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Capcha JMC, Rodrigues CE, Moreira RDS, Silveira MD, Dourado P, Dos Santos F, Irigoyen MC, Jensen L, Garnica MR, Noronha IL, Andrade L, Gomes SA. Wharton's jelly-derived mesenchymal stem cells attenuate sepsis-induced organ injury partially via cholinergic anti-inflammatory pathway activation. Am J Physiol Regul Integr Comp Physiol 2019; 318:R135-R147. [PMID: 31596111 DOI: 10.1152/ajpregu.00098.2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Sepsis induces organ dysfunction due to overexpression of the inflammatory host response, resulting in cardiopulmonary and autonomic dysfunction, thus increasing the associated morbidity and mortality. Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs) express genes and secrete factors with anti-inflammatory properties, neurological and immunological protection, as well as improve survival in experimental sepsis. The cholinergic anti-inflammatory pathway (CAP) is mediated by α7-nicotinic acetylcholine receptors (α7nAChRs), which play an important role in the control of systemic inflammation. We hypothesized that WJ-MSCs attenuate sepsis-induced organ injury in the presence of an activated CAP pathway. To confirm our hypothesis, we evaluated the effects of WJ-MSCs as a treatment for cardiopulmonary injury and on neuroimmunomodulation. Male Wistar rats were randomly divided into four groups: control (sham-operated); cecal ligation and puncture (CLP) alone; CLP+WJ-MSCs (1 × 106 cells, at 6 h post-CLP); and CLP+methyllycaconitine (MLA)+WJ-MSCs (5 mg/kg body wt, at 5.5 h post-CLP, and 1 × 106 cells, at 6 h post-CLP, respectively). All experiments, including the assessment of echocardiographic parameters and heart rate variability, were performed 24 h after CLP. WJ-MSC treatment attenuated diastolic dysfunction and restored baroreflex sensitivity. WJ-MSCs also increased cardiac sympathetic and cardiovagal activity. WJ-MSCs reduced leukocyte infiltration and proinflammatory cytokines, effects that were abolished by administration of a selective α7nAChR antagonist (MLA). In addition, WJ-MSC treatment also diminished apoptosis in the lungs and spleen. In cardiac and splenic tissue, WJ-MSCs downregulated α7nAChR expression, as well as reduced the phospho-STAT3-to-total STAT3 ratio in the spleen. WJ-MSCs appear to protect against sepsis-induced organ injury by reducing systemic inflammation, at least in part, via a mechanism that is dependent on an activated CAP.
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Affiliation(s)
- José Manuel Cóndor Capcha
- Laboratory of Genetics, Cellular Biology, and Molecular Biology, University of São Paulo School of Medicine, São Paulo, Brazil.,Laboratory of Basic Research, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Roberto de Souza Moreira
- Laboratory of Basic Research, University of São Paulo School of Medicine, São Paulo, Brazil.,Federal University of Goiás at Catalão, Catalão, Brazil
| | | | - Paulo Dourado
- Heart Institute, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Fernando Dos Santos
- Heart Institute, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Leonardo Jensen
- Heart Institute, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Margoth Ramos Garnica
- Laboratory of Genetics, Cellular Biology, and Molecular Biology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Irene L Noronha
- Laboratory of Genetics, Cellular Biology, and Molecular Biology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lúcia Andrade
- Laboratory of Basic Research, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Samirah Abreu Gomes
- Laboratory of Genetics, Cellular Biology, and Molecular Biology, University of São Paulo School of Medicine, São Paulo, Brazil
