Monitoring of vascular endothelial growth factor and its soluble receptor levels in early trauma

Traumatized triad of complementopathy, endotheliopathy, and coagulopathy ˗ Impact on clinical outcomes in severe polytrauma patients

Complementopathy, endotheliopathy, and coagulopathy following a traumatic injury are key pathophysiological mechanisms potentially associated with multiple-organ failure (MOF) and mortality. However, the heterogeneity in the responses of complementopathy, endotheliopathy, and coagulopathy to trauma, the nature and extent of their interplay, and their relationship to clinical outcomes remain unclear. Fifty-four poly-trauma patients were enrolled and divided into three subgroups based on their ISS. Biomarkers in blood plasma reflecting complement activation, endothelial damage, and coagulopathy were measured starting from admission to the emergency department and at 3, 6, 12, 24, and 120 hours after admission. Comparative analyses showed that severely injured patients (ISS>24) were associated with longer days on mechanical ventilation, in the intensive care unit and hospital stays, and a higher incidence of hyperglycemia, bacteremia, respiratory failure and pneumonia compared to mildly (ISS<16) or moderately (ISS=16-24) injured patients. In this trauma cohort, complement was activated early, primarily through the alternative complement pathway. As measured in blood plasma, severely injured patients had significantly higher levels of complement activation products (C3a, C5a, C5b-9, and Bb), endothelial damage markers (syndecan-1, sTM, sVEGFr1, and hcDNA), and fibrinolytic markers (D-dimer and LY30) compared to less severely injured patients. Severely injured patients also had significantly lower thrombin generation (ETP and peak) and lower levels of coagulation factors (I, V, VIII, IX, protein C) than less severely injured patients. Complement activation correlated with endothelial damage and hypocoagulopathy. Logistic regression analyses revealed that Bb >1.57 μg/ml, syndecan-1 >66.6 ng/ml or D-dimer >6 mg/L at admission were associated with a higher risk of MOF/mortality. After adjusting for ISS, each increase of the triadic score defined above (Bb>1.57 µg/ml/Syndecan-1>66.6 ng/ml/D-dimer>6.0mg/L) was associated with a 6-fold higher in the odds ratio of MOF/death [OR: 6.83 (1.04-44.96, P=0.046], and a 4-fold greater in the odds of infectious complications [OR: 4.12 (1.04-16.36), P=0.044]. These findings provide preliminary evidence of two human injury response endotypes (traumatized triad and non-traumatized triad) that align with clinical trajectory, suggesting a potential endotype defined by a high triadic score. Patients with this endotype may be considered for timely intervention to create a pro-survival/organ-protective phenotype and improve clinical outcomes.

Angiogenesis: A Cellular Response to Traumatic Injury

ABSTRACT

The development of new vasculature plays a significant role in a number of chronic disease states, including neoplasm growth, peripheral arterial disease, and coronary artery disease, among many others. Traumatic injury and hemorrhage, however, is an immediate, often dramatic pathophysiologic insult that can also necessitate neovascularization to promote healing. Traditional understanding of angiogenesis involved resident endothelial cells branching outward from localized niches in the periphery. Additionally, there are a small number of circulating endothelial progenitor cells that participate directly in the process of neovessel formation. The bone marrow stores a relatively small number of so-called pro-angiogenic hematopoietic progenitor cells-that is, progenitor cells of a hematopoietic potential that differentiate into key structural cells and stimulate or otherwise support local cell growth/differentiation at the site of angiogenesis. Following injury, a number of cytokines and intercellular processes are activated or modulated to promote development of new vasculature. These processes initiate and maintain a robust response to vascular insult, allowing new vessels to canalize and anastomose and provide timely oxygen delivering to healing tissue. Ultimately as we better understand the key players in the process of angiogenesis we can look to develop novel techniques to promote healing following injury.

Hardware Prototype for Wrist-Worn Simultaneous Monitoring of Environmental, Behavioral, and Physiological Parameters

We designed a low-cost wrist-worn prototype for simultaneously measuring environmental, behavioral, and physiological domains of influencing factors in healthcare. Our prototype continuously monitors ambient elements (sound level, toxic gases, ultraviolet radiation, air pressure, temperature, and humidity), personal activity (motion tracking and body positioning using gyroscope, magnetometer, and accelerometer), and vital signs (skin temperature and heart rate). An innovative three-dimensional hardware, based on the multi-physical-layer approach is introduced. Using board-to-board connectors, several physical hardware layers are stacked on top of each other. All of these layers consist of integrated and/or add-on sensors to measure certain domain (environmental, behavioral, or physiological). The prototype includes centralized data processing, transmission, and visualization. Bi-directional communication is based on Bluetooth Low Energy (BLE) and can connect to smartphones as well as smart cars and smart homes for data analytic and adverse-event alerts. This study aims to develop a prototype for simultaneous monitoring of the all three areas for monitoring of workplaces and chronic obstructive pulmonary disease (COPD) patients with a concentration on technical development and validation rather than clinical investigation. We have implemented 6 prototypes which have been tested by 5 volunteers. We have asked the subjects to test the prototype in a daily routine in both indoor (workplaces and laboratories) and outdoor. We have not imposed any specific conditions for the tests. All presented data in this work are from the same prototype. Eleven sensors measure fifteen parameters from three domains. The prototype delivers the resolutions of 0.1 part per million (PPM) for air quality parameters, 1 dB, 1 index, and 1 °C for sound pressure level, UV, and skin temperature, respectively. The battery operates for 12.5 h under the maximum sampling rates of sensors without recharging. The final expense does not exceed 133€. We validated all layers and tested the entire device with a 75 min recording. The results show the appropriate functionalities of the prototype for further development and investigations.

