Extending international sepsis epidemiology: the impact of organ dysfunction

Effects of Melatonin and Propolis Supplementation on Inflammation, Oxidative Stress, and Clinical Outcomes in Patients with Primary Pneumosepsis: A Randomized Controlled Clinical Trial

Background & Objective: The present study aimed to investigate the effects of propolis and melatonin supplementation on inflammation, clinical outcomes, and oxidative stress markers in patients with primary pneumosepsis. Materials and Methods: This pilot randomized controlled trial was conducted on 55 patients with primary pneumosepsis who were randomly assigned to the intervention and control groups. In the three intervention groups, the patients received propolis alone (1,000 mg/day), propolis (1,000 mg/day) plus melatonin (20 mg/day), and melatonin alone (20 mg/day). The control group received placebo. The inflammatory and oxidative stress markers as well as clinical outcomes were evaluated before and after the intervention, and the 28-day survival rate was also recorded. Results: After the intervention, the combination of propolis and melatonin significantly reduced interleukin-6 (-55.282 pg/ml ) and C-reactive protein (-21.656 mg/l ) levels, while increasing gavage intake (326.680 ml/day ) and improving some clinical outcomes (APACHE II, SOFA and NUTRIC scores) compared to control group. However, no significant difference was observed between the groups in terms of oxidative stress and hematological indices. In addition, the 28-day survival rate had no significant difference between the groups (P=0.07). Conclusion: Supplementation with propolis and melatonin may improve clinical outcomes by reducing inflammation. Further investigations are required to confirm these findings.

Diagnostic significance of heart-type fatty acid-binding protein as a potential biomarker to predict the mortality rate of patients with sepsis: a systematic review and meta-analysis

BACKGROUND

Some studies have found that heart-type fatty acid-binding protein (H-FABP) is related to the prognosis of patients with sepsis. This study aimed to explore whether H-FABP could predict the 28-day mortality in patients with sepsis.

METHODS

Seven databases were searched, and the studies were screened based on the inclusion and exclusion criteria to assess the quality. The pooled sensitivity (SEN), specificity (SPE) positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and the area under the curve (AUC) of the summary receiver operating characteristic (SROC) curve were calculated along with the 95% confidence interval (CI) values. Deeks' funnel plot was used to ascertain any publication bias. Meta-regression analysis was performed to explore the possible sources of heterogeneity.

RESULTS

Seven studies were assessed that included 822 patients with sepsis. The pooled SEN was 0.76 (95% CI, 0.71-0.81), SPE was 0.66 (95% CI, 0.61-0.70), PLR was 2.21 (95% CI, 1.73-2.83), NLR was 0.36 (95% CI, 0.29-0.54), DOR was 6.23 (95% CI, 4.27-9.11) and the pooled AUC was 0.8137. There was no publication bias. Race, literature language, sampling time, threshold division and threshold effect were not the causes for the large heterogeneity.

CONCLUSIONS

This meta-analysis suggests that H-FABP has high accuracy in predicting the 28-day mortality rate of patients with sepsis.

Early warning model for death of sepsis via length insensitive temporal convolutional network

Sepsis is a life-threatening systemic syndrome characterized by various biological, biochemical, and physiological abnormalities. Due to its high mortality, identifying sepsis patients with high risk of in-hospital death early and accurately will help doctors make optimal clinical decisions and reduce the mortality of sepsis patients. In this paper, we propose a length insensitive TCN-based model to predict sepsis patient's death risk in the future k hours, which is the first work for sepsis death risk early warning model only based on vital signs time series to our best knowledge. Furthermore, we design residual connections between temporal residual blocks to improve the prediction performance and stability especially on short input sequences. We validate and evaluate our model on two freely-available datasets, i.e., MIMIC-IV and eICU, from which 16,520 and 29,620 patients are selected respectively. The experiment results show that our model outperforms LSTM and other machine learning methods, as it has the highest sensitivity and Youden index in almost all cases. Meanwhile, the Youden index of the TCN-based model only slightly decreases by 0.0233 and 0.0307 when the time range of the input sequence changes from 24 to 4 h for k equal to 6 and 12, respectively.

Monocyte distribution width (MDW): a useful biomarker to improve sepsis management in Emergency Department

OBJECTIVES

Sepsis is a time-dependent and life-threating condition. Despite several biomarkers are available, none of them is completely reliable for the diagnosis. This study aimed to evaluate the diagnostic utility of monocyte distribution width (MDW) to early detect sepsis in adult patients admitted in the Emergency Department (ED) with a five part differential analysis as part of the standard clinical practice.

METHODS

A prospective cohort study was conducted on 985 patients aged from 18 to 96 and included in the study between November 2019 and December 2019. Enrolled subjects were classified into four groups based on sepsis-2 diagnostic criteria: control, Systemic Inflammatory Response Syndrome (SIRS), infection and sepsis. The hematology analyzer DxH 900 (Beckman Coulter Inc.) provides the new reportable parameter MDW, included in the leukocyte 5 part differential analysis, cleared by Food and Drug administration (FDA) and European Community In-Vitro-Diagnostic Medical Device (CE IVD) marked as early sepsis indicator (ESId).

RESULTS

MDW was able to differentiate the sepsis group from all other groups with Area Under the Curve (AUC) of 0.849, sensitivity of 87.3% and specificity of 71.7% at cut-off of 20.1. MDW in combination with white blood cell (WBC) improves the performance for sepsis detection with a sensitivity increased up to 96.8% when at least one of the two biomarkers are abnormal, and a specificity increased up to 94.6% when both biomarkers are abnormal.

CONCLUSIONS

MDW can predict sepsis increasing the clinical value of Leukocyte 5 Part Differential analysis and supporting the clinical decision making in sepsis management at the admission to the ED.

Red Cell Distribution Width as a Predictor of Mortality in Patients With Clinical Sepsis: Experience From a Single Rural Center in Central India

Introduction:

Early diagnosis of sepsis and its severity is essential for appropriate treatment to improve patient survival, especially in resource-limited settings. The aim of the present study was to study the role of red blood cell distribution (RDW) as a biomarker for the early detection of severe sepsis defined clinically and also in the prediction of mortality from sepsis.

Methods:

The cross-sectional study included a total of 175 subjects who met the inclusion criteria for the diagnosis of severe sepsis. After a thorough clinical examination, blood samples were taken from all patients within 3 hours of presenting the disease. The RDW values and other investigations were studied on the day of admission compared to other severity markers with the mortality index of 30 days.

Result:

The RDW value was significantly higher in patients with severe sepsis and in non-survivor patients than in survivors (P < .0001). There was a strong correlation between the SOFA score and RDW in predicting the disease outcome with the Pearson correlation coefficient of r = .46. The area under the receiver operating characteristic curve was found to be 0.852 at a CI of 95% (0.796-0.909) with RDW 17.15, sensitivity was 88.6% and specificity was 63.5%. There was a positive correlation with Pearson’s correlation coefficient of r = .46 between RDW and the SOFA score.

Conclusions:

RDW can be used as a potential marker for the early detection of severe sepsis and in the prediction of the outcome. Large multicenter prospective studies can confirm the utility of this routinely available marker for patients with sepsis.

Temporal Trends in the Microbiological Characteristics of Sepsis in the United States: A Population Based Study

BACKGROUND

Epidemiologic studies are needed for monitoring population-level trends in sepsis. This study examines sepsis-causing microorganisms from 2006 to 2014 in the United States using data from the Nationwide Inpatient Sample database.

METHODS

7 860 686 adults hospitalized with sepsis were identified using a validated ICD-9 coding approach. Associated microorganisms were identified by ICD-9 code and classified by major groups (Gram-positive, Gram-negative, fungi, anaerobes) and specific species for analysis of their incidence and mortality.

