Cardiovascular dysfunction in sepsis at the dawn of emerging mediators

Stillbirth Investigations: An Iconographic and Concise Diagnostic Workup in Perinatal Pathology

Introduction  Stillbirth is a dramatic event for the parents, health care team, and anyone close to the expectant parents. Multidisciplinary team (MDT) meetings are essential to improve communication in health care. We review the most frequent findings discussed at MDT meetings. Methods  A PubMed search was conducted through December 2021 since the inception (1965) using clinical queries with the key terms "stillbirth" AND "investigation" AND "pathology" AND "human." The search strategy included reviews, meta-analyses, randomized controlled trials, clinical trials, and observational studies. This systematic review is based on, but not limited to, the search results. It is the experience of more than 30 years of pediatrics, obstetrics, and pathology staff. Results  Two hundred and six articles were screened and complemented through the perusal of congressional activities and personal communications. Pathological findings following perinatal death can be divided into macroscopic, histologic, and placental findings. The placenta is crucial in fetal medicine and is key in determining the cause of stillbirth in a substantial number of events. Perinatal lung disease is essential to evaluate the response of newborns to extrauterine life and address newborns' outcomes appropriately. Conclusions  Stillbirth remains one of the less explored areas of medicine, and we can determine the cause in a limited number of cases. Nevertheless, placental pathology is critical in the etiology discovery pathway. Accurate investigations and discussion of photography-supported findings are vital in promoting communication at MDT meetings.

A sensitive dual-signal electrochemiluminescence immunosensor based on Ru(bpy)32+@HKUST-1 and Ce2Sn2O7 for detecting the heart failure biomarker NT-proBNP

A sensitive dual-signal electrochemiluminescence (ECL) immunosensor was proposed based on Ru(bpy)₃²⁺@HKUST-1/TPA and Ce₂Sn₂O₇/K₂S₂O₈ probes for detecting the NT-proBNP biomarker of heart failure. HKUST-1 with a high specific surface area facilitates the loading of more Ru(bpy)₃²⁺, effectively improving the anodic signal intensity, while the emerging Ce₂Sn₂O₇ emitter displays a potential-matching cathodic emission with moderate intensity. Two ECL probes were characterized with field emission scanning electron microscopy, X-ray diffraction, XPS, FT-IR spectroscopy and UV-Vis diffuse reflectance spectroscopy. This dual-signal immunosensor has a wide linear range (5 × 10^-4-1 × 10⁴ ng mL^-1) and a low quantitative detection limit, simultaneously showing high sensitivity, stability and reproducibility, as well as the detection capability of actual serum samples. This dual signal-calibrated immunoassay platform not only reduces the false positive rate of detection results but also provides a promising method for the early diagnosis of heart failure.

Combined Multiomics and In Silico Approach Uncovers PRKAR1A as a Putative Therapeutic Target in Multi-Organ Dysfunction Syndrome

Despite all epidemiological, clinical, and experimental research efforts, therapeutic concepts in sepsis and sepsis-induced multi-organ dysfunction syndrome (MODS) remain limited and unsatisfactory. Currently, gene expression data sets are widely utilized to discover new biomarkers and therapeutic targets in diseases. In the present study, we analyzed MODS expression profiles (comprising 13 sepsis and 8 control samples) retrieved from NCBI-GEO and found 359 differentially expressed genes (DEGs), among which 170 were downregulated and 189 were upregulated. Next, we employed the weighted gene co-expression network analysis (WGCNA) to establish a MODS-associated gene co-expression network (weighted) and identified representative module genes having an elevated correlation with age. Based on the results, a turquoise module was picked as our hub module. Further, we constructed the PPI network comprising 35 hub module DEGs. The DEGs involved in the highest-confidence PPI network were utilized for collecting pathway and gene ontology (GO) terms using various libraries. Nucleotide di- and triphosphate biosynthesis and interconversion was the most significant pathway. Also, 3 DEGs within our PPI network were involved in the top 5 significantly enriched ontology terms, with hypercortisolism being the most significant term. PRKAR1A was the overlapping gene between top 5 significant pathways and GO terms, respectively. PRKAR1A was considered as a therapeutic target in MODS, and 2992 ligands were screened for binding with PRKAR1A. Among these ligands, 3 molecules based on CDOCKER score (molecular dynamics simulated-based score, which allows us to rank the binding poses according to their quality and to identify the best pose for each system) and crucial interaction with human PRKAR1A coding protein and protein kinase-cyclic nucleotide binding domains (PKA RI alpha CNB-B domain) via active site binding residues, viz. Val283, Val302, Gln304, Val315, Ile327, Ala336, Ala337, Val339, Tyr373, and Asn374, were considered as lead molecules.

