Cytokine-Release Patterns in Elderly Patients with Systemic Inflammatory Response Syndrome

Metabolomics Coupled with Transcriptomics Approach Deciphering Age Relevance in Sepsis

Sepsis is a severe disease frequently occurred in the Intenisive Care Unit (ICU), which has a very high morbidity and mortality, especially in patients aged over 65 years. Owing to the aging effect and the ensuing deterioration of body function, the elder patients may have atypical responses to sepsis. Diagnosis and pathogenesis of sepsis in this population are thus difficult, which hindered effective treatment and management in clinic. To investigated age effects on sepsis, 158 elderly septic patients and 71 non-septic elderly participants were enrolled, and their plasma samples were collected for transcriptomics (RNA-seq) and metabolomics (NMR and GC-MS) analyses, which are both increasingly being utilized to discover key molecular changes and potential biomarkers for various diseases. Protein-protein interaction (PPI) analysis was subsequently performed to assist cross-platform integration. Real time polymerase chain reaction (RT-PCR) was used for validation of RNA-seq results. For further understanding of the mechanisms, cecal ligation and puncture (CLP) experiment was performed both in young and middle-aged rats, which were subjected to NMR-based metabolomics study and validated for several key inflammation pathways by western blot. Comprehensive analysis of data from the two omics approaches provides a systematic perspective on dysregulated pathways that could facilitate the development of therapy and biomarkers for elderly sepsis. Additionally, the metabolites of lactate, arginine, histamine, tyrosine, glutamate and glucose were shown to be highly specific and sensitive in distinguishing septic patients from healthy controls. Significant increases of arginine, trimethylamine N-oxide and allantoin characterized elderly patient incurred sepsis. Further analytical and biological validations in different subpopulations of septic patients should be carried out, allowing accurate diagnostics and precise treatment of sepsis in clinic.

Early Predictors of Abdominal Hemorrhage Among Critically Ill Patients With Pancreatitis: A Prospective Cohort Study

OBJECTIVE

To establish incidence, risk factors, and prognostic implications of abdominal hemorrhage (AH) among critically ill patients with acute pancreatitis (AP).

METHODS

Prospective cohort study in 46 intensive care units aimed at describing the characteristics of critically ill patients with AP (Epidemiología de la Pancreatitis Aguda en Medicina Intensiva Study). Adult patients with AP and at least 1 organ failure were included. The presence of AH was established either by using computed tomography, magnetic resonance imaging, or by direct visualization during surgery. Statistical analyses were carried out using multivariate logistic regression.

RESULTS

Three hundred seventy-four patients were studied. Most were men (62.6%), with a mean (standard deviation) age of 60.4 (15.6) years. Most episodes (56.4%) of AP were severe, and 28.9% died during their hospital stay. Thirty-eight patients (10.2%; 95% confidence interval, 7.3%-13.7%) developed AH. The odds of presenting AH was influenced by age, the underlying cause of pancreatitis, and the presence of shock or respiratory failure on admission.

CONCLUSIONS

Abdominal hemorrhages were common among critically ill patients with pancreatitis. These early predictors may be of use in detecting patients at risk of developing them.

Values of detection of NF-κB activation level combined with IL-6 and TNF-α levels in peripheral neutrophils in the prediction of multiple organ dysfunction syndrome in patients with severe multiple trauma

The aim of this study was to analyze the dynamic changes and predictive values of nuclear factor-κB (NF-κB) combined with interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in peripheral blood in multiple organ dysfunction syndrome (MODS) in patients with severe multiple trauma. Seventy patients diagnosed with severe multiple trauma in Emergency Department of Sichuan Provincial People's Hospital (Chengdu, China) from April 2014 to April 2016 were selected and retrospectively analyzed. The patients enrolled were divided into the MODS group (n=25) and the non-MODS group (n=45). The injury severity scores (ISSs), acute physiology and chronic health evaluation II (APACHE II) scores, NF-κB, IL-6 and TNF-α levels in patients were detected at different time points (12, 24 and 48 h after admission), the changes in different indexes and the areas under the receiver operating characteristic (ROC) curve (AUC) were analyzed. The predictive values of different detection methods in MODS patients were discussed and compared. The ISS, APACHE II score, NF-κB, IL-6 and TNF-α levels in the MODS group at admission and 24 and 48 h after admission were higher than those in the non-MODS group (P<0.05). Those indexes in the deceased patients at 12, 24 and 48 h after admission were higher than those in survivors (P<0.05). The ISS, APACHE II score, NF-κB, IL-6 and TNF-α levels were not the risk factors of MODS in patients with severe multiple trauma (P>0.05). AUCs of ISS >22 points and APACHE II score >14 points in predicting MODS were lower than that of combined detection of NF-κB >1.20. In conclusion, the combined detection of NF-κB, IL-6 and TNF-α in peripheral blood of patients with acute multiple trauma is more helpful to predict the occurrence of MODS, which has a certain guiding significance for the prognosis of patients with MODS.