RESULTS

The rate of sepsis incidence has increased for all four major categories of pathogens, while the mortality rate decreased. In 2014, Gram-negative pathogens had a higher incidence than Gram-positives. Anaerobes increased the fastest with an average annual increase of 20.17% (p < 0.001). Fungi had the highest mortality (19.28%) and the slowest annual decrease of mortality (-2.31%, p = 0.006) in 2013, while anaerobic sepsis had the highest hazard of mortality (adjusted HR 1.60, 95% CI 1.53-1.66).

CONCLUSIONS

Gram-negative pathogens have replaced Gram-positives as the leading cause of sepsis in the United States in 2014 during the study period (2006-2014). The incidence of anaerobic sepsis has an annual increase of 20%, while the mortality of fungal sepsis has not decreased at the same rate as other microorganisms. These findings should inform the diagnosis and management of septic patients, as well as the implementation of public health programs.

Risk factors for 28-day mortality in patients with sepsis-related myocardial injury in intensive care units

Objective

This study aimed to identify the risk factors for death in patients with sepsis-related myocardial injury.

Methods

A retrospective study was conducted in 158 patients with sepsis-related myocardial injury in a mixed medical intensive care unit from January 2009 to March 2020. The patients were divided into those who survived and those who died on the basis of whether they survived after 28 days. Demographic and clinical parameters were collected. Multivariate logistic regression was performed.

Results

Sixty-nine (43.7%) patients died within 28 days after admission to the intensive care unit. Multivariate logistic regression analysis showed that the oxygenation index (odds ratio [OR]: 0.979, 95% confidence interval [CI]: 0.970–0.989), acute kidney injury (OR: 4.787, 95% CI: 1.674–13.693), norepinephrine dose (OR: 1.706, 95% CI: 1.375–2.117), and abdominopelvic cavity infection (OR: 0.257, 95% CI: 0.076–0.866) were significantly associated with mortality within 28 days after admission in patients with sepsis-related myocardial injury.

Conclusions

Patients with sepsis-related myocardial injury have a high mortality rate. A high oxygenation index, occurrence of acute kidney injury, high norepinephrine dose, and occurrence of abdominopelvic cavity infection are independent risk factors for 28-day mortality in patients with sepsis-related myocardial injury.

Predictive performance of critical illness scores and procalcitonin in sepsis caused by different gram-stain bacteria

OBJECTIVES

To compare the early and late predictive values of several critical illness scores (CISs) and biomarkers in sepsis-3 patients with bloodstream infections (BSIs) and to identify the prognostic value of procalcitonin (PCT) for different gram-stain bacteria infections.

METHODS

Patients with at least one positive blood culture within 24h of emergency department admission and with a final diagnosis of sepsis/septic shock were enrolled. CISs were calculated based on the first parameters on the day of admission. The receiver operating characteristics curve was used to analyze the predictive value of CISs and biomarkers for early and late mortality.

RESULTS

Of 834 enrolled patients with sepsis-3, death occurred in 214 patients within 28 days and in 273 patients within 60 days. Compared with biomarkers, CISs showed a significantly higher area under the curve (AUC) in the prediction of early and late mortality (p<0.01), especially for patients with GNB infection. The Sequential Organ Failure Assessment score showed a higher AUC for predicting early mortality than the Mortality in Emergency Department Sepsis score (p=0.036). Compared with GNB infections, the AUC values of the PCT for gram-positive bacteria (GPB) infections were higher for predicting early or late mortality; PCT showed higher AUC than high-sensitivity C-reactive protein and white blood cells for predicting early mortality (p<0.05).

CONCLUSIONS

CISs were more advantageous in the assessment of early and late prognosis, especially for patients with GNB infections; however, for sepsis with GPB infection, PCT can be used for the prediction of early mortality.

TRIM31 promotes apoptosis via TAK1-mediated activation of NF-κB signaling in sepsis-induced myocardial dysfunction

Sepsis is a major condition caused by an overwhelming inflammatory response to an infection. Sepsis-induced myocardial dysfunction (SIMD) is a common complication in septic patients and a major predictor of morbidity and mortality. Here, we investigated the role of tripartite motif 31 (TRIM31) protein in sepsis progression in vitro and in vivo. Quantitative real-time PCR and western blot were used to detect the expression levels of relative genes and proteins. Cell proliferation and apoptosis were evaluated to determine cell viability. H&E and IHC staining were performed to examine morphological and pathological changes in mice. ELISA assay was used to detect inflammatory factors. TRIM31 was upregulated in septic patients compared with normal people. TRIM31 depletion reduced LPS-induced apoptosis whereas TRIM31 overexpression-elevated LPS-induced apoptosis. Furthermore, TRIM31 interacted with and ubiquitinated transforming growth factor-β-activated kinase-1 (TAK1), resulting in TAK1 activation and subsequent induction of NF-κB signaling. Of note, Trim31 depletion or blockade by PDTC treatment inhibited LPS-induced apoptosis in vivo. In conclusion, TRIM31 played an important role in SIMD by activating TAK1-mediated NF-κB signaling pathway.

Is Pyroglutamic Acid a Prognostic Factor Among Patients with Suspected Infection? A Prospective Cohort Study

Pyroglutamic acid (PGA) is a compound that accumulates during oxidative stress and hence, elevated levels may be associated with poor prognosis in patients with infection or sepsis. To examine this hypothesis, patients presenting with acute infection were recruited in the emergency department and prospectively followed for 30 days. Sport urine samples were quantified for PGA. Outcomes were mortality and composite outcome of death or organ failure. Thirty two (32%) patients had qSOFA≥2. Median urine PGA was 22.9 (IQR 17.64, 33.53) µmol/mmol creatinine. Four patients demonstrated PGA values ≥ 63 µmol/mmol creatinine. Univariate analysis showed that PGA concentration ≥ 75^th percentile (i.e. 33.53 µmol/mmol creatinine) was associated with higher rates of in-hospital mortality (p = 0.041) with similar trend for PGA ≥ 63 µmol/mmol creatinine (p = 0.04). However, multivariate analysis showed that PGA was not associated with worse outcomes, whereas heart rate was associated with both composite outcomes (HR 1.0, p = 0.008 and HR 1.02, p = 0.001 for composite outcome with 30 days and in-hospital mortality, respectively). Among low risk patients, high PGA levels were consistently associated with worse outcomes. In conclusion, urine PGA concentration was not associated with worse outcomes among septic patients. Nevertheless, future studies should evaluate this association in larger cohorts.

Sepsis trends: increasing incidence and decreasing mortality, or changing denominator?

Numerous studies suggest that the incidence of sepsis has been steadily increasing over the past several decades while mortality rates are falling. However, reliably assessing trends in sepsis epidemiology is challenging due to changing diagnosis and coding practices over time. Ongoing efforts by clinicians, administrators, policy makers, and patient advocates to increase sepsis awareness, screening, and recognition are leading to more patients being labeled with sepsis. Subjective clinical definitions and heterogeneous presentations also allow for wide discretion in diagnosing sepsis rather than specific infections alone or non-specific syndromes. These factors create a potential ascertainment bias whereby the inclusion of less severely ill patients in sepsis case counts over time leads to a perceived increase in sepsis incidence and decrease in sepsis mortality rates. Analyses that rely on administrative data alone are further confounded by changing coding practices in response to new policies, financial incentives, and efforts to improve documentation. An alternate strategy for measuring sepsis incidence, outcomes, and trends is to use objective and consistent clinical criteria rather than administrative codes or registries to identify sepsis. This is feasible using data routinely found in electronic health record systems, such as blood culture draws and sustained courses of antibiotics to identify infection and laboratory values, vasopressors, and mechanical ventilation to measure acute organ dysfunction. Recent surveillance studies using this approach suggest that sepsis incidence and mortality rates have been essentially stable over the past decade. In this review, we summarize the major epidemiologic studies of sepsis trends, potential biases in these analyses, and the recent change in the surveillance paradigm toward using objective clinical data from electronic health records to more accurately characterize sepsis trends.