Sepsis-associated acute respiratory distress syndrome in individuals of European ancestry: a genome-wide association study

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a lung inflammatory process caused mainly by sepsis. Most previous studies that identified genetic risks for ARDS focused on candidates with biological relevance. We aimed to identify novel genetic variants associated with ARDS susceptibility and to provide complementary functional evidence of their effect in gene regulation.

METHODS

We did a case-control genome-wide association study (GWAS) of 1935 European individuals, using patients with sepsis-associated ARDS as cases and patients with sepsis without ARDS as controls. The discovery stage included 672 patients admitted into a network of Spanish intensive care units between January, 2002, and January, 2017. The replication stage comprised 1345 individuals from two independent datasets from the MESSI cohort study (Sep 22, 2008-Nov 30, 2017; USA) and the VISEP (April 1, 2003-June 30, 2005) and MAXSEP (Oct 1, 2007-March 31, 2010) trials of the SepNet study (Germany). Results from discovery and replication stages were meta-analysed to identify association signals. We then used RNA sequencing data from lung biopsies, in-silico analyses, and luciferase reporter assays to assess the functionallity of associated variants.

FINDINGS

We identified a novel genome-wide significant association with sepsis-associated ARDS susceptibility (rs9508032, odds ratio [OR] 0·61, 95% CI 0·41-0·91, p=5·18 × 10^-8) located within the Fms-related tyrosine kinase 1 (FLT1) gene, which encodes vascular endothelial growth factor receptor 1 (VEGFR-1). The region containing the sentinel variant and its best proxies acted as a silencer for the FLT1 promoter, and alleles with protective effects in ARDS further reduced promoter activity (p=0·0047). A literature mining of all previously described ARDS genes validated the association of vascular endothelial growth factor A (VEGFA; OR 0·55, 95% CI 0·41-0·73; p=4·69 × 10^-5).

INTERPRETATION

A common variant within the FLT1 gene is associated with sepsis-associated ARDS. Our findings support a role for the vascular endothelial growth factor signalling pathway in ARDS pathogenesis and identify VEGFR-1 as a potential therapeutic target.

FUNDING

Instituto de Salud Carlos III, European Regional Development Funds, Instituto Tecnológico y de Energías Renovables.

Clinical characteristics and prognosis of serous body cavity effusions in patients with sepsis: a retrospective observational study

Background

Cavity effusion is common in patients with infectious diseases. However, the incidence rate and characteristics of serous cavity effusions (SCE) in septic patients are not clear to date. The objective of this study was to investigate the incidence and characteristics of SCE in septic patients and to explore the correlations between the bloody effusions and the illness severity/prognosis in septic patients.

Methods

From January 2010 to January 2015, a total of 214 patients with severe sepsis and septic shock were enrolled in this retrospective observational study. Thoracentesis or abdominal paracentesis was performed in 45 septic patients because of massive pleural effusions or ascites. The serum concentrations of VEGF, VEGFR, Ang, sICAM-1, sVCAM-1, E-selectin, Serpine1 and VE-cadherin in 45 septic patients underwent paracentesis were measured by enzyme-linked immunosorbent assay (ELISA).

Results

Of the 214 septic patients, 155 (72.4%) had SCE according to imaging or ultrasound manifestations. 45 subjects with SCE underwent therapeutic thoracentesis or abdominal paracentesis. Effusion laboratory analysis showed that exudates were predominant when compared with transudates (95.6% vs. 4.4%), and 16 (35.6%) patients suffered bloody effusions. Compared with patients with non-bloody effusions, those with bloody effusions showed higher critical illness scores (13 vs. 17 for APACHE II; 7 vs. 9 for SOFA), and higher mortality (6.9% vs. 62.5%). Moreover, patients with bloody effusions had delayed TT and APTT, increased D-dimer concentration, and higher serum levels of CRP and PCT (P < 0.05). In addition, the serum levels of Ang2, sVCAM-1 and E-selectin were significantly higher in patients with bloody effusions than in those with non-bloody effusions (P < 0.05). However, the serum level of VEGFR2 was lower in patients with bloody fluids (P = 0.025).

Conclusions

The incidence of serous cavity effusion is high in patients with sepsis. The septic patients with bloody effusions suffer a more inflammatory burden and a worse prognosis compared to septic patients with non-bloody effusions.

Role of biomarkers in acute traumatic lung injury

In severely injured patients severe thoracic trauma is common and can significantly influence the outcome of these critically ill patients by increased rates of mainly pulmonary complications. Furthermore, patients who sustained thoracic trauma are at increased risk for Acute Lung Injury (ALI) or Adult Respiratory Distress Syndrome (ARDS). Therapeutic options are limited, basically consisting of prophylactic antibiotic therapy and changing patient's positions. It is known, that ALI and ARDS differ clinically and pathobiologically from ALI/ARDS caused by other reasons, but the exact pathology remains elusive. Due to that no reliable predictive or surveillance biomarkers could be established for clinical diagnosis and identification of patients at high risk for acute traumatic lung injury. Nevertheless, there are plenty of promising markers that need to be further elucidated in larger case numbers and multicenter studies. This article sums up the recent status of those promising clinical biomarkers.