infused.

MEASUREMENTS AND MAIN RESULTS

Pro- and anti-inflammatory mediators, markers of endothelial and complement activation, hemodynamics, body temperature, and symptoms were measured. C1-esterase inhibitor reduced the release of proinflammatory cytokines as well as C-reactive protein (peak levels of: interleukin-6 1521 ± 209 vs. 932 ± 174 pg/mL [p = .04], tumor necrosis factor-α 1213 ± 187 vs. 827 ± 167 pg/mL [p = .10], monocyte chemotactic protein-1 6161 ± 1302 vs. 3373 ± 228 pg/mL [p = .03], interleukin-1β 34 ± 5 vs. 23 ± 2 pg/mL [p < .01], C-reactive protein 39 ± 4 vs. 29 ± 2 mg/L [p = .02]). In contrast, release of the anti-inflammatory cytokine interleukin-10 was increased by C1-esterase inhibitor (peak level 73 ± 11 vs. 121 ± 18 pg/mL, p = .02). The increase in interleukin-1 receptor antagonist tended to be smaller in the C1-esterase inhibitor group, but this effect did not reach statistical significance (p = .07). Markers for endothelial activation were increased after lipopolysaccharide infusion, but no significant differences between groups were observed. The lipopolysaccharide-induced changes in heart rate, blood pressure, body temperature, and symptoms (all p < .001 over time) were not influenced by C1-esterase inhibitor. Complement fragment C4 was not increased after lipopolysaccharide challenge.

CONCLUSIONS

This study is the first to demonstrate that C1-esterase inhibitor exerts anti-inflammatory effects in the absence of classic complement activation in humans.

Infections of respiratory or abdominal origin in ICU patients: what are the differences?

INTRODUCTION

There are few data related to the effects of different sources of infection on outcome. We used the Sepsis Occurrence in Acutely ill Patients (SOAP) database to investigate differences in the impact of respiratory tract and abdominal sites of infection on organ failure and survival.

METHODS

The SOAP study was a cohort, multicenter, observational study which included data from all adult patients admitted to one of 198 participating intensive care units (ICUs) from 24 European countries during the study period. In this substudy, patients were divided into two groups depending on whether, on admission, they had abdominal infection but no respiratory infection or respiratory infection but no abdominal infection. The two groups were compared with respect to patient and infection-related characteristics, organ failure patterns, and outcomes.

RESULTS

Of the 3,147 patients in the SOAP database, 777 (25%) patients had sepsis on ICU admission; 162 (21%) had abdominal infection without concurrent respiratory infection and 380 (49%) had respiratory infection without concurrent abdominal infection. Age, sex, and severity scores were similar in the two groups. On admission, septic shock was more common in patients with abdominal infection (40.1% vs. 29.5%, P = 0.016) who were also more likely to have early coagulation failure (17.3% vs. 9.5%, P = 0.01) and acute renal failure (38.3% vs. 29.5%, P = 0.045). In contrast, patients with respiratory infection were more likely to have early neurological failure (30.5% vs. 9.9%, P < 0.001). The median length of ICU stay was the same in the two groups, but the median length of hospital stay was longer in patients with abdominal than in those with respiratory infection (27 vs. 20 days, P = 0.02). ICU (29%) and hospital (38%) mortality rates were identical in the two groups.

CONCLUSIONS

There are important differences in patient profiles related to the site of infection; however, mortality rates in these two groups of patients are identical.

Direct hemoperfusion with polymyxin-B-immobilized fiber columns improves septic hypotension and reduces inflammatory mediators in septic patients with colorectal perforation

PURPOSE

Although some studies have reported favorable effects of direct hemoperfusion with polymyxin-B-immobilized fiber columns (PMX) for the treatment of septic shock, few studies have demonstrated the efficacy of PMX in studies with a uniform case definition and without any other blood purification techniques.

MATERIALS AND METHODS

Fifty-two patients with severe sepsis or septic shock secondary to colorectal perforation were treated with PMX. Hemodynamic alterations and plasma concentrations of endotoxin, interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-8, and IL-10 were evaluated following PMX treatment.