Prediction of median survival time in sepsis patients by the SOFA score combined with different predictors

Background

Sepsis is the leading cause of intensive care unit (ICU) admission. The purpose of this study was to explore the prognostic value of the Sequential Organ Failure Assessment (SOFA) score, the Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and procalcitonin (PCT), albumin (ALB), and lactate (LAC) levels in patients with sepsis.

Methods

Consecutive adult patients with suspected or documented sepsis at ICU admission were recruited. Their basic vital signs and related auxiliary examinations to determine their PCT and ALB levels and APACHE II score were recorded at ICU admission, and their LAC levels and SOFA scores were recorded for one week after admission. The influence of these variables on hospital mortality was evaluated. Logistic regression was used to derive the Sepsis Hospital Mortality Score (SHMS), a prediction equation describing the relationship between predictors and hospital mortality. The median survival time was calculated by the Kaplan-Meier method. In the validation group, the kappa value was calculated to evaluate the stability of the derived formula.

Results

This study included 894 sepsis patients admitted to 18 ICUs in 16 tertiary hospitals. Patients were randomly assigned to an experimental group (626 cases) and validation group (258 cases). In addition, a nonsurvival group (248 patients) of the experimental group was established according to the outcome at the time of discharge. The hospital mortality rate in the experimental group was 39.6% (248/626). Univariate and multivariate regression analyses revealed that the APACHE II score (odds ratio [OR] = 1.178), △SOFA (OR = 1.186), △LAC (OR = 1.157), and SOFA mean score (OR = 1.086) were independently associated with hospital mortality. The SHMS was calculated as logit(p) = 4.715 - (0.164 × APACHE II) - (0.171 × △SOFA) - (0.145 × △LAC) - (0.082 × SOFA mean). A receiver operating characteristic curve was constructed to further investigate the accuracy of the SHMS, with an area under the curve of 0.851 (95% confidence interval [CI] 0.821-0.882; p < 0.001) for hospital mortality. In the low-risk group and high-risk groups, the corresponding median survival times were 15 days and 11 days, respectively.

Conclusion

The APACHE II score, △SOFA, △LAC and SOFA mean score were independently associated with hospital mortality in sepsis patients and accurately predicted the hospital mortality rate and median survival time. Data on the median survival time in sepsis patients could be provided to clinicians to assist in the rational use of limited medical resources by facilitating prudent resource allocation.

Trial registration

ChiCTR-ECH-13003934, retrospectively registered on August 03, 2013.

Upregulation of UCP2 Expression Protects against LPS-Induced Oxidative Stress and Apoptosis in Cardiomyocytes

Uncoupling protein 2 (UCP2) has a cardioprotective role under septic conditions, but the underlying mechanism remains unclear. This study aimed at investigating the effects of UCP2 on the oxidative stress and apoptosis of cardiomyocytes induced by lipopolysaccharide (LPS). First, LPS increased UCP2 expression in cardiomyocytes in a time-dependent manner. LPS increased the production of lactate dehydrogenase (LDH), reactive oxygen species (ROS), and malondialdehyde (MDA) and decreased the level of superoxide dismutase (SOD). However, UCP2 knockdown increased the LPS-induced cardiac injury and oxidative stress. In addition, LPS damaged the mitochondrial ultrastructure and led to the disruption of mitochondrial membrane potential (MMP), as well as the release of mitochondrial cytochrome c. UCP2 knockdown aggravated mitochondrial injury and the release of mitochondrial cytochrome c. LPS increased the protein levels of Bax and cleaved-caspase-3, decreased the protein level of Bcl-2, and upregulated the protein level of mitogen-activated protein kinase. However, upon UCP2 knockdown, the protein levels of Bax and cleaved-caspase-3 increased even further, and the protein level of Bcl-2 was further decreased. The protein level of phosphorylated p38 was also further enhanced. Thus, UCP2 protects against LPS-induced oxidative stress and apoptosis in cardiomyocytes.

FAM46C inhibits lipopolysaccharides-induced myocardial dysfunction via downregulating cellular adhesion molecules and inhibiting apoptosis

AIMS

Sepsis is a syndrome of inflammatory response induced by infection. Cellular adhesion molecules may involve in sepsis-induced myocardial dysfunction (SIMD) which is a major predictor of morbidity and mortality of sepsis. Here we studied the role of FAM46C in AC16 cells and c57 mice with lipopolysaccharides (LPS) treatment.

MAIN METHODS

Real-time PCR and western blot were used to detect the expression level of relative genes and protein. Cell proliferation and apoptosis were evaluated.

KEY FINDINGS

Interestingly, negative correlation between Toll-like receptor 4 (TLR4) and FAM46C in sepsis was observed. The overexpression of FAM46C reduced the apoptosis induced by LPS in AC16 cells. Inhibition of apoptosis contributed by FAM46C was mediated by adhesion molecule via blocking p38 and ERK/MAPK signaling pathway. Moreover, overexpression of Fam46c and inhibition of TLR4 by TAK-242 could attenuate apoptosis induced by LPS in vivo.

SIGNIFICANCE

FAM46C played an important role in SIMD via inhibiting LPS-induced myocardial dysfunction by downregulating cellular adhesion molecules and inhibiting apoptosis. It was the first time to explore the role of FAM46C in SIMD in this study.

GM-CSF Administration Improves Defects in Innate Immunity and Sepsis Survival in Obese Diabetic Mice

Sepsis is the leading cause of death in the intensive care unit with an overall mortality rate of 20%. Individuals who are obese and have type 2 diabetes have increased recurrent, chronic, nosocomial infections that worsen the long-term morbidity and mortality from sepsis. Additionally, animal models of sepsis have shown that obese, diabetic mice have lower survival rates compared with nondiabetic mice. Neutrophils are essential for eradication of bacteria, prevention of infectious complications, and sepsis survival. In diabetic states, there is a reduction in neutrophil chemotaxis, phagocytosis, and reactive oxygen species (ROS) generation; however, few studies have investigated the extent to which these deficits compromise infection eradication and mortality. Using a cecal ligation and puncture model of sepsis in lean and in diet-induced obese mice, we demonstrate that obese diabetic mice have decreased "emergency hematopoiesis" after an acute infection. Additionally, both neutrophils and monocytes in obese, diabetic mice have functional defects, with decreased phagocytic ability and a decreased capacity to generate ROS. Neutrophils isolated from obese diabetic mice have decreased transcripts of Axl and Mertk, which partially explains the phagocytic dysfunction. Furthermore, we found that exogenous GM-CSF administration improves sepsis survival through enhanced neutrophil and monocytes phagocytosis and ROS generation abilities in obese, diabetic mice with sepsis.

APRIL and sTACI could be predictors of multiorgan dysfunction syndrome in sepsis

Although the role of B cells in sepsis immunoregulation has become an interesting topic, there is lack of data on the role of B cell function regulators in prediction of multiorgan dysfunction syndrome (MODS). The aim of this study was to evaluate the prognostic value of A Proliferation Inducing Ligand (APRIL) and soluble Transmembrane Activator and CAML Interactor Protein (sTACI), the main B cell function regulators, in prediction of MODS development within the first 48 h after admission to intensive care unit, among septic patients. We included 112 patients with sepsis, treated at Clinic for Infectious Diseases and Emergency Center, Clinical Center of Vojvodina, Novi Sad, Serbia. Plasma concentrations of APRIL and sTACI were determined at the admission and potential development of MODS was confirmed in the first 48 h. Concentrations of APRIL (p = 0.003) and sTACI (p<0.001) were higher in patients who developed MODS (n = 30). ROC curve analysis showed that AUC for sTACI (AUC = 0.764) was greater than that for procalcitonin (AUC = 0.719) and APRIL (AUC = 0.673) in MODS development prediction. Multivariate regression analysis showed that sTACI, as an anti-inflammatory biomarker stimulating the apoptosis of B cells, was the only independent predictor of MODS, beside SOFA score. Elevated level of sTACI could be the alarm for the increased B cell apoptosis and development of immune paralysis. Including these biomarkers into predictive scores specific for septic patients may potentially improve their sensitivity and specificity. Measurement of their concentrations dynamics could contribute to better assessment of sepsis evolution and timely introduction of immunomodulatory therapy.