Point of care with serial N-terminal pro-B-type natriuretic peptide (NT-proBNP) for heart failure in patients with acute decompensation. An invited commentary

Point-of-care (POC) Testing (POCT) is a medical diagnostic approach carried out outside the clinical laboratory and close to the patient. The results are used for the immediate clinical decision to improve patient care. Accreditation Canada and Diagnostic Accreditation Programs regulatory standards and the College of the American Pathologists for POCT have implemented several guidelines and certifications. POC in heart failure (POC-HF) will demonstrate that it is helpful to develop a preliminary understanding of the value of serial N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements in the diagnostic and therapeutic process in patients hospitalized with acute decompensation of heart failure. In addition, POC-HF will hopefully answer questions on the workability of this approach in clinical routine and the usefulness and justification to perform larger-scale studies investigating this strategy.

Yin Yang 1 (YY1)-induced long intergenic non-protein coding RNA 472 (LINC00472) aggravates sepsis-associated cardiac dysfunction via the micro-RNA-335-3p (miR-335-3p)/Monoamine oxidase A (MAOA) cascade

As a leading complication of sepsis, sepsis-induced cardiac dysfunction (SICD) contributed to the high mortality of patients with sepsis. Long non-coding RNA (LncRNA) LINC00472 has been reported to be in sepsis-induced disease. Nonetheless, its biological function and underlying molecular in SICD remain largely unknown. In this study, in vivo and in vitro SICD models were established via LPS treatment. H&E staining was employed for the evaluation of myocardial injury. ELISA assay was performed to detect cardiac Troponin I (cTnI), creatine kinase-MB (CK-MB), interleukin (IL)-1β, and tumor necrosis factor-α (TNF-α) levels. Cardiomyocyte viability and apoptosis were assessed via CCK-8 and flow cytometry assays. The transcriptional regulation of YY1 on LINC00472 was demonstrated via ChIP assay. Besides, the interaction between YY1 and LINC00472, as well as the association between miR-335-3p and LINC00472 or MAOA were verified via luciferase reporter assay and RNA immunoprecipitation (RIP) assay. Herein, highly expressed LINC00472 was observed in both in vivo and in vitro SICD models. LINC00472 knockdown substantially attenuated LPS-induced inhibition on cardiomyocyte viability and reversed cardiomyocyte apoptosis and inflammatory response mediated by LPS treatment. YY1 induced LINC00472 upregulation, thereby promoting cardiomyocyte dysfunction induced by LPS. In addition, MAOA upregulation or miR-335-3p inhibition could partly reverse the suppressive effect on LPS-induced cardiomyocyte dysfunction mediated by LINC00472 knockdown. Based on our results, it seemed that YY1-activated LINC00472 might contribute to SICD progression via the miR-335-3p/MAOA pathway.

Knockdown of lncRNA LUCAT1 attenuates sepsis‑induced myocardial cell injury by sponging miR-642a

The heart is one of the most common organs involved in sepsis-induced organ dysfunction and about 50% septic patients complicated with myocardial injury. So far, the molecular mechanisms underlying sepsis-induced cardiac damage remain unclear. In this study we aimed to evaluate the effect of miR-642a on sepsis-induced cardiac injury in vitro and explore the possible lncRNA-microRNA mechanism. We first downloaded GSE101639 to identify differentially expressed genes (DEGs) in sepsis. The expression of miR-642a in LPS-induced H9C2 cells was detected by qRT-PCR. MTT assay, cell migration, flow cytometry analysis, ELISA, qRT-PCR and Western blotting analysis were applied to evaluating the effect of miR-642a mimic on LPS-induced H9C2 cells. The bioinformatics analysis and the rescue experiment were devoted to the underlying mechanism. The results showed miR-642a expression was decreased in septic patients and LPS-induced H9C2 cells. Besides, MiR-642a mimic promoted cell viability and migration, inhibited cell apoptosis of LPS-induced H9C2 cells. Bioinformatics analysis showed miR-642a directly targets with 3'-UTR of ROCK1. Moreover, LUCAT1 regulated ROCK1 expression act as a competing endogenous RNA (ceRNA) for miR-642a. Our data demonstrated that lncRNA LUCAT1 could function via sponging miR-642a to regulate ROCK1 expression in LPS-induced H9C2 cells. And knockdown of lncRNA LUCAT1 could suppress LPS-induced cardiac injury in vitro.