RESULTS

We observed a significant reduction in plasma endotoxin in the nonsurvivors immediately after PMX treatment compared to before treatment. Systolic blood pressure was markedly increased and circulating levels of IL-1beta, IL-1Ra, and IL-8 were significantly reduced during a 2-h interval of PMX.

CONCLUSIONS

Our findings suggested that PMX treatment appears to adsorb endotoxin and also modulates circulating cytokine during a 2-h interval of direct hemoperfusion in septic patients with such condition.

Evaluation of neutrophil CD64 expression and procalcitonin as useful markers in early diagnosis of sepsis

Quantitation of neutrophil CD64 expression and procalcitonin (PCT) levels in blood samples have been recently proposed as useful tools for early detection of sepsis. To determine the usefulness of these tests, we analyzed blood samples of 112 patients, admitted to an intensive care unit (ICU), presenting clinical symptoms of sepsis, as well as of 50 healthy controls. At the end of the study, a retrospective analysis showed that only 52 of the 112 ICU-patients presented a real sepsis (positive blood culture). The results obtained indicated that of the 52 patients with sepsis, 50 and 49 presented levels of neutrophil CD64 expression >or= 2398 molecules per cell (cut-off determined by receiver operator characteristic analysis) and PCT levels >0.5 ng/ml (cut-off suggested by the manufacturer), respectively. However, the neutrophil CD64 test showed higher specificity in detecting sepsis since 5 out of the 60 ICU-patients without sepsis (negative blood culture), presented CD64 expression levels >or= 2398 molecules per cell, PCT levels >or= 0.5 ng/ml were shown in 27 patients. Moreover, while none of the 50 healthy controls presented a neutrophil CD64 level higher than the cut-off value, 5 patients presented PCT levels >or= 0.5 ng/ml. In conclusion, our data seem to indicate that the quantitation of CD64 expression could be taken into consideration as a sensitive and specific test for early diagnosis of sepsis.

A novel endotoxin-induced pathway: upregulation of heme oxygenase 1, accumulation of free iron, and free iron-mediated mitochondrial dysfunction

Mitochondria are involved in the development of organ failure in critical care diseases. However, the mechanisms underlying mitochondrial dysfunction are not clear yet. Inducible hemoxygenase (HO-1), a member of the heat shock protein family, is upregulated in critical care diseases and considered to confer cytoprotection against oxidative stress. However, one of the products of HO-1 is Fe2+ which multiplies the damaging potential of reactive oxygen species catalyzing Fenton reaction. The aim of this study was to clarify the relevance of free iron metabolism to the oxidative damage of the liver in endotoxic shock and its impact on mitochondrial function. Endotoxic shock in rats was induced by injection of lipopolysaccharide (LPS) at a dose of 8 mg/kg (i.v.). We observed that the pro-inflammatory cytokine TNF-alpha and the liver necrosis marker aspartate aminotransferase were increased in blood, confirming inflammatory response to LPS and damage to liver tissue, respectively. The levels of free iron in the liver were significantly increased at 4 and 8 h after onset of endotoxic shock, which did not coincide with the decrease of transferrin iron levels in the blood, but rather with expression of the inducible form of heme oxygenase (HO-1). The proteins important for sequestering free iron (ferritin) and the export of iron out of the cells (ferroportin) were downregulated facilitating the accumulation of free iron in cells. The temporarily increased concentration of free iron in the liver correlated with the temporary impairment of both mitochondrial function and tissue ATP levels. Addition of exogenous iron ions to mitochondria isolated from control animals resulted in an impairment of mitochondrial respiration similar to that observed in endotoxic shock in vivo. Our data suggest that free iron released by HO-1 causes mitochondrial dysfunction in pathological situations accompanied by endotoxic shock.