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Westphal GA, Pereira AB, Fachin SM, Barreto ACC, Bornschein ACGJ, Caldeira Filho M, Koenig Á. Characteristics and outcomes of patients with community-acquired and hospital-acquired sepsis. Rev Bras Ter Intensiva 2019; 31:71-78. [PMID: 30970093 PMCID: PMC6443308 DOI: 10.5935/0103-507x.20190013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022] Open
Abstract
Objective To compare the clinical characteristics and outcomes of patients with
community-acquired and hospital-acquired sepsis. Methods This is a retrospective cohort study that included all patients with a
diagnosis of sepsis detected between January 2010 and December 2015 at a
private hospital in southern Brazil. Outcomes (mortality, intensive care
unit and hospital lengths of stay) were measured by analyzing electronic
records. Results There were 543 hospitalized patients with a diagnosis of sepsis, with a
frequency of 90.5 (85 to 105) cases/year. Of these, 319 (58%) cases were
classified as hospital-acquired sepsis. This group exhibited more severe
disease and had a larger number of organ dysfunctions, with higher hospital
[8 (8 - 10) versus 23 (20 - 27) days; p <
0.001] and intensive care unit [5 (4 - 7)
versus 8.5 (7 - 10); p < 0.001] lengths of
stay and higher in-hospital mortality (30.7% versus 15.6%;
p < 0.001) than those with community-acquired sepsis. After adjusting for
age, APACHE II scores, and hemodynamic and respiratory dysfunction,
hospital-acquired sepsis remained associated with increased mortality (OR
1.96; 95%CI 1.15 - 3.32, p = 0.013). Conclusion The present results contribute to the definition of the epidemiological
profile of sepsis in the sample studied, in which hospital-acquired sepsis
was more severe and was associated with higher mortality.
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Affiliation(s)
| | | | | | | | | | | | - Álvaro Koenig
- Centro Hospitalar Unimed Joinville - Joinville (SC), Brasil
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Zaccone V, Tosoni A, Passaro G, Vallone CV, Impagnatiello M, Li Puma DD, De Cosmo S, Landolfi R, Mirijello A. Sepsis in Internal Medicine wards: current knowledge, uncertainties and new approaches for management optimization. Ann Med 2017; 49:582-592. [PMID: 28521523 DOI: 10.1080/07853890.2017.1332776] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Sepsis represents a global health problem in terms of morbidity, mortality, social and economic costs. Although usually managed in Intensive Care Units, sepsis showed an increased prevalence among Internal Medicine wards in the last decade. This is substantially due to the ageing of population and to multi-morbidity. These characteristics represent both a risk factor for sepsis and a relative contra-indication for the admission to Intensive Care Units. Although there is a lack of literature on the management of sepsis in Internal Medicine, the outcome of these patients seems to be gradually improving. This is due to Internists' increased adherence to guidelines and "bundles". The routine use of SOFA score helps physicians in the definition of septic patients, even if the optimal score has still to come. Point-of-care ultrasonography, lactates, procalcitonin and beta-d-glucan are of help for treatment optimization. The purpose of this narrative review is to focus on the management of sepsis in Internal Medicine departments, particularly on crucial concepts regarding diagnosis, risk assessment and treatment. Key Messages Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The prevalence of sepsis is constantly increasing, affecting more hospital patients than any other disease. At least half of patients affected by sepsis are admitted to Internal Medicine wards. Adherence to guidelines, routine use of clinical and lab scores and point-of-care ultrasonography are of help for early recognition of septic patients and treatment optimization.