Myocardial Edema: an Overlooked Mechanism of Septic Cardiomyopathy?

Septic cardiomyopathy is an increasingly relevant topic in clinical management of septic shock. However, pathophysiological mechanisms and long-term consequences of sepsis-induced myocardial injury are still poorly understood. Herein, new clinical and histological evidence is provided suggesting an association of myocardial edema formation with tissue injury and subsequent remodeling in septic shock patients. This preliminary data supports myocardial edema as a potentially relevant and largely unexplored mechanism of human septic cardiomyopathy.

Human bile microbiota: A retrospective study focusing on age and gender

AIMS

The emerging biliary colonization of microorganisms in patients with biliary diseases may be devastating. Recent evidence suggests that age and gender may influence changes in the microbial composition of gut microbiota. To study the relationship between these parameters on bile microbiota, we retrospectively reviewed positive bile cultures following an endoscopic retrograde cholangiopancreatography (ERCP) in a QA-certified academic surgical unit of a single institution.

METHODS

449 positive bile cultures from 172 Italian patients with diseases of the biliopancreatic system hospitalized from 2006 through 2017 were investigated for aerobic, anaerobic, and fungal organisms. The patients were stratified into four age intervals (22-66, 67-74, 75-81, and 82-93 years) and followed up for five years.

RESULTS

Gram-positive bacteria (GPB) was negatively associated with age only in multivariate analysis (R_partial = -0.114, p = 0.017), with younger patients prone to harbor GPB and older patients likely to have Gram-negative bacteria (GNB). There was a definite link with the male gender using both univariate and multivariate analysis (p < 0.001). Enterococcus spp. was the most common strain identified in patients with GPB except for patients aged 67-74 years for male (95.2%) and female (80.9%) patients. Escherichia coli and Klebsiella spp. were most frequent than others in every group analyzed. Analogous results were found for bacteria Non-fermenting Gram-negative bacilli (NFGNB), such as Pseudomonas spp. and Stenotrophomonas spp. apart of the 2nd quartile.

CONCLUSIONS

Our study strengthens the bond of age and gender with bile microbiota composition and suggests that further investigations may be required in targeting the aging microbiome. Other studies should also focus on Mediterranean epidemiological characteristics and antibiotic resistance surveillance system strategies.

MicroRNAs and Sepsis-Induced Cardiac Dysfunction: A Systematic Review

Sepsis is a severe condition characterized by systemic inflammation. One of the most involved organs in sepsis is the heart. On the other hand, heart failure and dysfunction are some of the most leading causes of death in septic patients. miRNAs are short single-strand non-coding ribonucleic acids involved in the regulation of gene expression on a post-transcriptional phase, which means they are a part of the epigenetic process. Recently, researchers have found that miRNA expression in tissues and blood differs depending on different conditions. Because of this property, their use as serum sepsis biomarkers has also been explored. A narrative review is carried out to gather and summarize what is known about miRNAs' influence on cardiac dysfunction during sepsis. When reviewing the literature, we found at least 77 miRNAs involved in cardiac inflammation and dysfunction during sepsis. In the future, miRNAs may be used as early sepsis-induced cardiac dysfunction biomarkers or as new drug targets. This could help clinicians to early detect, prevent, and treat cardiac damage. The potential role of miRNAs as new diagnostic tools and therapeutic strategies worth deepening the complex network between non-coding RNA and biological pathways. Additional studies are needed to further investigate their role in sepsis-induced myocardium injury.