Ligation of the adhesion-GPCR EMR2 regulates human neutrophil function

At present, approximately 150 different members of the adhesion-G protein-coupled receptor (GPCR) family have been identified in metazoans. Surprisingly, very little is known about their function, although they all possess large extracellular domains coupled to a seven-transmembrane domain, suggesting a potential role in cell adhesion and signaling. Here, we demonstrate how the human-restricted adhesion-GPCR, EMR2 (epidermal growth factor-like module-containing mucin-like hormone receptor), regulates neutrophil responses by potentiating the effects of a number of proinflammatory mediators and show that the transmembrane region is critical for adhesion-GPCR function. Using an anti-EMR2 antibody, ligation of EMR2 increases neutrophil adhesion and migration, and augments superoxide production and proteolytic enzyme degranulation. On neutrophil activation, EMR2 is rapidly translocated to membrane ruffles and the leading edge of the cell. Further supporting the role in neutrophil activation, EMR2 expression on circulating neutrophils is significantly increased in patients with systemic inflammation. These data illustrate a definitive function for a human adhesion-GPCR within the innate immune system and suggest an important role in potentiating the inflammatory response. Ligation of the adhesion-GPCR EMR2 regulates human neutrophil function.

New evaluation therapies for sepsis

This article presents an analysis of the literature of the last 2 years on the treatment of sepsis and septic shock. It appears that most of the antimediator therapies applied in phase II or III clinical trials yielded disappointing results. But, many other therapeutic approaches are proposed or are ongoing, and many papers report critical analysis of the reasons for the lack of success of past clinical trials.

Quo vadis haemapheresis. Current developments in haemapheresis

The techniques of haemapheresis originated in the development of centrifugal devices separating cells from plasma and later on plasma from cells. Subsequently membrane filtration was developed allowing for plasma-cell separation. The unspecificity of therapeutic plasma exchange led to the development of secondary plasma separation technologies being specific, semi-selective or selective such as adsorption, filtration or precipitation. In contrast on-line differential separation of cells is still under development. Whereas erythrocytapheresis, granulocytapheresis, lymphocytapheresis and stem cell apheresis are technically advanced, monocytapheresis may need further improvement. Also, indications such as erythrocytapheresis for the treatment of polycythaemia vera or photopheresis though being clinically effective and of considerable importance for an appropriate disease control are to some extent under debate as being either too costly or without sufficient understanding of the mechanism. Other forms of cell therapy are under development. Rheohaemapheresis as the most advanced technology of extracorporeal haemorheotherapy is a rapidly developing approach contributing to the treatment of microcirculatory diseases and tissue repair. Whereas the control of a considerable number of (auto-) antibody mediated diseases is beyond discussion, the indication of apheresis therapy for immune complex mediated diseases is quite often still under debate. Detoxification for artificial liver support advanced considerably during the last years, whereas conclusions on the efficacy of septicaemia treatment are debatable indeed. LDL-apheresis initiated in 1981 as immune apheresis is well established since 24 years, other semi-selective or unspecific procedures, allowing for the elimination of LDL-cholesterol among other plasma components are also being used. Correspondingly Lp(a) apheresis is available as a specific, highly efficient elimination procedure superior to techniques which also eliminate Lp(a). Quality control systems, more economical technologies as for instance by increasing automation, influencing the over-interpretation of evidence based medicine especially in patients with rare diseases without treatment alternative, more insight into the need of controlled clinical trials or alternatively improved diagnostic procedures are among others tools ways to expand the application of haemapheresis so far applied in cardiology, dermatology, haematology, immunology, nephrology, neurology, ophthalmology, otology, paediatrics, rheumatology, surgery and transfusion medicine.

