Mediators of systemic inflammatory response syndrome and the role of recombinant activated protein C in sepsis syndrome

Smoking is associated with an improved short-term outcome in patients with rib fractures

BACKGROUND

Smokers with cardiovascular disease have been reported to have decreased mortality compared to non-smokers. Rib fractures are associated with significant underlying injuries such as lung contusions, lacerations, and/or pneumothoraces. We hypothesized that blunt trauma patients with rib fractures who are smokers have decreased ventilator days and risk of in-hospital mortality compared to non-smokers.

STUDY DESIGN

The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a blunt rib fracture. Patients that died within 24 h of admission were excluded. A multivariable logistic regression model was performed.

RESULTS

From 282,986 patients with rib fractures, 57,619 (20.4%) were smokers. Compared to non-smokers with rib fractures, smokers had a higher median injury severity score (17 vs. 16, p < 0.001). Smokers had a higher rate of pneumonia (7.5% vs. 6.6%, p < 0.001), however, less ventilator days (5 vs. 6, p = 0.04), and lower in-hospital mortality rate (2.3% vs. 4.6%, p < 0.001), compared to non-smokers. After controlling for covariates, smokers with rib fractures were associated with a decreased risk for in-hospital mortality compared to non-smokers with rib fractures (OR 0.64, 0.56-0.73, p < 0.001).

CONCLUSION

Despite having more severe injuries and increased rates of pneumonia, smokers with rib fractures were associated with nearly a 40% decreased risk of in-hospital mortality and one less ventilator day compared to non-smokers. The long-term detrimental effects of smoking have been widely established. However, the biologic and pathophysiologic adaptations that smokers have may confer a survival benefit when recovering in the hospital from chest wall trauma. This study was limited by the database missing the number of pack-years smoked. Future prospective studies are needed to confirm this association and elucidate the physiologic mechanisms that may explain these findings.

Metabolism of albumin after continuous venovenous hemofiltration in patients with systemic inflammatory response syndrome

BACKGROUND

The systemic inflammatory response syndrome (SIRS) is characterized by a hypercatabolic state induced by inflammatory mediators. Continuous venovenous hemofiltration (CVVH) stabilizes the internal environment but also aggravates loss of amino acids. The effect of CVVH on protein dynamics is largely unknown. We adopted the stable isotopic tracer technology to investigate how CVVH changed serum albumin metabolism.

METHODS

Twenty SIRS patients were randomized into low- (2000 mL/h) and high- (4000 mL/h) volume CVVH groups according to the rate of replacement fluid. Eight patients with abdominal infection matched for age, sex, and laboratory index served as controls. Consecutive arterial blood samples were drawn during a primed-constant infusion of two stable isotopes to determine the albumin fractional synthesis rate (FSR) and fractional breakdown rate (FBR).

RESULTS

Before treatment, there was no significant difference of FSR and FBR among 3 groups. After CVVH, the albumin FSR in high- and low-volume groups was 7.75±1.08% and 7.30±0.89%, respectively, both higher than in the control (5.83±0.94%). There was no significant difference in albumin FBR after treatment.

CONCLUSIONS

Protein dynamic indicators could reflect protein synthesis and breakdown state directly and effectively. CVVH increased albumin synthesis, while the breakdown rate remained at a high level independently of the CVVH rate.

Multiple organ dysfunction syndrome in humans and animals

Multiple organ dysfunction syndrome (MODS), defined as the presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention, is a cause of high morbidity and mortality in humans and animals. Many advances have been made in understanding the pathophysiology and treatment of this syndrome in human medicine, but much still is unknown. This comparative review will provide information regarding the history and pathophysiology of MODS in humans and discuss how MODS affects each major organ system in animals.

Autotaxin in the crosshairs: taking aim at cancer and other inflammatory conditions

Autotaxin is a secreted enzyme that produces most of the extracellular lysophosphatidate from lysophosphatidylcholine, the most abundant phospholipid in blood plasma. Lysophosphatidate mediates many physiological and pathological processes by signaling through at least six G-protein coupled receptors to promote cell survival, proliferation and migration. The autotaxin/lysophosphatidate signaling axis is involved in wound healing and tissue remodeling, and it drives many chronic inflammatory conditions from fibrosis to colitis, asthma and cancer. In cancer, lysophosphatidate signaling promotes resistance to chemotherapy and radiotherapy, and increases both angiogenesis and metastasis. Research into autotaxin inhibitors is accelerating, both as primary and adjuvant therapy. Historically, autotaxin inhibitors had poor bioavailability profiles and thus had limited efficacy in vivo. This situation is now changing, especially since the recent crystal structure of autotaxin is now enabling rational inhibitor design. In this review, we will summarize current knowledge on autotaxin-mediated disease processes including cancer, and discuss recent advancements in the development of autotaxin-targeting strategies. We will also provide new insights into autotaxin as an inflammatory mediator in the tumor microenvironment that promotes cancer progression and therapy resistance.

Immunotherapies in infectious diseases

The development of an infection involves interplay between the host's immune system and the virulence of the infecting microorganism. The traditional treatment of an infection involves antimicrobial chemotherapy to kill the organism. The use of immunotherapies in infections includes treatment options that modulate the immune response and can lead to control of infections. These therapies are expected to become more important therapeutic options with the increase in infections due to multidrug-resistant organisms and the increasing number of immunocompromised patients.

Live liver donors: Are they at a higher risk for post-operative thrombotic complications?

Live liver donor transplantation to adult recipients is becoming a common practice, increasing the organ pool and providing an alternative to whole cadaveric liver transplantation. These patients are healthy adults without serious medical conditions and typically have normal coagulation profiles preoperatively. Right hepatic lobectomy is usually performed for adult recipients, while left hepatic lobectomy is performed for pediatric recipients. Removal of the whole right lobe from the donors may expose theses patients to multiple intraoperative and postoperative complications. Hypercoagulability has been identified as a serious complication which leads to thromboembolic phenomena with potential fatal consequences. The primary aim of this review is to look at possible changes in post-operative coagulation dynamics that may increase the risk for development of thromboembolic complications in live liver donors. In this article, we stress the importance of addressing the issue that conventional clotting tests (PT, INR, PTT) are unable to detect a hypercoagulable state, and therefore, we should examining alternative laboratory tests to improve diagnosis and early detection of thrombotic complications. Measurement of natural anticoagulant/procoagulant biomarkers combined with conventional coagulation studies and thromboelastography offers a more accurate assessment of coagulation disorders. This allows earlier diagnosis, permitting appropriate intervention sooner, hence avoiding potential morbidity and mortality. Biomarkers that may be evaluated include, but are not limited to: protein C, soluble P-selectin, antithrombin III, thrombin-antithrombin complex, and thrombin generation complex.