Nafamostat Mesylate Improved Survival Outcomes of Sepsis Patients Who Underwent Blood Purification: A Nationwide Registry Study in Japan

Nafamostat mesylate (NM) is a synthetic serine protease inhibitor that can be used as an anticoagulant during blood purification in critically ill patients, as well as a treatment for disseminated intravascular coagulation. Although NM has been reported to reduce the risk of bleeding during blood purification, its effect on survival outcomes of patients who received blood purification treatments is unclear. We hypothesized that administration of NM during blood purification can reduce mortality in patients with sepsis. A post hoc analysis was conducted on a nationwide retrospective registry that included data from 3195 sepsis patients registered at 42 intensive care units throughout Japan. We evaluated the effect of NM on hospital mortality and bleeding complications using propensity score matching in 1216 sepsis patients who underwent blood purification in the intensive care unit (ICU). Two-hundred-and-sixty-eight pairs of propensity score-matched patients who received NM and conventional therapy were compared. Hospital and ICU mortality rates in the NM group were significantly lower than those in the conventional therapy group. However, rates of bleeding complications did not differ significantly between the two groups. These data suggest that administration of NM improved the survival outcomes of sepsis patients who underwent blood purification in the ICU.

Preterm birth and sustained inflammation: consequences for the neonate

Almost half of all preterm births are caused or triggered by an inflammatory process at the feto-maternal interface resulting in preterm labor or rupture of membranes with or without chorioamnionitis (“first inflammatory hit”). Preterm babies have highly vulnerable body surfaces and immature organ systems. They are postnatally confronted with a drastically altered antigen exposure including hospital-specific microbes, artificial devices, drugs, nutritional antigens, and hypoxia or hyperoxia (“second inflammatory hit”). This is of particular importance to extremely preterm infants born before 28 weeks, as they have not experienced important “third-trimester” adaptation processes to tolerate maternal and self-antigens. Instead of a balanced adaptation to extrauterine life, the delicate co-regulation between immune defense mechanisms and immunosuppression (tolerance) to allow microbiome establishment is therefore often disturbed. Hence, preterm infants are predisposed to sepsis but also to several injurious conditions that can contribute to the onset or perpetuation of sustained inflammation (SI). This is a continuing challenge to clinicians involved in the care of preterm infants, as SI is regarded as a crucial mediator for mortality and the development of morbidities in preterm infants. This review will outline the (i) role of inflammation for short-term consequences of preterm birth and (ii) the effect of SI on organ development and long-term outcome.

miR-331 inhibits CLDN2 expression and may alleviate the vascular endothelial injury induced by sepsis

The present study aimed to determine the expression level of claudin-2 (CLDN2) in the peripheral blood of patients with sepsis, and to investigate its potential function and mechanism of action in vascular endothelial injury. A total of 25 patients with sepsis were included in the present study. Reverse transcription-quantitative PCR was used to determine CLDN2 levels in peripheral blood. HUVECs stably expressing CLDN2 were prepared and Cell Counting Kit-8, flow cytometry and Transwell assays were performed to study the proliferation, apoptosis and migration of HUVECs, respectively. Using bioinformatics, microRNA (miR) molecules that interact with CLDN2 were predicted. A dual luciferase reporter assay was used to test whether miR-331 regulated CLDN2. Western blotting was employed to determine CLDN2 protein expression. In addition, in vitro transfection of HUVECs with miR-331 mimics was performed to test the rescue effects of miR-331 on the cell function changes induced by CLDN2. The results indicated that elevated CLDN2 expression altered the proliferation and cell cycle of peripheral vascular endothelial cells. CLDN2 overexpression inhibited HUVEC proliferation via mechanisms not associated with the cell cycle. CLDN2 mRNA levels in the peripheral blood of patients with sepsis were significantly higher than those in healthy subjects. Upregulated CLDN2 expression promoted the apoptosis of HUVECs, but reduced their proliferation and migration. Notably, miR-331 was able to bind with CLDN2 mRNA and regulate its expression. Upregulation of miR-331 expression inhibited the expression of CLDN2 and restored nearly normal proliferation, apoptosis and migration to HUVECs. The present study demonstrated that CLDN2 expression is elevated in peripheral blood from patients with sepsis, and promotes the injury of vascular endothelial cells. In addition, miR-331 participates in the direct regulation of CLDN2, and upregulation of miR-331 expression inhibits the expression of CLDN2 and restores cellular functions to HUVECs.