Evaluation of plasma angiopoietin-2 and vascular endothelial growth factor in healthy dogs and dogs with systemic inflammatory response syndrome or sepsis

Background

Angiopoietin‐2 (Ang‐2) and vascular endothelial growth factor (VEGF) are regulators of endothelial permeability.

Objective

Plasma concentrations of Ang‐2 and VEGF are increased in dogs with systemic inflammatory response syndrome (SIRS) and sepsis and are correlated with disease severity and outcome.

Animals

Healthy dogs (n = 18) and client‐owned dogs with SIRS (n = 34) or sepsis (n = 25).

Methods

Prospective observational study. Ang‐2 and VEGF concentrations in admission plasma samples were compared between healthy dogs and dogs with SIRS or sepsis, and between survivors and non‐survivors. Correlations with the acute patient physiologic and laboratory evaluation (APPLE_fast) disease severity score were examined.

Results

Median Ang‐2 was significantly higher in dogs with SIRS (19.3; interquartile range [IQR]: 8.6‐25.7 ng/mL) and sepsis (21.2; IQR: 10.3‐30.1 ng/mL) compared to healthy dogs (7.6; IQR: 6.7‐9.8 ng/mL). Ang‐2 was significantly higher in non‐survivors (24.1; IQR: 11.9‐50.0 ng/mL) than survivors (10.2; IQR: 7.2‐21.5 ng/mL) but did not correlate with the APPLE_fast score. Admission Ang‐2 predicted negative outcome in dogs with SIRS and sepsis with reasonable accuracy (area under the curve [AUC]: 0.75, confidence interval [CI]: 0.59‐0.85; sensitivity: 0.5, CI: 0.29‐0.71; specificity: 0.87, CI: 0.75‐0.95); differentiation between sepsis and SIRS was poor (AUC: 0.58). Plasma VEGF was significantly higher in dogs with sepsis (45; IQR: 14‐107.5 pg/mL) than in dogs with SIRS (3.3; IQR: 0‐35.6 pg/mL) or healthy dogs (0; IQR: 0 pg/mL; P = 0.008). VEGF was significantly (P = .0004) higher in non‐survivors (34.5; IQR: 0‐105.7 pg/mL) than in survivors (0; IQR: 0‐55.2 pg/mL). The ability of VEGF to predict a negative outcome was poor.

Conclusions and Clinical Importance

Ang‐2 may represent a useful additional prognostic marker in dogs with SIRS.

Diagnostic and predictive performance of biomarkers in patients with sepsis in an intensive care unit

Objective

This study was performed to compare the predictive performance of serum procalcitonin (PCT), N-terminal brain natriuretic propeptide (NT-proBNP), interleukin-6 (IL-6), prothrombin time (PT), thrombin time (TT), and Sequential Organ Failure Assessment (SOFA) score in the intensive care unit (ICU).

Methods

This retrospective cohort study enrolled 150 patients with sepsis and septic shock and 30 control patients without sepsis. Each patient was followed until death or 28 days. Correlations between variables were assessed with Spearman’s rho test. The Kruskal–Wallis and Mann–Whitney U tests were used for between-group comparisons.

Results

Receiver operating characteristic curve analysis of the SOFA score, PCT, NT-proBNP, IL-6, PT, and TT showed an area under the curve of 0.872, 0.732, 0.711, 0.706, 0.806, and 0.691, respectively, for diagnosing sepsis. Binary logistic regression demonstrated that the SOFA score was an independent predictor of 28-day mortality and septic shock. The correlation coefficient (r) between SOFA and PCT, NT-proBNP and SOFA, IL-6 and SOFA, PT and SOFA, and TT and SOFA was 0.79, 0.52, 0.57, 0.56, and 0.58, respectively.

Conclusion

While the SOFA score is the gold standard, analysis of multiple biomarkers could increase the performance capacity for diagnosis and prognosis in patients with sepsis in the ICU.

Exploring the Protective Role and the Mechanism of Sphingosine 1 Phosphate in Endotoxic Cardiomyocytes

FTY720 is a sphingosine 1 phosphate (S1P) receptor agonist approved for the treatment of multiple sclerosis, which is a chronic inflammatory autoimmune disorder. Sepsis is a complex syndrome associated with progressive endotoxemic developments, which finally leads to damage of multiple organs, including the heart. In critical patients, cardiovascular dysfunction due to sepsis is a major cause of death. Previous studies have shown an association between S1P and cardioprotection in the situation of ischemia reperfusion and myocardial infarction. Therefore, we will study the role of S1P towards endotoxic cardiomyocytes. Different doses of FTY720 were applied or not to endotoxic cardiomyocytes. The concentration of inflammatory cytokines, including tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10 was measured by enzyme-linked immuno sorbent assay. Western blotting was used to analyze the downstream signaling pathways. We discovered that FTY720 reduced the levels of TNF-α and IL-6 through the NF-ΚB pathway, inhibited the expression of caspase-3, and activated both protein kinase B and extracellular signal-regulated kinase 1/2. Additionally, the activation of protein kinase B and extracellular signal-regulated kinase 1/2 could be inhibited by the S1P1 and S1P3 receptor antagonist vulcanized polyethylene23019. Therefore, we infer that S1P exerts a protective effect towards endotoxic cardiomyocytes by decreasing the levels of TNF-α and IL-6, regulating apoptotic and survival signaling pathway. The S1P1 and S1P3 receptors are involved in the prosurvival signal activation.

Obesity and type 2 diabetes mellitus drive immune dysfunction, infection development, and sepsis mortality

Obesity and type 2 diabetes mellitus (T2D) are global pandemics. Worldwide, the prevalence of obesity has nearly tripled since 1975 and the prevalence of T2D has almost doubled since 1980. Both obesity and T2D are indolent and chronic diseases that develop gradually, with cellular physiologic changes occurring before the clinical signs and symptoms of the diseases become apparent. Individuals with obesity and T2D are physiologically frail and have an increased risk of infections and mortality from sepsis. Improvement in the morbidity and mortality of these at-risk populations would provide a great societal benefit. We believe that the worsened outcomes observed in these patient populations is due to immune system dysfunction that is triggered by the chronic low-grade inflammation present in both diseases. As immune modulatory therapies have been utilized in other chronic inflammatory diseases, there is an emerging role for immune modulatory therapies that target the chronically affected immune pathways in obese and T2D patients. Additionally, bariatric surgery is currently the most successful treatment for obesity and is the only weight loss method that also causes a sustained, substantial improvement of T2D. Consequently, bariatric surgery may also have a role in improving immunity in these patient populations.

The Importance of Haemogram Parameters in the Diagnosis and Prognosis of Septic Patients

Sepsis represents a severe pathology that requires both rapid and precise positive and differential diagnosis to identify patients who need immediate antimicrobial therapy. Monitoring septic patients’ outcome leads to prolonged hospitalisation and antibacterial therapy, often accompanied by substantial side effects, complications and a high mortality risk.

Septic patients present with complex pathophysiological and immunological disorders and with a predominance of pro-inflammatory or anti-inflammatory mediators which are heterogeneous with respect to the infectious focus, the aetiology of sepsis or patients’ immune status or comorbidities. Previous studies performed have analysed inflammatory biomarkers, but a test or combinations of tests that can quickly and precisely establish a diagnosis or prognosis of septic patients has yet to be discovered. Recent research has focused on re-analysing older accessible parameters found in the complete blood count to determine the sensitivity, specificity, positive and negative predictive values for the diagnosis and prognosis of sepsis.

The neutrophil/lymphocyte count ratio (NLCR), mean platelet volume (MPV) and red blood cells distribution width (RDW) are haemogram indicators which have been evaluated and which are of proven use in septic patients’ management.