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Affiliation(s)
- Vincenzo Zaccone
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Alberto Tosoni
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Giovanna Passaro
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Carla Vincenza Vallone
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Michele Impagnatiello
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | | | - Salvatore De Cosmo
- c Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza Hospital , San Giovanni Rotondo , Italy
| | - Raffaele Landolfi
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Antonio Mirijello
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy.,c Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza Hospital , San Giovanni Rotondo , Italy
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López-Mestanza C, Andaluz-Ojeda D, Gómez-López JR, Bermejo-Martín JF. Clinical factors influencing mortality risk in hospital-acquired sepsis. J Hosp Infect 2017; 98:194-201. [PMID: 28882641 DOI: 10.1016/j.jhin.2017.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/29/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Identification of factors that confer an increased risk of mortality in hospital-acquired sepsis (HAS) is necessary to help prevent, and improve the outcome of, this condition. AIM To evaluate the clinical characteristics and factors associated with mortality in patients with HAS. METHODS Retrospective study of patients with HAS in a major Spanish Hospital from 2011 to 2015. Data from adults receiving any of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with sepsis were collected. Those fulfilling the SEPSIS-2 definition with no evidence of infection during the first 48 h following hospitalization were included (N = 196). Multivariate analysis was employed to identify the risk factors of mortality. FINDINGS HAS patients were found to have many of the risk factors associated with cardiovascular disease (male sex, ageing, antecedent of cardiac disease, arterial hypertension, dyslipidaemia, smoking habit) and cancer. Vascular disease or chronic kidney disease were associated with 28-day mortality. Time from hospital admission to sepsis diagnosis, and the presence of organ failure were risk factors for 28-day and hospital mortality. Experiencing more than one episode of sepsis increased the risk of hospital mortality. 'Sepsis code' for the early identification of sepsis was protective against hospital mortality. CONCLUSION This study identifies several major factors associated with mortality in patients suffering from HAS. Implementation of surveillance programmes for the early identification and treatment of sepsis translate into a clear benefit.
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Affiliation(s)
- C López-Mestanza
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain.
| | - D Andaluz-Ojeda
- Critical Care Medicine Service, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - J R Gómez-López
- General Surgery Service, Hospital de Medina del Campo, SACYL, Medina del Campo-Valladolid, Spain
| | - J F Bermejo-Martín
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain
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Abstract
Prehospital care providers are tasked with the delivery of time-sensitive care, and emergency medical services (EMS) systems must match patients to appropriate clinical resources. Modern systems are uniquely positioned to recognize and treat patients with sepsis. Interventions such as administration of intravenous fluid and transporting patients to the appropriate level of definitive care are linked to improved patient outcomes. As EMS systems refine their protocols for the recognition and stabilization of patients with suspected or presumed sepsis, EMS providers need to be educated about the spectrum of sepsis-related presentations and treatment strategies need to be standardized.
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Affiliation(s)
- Jerrilyn Jones
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th floor, Suite 200, Baltimore, MD 21201, USA.
| | - Benjamin J Lawner
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th floor, Suite 200, Baltimore, MD 21201, USA; Baltimore City Fire Department, Emergency Medical Services, 3500 West Northern Parkway, Baltimore, MD 21215, USA
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Holmbom M, Giske CG, Fredrikson M, Östholm Balkhed Å, Claesson C, Nilsson LE, Hoffmann M, Hanberger H. 14-Year Survey in a Swedish County Reveals a Pronounced Increase in Bloodstream Infections (BSI). Comorbidity - An Independent Risk Factor for Both BSI and Mortality. PLoS One 2016; 11:e0166527. [PMID: 27835663 PMCID: PMC5106013 DOI: 10.1371/journal.pone.0166527] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/31/2016] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES we assessed the incidence, risk factors and outcome of BSI over a 14-year period (2000-2013) in a Swedish county. METHODS retrospective cohort study on culture confirmed BSI among patients in the county of Östergötland, Sweden, with approximately 440,000 inhabitants. A BSI was defined as either community-onset BSI (CO-BSI) or hospital-acquired BSI (HA-BSI). RESULTS of a total of 11,480 BSIs, 67% were CO-BSI and 33% HA-BSI. The incidence of BSI increased by 64% from 945 to 1,546 per 100,000 hospital admissions per year during the study period. The most prominent increase, 83% was observed within the CO-BSI cohort whilst HA-BSI increased by 32%. Prescriptions of antibiotics in outpatient care decreased with 24% from 422 to 322 prescriptions dispensed/1,000 inhabitants/year, whereas antibiotics prescribed in hospital increased by 67% (from 424 to 709 DDD per 1,000 days of care). The overall 30-day mortality for HA-BSIs was 17.2%, compared to 10.6% for CO-BSIs, with an average yearly increase per 100,000 hospital admissions of 2 and 5% respectively. The proportion of patients with one or more comorbidities, increased from 20.8 to 55.3%. In multivariate analyses, risk factors for mortality within 30 days were: HA-BSI (2.22); two or more comorbidities (1.89); single comorbidity (1.56); CO-BSI (1.21); male (1.05); and high age (1.04). CONCLUSION this survey revealed an alarming increase in the incidence of BSI over the 14-year study period. Interventions to decrease BSI in general should be considered together with robust antibiotic stewardship programmes to avoid both over- and underuse of antibiotics.