Gracillin inhibits apoptosis and inflammation induced by lipopolysaccharide (LPS) to alleviate cardiac injury in mice via improving miR-29a

Sepsis induces critical myocardial dysfunction, resulting in an increased mortality. Gracillin (GRA) is a natural steroidal saponin, showing strong capacities of anti-inflammation, but its pharmacological effects on lipopolysaccharide (LPS)-induced acute cardiac injury still remain unclear. In this study, we attempted to explore if GRA was effective to attenuate cardiac injury in LPS-challenged mice and the underlying mechanisms. First, we found that GRA treatments markedly up-regulated the expression of miR-29a in cardiomyocytes. LPS-induced cytotoxicity in cardiomyocytes was significantly alleviated by GRA treatment, as evidenced by the improved cell viability and reduced lactate dehydrogenase (LDH) release. In addition, LPS-triggered apoptotic cell death was clearly ameliorated in cardiomyocytes co-treated with GRA. Notably, LPS-exposed cells showed significantly reduced expression of miR-29a, while being rescued by GRA treatment. In vivo, LPS apparently impaired cardiac function in mice, which was, however, alleviated by GRA administration. In addition, GRA markedly attenuated apoptosis in hearts of LPS-challenged mice by decreasing the expression of cleaved Caspase-3. LPS-triggered inflammatory response in cardiac tissues was also suppressed by GRA through blocking nuclear factor κB (NF-κB) signaling pathway. We also found that miR-29a expression was highly reduced in hearts of LPS-treated mice but was rescued by GRA pretreatment. Besides, miR-29a mimic alleviated LPS-induced apoptosis and inflammation in cardiomyocytes; however, LPS-caused effects were further accelerated by miR-29a. Of note, the protective effects of GRA on LPS-injured cardiac tissues were significantly abrogated by miR-29a suppression. In conclusion, our findings demonstrated that GRA exerted an effective role against LPS-induced acute cardiac injury through impeding apoptosis and inflammation regulated by miR-29a.

Epidemiological Characteristics of Postoperative Sepsis

Background

Postoperative sepsis is a major type of sepsis. Sociodemographic characteristics, incidence trends, surgical procedures, comorbidities, and organ system dysfunctions related to the disease burden of postoperative sepsis episodes are unclear.

Methods

We analyzed epidemiological characteristics of postoperative sepsis based on the ICD-9-CM codes for the years 2002 to 2013 using the Longitudinal Health Insurance Databases of Taiwan’s National Health Insurance Research Database.

Results

We identified 5,221 patients with postoperative sepsis and 338,279 patients without postoperative sepsis. The incidence of postoperative sepsis increased annually with a crude mean of 0.06% for patients aged 45–64 and 0.34% over 65 years. Patients with postoperative sepsis indicated a high risk associated with the characteristics, male sex (OR:1.375), aged 45–64 or ≥ 65 years (OR:2.639 and 5.862), low income (OR:1.390), aged township (OR:1.269), agricultural town (OR:1.266), and remote township (OR:1.205). Splenic surgery (OR:7.723), Chronic renal disease (OR:1.733), cardiovascular dysfunction (OR:2.441), and organ system dysfunctions had the highest risk of postoperative sepsis.

Conclusion

Risk of postoperative sepsis was highest among men, older, and low income. Patients with splenic surgery, chronic renal comorbidity, and cardiovascular system dysfunction exhibited the highest risk for postoperative sepsis. The evaluation of high-risk factors assists in reducing the disease burden.

Transcriptional sex and regional differences in paired human atrial and ventricular cardiac biopsies collected in vivo

Transcriptional studies of the human heart provide insight into physiological and pathophysiological mechanisms, essential for understanding the fundamental mechanisms of normal cardiac function and how they are altered by disease. To improve the understanding of why men and women may respond differently to the same therapeutic treatment it is crucial to learn more about sex-specific transcriptional differences. In this study the transcriptome of right atrium and left ventricle was compared across sex and regional location. Paired biopsies from five male and five female patients undergoing aortic valve replacement or coronary artery bypass grafting were included. Gene expression analysis identified 620 differentially expressed transcripts in atrial and ventricular tissue in men and 471 differentially expressed transcripts in women. In total 339 of these transcripts overlapped across sex but notably, 281 were unique in the male tissue and 162 in the female tissue, displaying marked sex differences in the transcriptional machinery. The transcriptional activity was significantly higher in atrias than in ventricles as 70% of the differentially expressed genes were upregulated in the atrial tissue. Furthermore, pathway- and functional annotation analyses performed on the differentially expressed genes showed enrichment for a more heterogeneous composition of biological processes in atrial compared with the ventricular tissue, and a dominance of differentially expressed genes associated with infection disease was observed. The results reported here provide increased insights about transcriptional differences between the cardiac atrium and ventricle but also reveal transcriptional differences in the human heart that can be attributed to sex.