Significance of hydrogen sulfide in sepsis-induced myocardial injury in rats

Sepsis-induced myocardial injury is a detrimental disorder for intensive care medicine due to its high rates of morbidity and mortality. Data suggest that nuclear factor (NF)-κB serves a critical role in the pathogenesis of myocardial injury. Hydrogen sulfide (H₂S) serves an important role in the physiology and pathophysiology of regulatory mechanisms, particularly during an inflammatory reaction. However, the relationship between NF-κB and H₂S in sepsis-induced myocardial injury is not well understood, and the underlying mechanisms remain unclear. In the present study, 60 male Sprague Dawley rats were randomly divided into the following six groups: A sham group, cecal ligation and puncture (CLP) group, sham + propargylglycine (PAG) group, CLP + PAG group, sham + sodium hydrosulfide (NaHS) group and CLP + NaHS group, with 10 rats in each group. The rats in all groups were sacrificed 12 h after surgery for sample collection. Compared with the sham group, it was observed that the concentrations of Creatine Kinase-MB (CK-MB) and cardiac troponin I (cTnI) in the serum, and pathological scores of myocardial tissue were significantly increased in the CLP, CLP + NaHS and CLP + PAG groups (P<0.05). The pathological scores and concentrations of CK-MB and cTnI were significantly higher in the CLP + PAG group (P<0.05) and significantly lower in the CLP + NaHS group (P<0.05) when compared with the CLP group. The expression of cystathionine-γ-lyase (CSE) mRNA and content of interleukin (IL)-10 were significantly higher in the CLP group compared with the CLP + PAG group (P<0.05), while the expression of myocardial NF-κB and content of tumor necrosis factor (TNF)-α in the CLP group were significantly lowered compared with the CLP + PAG group (P<0.05). The expression of NF-κB and content of TNF-α were significantly increased in the CLP group when compared with the CLP + NaHS group (P<0.05), while the content of myocardial IL-10 in the CLP group was significantly lower than in the CLP + NaHS group (P<0.05). In conclusion, H₂S acted as an anti-inflammatory cytokine and biomarker in sepsis-induced myocardial injury. Furthermore, H₂S may downregulate the NF-κB subunit p65 to mediate inflammatory responses. The present data suggest that myocardial injury in sepsis may be relieved through the regulation of H₂S expression, and provide an experimental basis for the treatment of sepsis patients presenting with myocardial injury. In addition, myocardial injury in sepsis may be identified by monitoring changes in the expression of H₂S.

Systemic Inflammation as a Driver of Brain Injury: the Astrocyte as an Emerging Player

Severe systemic inflammation has strong effects on brain functions, promoting permanent neurocognitive dysfunction and high mortality rates. Additionally, hippocampal damage seems to be directly involved in this process and astrocytes play an important role in neuroinflammation and in the neuroimmune response. However, the contribution of the astrocytes to the pathology of acute brain dysfunction is not well understood. Recently, our group established a protocol for obtaining astrocyte cultures from mature brain to allow the characterization of these cells and their functions under pathologic conditions. The present study was designed to characterize astrocyte function after acute systemic inflammation induced by cecal ligation and perforation (CLP). Hippocampal astrocyte cultures from CLP animals presented increased levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, IL-6, IL-18, and cyclooxygenase-2 and decreased levels of IL-10. This proinflammatory profile was accompanied by an increase in Toll-like receptor (TLR)2 mRNA expression levels and no change either in TLR4 or in vascular endothelial growth factor (VEGF) gene expression. These alterations were associated with increased expressions of p21, nuclear factor kappa B (NFκB), and inducible nitric oxide synthase (iNOS) in astrocytes from CLP animals. The same parameters were also evaluated in whole hippocampal tissue, but differences in this profile were found compared to hippocampal astrocyte cultures from CLP, reflecting an interaction between other central nervous system cell types, which may mask specific astrocytic changes. These results improve our understanding of the mechanisms by which astrocytes react against systemic inflammation, and suggest these cells to be potential targets for therapeutic modulation.

Association of pre-hospital theophylline use and mortality in chronic obstructive pulmonary disease patients with sepsis

BACKGROUND

Although theophylline has been shown to have anti-inflammatory effects, the therapeutic use of theophylline before sepsis is unknown. The aim of our study was to determine the effect of theophylline on COPD patients presenting with sepsis.

METHODS

This nationwide, population-based, propensity score-matched analysis used data from the linked administrative databases of Taiwan's National Health Insurance program. Patients with COPD who were hospitalized for sepsis between 2000 and 2011 were divided into theophylline users and non-users. The primary outcome was 30-day mortality. The secondary outcome was in-hospital death, intensive care unit admission, and need for mechanical ventilation. Cox proportional hazard model and conditional logistic regression were used to calculate the risk between groups.

RESULTS

A propensity score-matched cohort of 51,801 theophylline users and 51,801 non-users was included. Compared with non-users, the 30-day (HR 0.931, 95% CI 0.910-0.953), 180-day (HR 0.930, 95% CI 0.914-0.946), 365-day (HR 0.944, 95% CI 0.929-0.960) and overall mortality (HR 0.965, 95% CI 0.952-0.979) were all significantly lower in theophylline users. Additionally, the theophylline users also had lower risk of in-hospital death (OR 0.895, 95% CI 0.873-0.918) and need for mechanical ventilation (OR 0.972, 95% CI 0.949-0.997).

CONCLUSIONS

Theophylline use is associated with a lower risk of sepsis-related mortality in COPD patients. Pre-hospital theophylline use may be protective to COPD patients with sepsis.

Ulinastatin - a newer potential therapeutic option for multiple organ dysfunction syndrome

Despite significant improvements in medical and surgical management, multiple organ dysfunction syndrome (MODS) or multiple organ failure following conditions such as acute pancreatitis, severe sepsis, and traumatic, hemorrhagic, and endotoxin shocks is still accompanied with a high mortality rate. In light of the crucial role of immunologic derangement recently conceptualized in these conditions, ulinastatin, a urinary trypsin inhibitor, is considered as a potentially beneficial immunomodulator drug for MODS. Mechanisms involving protections against tissue organs and endothelial cell and anti-inflammatory effects by ulinastatin are dependent on the inhibition of polymorphonuclear leukocyte (PMN)-derived elastase, tumor necrosis factor α, and other pro-inflammatory cytokines and interleukins (IL-1, IL-6, and IL-8). Ulinastatin also suppresses the activation of PMN cells, macrophages, and platelets. Derived from these properties, ulinastatin has been investigated as a potential clinical therapy for indications including shock and pancreatitis and approved in Japan and China with ongoing clinical trials around the globe. Off-label potential uses of ulinastatin have been reported in preterm labor and hematological, hepatic, renal, and cardiovascular diseases including vasculitis syndromes such as Kawasaki disease.

Multiplex cytokine analyses in dogs with pyometra suggest involvement of KC-like chemokine in canine bacterial sepsis

Clinical diagnostic criteria for sepsis (systemic inflammatory response syndrome caused by infection) are unspecific and, therefore, biomarkers for sepsis diagnosis are needed for appropriate treatment and patient survival. Pyometra, a common disease caused by bacterial infection of the uterus, results in sepsis in nearly 60% of cases in dogs. We used dogs with pyometra as a natural model for sepsis and collected serum samples from 39 dogs, of which 22 with pyometra and 17 healthy controls. Dogs with pyometra were further grouped into dogs with sepsis (n=18) and without sepsis (n=4). Serum concentrations of a panel of cytokines, including keratinocyte-derived chemokine (KC)-like, granulocyte-macrophages colony stimulating factor (GM-CSF), interleukin (IL)-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-15, IL-18, chemokine C-X-C motif ligand (CXCL)10 and tumor necrosis factor (TNF)-α, were measured using multiplex analyses. Serum C-reactive protein (CRP) levels were determined using an automated immunoturbidimetric assay. In addition to physical examination hematological and serum biochemical analyses were performed to evaluate the overall status of the dogs. Significantly higher concentrations of KC-like (757 vs 304 pg/ml) were detected in dogs with pyometra as compared to healthy dogs. Within the pyometra group, dogs with sepsis compared to dogs without sepsis had a higher KC-like concentration (873 vs 300 pg/ml). Hemoglobin levels were significantly lower in dogs with pyometra compared to healthy dogs, regardless of the presence or absence of sepsis, and correlated negatively with KC-like. KC-like concentrations correlated positively with CRP, number of hospitalization days, number of monocytes, concentrations of IL-8, and percentage band neutrophils. Our data suggest that bacterial infection triggers the expression of KC-like and further studies are warranted of KC-like as a possible biomarker for diagnosing sepsis and uterine bacterial infection in dogs.