Geniposide demonstrates anti-inflammatory and antiviral activity against pandemic A/Jiangsu/1/2009 (H1N1) influenza virus infection in vitro and in vivo

BACKGROUND

Influenza A viruses (IAVs) have been a great threat to human health for centuries, without effective control. Geniposide, a main iridoid glycoside compound extracted from Gardenia jasminoides Ellis fruit, possesses various biological activities including anti-inflammation and anti-virus.

METHODS

Madin-Darby canine kidney (MDCK) cells were infected with pandemic A/Jiangsu/1/2009 (H1N1) influenza virus in vitro. Cytotoxicity and antiviral activity of geniposide were estimated by MTT assay. The influenza respiratory tract infection murine model was established by intranasal instillation of pandemic A/Jiangsu/1/2009 (H1N1) influenza virus. One day after infection, the mice were administered with geniposide (5, 10 or 20 mg/kg/day) or the neuraminidase inhibitor (NAI) peramivir (30 mg/kg/day). Body weight, survival time, viral titre and lung index of the mice were measured. The sandwich enzyme-linked immunosorbent assay (ELISA) was used to examine levels of inflammatory cytokines.

RESULTS

The data showed that geniposide had little cytotoxicity on MDCK cells and protected them from pandemic A/Jiangsu/1/2009 (H1N1) influenza virus-induced cell injury. In the infected mice, geniposide treatment significantly restored the body weights, decreased the mortality, alleviated viral titres and virus-induced lung lesions. Geniposide substantially inhibited the virus-induced alveolar wall changes, alveolar haemorrhage and neutrophil-infiltration in lung tissues. Levels of inflammatory mediators, including tumour necrosis factor-α (TNF-α), interferon-γ (IFN-γ), interleukin (IL)-4, IL-6 and IL-10 were also markedly altered after treatment with geniposide.

CONCLUSIONS

Our investigation suggested that geniposide effectively inhibited cell damage mediated by pandemic A/Jiangsu/1/2009 (H1N1) influenza virus and mitigated virus-induced acute inflammation.

Systemic inflammatory response syndrome is more associated with bacteremia in elderly patients with suspected sepsis in emergency departments

Early diagnosis of bacteremia for patients with suspected sepsis is 1 way to improve prognosis of sepsis. Systemic inflammatory response syndrome (SIRS) has long been utilized as a screening tool to detect bacteremia by front-line healthcare providers. The value of SIRS to predict bacteremia in elderly patients (≥65 years) with suspected sepsis has not yet been examined in emergency departments (EDs).We aimed to evaluate the performance of SIRS components in predicting bacteremia among elderly patients in EDs.We retrospectively evaluated patients with suspected sepsis and 2 sets of blood culture collected within 4 hours after admitting to ED in a tertiary teaching hospital between 2010 and 2012. Patients were categorized into 3-year age groups: young (18-64 years), young-old (65-74 years), and old patients (≥75 years). Vital signs and Glasgow Coma Scale with verbal response obtained at the triage, comorbidities, sites of infection, blood cultures, and laboratory results were retrieved via the electronic medical records.A total of 20,192 patients were included in our study. Among them, 9862 (48.9%) were the elderly patients (young-old and old patients), 2656 (13.2%) developed bacteremia. Among patients with bacteremia, we found the elderly patients had higher SIRS performance (adjusted odds ratio [aOR]: 2.40, 95% confidence interval [CI]: 1.90-3.03 in the young-old and aOR: 2.66, 95% CI: 2.19-3.23 in the old). Fever at the triage was most predictive of bacteremia, especially in the elderly patients (aOR: 2.19, 95% CI: 1.81-2.65 in the young-old and aOR: 2.27, 95% CI: 1.95-2.63 in the old), and tachypnea was not predictive of bacteremia among the elderly patients (all P > 0.2).The performance of SIRS to predict bacteremia was more suitable for elderly patients in EDs observed in this study. The elderly patients presented with more fever and less tachypnea when they had bacteremia.

Off-pump coronary artery bypass grafting in octogenarians

Enhanced life expectancy has confronted cardiac surgery with a rapidly growing population of octogenarians needing coronary artery bypass grafting (CABG). Octogenarians are deemed a high-risk patient population with increased postoperative morbidity and mortality following conventional CABG using cardiopulmonary bypass (CPB). In such patients reducing the invasiveness of the surgical procedure by avoiding CPB may be tried in an attempt to improve outcomes. The increasing performance of off-pump coronary artery bypass (OPCAB) grafting within certain centers reflects surgeon preference to avoid the inherent risks of CPB and cardioplegic arrest including hemodilution, nonpulsatile arterial flow, global myocardial ischemia, atherosclerotic embolization from aortic manipulation, and systemic inflammatory response. Although OPCAB grafting is a well-established surgical myocardial revascularization strategy, its actual benefits in terms of morbidity and mortality remain questionable in the general population. In the higher risk octogenarian patients, however, there is a potential for more tangible clinical benefits when CPB is avoided. This review article provides an overview of the impact of OPCAB grafting on postoperative mortality and morbidity in octogenarians.