Pediatrics: An Evolving Concept for the 21st Century

Pediatrics is rapidly evolving, and the diagnostic tools are expanding the spectrum of diagnoses that can be identified at the bedside [...].

The PARP inhibitor olaparib exerts beneficial effects in mice subjected to cecal ligature and puncture and in cells subjected to oxidative stress without impairing DNA integrity: A potential opportunity for repurposing a clinically used oncological drug for the experimental therapy of sepsis

Poly(ADP-ribose) polymerase (PARP) is involved in the pathogenesis of cell dysfunction, inflammation and organ failure during septic shock. The goal of the current study was to investigate the efficacy and safety of the clinically approved PARP inhibitor olaparib in experimental models of oxidative stress in vitro and in sepsis in vivo. In mice subjected to cecal ligation and puncture (CLP) organ injury markers, circulating and splenic immune cell distributions, circulating mediators, DNA integrity and survival was measured. In U937 cells subjected to oxidative stress, cellular bioenergetics, viability and DNA integrity were measured. Olaparib was used to inhibit PARP. The results show that in adult male mice subjected to CLP, olaparib (1-10 mg/kg i.p.) improved multiorgan dysfunction. Olaparib treatment reduced the degree of bacterial CFUs. Olaparib attenuated the increases in the levels of several circulating mediators in the plasma. In the spleen, the number of CD4+ and CD8+ lymphocytes were reduced in response to CLP; this reduction was inhibited by olaparib treatment. Treg but not Th17 lymphocytes increased in response to CLP; these cell populations were reduced in sepsis when the animals received olaparib. The Th17/Treg ratio was lower in CLP-olaparib group than in the CLP control group. Analysis of miRNA expression identified a multitude of changes in spleen and circulating white blood cell miRNA levels after CLP; olaparib treatment selectively modulated these responses. Olaparib extended the survival rate of mice subjected to CLP. In contrast to males, in female mice olaparib did not have significant protective effects in CLP. In aged mice olaparib exerted beneficial effects that were less pronounced than the effects obtained in young adult males. In in vitro experiments in U937 cells subjected to oxidative stress, olaparib (1-100 μM) inhibited PARP activity, protected against the loss of cell viability, preserved NAD⁺ levels and improved cellular bioenergetics. In none of the in vivo or in vitro experiments did we observe any adverse effects of olaparib on nuclear or mitochondrial DNA integrity. In conclusion, olaparib improves organ function and extends survival in septic shock. Repurposing and eventual clinical introduction of this clinically approved PARP inhibitor may be warranted for the experimental therapy of septic shock.

Transient left bundle branch block and left ventricular dysfunction in a patient with NLRP1-associated autoinflammation with arthritis and dyskeratosis syndrome

The NLRP1-associated autoinflammation with arthritis and dyskeratosis syndrome is a rare novel autoinflammatory disorder. Cardiac involvement has not been previously reported. We present a 12-year-old girl with NLRP1-associated autoinflammation with arthritis and dyskeratosis syndrome who was diagnosed with severely impaired left ventricular function and complete left bundle branch block during an exacerbation of the disease. Cardiac dysfunction proved to be rapidly reversible after initiation of high-dose methylprednisolone.

Promptly reporting of critical laboratory values in pediatrics: A work in progress

In the 21^st century, the determination of alert thresholds remains the most challenging and controversial issue in clinical pediatrics. Pre-analytical, analytical, and post-analytical matters will consolidate or undermine the fate of any laboratory process. Pre-analytical issues need to be cleared off before the laboratory physician can dispatch the result to the pediatrician in charge. Once it is cleared off, the classification of essential laboratory results is paramount. It is more than an academic exercise and may be subdivided in the order of priority we handle it to inform promptly and safely the primary physicians. Currently, we are applying new modes of making sure relevant information is transmitted without interrupting the standard workflow of the primary physicians in charge for the child, who eventually need a fast line of action for results that may be life-threatening.