Thrombocytopenia: A Risk Factor of Mortality for Patients with Sepsis in the Intensive Care Unit

OBJECTIVES

The objective of this study was to evaluate the intensive care unit (ICU) and long-term mortality in sepsis patients with/without thrombocytopenia on the fifth day of ICU admission.

MATERIALS AND METHODS

The retrospective observational cohort study was performed in a teaching hospital, and patients with sepsis who stayed more than 4 days in the ICU between January 2012 and December 2012 were included. Patients were divided into two groups according to thier platelet count at fifth day of ICU stay: Group 1, < 150.000/μL; Group 2, >150.000/μL. Patients having thrombocytopenia on admission were excluded. The patients' characteristics, comorbid diseases, body mass index, arterial blood gas analysis and blood biochemistry results, SIRS criteria, Acute Physiological and Chronic Health Evaluation Score II (APACHE II), implication of invasive and non-invasive mechanical ventilation, use of sedation, nutrition information, and culture results of microbiological samples were recorded. The groups were compared according to the recorded data. Logistic regression analysis was performed for ICU mortality; the Kaplan-Meier test was used to evaluate 12-month survival after ICU discharge.

RESULTS

During the period, 1003 patients were admitted to the ICU; 307 sepsis patients were included in the study. Group 1 (n= 67) and Group 2 (n=240) had similar patient characteristics and sepsis findings. The groups had similar ICU and hospital stays; mortality was higher in Group 1 than in Group 2 (40.3% vs. 17.5%, respectively, p< 0.001). Fifth day thrombocytopenia, septic shock, male gender, and low albumin levels were found to be risk factors of ICU mortality; the respective odds ratios, 95% confidence intervals, and p values for these factors were 3.03, [1.15-7.45], p= 0.025; 4.97, [1.79-13.86], p= 0.002; 3.61, [1.27-10.23], p= 0.001; and 0.19, [0.07-0.52], p= 0.001. Follow-up after a year indicated that 124 out of 238 (52.1%) patients died, and 50% of the deaths occurred in the first 2 months. Kaplan-Meier analysis revealed no statistically significant effects of thrombocytopenia at ICU day 5 on 12-month mortality after ICU discharge.

CONCLUSION

Higher rates of septic shock and mortality were seen in sepsis patients with thrombocytopenia in the ICU. The measurement of thrombocytopenia in the ICU, which is easy and low-cost, may help to predict mortality. Thus, precautions can be taken early in patient treatment and follow-up. As we know, early intervention is crucial in the approach to sepsis.

Association of susceptibility to septic shock with platelet endothelial cell adhesion molecule-1 gene Leu125Val polymorphism and serum sPECAM-1 levels in sepsis patients

Sepsis is a systemic inflammatory response to infection and includes severe sepsis, septic shock and death. Platelet endothelial cell adhesion molecule-1 (PECAM-1) is one cell adhesion molecule expressed on platelets and leukocytes. It regulates platelet activation and mediates transendothelial migration of leukocytes, thus maintaining the integrity of the vasculature. There are some animal experiments associated with the protective role of PECAM-1 against septic shock. However few host genetic risk factors have been identified for sepsis severity and susceptibility to septic shock. A case-control study was conducted, which included 217 patients with sepsis and 90 control subjects recruited from our hospital. One single nucleotide polymorphisms (SNP) of PECAM-1 gene Leu125Val (C373G) was analyzed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. Serum soluble PECAM-1 (sPECAM-1) levels were determined by enzyme-linked immunosorbent assay (ELISA). Our results showed that the CG and GG genotypes of SNP in Leu125Val of PECAM-1 (rs668: C>G) was significantly associated with increased susceptibility to septic shock compared with CC genotype in sepsis patients (CG genotype, OR: 2.493, 95% CI: 1.175~5.287, P = 0.016; GG genotype: OR: 3.328, 95% CI: 1.445~7.666, P = 0.004). The serum levels of sPECAM-1 in the sepsis patients (47.1 ± 17.5 ng/ml) were significantly higher than those in the healthy controls (61.3 ± 20.9 ng/ml, P<0.01). Among sepsis patients, the serum levels of sPECAM-1 were significantly higher in CG and GG genotype than in CC genotype. In septic shock patients, nonsurvivors (83.7 ± 12.6 ng/ml, n = 69) had a significantly higher serum sPECAM-1 level than the survivors (76.9 ± 12.7 ng/ml, n = 53) (P<0.01). In conclusion, PECAM-1 Leu125Val polymorphism and its sPECAM-1 levels are associated with sepsis severity and susceptibility to septic shock.

Effect of Cholecalciferol Supplementation on Vitamin D Status and Cathelicidin Levels in Sepsis: A Randomized, Placebo-Controlled Trial

OBJECTIVES

To compare changes in vitamin D status and cathelicidin (LL-37) levels in septic ICU patients treated with placebo versus cholecalciferol.

DESIGN

Randomized, placebo-controlled, trial.

SETTING

Medical and surgical ICUs of a single teaching hospital in Boston, MA.

PATIENTS

Thirty adult ICU patients.

INTERVENTIONS

Placebo (n = 10) versus 200,000 IU cholecalciferol (n = 10) versus 400,000 IU cholecalciferol (n = 10), within 24 hours of new-onset severe sepsis or septic shock.

MEASUREMENTS AND MAIN RESULTS

Blood samples were obtained at baseline (day 1) and on days 3, 5, and 7, to assess total 25-hydroxyvitamin D, as well as vitamin D-binding protein and albumin to calculate bioavailable 25-hydroxyvitamin D. Plasma LL-37 and high-sensitivity C-reactive protein levels were also measured. At baseline, median (interquartile range) plasma 25-hydroxyvitamin D was 17 ng/mL (13-22 ng/mL) and peaked by day 5 in both intervention groups. Groups were compared using Kruskal-Wallis tests. Relative to baseline, on day 5, median change in biomarkers for placebo, 200,000 IU cholecalciferol, and 400,000 IU cholecalciferol groups, respectively, were as follows: 1) total 25-hydroxyvitamin D, 3% (-3% to 8%), 49% (30-82%), and 69% (55-106%) (p < 0.001); 2) bioavailable 25-hydroxyvitamin D, 4% (-8% to 7%), 45% (40-70%), and 96% (58-136%) (p < 0.01); and 3) LL-37: -17% (-9% to -23%), 4% (-10% to 14%), and 30% (23-48%) (p = 0.04). Change in high-sensitivity C-reactive protein levels did not differ between groups. A positive correlation was observed between bioavailable 25-hydroxyvitamin D and LL-37 (Spearman ρ = 0.44; p = 0.03) but not for total 25-hydroxyvitamin D and LL-37.

CONCLUSIONS

High-dose cholecalciferol supplementation rapidly and safely improves 25-hydroxyvitamin D and bioavailable 25-hydroxyvitamin D levels in patients with severe sepsis or septic shock. Changes in bioavailable 25-hydroxyvitamin D are associated with concomitant increases in circulating LL-37 levels. Larger trials are needed to verify these findings and to assess whether optimizing vitamin D status improves sepsis-related clinical outcomes.