Biomarkers of Endothelial Activation Are Associated with Poor Outcome in Critical Illness

Background

Endothelial activation plays a role in organ dysfunction in the systemic inflammatory response syndrome (SIRS). Angiopoietin-1 (Ang-1) promotes vascular quiescence while angiopoietin-2 (Ang-2) mediates microvascular leak. Circulating levels of Ang-1 and Ang-2 in patients with SIRS could provide insight on risks for organ dysfunction and death distinct from inflammatory proteins. In this study, we determined if biomarkers of endothelial activation and inflammation exhibit independent associations with poor outcomes in SIRS.

Methods

We studied 943 critically ill patients with SIRS admitted to an Intensive Care Unit (ICU) of an academic medical center. We measured plasma levels of endothelial markers (Ang-1, Ang-2, soluble vascular cell adhesion molecule-1 (sVCAM-1)) and inflammatory markers (interleukin-6 (IL-6), interleukin-8 (IL-8), granulocyte-colony stimulating factor (G-CSF), soluble tumor necrosis factor receptor-1 (sTNFR-1)) within 24 hours of enrollment. We tested for associations between each marker and 28 day mortality, shock, and day 3 sequential organ failure assessment (SOFA) score. For 28 day mortality, we performed sensitivity analysis for those subjects with sepsis and those with sterile inflammation. We used multivariate models to adjust for clinical covariates and determine if associations identified with endothelial activation markers were independent of those observed with inflammatory markers.

Results

Higher levels of all biomarkers were associated with increased 28 day mortality except levels of Ang-1 which were associated with lower mortality. After adjustment for comorbidities and sTNFR-1 concentration, a doubling of Ang-1 concentration was associated with lower 28 day mortality (Odds ratio (OR) = 0.81; p<0.01), shock (OR = 0.82; p<0.001), and SOFA score (β = -0.50; p<0.001), while Ang-2 concentration was associated with increased mortality (OR = 1.55; p<0.001), shock (OR = 1.51; p<0.001), and SOFA score (β = +0.63; p<0.001). sVCAM-1 was not independently associated with SIRS outcomes.

Conclusions

In critically ill patients with SIRS, early measurements of Ang-1 and Ang-2 are associated with death and organ dysfunction independently of simultaneously-measured markers of inflammation.

Outcomes and predictors of mortality and stroke after on-pump and off-pump coronary artery bypass surgery in octogenarians

OBJECTIVE

Octogenarians, as the fastest growing stratum of the population and with the highest prevalence of coronary artery disease, are being increasingly referred for coronary artery bypass grafting (CABG). The general perception is that the presence of comorbidities and the propensity for neurological injury expose them to a higher risk for mortality and morbidity after conventional on-pump CABG, and therefore, off-pump CABG should be preferentially offered to octogenarians to improve outcomes. This study evaluates the in-hospital outcomes and predictors of mortality and stroke in octogenarians undergoing on- and off-pump CABG at our institution.

METHODS

From January 2000 to December 2010, a total of 290 octogenarians underwent off-pump (n = 217) and on-pump (n = 73) CABG. Their data were prospectively entered into the cardiac surgery database (Patients Analysis & Tracking System; Dendrite Clinical Systems, Ltd, Oxford, England, United Kingdom) and analyzed retrospectively. Outcome measures included in-hospital mortality, major complications, and length of stay. Multivariate analysis was performed to identify predictors of combined outcome of in-hospital mortality and stroke.

RESULTS

The mean ± SD age of the patients was 82 ± 2.0 years. Preoperative demographics were similar for the on-pump and off-pump groups. The patients who underwent off-pump CABG had a lower number of distal anastomoses performed compared with the patients who underwent on-pump CABG [mean difference, 0.2; 95% confidence interval (CI), 0.02-0.4; P = 0.03]. However, the ratio of grafts (received/needed) was the same in both groups. In-hospital mortality for the entire cohort was 7.2%, with no significant difference between the groups for death (6.0% vs 11.0%; P = 0.08), stroke (2.8% vs 2.8%; P = 1.0), other major complications, and length of hospital stay. Independent predictors of combined outcome identified from the multiple logistic model included heart failure [odds ratio (OR), 4.4; 95% CI, 1.5-13.0; P = 0.008], diabetes (OR, 2.6; 95% CI, 1.0-6.0; P = 0.046), nitrate infusion (OR, 2.9; 95% CI, 1.1-8.0; P = 0.04), postoperative renal failure requiring hemofiltration (OR, 8.6; 95% CI, 3.5-21.1; P < 0.001), and postoperative ventricular arrhythmias (OR, 7.3; 95% CI, 1.9-27.8; P = 0.009).