Regulation of Toll-like receptor (TLR)2 and TLR4 on CD14dimCD16+ monocytes in response to sepsis-related antigens

Rapid overproduction of proinflammatory cytokines are characteristic of sepsis. CD14(dim)CD16(+) monocytes are thought to be major producers of cytokine and have been shown to be elevated in septic patients. Toll-like receptors (TLR) are pattern recognition receptors important in mediating the innate immune response and their activation can lead to production of cytokines. Using whole blood culture and flow cytometry we have investigated TLR2 and TLR4 regulation after stimulation with sepsis-relevant antigens [lipopolysaccharide (LPS), Staphylococcal enterotoxin B (SEB) and peptidoglycan (PGN)]. The percentage of CD14(dim)CD16(+) monocyte population expanded at 20 h post-stimulation, after a rise in tumour necrosis factor (TNF)-alpha and interleukin (IL)-6 at 2 h. A strong positive correlation between the percentage of CD14(dim)CD16(+) monocytes and secreted TNF-alpha was demonstrated (r = 0.72). Furthermore, we were able to induce expansion of the CD14(dim)CD16(+) population to approximately 35% of all monocytes with the addition of recombinant TNF-alpha to the whole blood culture. TLR4 was found to be expressed 2.5 times higher on CD14(dim)CD16(+) compared to CD14(+) CD16(-) monocytes, while TLR2 expression was similar in both subpopulations. The CD14(dim)CD16(+) and CD14(+) CD16(-) monocyte populations were different in their response to various antigens. LPS down-regulated TLR4 by 4.9 times in CD16(+) monocytes compared to only 2.3 times in CD16(-) monocytes at 2 h. LPS was able to up-regulate TLR2 by 6.2 times after 2 h, with no difference between the subpopulations. LPS further up-regulated TLR2 by 18.4 times after 20 h only in the CD14(+) CD16(-) population. PGN and SEB induced no significant changes in TLR2 or TLR4 expression. We hypothesize that following exposure to bacterial antigens, subsequent TNF-alpha drives a differentiation of monocytes into a CD14(dim)CD16(+) subpopulation.

[Necessity and problems with case-related costing for intensive care patients]

To evaluate whether a German refined diagnosis-related groups (GR-DRGs)-based reimbursement of hospitals/departments covers costs per case, total cost per case accounting is necessary. The aim of the present paper is to delineate the necessity and problems with costs per case accounting for intensive care medicine. The new performance category 8-980 "complex intensive care treatment", in force from 2005 onwards, was integrated into the OPS catalogue to document intensive care work. Whether this will lead to more achievement-oriented cost accounting, has to be demonstrated by the calculations of the institute for reimbursement in hospitals. Basic financing of hospital allowance on a daily basis should be supplemented by extra charges due to analytical concepts of personnel share and to cost-consuming organ replacement procedures. This might lead to a more achievement-oriented cost accounting per case in the ICU.

Role of intestine in postsurgical complications: involvement of free radicals

Surgery at any location in the body leads to surgical stress response and alterations in normal body homeostasis. The intestine is extremely sensitive to surgical stress even at remote locations and the gastrointestinal tract plays an important role in the development of postsurgical complications such as sepsis, the systemic immune response syndrome (SIRS), and multiple organ failure syndrome (MOFS). The generation of free radicals and subsequent biochemical alterations at the cellular and subcellular level in the intestine has been suggested to play an important role in this process. These oxidative stress-induced events in the mucosa might act as an initiator of distant organ damage and also facilitate bacterial adherence onto the epithelium and translocation into the systemic circulation. This review attempts to highlight the important role of intestine and oxygen free radicals in initiating post-surgical complications.

Interleukin-1 beta rapidly inhibits aortic endothelium-dependent relaxation by a DNA transcription-dependent mechanism

OBJECTIVES

This study examined the effects of interleukin-1 beta on isometric tension development and relaxation in isolated rat aortic rings in response to the alpha-1 adrenergic agonist phenylephrine, the endothelium-dependent vasodilator acetylcholine, and the endothelium-independent vasodilator sodium nitroprusside.

DESIGN

Randomized, controlled, paired design.

SETTING

Animal laboratory within a university department of physiology. SUBJECTS Paired aortic thoracic aortic rings from specific pathogen-free Sprague-Dawley rats.