Update of Sepsis: Recent Evidences about Early Goal Directed Therapy

Severe sepsis and septic shock is a life-threatening disease. It is combined with multi-organ failure. In the past decade, early goal directed therapy has been proposed as an effective treatment strategy for better outcome. Recent epidemiologic studies showed that the outcome of sepsis has been improved with the introduction of early goal directed therapy. However, it is unclear which elements of early goal directed therapy contributed to the better outcome. Recent prospective and randomized trials suggested that some elements of early goal directed therapy did not have any effect on the outcome benefit. In this paper, recent articles about early goal directed therapy will be reviewed and the effectiveness of individual elements of early goal directed therapy will be discussed.

Rs1800625 in the receptor for advanced glycation end products gene predisposes to sepsis and multiple organ dysfunction syndrome in patients with major trauma

Introduction

The receptor for advanced glycation end products (RAGE) is a transmembrane receptor of the immunoglobulin superfamily, it plays pivotal roles in the pathogenesis of sepsis in several ways. Our previous study showed that rs1800625 (−429T/C) revealed a strong clinical relevance with sepsis morbidity rate and multiple organ dysfunction syndrome (MODS) in patients with major trauma. In this study, we enlarged the sample size, added two validation populations and examined the expression of RAGE on the surface of peripheral leukocytes to ex vivo lipopolysaccharide (LPS) stimulation in subjects with different genotypes.

Methods

Rs1800625 was genotyped using pyrosequencing in 837 Chinese Han patients with major trauma in Chongqing. We then validated the clinical relevance in 340 Zhejiang and 347 Yunnan patients. The expression of RAGE on the surface of peripheral blood mononuclear cells was measured by flow cytometric analysis.

Results

The results indicated that rs1800625 was significantly associated with sepsis morbidity rate and MODS in patients with major trauma in the Chongqing, Zhejiang and Yunnan districts. Patients with CC genotype had lower sepsis morbidity rate and MODS after major trauma. Furthermore, patients with CC genotype had significantly higher RAGE expression (P = 0.009).

Conclusions

The rs1800625 polymorphism is a functional single nucleotide polymorphism and confers host susceptibility to sepsis and MODS in patients with major trauma.

Comparison of trends in sepsis incidence and coding using administrative claims versus objective clinical data

BACKGROUND

National reports of a dramatic rise in sepsis incidence are largely based on analyses of administrative databases. It is unclear if these estimates are biased by changes in coding practices over time.

METHODS

We calculated linear trends in the annual incidence of septicemia, sepsis, and severe sepsis at 2 academic hospitals from 2003 to 2012 using 5 different claims methods and compared case identification rates to selected objective clinical markers, including positive blood cultures, vasopressors, and/or lactic acid levels.

RESULTS

The annual incidence of hospitalizations with sepsis claims increased over the decade, ranging from a 54% increase for the method combining septicemia, bacteremia, and fungemia codes (P < .001 for linear trend) to a 706% increase for explicit severe sepsis/septic shock codes (P = .001). In contrast, the incidence of hospitalizations with positive blood cultures decreased by 17% (P = .006), and hospitalizations with positive blood cultures with concurrent vasopressors and/or lactic acidosis remained stable (P = .098). The sensitivity of sepsis claims for capturing hospitalizations with positive blood cultures with concurrent vasopressors and/or lactic acidosis increased (P < .001 for all methods), whereas the proportion of septicemia hospitalizations with positive blood cultures decreased from 50% to 30% (P < .001).

CONCLUSIONS

The incidence of hospitalizations with sepsis codes rose dramatically while hospitalizations with corresponding objective clinical markers remained stable or decreased. Coding for sepsis has become more inclusive, and septicemia diagnoses are increasingly being applied to patients without positive blood cultures. These changes likely explain some of the apparent rise in sepsis incidence and underscore the need for more reliable surveillance methods.

Prognostic evaluation of severe sepsis and septic shock: procalcitonin clearance vs Δ Sequential Organ Failure Assessment

PURPOSE

The purpose of the study is to compare the clearance of procalcitonin (PCT-c) in the first 24 and 48 hours of treatment of severe sepsis and septic shock with another early prognostic marker represented by the 48-hour Δ Sequential Organ Failure Assessment (SOFA).

MATERIALS AND METHODS

Prospective, observational cohort study conducted in a general intensive care unit including patients with severe sepsis and septic shock. The PCT-c was determined at the diagnosis of sepsis and after 24 and 48 hours. The SOFA score was determined at the time of intensive care unit admission and after 48 hours.

RESULTS

One hundred thirty adult patients with severe sepsis and septic shock were studied over an 18-month period. The 24- and 48-hour PTC-c scores were significantly higher in survivors (P < .0001). In nonsurvivors, the initial SOFA was significantly higher, and the 48-hour Δ SOFA was significantly smaller (P = .01). The area under the receiver operating characteristic curve was 0.68 for Δ SOFA and 0.76 for 24- and 48-hour PCT-c.

CONCLUSIONS

The 48-hour Δ SOFA score and the clearance of 24- and 48-hour PCT are useful markers of prognosis in patients with severe sepsis and septic shock. A decrease in PCT-c in the first 24 hours of treatment should prompt the reassessment of the appropriateness and adequacy of treatment.

A latent class approach for sepsis diagnosis supports use of procalcitonin in the emergency room for diagnosis of severe sepsis

Background

Given the acknowledged problems in sepsis diagnosis, we use a novel way with the application of the latent class analysis (LCA) to determine the operative characteristics of C-reactive protein (CRP), D-dimer (DD) and Procalcitonin (PCT) as diagnostic tests for sepsis in patients admitted to hospital care with a presumptive infection.

Methods

Cross-sectional study to determine the diagnostic accuracy of three biological markers against the gold standard of clinical definition of sepsis provided by an expert committee, and also against the likelihood of sepsis according to LCA. Patients were recruited in the emergency room within 24 hours of hospitalization and were follow-up daily until discharge.

Results

Among 765 patients, the expert committee classified 505 patients (66%) with sepsis, 112 (15%) with infection but without sepsis and 148 (19%) without infection. The best cut-offs points for CRP, DD, and PCT were 7.8 mg/dl, 1616 ng/ml and 0.3 ng/ml, respectively; but, neither sensitivity nor specificity reach 70% for any biomarker. The LCA analysis with the same three tests identified a “cluster” of 187 patients with several characteristics suggesting a more severe condition as well as better microbiological confirmation. Assuming this subset of patients as the new prevalence of sepsis, the ROC curve analysis identified new cut-off points for the tests and suggesting a better discriminatory ability for PCT with a value of 2 ng/ml.

Conclusions

Under a “classical” definition of sepsis three typical biomarkers (CRP, PCT and DD) are not capable enough to differentiate septic from non-septic patients in the ER. However, a higher level of PCT discriminates a selected group of patients with severe sepsis.

Modulation of the number and functions of endothelial progenitor cells by interleukin 1β in the peripheral blood of pigs: involvement of p38 mitogen-activated protein kinase signaling in vitro

BACKGROUND

Endothelial progenitor cells (EPCs) have therapeutic potential for the treatment of organ ischemia following trauma or sepsis, frequently associated with inflammatory conditions. We aimed to investigate the effects of interleukin 1β (IL-1β) on the properties of EPCs and explore its possible relationship with p38 mitogen-activated protein kinase (MAPK).

METHODS

EPCs were isolated from peripheral blood of a porcine model and were characterized. Effects of IL-1β on cell number, proliferation, migration, adhesion, and angiogenic function of EPCs were evaluated in a time- and dose-dependent manner. The activity of p38 MAPK in EPCs was measured by Western blot. Moreover, the effects of SB203580, a specific p38 MAPK inhibitor, on levels of p38 MAPK phosphorylation and the number and functions of EPCs under IL-1β conditions were examined.

RESULTS

Incubation of EPCs with IL-1β (5 ng/mL) for 5 days and with IL-1β (0.05-50 ng/mL) for 48 hours induced a significant reduction in EPC numbers and proliferation, respectively (p < 0.01 vs. control cells). The capacities for migration, adhesion, and angiogenic function of EPCs were also reduced in a time- and dose-dependent manner. IL-1β induced dose- and time-dependent activation of p38 MAPK in EPCs. Moreover, inhibition of p38 MAPK by SB203580 significantly increased the total number of EPCs by twofold as compared with the IL-1β-alone group (p < 0.01) and blocked the ability of IL-1β to impair the functional response of EPCs.