CONCLUSIONS

Both on-pump and off-pump CABG are reasonable revascularization strategies in octogenarians. Careful patient selection and individualized treatment decisions can minimize postoperative mortality and morbidity in octogenarians undergoing on- and off-pump CABG.

The evolution of cardiovascular surgery in elderly patient: a review of current options and outcomes

Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.

Myocardial revascularization for the elderly: current options, role of off-pump coronary artery bypass grafting and outcomes

The increase in life expectancy has confronted cardiac surgery with a rapidly growing population of elderly patients requiring surgical myocardial revascularization. Recent advances in surgical and anesthetic techniques and improvements in postoperative care have made coronary artery bypass grafting an established therapeutic option for the treatment of coronary artery disease in this group of patients. However, conventional coronary artery bypass grafting on cardiopulmonary bypass is associated with significant risk and related morbidity and mortality in the elderly. In recent years off-pump coronary artery bypass grafting has emerged as a safe and less invasive strategy for surgical myocardial revascularization. Off-pump coronary artery bypass grafting by avoiding the deleterious effects of cardiopulmonary bypass can offer potential benefits to elderly patients requiring surgical myocardial revascularization. This review article provides an overview of the age-related cardiovascular changes, epidemiology of coronary artery disease in the elderly and focuses on outcomes of surgical myocardial revascularization with special emphasis on the impact of off-pump coro-nary artery bypass surgery in the elderly.

Serum C-reactive protein as a biomarker for early detection of bacterial infection in the older patient

BACKGROUND

although C-reactive protein (CRP) is widely used in younger populations, its value for diagnosing bacterial infection in older population is not well established. This study examined the usefulness of serum CRP level in the early detection of bacterial infection in older patients.

METHODS

in a prospective cohort study, consecutive patients aged 70 years or over admitted to Aged Care wards were recruited. CRP levels were measured within 24 h of presentation, and their significance in predicting bacterial infections was analysed. The relationship between CRP and other clinical features of diagnosing bacterial infections (e.g. temperature, white cell count, neutrophil count, oxygen saturation, blood pressure and heart rate) was also examined.

RESULTS

a total of 232 patients were recruited over a period of 3 months. CRP levels were 21.3 +/- 36.0 and 150.5 +/- 114.1 mg/l (mean +/- SD) in the non-infection and infection groups, respectively (P < 0.001). We found that the CRP cut-off value of 60 mg/l had the best combination of sensitivity and specificity. At this level, the sensitivity of diagnosing bacterial infection was 80.7%, specificity 96.0%, positive predictive value 91.9% and negative predictive value 89.8%. CRP and temperature had higher sensitivity and specificity than white cell count and neutrophil count in the diagnosis of infection. For every 1-mg/l increment in CRP, the risk of bacterial infection increases by 2.9%.

CONCLUSION

CRP is a convenient and useful biomarker to predict early bacterial infection in older patients especially when other markers are atypical or not present.

Cytokine profile in elderly patients with sepsis

Context:

Sepsis is a serious health problem in the elderly with a high degree of mortality. There is very limited data available in elderly subjects regarding the markers for sepsis. Development of good markers will help in overall management and prediction of sepsis.

Objectives:

Serial estimation of Interleukin-6 (IL-6) and Tumor Necrosis Factor-Alpha (TNF-α) and their correlation with mortality in sepsis in elderly patients and to determine the influence of gender on cytokine production and mortality in elderly patients with sepsis.

Settings and Design:

The prospective study was conducted at our tertiary care center from April 2007 to September 2008. Elderly Patients satisfying the Systemic Inflammatory Response Syndrome (SIRS) criteria were included.

Methods and Material:

TNF-α and IL-6 were estimated in 30 elderly patients admitted to our intensive care unit with SIRS and sepsis. The estimations were done on day 1, 3 and 7 of admission.

Statistical Analysis Used:

Student and paired ‘t’ tests, and ANOVA, which were further followed up by post-hoc ‘t’ tests with Bonferroni correction using SPSS.

Results:

Reducing levels of IL-6 levels from day 1 to 7 was found in the survivor group. TNF-α level was significantly low on day 1 in the nonsurvivor female group.

Conclusions:

Serial estimation of cytokines in elderly patients with sepsis will help in prediction of mortality. Female gender was an independent predictor of increased morality in critically ill patients with sepsis.