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Affiliation(s)
- Martin Holmbom
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department of Urology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Christian G. Giske
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
- Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Fredrikson
- Occupational and Environmental Medicine, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Forum Östergötland, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Åse Östholm Balkhed
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Carina Claesson
- Division of Clinical Microbiology, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Lennart E. Nilsson
- Division of Clinical Microbiology, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Mikael Hoffmann
- The NEPI foundation, Division of Health Care Analysis, Department of Medical and Health Sciences, Faculty of Medicine and Health Sciences, Linköping university, Linköping, Sweden
| | - Håkan Hanberger
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
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Tsertsvadze A, Royle P, Seedat F, Cooper J, Crosby R, McCarthy N. Community-onset sepsis and its public health burden: a systematic review. Syst Rev 2016; 5:81. [PMID: 27194242 PMCID: PMC4870814 DOI: 10.1186/s13643-016-0243-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 04/12/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sepsis is a life-threatening condition and major contributor to public health and economic burden in the industrialised world. The difficulties in accurate diagnosis lead to great variability in estimates of sepsis incidence. There has been even greater uncertainty regarding the incidence of and risk factors for community-onset sepsis (COS). We systematically reviewed the recent evidence on the incidence and risk factors of COS in high income countries (North America, Australasia, and North/Western Europe). METHODS Cohort and case-control studies were eligible for inclusion. Medline and Embase databases were searched from 2002 onwards. References of relevant publications were hand-searched. Two reviewers screened titles/abstracts and full-texts independently. One reviewer extracted data and appraised studies which were cross-checked by independent reviewers. Disagreements were resolved via consensus. Odds ratios (ORs) and 95 percent confidence intervals (95 % CIs) were ascertained by type of sepsis (non-severe, severe, and septic shock). RESULTS Ten cohort and 4 case-control studies were included. There was a wide variation in the incidence (# cases per 100,000 per year) of non-severe sepsis (range: 64-514), severe sepsis (range: 40-455), and septic shock (range: 9-31). Heterogeneity precluded statistical pooling. Two cohort and 4 case-control studies reported risk factors for sepsis. In one case-control and one cohort study, older age and diabetes were associated with increased risk of sepsis. The same case-control study showed an excess risk for sepsis in participants with clinical conditions (e.g., immunosuppression, lung disease, and peripheral artery disease). In one cohort study, higher risk of sepsis was associated with being a nursing home resident (OR = 2.60, 95 % CI: 1.20, 5.60) and in the other cohort study with being physically inactive (OR = 1.33, 95 % CI: 1.13, 1.56) and smoking tobacco (OR = 1.85, 95 % CI: 1.54, 2.22). The evidence on sex, ethnicity, statin use, and body mass index as risk factors was inconclusive. CONCLUSIONS The lack of a valid standard approach for defining sepsis makes it difficult to determine the true incidence of COS. Differences in case ascertainment contribute to the variation in incidence of COS. The evidence on COS is limited in terms of the number and quality of studies. This review highlights the urgent need for an accurate and standard method for identifying sepsis. Future studies need to improve the methodological shortcomings of previous research in terms of case definition, identification, and surveillance practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015023484.
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Affiliation(s)
- Alexander Tsertsvadze
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Pam Royle
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Farah Seedat
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Jennifer Cooper
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Rebecca Crosby
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Noel McCarthy
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,NIHR Health Protections Research Unit in Gastrointestinal Infections, University of Oxford, Oxford, UK
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