CONCLUSION

These results demonstrate that there is a negative cause-effect relationship between IL-1β and EPCs. Thus, IL-1β inhibits EPC proliferation, migration, adhesion, and tube formation by a mechanism, which involves p38 MAPK signaling in regulating the number and functions of EPCs in vitro.

Prediction of pulmonary edema by plasma protein levels in patients with sepsis

PURPOSE

The difficulties of fluid therapy in patients with septic shock are to maintain sufficient vascular volume while preventing pulmonary edema formation. Thus, it is important to find a biomarker that can reliably predict pulmonary edema formation after fluid loading. We evaluated the association of plasma protein levels with the increase in extravascular lung water index (ΔEVLWI) after fluid loading.

METHODS

This was an observational study in which we retrospectively reviewed medical records of septic patients in whom hemodynamic variables were measured by transpulmonary thermodilution technique before and after fluid loading. Plasma protein levels were measured before fluid loading. Patients were divided into 2 groups according to the changes in EVLWI (ΔEVLWI ≥ 10%) after fluid loading. Diagnostic performance of plasma proteins in predicting pulmonary edema formation was assessed.

RESULTS

A total of 62 patients were included, and 27 of them showed a ΔEVLWI 10% or higher after fluid loading. Plasma albumin and transferrin were significantly lower in this group than in the group with ΔEVLWI less than 10% (21.7 ± 5.8 vs 25.3 ± 5.0 g/L for albumin, P < .05; 107.9 ± 50.1 vs 136.8 ± 44.2 mg/dL for transferrin, P < .05). Areas under the curve of albumin and transferrin were 0.68 (cardiac index, 0.54-0.83) and 0.72 (cardiac index, 0.59-0.86), respectively. At a cutoff value of 87.9 mg/dL, transferrin had a sensitivity of 0.91 in predicting ΔEVLWI 10% or higher.

CONCLUSIONS

Plasma transferrin and albumin levels were associated with ΔEVLWI 10% or higher after fluid loading. The high sensitivity of both biomarkers indicated that patients with normal values were less likely to develop pulmonary edema after fluid loading.

A non-synonymous SNP in the NOS2 associated with septic shock in patients with sepsis in Chinese populations

Sepsis represents a systemic inflammatory response to infection and its sequelae include severe sepsis, septic shock, multiple organ dysfunction syndrome (MODS) and death. Studies in mice and humans indicate that the inducible nitric oxide synthase (iNOS, NOS2) plays an important role in the development of sepsis and its sequelae. It was reported that several single nucleotide polymorphisms (SNPs) within NOS2 could influence the production or activity of NOS2. In this study, we assessed whether SNPs within NOS2 gene were associated with severity of sepsis in Chinese populations. A case-control study was conducted, which included 299 and 280 unrelated patients with sepsis recruited from Liaoning and Jiangsu provinces in China, respectively. Six SNPs within NOS2 were genotyped using Sequenom MassARRAY system. The associations between the SNPs and risk of sepsis complications were estimated by a binary logistic regression model adjusted for confounding factors. Functional assay was performed to assess the biological significance. The GA + AA genotype of a non-synonymous SNP in the exon 16 of NOS2 (rs2297518: G>A) was significantly associated with increased susceptibility to septic shock compared with GG genotype in Liaoning population (OR = 3.29, 95% CI = 1.40-7.72, P = 0.0047). This association was confirmed in the Jiangsu population (OR = 3.49, 95% CI = 1.57-7.79, P = 0.0019). Furthermore, the functional assay performed in the immortalized lymphocyte cell lines indicated that the at-risk GA genotype had a tendency of higher NOS2 activity than the GG genotype (P = 0.32). Our findings suggest that the NOS2 rs2297518 may play a role in mediating the susceptibility to septic shock in patients with sepsis in Chinese populations.

Respiratory dysfunction in patients with sepsis: protective effect of diabetes mellitus

BACKGROUND

Sepsis is a common complication in patients with diabetes mellitus. In a Western population, risk of respiratory dysfunction was lower in diabetic patients with sepsis.

OBJECTIVE

To compare organ dysfunction, particularly respiratory dysfunction, between sepsis patients with and without diabetes mellitus in an Asian population.

METHOD

Hospital discharge data were collected for the period 2004 through 2008. Patients with sepsis, diabetes mellitus, and organ dysfunction were identified by using the International Statistical Classification of Diseases and Related Health Problems, 9th Revision, Australian Modification codes.

RESULTS

Of the 383 238 patients hospitalized during the 5 years, 2943 of the 9221 who had sepsis also had diabetes (31.9%).The most common organ dysfunctions in patients with sepsis were renal (31.5%), cardiovascular (19.2%), and respiratory (10.9%). Among patients with sepsis, respiratory dysfunction was less likely in patients with diabetes (9.4%) than in those without (11.6%; P = .002), but renal dysfunction was more likely in patients with diabetes (46.5%) than in those without (24.4%; P < .001). However, only 27.6% of patients with diabetes had a respiratory source of sepsis compared with 33.4% in patients without diabetes (P < .001). Among patients with sepsis, diabetes mellitus was a significant and independent predictor of respiratory dysfunction (odds ratio, 0.80; 95% confidence interval, 0.66-0.98) after adjustments for age, sex, ethnicity, admission to intensive care, number of comorbid conditions, and other infection sources.

CONCLUSION

Among an Asian population, respiratory dysfunction in patients with sepsis is less likely to develop in those with diabetes than in those without diabetes.

Change of transferrin sialylation differs between mild sepsis and severe sepsis and septic shock

OBJECTIVE AND DESIGN

To investigate the association between the severity of sepsis and changes in sialylation of serum proteins we have conducted a single center pilot study.

SUBJECTS AND METHODS

Sialylation of transferrin (with enzyme-linked lectin assay-ELLA) and total serum proteins (with colorimetric assay) as well as serum iron and transferrin levels were measured in 27 patients with sepsis through the first eight days of the disease.

RESULTS

Total serum sialylation increased in the first two days, transferrin sialylation decreased, while serum iron and transferrin fell. Patients who developed severe sepsis had either a small or marked change in transferrin sialylation while in patients with mild sepsis sialylation decreased moderately.

CONCLUSION

We hypothesize that the change in transferrin sialylation could be a reflection of the intensity of inflammatory response which is insufficient if under-expressed and detrimental if over-expressed. This new feature is a potential marker of sepsis severity early in the disease.

Interplay between inflammation, immune system and neuronal pathways: Effect on gastrointestinal motility

Sepsis is a systemic inflammatory response representing the leading cause of death in critically ill patients, mostly due to multiple organ failure. The gastrointestinal tract plays a pivotal role in the pathogenesis of sepsis-induced multiple organ failure through intestinal barrier dysfunction, bacterial translocation and ileus. In this review we address the role of the gastrointestinal tract, the mediators, cell types and transduction pathways involved, based on experimental data obtained from models of inflammation-induced ileus and (preliminary) clinical data. The complex interplay within the gastrointestinal wall between mast cells, residential macrophages and glial cells on the one hand, and neurons and smooth muscle cells on the other hand, involves intracellular signaling pathways, Toll-like receptors and a plethora of neuroactive substances such as nitric oxide, prostaglandins, cytokines, chemokines, growth factors, tryptases and hormones. Multidirectional signaling between the different components in the gastrointestinal wall, the spinal cord and central nervous system impacts inflammation and its consequences. We propose that novel therapeutic strategies should target inflammation on the one hand and gastrointestinal motility, gastrointestinal sensitivity and even pain signaling on the other hand, for instance by impeding afferent neuronal signaling, by activation of the vagal anti-inflammatory pathway or by the use of pharmacological agents such as ghrelin and ghrelin agonists or drugs interfering with the endocannabinoid system.