INTERVENTIONS

Series I examined the potential for interleukin-1 beta to cause early arterial endothelial dysfunction. Paired aortic rings were incubated for 2 hrs with interleukin-1 beta or vehicle. Series II examined the potential for inhibition of DNA transcription to attenuate interleukin-1 beta-mediated endothelial dysfunction. Paired rings received either dactinomycin or vehicle before interleukin-1 beta incubation. Series III quantified the degree to which inhibition of DNA transcription inhibited early interleukin-1 beta-mediated endothelial dysfunction. Paired rings received either dactinomycin pretreatment followed by interleukin-1 beta incubation, or pretreatment and incubation with inert vehicles. Series IV assessed the effects of interleukin-1 beta on responsiveness to an exogenous nitric oxide donor, sodium nitroprusside, in the presence of the nitric oxide synthesis inhibitor N omega-nitro-L-arginine methyl ester.

MEASUREMENTS AND MAIN RESULTS

Incubation with interleukin-1 beta for 2 hrs had no effect on contractile response but attenuated endothelium-dependent relaxation significantly relative to control. Dactinomycin pretreatment inhibited early interleukin-1 beta-mediated endothelial dysfunction. The combination of interleukin-1 beta and dactinomycin produced effects on endothelium-dependent relaxation that were not different from that seen in rings not exposed to interleukin-1 beta. Interleukin-1 beta attenuated responsiveness to sodium nitroprusside relative to control.

CONCLUSIONS

Interleukin-1 beta causes an early impairment of endothelium-dependent vasorelaxation with an onset that precedes its effects on systemic contractility. This impairment occurs via a mechanism that is wholly or predominantly dependent on DNA transcription. The altered vasorelaxation induced by interleukin-1 beta is at least partly mediated by a reduction in nitric oxide responsiveness.

A predictive model for mortality of bloodstream infections. Bedside analysis with the Weibull function

This paper describes the construction and validation of a prognostic model for predicting post-bloodstream infection survival up to Day 21. A Weibull multiple regression model was adopted in a prospective cohort study of all patients diagnosed with true bacteremia or fungemia in a teaching hospital between 1991 and 1994 (training set, 1,577 patients). The final model included six variables easily detected in any institution: source of infection, underlying neoplasm, septic shock, community-acquired, age over 65, and polymicrobial bacteremia. Using this model, it is possible to obtain a graphic representation of survival probability for any combination of these risk factors. The model was tested on a second set of patients diagnosed in the same hospital between 1996 and 1997 (validation set, 952 patients), confirming its reliability in predicting survival. In conclusion, the Weibull function, together with variables easily identified at bedside, enables a precise prediction of the short-term, post-bloodstream infection mortality of a given patient.

Increased distribution and expression of CD64 on blood polymorphonuclear cells from patients with the systemic inflammatory response syndrome (SIRS)

Evidence is growing to suggest that the multiple organ damage of the systemic inflammatory response syndrome (SIRS) arises from the untoward activity of blood polymorphonuclear cells (PMNs), which upon activation acquire the IgG high affinity receptor, CD64. In the current study, flow cytometry was used to assess the prevalence of CD64-bearing PMNs and the intensity of expression of CD64 in whole blood samples from 32 SIRS patients, 11 healthy normal subjects and from eight non-SIRS patients in the intensive care unit (ICU). The percentage of PMNs expressing CD64 was higher in SIRS patients (mean 65%) than in non-SIRS patients (mean 42%; P < 0.02) and in healthy controls (mean 19%; P < 0.001) and was particularly evident in patients with SIRS and sepsis (mean 71%; P < 0.02) as opposed to SIRS alone (mean 55%). There were more CD64 molecules expressed on PMNs from patients with SIRS (median 1331 molecules/cell) in comparison with PMNs from healthy subjects (median 678 molecules/cell; P < 0.01). The highest intensity of CD64 expression was associated with PMNs from patients with both SIRS and sepsis. Functional studies revealed that the supranormal binding of PMNs from patients with SIRS to endothelial monolayers treated with TNFalpha was impeded by anti-CD64 antibodies (mean 24% inhibition; P < 0.01). Monitoring the distribution of CD64+ PMNs and their level of CD64 expression could be of assistance in the rapid discrimination of patients with SIRS from other ICU patients and in the identification of PMNs which are likely to participate in the pathological manifestations of the disease.