Bactibilia in women affected with diseases of the biliary tract and pancreas. A STROBE guidelines-adherent cross-sectional study in Southern Italy

PURPOSE

Bile is a hepatobiliary lipid-rich sterile solution, and its colonization by microorganisms defines the condition of bactibilia. In this study, we aimed to assess the bile microbiological flora and its potential link with comorbidity in women.

METHODOLOGY

We performed a microbiologic investigation on 53 female patients with biliopancreatic diseases who granted consent, and we analysed the data using a MATLAB platform.

RESULTS

We found that the most frequent disease associated with bactibilia was pancreas head carcinoma (PHC) (P=0.0015), while the least frequent disease was gall bladder carcinoma (GBC) (P=0.0002). The most common microorganisms were Pseudomonas spp. (P<0.0001) and Escherichia coli (P<0.0001). In particular Pseudomonas spp. and E. coli were negatively correlated to PHC presence and positively correlated to CCA by both univariate and multivariate analysis.

CONCLUSIONS

Gram-negative bacteria have been linked to a tumour-associated inflammatory status. In the last 30 years, the analysis of mortality rate in Italy for PHC and GBC shows an increasing and a decreasing trend, respectively. Although this study targeted only 53 patients and does not reflect the frequency of diagnosis in a Southern Italian population, the decrease in GBC may raise the suggestion ofnon-adherence to a Mediterranean diet that may have become more prevalent in Southern Italy since the 1990s.

Atypical Presentation of Lemierre's Syndrome Causing Septic Shock and Acute Respiratory Distress Syndrome

Lemierre's disease is a rare but life-threatening condition characterized by an oropharyngeal infection complicating with thrombophlebitis of the internal jugular vein and disseminated abscesses. We are presenting a case of a young female who initially presented with fevers, chills, sore throat, and swollen neck later developed progressively worsening shortness of breath along with sudden onset pleuritic chest pain. She then developed progressively worsening acute hypoxic respiratory failure requiring intubation and mechanical ventilation. Interval chest X-ray showed worsening bilateral effusions. She also developed septic shock requiring pressors. Blood culture showed Fusobacterium, and antibiotics were changed accordingly following which there was a clinical improvement. The diagnosis of Lemierre's syndrome was then established based on her presenting age and bilateral pulmonary empyema in the setting of septicemia with Fusobacterium.

Septic Pulmonary Emboli and Renal Abscess Caused by Staphylococcus aureus in an HIV-Infected Patient

Staphylococcus aureus is a common cause of bacteremia in the general population and can lead to serious metastatic infection particularly in immunocompromised persons. However, prompt diagnosis and management can result in favorable outcomes. In the following case report, the clinical course of an HIV-infected man is presented; he developed bloodstream infection (BSI) and associated complications: septic pulmonary embolism, right renal abscess, and ipsilateral renal vein thrombosis. Methicillin-resistant Staphylococcus aureus (MRSA) was identified as the cause of sepsis and successfully treated with surgery and antimicrobials. Intravenous vancomycin was the primary therapy, followed by oral linezolid after resolution of bacteremia.

Evaluation of revascularization after total arch replacement in common carotid artery occlusion

Occlusion of the common carotid artery (CCA) is rare. CCA occlusion (CCAO) can present as drowsiness and right hemiplegia related to emboli after total arch replacement. Although we selected a follow-up at first because color duplex sonography showed retrograde flow from the left external carotid artery to the internal carotid artery, this patient had epilepsy and single-photon emission computed tomography (SPECT) acquired quantitative results of actual brain perfusion and showed insufficient collateral blood flow. To improve brain perfusion, we performed a bypass of the left subclavian artery to left CCA bypass. Postoperatively, the patient did not have epilepsy and drowsiness. Also, right hemiplegia improved enough for him to walk with support. SPECT showed increased left cerebral flow (the asymmetry ratio was 71% to 81%). Evaluation of the carotid artery with color duplex sonography alone was insufficient when CCAO showed retrograde or collateral flow. We should have performed quantitative evaluation with SPECT at the same time.